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PubMed1990

Soft-tissue infection in lower-extremity trauma.

Soft-tissue infection after lower-extremity trauma has not been studied in detail in light of recent data on the biology of infection. This article examines specific problems in lower-extremity trauma that allow the wound to become susceptible to wound infection. It also illustrates the various principles of wound management in lower-extremity trauma that serve to prevent infection. Two case examples are used to illustrate principles of management. Other wound problems in lower-extremity trauma are also discussed, such as rabies, necrotizing soft-tissue infection, tetanus, and diabetic foot infections.

Adult↗
PubMed2002

Predictors of lower extremity injury among recreationally active adults.

OBJECTIVE: To identify gender-specific predictors of lower extremity injury among a sample of adults engaging in running, walking, or jogging (RWJ) for exercise. DESIGN: Prospective cohort study. SETTING: Cooper Clinic Preventive Medicine Center, Dallas, Texas. PARTICIPANTS: Participants were 2,481 men and 609 women who underwent a physical examination between 1970 and 1981 and returned a follow-up survey in 1986. Predictor variables measured at baseline included height, weight, and cardiorespiratory fitness. At follow-up, participants recalled information about musculoskeletal injuries, physical activity levels, and other predictors for lower extremity injury over two time periods, 5 years and 12 months. MAIN OUTCOME MEASURES: An injury was defined as any self-reported lower extremity injury that required a consultation with a physician. Cox proportional hazards regression (HR) was used to predict the probability of lower extremity injury for the 5-year recall period, and unconditional logistic regression was used for the 12-month recall period. RESULTS: Among men, previous lower extremity injury was the strongest predictor of lower extremity injury (HR = 1.93-2.09), regardless of recall period. Among women, RWJ mileage >20 miles/wk was the strongest predictor for the 5-year period (HR = 2.08), and previous lower extremity injury was the strongest predictor for the 12-month period (HR = 2.81). CONCLUSIONS: For healthy adults, walking at a brisk pace for 10-20 miles per week accumulates adequate moderate-intensity physical activity to meet national recommendations while minimizing the risk for musculoskeletal lower extremity injury. Clinicians may use this information to provide appropriate injury prevention counseling to their active patients.

Adult↗
PubMedDate not supplied

Protocol for lower extremity trauma.

Trauma to the lower extremity has been treated in the past by many specialties and subspecialties of medicine. No specialty, however, should be better qualified or trained in treating lower extremity trauma than the podiatrist. This study reviews some critical principles of acute trauma management and treatment. A simple algorithm is suggested. Three representative case studies are presented, demonstrating the importance and value of an established protocol.

Adult↗
PubMed1991

Soft-tissue expansion in lower extremity reconstruction.

Soft-tissue expansion in the lower extremities is typically well tolerated. The more proximal one is--that is, the closer to the thigh and buttocks--the easier and less complication prone the expansion will be. It is another valuable technique for resurfacing the lower extremity and for reconstructing defects in contour and in skin character. There are limitations to this technique, which generally is most useful in late reconstructions. Intraoperative expansion has no place in lower extremity reconstruction. Soft-tissue expansion may be limited by an unsuitable geometry or the sheer size of defects. It should not be used next to open wounds. Soft-tissue expansion offers significant advantage in that the coverage of a defect will be replaced with tissue like that lost. Seldom does one see necrosis of advanced flaps, so that there is little risk of tissue loss in using this modality. There is an excellent vascularity to the flaps and an excellent character to the skin. In addition, in this cost-conscious era, soft-tissue expansion is quite cost effective, and in many cases the procedures can be conducted on an outpatient basis with a minimum of hospitalization, if any. With care to select patients properly, design carefully, and conduct expansion in a leisurely fashion, soft-tissue expansion offers a valuable means of reconstructing both large and small lower extremity defects.

Adult↗
PubMed1983

Myofascial origins of low back pain. 3. Pelvic and lower extremity muscles.

Gluteal, pelvic, and lower extremity muscles are common sites of origin of myofascial low back pain. Trigger points (TPs) in the gluteus maximus and medius muscles refer pain locally to the gluteal and sacral regions, while those in the gluteus minimus are likely to refer pain down the lower extremity as far as the ankle on the same side. TPs in intrapelvic muscles refer pain chiefly to the pelvic region. Besides producing referred myofascial pain, TPs in the piriformis muscle can cause symptoms of entrapment of the peroneal portion or all of the sciatic nerve. TPs in the soleus muscle may refer pain to the sacroiliac joint.

Buttocks↗
PubMed2001

Open surgical repair versus endovascular therapy for chronic lower-extremity occlusive disease.

Chronic lower-extremity occlusive disease is most often manifested by mild symptoms of claudication that can be managed conservatively. When conservative therapy fails, endovascular procedures may be effective, particularly if the disease extent is minimal. Surgery may be considered for selected patients with claudication who fail endovascular therapy or are not candidates for it. Patients with more severe symptoms of lower-extremity occlusive disease typically have more extensive disease that is treated best with surgery or with a combination of surgery and endovascular therapy. Occasionally, endovascular procedures are performed on patients with more extensive disease who are poor candidates for traditional open surgery because of severe comorbidity. Further advances in endovascular technology may improve patency after endovascular procedures in these patients.

Angioplasty, Balloon↗
PubMed1989

Office evaluation and treatment of lower extremity injuries in the runner.

Lower extremity problems in the runner are common and often perplexing. Although many problems such as acute tendinitis and mild sprains can be treated with short periods of rest and nonsteroidal anti-inflammatory drugs, some will be chronic or recurrent in nature. These persistent problems can cause even a serious runner to reduce his activity greatly or even give up the sport entirely. Chronic recurring ailments should be examined carefully with a high suspicion of a biomechanical imbalance in the foot or lower extremity. With a basic understanding of the biomechanics of the foot and ankle and the stresses incurred during running, most of the problems can be managed conservatively.

Athletic Injuries↗
PubMed1986

Acute management of severe soft-tissue damage accompanying open fractures of the lower extremity.

Open fractures of the lower extremity accompanied by extensive soft-tissue damage can be effectively managed by a collaborative approach between orthopedic and plastic surgeons. The fundamental concepts of this aggressive, systematic approach are adequate debridement and soft-tissue healing by delayed primary intention. The protocol that has evolved at the MIEMSS Shock Trauma Unit involves emergency radical debridement of all devitalized soft tissue and bone fragments together with external stabilization of the fractured extremity. The zone of injury, which is often not apparent at presentation, is determined by serial debridements performed in the operating room over several days. When the wound is defined, soft-tissue closure is obtained with local or free muscle transfer. In very high energy-induced trauma, local muscle flaps are often involved in the zone of injury or are inadequate to cover the resultant defects. Free muscle transfers that provide large amounts of undamaged, well-vascularized tissue are therefore the reconstructive alternative of choice for such injuries. Bone defects are bridged 4 to 6 weeks after soft-tissue closure with cancellous or vascularized fibula grafts depending on defect size. This regimen, which has virtually eliminated the problem of infection, has been successful in salvaging and rehabilitating these severely injured lower extremities.

Accidents, Traffic↗
PubMed2005

Peripheral nerve blocks for perioperative management of patients having orthopedic surgery or trauma of the lower extremity.

Over the past decade several developments have lead to an increased interest in lower extremity PNBs including transient neurologic symptoms associated with spinal anesthesia, increased risk of epidural hematoma with the introduction of new antithromboembolic prophylaxis regimens, and evidence of improved rehabilitation outcome with continuous lower extremity PNBs. Simultaneously, the field of lower extremity blockade has been revolutionized through our better understanding of functional regional anesthesia anatomy, introduction of new drugs, better and more sophisticated equipment and wider teaching of lower extremity nerve block techniques. This review focuses on techniques and applications of lower extremity nerve blocks in patients having orthopedic surgery or trauma of the lower extremity, as well as potential complications and means to avoid them.

Anesthetics, Local↗
PubMedDate not supplied

Radiographic characteristics of lower-extremity bowing in children.

Lower-extremity bowing is common in infants and children and can result from a variety of conditions. At radiography, developmental bowing shows varus angulation centered at the knee, "metaphyseal beaking," thickening of the medial tibial cortices, and tilted ankle joints. Tibia vara (Blount disease) demonstrates genu varum and depression of the proximal tibia medially. Congenital bowing manifests as posteromedial bowing with cortical thickening along the concavity of the curvature and, in some cases, diaphyseal broadening. In rickets, radiographic changes occur primarily at sites of rapid growth and are predominantly metaphyseal, with widening of the zone of provisional calcification. Achondroplasia is characterized by shortening and thickening of the long bones with metaphyseal flaring and cupping. In neurofibromatosis, there may be anterolateral bowing of the tibia, and there is often focal narrowing and intramedullary sclerosis or cystic change at the apex of the angulation. The tibia is typically involved at the junction of the middle and distal thirds. Osteogenesis imperfecta demonstrates bowing from softening due to osteoporosis and multiple fractures and typically involves the entire skeleton. In camptomelic dysplasia, lower-extremity bowing is associated with a short trunk, short limbs, and deficiencies in pelvic bone development. Recognition of these pathologic conditions is important for differentiating those that will resolve spontaneously from those that require surgery or other treatment.

Abnormalities, Multiple↗
PubMed2006

Correlates of decline in lower extremity performance in older women: A 10-year follow-up study.

BACKGROUND: Decline in lower extremity performance increases the risk of functional disability. This study examined the correlates of decline in lower extremity performance in older women. METHODS: A total of 5178 women aged 65-91 years were recruited from population-based listings from four centers in the United States. Clinical examinations were performed and lifestyle information was obtained at baseline and 10 years later. Lower extremity performance was measured by walking speed (meters/second) and time (seconds) to complete five chair-stands. Changes were calculated by subtracting baseline values from follow-up values. RESULTS: During the 10-year follow-up period, walking speed declined 17% and time to complete five chair-stands increased 22% (p < .0001). The decline in performance during the follow-up increased with baseline age: women aged 65-69 years experienced an 11% decline in walking speed and a 16% increase in the time to complete five chair-stands, while women aged 80 years or older experienced a 37% decline in walking speed and a 38% increase in chair-stand time. After adjusting for age, baseline physical performance, greater weight, greater height loss, smoking, history of arthritis and diabetes, and use of thyroid and estrogen medications were independently related to greater declines in lower extremity performance. CONCLUSIONS: Lower extremity performance decreased dramatically with advancing age in older women. Effective management of common diseases, such as arthritis and diabetes, and a healthy lifestyle, including avoidance of smoking and weight control, could help older women maintain their lower extremity physical functions.

Aged↗
PubMed1993

Lower extremity revascularization.

Atherosclerotic occlusive disease of the lower extremity in patients exhibiting severe rest pain, ulceration, or tissue necrosis represents a serious threat to extremities. In the past two decades the surgical approach in the treatment of lower extremity ischemia has changed significantly due to better understanding of segmental disease and infrapopliteal disease. Also, better visualization of leg and foot arteries due to improved angiographic and surgical techniques aided by magnification have all significantly contributed to increased limb salvage. Vein, when available, is the ideal graft material both for supra and infrapopliteal reconstruction. Availability of vein as a conduit can be increased when ectopic veins such as cephalic etc., are used and also when short segments of veins are used with unconventional distal inflow sites such as SFA, distal deep femoral artery, and popliteal artery. However, when vein is unavailable, PTFE graft is a good option particularly in patients with life expectancy of less than three years. Better understanding of graft failure has lead to better graft surveillance with PVR, ABI and Duplex scanning. Timely intervention with either PTA or surgery has lead to better secondary patency of grafts. Veith et al. looked at amputation rates during the period of changing therapeutic approach and found both a decrease in primary and secondary amputation rate implying the effectiveness of an aggressive therapeutic approach. Not all aspects of lower extremity disease are understood. However, infrapopliteal disease has now been addressed and new, innovative therapeutic approaches have made significant advances in limb salvage.

Amputation, Surgical↗
PubMed1983

Combined free flap and local muscle flap for lower extremity salvage.

Reconstruction of extensive compound lower-extremity injuries may require the use of local flaps or free-tissue transfer. When either method alone is inadequate for reconstruction of two isolated defects on the same lower extremity, a combined approach may be utilized to reconstruct a functional lower extremity.

Adult↗
PubMed2006

Surgical procedures and lymphedema of the upper and lower extremity.

BACKGROUND: Lymphedema occurs in the upper and lower extremity, in a minority of patients, following axillary and groin dissections, respectively. Several technical operative factors have been implicated through the years whose relative significance remains unknown. METHODS: Retrospective review of the author's personal experience with axillary and groin dissections and review of the articles and results written on the author's series of patients. The results, specifically lymphedema, are reported in relation to components of each surgical procedure and the presence or absence of additional surgical procedures, e.g., wide excision of the primary site when performed in the distal leg. RESULTS: In the axilla, skeletonization of the axillary vein, dissection up to and including Level III nodes, removal of the fat and nodes above the level of the axillary vein (exposing the brachial plexus), removal of pectoralis minor and all the axillary fat, exposing thus serratus anterior, latissimus dorsi and subscapularis are all technical components which do not cause lymphedema. It seems excessively thin flaps in axillary dissections may be the most likely cause for upper extremity lymphedema. The incidence of upper extremity lymphedema, in our experience, after axillary dissection is low (2%). For the lower extremity, skeletonization of the femoral and iliac vessels, in continuity dissection of the femoral and deep nodes (iliac and obturator), do not cause in themselves lymphedema (which occurs in 30% of the patients). The incidence of lymphedema increases with making thin flaps, with wide resection of a primary melanoma below the knee, postoperative incidence of cellulites, failure to follow a prophylactic regimen of leg elevation and compression stockings, and obesity. CONCLUSIONS: Lymphedema in the upper and lower extremity may be caused by making thin flaps during node dissection, the additional wide excision of primary sites in the distal half of the extremity, postoperative cellulitis, and failure to follow an antilymphedema regimen.

Axilla↗
PubMed1998

Carotid and lower extremity arterial disease in patients with renal artery atherosclerosis.

BACKGROUND: Atherosclerotic lesions of the carotid and lower extremity arteries may be associated with renal artery stenosis and influence the management of patients with renal artery disease. OBJECTIVE: To document the prevalence and clinical features of carotid and lower extremity arterial disease in patients with renal artery atherosclerosis. METHODS: An analysis of baseline data on 149 patients enrolled in a prospective natural history study of atherosclerotic renal artery stenosis. Patients with at least 1 abnormal renal artery by duplex scanning were eligible. Carotid artery disease was evaluated by duplex scanning, and ankle/brachial indices were used to assess the lower extremity arteries. Disease at each of the 3 arterial sites was classified as mild, moderate, or severe based on the extent of involvement on both sides. Serum urea nitrogen, creatinine, and lipid levels were also measured. RESULTS: Severe renal, carotid, or lower extremity arterial disease was present in 44%, 19%, and 21% of the patients, respectively. There was a trend for patients with increasing degrees of renal artery disease to have increasing degrees of carotid and lower extremity arterial disease. The prevalence of severe carotid artery disease increased from 7% in the mild renal artery group to 28% in the severe renal artery group. Clinical factors that were most predictive of severe disease were elevated apolipoprotein B levels for the renal arteries, high serum urea nitrogen or creatinine levels for the carotid arteries, and smoking for the lower extremity arteries. CONCLUSIONS: There was a strong association between severe renal artery atherosclerosis and severe carotid artery disease. Patients with renal artery disease also had a high prevalence of lower extremity arterial disease. In this patient population, screening for lower extremity arterial disease can be reserved for those with signs or symptoms of peripheral ischemia. Noninvasive carotid screening is justified in patients with renal artery disease to detect asymptomatic lesions that require either immediate surgical treatment or serial follow-up for disease progression.

Aged↗
PubMed2004

Predictors of lower extremity injuries at the community level of Australian football.

OBJECTIVE: To identify risk factors for general lower extremity injury at the community level of Australian football. DESIGN: Prospective cohort study. SETTING: Community-level Australian football. PARTICIPANTS: One hundred twenty-six adult players from 4 community-level Australian football clubs. METHODS: During the 2000 preseason period, all participants underwent a baseline assessment involving a self-report questionnaire and a battery of musculoskeletal screening tests to collect information about potential risk factors for lower extremity injury. Over the course of the season, injury surveillance and exposure data collection were undertaken at each club. MAIN OUTCOME MEASURE: A lower extremity injury, resulting in missed participation and/or treatment from a health professional, as the first injury during the season. RESULTS: For 59 players, a lower extremity injury was the first injury sustained during the season. Only ankle dorsiflexion range of movement, measured using the weightbearing lunge test, was significantly associated with sustaining a lower extremity injury through univariate analyses. Using survival analyses, and after adjusting for exposure, age, frequency of weight training participation, and the past injury status of players were identified as independent, but not significant, predictors of time to sustaining a lower extremity injury. CONCLUSIONS: Despite the large number of potential risk factors studied and the high incidence of lower extremity injuries in the cohort, a definitive individual injury risk profile for all lower extremity injuries was not identified, potentially due to the heterogeneity of the outcome of interest. Further research should focus on the identification of risk factors for the most common and costly individual injuries in Australian football.

Adult↗
PubMed1985

Neutrophil delivery to wounds of the upper and lower extremities.

Clinical observations and experimental evidence indicate that wounds of the lower extremity are more susceptible to infection than are wounds located elsewhere on the body. The details of this regional relative immunoincompetence are not described. In this initial study of regional inflammatory response, neutrophil delivery to standard wounds of the upper and lower extremities was measured in 15 human volunteer subjects using a quantitative skin-window technique. Neutrophil delivery proved to be relatively deficient in the lower extremity. Neutrophil delivery (mean +/- SEM) was significantly lower to the lower-extremity wounds (5,890 +/- 590 cells per cubic millimeter) than to the upper-extremity wounds (16,600 +/- 1,680 cells per cubic millimeter). This lower neutrophil response may be a part of the lower extremity's increased susceptibility to infection. Further functional study of regionally collected neutrophils may provide more details of differences in regional inflammatory response. The mechanisms underlying these differences remain undescribed.

Adult↗