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Anatomy Lect 8 Le

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Anatomy Lect 8 Le

  1. 1. Anatomy Lecture 8 Lower Extremities Physician Assistant Program Miami Dade College
  2. 2. <ul><li>&quot;Whatever your mind can conceive and believe it can achieve.&quot; </li></ul><ul><li>Napoleon Hill </li></ul>
  3. 10. Pelvis & Hips
  4. 11. Hip dislocation <ul><li>90% are posterior dislocations </li></ul>
  5. 12. Hip Dislocation
  6. 14. Femur Fx
  7. 20. Iliotibial Band Friction Syndrome <ul><li>Occurs in runners and cyclists </li></ul><ul><li>Result of abrasion b/t iliotibial band and lateral femoral condyle </li></ul><ul><li>+ tenderness over lateral epicondyle @ 30 degrees of flexion </li></ul><ul><ul><li>tenderness may be present throughout length of ITB </li></ul></ul><ul><li>Tx: </li></ul><ul><ul><li>Decrease activity </li></ul></ul><ul><ul><li>Ice massage </li></ul></ul><ul><ul><li>Stretching of ITB </li></ul></ul>
  8. 22. Hamstring injury <ul><li>Hamstring injuries are one of the most common among runners. </li></ul><ul><li>The hamstring muscles run down the back of the leg from the pelvis to the lower leg bones, and an injury can range from minor strains to total rupture of the muscle. </li></ul><ul><li>A sudden, sharp pain in the back of the thigh that stops you in mid-stride, is probably a hamstring injury, </li></ul><ul><li>After such an injury, the knee may not extend more than 30 to 40 degrees short of straight without intense pain. </li></ul>
  9. 30. Knee
  10. 34. The Knee <ul><li>Ligaments: </li></ul><ul><ul><li>Anterior Cruciate Ligament (ACL) </li></ul></ul><ul><ul><li>Posterior Cruciate Ligament (PCL) </li></ul></ul><ul><ul><li>Medial Collateral Ligament (MCL) </li></ul></ul><ul><ul><li>Lateral Collateral Ligament (LCL) </li></ul></ul>
  11. 35. Anterior Cruciate Ligament (ACL) <ul><li>originates in front of the intercondylar eminance of the tibia and inserts on the posteromedial aspect of the lateral femoral condyle. </li></ul><ul><ul><li>Lat  med </li></ul></ul><ul><li>It is composed of two “bundles”. </li></ul><ul><ul><li>The anteromedial bundle is tight in flexion </li></ul></ul><ul><ul><li>The posterior bundle is tight in extension. </li></ul></ul><ul><li>The ACL prevents anterior translation of the tibia </li></ul>
  12. 36. Posterior Cruciate Ligaments (PCL) <ul><li>Originates on the medial femoral condyle and inserts on the tibia. </li></ul><ul><ul><li>Med  lat </li></ul></ul><ul><li>It is also composed of two bundles </li></ul><ul><ul><li>An anteriolateral bundle that is tight in flexion </li></ul></ul><ul><ul><li>And an posteromedial bundle that is tight in extension </li></ul></ul><ul><li>The PCL prevents posterior translation of the tibia </li></ul>
  13. 37. Medial Collateral Ligament (MCL) <ul><li>Originates on the medial femoral epicondyle and inserts on the proximal tibia </li></ul><ul><li>The deep portion of the ligament is intimately associated with the medial meniscus </li></ul><ul><li>The MCL prevents valgus angulation of the knee </li></ul>
  14. 38. Lateral Collateral Ligament (LCL) <ul><li>Originates on the lateral femoral epicondyle and inserts on the lateral aspect of the fibular head. </li></ul><ul><li>It prevents varus angulation of the knee </li></ul>
  15. 39. Medial Supporting Structures <ul><li>(From superficial to deep layers) </li></ul><ul><ul><li>Sartorus and fascia </li></ul></ul><ul><ul><li>Superficial MCL, posterior oblique ligament, semimembranous </li></ul></ul><ul><ul><li>Deep MCL, capsule </li></ul></ul>
  16. 40. Lateral Supporting Structures <ul><li>Iliotibial tract, biceps, fascia </li></ul><ul><li>Patella retinaculum, patellofemoral ligament </li></ul><ul><li>LCL, arcuate ligament, fabellofibular ligament, capsule </li></ul>
  17. 41. Menisci <ul><li>Crescent shaped fibrocartilagenous structures that are triangular in cross section. </li></ul><ul><li>Only the peripheral 20-30% of the menisci are vascularized </li></ul><ul><li>These structures deepen the articular surface of the tibial plateau </li></ul><ul><li>Also play a role in stability, lubrication, and nutrition </li></ul>
  18. 42. Joint Relationships <ul><li>The height of the lateral femoral condyle is greater than that of the medial femoral condyle </li></ul><ul><li>The lateral condyle is relatively straight, but the medial condyle is curved, allowing the medial tibial plateau to externally rotate in full extension </li></ul><ul><ul><li>(The screw home mechanism) </li></ul></ul><ul><li>The patellofemoral joint is composed of the patella and the femoral trochlea </li></ul>
  19. 44. Meniscal Tear <ul><li>MC injury to the knee requiring surgery </li></ul><ul><li>Medial meniscal tears occur 3x more frequently than lateral meniscal tears </li></ul><ul><li>May be caused by acute trauma or long term wear and tear </li></ul><ul><li>Locked knee requires urgent intervention </li></ul>
  20. 45. Meniscal Tear <ul><li>Diagnosis: </li></ul><ul><ul><li>History: </li></ul></ul><ul><ul><ul><li>locking </li></ul></ul></ul><ul><ul><ul><li>catching episodes </li></ul></ul></ul><ul><ul><ul><li>giving way episodes </li></ul></ul></ul><ul><ul><ul><li>pain with squatting </li></ul></ul></ul><ul><ul><ul><li>Swelling </li></ul></ul></ul><ul><ul><li>Physical Exam: </li></ul></ul><ul><ul><ul><li>+ effusion </li></ul></ul></ul><ul><ul><ul><li>+ joint line tenderness </li></ul></ul></ul><ul><ul><ul><li>+ McMurray </li></ul></ul></ul><ul><ul><li>MRI= >90% accurate </li></ul></ul>
  21. 47. Meniscal Tear <ul><li>Treatment: </li></ul><ul><ul><li>Meniscal repair may be achieved arthroscopically by suturing the torn meniscus </li></ul></ul><ul><ul><ul><li>This may be an option if tear occurs in an area with blood supply </li></ul></ul></ul><ul><ul><li>Partial meniscectomy </li></ul></ul><ul><ul><ul><li>Arthroscopic removal of the torn meniscus </li></ul></ul></ul>
  22. 49. Menisci <ul><li>Meniscal Cysts </li></ul><ul><ul><li>Most commonly involve lateral meniscus in conjunction with horizontal cleavage tears </li></ul></ul><ul><li>Discoid Meniscus (Popping Knee Syndrome) </li></ul><ul><ul><li>Congenitally round (discoid) lateral meniscus that does not acquire its normal semilunar shape </li></ul></ul><ul><ul><li>Patients develop popping with knee extension </li></ul></ul>
  23. 50. Ligament Sprains
  24. 51. Ligament sprains
  25. 52. Medial Collateral Ligament (MCL) Sprain <ul><li>Caused by valgus force to knee </li></ul><ul><li>Diagnosis: </li></ul><ul><ul><li>+ tenderness along MCL (Grade I-III) </li></ul></ul><ul><ul><li>+ opening of medial joint line with valgus stress when knee is @ 30 degrees of flexion (Grades II-III) </li></ul></ul><ul><ul><li>(Posterior Cruciate Ligament is most responsible for medial-lateral stability when knee is fully extended) </li></ul></ul><ul><li>Tx: </li></ul><ul><ul><li>Ice </li></ul></ul><ul><ul><li>NSAIDS </li></ul></ul><ul><ul><li>Physical Therapy </li></ul></ul><ul><ul><li>Grade III sprains may require surgical repair </li></ul></ul>
  26. 53. Lateral Collateral Ligament (LCL) Sprain <ul><li>Caused by varus force to knee </li></ul><ul><li>Uncommon </li></ul><ul><li>Dx: </li></ul><ul><ul><li>+ tenderness along LCL (Grade I-III) </li></ul></ul><ul><ul><li>+ opening of lateral joint line with varus stress when knee is @ 30 degrees of flexion </li></ul></ul><ul><li>Tx: </li></ul><ul><ul><li>Non-operative: </li></ul></ul><ul><ul><ul><li>Ice </li></ul></ul></ul><ul><ul><ul><li>NSAIDS </li></ul></ul></ul><ul><ul><ul><li>Physical therapy </li></ul></ul></ul>
  27. 54. Anterior Cruciate Ligament (ACL) Sprains <ul><li>Caused by twisting of knee while foot is firmly planted on ground </li></ul><ul><li>Hx: </li></ul><ul><ul><li>Patient hears a “pop” feels a tear and acute pain in knee </li></ul></ul><ul><ul><li>Knee may feel unstable with weight bearing </li></ul></ul><ul><ul><li>Acute swelling at time of injury </li></ul></ul>
  28. 55. Anterior Cruciate Ligament (ACL) Sprains <ul><li>Dx: </li></ul><ul><ul><li>+ Lachman (20-30 degrees flexion, pull tibia anteriorly) </li></ul></ul><ul><ul><li>+ anterior drawer (90 degrees) </li></ul></ul><ul><ul><li>+ pivot shift with anterolateral instability </li></ul></ul><ul><ul><li>Arthrocentesis reveals hemarthrosis </li></ul></ul><ul><ul><li>MRI >90% accurate </li></ul></ul><ul><li>Tx: </li></ul><ul><ul><li>Physical therapy (pre/post op) </li></ul></ul><ul><ul><li>Open vs. Arthroscopic surgical reconstruction with patella tendon or hamstring tendon autograft; allograft (cadaver); xenograft (another animal) </li></ul></ul><ul><ul><li>CPM (continuous passive motion machine) and hinged knee brace post-op </li></ul></ul><ul><ul><li>If stable = no surgery nec. </li></ul></ul>
  29. 56. ACL tear
  30. 57. Posterior Cruciate Ligament (PCL) Sprain <ul><li>Caused by hyperextension of knee or direct blow to anterior aspect of flexed knee (Dashboard) </li></ul><ul><li>Dx: </li></ul><ul><ul><li>+ posterior drawer </li></ul></ul><ul><ul><li>+ posterior sag sign </li></ul></ul><ul><ul><li>MRI >90% accurate </li></ul></ul><ul><li>Tx: </li></ul><ul><ul><li>Physical therapy </li></ul></ul><ul><ul><li>Surgical reconstruction in patients who have high demand knees (athletes) and severe instability </li></ul></ul>
  31. 58. Unhappy Triad <ul><li>This is the term given to an injury where the ACL, MCL and Medial Meniscus are all three torn.  </li></ul><ul><li>The mechanism for this injury is usually a lateral blow to the knee with the foot fixed.  </li></ul><ul><li>1. ACL tear </li></ul><ul><li>2. MCL tear </li></ul><ul><li>3. Medial meniscus tear </li></ul>
  32. 60. History & significance <ul><li>Pain after sitting/stair climbing= patellofemoral etiology </li></ul><ul><li>Dashboard injury= PCL tear/ dislocation </li></ul><ul><li>Locking/ pain after squatting= Meniscal tear </li></ul><ul><li>Non-contact injury with “pop”= ACL tear </li></ul><ul><li>Contact injury with “pop”= Collateral ligament, meniscus, patellar dislocation </li></ul>
  33. 61. History & significance <ul><li>Acute swelling= ACL, peripheral meniscus tear, osteochondral fx, +/- capsule tear </li></ul><ul><li>Knee “gives way”= Ligamentous laxity, patella subluxation or dislocation, meniscal tear, chondromalacia patella </li></ul><ul><li>Anterior force- dorsiflexed foot= patella injury </li></ul><ul><li>Anterior force- plantarflexed foot= PCL injury </li></ul>
  34. 62. Examination & Significance <ul><li>+ Effusion= Ligamentous/ meniscus injury (acute) or Arthritis (chronic) </li></ul><ul><li>ROM= Block-meniscus tear loose body, ACL tear impinging </li></ul><ul><li>+ patella crepitus with PROM= patellofemoral pathology </li></ul><ul><li>+ patella grind= patellofemoral pathology </li></ul><ul><li>+ McMurray= meniscal pathology or chondromalacia of articular surface </li></ul>
  35. 63. Examination & Significance <ul><li>Varus/valgus @ 30 degrees= LCL/MCL laxity </li></ul><ul><li>Varus/ valgus @ 0 degrees= LCL/MCL & PCL/posterior capsule </li></ul><ul><li>+ Lachman= ACL tear </li></ul><ul><li>+ Anterior drawer= ACL tear </li></ul><ul><li>+ Pivot shift= Anterolateral rotational instability </li></ul><ul><li>+ Tibia sag= PCL tear </li></ul>
  36. 64. Patella Tendinitis <ul><li>“ Jumper’s Knee” </li></ul><ul><li>Seen mostly in basketball & volleyball players </li></ul><ul><li>+ tenderness along patella tendon </li></ul><ul><li>Tx: </li></ul><ul><ul><li>Ice </li></ul></ul><ul><ul><li>NSAIDS </li></ul></ul><ul><ul><li>Refrain from jumping activities </li></ul></ul><ul><ul><li>Physical therapy </li></ul></ul><ul><ul><li>Rarely surgery </li></ul></ul>
  37. 65. Patellar Tendinitis <ul><li>Overuse during sports can injure the tendon attachment on the tibial tuberosity . </li></ul><ul><ul><li>In adolescents this produces Osgood-Schlatters Disease. </li></ul></ul><ul><li>Central core degeneration may occur in the patellar tendon in middle age as it does in the achilles tendon. </li></ul><ul><li>This may leave it vulnerable to complete rupture. </li></ul>
  38. 67. Patella Tendon Rupture <ul><li>Most frequently in patient <40 y/o </li></ul><ul><li>Exam: </li></ul><ul><ul><li>Patient cannot actively extend knee </li></ul></ul><ul><ul><li>Palpable defect inferior to patella </li></ul></ul><ul><li>Xray: </li></ul><ul><ul><li>+ patella alta </li></ul></ul><ul><li>Tx: </li></ul><ul><ul><li>Surgical repair </li></ul></ul><ul><ul><li>Weight bear as tolerated (wbat) with knee in extension </li></ul></ul>
  39. 69. <ul><li>Patella tendon rupture </li></ul><ul><ul><li>Notice superior appearing patella </li></ul></ul>Normal Knee
  40. 70. Patella Femoral Syndrome/ Chondromalacia Patella <ul><li>“ Runner’s Knee” </li></ul><ul><li>Degeneration of cartilage under the surface of the patella </li></ul><ul><li>Hx: </li></ul><ul><ul><li>Pain with ascending or descending stairs, running downhill, or sitting knees bent for prolonged periods </li></ul></ul><ul><li>Xray: </li></ul><ul><ul><li>Lateral tilt of patella on sunrise/ skyline/ merchant’s view </li></ul></ul><ul><li>Tx: </li></ul><ul><ul><li>Physical therapy focusing on quadriceps (vastus medialis) strengthening </li></ul></ul><ul><ul><li>NSAIDS </li></ul></ul><ul><ul><li>Ice </li></ul></ul><ul><ul><li>Knee sleeve may be helpful </li></ul></ul>
  41. 71. Prepatellar Bursitis <ul><li>&quot; Housemaid's Knee“ </li></ul><ul><li>Brought on by unaccustomed kneeling on hard surfaces. </li></ul><ul><li>The bursa lies between the front of the patella and the overlying skin </li></ul><ul><li>Examination reveals a tender inflamed lump. </li></ul><ul><li>Tx: </li></ul><ul><ul><li>Local anesthetics </li></ul></ul><ul><ul><li>Steroid injection </li></ul></ul><ul><ul><li>avoiding kneeling. </li></ul></ul><ul><li>Needs to be differentiated from infection and Gout. </li></ul>
  42. 72. Haemarthrosis <ul><li>Trauma to the knee may cause internal bleeding into the joint (haemarthrosis), with rapid onset swelling, and an extremely painful, warm and tender joint. </li></ul><ul><li>The joint is usually held in a degree of flexion (partially bent). </li></ul><ul><li>Bleeding can occur after an injury to the joint capsule, ligament sprains , and meniscal tears . </li></ul><ul><li>Non-traumatic bleeding into the joint can occur with </li></ul><ul><ul><li>haemophilia and other blood disorders, </li></ul></ul><ul><ul><li>anticoagulant treatment with warfarin and heparin, </li></ul></ul><ul><ul><li>and secondary cancer spread. </li></ul></ul><ul><li>Other conditions which can cause sudden swelling (effusion) of the joint without a haemarthrosis include </li></ul><ul><ul><li>crystal deposition disease (gout), </li></ul></ul><ul><ul><li>inflammatory arthritis (rheumatoid arthritis), </li></ul></ul><ul><ul><li>and septic arthritis (infected joint) </li></ul></ul>
  43. 76. Patella Dislocation/ Subluxation <ul><li>Lateral displacement of patella </li></ul><ul><li>Acute vs. recurrent </li></ul><ul><li>Reduction occurs with knee in extension </li></ul><ul><li>+ patella apprehension test </li></ul><ul><li>Tx: </li></ul><ul><ul><li>Immediate mobilization and strengthening exercises & patella sleeve </li></ul></ul><ul><ul><li>Vs. </li></ul></ul><ul><ul><li>Immobilization in cylinder cast x 6 wks </li></ul></ul><ul><ul><li>Vs. </li></ul></ul><ul><ul><li>Surgical repair </li></ul></ul>
  44. 80. Patellar fracture
  45. 82. Condylar fractures
  46. 83. Popliteal Mass <ul><li>Popliteal Abscess </li></ul><ul><li>Tumor </li></ul><ul><li>Baker’s cyst </li></ul><ul><li>Popliteal aneurysm </li></ul>
  47. 84. Baker’s Cyst <ul><li>Baker cyst, also termed popliteal cyst, is the most common mass in the popliteal fossa and results from fluid distension of the gastrocnemio-semimembranosus bursa. </li></ul><ul><li>Baker cysts are not uncommon and can be caused by virtually any cause of joint swelling ( arthritis ). The most common form of arthritis associated with Baker cysts is osteoarthritis , also called degenerative arthritis . Baker cysts also can result from cartilage tears (such as a torn meniscus ), rheumatoid arthritis , and other knee problems. </li></ul>
  48. 85. Popliteal Artery Aneurysm <ul><li>Popliteal artery aneurysms are the most common peripheral artery aneurysms, comprising 70% to 85% of the total aneurysms in the periphery </li></ul>
  49. 95. Shin splints <ul><li>Shin splints is the general name given to pain at the front of the lower leg. </li></ul><ul><li>Shin splints is not a diagnosis in itself but a description of symptoms of which there could be a number of causes. </li></ul><ul><li>The most common cause is inflammation of the periostium of the tibia (sheath surrounding the bone). </li></ul><ul><li>Traction forces occur from the muscles of the lower leg on the periostium. </li></ul><ul><li>Shin splints is an overuse injury and can be caused by running on hard surfaces or running on tip toes. </li></ul><ul><li>It is also common in sports where a lot of jumping is involved. </li></ul><ul><li>If you over pronate then you are also more susceptible to this injury. </li></ul>
  50. 96. Compartment Syndrome <ul><li>Increased intracompartmental pressures that compromise the bloodflow to the compartment musculature </li></ul><ul><li>Muscles will develop ischemic necrosis if not treated properly </li></ul><ul><li>Dx: </li></ul><ul><ul><li>Skin becomes erythematous, shiny, warm, TENSE, tender to palpation </li></ul></ul><ul><ul><li>+ pain with passive plantar flexion of foot </li></ul></ul><ul><ul><li>+ paresthesias or foot drop </li></ul></ul><ul><ul><li>Severe pain </li></ul></ul><ul><li>Check compartment pressures </li></ul><ul><li>MC affected is Anterior Tibial Compartment </li></ul><ul><li>Tx: </li></ul><ul><ul><li>Ice packs, elevation </li></ul></ul><ul><ul><li>If no response: fasciotomy <12 hrs after onset of symptoms </li></ul></ul>
  51. 97. Compartment Syndrome <ul><li>The muscles of the leg are wrapped with dense leathery tissue called fascia that divides them into groups called compartments. </li></ul><ul><li>This dense, inelastic cover prevents muscles from bulging during normal walking. </li></ul><ul><li>Unfortunately, this fascial envelope is unable to stretch to accommodate swollen muscles. </li></ul><ul><li>Severe fractures, trauma, vascular injuries and electrical injuries can all produce muscle damage. </li></ul><ul><li>As the injured muscle swells the pressure rises within the constricting compartment. </li></ul><ul><li>Eventually, the internal pressure rises so high that local circulation is cut off and the affected muscle dies. </li></ul><ul><li>The local increased pressure can also damage associated nerves resulting in a loss of both power and sensation. </li></ul>
  52. 102. Vericose Veins (Tortuous) <ul><li>Usually, varicose veins and telangiectasia (spider veins) are normal veins that have dilated under the influence of increased venous pressure. </li></ul><ul><li>They are the visible surface manifestation of an underlying syndrome of venous insufficiency. </li></ul><ul><li>Venous insufficiency syndromes allow venous blood to escape from its normal flow path and flow in a retrograde direction down into an already congested leg. </li></ul>
  53. 103. Thrombophlebitis <ul><li>Superficial vein thrombophlebitis may occur spontaneously or as a complication of medical or surgical interventions. </li></ul><ul><li>Sterile thrombophlebitis limited to the superficial veins rarely is life threatening, but a thorough diagnostic evaluation is mandatory because many patients with superficial phlebitis also have occult deep vein thrombosis (DVT), which carries very high rates of morbidity and mortality. </li></ul><ul><li>Phlebitis should be assumed to involve the deep veins until proven otherwise, because superficial vein thrombophlebitis and deep vein thrombophlebitis share the same pathophysiology, pathogenesis, and risk factors. </li></ul>
  54. 104. Deep vein thrombosis (DVT) <ul><li>Deep venous thrombosis (DVT) and its sequela, pulmonary embolism, are the leading causes of preventable in-hospital mortality in the United States </li></ul><ul><li>The bedside diagnosis of venous thrombosis is insensitive and inaccurate. </li></ul><ul><li>Many thrombi do not produce significant obstruction to venous flow; venous collaterals may develop rapidly, and venous wall inflammation may be minimal. </li></ul><ul><li>Conversely, many nonthrombotic conditions produce signs and symptoms suggestive of DVT </li></ul>
  55. 105. DVT <ul><li>A clinical suspicion of DVT or PE often stimulates efforts to identify known risk factors for venous thrombosis. </li></ul><ul><li>All recognized risk factors for DVT (and thus for PE) arise from the 3 underlying components of the </li></ul><ul><li>Virchow triad: </li></ul><ul><ul><li>venous stasis, </li></ul></ul><ul><ul><li>hypercoagulability, and </li></ul></ul><ul><ul><li>vessel intimal injury </li></ul></ul>
  56. 106. Deep Venous Thrombosis (DVT) <ul><ul><li>Edema, principally unilateral , is the most specific symptom. Massive edema with cyanosis and ischemia (phlegmasia cerulea dolens) is rare. </li></ul></ul><ul><ul><li>Leg pain occurs in 50%, but this is entirely nonspecific. Pain can occur on dorsiflexion of the foot (Homans sign). </li></ul></ul><ul><ul><li>Tenderness occurs in 75% of patients but is also found in 50% of patients without objectively confirmed DVT </li></ul></ul><ul><ul><li>Homan’s sign : Discomfort in the calf muscles on forced dorsiflexion of the foot with the knee straight has been a time-honored sign of DVT. However, this sign is present in less than one third of patients with confirmed DVT </li></ul></ul><ul><ul><li>Clinical signs and symptoms of pulmonary embolism as the primary manifestation occur in 10% of patients with confirmed DVT. </li></ul></ul><ul><ul><li>The pain and tenderness associated with DVT does not usually correlate with the size, location, or extent of the thrombus. </li></ul></ul><ul><ul><li>Warmth or erythema of skin can be present over the area of thrombosis </li></ul></ul>
  57. 107. <ul><li>Well’s Criteria </li></ul>Wells Clinical Score for DVT* Clinical Parameter Score Score Active cancer (treatment ongoing, or within 6 months or palliative) +1 Paralysis or recent plaster immobilization of the lower extremities +1 Recently bedridden for >3 d or major surgery <4 wk +1 Localized tenderness along the distribution of the deep venous system +1 Entire leg swelling +1 Calf swelling >3 cm compared to the asymptomatic leg +1 Pitting edema (greater in the symptomatic leg) +1 Previous DVT documented +1 Collateral superficial veins (nonvaricose) +1 Alternative diagnosis (as likely or > that of DVT) -2 Total of Above Score High probability > 3 Moderate probability 1 or 2 Low probability < 0
  58. 108. DVT <ul><li>The D-dimer assays have low specificity for DVT; therefore, they should only be used to rule out DVT in low probability cases, not to confirm the diagnosis of DVT </li></ul><ul><li>Sensitivity of duplex ultrasonography for proximal vein DVT is 97%, but only 73% for calf vein DVT. </li></ul>
  59. 109. Fibula Shaft Fractures <ul><li>Treated symptomatically & usually heal without complication </li></ul>
  60. 110. Tibial Shaft Fractures <ul><li>Mechanisms of injury </li></ul><ul><ul><li>1. direct trauma: MVA, skiing, (boot top) </li></ul></ul><ul><ul><li>2. indirect trauma: assoc with rotary & compressive forces as from skiing or a fall </li></ul></ul><ul><li>Type I </li></ul><ul><ul><li>Slightly displaced 0-50% & non-comminuted, 90% chance of union </li></ul></ul><ul><li>Type II </li></ul><ul><ul><li>>50% displacement, but continued bony contact, may be slightly comminuted, may be open or closed </li></ul></ul><ul><li>Type III </li></ul><ul><ul><li>Complete displacement with comminution, may be open or closed, 70% chance of union </li></ul></ul>
  61. 111. Tibial Shaft Fractures <ul><li>Exam: </li></ul><ul><ul><li>Pain, swelling, deformity </li></ul></ul><ul><li>XR: </li></ul><ul><ul><li>AP/lateral tibia fibula </li></ul></ul><ul><li>Tx: </li></ul><ul><ul><li>closed fx: </li></ul></ul><ul><ul><ul><li>initial- splint, ice, elevation, monitor for compartment syndrome </li></ul></ul></ul><ul><ul><ul><li>Definitive- LLC vs intramedullary (IM) nailing </li></ul></ul></ul><ul><ul><li>Open fx: </li></ul></ul><ul><ul><ul><li>Irrigation, IV antibiotics, open vs closed reduction, external fixation, monitor for compartment syndrome </li></ul></ul></ul>
  62. 112. Tibial shaft Fracture types
  63. 114. Tibial Plateau Fractures <ul><li>Involve proximal articular surface of tibia </li></ul><ul><li>Exam: </li></ul><ul><ul><li>Pain localized to proximal tibia, +/- swelling </li></ul></ul><ul><li>Imaging: </li></ul><ul><ul><li>AP, lateral knee </li></ul></ul><ul><ul><li>CT scan </li></ul></ul><ul><li>Initial Tx: </li></ul><ul><ul><li>Ice, Splinting </li></ul></ul><ul><ul><li>Non-displaced fractures are treated with LLC </li></ul></ul><ul><ul><li>Surgical Tx </li></ul></ul><ul><ul><ul><li>ORIF, External fixation, or combination of both </li></ul></ul></ul>
  64. 115. Tibial Plateau Fracture Classification
  65. 118. The Ankle <ul><li>Bones </li></ul><ul><ul><li>Tibia </li></ul></ul><ul><ul><li>Fibula </li></ul></ul><ul><ul><li>Talus </li></ul></ul><ul><li>Obtain AP/lat/obliq to r/o fracture </li></ul><ul><li>Ottowa Ankle rules </li></ul>
  66. 123. Ankle
  67. 128. Ankle Sprains <ul><li>MCC ankle injury is sprain </li></ul><ul><li>Grade I </li></ul><ul><li>Mild sprain, mild pain, little swelling, and joint stiffness may be apparent </li></ul><ul><li>Stretch and/or minor tear of the ligament without laxity (loosening) </li></ul><ul><li>Usually affects the anterior talofibular ligament </li></ul><ul><li>Minimum or no loss of function </li></ul><ul><li>Can return to activity within a few days of the injury (with a brace or taping) </li></ul>
  68. 129. Ankle Sprains <ul><li>Grade II </li></ul><ul><li>Moderate to severe pain, swelling, and joint stiffness are present </li></ul><ul><li>Partial tear of the lateral ligament(s) </li></ul><ul><li>Moderate loss of function with difficulty on toe raises and walking </li></ul><ul><li>Takes up to 2-3 months before regaining close to full strength and stability in the joint </li></ul>
  69. 130. Ankle Sprains <ul><li>Grade III </li></ul><ul><li>Severe pain may be present initially, followed by little or no pain due to total disruption of the nerve fibers </li></ul><ul><li>Swelling may be profuse and joint becomes stiff some hours after the injury </li></ul><ul><li>Complete rupture of the ligaments of the lateral complex (severe laxity) </li></ul><ul><li>Usually requires some form of immobilization lasting several weeks </li></ul><ul><li>Complete loss of function (functional disability) and necessity for crutches </li></ul><ul><li>Usually managed conservatively with rehabilitation exercises, but a small percentage may require surgery </li></ul><ul><li>Recovery can be as long as 4 months </li></ul>
  70. 131. Ankle Sprains <ul><li>Inversion injury= injures lateral structures of ankle </li></ul><ul><li>MC mechanism of injury </li></ul><ul><li>MC ligament sprained= </li></ul><ul><ul><li>1. Anterior talofibular ligament (front) - tears first </li></ul></ul><ul><ul><li>2. Posterior talofibular ligament (back) - tears second </li></ul></ul><ul><ul><li>3. Calcaneofibular ligament (middle) - tears last </li></ul></ul><ul><li>Tx: </li></ul><ul><ul><li>Ice x 20min several x/day </li></ul></ul><ul><ul><li>Elevation </li></ul></ul><ul><ul><li>NSAIDS </li></ul></ul><ul><ul><li>WBAT c crutches prn </li></ul></ul><ul><ul><li>Early ROM </li></ul></ul><ul><ul><li>strengthening </li></ul></ul>
  71. 132. Ankle Sprains <ul><li>Eversion injury: sequence of structures ruptured </li></ul><ul><ul><li>1. avulsion of medial malleolus or deltoid ligament rupture </li></ul></ul><ul><ul><li>2. anterior inferior tibiofibular ligament </li></ul></ul><ul><ul><li>3. Interosseous membrane </li></ul></ul><ul><li>Tx: Depending on extent of injury </li></ul><ul><ul><li>May be tx’d conservatively as c inversion </li></ul></ul><ul><ul><li>May require internal fixation </li></ul></ul>
  72. 136. Medial Malleolar fracture <ul><li>Medial Malleolar inversion fracture: </li></ul><ul><ul><li>Must be accompanied by a lateral fracture or ligamentous rupture </li></ul></ul><ul><li>Medial Malleolar eversion fracture: </li></ul><ul><ul><li>Usually accompanied by a lateral malleolar fracture or tibiofibular ligament rupture </li></ul></ul><ul><li>Tx: </li></ul><ul><ul><li>Depends on extent of injury </li></ul></ul>
  73. 138. Lateral Malleolar Fracture <ul><li>Most common of the ankle fractures </li></ul><ul><li>Weber A: </li></ul><ul><ul><li>Fracture distal to the joint line </li></ul></ul><ul><ul><li>Tx: SLWC vs aircast vs running sneakers </li></ul></ul><ul><li>Weber B: </li></ul><ul><ul><li>Fracture @ joint line </li></ul></ul><ul><ul><li>Tx: SLC vs LLC vs internal fixation </li></ul></ul><ul><li>Weber C: </li></ul><ul><ul><li>Fracture above the joint line </li></ul></ul><ul><ul><li>Tx: internal fixation, SLC NWB x 6wks </li></ul></ul>
  74. 140. Bimalleolar Fracture <ul><li>Both medial and lateral disruption </li></ul><ul><li>Unstable fracture </li></ul><ul><li>Generally requires surgical intervention to restore normal joint kinematics </li></ul><ul><li>When deltoid ligament is ruptured in the setting of a lateral malleolar fracture, the ankle is exposed to the mechanical equivalent of a bimalleolar ankle fracture & should be operated on </li></ul>
  75. 141. Bimalleolar fracture
  76. 143. Trimalleolar Fracture <ul><li>Occurs when posterior injury to ankle includes avulsion of the tibial insertion of the posterior tibiofibular ligament </li></ul><ul><li>Tx: </li></ul><ul><ul><li>Usually surgical intervention </li></ul></ul>
  77. 145. Trimalleolar fx
  78. 147. Maisonneuve Fracture <ul><li>Fracture of the proximal fibula with syndesmosis rupture and associated medial malleolus fracture or deltoid ligament rupture </li></ul><ul><li>For all medial malleolar fx’s do additional xrays of knee to check for proximal fibular fx </li></ul><ul><li>Exam: </li></ul><ul><ul><li>+ tenderness medial ankle, proximal fibula, & interosseous membrane </li></ul></ul><ul><li>Xray: </li></ul><ul><ul><li>AP/lat/obliq ankle </li></ul></ul><ul><ul><li>AP/lat tibia fibula </li></ul></ul><ul><li>Tx: </li></ul><ul><ul><li>Syndesmotic screw fixation </li></ul></ul>
  79. 148. Maisonneuve Fracture
  80. 149. Tibial Pilon Fracture <ul><li>Mechanism of injury: </li></ul><ul><ul><li>Produced primarily by rotational force </li></ul></ul><ul><ul><li>“ explosion fracture” produced by axial loading </li></ul></ul><ul><li>Type I: </li></ul><ul><ul><li>intraarticular through the tibial plafond without significant displacement of articular surface </li></ul></ul><ul><li>Type II: </li></ul><ul><ul><li>incongruity of articular surface without a great deal of comminution </li></ul></ul><ul><li>Type III: </li></ul><ul><ul><li>demonstrates incongruity as well as displacement of multiple small fracture fragments involving the metaphysis of the distal tibia </li></ul></ul>
  81. 150. Tibial Pilon Fractures <ul><li>XR: </li></ul><ul><ul><li>AP/lat/obliq distal tibia (ankle) </li></ul></ul><ul><li>Accurate classification requires CT scan </li></ul><ul><li>Complications range as high as 54% in some series </li></ul><ul><li>Most complications, such as infections & wound breakdown, relate to soft tissues </li></ul><ul><li>Tx: </li></ul><ul><ul><li>ORIF </li></ul></ul><ul><ul><li>External fixation or a combination of both </li></ul></ul>
  82. 153. Achilles Tendinitis <ul><li>Pain at achilles tendon, increased by running decreased by rest </li></ul><ul><li>Pain is often worse following activity, rather than during </li></ul><ul><li>Often palpable thickening over tendon or peritendinous tissues </li></ul><ul><li>Tx: </li></ul><ul><ul><li>1. decrease running activities, small heel lift, NSAIDS, ice after activity, achilles tendon stretching </li></ul></ul><ul><ul><li>2. SLWC x 10 days, then repeat above tx </li></ul></ul><ul><ul><li>3. occasionally surgical debridement or achilles tendon lengthening </li></ul></ul>
  83. 154. Achilles Tendon Rupture <ul><li>Occurs most commonly at narrowest portion of tendon approx. 2 inches superior to point of attachment to calcaneus </li></ul><ul><li>Mechanisms of injury: </li></ul><ul><ul><li>1. extra stretch applied to taut tendon </li></ul></ul><ul><ul><li>2. forceful dorsiflexion with ankle in relaxed state </li></ul></ul><ul><ul><li>3. direct trauma to taut tendon </li></ul></ul>
  84. 155. Achilles Tendon Rupture <ul><li>C/O acute pain in lower calf & difficulty ambulating </li></ul><ul><li>+/- palpable defect or mass in post. calf </li></ul><ul><li>+ Thompson test </li></ul><ul><ul><li>squeeze calf, foot should plantarflex, if no plantarflexion then achilles tendon is out </li></ul></ul><ul><li>Tx: </li></ul><ul><ul><li>1. surgical repair </li></ul></ul><ul><ul><li>2. equinus walking boot x 8 wks followed by 2.5 cm heel for another 4 weeks </li></ul></ul>
  85. 157. Foot <ul><li>Bones of the foot: </li></ul><ul><ul><li>7 tarsals </li></ul></ul><ul><ul><ul><li>Talus </li></ul></ul></ul><ul><ul><ul><li>Calcaneus </li></ul></ul></ul><ul><ul><ul><li>Navicular </li></ul></ul></ul><ul><ul><ul><li>Medial Cuneiform </li></ul></ul></ul><ul><ul><ul><li>Intermediate Cuneiform </li></ul></ul></ul><ul><ul><ul><li>Lateral Cuneiform </li></ul></ul></ul><ul><ul><ul><li>Cuboid </li></ul></ul></ul><ul><ul><li>5 metatarsals </li></ul></ul><ul><ul><ul><li>“ rays of the foot” </li></ul></ul></ul><ul><ul><li>14 phalanges </li></ul></ul>
  86. 163. Plantar Fasciitis <ul><li>Plantar fasciitis is the #1 most common foot problem. </li></ul><ul><li>It is caused by activity, overuse and aging. </li></ul><ul><li>Plantar fasciitis is an inflammation due to repeated overstretching of the plantar fascia ligament (fat pad of the foot), usually at the point where the fascia is attached to the calcaneus. </li></ul><ul><li>Pain is most severe in the morning and stepping down onto foot, decreases as day goes on </li></ul>
  87. 164. Plantar Fasciitis <ul><li>Contributing factors are: </li></ul><ul><ul><li>flat (pronated feet) </li></ul></ul><ul><ul><li>high arches (supinated feet) </li></ul></ul><ul><ul><li>increasing age </li></ul></ul><ul><ul><li>sudden weight increase </li></ul></ul><ul><ul><li>sudden increase in activity level </li></ul></ul><ul><ul><li>running in sand </li></ul></ul><ul><ul><li>hereditary factors </li></ul></ul><ul><li>Xray: May reveal bony spur at same site </li></ul><ul><li>Tx: </li></ul><ul><ul><li>Achilles stretching </li></ul></ul><ul><ul><li>Ice massage </li></ul></ul><ul><ul><li>Rest from activities </li></ul></ul><ul><ul><li>NSAIDS </li></ul></ul><ul><ul><li>Shock absorbing heel cups </li></ul></ul><ul><ul><li>Ankle orthosis (AFO) for recalcitrant cases </li></ul></ul><ul><ul><li>Avoid cortisone injections </li></ul></ul>
  88. 166. Hammer Toe Deformity <ul><li>Plantar flexion deformity of the PIP joint which is either flexible or rigid </li></ul><ul><li>The deformity is usually accompanied by a flexion deformity of the DIP joint, but an extension deformity is occasionally observed </li></ul><ul><li>Tx: </li></ul><ul><ul><li>Shoewear with wide toe box, toe trainers </li></ul></ul><ul><li>Surgery: </li></ul><ul><ul><li>A. flexor tendon transfer from plantar aspect of toe to extensor hood </li></ul></ul><ul><ul><li>B. resection of head of proximal phalanx, K-wire fixation </li></ul></ul>
  89. 168. Hallux Valgus <ul><li>Most common deformity of the foot </li></ul><ul><li>Results in excessive valgus angulation of the big toe </li></ul><ul><li>Splaying of the forefoot with varus angulation of the first metatarsal predisposes </li></ul><ul><li>The anatomical deformity consists of: </li></ul><ul><ul><li>Increased forefoot width </li></ul></ul><ul><ul><li>Lateral deviation of the hallux </li></ul></ul><ul><ul><li>Prominence of the first metatarsal head </li></ul></ul><ul><li>Clinical features </li></ul><ul><ul><li>More common in women </li></ul></ul><ul><ul><li>Often bilateral </li></ul></ul><ul><li>Symptoms result from </li></ul><ul><ul><li>A bursa over metatarsal head = bunion </li></ul></ul><ul><ul><li>Osteoarthritis of the first MTPJ </li></ul></ul>
  90. 169. Hallux Valgus <ul><li>Xray: </li></ul><ul><ul><li>Bilateral weight bearing AP/ lateral/ oblique foot </li></ul></ul><ul><li>Initial Tx: </li></ul><ul><ul><li>Shoewear education/ modification (sneakers) </li></ul></ul><ul><li>Surgical Tx: </li></ul><ul><ul><li>Distal metatarsal osteotomy +/- internal fixation for mild deformity </li></ul></ul><ul><ul><li>1 st tarsal metatarsal arthodesis (fusion) for hypermobile 1 st ray </li></ul></ul>
  91. 171. Lisfranc Injury <ul><li>There is no ligament b/t the base of the 1 st & 2 nd metatarsal. </li></ul><ul><li>The 2 nd metatarsal is attached obliquely to the medial cuneiform by an interosseous ligament termed Lisfranc’s ligament </li></ul><ul><li>Exam: </li></ul><ul><ul><li>+ tenderness at lisfranc joint </li></ul></ul><ul><ul><li>+ swelling dorsally </li></ul></ul><ul><li>Xray: </li></ul><ul><ul><li>AP/ lateral/ oblique foot (weight bearing when possible): </li></ul></ul><ul><ul><li>May reveal widening at joint </li></ul></ul><ul><li>Tx: </li></ul><ul><ul><li>Reduced & treated with screw fixation </li></ul></ul><ul><ul><li>NWB x 6-8 wks </li></ul></ul>
  92. 172. <ul><li>Dorsal dislocation of the proximal base of the second metatarsal ( small arrow ) when the foot is placed in extreme plantar flexion with an axial load ( large arrow ). This dislocation occurs because the base of the second metatarsal extends beyond the horizontal axis. </li></ul>
  93. 176. Lisfranc
  94. 177. Jones Fracture <ul><li>Transverse fracture of the 5 th metatarsal at the junction of the proximal metaphysis & diaphysis </li></ul><ul><li>PE: </li></ul><ul><ul><li>+ tenderness lateral aspect of foot </li></ul></ul><ul><ul><li>+ swelling </li></ul></ul><ul><ul><li>+/- ecchymosis </li></ul></ul><ul><li>Xray: </li></ul><ul><ul><li>AP/ lat/ obliq </li></ul></ul><ul><li>Tx: </li></ul><ul><ul><li>Short leg cast (SLC) </li></ul></ul><ul><ul><li>Non-wt bearing (NWB) x 6wks </li></ul></ul><ul><li>Frequently fail to heal when treated non-operatively, especially in smokers </li></ul><ul><li>Surg: </li></ul><ul><ul><li>ORIF </li></ul></ul>
  95. 179. Jones fx
  96. 180. Avulsion Fracture of the base of the 5 th Metatarsal <ul><li>Pseudo-Jones fx/ dancer fx/ tennis fx </li></ul><ul><li>Occurs when the insertion of the peroneus brevis is avulsed during forced inversion of the forefoot </li></ul><ul><li>Exam: </li></ul><ul><ul><li>+ tenderness </li></ul></ul><ul><ul><li>+ swelling at base of 5 th metatarsal </li></ul></ul><ul><ul><li>+/- ecchymosis </li></ul></ul><ul><li>Xray: </li></ul><ul><ul><li>AP/lat/obliq </li></ul></ul><ul><li>Tx: </li></ul><ul><ul><li>Short leg walking cast (SLWC) x 6 wks </li></ul></ul>
  97. 181. Pseudo-Jones Fracture Dancer Fracture Tennis Fracture Avulsion Fracture
  98. 182. Pseudo-Jones Fracture
  99. 183. Comminuted Fracture of proximal and/ or distal phalanx of great toe <ul><li>Xray: </li></ul><ul><ul><li>AP/lat/obliq </li></ul></ul><ul><li>Tx: </li></ul><ul><ul><li>Splint </li></ul></ul><ul><ul><li>Hard sole shoe </li></ul></ul><ul><ul><li>Ice </li></ul></ul>
  100. 184. Fractures of phalanges of lesser toes <ul><li>Xray: </li></ul><ul><ul><li>AP/lat/obliq </li></ul></ul><ul><li>Tx: </li></ul><ul><ul><li>Buddy tape </li></ul></ul><ul><ul><li>Ice </li></ul></ul><ul><ul><li>NSAIDS </li></ul></ul>
  101. 185. March Fracture <ul><li>Stress fracture usually of the middle of the shaft of the 3 rd metatarsal (or 4 th ) </li></ul><ul><li>History of having gone on long walk/march with no clear h/o trauma </li></ul><ul><li>Also seen in females with eating/exercising disorders </li></ul><ul><li>Exam: </li></ul><ul><ul><li>+ tenderness midshaft of the involved metatarsal </li></ul></ul><ul><ul><li>Pain with increased flexion or extension of toes </li></ul></ul><ul><ul><li>Pain subsides with rest </li></ul></ul>
  102. 186. March Fracture <ul><li>Initial Xray: </li></ul><ul><ul><li>AP/lat/obliq weight bearing foot will be negative </li></ul></ul><ul><li>Follow up Xray: </li></ul><ul><ul><li>In 2 wks will show callus formation </li></ul></ul><ul><li>Tx: </li></ul><ul><ul><li>Symptomatically with crutches or if patient’s occupation requires prolonged standing or ambulation </li></ul></ul><ul><ul><li>SLWC x 3-4 wks </li></ul></ul>
  103. 187. Stress fx
  104. 188. Metatarsal Fracture <ul><li>Class A: </li></ul><ul><ul><li>Neck Fractures---  </li></ul></ul><ul><li>Class B: </li></ul><ul><ul><li>Shaft fractures---------------------  </li></ul></ul><ul><li>Class C: </li></ul><ul><ul><li>Proximal 5 th metatarsal fracture (Jones) </li></ul></ul>
  105. 189. Calcaneus Fractures <ul><li>May be intraarticular or extraarticular </li></ul><ul><li>h/o fall or twisting injury & pain localized to hindfoot </li></ul><ul><li>Xray: </li></ul><ul><ul><li>AP/lat/obliq/ axial heel/ Broden’s view (lateral xray with foot passively dorsiflexed/ supinated & internally rotated) </li></ul></ul><ul><ul><li>Also should have CT scan of heel to see extent of injury </li></ul></ul><ul><ul><li>Include L/S spine due to associated injuries </li></ul></ul><ul><li>Initial management: </li></ul><ul><ul><li>Splint </li></ul></ul><ul><ul><li>Ice </li></ul></ul><ul><ul><li>Elevation </li></ul></ul>
  106. 190. Calcaneus Fracture <ul><li>Tx: </li></ul><ul><ul><li>Non-displaced intraarticular fx= NWB 4-6 wks </li></ul></ul><ul><ul><li>Displaced intraarticular fx= ORIF, NWB x 6-8 wks, early motion </li></ul></ul><ul><ul><li>Minimally displaced tuberosity fracture= NWB 3-6 wks </li></ul></ul><ul><ul><li>Displaced tuberosity fx= internal fixation, NWB 4-6wks </li></ul></ul><ul><ul><li>Sustentaculum tali= SLWC x 4-6 wks </li></ul></ul><ul><ul><li>Non-displaced anterior process fx= SLWC x 4-6 wks </li></ul></ul><ul><ul><li>Displaced anterior process fx = ORIF </li></ul></ul>
  107. 194. Clubfoot <ul><li>High arched foot that may have a crease across the sole of the foot. </li></ul><ul><li>The heel inversion (varus) c internal rotation </li></ul><ul><li>Forefoot inverted and adducted (soles face each other) </li></ul><ul><li>Plantar flexion c inabiliity to dorsiflex </li></ul><ul><li>Leg internal rotation </li></ul>
  108. 196. Angular limb deformities <ul><li>Bowlegs (Genu Varum) and Knock knees (Genu Valgum) are a common cause of orthopedic consultation. </li></ul><ul><li>For most children, these conditions represent the spectrum of normal development. </li></ul><ul><li>Pathologic cases of bowlegs and knock knees are uncommon (Rickets). </li></ul>
  109. 198. Flat feet (pes planus) <ul><li>another common skeletal variation. </li></ul><ul><ul><li>The most common type is the hyper-mobile or flexible flat foot. </li></ul></ul><ul><ul><ul><li>The longitudinal arch of the foot is absent or flat in stance, but reconstitutes when the foot is non-weight bearing. </li></ul></ul></ul><ul><li>Most flat feet are asymptomatic. </li></ul><ul><li>A flat foot associated with a tight heel cord may be caused by muscular dystrophy or cerebral palsy. </li></ul>
  110. 200. Limp <ul><li>Common etiologies across the age spectrum are </li></ul><ul><ul><li>Limb length inequalities </li></ul></ul><ul><ul><li>Infections: septic arthritis, osteomyelitis. </li></ul></ul><ul><ul><li>Non-infectious causes: transient synovitis,JRA, trauma, child abuse, DDH, LCPD, SCFE. </li></ul></ul><ul><ul><li>Neoplasia: leukemia, primary bone tumor, metastatic disease. </li></ul></ul>
  111. 202. 'Excellence is an art won by training and habituation. We do not act rightly because we have virtue or excellence, but rather we have those because we have acted rightly. We are what we repeatedly do. Excellence, then, is not an act but a habit.' Aristoteles <ul><li>A journey of a thousand miles begins with a single step. </li></ul><ul><li>Lao Tsu </li></ul><ul><li>“ I find that the harder I work, the more luck I seem to have”. </li></ul><ul><li>  Thomas Jefferson </li></ul><ul><li>Self conquest is the greatest of victories. </li></ul><ul><li>Plato </li></ul><ul><li>“ Imagination is everything. It is the preview of life’s coming attractions.” </li></ul><ul><li>Albert Einstein </li></ul>
  112. 203. Nothing great was ever achieved without enthusiasm. Ralph Waldo Emerson <ul><li>“ If a man empties his purse into his head, no man can take it away from him. An investment in knowledge always pays the best interest” Benjamin Franklin </li></ul><ul><li>“ I will persist until I succeed”. Og Mandino </li></ul><ul><li>&quot;Whatever your mind can conceive and believe it can achieve.&quot; </li></ul><ul><li>Napoleon Hill </li></ul>
  113. 205. GOOD LUCK IN THE EXAMEN !!! <ul><li>ENJOY YOUR VACATION TIME </li></ul><ul><li>WISELY </li></ul><ul><li>AND </li></ul><ul><li>SAFETLY </li></ul><ul><li>Ciao, ci vediamo!!! </li></ul>
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