knees Flashcards
(26 cards)
Pre-Patella Bursitis
Chronic condition secondary to KNEELING.
Domed shape swelling over anterior aspect of knee.
Symptoms:
● Pain with pressure
● Localized swelling
Diagnosis
● Clinical
● X-rays to r/o bony
abnormality
Treatment
● RICE
● NSAIDs
● Aspiration
18 y.o. Female presents to orthopedic urgent care complaining of knee pain x 24 hours. Playing soccer yesterday she planted on her left knee to kick with her right foot and she states she twisted her left knee. She felt pain and came out of the game. She said she felt okay to go back in after ice and performing some sideline drills, but when she went to run her knee buckled on her. She complains of predominantly lateral knee pain and has an effusion. Her x-rays are unremarkable.
ACL injury: audible POP in the knee then acute swelling (hemarthroses) -> knee giving out
Anterior Cruciate Ligament (ACL) Injury
overview, MOA, sx, PE
MC ligamental injury of the knee
- >70% sports related
- Females>males
Mechanism of Injury: Noncontact PIVOTING!!!
(e.g. cutting, jumping, plant foot in kicking.
Signs & Symptoms:
● May or may be associated with a “pop”
● Acute swelling followed by effusion (hemarthrosis)
● Knee buckling or inability to bear weight.
● Lateral pain
Physical Exam:
● LACHMAN test (most sensitive)-Patient supine, knee 15deg. Forward anterior translational >approx. 2mm when tibia is pulled forward***
● Pivot Shift test-While maintaining IR, valgus force is applied to knee while it is slowly flexed. + if the tibia’s position on the femur is reduced or there is ant. Subluxation with extension.
● Anterior Drawer test-Similar to Lachman but @ 90o
● +Lateral joint space tenderness
● +Effusion
Unhappy Triad: injury to what three things
- ACL
- MCL
- Medial Meniscus
Anterior Cruciate Ligament (ACL) Injury imaging tx
what xray sign to look out for
Radiographs
● X-rays to R/O fracture
○ +/- SEGOND fracture: Avulsion of the lateral tibial condyle. If present ligamental injuries are most likely present.
● MRI - BEST test to evaluate ACL tears
Treatment
● Operative vs Non-operative depending on activity level
● Non- Op: Rest, Ice, Compression, P.T.
● Operative: ACL reconstruction with autograft vs allograft.
Lateral collateral and Medial Collateral Ligament Injuries: MOA and which is varus/valgus
MCL:
- Valgus force on the knee (Lateral trauma)
- Localized pain, swelling, ecchymosis, stiffness.
- Pain & laxity with VALGUS stress
LCL:
- Varus force on knee (Medial trauma)
- Localized pain, swelling, ecchymosis, stiffness.
- Pain & laxity with VARUS stress
Lateral collateral and Medial Collateral Ligament Injuries: tx
● Grades I (sprain) & II (incomplete tear)- pain control, Physical therapy, RICE, brace
● Grades III (complete tear)-
may require surgical repair if gross instability, refractory to conservative care, associated intra-articular injuries.
Posterior Cruciate Ligament (PCL) Injury
Mechanism: DIRECT BLOW to proximal tibia with a flexed knee
● High Energy (e.g. MVA (knee striking dashboard))
● Fall on flexed knee
Signs & Symptoms:
● posteior knee pain with Anteromedial BRUISING
● +effusion
Physical Exam:
● +POSTERIOR drawer test (post.Translational movement of the tibia
● Posterior Sag sign
● May have gross instability - Assess all ligaments
Diagnosis:
● X-rays to R/O other causes
● MRI- most sensitive
Treatment
● Rest, Ice, Compression, NSAIDs
● Immobilization with knee in extension x 2-3 weeks.
● Surgical repair often especially if other injuries to the knee.
Meniscus Tears
Mechanism:
● Acute: TWISTING INJURY while the foot is planted
- Medial > Lateral
● older pts: Degenerative with no or minimal trauma
sx:
● Popping, catching, locking, buckling
● Pain, especially with deep flexion
- effusion after 24+ hrs, slower onset than ACL
Physical Exam:
● JOINT LINE tenderness*
● Pain with deep flexion
● + MCMURRAY TEST: pop, click and/or pain when knee is FLEXED & then externally or internally rotated & extended.
● +Apley test
Diagnosis:
● X-rays to R/O other causes
● MRI- most sensitive
Treatment: conservative
● ICE, NSAIDs, Physical Therapy
● Arthroscopic repair vs partial meniscectomy if failed conservative tx
13 y.o. Male presents to the clinic complaining of anterior knee pain the past 3 months. He states the pain is mostly after activities. He points to just below his patella as the location of pain. It is relieved with icing and Tylenol.
Physical Exam:
Normal ROM
+tenderness localized over tibial tubercle
Radiographs
Sometimes + for bone fragmentation of tibial tuberosity
Osgood-Schlatter Disease aka Tibial Tubercle Apophysitis
Osgood-Schlatter Disease aka Tibial Tubercle Apophysitis
Patella tendon inflammation at its insertion on the tibial tubercle
Risk Factors
● Repetitive stress (knee extension & quadriceps contraction)
● Males 10-15 y.o
● Athletes
● Growth spurts
Physical Exam:
● Normal ROM
● +tenderness localized over tibial tubercle
Radiographs
● Sometimes + for bone fragmentation of tibial tuberosity
Treatment - conservative
● RICE
● NSAIDs
● Physical therapy
Patellofemoral Syndrome (Chondromalacia Patella)
Softening of the patella cartilage
- Chondro = Cartilage Malacia = Softening
Risk Factors
● Overuse: cyclists, runners
Signs & Symptoms
● ANTERIOR KNEE PAIN behind the patella
● Pain worsened with activity
● Pain going w/ flexion (sitting, squatting, kneeling, stairs)
Physical Exam
● +Anterior tenderness
● +Grind Test
Treatment - conservative
● RICE
● Vastus Medialis Obliquus (VMO) strengthening
● PT
● Neoprene sleeve
Illiotibial Band Syndrome
Inflammation of the ITB bursa most notably because excessive friction between the ITB and the femoral condyle.
Risk Factors
● Repetitive use: (cyclists, runners)
Signs & Symptoms
● LATERAL knee pain
● Worse with activities such as running
● Worse with a change in running surface
● Relieved with rest
Physical Exam
● +tenderness over LATERAL femoral condyle
● +tenderness over Gerdy’s Tubercle
● Noble Compression test - knee flexed to 30 degrees with pressure over distal ITB. + if pain.
● Ober Test - pain or resistance to adduction of the leg.
Treatment: conservative
● RICE
● Physical Therapy
● Corticosteroid injection
● PRP injection
Tendon Ruptures: quadriceps and patellar tendon
which is more common, RF, sx
Quadriceps tendon > Patella tendon Forceful quad contraction
Risk Factors
● Males > 40 y.o.
● Systemic disease: (e.g. DM, gout, obesity, renal disease)
● Tendinosis
● Anabolic steroid use
Signs & Symptoms
● Pain
● Inability to SLR or extend knee**
● Palpable defect either above knee with low riding patella (quadriceps) or below knee with high riding patella (patella tendon) **
Tendon Ruptures: quadriceps and patellar tendon
imaging and tx
Radiographs
● Quadriceps tendon = patella baja (LOW RIDING PATELLA - q is low on the alphabet)
● Patella tendon = patella alta (HIGH RIDING PATELLA)
Treatment
● RICE, Knee Immobilizer for comfort
● Surgical repair: complete teears or non-intact extensor mechanism -> within 7-10 days
16 y.o female presents to the clinic complaining of anterior knee pain x 1 day. She states she was playing soccer when she twisted her knee and fell. She states the saw a big bump on her knee and “pushed” her kneecap and it relieved some of the pain. Presently she presents with an effusion and she is apprehensive with your exam as you try to push on her patella laterally. You get x-rays and they are normal.
Patella Dislocation
Patella Dislocation
Valgus stress after twisting, or direct blow.
● Lateral most common
● Females>Males
Treatment
● Often reduced on the field. Push anteromedially while gently extending knee
● X-rays to ensure reduction and r/o fracture
● Knee immobilizer in extension
● Physical therapy with VMO strengthening
● Surgery with chronic dislocators
Tibial-femoral Dislocation
MOA, is it bad, what is the risk, tx, complicaiton
● Orthopedic Emergency**
- ( Surgical emergency: risk of neurovascular injury; if you miss a popliteal artery injury after 8 hrs -> ampuation)
● HIGH Velocity Trauma
● Anterior most common - results from
hyperextension
● Posterior - Increased popliteal artery injury
Treatment
● Immediate Reduction!!!
● Most need emergent surgical reduction and
vascular evaluation
Complications:
● 1⁄3 of patient popliteal artery injury. Vascular
consult to evaluate - CT Angio
● Peroneal nerve injury common
Tibial Plateau Fractures
def (MC type), moa, sx
Def: Fracture of the proximal tibia involving the articular surface (tibial plateau)
- lateral plateau > bicondylar> medial plateau
MOA:
- Axial loading with varus/valgus stress + rotation
- Common in: MVA, falls from heights
Signs & Symptoms
● Pain
● Swelling
● Hemarthrosis
● Peroneal nerve injury: check for FOOT DROP, decreased sensation in the postieor first web space of the foot
Tibial Plateau Fractures dx tx complications
Radiographs
● X-Rays: AP, Lateral, Tunnel
● CT because x-rays may be hard to see and needed for surgical planning
Treatment
● Non-Op: if non displaced. NWB, Bracing
● Operative: Displaced or severe injury
Tibial Plateau Fractures
Complications
● Often associated with other injuries (Meniscus tears, ligament tears)
● Compartment syndrome
● Post-traumatic arthritis
Femoral Condyle Fractures
MOA: AXIAL LOADING - fall from height, Direct blow to femur
sx: Pain, swelling, pain with weight-bearing
Treatment: SURGERY
● Surgical fixation depending on Type
● ORIF vs Distal Femoral Replacement
● Both have their own set of problems
Complications
● Heal poorly
● Peroneal nerve injury
● Popliteal artery injury
Knee Osteoarthritis
MC type, rF, sx
Three compartments (Medial, Lateral, Patellofemoral)
Medial m.c. = Varus deformity
Risk Factors
● Trauma
● Fractures
● Previous arthroscopy
● Ligament injuries
● Age
● Weight
Signs & Symptoms
● Pain with weight bearing activities, stairs, going from sit to stand & vice versa
● Pain at night
● Buckling or giving out. Locking or catching.
● Stiffness
● Joint swelling
● Limited ROM
Knee Osteoarthritis
dx and tx, complications
Diagnostic Tests
● Weightbearing X-rays
○ Asymmetric joint space narrowing
○ Sclerosis
○ Subchondral
cysts
○ Osteophytes
Treatment: rec WEIGHT LOSS, EXERCISE FIRST
● NSAIDs (oral & topical)
● Intra-articular corticosteroid injections
● Viscosupplementation injections
● Physical Therapy
● Exercise(modification of activities)
● Weight loss
● Bracing
● Total Knee Replacement
Complications
● Repeated steroid injections can result in accelerated cartilage destruction.
● Prosthetic joint infection
● Peri-prosthetic fractures
● Revision surgery
