Knee

Question 1

(Bone) Osgood slatters disease apophysitis: interview

Answer 1

Age - childhood
Sporty children who complain of pain after sport
Develop a characteristic lump over tibial tuberosity
Localised pain and swelling

Question 2

(Bone) Osgood slatters disease apophysitis: examination

Answer 2

Observation
Palpation
Pain on isometric quadriceps testing - load up the patella tendon

Question 3

Osteoarthritis: pathological features - bone

Answer 3

Bony sclerosis and eburnation (thickening)
Osteophyte (bony spurs) development at joint margins

Question 4

Osteoarthritis: phathological features - hyaline cartilage

Answer 4

Softening of articular cartilage
Irregular thinning/loss of cartilage
Fissures - long, narrow opening, crack in cartilage expose underlying bone

Question 5

Osteoarthritis: interview

Answer 5

Gradual onset
> 45 years old
Joint pain related to activity and weight bearing
Mild swelling
Crepitus
Early mourning stiffness (EMS) that lasts no longer than 30 minutes
Exclusion of other diagnosis including gout, rheumatoid arthritis, septic arthritis and malignancy

Question 6

Osteoarthritis: examination

Answer 6

Passive motion - stiffness
Observation - mild effusion, joint deformity (later stage)
Active range

Question 7

Rheumatoid arthritis: pathological features - bone

Answer 7

Invasion and erosion of underlying bone

Question 8

Rheumatoid arthritis: pathological features - synovial membrane

Answer 8

Non-specific inflammatory synovitis (inflammation of synovial membrane)
Exudate (fluid) into joint cavity - puffy
Proliferation (rapid increase in amount) of synovial tissue

Question 9

Rheumatoid arthritis: pathological features - hyaline cartilage

Answer 9

Destruction of cartilage

Question 10

Rheumatoid arthritis: interview

Answer 10

Early morning stiffness (EMS) for longer than 30 minutes
Swelling and heat
General health - malaise (feeling unwell), fatigue and low grade fever as systemic
Extra-articular rheumatoid arthritis, vasculitis, pulmonary fibrosis, carditis, ocular disease

Question 11

Rheumatoid arthritis: examination

Answer 11

Palpation - swelling and temperature
Measure swelling
Passive rage of motion - non-contractile structures

Question 12

Rheumatoid arthritis: treatment

Answer 12

Refer for specialist opinion any adult with suspected persistent synovitis of undermined cause

Question 13

Prepatella bursitis: interview

Answer 13

Localised pain
Housemaids knee
Carpet layers, gardeners, roofers and plumbers
On their knees for long periods of time

Question 14

Infrapatella bursitis: interview

Answer 14

Superficial and deep
Localised pain
Jumpers knew
Repetitive strain and irritation to patella tendon
Often due to jumping activities

Question 15

Pes anserine bursitis: interview

Answer 15

Localised pain
Sports that requires repetitive use of sartorius, gracilis and Semitendinosus
E.g. running, cycling, breaststroke swimming and changing direction

Question 16

Suprapatellar bursitis: interview

Answer 16

Localised pain
Blunt trauma - e.g. fall onto knee
Repetitive overuse - e.g. running

Question 17

Plica syndrome: pathological features - synovial fluid

Answer 17

Fold of synovial membrane
Plica found in only 50% of people
Irritation causes Plica syndrome

Question 18

Plica syndrome: interview

Answer 18

Blunt trauma
Repetitive bending and straightening

Question 19

Bursitis and Plica syndrome: examination

Answer 19

Palpation - local tenderness, bursae; swelling and heat
Pes anserine - observation; wide Q angle, knee valgus, functional task; single leg squat, step up noting excessive valgus strain
Pes anserine and Plica syndrome - pain on repetitive active knee flexion and extension
Infrapatella bursitis and patella tendonitis - isometric quadriceps testing reproducing pain

Question 20

Muscle injuries and tendonitis: interview

Answer 20

Strains - hamstring, gastrocnemius, quadriceps
Tendinitis - patella tendonitis
Mechanism of injury - sudden (strain), gradual onset (tendonitis)

Question 21

Muscle injuries and tendonitis: examination

Answer 21

Muscle isometric testing - contractile tissue
Palpation - show me where your pain is?
Pain on passive movement in opposite direction

Question 22

Ligament injuries: interview

Answer 22

Mechanism of injury: MCL and LCL; valgus, PCL; direct blow to anterior tibia
ACL - non-contact, knee externally rotated (10-30 degrees) then goes into varus and internal rotation e.g. in side-stepping or cutting movements
Immediate swelling
Reduced movement especially inability to fully extend
Giving way on twisting movements
Can occurs in combination with meniscus injuries

Question 23

Ligament injuries: examination

Answer 23

Special tests - MCL and LCL; varus and valgus strain, ACL; Lachlan’s and anterior draw, PCL; posterior draw and posterior sag sign
Accessory movements - anterior-posterior translation (AP/PA), varus and valgus
Palpation

Question 24

Meniscal damage: interview

Answer 24

Age
Mechanism of injury - rotational forces in a flexed knee
Acute tear - non-contact; twisting, contact; foot planted, varus force on flexed knee with femur externally rotated (lateral meniscus), valgus force on flexed knee with femur internally rotated (medial meniscus)
Localised pain on joint line
Localised swelling
Locking
Degenerative meniscus - gradual onset
Pain difficult to pin-point
Recurrent swelling

Question 25

Meniscal damage: examination

Answer 25

Special tests - McMurry’s, Apley’s, Thessaly test Palpation - joint line Active internal and external rotation

Question 26

Blood supply

Answer 26

Deep vein thrombosis - calf and popliteal vein Peripheral artery disease

Question 27

Blood supply: history

Answer 27

Swelling Past medical history - smoking, diabetes, obesity, high blood pressure Leg pain (cramping) when walking (claudication) relieved with rest

Question 28

Blood supply: examination

Answer 28

Observation - discolouration, swelling, shiny skin, sores that wont heel Palpation - temperature difference, loss of pulses Posterior tibial pulse Dorsal pedis pulse