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MSK Practical Exam > Knee > Flashcards

Knee Flashcards

(73 cards)

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1
Q

What percentage of knee injuries are ligament injuries?

A

40%

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2
Q

What percentage of ligament knee injuries are ACL?

A

50%

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3
Q

What healing capacity has the ACL got and why?

A

Poor due to its limited blood supply

Cant repair itself

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4
Q

Why are the ACL injury rates higher for females compared to males?

A

Increased Q angles

Ligaments have greater laxity

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5
Q

What is the origin and insertion of the ACL and its direction?

A

Origin: Antero-medial intercondylar area of tibia

Insertion: Posterior lateral femoral condyle

Direction: From tibia goes laterally and posteriorly (30 degree angle)

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6
Q

What are the 2 bundles of the ACL?

A
  1. Antero-medial bundle - taut at full flexion

2. Postero-lateral bundle - taut at full extension

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7
Q

What are the main function of the ACL

A

Reduces anterior tibial translation

Restricts foot abduction and hyperextension of the tibia

Limiting knee IR

Proprioceptive feedback

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8
Q

After ACL reconstruction surgery, what do people struggle with the most?

A

Proprioception

ACL loses its proprioceptive fibres

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9
Q

What are the subjective signs of an ACL rupture

A

Popping sensation

Traumatic knee injury

Instability and giving way - secondary to pain, eccentric loading of the knee (going downstairs)

Joint pain

Haemarthrosis

Mechanism of injury - non-contact, pivot, hyperextension, landing in extension, foot planted, valgus collapse

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10
Q

What is the mechanism of an ACL injury?

A

Non-contact

Pivot

Hyperextension

Landing in extension

One step-stop deceleration

Can be contact - tackling from behind (side), valgus collapse

Describe that they cant anticipate the event or loss of concentration

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11
Q

Explain valgus collapse

A

Fixed foot and patient goes to change direction

Ankle eversion

Knee abduction (distal tibia goes away from the midline)

Femoral adduction

Forced medial opening of the knee

30 degree knee flexion

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12
Q

Name the special tests for the ACL

A

Lachmans

Anterior Draw

Prone Lachman’s

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13
Q

What has the literature stated regarding the sensitivity of diagnosing an ACL injury?

A

If you get a good subjective information and objective information = almost 100% sensitivity

Mostly done on the chronic stage of injury

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14
Q

What is the best test for acute ACL injuries?

A

Lachmans = High sens, high spec and high intra-tester reliability

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15
Q

What is the best test for chronic ACL injuries?

A

Anterior drawer = high sens and high spec

Lachmans also has high sens, high spec and intra-tester reliability

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16
Q

How do you grade ACL laxity?

A

1 (1mm to 5mm)
2 (6mm to 10mm)
3 (>10mm)

Difficult to feel the difference

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17
Q

What type of physio is the anterior drawer good for?

A

Inexperienced physios

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18
Q

Why should you not do the pivot shift test?

A

Can make patients nauseas and they do not like it

Brutal test usually used by surgeons when patients are under anaesthetic

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19
Q

What type of patient is the prone lachmans good for?

A

Large patients

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20
Q

Should you use imaging for ACL injuries?

A

Alot of joint line pain = x-ray to rule out bony injuries

MRI has similar diagnostic accuracy to good subjective and objective assessment

MRI before surgery

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21
Q

What is the most common knee pathology?

A

NICE 2014

Knee OA

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22
Q

How do you diagnose knee OA?

A

Diagnosis of exclusion - cant find a pathology then send patient for an x-ray

X-ray would confirm knee OA through the Kellgren & Lawrence classification

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23
Q

What is the Kellgren & Lawrence classification?

A

How to diagnose and grade Knee OA on an x-ray

Joint space narrowing, osteophytes, sclerosis and bone end deformity

Grade 0 - None

Grade 1 Doubtful

Grade 2 Minimal

Grade 3 Moderate

Grade 4 Severe

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24
Q

What is the problems with x-ray and knee OA?

A

Poor correlation between imaging and pain experience

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25
What is knee OA symptoms, level of pain and level of disability potentially linked to?
Psychosocial factors and central sensitisation
26
How can you diagnose someone with knee OA?
NICE 2014 Guidelines Atraumatic knee pain Activity related joint pain and >45 years old and Morning joint-related stiffness that does not last longer than 30 minutes
27
How can you manage someone with knee OA with yellow flags?
Reassure that the person does not need an x-ray and how these poorly correlate with pain experience Educate how increasing strength and balance can reduce pain Encourage patient to be as active as possible If conservative management does not work = x-ray to confirm Just get an x-ray if patient is so anxious and it will help management
28
What is a patient reported outcome measure for knee OA?
WOMAC 3 Parts - Pain, stiffness and function high sens and high sens Pain and stiffness have high ceiling effects but function has low ceiling effect Low ceiling effect = cant measure higher levels of function
29
What are the subjective indicators of PFPS?
Nunes et al 2013/Cook et al 2012 Diagnosed through exclusion Pain during squatting - high sens, moderate spec (most useful Pain during stair climbing - good sens, moderate spec Pain during prolonged sitting or flexion - good sens, moderate spec Pain location - U Shape <5 years Usual bilateral pain - biomechanics or central sensitisation?
30
What are the special tests for PFPS?
Clarke's sign - good spec, low sens Apprehension test - also used to assess patella dislocation Patellar tilt - high spec, low sens
31
What is a positive patellar apprehension test?
Patient become apprehensive or feels a sensation of the patella going to dislocate Patient may activate quads to stop movement of the patella Laxity alone = not a positive test Good spec for patella dislocation
32
What force do you apply to the patella with Clarkes sign?
Compression and distal - then ask patient to contract quads
33
What other functional movements may someone with PFPS find painful?
Running Hopping Pain with step down
34
What muscles are important with PFPS?
Hip musculature Weak glutes = IR of Femur = lateral mal-tracking of the patella
35
Why is PFPS multifactorial?
Weakness of hip musculature (Glutes), knee musculature (quads/hamstrings) and poor foot biomechanics (weak tib post) Medial collapse
36
Explain the anatomy of the meniscus
Fibro-cartilaginous plates that sit on top of the tibial plateau Medial and lateral Medial is more stretched out C-shaped Lateral is more rounded C-shaped with larger surface area Attached together by the transverse ligament Attached to the tibia plateaus by the coronary ligaments Thick peripheral border and attaches to the joint capsule Divided into the anterior horn, body and posterior horn
37
Which of the menisci get injured (50%) with an ACL injury and why?
Medial meniscus - close to the origin of the ACL
38
What ligament fuses with the medial meniscus?
Deep fibres of the MCL Commonly injured together
39
Explain the blood and nerve supply of the menisci
Poor blood supply - only periphery and horns are vascular Nerve supply is the same as the vascular supply (periphery and horns)
40
Where does the menisci get there main source of nutrition from and what is the implication for this?
Synovial fluid Takes the meniscus a long time to heal
41
Where are mechanoreceptors found in the meniscus?
Horns = proprioceptive feedback and joint position sense
42
What are the subjective indicators of a meniscal tear?
Logerstedt et al., 2018; Nie et al., 2011 Mechanism of injury: Twisting injury with foot planted - weight bearing Traumatic Tearing sensation at time of injury Symptoms: Localised pain - patient will point to specific area, usually the joint line Delayed effusion (6-24 hours post injury) Clicking Catching or locking Feeling of giving way - Associated with pain Pain with forced knee hyperextension - Anterior Horn Pain with forced max knee flexion - Posterior Horn
43
How do you differentiate between an isolated meniscus injury and a meniscus injury with ACL injury?
Rate of swelling
44
What is it important not to do when asking about patients symptoms especially with potential meniscus injuries?
Do not lead the patient - try and get them to describe as many symptoms as they can Meniscus symptoms can be similar to non-specific knee pain and other knee injuries
45
What are the special tests for meniscal injuries?
Joint line tenderness McMurrays Apleys Thessalys
46
How accurate is special tests for diagnosing meniscal injuries?
Hegedus et al., 2017 Joint line tenderness, McMurrays or Apleys alone are not accurate to diagnose meniscal tears Specificity generally better than sensitivity for all 3 tests Joint line tenderness has the best sens and spec but can get a lot of false positives
47
What are the advantages and disadvantages of the Thessaly test?
Advantages - Function Disadvantages - cant standardise the degree of knee flex and amount of rotation High Spec but moderate sens
48
How should you order the special tests for meniscal injuries and why?
1. Joint line tenderness 2. McMurrays 3. Thessalys At least 2 are positive = meniscal tear likely At least 2 are negative = meniscal tear unlikely Irritability
49
What are the limitations of meniscal testing?
Variations in the literature for what is a -ve and +ve test Tests done in a variety of different ways and this isnt described in the literature Literature is of poor methodological quality and have high bias
50
Why are there limitations to meniscus testing?
Due to the variety of tears
51
What are the different types of meniscus tears?
Bucket handle tear Radial tear Parrots beak tear Horizontal tear Root tear Degenerative tear
52
What causes degenerative meniscus tears?
General wear and tear e.g. walking, hereditary, footwear, occupations that involve patients kneeling a lot (plumbers)
53
What type of meniscus tear will you get a true locking and a positive test for all special tests?
Bucket handle tear
54
Where in the meniscus could a patient get a tear but not get any symptoms and why?
Centrally (radial tear) as there is no nerve supply Although this may not heal due to poor vascular supply
55
Why may a patient get symptoms if the tear is in the area of the meniscus with no nerve supply?
Scan that shows tear = patient becomes anxious = increase in pain
56
When should you image a meniscus tear?
Bucket handle tears as they require surgery (true locking) NICE guidelines?
57
Why does lateral meniscus tear injuries cause more symptoms and take longer to heal?
More load goes down through the lateral meniscus (70%) = more pressure The lateral joint surface does not come together very well compared to the medial joint surface Less surface area = more pressure
58
What is the anatomy of the medial collateral ligament (MCL)?
2 components Superficial fibres Superior to inferior As the fibres go over the medial joint line it spreads out Deep capsular fibres is continuous with the medial meniscus If meniscus is injured means that the deep capsular fibres are involved Bursa between superficial and deep fibres
59
What is the function of the MCL
Primary medial knee stabiliser Limit valgus stress
60
Which hamstring is connected with the MCL, how and why is this important?
Semimebranosus tendon fuses with the superficial fibres of the MCL Injury to one of these structures usually causes injury to the other Semimem tendon injury e.g. tendinopathy
61
What is the mechanism of injury of an MCL injury?
Foot planted Valgus knee loading External rotation or. combined cutting movement that opens the joint Usually accompanied with an external force (how to differentiate from an ACL injury)
62
In football when do most MCL injuries occur?
Last 10 mins Strong association with fatigue - hamstrings
63
How you diagnose an MCL injury?
``` History Trauma by external force to the leg Rotational trauma Valgus knee loading Planted foot ``` Physical exam Laxity and pain with valgus stress test 30 degrees knee flexion This combined method has moderate sens and high spec
64
At what knee angles do you test for the valgus stress test and why?
0 degrees - laxity and pain means an ACL injury 30 degrees - laxity and pain means an MCL injury Laxity and pain on both = ACL and MCL injury
65
What is the anatomy of the PCL?
More vertical than the ACL and posterior of the midline PCL has a lot of surrounding support that the ACL does not have Goes beyond the joint capsule 2 components Anterior-lateral Posterior-medial
66
What are the signs and symptoms of a PCL injury?
95% of people with PCL injuries will have associated injuries Vague, non-specific symptoms e.g. discomfort that is difficult to isloate Mild/mod non-specific pain posterior knee (especially when squatting/kneeling/going downstairs) Instability
67
What is the mechanism for a PCL injury?
Anterior tibial blow injury with knee slightly flexed (dashboard injury) Fall on flexed knee with foot in PF Violent hyperextension of the knee joint
68
What are the special tests for the PCL?
Posterior drawer test Sag sign Variety sens and poor data on spec
69
What are the key elements of performing the posterior drawer test?
Need to bring tibia as far forward as possible - if person has no PCL the tibia will sag = false negative ACL rupture could give you a false positive Iso quad contraction during this test will move the tibia anteriorly = sucking sound and see tibia relocating Can support patient in 90 degrees knee and hip flexion to use gravity to increase the sag Variety sens and poor data on spec
70
What is the anatomy of the Lateral collateral ligament?
Shorter than the MCL Cord like Slants posteriorly from lateral epicondyle to the head of the fibula Seperated from the lateral meniscus by the popliteus Surrounded by tendon of the bicep femoris Tightens in full extension Stops varus, rotation in full extension
71
What are the signs and symptoms of a LCL injury?
Usually combined with more extensive damage May get an arcuate fracture = avulsion fracture of the head of the fibula
72
What is the objective examination for a LCL injury?
Palpation of the head of the fibula to rule out an arcuate fracture Varus stress test No research
73
At what angles of the knee should you do the varus stress test?
0 degrees = to test the PCL 30 degrees = to test the LCL Pain and laxity for both = LCL and PCL are injured

MSK Practical Exam (11 decks)

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