Knee Flashcards
(103 cards)
1
Q
Pes anserinus
A
Refers to conjoined tendons of 3 muscles that insert onto the anteromedial surface of proximal tibia
2
Q
Pes anserinus muscles
A
Sartorius
Gracilis
Semitendinosus
–> Graft for ACL
3
Q
Lateral structures of knee- layer 1
A
Iliotibial tract
Biceps femoris
4
Q
Lateral structures of knee- between layers 1 and 2
A
Common peroneal nerve
5
Q
Lateral structures of knee- layer 2
A
Patellar retinaculum
6
Q
Lateral structures of knee- layer 3- superficial
A
LCL
Fabellofibular ligament
ALL
7
Q
Lateral structures of knee- between layer 3 superficial and deep
A
Lateral geniculate atery
8
Q
Lateral structures of knee- layer 3 deep
A
Arcuate ligament Coronary ligament Popliteus tendon Popliteofibular ligament Capsule
9
Q
Medial structures of knee- layer 1
A
Sartorius and fascia (patellar retinaculum)
10
Q
Medial structures of knee- between layer 1 and 2
A
Gracilis, semitendinosus, and saphenous nerve
11
Q
Medial structures of knee- layer 2
A
Semimembranosus
Superficial MCL
MPFL
Posterior oblique ligament
12
Q
Medial structures of knee- layer 3
A
Deep MCL
Capsule
Coronary ligament
13
Q
MCL originates
A
Posterior to medial epicondyle
Inserts 1cm long and 6cm long tibial aspect
14
Q
ACL rupture more likely to have…. injury
A
Lateral meniscus
15
Q
Traumatic knee injuries
A
Anterior cruciate ligament tear Posterior cruciate ligament injury Chondral fracture Patellar dislocation Meniscal tear Intraarticular fracture Tear in deep portion of joint capsule
16
Q
Atraumatic knee injuries
A
Pigmented villonodular synovitis Hemangioma Hemophilia Sickle cell anaemia Charcot arthropathy Pharmacologic coagulopathy Thrombocytopenia
17
Q
Pain
A
VAS
Constant/related to activity?
Anterior/stair climbing/prolonged sitting=patellofemoral?
PFP
Twisting rotating-meniscal?
Pain they are currently experiencing, then pain at time of injury and how it has changed
18
Q
Pain on anterior/stair climbing/prolonged sitting
A
Patellofemoral
19
Q
Pain on twisting rotating
A
Meniscal
20
Q
Instability on pivoting, twisting or cutting
A
ACL
21
Q
Linear instability- stairs/level groung
A
Quad weakness
22
Q
Instability side to side
A
PLC
23
Q
Meniscus bucket handle
A
Goes into the notch in the middle/loose body
24
Q
Mechanical symptoms- locked, clicking, snappis
A
Meniscus
Could be flipped meniscus
25
Loose body?
From condylar fracture
26
Other relevant Qs for knee pain
Treatment received on pitch-side, to date
Benefits of previous treatment
Athletic hx, past level of play, hours/week, skill level, potential and athletic goals
PMHx/review of symptoms
Occupational hx
What happened at time of injury
What do you do for job
27
Knee pain- Anterior
```
Patellofemoral syndrome
Hypertrophic fat pad syndrome
Patellar instability
Quadriceps tendonitis
Patellar tendonitis
Arthritis
```
28
Knee pain- Medial
```
Mensicus tear
MCL injury
Pes anserinus bursitis
Medial plica syndrome
Hypertrophic fat pad syndrome
```
29
Knee pain- Lateral
Meniscus tear
Biceps tendonitis
Hypertrophic fat pad syndrome
Iliotibial band syndrome
30
Knee pain- diffuse
```
OA
Inflammatory arthritis
Infection
Acute trauma with resultant hemoarthrosis
PVNS
Neoplastic
```
31
Common causes acute knee pain
```
Medial meniscus tear
MCL sprain
ACL sprain (rupture)
Lateral meniscus tear
Articular cartilage injury
PCL sprain
Patellar dislocation
```
32
Sequence of exam
Inspection
Palpation
ROM + strength
Patella- tilt, apprehension, translation, crepitus, J-sign, Q-angle
Meniscal tests- McMurray's, Apley's, Thessaly's
Ligamentous stability- ant drawer, Lachman's, pivot shift, posterior drawer, quad active, varus/valgus, dial test, ext rot recurvatum
Gait
Joint above + below
N/V
33
Medial meniscus looks like
Big C
34
Lateral meniscus looks like
Smaller C
35
Which tears are more common
Medial Tears
36
In ACL, rupture more likely to be
Lateral
| Has popliteal hiatus where it isn't attached to the capsule
37
How do fibres run in meniscus- tears
Either have longitudinal tear that runs around the periphery
| OR a horizontal cleavage tear along the fibres
38
Degenerative tears in older patients
Posterior horn of medial meniscus
39
Zones of meniscus- Red zone
Outer 1/3rd
Vascularized
Try to repair as increased chance of healing
40
Zones of meniscus- Red white zone
Middle third
41
Zones of meniscus- white zone
Inner third
Avascular
Will not heal
Need debridement
42
Symptoms meniscal injuries
Pain
Locking/clicking
Delayed or intermittent swelling
43
What is locking
When have knee slightly flexed and cannot fully extend it
44
Meniscal injuries O/E
Joint line tenderness
Effusion
McMurray's
45
Meniscal injuries age
14-55 years
46
Meniscal injuries Investigations
Radiographs
| MRI
47
Double PCL sign
Bucket handle tear (vertical tear which may displace into the notch)
Fluid where meniscus should be
48
Meniscal injuries management
Degenerative tears (non-operative) but partial meniscectomy or arthroscopic meniscal repair in general
49
Arthroscopy for meniscal injury
Majority of people who have meniscal tear reported on MRI will probably have to have an arthroscopy if between 15 and 50
Most of the time will try + fix a tear to try and reserve as much cushioning as possible- so even if its supposedly inoperable, can try and arrest the progression of the tear and making it worse
50
Meniscal injury non-operative management
<5mm stable peripheral tear
Stable vertical longitudinal tears (peripheral)
Infrequent and minimal mechanical symptoms
Associated ligamentous instabilities
Medically unfit
51
Meniscal injuries after 50
People have degenerative tears after 50
| Pain won't go away as its arthritis causing pain- meniscus is collateral damage
52
Articular cartilage lesions
Large proportion associated with structural abnormality- patella realignment/osteotomies
Usually follows trauma
Give rise to loose bodies, painful + accelerate OA
Incidental finding/accompanies another injury
Meniscal insufficiency
53
Articular cartilage lesions- symptoms
Joint line tenderness/localized pain
Effusion
Catching sensation
54
Articular cartilage defect- Grade 0
Intact cartilage
55
Articular cartilage defect- Grade I
Chondral softening or blistering with an intact surface
56
Articular cartilage defect- Grade II
Shallow superficial ulceration, fibrillation, or fissuring involving less than 50% of the depth of the articular surfacce
57
Articular cartilage defect- Grade III
Deep ulceration, fibrillation, fissuring, or a chondral flap involving 50% or more of the depth of the articular cartilage without exposure of subchondral bone
58
Articular cartilage defect- Grade IV
Full-thickness chondral wear with exposure of subchondral bone
59
Pathway of treatment
Microfracture --> OATS --> ACI
| Synthetic patch also available (blood clot fills the gap)
60
Articular cartilage imaging
MRI with gadolinium
| Often done when you have done repair and want to see how it's gone
61
Articular cartilage treatment
Surgery better for grade 3 or 4 lesions
| Avoid surgery in obesity, inflammatory conditions and degenerative change
62
Articular cartilage- Microfracture
Better if <2cm2 and <35
If grade 4 + it's down to bone, and less than 2cm2, will do microfracture
Punch holes in subchondral bone, makes bone bleed, clot fills defect, defect surrounded by solid wall of cartilage around it, so it contains the defect, then becomes fibrocartilage
63
Articular cartilage- OATS
better in lesions <2cm2 and patient older/lower demand
Good for small lesions
Use dau grafts- take from inside knee or pre-prepared- and plug it into affected area
64
Articular cartilage- ACI
Chondrocyte cells into defect + cover with patch
| Better in larger lesions, bigger than 2cm2
65
What is better in larger lesions
Osteochondral allograft
| ACI
66
Osteochondral allograft
Bone graft from cadaver- like ACI but from cadaver rather than own person
67
Patellofemoral joint defects
Have poorer results with any technique
| ACI preferred
68
Osteochondral defects
Better treated non-op in pts with open growth plates
69
What techniques perform best
OATS
ACI
Osteochondral allograft
70
Microfracture recovery
Immediate post-op ROM on CPM instituted
TWB'ing for 6-8 weeks
RTS after 4-9 months depending on size of defect + type of sport
71
OATS
NWB'ing for 3 weeks
Full ROM immediately
4/12 RTS
72
ACL Injury
Non-contact pivoting injury
| Often associated with lateral meniscus injury
73
ACL- symptoms
Pop
Pain deep in knee
Immediate swelling
74
ACL- O/E
Effusion
Quadricep avoidance gait (don't fully extend knee)
Lachman's test (positive anterior draw), pivot shift sound --> reocn required
75
ACL- Ix
Radiograph
| MRI
76
ACL- Mx
Bone, PT, bone (graft)
| Reduced laxity in graft, bone on bone healing
77
ACL- hamstring graft
Jumping sports athletes- RTP delayed by 6 months
Closed chain exercises emphasised early in rehab as open chain stretches the graft
Running delayed 3-4 months and sports delayed 6-9 months
78
PCL injury
Hyperflexion of the knee with plantar-flexed foot, dashboard injury
79
PCL Sx
Posterior knee pain
| Instability
80
PCL O/E
Posterior sag
Posterior draw
Quadriceps active test
81
PCL Ix
Radiographs
| MRI
82
PCL Mx- first 6 weeks
* PWB’ing, hamstring and gastrocnemius stretching and quadriceps strengthening
* Avoid hamstrings active engagement
* Use of PCL that provides dynamic anterior drawer
83
PCL Mx- 6-12 weeks
Increase strength + ROM
84
PCL Mx- 13-18 weeks
Running and sports specific exercise
| RTS 4-6 months when quad strength equal to contralateral side
85
MCL Injury
Excessive valgus stress e.g. skiing, rugby, football
| 40% of knee ligament injuries (most common ligamentous injury)
86
MCL Sx
Pop
| Medial joint line pain
87
MCL O/E
Tenderness
Effusion
Valgus stress
88
MCL Ix
Radiographs
| MRI
89
MCL Mx- Grade 1
NSAIDs
Rest
Therapy (RTP 1 week)
90
MCL Mx- Grade 2
```
Bracing
NSAIDs
Rest
Therapy (RTP 2-4 weeks)
Grade 1 + 2 will heal- good blood supply
```
91
MCL Mx- Grade 3
operative
| Repair or reconstruction
92
ACL + MCL rupture
6 weeks in ROM brace before think of reconstructing ACL
93
Posterolateral corner injury
LCL
Popliteus tendon
Popliteofibular ligament
94
Posterolateral corner injury Sx
Instability when knee is in full extension
Dial test- discriminates between posterolateral, PCL rupture or both? 30 degrees = posterolateral corner, 90 degrees = PCL
95
Posterolateral corner injury Ix
Radiographs
| MRI
96
Posterolateral corner injury Mx
Knee immobilization in full extension for 4 weeks then rehab OR PLC repair (grade 2+)
97
Patella instability
* Increased TTTG (tibial tuberosity and trochlear groove sulcus – J sign)
* RF: "miserable malalignment syndrome" - increased Q angle (femoral anteversion, genu valgum, external tibial torsion / pronated feet)
* Non-contact twisting injury with knee extended and foot externally rotated
98
Patella tendinopathy
Jumping athletes- repetitive forceful eccentric contraction of extensor mechanism
99
Patella tendinopathy Sx
Insidious onset of anterior knee pain at inferior border of patella- pain after or during activity
100
Patella tendinopathy O/E
Swelling over tendon
Tenderness inf border of patella
Basset's sign (tenderness to palpation at distal pole of patella in full extension but none in flexion)
101
Patella tendinopathy Ix
Radiographs
US
MRI
102
Patella tendinopathy Mx
Eccentric exercise programme and stretching of quadriceps and hamstrings
US therapy
Chopat's strap or taping
NO cortisone injections- risk of rupture
103
Patella dislocation
Increase VMO
Reconstruct MPFL
Reduce TT
