Lower limb injuries

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Lower limb injuries

• Richard Hardern

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Content

• Knee, ankle, foot
• Anatomy
• History and examination
• Treatment of limb threatening problems

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Not a case for the Emergency Nurse Practitioner!
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Knee anatomy

• Bones
• Ligaments cruciate and collateral
• Menisci

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Ankle anatomy

• Bones
• Ligaments medial lateral
• Tendons

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Peroneus brevis
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Gastrocnemius
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Foot anatomy

• Bones

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History examination

• Mechanism of injury
• Mechanism of injury
• Mechanism of injury

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General Considerations

• Always inquire about the mechanism of injury.
• Always inquire about the effect on function.
• Always do the following in this order
• Inspection
• Palpation
• Range of Motion (active before passive)

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Knee look

• Skin- scars, redness
• Muscle- wasting of quads (compare diameter of
  thigh if quads wasted)
• Bone/joint- Effusion, Varus Valgus deformity(
  measure intermalleolar distance if valgus),
• Watch them walking too at some point (even if
  only from WR into examination cubicle)

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Knee feel

• Skin - Temperature, back of hand
• Muscle- Ask patient to contract quads
• Bone/joint- Effusion fluid displacement test,
  patellar tap test (may be negative if tense
  effusion)
• Joint line tenderness (with knee bent)
• Patellar tendon
• MCL,LCL
• Popliteal swellings

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Knee move

• Active then passive-
• Flexion (135 degrees normal)
• Extension (put hand behind knee)
• Feel for crepitus

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Knee special tests - collaterals
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Knee special tests - cruciates
ACL
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PCL
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Knee special tests - menisci
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Knees active resisted extension
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Ankle/foot examination

• Look
• Knee distally
• Walking too (at some point)

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Ankle/foot examination

• Feel
• Knee distally
• Medial lateral (include base 5th MT)
• Leave tender area until last

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Ankle / foot examination

• Move
• Ankle
• Midtarsal
• Stability test anterior drawer

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Anterior draw test
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Emergency problems

• Dislocation (not patellar)
• Compartment syndrome

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• Skin medially is at risk.
• If skin becomes broken/necrotic, becomes an
  open one.
• Risks of complications much greater (especially
  infection).
• Needs emergent reduction (with analgesia).
• Damage to popliteal artery if dislocated knee

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Compartment syndrome

• The pain may be intensely out of proportion to
  the injury, especially if no bone is broken.
• There may also be a tingling or burning sensation
  (paresthesias) in the muscle.
• The muscle may feel tight or full.
• If the area becomes numb or paralysis sets in,
  cell death has begun and efforts to lower the
  pressure in the compartment may not be successful
  in restoring function.
• Pain worse if affected muscle passively
  stretched.
• Pulses not lost (until very late).

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