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Musculoskeletal 2 > Knee - Fx, Dislocation, Patellorfemoral Joint > Flashcards

Knee - Fx, Dislocation, Patellorfemoral Joint Flashcards

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1
Q

Meniscus

- describe

A
  • semi-lunar cartilage
  • fibrocartilagenous disks
  • aid in shock absorption and load distribution in knee during motion
  • articulate with tibia
  • concave in shape, thin to free medial edge
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2
Q

Meniscal injuries

- common cause

A
  • combo of loading/shearing force on meniscus during rotation
  • Mostly in young/healthy patient
  • may be chronic
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3
Q

Meniscal injury in elderly often dt what

A

often atraumatic

- as simple as rising from seated position or stooping over to reach something on low shelf

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4
Q

Three zones of meniscal injury and description

A
  1. Red/Red: outer 1/3, plentiful blood supply from capsular margin of meniscus
  2. Red/White: middle 1/3, diminished vasculature, less capacity to heal
  3. White/white: completely avascular inner 1/3 (won’t heal)
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5
Q

Why is it important to know the meniscal zones?

A
  • location dictates treatment
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6
Q

where are the majority of symptomatic meniscal tears?

A

inner 2/3 - where low/no capacity to heal

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7
Q

Meniscal tear presentation

A
  • catching, locking, popping sensations
  • one-sided knee pain (all medial or all lateral)
  • effusion over 12-24 hours (slower than ACL/PCL)
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8
Q

Classic meniscal tear case

A

twisting injury playing basketball, small amt swelling the next day, now pain on stairs and catching sensation

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9
Q

Meniscal tear

- PE

A
  • impingement causes pain at terminal ends of motion (flexion and extension)
  • medial/lateral joint line pain at 90 degrees flexion
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10
Q

Meniscal tear

- special tests

A
  • Apley’s (compression or distraction)
  • McMurray’s (GS)
  • Deep Squat/Duck walk: if can perform, unlikely have tear
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11
Q

What does McMurray’s actually test

A

compression with varus/valgus stress and terminal flexion/extension
**low sensitivity and specificity… difficult to reproduce pain…

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12
Q

Mensical tear

- imaging

A

XR

  • weight-bearing
  • AP and lateral minimum
  • Specialty: bilateral with notch view

MRI
- GS (second only to diagnostic arthroscopy)

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13
Q

Who is a candidate for meniscal tear conservative tx

A
  • Pt has well-tolerated sx
  • no deficit in PROM (no locking)
  • no medical co-morbiidities
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14
Q

Meniscal tear conservative treatment

A
  • RICE
  • oral NSAIDs
  • intra-articular steroid injection
  • activity modification
  • bracing not effective other than effusion control
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15
Q

Who is a candidate for surgical tx for meniscal tear

A
  • Sx affect ADL or athletics
  • bucket-handle tear that blocks ROM
  • lrg tear in repairable zone
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16
Q

Surgical tx of meniscal tear - three types

A
  • partial menisectomy
  • meniscal repair
  • trephination
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17
Q

Tibial plateau fracture

- describe

A
  • fx of tibial condyles just below joint line of knee

- generally above or includes tibial tubercle

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18
Q

Tibial plateau fracture

- locations

A
  • 60% lateral condyle
  • 15% medial condyle
  • 25% bicondylar
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19
Q

Tibial plateau fracture

- Exam

A
  • R/O compartment sx
  • evaluate ligaments for injury
  • test peroneal nerve function (foot drop)
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20
Q

Tibial plateau fracture

- Imaging

A

XR

  • AP and lateral min
  • oblique and bilateral comparison helpful
  • CT if intra-articular depression or comminution (3D reconstruction!)
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21
Q

Tibial plateau fracture non-operative management

  • describe fracture
  • describe
A
  • non-displaced or minimally displaced with stable knee on exam
  • immobilization brace
  • NWB
  • referral
  • early ROM
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22
Q

Tibial plateau fracture operative tx

- describe fracture

A
  • majority
  • displaced wedge
  • condylar widening
  • depression of articular surface **
  • gross comminution
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23
Q

Patella fracture

- MC dt what

A
  • majority: direct trauma to patella (fall or blow)

- also forceful contraction of quads, usually = avulsion fx of quad tendon or patellar tendon at distal patellar pole

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24
Q

Patella fracture

- presentation

A
  • severe anterior knee pain
  • knee held in full extension with little to no ROM
  • large effusion
  • ecchymosis and potentially low leg edema
  • usually unable to bear weight
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25
Patella fracture | - imaging
XR - 3 view of knee (AP, lateral, oblique) - sunrise if possible - bilateral helpful - CT with 3D reconstruction if possible - MRI might be helpful if no CT/pt can remain still
26
Patellar fracture types
Direct trauma - comminution common - articular cartilage damage Indirect trauma - less comminution - transverse fx
27
Displacement of patellar fractures | - 2 descriptions
1. any incongruence of articular surface >2mm | 2. greater than 3mm separation of fragments
28
Patellar fractures nonoperative treatment - when appropriate - tx options
If non-displaced and extensor mechanism is intact and can actively straight leg raise - aspirate tense hemarthrosis - knee immobilizer brace x 4-6 wks - slow, progressive ROM with PT after 4-6 weeks - quad strengthening
29
Patellar fractures operative treatment | - when appropriate
- Extensor mechanism is disrupted - Displacement of transverse fx - displacement or comminution or articular step-off - compromised skin overlying patella dt trauma
30
Knee dislocation | - what joint
- tibia-femoral articulation NOT patello-femoral :)
31
Knee dislocation | - how dangerous?
- limb-threatening injury - time is of the essence! - laceration of popliteal artery/vein possible (not common)
32
Knee dislocation | - extent of injury
- generally multi-ligament injury d/t high E trauma - often both ACL and PCL - + either MCL or LCL
33
Patellar subluxation/dislocation | - describe
Traumatic subluxation/dislocation of patella out of femoral trochlea
34
Patellar subluxation/dislocation | - what must happen for this to occur?
One of the stabilizing structures must fail: - medial patellofemoral ligament (MPFL) - medial retinaculum - chondral surfaces
35
Patellar subluxation/dislocation | - common in what population
- adolescents | - F>M (probably due to skinnier trochlear space, easier for patella to get out)
36
Patellar subluxation/dislocation | - MC medial or lateral?
lateral!! unless crazy blunt trauma
37
Patellar subluxation/dislocation | - what anatomic variances predispose
- hypoplastic femoral trochlea - Patella alta - lateralized tibial tubercle
38
Patellar subluxation/dislocation | - presentation of acute dislocation
- gross deformity - empty trochlea - patella lateral - often in flexed knee position
39
Patellar subluxation/dislocation | - presentation of subluxation or reduced dislocation
- large effusion - medicalized knee pain - painful PROM - quad inhibition
40
Patellar subluxation/dislocation | - reduction technique
- pressure applied to patella in medial direction - knee brought passively into extension - reduce ASAP
41
Patellar subluxation/dislocation | - special test
- apprehension test: similar to shoulder
42
Patellar subluxation/dislocation | - Imaging
- AP and lateral XR w/comparison views | - Sunrise/Rosenburg is vital
43
Patellar subluxation/dislocation | - Conservative tx requirements
- no lateral tilt on sunrise - no lateralization on AP - no loose body
44
Patellar subluxation/dislocation | - conservative tx
- brace in full extension - WBAT on crutches - PT for quad strength after 4-6 weeks immobile - patellar stabilizer for activity
45
Patellar subluxation/dislocation | - sx requirements
- chronic - failed conservative - loose body on XR from MPFL avulsion
46
Patellar tendon rupture - describe - MC population
- failure of extensor mech d/t excessive loading and/or unhealthy soft tissue (+/- quadriceps tendon rupture) - middle-aged (rec basketball league player)
47
Patellar tendon rupture classic case
48 yo male w/ acute pain and inability o perform straight-leg raise after jumping injury
48
Patellar tendon rupture | - presentation
- difficulty with full weight bearing and ambulation d/t loss of extensor mechanism - sig soft tissue edema and ecchymosis
49
Patellar tendon rupture | - exam findings
- Inability to perform straight leg raise | - palpable/visible defect in normally firm contour of quads or patellar tendon
50
Patellar tendon rupture | - workup
- AP and lateral XR - patellar misalignment - MRI: helpful if partial rupture - often a simple clinical dx
51
Patellar tendon rupture | - tx
- referral for sx consult | - require soft tissue repair to restore extensor mechanism
52
Osgood-Schlatter's Dz | - describe
- Traction apophysis in the adolescent at the insertion of the patellar tendon onto the tibial tubercle - Tibial tubercle has its own ossification center, which maybe disrupted - D/t rapid change in height in osseous centers w/o compensatory lengthening in the extensor mechanism or overuse/over demand is placed on immature skeleton
53
Osgood-Schlatter's Dz | - presentation
- painful anterior knee in adolescent (MC male) - inflammation and calcification at tubercle = characteristic prominent tubercle - able to straight leg raise - often atraumatic, usually overuse/chronic - unable to kneel on affected side dt pain
54
Osgood-Schlatter's Dz | - workup
- clinical dx - XR often unnecessary unless traumatic injury present or very acute sx - avulsion/fragmentation of apophysis do not gen need intervention
55
Osgood-Schlatter's Dz | - Treatment
- reassurance is self-limiting - sx can last 1-2 yrs during height of growth - activity modification: avoid some activities or completely cease athletics - RICE, mild analgesics - patellar tendon straps
56
Osgood-Schlatter's Dz | - indications for sx tx
- non-union or fibrous union of apophysis after skeletal maturity - pain refractory to tx
57
Chondromalacia patella | - describe
- softening and fissuring of articular cartilage on post surface of patella - MC adolescent/young female - dt misalignment of patella in trochlea (anatomic variance, increased Q-angle, quad weakness)
58
Chondromalacia patella | - classic case
- 16 yo track and field female has slow onset anterior knee pain over 3-4 months. No injury, occasional swelling, "grating sensation behind knee cap"
59
Chondromalacia patella | - Presentation
- *diff ascending stairs and walking down decline - chronic anterior knee pain - insidious onset - "grinding" or "grating" sensation behind patella
60
Chondromalacia patella | - exam findigns
- patellofemoral crepitus with PROM - crepitus increases with AROM - painful squatting/duck walk like meniscal tear but no joint line pain - no TTP of patellar tendon
61
Chondromalacia patella | - imaging
Usually not helpful, may indicate alignment problems: - Patella alta - Patella baja - lateralization of patellar tracking
62
Chondromalacia patella | - conservative tx
- exhaust PT (months??) - activity mods - NSAIDs and analgesics - bracing
63
Chondromalacia patella | - sx tx
- pts recalcitrant to conservative - shaving chondroplasty of articular surface - patellar realignment
64
Plica syndrome - presentation - location
- presents like medial meniscal tear (mechanical sounds and catching) - clean MRI and fail weeks of conservative tx - almost always medial
65
Plica syndrome | - describe
- redundant strap of medial synovial membrane that rubs upon joint movement - not an injury
66
Plica syndrome | - tx
- steroid shots: if work, even for a minute or two, know problem is intraarticular
67
OA of knee - must distinguish between... - 3 locations
- primary vs. secondary | - medial, lateral, patellofemoral
68
OA of knee | - how to take images
- always weight bearing!
69
OA of knee | - post-traumatic causes
- post-surgical changes - non-operative management of ligamentous injury (don't tx ACL injury) - fracture-related
70
OA of knee | - Tx
- NSAIDs - Injections: corticosteroids, hyaluronic acid - PT - Brace - Activity mods - Sx - arthorplasty
71
PEARLS
- always compare bilaterally - effusion (hips?) never lies = intra-articular pathology - ACL = acute injury, effusion, hear/feel pop - HISTORY

Musculoskeletal 2 (14 decks)

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