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Musculoskeletal 2 > Knee - Fx, Dislocation, Patellorfemoral Joint > Flashcards

Knee - Fx, Dislocation, Patellorfemoral Joint Flashcards

1
Q

Meniscus

- describe

A
  • semi-lunar cartilage
  • fibrocartilagenous disks
  • aid in shock absorption and load distribution in knee during motion
  • articulate with tibia
  • concave in shape, thin to free medial edge
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2
Q

Meniscal injuries

- common cause

A
  • combo of loading/shearing force on meniscus during rotation
  • Mostly in young/healthy patient
  • may be chronic
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3
Q

Meniscal injury in elderly often dt what

A

often atraumatic

- as simple as rising from seated position or stooping over to reach something on low shelf

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4
Q

Three zones of meniscal injury and description

A
  1. Red/Red: outer 1/3, plentiful blood supply from capsular margin of meniscus
  2. Red/White: middle 1/3, diminished vasculature, less capacity to heal
  3. White/white: completely avascular inner 1/3 (won’t heal)
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5
Q

Why is it important to know the meniscal zones?

A
  • location dictates treatment
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6
Q

where are the majority of symptomatic meniscal tears?

A

inner 2/3 - where low/no capacity to heal

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7
Q

Meniscal tear presentation

A
  • catching, locking, popping sensations
  • one-sided knee pain (all medial or all lateral)
  • effusion over 12-24 hours (slower than ACL/PCL)
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8
Q

Classic meniscal tear case

A

twisting injury playing basketball, small amt swelling the next day, now pain on stairs and catching sensation

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9
Q

Meniscal tear

- PE

A
  • impingement causes pain at terminal ends of motion (flexion and extension)
  • medial/lateral joint line pain at 90 degrees flexion
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10
Q

Meniscal tear

- special tests

A
  • Apley’s (compression or distraction)
  • McMurray’s (GS)
  • Deep Squat/Duck walk: if can perform, unlikely have tear
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11
Q

What does McMurray’s actually test

A

compression with varus/valgus stress and terminal flexion/extension
**low sensitivity and specificity… difficult to reproduce pain…

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12
Q

Mensical tear

- imaging

A

XR

  • weight-bearing
  • AP and lateral minimum
  • Specialty: bilateral with notch view

MRI
- GS (second only to diagnostic arthroscopy)

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13
Q

Who is a candidate for meniscal tear conservative tx

A
  • Pt has well-tolerated sx
  • no deficit in PROM (no locking)
  • no medical co-morbiidities
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14
Q

Meniscal tear conservative treatment

A
  • RICE
  • oral NSAIDs
  • intra-articular steroid injection
  • activity modification
  • bracing not effective other than effusion control
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15
Q

Who is a candidate for surgical tx for meniscal tear

A
  • Sx affect ADL or athletics
  • bucket-handle tear that blocks ROM
  • lrg tear in repairable zone
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16
Q

Surgical tx of meniscal tear - three types

A
  • partial menisectomy
  • meniscal repair
  • trephination
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17
Q

Tibial plateau fracture

- describe

A
  • fx of tibial condyles just below joint line of knee

- generally above or includes tibial tubercle

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18
Q

Tibial plateau fracture

- locations

A
  • 60% lateral condyle
  • 15% medial condyle
  • 25% bicondylar
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19
Q

Tibial plateau fracture

- Exam

A
  • R/O compartment sx
  • evaluate ligaments for injury
  • test peroneal nerve function (foot drop)
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20
Q

Tibial plateau fracture

- Imaging

A

XR

  • AP and lateral min
  • oblique and bilateral comparison helpful
  • CT if intra-articular depression or comminution (3D reconstruction!)
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21
Q

Tibial plateau fracture non-operative management

  • describe fracture
  • describe
A
  • non-displaced or minimally displaced with stable knee on exam
  • immobilization brace
  • NWB
  • referral
  • early ROM
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22
Q

Tibial plateau fracture operative tx

- describe fracture

A
  • majority
  • displaced wedge
  • condylar widening
  • depression of articular surface **
  • gross comminution
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23
Q

Patella fracture

- MC dt what

A
  • majority: direct trauma to patella (fall or blow)

- also forceful contraction of quads, usually = avulsion fx of quad tendon or patellar tendon at distal patellar pole

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24
Q

Patella fracture

- presentation

A
  • severe anterior knee pain
  • knee held in full extension with little to no ROM
  • large effusion
  • ecchymosis and potentially low leg edema
  • usually unable to bear weight
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25
Q

Patella fracture

- imaging

A

XR

  • 3 view of knee (AP, lateral, oblique)
  • sunrise if possible
  • bilateral helpful
  • CT with 3D reconstruction if possible
  • MRI might be helpful if no CT/pt can remain still
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26
Q

Patellar fracture types

A

Direct trauma

  • comminution common
  • articular cartilage damage

Indirect trauma

  • less comminution
  • transverse fx
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27
Q

Displacement of patellar fractures

- 2 descriptions

A
  1. any incongruence of articular surface >2mm

2. greater than 3mm separation of fragments

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28
Q

Patellar fractures nonoperative treatment

  • when appropriate
  • tx options
A

If non-displaced and extensor mechanism is intact and can actively straight leg raise

  • aspirate tense hemarthrosis
  • knee immobilizer brace x 4-6 wks
  • slow, progressive ROM with PT after 4-6 weeks
  • quad strengthening
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29
Q

Patellar fractures operative treatment

- when appropriate

A
  • Extensor mechanism is disrupted
  • Displacement of transverse fx
  • displacement or comminution or articular step-off
  • compromised skin overlying patella dt trauma
30
Q

Knee dislocation

- what joint

A
  • tibia-femoral articulation NOT patello-femoral :)
31
Q

Knee dislocation

- how dangerous?

A
  • limb-threatening injury
  • time is of the essence!
  • laceration of popliteal artery/vein possible
    (not common)
32
Q

Knee dislocation

- extent of injury

A
  • generally multi-ligament injury d/t high E trauma
  • often both ACL and PCL
    • either MCL or LCL
33
Q

Patellar subluxation/dislocation

- describe

A

Traumatic subluxation/dislocation of patella out of femoral trochlea

34
Q

Patellar subluxation/dislocation

- what must happen for this to occur?

A

One of the stabilizing structures must fail:

  • medial patellofemoral ligament (MPFL)
  • medial retinaculum
  • chondral surfaces
35
Q

Patellar subluxation/dislocation

- common in what population

A
  • adolescents

- F>M (probably due to skinnier trochlear space, easier for patella to get out)

36
Q

Patellar subluxation/dislocation

- MC medial or lateral?

A

lateral!! unless crazy blunt trauma

37
Q

Patellar subluxation/dislocation

- what anatomic variances predispose

A
  • hypoplastic femoral trochlea
  • Patella alta
  • lateralized tibial tubercle
38
Q

Patellar subluxation/dislocation

- presentation of acute dislocation

A
  • gross deformity
  • empty trochlea
  • patella lateral
  • often in flexed knee position
39
Q

Patellar subluxation/dislocation

- presentation of subluxation or reduced dislocation

A
  • large effusion
  • medicalized knee pain
  • painful PROM
  • quad inhibition
40
Q

Patellar subluxation/dislocation

- reduction technique

A
  • pressure applied to patella in medial direction
  • knee brought passively into extension
  • reduce ASAP
41
Q

Patellar subluxation/dislocation

- special test

A
  • apprehension test: similar to shoulder
42
Q

Patellar subluxation/dislocation

- Imaging

A
  • AP and lateral XR w/comparison views

- Sunrise/Rosenburg is vital

43
Q

Patellar subluxation/dislocation

- Conservative tx requirements

A
  • no lateral tilt on sunrise
  • no lateralization on AP
  • no loose body
44
Q

Patellar subluxation/dislocation

- conservative tx

A
  • brace in full extension
  • WBAT on crutches
  • PT for quad strength after 4-6 weeks immobile
  • patellar stabilizer for activity
45
Q

Patellar subluxation/dislocation

- sx requirements

A
  • chronic
  • failed conservative
  • loose body on XR from MPFL avulsion
46
Q

Patellar tendon rupture

  • describe
  • MC population
A
  • failure of extensor mech d/t excessive loading and/or unhealthy soft tissue (+/- quadriceps tendon rupture)
  • middle-aged (rec basketball league player)
47
Q

Patellar tendon rupture classic case

A

48 yo male w/ acute pain and inability o perform straight-leg raise after jumping injury

48
Q

Patellar tendon rupture

- presentation

A
  • difficulty with full weight bearing and ambulation d/t loss of extensor mechanism
  • sig soft tissue edema and ecchymosis
49
Q

Patellar tendon rupture

- exam findings

A
  • Inability to perform straight leg raise

- palpable/visible defect in normally firm contour of quads or patellar tendon

50
Q

Patellar tendon rupture

- workup

A
  • AP and lateral XR - patellar misalignment
  • MRI: helpful if partial rupture
  • often a simple clinical dx
51
Q

Patellar tendon rupture

- tx

A
  • referral for sx consult

- require soft tissue repair to restore extensor mechanism

52
Q

Osgood-Schlatter’s Dz

- describe

A
  • Traction apophysis in the adolescent at the insertion of the patellar tendon onto the tibial tubercle
  • Tibial tubercle has its own ossification center, which maybe disrupted
  • D/t rapid change in height in osseous centers w/o compensatory lengthening in the extensor mechanism or overuse/over demand is placed on immature skeleton
53
Q

Osgood-Schlatter’s Dz

- presentation

A
  • painful anterior knee in adolescent (MC male)
  • inflammation and calcification at tubercle = characteristic prominent tubercle
  • able to straight leg raise
  • often atraumatic, usually overuse/chronic
  • unable to kneel on affected side dt pain
54
Q

Osgood-Schlatter’s Dz

- workup

A
  • clinical dx
  • XR often unnecessary unless traumatic injury present or very acute sx
  • avulsion/fragmentation of apophysis do not gen need intervention
55
Q

Osgood-Schlatter’s Dz

- Treatment

A
  • reassurance is self-limiting
  • sx can last 1-2 yrs during height of growth
  • activity modification: avoid some activities or completely cease athletics
  • RICE, mild analgesics
  • patellar tendon straps
56
Q

Osgood-Schlatter’s Dz

- indications for sx tx

A
  • non-union or fibrous union of apophysis after skeletal maturity
  • pain refractory to tx
57
Q

Chondromalacia patella

- describe

A
  • softening and fissuring of articular cartilage on post surface of patella
  • MC adolescent/young female
  • dt misalignment of patella in trochlea (anatomic variance, increased Q-angle, quad weakness)
58
Q

Chondromalacia patella

- classic case

A
  • 16 yo track and field female has slow onset anterior knee pain over 3-4 months. No injury, occasional swelling, “grating sensation behind knee cap”
59
Q

Chondromalacia patella

- Presentation

A
  • *diff ascending stairs and walking down decline
  • chronic anterior knee pain
  • insidious onset
  • “grinding” or “grating” sensation behind patella
60
Q

Chondromalacia patella

- exam findigns

A
  • patellofemoral crepitus with PROM
  • crepitus increases with AROM
  • painful squatting/duck walk like meniscal tear but no joint line pain
  • no TTP of patellar tendon
61
Q

Chondromalacia patella

- imaging

A

Usually not helpful, may indicate alignment problems:

  • Patella alta
  • Patella baja
  • lateralization of patellar tracking
62
Q

Chondromalacia patella

- conservative tx

A
  • exhaust PT (months??)
  • activity mods
  • NSAIDs and analgesics
  • bracing
63
Q

Chondromalacia patella

- sx tx

A
  • pts recalcitrant to conservative
  • shaving chondroplasty of articular surface
  • patellar realignment
64
Q

Plica syndrome

  • presentation
  • location
A
  • presents like medial meniscal tear (mechanical sounds and catching)
  • clean MRI and fail weeks of conservative tx
  • almost always medial
65
Q

Plica syndrome

- describe

A
  • redundant strap of medial synovial membrane that rubs upon joint movement
  • not an injury
66
Q

Plica syndrome

- tx

A
  • steroid shots: if work, even for a minute or two, know problem is intraarticular
67
Q

OA of knee

  • must distinguish between…
  • 3 locations
A
  • primary vs. secondary

- medial, lateral, patellofemoral

68
Q

OA of knee

- how to take images

A
  • always weight bearing!
69
Q

OA of knee

- post-traumatic causes

A
  • post-surgical changes
  • non-operative management of ligamentous injury (don’t tx ACL injury)
  • fracture-related
70
Q

OA of knee

- Tx

A
  • NSAIDs
  • Injections: corticosteroids, hyaluronic acid
  • PT
  • Brace
  • Activity mods
  • Sx - arthorplasty
71
Q

PEARLS

A
  • always compare bilaterally
  • effusion (hips?) never lies = intra-articular pathology
  • ACL = acute injury, effusion, hear/feel pop
  • HISTORY

Musculoskeletal 2 (14 decks)

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