Knee Flashcards
(129 cards)
1
Q
MSK: knee
Gold standard graft for ACL reconstruction
A
patella tendon graft since mid-1980s
- Faster incorporation and healing
- Better outcomes young patients
2
Q
MSK: knee
During the swipe test, if the downward stroke produces a large bulge on the medial aspect of the knee
A
1+ grade
3
Q
MSK: knee
Ottawa knee rules:
A
- Age 2-55
- No fibular head TTP
- No isolated patella TTP
- Able to flex knee 90 deg
- Able to WB for steps after injury AND in the emergency department (regardless of limping)
- if the patient is negative for all criteria, the patient is likely not to have a knee fracture.
- If any of the criteria are met, this patient may need knee imaging: the rule is sensitive to rule-out fractures, but not specific to suggest who may have a fracture.
4
Q
MSK: knee
symptoms are aggravated with prolonged sitting, stairs, and kneeling:
A
Patellofemoral syndrome
5
Q
MSK: knee
tear in the outer 1/3 of the menisci?
A
it may heal
6
Q
MSK: knee
PCL especial tests:
A
- Posterior drawer test
- sag sign
- dial test
7
Q
MSK: knee
Advantages of allograft bone-tendon
A
- Bone to bone healing
- Decreased surgical time
- Predictable graft size
- Availability
8
Q
MSK: knee
The prepatellar bursa is located
A
between the skin and the anterior aspect of the patella.
9
Q
MSK: knee
ACL ligament prevents…
A
anterior translation of the tibia
10
Q
MSK: knee
LCL Provides the primary restraint for _____ and lateral rotation of the tibia, and is a secondary restraint to anterior and posterior translation of the tibia on the femur.
A
varus
11
Q
MSK: knee
MCL tear treatment:
A
conservative unless another ligament is also torn
12
Q
MSK: knee
Hamstring tendon autograft rehab:
A
- Less aggressive
- Delay hamstring strengthening 6 wks
13
Q
MSK: knee
During the swipe test, If the downward stroke produces a small bulge on the medial aspect of the knee
A
a trace
14
Q
MSK: knee
Bleeding into a joint is referred to as
A
hemarthrosis
associate with fractures
15
Q
A
ITB FRICTION SYNDROME
16
Q
MSK: knee
whatever the angle of knee flexion, the ACL absorbs nearly ______ of the force causing anterior translation. The anteromedial bundle of the ACL is taut in flexion, whereas in extension, the posterolateral fibers are stretched. These unique properties not only make the ACL the crucial, ligament of the knee joint, but also increase its potential for injury.
A
90%
17
Q
MSK: knee
During CKC movements (such as during descent into a squat position), the intercondylar groove of the femur…
A
slides relative to the fixed patella.
The patella is held in place primarily by its connection to the tibia via the patellar tendon.
18
Q
MSK: knee
Squating, think….?
A
Meniscus
19
Q
MSK: knee
Compartment syndrome:
A
– Trauma
– Rigorous unaccustomed activity
– Severe leg pain intensified with passive stretching
– Paresthesias
– Decreased pulses
20
Q
MSK: knee
Indications for TKA:
A
- Can no longer stand the pain
- Radiographic severity is not an inidcator
21
Q
MSK: knee
Continue passive motion in ACL rehab
A
No long term benefit
(6 studies)
22
Q
MSK: knee
Locking?
A
Meniscus
23
Q
MSK: knee
Pt present with Hx of recent trauma, osteoporosis, unwillingness to bear weight, point tenderness to bony structure, and hemarthrosis:
A
FRACTURES
24
Q
MSK: knee
the PCL is most taut with further ______ of the knee
A
flexion
25
# MSK: knee
Injury (trauma), **yes** or **no**?
* No, think PFPS
* Yes, ligament or meniscus tears
26
# MSK: knee
a condition in which cramping pain in the leg is induced by exercise, typically caused by obstruction of the arteries.
**vascular intermittent claudication**
Claudication is pain caused by too little blood flow, usually during exercise.
27
# MSK: knee
Most forces in the patella are in what direction?
lateral
28
# MSK: knee
What gives **passive** stability to the knee?
* Bony fit
* Capsule
* Menisci
* Ligaments (ACL, PCL, MCL, LCL)
29
# MSK: knee
treatment of osteoarthritis of the knee:
* **Manual therapy and exercise combined**
* **Gait training:** lack of terminal knee extension
* they walk in flexion because knee extension is the closed pack position of the joint
* **Hip mobilization**
* Clinical Prediction Rule for patients with knee OA likely to benefit for hip mobilization
30
# MSK: knee
MCL provides the primary restraint for ______ and lateral rotation of the tibia, and is a secondary restraint to anterior and posterior translation of the tibia on the femur.
valgus
31
# MSK: knee
Advantages of using **autograft bone tendon**
* Faster incorporation and healing
* Better outcomes young patients
32
# MSK: knee
Non-contact injury?
* One ligament (may be ACL)
* Pop? ACL
* Swelling withing hours = ACL
* Sweeling over night = meniscus
33
# MSK: knee
The Ottawa Knee Rules are a set of rules used to
**help physicians determine whether an x-ray of the knee is needed**
* if the patient is negative for all criteria, the patient is likely not to have a knee fracture.
* If any of the criteria are met, this patient may need knee imaging: the rule is sensitive to rule-out fractures, but not specific to suggest who may have a fracture.
34
# MSK: knee
The quadriceps (Q) angle can be described as the angle formed by the bisection of two lines, one line drawn from \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, and the other line drawn from ____________________________ .
1. the ASIS to the center of the patella
2. the center of the patella to the tibial tubercle
35
# MSK: knee
At 135 degrees of flexion, the patella contacts the femur primarily near its...
superior pole
In this position, the lateral edge of **the lateral facet** and the “odd” facet (medial) of the patella share articular contact with the femur
36
# MSK: knee
Knee OA symptoms:
* Pain with WB
* Morning stiffness \<30 min
* Diffuse tenderness
37
# MSK: knee
S & S ACL injury
* Inability to continue to play
* Immediate joint effusion
* Commonly feel/hear pop
* Instability
* Limited ROM
* Quad atrophy
38
# MSK: knee
ACL tears special tests:
1. Lachman
2. anterior drawer
3. Pivot-shit test
39
# MSK: knee
First most common injury in runners
PFPS
40
# MSK: knee
During stationary standing, the primary function of the ITB is
**to maintain knee and hip extension**, providing the thigh muscles an opportunity to rest
41
# MSK: knee
Because of the bony attachment of the patellar tendon to the tibial tuberosity, the patella follows the direction of the\_\_\_\_\_ during knee flexion
tibia
42
# MSK: knee
PCL prevents....
posterior translation of the tibia
43
# MSK: knee
can menisci produce pain?
no, aneural
the pain comes from the inflammatory process
44
# MSK: knee
Long term consequences of ACL injuries remains under debate:
* Meniscal injuries
* Failure secondary stabilizers
* Early onset of OA
45
# MSK: knee
Q Angles of greater than ______ degrees are considered abnormal and may be indicative of potential displacement of the patella.
**20**
46
# MSK: knee
Swipe test: it is impossible to stroke the medial fluid away
grade 3+
47
# MSK: knee
ACL surgery indications:
* Patients who are athletically active and unwilling to modify their lifestyle and want to return to pre-injury level of function
* Patients who demonstrate functional **instability** despite adequate conservative therapy
48
# MSK: knee
After ACL reconstruction, return to sport assessments tests?
* Limb Symmetry Index of less than 85%
* Quad strenght
49
# MSK: knee
As the knee extends through the last 20 to 30 degrees of flexion, the primary contact point on the patella migrates to its
inferior pole
50
# MSK: knee
Menisci are avascular except
the outer 1/3 or perifery
51
# MSK: knee
Home-based rehab: 6 studies
No deleterious effects with motivated patients
(measure motivation)
52
# MSK: knee
The circumstances that cause the highest loads and strains on the ACL during daily function are quadriceps-powered extension of the knee, moving it from approximately ____ to \_\_\_; hyperextension of the knee; excessive internal tibial rotation; or excessive varus or valgus stress on the tibia if a collateral ligament is torn.
40 degrees of flexion to full extension
53
# MSK: knee
OKC vs CKC exercises (few studies)
OKC activities safe after 6 weeks
54
# MSK: knee
Pellegrini-Stieda lesions
* are ossified post-traumatic lesions at (or near) the medial femoral collateral ligament adjacent to the margin of the medial femoral condyle.
* One presumed mechanism of injury is a Stieda fracture (avulsion injury of the medial collateral ligament at the medial femoral condyle).
* Calcification usually begins to form a few weeks after the initial injury.
* **MCL injury complication**
55
# MSK: knee
True or false: there is no patella-femur contact with the femur in full knee extension or during standing
**true**
56
# MSK: knee
Factors for return to sport:
* **Functional test (Limb Symmetry Index) \<85%**
* Hope distance
* Triple hop distance
* Crossover hop distance
* **Quad** **strength** **90%**
* **Soreness rules**
57
# MSK: knee
Non-contact, traumatic injury with swelling that occurs over night. Think.....
Meniscus
58
# MSK: knee
Devastating condition where an osseofascial compartment pressure rises to a level that decreases perfusion; may lead to irreversible muscle and nerve damage
**Compartment syndrome**
_http://www.orthobullets.com/video/view?id=500_
59
# MSK: knee
Most pain when landing from a jump, think...?
Tondonitis
60
# MSK: knee
MOI: blow in MVA, sports may result in
Tibial and fibular Fx
61
# MSK: knee
functional assessment of the knee
ex.
* Squat
* Step down
* Walking
62
# MSK: knee
Disadvantages of using **autograft bone tendon**
1. Prolonged surgical time
2. **PFPS**
3. Risk of fracture
63
# MSK: knee
PCL Provides the primary restraint for ________ translation and medial rotation of the tibia on the femur and is a secondary restraint to valgus and varus rotation of the tibia.
**posterior**
64
# MSK: knee
in open chain motions, the patella
slides on intercondylar groove of the femur
65
# MSK: knee
Discoid lateral meniscus
* Lateral meniscus is round and large
* Clinical exam: click, extension block
* Tx: reshaping or excision if symptomatic
66
# MSK: knee
Complications of MCL tears:
* instability,
* Pellegrini-Stieda lesion,
* adhesions
67
# MSK: knee
Swipe test: the medial fluid returns to its position without performing a downward sweep:
**grade 2+**
68
# MSK: knee
Advantages of using **allograft soft tissue**
* Decreased surgical time
* Predictable graft size
* Availability
69
# MSK: knee
ACL surgery **indications**:
* Patients who are athletically active and unwilling to modify their lifestyle and want to return to pre-injury level of function •
* Patients who demonstrate **functional instability** despite adequate conservative therapy
70
# MSK: knee
After ACL recontruction, what should be the quad strength before returning to play as compared to the other leg?
90%
71
# MSK: knee
contraindications for TKA:
* Major psychiatric disorder (dementia)
* Poor soft tissue coverage
* Infection
* PVD (peripheral vascular disease)
* Poor motivation
* Alcohol and drug abuse
72
# MSK: knee
Knee OA and RA account for over \_\_\_\_% TKAs
90
73
# MSK: knee
The bursae serve to
**reduce friction** and to cushion the movement of one body part over another.
74
# MSK: knee
Patellar tendon autograft rehab considerations:
* more aggressive
* early intro to balance and proprioception
75
# MSK: knee
ACL MOI
hyperextension, valgus, anterior tibial translation, rotation
76
# MSK: knee
The tensile strength of the ACL is equal to that of the knee collaterals, but is half that of the PCL. Since its fibers are unyielding, forcing the ACL more than _____ beyond its resting length may result in rupture. Several factors can influence the amount of tension on the ACL
5%
77
# MSK: knee
Disadvantages of using **allograft soft tissue**
* Cost
* Infection
* Higher failure
* Delayed incorporation
78
# MSK: knee
It is known that the PCL is _____ thicker and has twice the tensile strength of the ACL
50%
79
# MSK: knee
Neuromuscular stim (17 studies)
Up to discretion of PT with variation in study
combined with quad sets
80
# MSK: knee
Grading of the **swipe test**
* 0 (zero) grade is given when there is no fluid-wave while performing a downward stroke
* If the downward stroke produces a small bulge on the medial aspect of the knee, a **trace** is given
* a larger bulge is scored with a **1+** grade
* If the medial fluid returns to its position without performing a downward sweep, a grade of **2+** is given
* And if there is such an excess of fluid that makes it impossible to stroke the medial fluid away, a **3+** grade is given.
81
# MSK: knee
Pathology?
* **A discoid meniscus** is an abnormally shaped meniscus (cartilage that cushions the bones of the knee) present in 1% to 3% of people born in the United States.
* The condition is the result of abnormal formation of the meniscus during development in the womb. While some people may be unaware of their discoid meniscus and never experience symptoms related to it, they live at a higher risk of injury than those born with a normal meniscus.
* A discoid meniscus is commonly detected in childhood or adolescence, and often requires surgical intervention.
* Physical therapists provide treatment prior to and following surgery, and for conditions not requiring surgery.
82
# MSK: knee
MOI: Direct blow or the result of a strong quad contraction may result in
Patella Fx
83
# MSK: knee
Descending stairs think....?
Patellofemoral
84
# MSK: knee
there are 4 compartments of the leg; **anterior compartment** function is dorsiflexion of foot and ankle
**muscles?**
1. tibialis anterior
2. extensor hallucis longus
3. extensor digitorum longus
4. peroneus tertius
all innervated by deep fibular nerve
85
# MSK: knee
4 days p/o TKR patient present with calf pain, tenderness to touch, edema \>3cm compared to the other side. Homan's sign is positive
**DVT**
86
# MSK: knee
ACL/PCL Intra-articular and....
Extrasynovial
87
# MSK: knee
What is the swipe test?
sweeling/effusion test
88
# MSK: knee
Joint line tenderness?
Meniscus or arthritis
89
# MSK: knee
Advantages of using **autograft soft tissue**
1. Faster incorporation and healing
2. Better outcomes young patients
90
# MSK: knee
Revision rates of TKA:
at 10 yrs 90% still funtional
91
# MSK: knee
Wells criteria score of 1 to 2
**probability DVT 17%** 95%CI (12-23%)
92
# MSK: knee
Pittsburg knee rules:
1. **No fall or blunt knee trauma**
2. **Age 12-50 y/o**
3. **Able to walk 4 WB steps in the emergency department**
* if the patient is negative for all criteria, the patient is likely not to have a knee fracture.
* If any of the criteria are met, this patient may need knee imaging: more specific than Ottawa rules)
93
# MSK: knee
the PCL provides _______ of the total restraint to posterior translation of the tibia on the femur, with the remainder being provided by the collateral ligaments, posterior portion of the medial and lateral capsules, and the popliteus tendon
90–95%
94
# MSK: knee
Post-op bracing: 11 studies
No improvement in safety, ROM, other outcomes
95
# MSK: knee
The hip external rotators and abductors affect lower limb control, and a strengthening program that addresses these muscle groups should be integrated into the overall progression. For example, weakness of the hip external rotators may allow uncontrolled and excessive pronation of the foot to occur along with excessive femoral internal rotation, both contributing to an increase in the valgus alignment of the knee, thereby increasing the Q-angle
from text book
96
# MSK: knee
Early WB/motion: 1 study
– Significant decrease in PFP
97
# MSK: knee
Disadvantages of allograft bone-tendon
1. Cost
2. Infection
3. Higher failure
4. Delayed incorporation
98
# MSK: knee
Neuromuscular training (9 studies)
– Efficacy for its use (DiStasi 2013)
99
# MSK: knee
\>55 y/o sedentary lifestyle Pt with type II diabetes, smoker, intermittent claudication, presents with decreased pulses, increased capillary refill time of (6 seconds), one LE is colder than the other.
**Peripheral arterial disease**
100
# MSK: knee
Non-modifiable FACTORS FOR RETURNING TO SPORT,
(graft, age, sex, sport level)
* Increase odds returning pre-injury HS graft
* \> 25yo 50% less likely return pre-injury
* \> 32 2/3 not playing pre-injury level
* Men 1.5X more likely return pre-injury
* Elite athletes 2.5X more likely return pre-injury
* Elite athletes 6X more likely return to competitive
101
# MSK: knee
consequences of ACL injuries remains under debate:
* Meniscal injuries
* Failure secondary stabilizers
* Early onset of OA
102
# MSK: knee
disc herniation pressing on the L4 may cause what gait deviation?
myotome for dorsiflexion is L4
(UMN lesion because the spinal cord ends at L1-L2)
foot drop, can't DF the foot so they trip
103
# MSK: knee
ACL reconstruction preoperatively rehabilitation:
* Full passive extension
* Good quad strength
* Minimal swelling
* Patient education regarding expectations
104
# MSK: knee
Both the ACL and PCL lie in the center of the joint, and each is named according to
their attachment sites on the tibia
105
# MSK: knee
ITB friction syndrome treatment
Conservative
106
# MSK: knee
ITB friction syndrome occurs at\_\_\_\_\_\_ degrees knee flexion
20-30
107
# MSK: knee
Recommendations for nonsurgical OA Tx:
* BMI \< 25 encouraged to lose weight
* Low to moderate impact aerobic fitness
* Glucosamine
108
# MSK: knee
The middle 1/3 of the tendon 10-11mm wide is removed longitudinally along with 2-2.5 cm long bone blocks.
PATELLA TENDON AUTOGRAFT
109
# MSK: knee
Accelerated rehab (2 studies)
Neither shortened rehab to less than 6 months
110
# MSK: knee
MOI of fx: valgus or varus force and axial loading may result in
Tibial Plateau Fx
111
# MSK: knee
what is the target population of **patella tendon autograft**
young, active, returning to high level sport
* bone to bone fixation.
* Excellent Surgical Outcomes- 90-95%
112
# MSK: knee
ACL provides the primary restraint for _______ translation and medial rotation of the tibia on the femur and is a secondary restraint to valgus and varus rotation of the tibia.
**anterior**
113
# MSK: knee
Especial tests for PFPS
* Patella grind test
* Clarke's test
114
# MSK: knee
Types of ACL **allografts:**
* Bone Patella Tendon Bone
* Tibialis Anterior/Posterior
* Achilles Tendon
From cadaver tissues.
Used for older pt who need a revision
115
# MSK: knee
ACL reconstruction post-operative rehabilitation:
* Decrease inflammation and swelling
* Attain full ROM, **particularly extension**
* Restore strength (careful with OKC last 30° first 6 weeks)
* Restore patellar mobility
* Re-establish neuromuscular control
* Full return to sporting activities
116
# MSK: knee
Avulsion Fx of the Anterior Tibial Spine
* ACL injury in children
* Intra-articular Fx, hemarthrosis
* ORIF or reduction by extending the knee
117
# MSK: knee
As the knee extends toward 90 degrees of flexion, the primary contact region on the patella starts to migrate toward its...
inferior pole
118
# MSK: knee
Risk factors of ITB friction syndrome:
* \> 20 miles running/week
* Training on canted surfaces
* Training on inclined or declined surfaces
119
# MSK: knee
Types of ACL autografts:
* Bone Patella Tendon Bone 2977N
* **Hamstrings** 4140N
* Quadriceps Tendon 2353N
* Iliotibial Band
120
# MSK: knee
Other functions of the PCL include acting as a secondary restraint to ______ of the tibia on the femur at 90 degrees of flexion
external rotation
121
# MSK: knee
Complications of LCL lesions:
* traction injury of the peroneal nerve (foot drop)
* instability
122
# MSK: knee
Bursitis:
123
# MSK: knee
Meniscus tears especial tests:
1. **McMurray**
2. **Apley**
3. **Thessaly**
(palpation)
124
# MSK: knee
gold standard TKA surgery technique
median parapatellar
125
# MSK: knee
Second most common injury in runners:
ITB FRICTION SYNDROME
126
# MSK: knee
Allograft rehab considerations:
* less aggressive due to graft fixation soft tissue
127
# MSK: knee
Wells criteria score for identifying DVT of 3 or more that 3:
**probability DVT 75%** 95%CI (63-84%)
128
# MSK: knee
ACL becomes increasingly taut as the knee approaches and reaches full
extension
129
# MSK: knee
screw home mechanism of the knee
During last 10 deg of extension in OKC, ER of the tibia
Because of the ACL tension, shape of medial condyle, and lateral pull of the quads
