Knee Flashcards
1
Q
Patellar Dislocation Treatment
A
Reduce if possible- slowly move into extension
-if can’t relocated: need standard merchant view plain film bc can’t flex knee to 115 for sunrise
-if relocated- sunrise view
-RX: bracing, splinting r casting up to 6 weeks
2
Q
Describe a Merchant view xray
A
plain film for knee that can’t flex- only need 45 dgr over end of table
- good for patellar instability
3
Q
describe a sunrise view xray
A
taken in 115 dgr flexion
-used for patella viewing and patellofemoral issues
4
Q
Fabella
A
normal variant of sesmoid bone outside joint
smooth and teardropped
no pain no fxnl problems
5
Q
Ottowa Knee Rules
A
If TRAUMA AND any below positive order xray
1. > 55 yrs
2. isolated TTP over patella
3. TTP fibular head
4. UA to flex > 90 deg
5. UA to WB immediately or in ER 4 steps
SP 48.6, SN 98.5
6
Q
chondrocalanosis
A
calification in joints- can see of meniscus on xray- cloudy lines in jt space
7
Q
Segond Fracture
A
=avulsion fracture at insertion of LCL on tibia
-caused by excessive IR and varus
-appears like small fleck of bone on tibia
-associated with ACL tears 75-100% and with meniscal and PCL tears 66-75%
-sign of ligament or meniscal tears
-do MRI after xray bc suspect other soft tissue damage as above
8
Q
patellar fracture on xray:
A
jagged edges at fracture line
effusion
exquisite TTP
quad inhibition
9
Q
Biparate patella
A
normal
looks like a fracture at corner of patella on xray
10
Q
OCD
A
osteochondritis dessicans
-focal part of subchondral bone and adjacent articular cartilage separates from the surrounding bone
usually trauma, ischemic or genetic
causes 50% loose bodies in knee
-3:1 men vs women
-85% on Medial Femoral Condyle (most on post/lateral aspect)
and in ankle
-hard to see on xray early on and may go undiagnosed
-persistent knee effusion and locking of joint
11
Q
What are 3 syndromes affecting growth plates in LE?
A
Osgood Schlatters- tibial tubercle
Sinding- Larsen- Johansson - inf patella
-Sever’s- calcaneus
12
Q
What predisposes someone to plica syndrome
A
repetitive movement or trauma
13
Q
1st 6-8 weeks after meniscal repair
A
NWB or controlled WB
lock in ext brace
ROM up to 90 dgrs
if medial repair avoid HS resistance
14
Q
Does CPM help post op ACLR?
A
NO
15
Q
When start Open chain after ACLR according to some studies?
A
6 weeks
16
Q
What helps prevent PF pain after ACLR?
A
early WB
17
Q
Signs and Sx;s of ACL tear>
A
-audible pop or crack
-feeling of initial instability, masked later by swelling
-swelling- usually immediate and extension (sometimes otherwise )
-possible widespread tenderness
-buckling, giving way
-TTP. at medial joint potential indicating cartilage damage
18
Q
How more likely will women tear ACL than men?
A
3-6 times more likely
19
Q
PCL tear signs and sx’s
A
-pop
-inability to straighten knee
-sig swelling w/in 6-8 hours
-diffuse knee pain
-pain worse sitting for long periods, going up or down stairs / hills and jumping
-
20
Q
Tests for PCL
A
posterior drawer
posterior sag
dial test
21
Q
What is the Dial test?
A
tests post/lateral instability
“prone ER test”
-perform at 30 and 90 der
- used to differentiate btw isolated PCL and PLL/PCL
-flex both knees to 30 and max ER, then in 90 max ER
if > 10 degrees difference side to side- instability
22
Q
Why is surgery not recommended for isolated PCL tear?
A
- ligament is complex and cannot be replicated with surgery
23
Q
What is grade II meniscal tear
A
- incomplete tear
-sx’s- instability when cut or pivot
-3-4 weeks of rest and rehab needed before RTS
24
Q
Grade III meniscal tear
A
complete tear
sig pain and swelling
difficulty bending kee
instability and giving out
brace or knee immobilizer usually needed for comfort
healing 6 weeks or more
repair in isolation controversial
25
Meniscal Injuries
swelling usually begins 1-2 days later
pain esp w/ WB, squatting,
-*tenderness along joint line
-locking/catching, giving way
-inability to fully ext
26
What are the most sensitive and specific tests for meniscal tears?
Medial tears:
Thessaly most sensitive
Mcmurry's and jt line tenderness most sensitive
Lateral tears :
Mcmurry's most sensitive and all 3 specific
27
Plica syndrome- describe
-caused by trauma or repetitive KF/E
which causes thickening of tissue and lack of elasticity
-so it pinches on the inner knee joint and inner patella
-plica highly innervated
28
symptoms of plica syndrome
pain anterior knee, often towards medial Sid
-pain when kneeling, squatting, or sitting for long periods
-catching, locking and clicking of the knee
-pain and tenderness under knee cap
29
Treatment for patellar dislocation/sublux
-to relocate gently extend knee
-xray to determine any fractures or loose bodies
-knee immobilizer for 6 weeks
30
How to treat Osgood schlatters
control inflammation
**must stretch and strengthen quads and hamstrings
31
Special Tests for ITB syndrome
Ober's
Nobels- palpation while SLY and passively flexing/ext knee
Renne's- palpate while pt single leg squats then compression on ITB while pt squats
None of these are great tests
32
HO- Heterotrophic Ossificans
bone formation in abnormal anatomical site
3 types
1. myositis ossificans- progressive and genetic
2. Traumatic myositis ossificans- results from direct blow to area or mm tear
3. neurogenic HO- can come from Traumatic spinal cord injury
33
Traumatic myositis ossificans
radiographs, bone scan, biopsy, LE angiography
-managment- aggressive PROM and cont'd mobilization after acute inflammatory signs decreased,
Resting appears to lead to loss of ROM and analysis
34
What factors incr likelihood of OA after ACL tear?
1. concomitant mensical tear or cartilage lesion
2. higher BMI
3. older aged
35
What factors incr likelihood of OA after ACLR?
1. more than 6 months btw injury and surgery
2. Patellar -tendon graft
3. Dear K ext ROM
4. Laxity
5. poor hop tests after 1 year
36
What grafts are used for PCL-R?
achilles or patellar tendons
37
Rehab for PCL R
-12 weeks no open chain KF
-No aggressive KF ROM
38
Which portion of ACL bundle is more taut in flexion?
anterior medial
39
which portion of ACL bundle is more taut in extension?
posterior lateral
40
What special test is ideal for chronic ACL deficiency
anterior drawer test
41
What is best special test for acute ACL tear?
Lachmans
42
Why is double bundle ACL repair better?
provides better stability especially rotatory stability
studies split about whether less OA
43
Why are females more likely to sustain ACL injury?
studies around Q angle and hormones not well established
**Neuromuscular control deficits**
44
What are the 4 NM deficit causes of female ACL injuries
1. ligament dominance: Inability to control LE frontal plane motion during landing and cutting
2. Quad dominance: imbalance of extensor and flexor strength, recruitment and coordination
3. Leg dominance: Imbalance of 2 LE's in strength , coordination and control
4. Trunk dominance- core dysfxn, lack of control to resist inertial demands
45
What are the two foci for prevention of ACL injury?
Risk Screening
Dynamic NM training
46
What is a screening tool for ACL injury prevention?
Tuck jump 10 times
Athletes who demonstrate 6 or more flaws should be targeted for further technique training
47
According to MOON (Multicenter Orthopedic Outcomes
Network)- what is the deal for open chain KE after ACLR?
Safe after 6 weeks and should only include SAQ and light load
48
MR findings for ACL
1) Discontinuity of fibers;
2) Abnormal slope of ACL;
3) Nonvisualization of the ACL fibers on both sagittal and coronal
planes;
4) Avulsion of the anterior tibial spine
49
MR findings for meniscus injury
1) Absent bow tie sign (1 or fewer);
2) Double PCL
sign (displaced bucket-handle tear of the medial meniscus);
3) Large anterior
horn sign (displaced bucket-handle tear of the lateral meniscus);
4) Too many bow ties (3 or more);
5) Notch sign (small notch out of the articular surface of
the meniscus)
should have 1.5-2 bow ties
50
MOI for PCL
Falling with foot in plantar flexion, dashboard injury,
hyperextension
falling on flexed knee
51
Anteromedial Rotatory Instability (AMRI) MOI
abrupt external rotation/abduction force (ex: clipping injury in American
football)
Special Test : Slocum test (based on premise that PMC is secondary restraint to anterior
translation when ACL is deficient
52
How and why to perform the Slocum test?
Test for anterior medial rotatory instability
Ant drawer in 15 dgrs ER of tibia
53
Anterolateral Rotatory Instability (ALRI)
-least common
MOI- concominant valgus force with hyperextension of the knee
Test: apply valgus stress and assess for posterior shift of proximal medial
tibia
54
Posterolateral Rotatory Instability (PLRI)
Injury to posterior lateral corner
-MOI: force directed posteriorly against the knee with resulting hyperextension
-Posterior drawer test; Posterior lachman test; Dial test at 30 and 90
degrees; Reverse pivot-shift test; Posterolateral drawer test; External
rotation recurvatum test; Posterolateral external rotation test
Diagnosis and treatment failure could result in
**failure of ACL reconstruction
55
In what position is PCL 95% taut?
flexion
56
What is best test for anterior bundle of ACL tear?
ANTERIOR BUNDLE test
Performing this test at 90 degrees of knee flexion
bc anterior bundle is most taut in knee flexion
57
The portion of the anterior cruciate ligament most often injured when the knee is in extension is the
posterior lateral
58
how do you stress both medial and anterior bundles of ACL?
perform Lachman's which is in 30 dgr of flexion so that both the anteriomedial and posteriolateral bundles are equally stressed
59
In what position is the anterior medial ligament ?
90 degrees of flexion
60
What is the most likely cause of ACL Post op inability to gain flexion is:
surgical error- the drilling the femoral tunnel too anterior
61
At 3 weeks post- op an arthroscopic meniscus debridement, ACL reconstruction using an allograft, as well as an articular cartilage procedure, what is recommended for treatment?
Toe Touch WB
62
In open chain, the ACL is under the most stress in what ROM?
10-30
63
What is the most likely cause of ACL Post op inability to gain extension is:
surgical error: too far anterior placement of the tibial tunnel
64
Discuss micro fracture knee sx
Microfracture has been shown to have excellent long term results. Additionally, The microfracture technique is a reasonable first-line approach to the treatment of full thickness chondral defects. This technique does not burn any bridges with regard to future procedures such as a mosaicplasty or an autologous chondrocyte transplant as a second procedure should the microfracture fail
65
What ROM in closed chain is appropriate for post op ACL-R at 5 weeks?
30-45 degrees squats
66
What ROM would be safe to limit forces on PF joint in open chain?
50-90
67
What injuries can occur with knee hyperextension>
-popliteal artery tear
-postlateral ligament tear
-possibly PCL
68
What ROM would be safe to limit forces on PF joint in closed chain?
50-90
69
Which structures are most often injured in the unhappy triad?
ACL, MCL and lateral meniscus
70
What is a Segond fracture
-avulsion fracture of knee that involves the lateral aspect of the tibial plateau
- very frequently (~75% of cases) associated with ACL tear l
71
Signs sx's of osteochondral defect?
- TTP around medial femoral condyle
-persistent effusion , locking of joint
-causes 50% of loose bodies in knee
- 3:1 men:women
-85% are on MFC (and mostly on post lateral aspect of medial fem condyl) and many seen in ankle
-may not see early OCD on xray so many go undiagnosed
72
What imaging modality may be useful for differentiating a symptomatic disruption of a bipartite patella from an asymptomatic bipartite patella
MRI
73
Revascularization of the bone-patellar-tendon-bone ACL autograft occurs most rapidly at which portion of the graft?
mid substance
74
Does chondromalaica cause pain?
Not likely
patellofemoral chondromalacia does not necessarily produce patellofemoral pain. In other words, mild damage to cartilage (ie, chondral softening/blistering) is not likely to be a source of pain in patients with PFP or chondromalacia; instead, the surrounding soft tissue is likely the culprit.
75
HEP perscriptin for PFS/patellar tendinitis :
Closed-chain exercises: 0- 45 flexion (step-ups, minisquats, and leg presses).
Open-chain exercises : from 50 to 90 degrees.
In these ranges, the quadriceps is loaded while minimizing patellofemoral forces. An elliptical machine, hamstring curl, and running all produce less patellofemoral force than a deep squat past 90 degrees of flexion.
76
Can BTB patellar graft ACL reconstruction be done on a prepubescent?
No- will disrupt growth plate
77
What is the most important factor to consider whether to repair or debride the meniscus?
patient compliance with restrictions
78
What are the best special tests to rule IN meniscal tear
Mc Murrys
jt line tenderness
79
What is the most predictive risk factor for developing knee OA following meniscectomy?
BMI>30
80
What complication will placing the FEMORAL tunnel to ANTERIOR?
lack of flexion
81
What complication will placing the TIBIAL tunnel to ANTERIOR?
lack of extension
82
DVT risk factors
-hx of cancer
- use of birth conrol
- recent surgery
-recently bedridden
-paralysis of affected LE
-locallized tenderness
-swelling of whole leg or calf >3cm of opposite calf
-pitting edema
-collateral superficial veins (NOT VARICOSE)
83
What is the ligament yield point?
The yield point is the point at which a permanent deformation occurs, but the ligament does not totally tear.
84
ACL sprain copers vs non copers
non-copers have deficits in quadriceps strength,
-vastus lateralis atrophy,
-quadriceps activation deficits, -altered knee movement patterns,
-reduced knee flexion moment,
-greater quadriceps/hamstring contraction
85
in knee surgery: a femoral nerve block causes weakness of the quadriceps and which other muscle?
sartorious
86
Femoral Nerve
stems from L2-4
supplies quads, sartorius, iliacus, and pectineus and skin of ant thigh
87
What is an adductor canal block and why used?
Adductor canal block (ACB) is a relatively new alternative providing pure sensory blockade with minimal effect on quadriceps strength during knee surgery- usually TKA
88
How to Idenify an ACL tear on MRI?Avulsion fractures of the lateral tibial plateau, known as the lateral capsular sign, are increasingly associated with anterior cruciate ligament (ACL) ruptures. This phenomenon, known as the Ségond fracture, is a bony avulsion of the menisco-tibial ligament. Stress, which can lead to an avulsion of this kind, almost always occurs during knee flexion and internal tibial rotation, and in most cases only after damage to the primary ACL stabilizer.
Avulsion fractures of the lateral tibial plateau, known as the lateral capsular sign, are increasingly associated with anterior cruciate ligament (ACL) ruptures. This phenomenon, known as the Ségond fracture, is a bony avulsion of the menisco-tibial ligament. Stress, which can lead to an avulsion of this kind, almost always occurs during knee flexion and internal tibial rotation, and in most cases only after damage to the primary ACL stabilizer.
89
what is an ideal exercise for a grade 2 MCL sprain?
lateral step up- largely unilateral and closed-chain
90
why is the weight-bearing progression slow after LCL lateral corner surgery?
The LCL sees significant loads in gait; thus, protection from these loads is required.
A unique feature of this progression with collateral injured athletes involves the impact of loading related to extension.
91
Best exercises for post op LCL/Lateral corner STRENGTHENING (no weight bearing restrictions) in first 4 months
0º–90º ROM and open chain limit loading to LCL/lateral corner stress
The 0º–90º limits loading seen by deeper flexion while the open chain minimizes loading that is requisite to weight-bearing, so this is the best option.
Full flexion closed chain would allow increased load to the healing restraints.
Open chain typically helps protect the menisci.
Closed-chain extension loads the MCL
92
describe mechanics of PF joint
The patella contact area increased as the knee flexes from 20 to 90 degrees of flexion
The patella sits superior to the trochlear groove when the knee is fully extended
The inferior pole of the patella makes contact with the superior aspect of the trochlea at 20 degrees of flexion
93
When MRI is used to diagnose a meniscus tear, What injuries account for the highest rate of false negatives among
types of tears (Dawkins, 2022
lateral meniscus tears
Therefore, all athletes should be educated preoperatively of the possibility of
finding an undiagnosed lateral meniscus tear during ACL reconstruction surgery
94
Best test for patellar tendinopathy
Single leg squat test best for patellar tendinosis bc this injury is associated with decr quad strength especially eccentric,
Can also provide patient;s symptom tolerance and dynamic stability
95
Best test to rule IN ACL tear
The pivot-shift test and Lachman's
96
Best test to rule OUT ACL tear
Lachmans
97
Best image for OCD lesions?
MRI
98
complications of Marfan's syndrome?
cardiovascular problems
99
What is the increase in
meniscectomy with removal of some (~20%) inner avascular portion of the medial meniscus
350%
100
Importance of ALC
anteriolateral ligament/complex
anterolateral complex (ALC) has a role as a secondary stabilizer to the ACL in opposing anterior tibial translation and internal tibial rotation.
101
which is more mobile medial or lateral meniscus?
Lateral- therefore LESS vulnerable
102
which is more mobile anterior or posterior horn?
anterior- therefore LESS vulnerable
103
medial and posterior horn meniscus most vulnerable
because do not move in joint as much
104
General guidelines for PCL- R
-In brace locked for 4 weeks, unlocked until 12 weeks
-Flexion ROM only to 60 for at 4 weeks; 100 for 12 weeks
-Avoid posterior tib translation- pillow under knee to prevent sag 4 weeks
-resistance placed above knee for ex
-more conservative than ACL
-Knee flexion can lack 10dgr for up to 5 months
105
Acute isolated PCL injury what is RX course
- Grade I and II- protected WB, return 2-4 weeks
-Grade III- splint in ext for 2-4 weeks
-SX- if active, young, have chondrosis or cont'd dysfxn
-No sx if older or inactive
106
If combined PCL injury What is treatment course?
Surgery within 2 weeks
107
When are MCL and LCL fibers most tight?
extension
108
MCL and LCL signs
extra- articular swelling, effusion not as common
109
if posterior horn meniscal tear repair, when can start resisted HS ex?
6 weeks
110
Articular cartilage Knee procedure Guidelines
- progressive WB starting at 6 weeks
unless only debridement (can WB immediately)
-Immediately begin unloaded PROM or AROM
Avoid closed chain ex for 6 weeks
111
Signs sx of OCD in knee
clicking, popping, swelling
- commonly at med fem condyle
-image with tunnel view
-Sx if PT fails
112
Patellar Dislocation signs and sxs
misalignment
TTP over medial aspect
effusion
Test: patellar apprehension, lateral glide test
113
Stroke Test
Zero: no waive produced on down stroke
Trace: small wave on medial side with down stroke
1+: Larger bulge on medial side with downstroke
2+: effusion spontaneously returns to med side WITHOUT down stroke
3+: so much fluid that it is not possible to move the effusion out of the media aspect
114
Wilsons Test
For OCD
The test has to be performed as follows:[1]
- Ask the patient to sit on a table with his legs dangling over the edge.
- Bend the patient’s knee so that it is flexed at a 90° angle.
- Grasp the patient’s foot and bring the tibia in internally rotation.
- Instruct the patient to extend his leg until he/she feels pain.
The test is positive when the patient reports pain in the knee about 30° from full extension and when by rotating the foot back (externally rotation of the tibia) in it’s normal position the pain disappears.[1][3]
115
After ACL R, What % of athletes suffer a 2nd ACL injury within 2 years?
30%
21% on contralateral
9% on ipsilateral
116
How many more times likely will ACL-R athlete with allograft suffer graft failure than those with autograft?
4 X
117
What is the appropriate amount of knee flexion at bottom of pedal stroke on bike?
20-25 degrees
118
best xray view for tibial plateau
AP
119
best xray view for patella and joint effusion
AP at 30 degrees flexion
120
Sunrise/merchnat views
relationship of patella and femur
121
tunnel xray view
tibial and femoral condyles
122
Repair of Patellar Rupture Protocol
Hinged knee brace locked in ext
-TTWB w/ 2 AC fir 2 weeks
-ROM --15 for 2 weeks
WBAT after 2 weeks
Brace at 0-45/60 4 weeks
0-90 5-6 weeks
Full ROM and WB by 6 weeks
weeks 7-12 Closed chain strength up to 70 degrees
123
Lysholm Knee Score
is a questionnaire consisting of 8 items
evaluates patient's perception of knee instability after surgery
high score= low instability
124
Stages of OCD
Stage 1 describes damage to the articular cartilage,
Stage 2 includes an underlying subchondral fracture,
Stage 3 involves a detached but undisplaced fragment,
Stage 4 involves a displaced osteochondral fragment
Stage 5 is formation of subchondral cysts with degenerative changes.
