Delahay rounds 1/9/17 Flashcards by william hennrikus

the osseus anatomy of the knee provides stability

f
little osseus stability
provided by complex soft tissue envelope

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pts with patella removed because of arthritis or trauma have what changes in strength

30% reduction in quadriceps strength
because the patella (all sesamoid bones) function to increase the line of pull (moment = force x distance to fulcrum ~ torque, per delahay) to decrease the force for quadriceps function

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msk pain will commonly be relieved by rest

if not, start thinking neoplasm

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two etiologies of instability in the knee

ligamentous - ligaments crossing from femur to tibia

patello-femoral joint - buckling/giving away… sometimes stretch pain causes reflex relaxation and collapse

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in what activities is the patello-femoral joint least stable

any that require quad contraction WHILE IN FLEXION
walking DOWN stairs
bicycling

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normal lateral knee angulation

5-7 degrees valgus

(medial condyle is larger as more force through it on way from center of femoral head to center of ankle joint

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knee xr’s helpful for

fractures (trauma)
joint subluxations (alignment)
articular surface condition (arthritis)

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xr views of knee

ap
lat
merchant/sunrise
(45deg flex beam pointed inf, parallel w patellar articular surface)

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clear space on merchant/sunrise view of knee represents…

articular cartilage

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study of choice for intraarticular pathology of knee

MRI

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presentation of ligamentous injury of knee

mgmt

instability
pain swelling
sense of knee shifting/giving away
e.g. descending stairs or turning on loaded knee
immobilization – brace and rom – strengthening (progression as pain subsides) – surgical candidate if still unstable after strengthening program

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patellofemoral joint is one of the most common areas of pain in the knee

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patello-femoral pathology

etiology
presentation
mgmt

degenerative changes or maltracking in trochlear groove - anterior knee pain w loading flexed eg down stairs bicycle, relieved w rest but not one position too long (movie sign) needing to change position to relieve discomfort (degenerative change eg chondromalacia patella is softening of articular surface can be primary or secondary to trauma)
mgmt nonop quad and patellar tracking exercises 6-8 wks, if fail can consider op to improve pt results

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movie sign

anterior knee pain while in one position for too long (eg at movie) feeling like need to change position to relieve discomfort eg due to chondromalacia (articular softening) of patella aka patellofemoral pathology

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approach to osteoarthritis in knee

same as arthritis everywhere
5 modalities
-nsaids for pain and swelling
(same mech but diverse pt response so try 2 or 3 before considering failed, watch gastritis and GI intolerance)
-intraartic corticosteroid inj for acute exacerbation back to baseline
(consider surg if inj more than q6-8 wks or 2-3x/y as detriment to articular cartilage)
-pt maintain rom strengthen quads and hamstrings to reinforce soft tissue sleeve, limit to pt ability as can worsen sx in late stages of degenerative arthritis
-cane or crutch assistive devices to limit stretch across knee and increase walking tolerance
-activity mod eg sports work parking weight loss (knee can bear 3-5x body weight)
6 - surg

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how much force can be generated at knee joint

3-5x body weight (eg jumping)

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surg for knee arthritis

arthroscopic debridement lb remov (3-6mos relief, if sig oa found may opt for replacement

osteotomy to realign (eg most common varus deformity from medial erosion places greater force on medial), wedge resected from lat tib or wedge placed on med side… 5-10yr relief, not for unstable or stiff knee, replacement when sx return

arthrodesis (fusion) for young active... but stiff straight leg not ideal...
resection arthroplasty (fibrous pseudoarthrosis forms in place) and walk w brace ... these rarely performed only for tka failures

TKR total knee replacement common 1/4 mill /yr US , pts 65-70 typical… 95% successful 10-15 yr survivorship. bone cement, non cement improving. cut articular surfaces, remove acl, some allow keep pcl, must balance lcl mcl +- pcl, resurface patella. immed chair mobi w full weight bearing allowed w stabilizer preventing hyperflexion. d/c 3-4 days, need rom 3-6 wks or else scar invation prevents major gains.functional 2-3 wks but rehab 3-6 mos

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complications of TKA total knee arthroplasty

aseptic loosening 0.5%/year… 90% 15y survivorship
loose v 5yr, eval for deep infection (young, obese, high demand also risks)

patellofemoral complaints common (poor soft tissue balancing/alignment, arthritic w/o patellar resurfacing and ^60kg 160cm)

thromboembolism most common, 25-50% dvt rate, ppx SCDs warfarin asa lmwh NOACs coming along

deep infection 1% incidence
staph a, staph epi
thin inferior wound dehicence
DM a risk
treat aggressively - remove everything, debride, ivabx 6wks, can reimplant w low expectations s/p extensive debridement

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ddx for knee pain in adult

arthritis
patellofemoral pathology
meniscal tear
ligamentous injury

per delahay book

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knee physical exam

INSPECT GAIT PALPATE RANGE SPECIAL TESTS
angulation, swelling bruising ecchymosis, gait 65deg flexion smooth cadence step length equal bilat, no sudden shifts, seated position of patella anterior and symmetric, palpate while flex extend for patellar tracking and crepitus, palpate supine for point tenderness and ant/post same time for displaceable edema, normal flex extend 0-135, var valg stress, lachman ant post drawer recurvatum (backbendknee), mcmurray squat and twist for meniscal tear

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mcmurray test

knee
flex
adduct
ext rot ankle
extend knee
pain or snap ~ meniscal tear

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delahay dx for hip pain

trochanteric bursitis
it band snapping over trochanteric bursa
iliopsoas snapping
acetabular labral tear
loose bodies
AVN (hip prox hum knee talus)
arthritis

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types of hip arthritis

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osteoarthritis (primary idiopathyic congenital vs secondarymdevelopmental avn post-trauma immunogenic)
inflammatory (RA ank spondy psoriatic sle
infectious (pyogenic - staph a, staph epi, gonococcal)
other (lyme borrelia, nonpyogenic mycobacterium, crystals gout psuedogout, hemophilia hemosiderin dep)

referred pain is pain in structures which have the same __ origin

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mesodermal

referred pain vs radicular pain

dull deep boring localized injury does not signify compression of neural elements pain in structures w same mesodermal origin (e.g. lumbar back pain to buttocks and thigh) sharp lancinating numbness tingling maybe mechanical compression of inflamed nerve root w pain traveling along anatomic course of nerve e.g. lumbar back pain to foot

define radicular pain

radiculopathy mechanical compression of inflamed nerve root w pain traveling along anatomic course of nerve e.g. lumbar back pain to foot

define referred pain

pain in structures which have the same mesodermal origin

most common nerve roots in radiculopathy

L5 S1 (levels that account for pain below the knee)

severe lumbar back pain urinary retention urinary incontinence are major symptoms of...

cauda equina syndrome | large midline disc herniation compressing several roots of cauda equina

cauda equina compression syndrome path pres

massive herniation (midline..?) of L3 L4 L5 disk compresses cauda equina pain buttocks and back of thighs and legs numbness buttocks, backs of legs, soles of feet weakness/paralysis legs and feet atrophy of calves paralysis of bowel and bladder

how does the straight leg raise test work

compresses inflamed lumbar root against a herniated disc or bony spur

what constitutes a positive straight leg raise

leg pain BELOW KNEE reproduced or intensified | back or buttock pain not sufficient

physical exam of lumbar pain to include what other than ortho exam

peripheral vascular exam hip exam abdominal exam

at what angles does straight leg raise actually stretch sciatic and potentially yield positive result

35-70 degrees less than that just slack beyond that not stretching much more

when are plain radiographs helpful for spine ortho

stenosis spondylolisthesis gross segmental instability fracture

xr views to get of lumbosacral spine

ap lat coned-down lateral view of lower two interspaces occasionally but not routinely two oblique views to id subtle spondylolysis or pars interarticularis defects

what is a lateral cone-down spine xr

In a typical non-cone-down image, the pelvis bones are superimposed over the spine. Cone-down views result in clearer pictures and allow better visual of lower lumbar/sacral spine and the joint space. You may see this view called the "L5/S1 spot."

bony lesions may not be visualize on spine plain film until what % of cancellous bone has been destroyed

50%

tf | MRI is often image of choice for spine

tish | but significant false positive (asymptomatic abnorms) so be judicious with it

indications for myelography for low back pain pt

eval neural compression when MRI cannot be used -dye injected into dural sac, outlines structures eg herniated discs, extrathecal masses (invasive and complicated by headaches nausea vomiting even rarely seizures so not taken lightly or often used)

use of CT scan for spine ortho

as confirmatory diagnostic tool, high false positive if used without clinical correlation...

when do signs of denervation with fibrillation in setting of a compressed nerve root become apparent by EMG

3 weeks pressure | earlier may only show muscle irritability despite nerve entrapment

4 most common ddx for low back pain evaluated by ortho

back strain herniated disc spinal stenosis spondylolisthesis

back strain aka

lumbago

lumbago aka

back strain

``` back strain aka eti pres dx tx ```

lumbago trauma or postural inadequacy results in legamentous or muscle strain nonradiating lumbosacral pain, may refer to posterior thigh or buttock, mild is pain wo objective findings can continue activity, mod is limited spinal motion and paravertebral muscle spasm return to activity 2 wks, sev is tilted forward or side diff ambulation may take 3 wks to function clx, if persists (eg more than 2 wks) xr to ro spondylolisthesis or tumor tx w controlled physical activity

herniated disk | path/eti

herniation of nucleus pulposus thru torn annulus fibrosis usually 20-40yo 3rd or 4th decade of life when pulpsosus still gelatenous, perf usually lateral to post midline where posterior longitudinal ligament weakest, L4-L5 L5-S1 most common, just above those much less common pain radiating to leg along root distribution

a disc herniation at L4-L5 will most often compress...

L5 nerve root

a disc herniation at L5-S1 will most often compress...

S1 nerve root

which nerve root does a lumbar disk herniation most often compress

the root that exits just below the herniation but can get the one two below sometimes and the one above if an extreme lateral herniation

which muscles and tendons attatch to talus

none

tf | relationship if tibia to fibula is static

f | w dorsiflexion fibula moves laterally proximally and externally rotates

how much weight does fibula bear

1/6 in stance phase

what is the mortise of the ankle

tibio fibular recess that accepts talus

mortise and tenon

hole space | thing that fitsl

define forefoot midfoot hindfoot

phalanges and metatarsals tarsals talus calcaneous

Delahay rounds 1/9/17 Flashcards

(56 cards)