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P-2 Ortho 3 > Lecture 4 > Flashcards

Lecture 4 Flashcards

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1
Q

Claw vs hammer vs mallet

A

Claw: MTP extension
Hammer: PIP flexion
Mallet: DIP flexion

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2
Q

Important HX questions for knee injuries?

A

Onset of pain
Location of pain
Injury-associated events (catching/locking, pop etc)

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3
Q

What are the degrees of immediate dysfunction

A

Unable to ambulate
Antalgic gait
Continued to participate (sports)

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4
Q

Knee anterior structures

A 
Tibial tubercle
Infrapatellar tendon
Quad insertion
Patellar facets
Crepitus
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5
Q

Posterior knee structures

A

Meniscus
Popliteal fossa
Hamstring tendons

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6
Q

Medial knee structures?

A 
MCL
Meniscus
Pes anserine
Tibial plateau
Femoral condyle
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7
Q

Lateral knee structures?

A 
LCL
Meniscus
Gerdy’s tubercle
Tibia plateau
Femoral condyle
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8
Q

posterior lateral corner of knee injury involves what structures?

A

Lateral collateral ligament
Popliteus tendon
Popliteofibular ligament
Lateral gastrocnemius

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9
Q

Theatre sign?

A

Prolonged sitting causes patella pain.

Knee is in relaxed flexed position, the patella will ride on one side of the knee and it will cause pain.

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10
Q

Noncontact injury with “pop” is probably?

A

ACL tear

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11
Q

Contact injury with “pop” is probably?

A

MCL, LCL tear
Meniscus tear
Fracture

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12
Q

Acute effusion (<12hrs) is probably?

A 
ACL tear
PCL tear
Fracture
Knee dislocation
Patellar dislocation
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13
Q

Lateral blow to the knee is probably?

A

MCL tear

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14
Q

Medial blow to the knee is probably?

A

LCL tear

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15
Q

Knee “gave out” or “buckled” is probably?

A

ACL tear

Patellar dislocation

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16
Q

Fall onto flexed knee is probably?

A

PCL tear

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17
Q

Joint injuries and their likelihood of hemarthrosis?

A 
ACL: 65-70%
Meniscus: 12.5-50%
Fracture: 1-20%
Patellar dislocation: 11-20%
W/ osteochondral lesion: 5%
PCL: 1-5%
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18
Q

Genu varum vs genu valgum?

A

Varum: knees out
Valgum: knees in (gum)

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19
Q

Diagnostic studies you should get on pts with genu varum and ganu valgum?

A

Leg length radiographs and hip radiographs

The deformity may be in the hip or legs not the knee

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20
Q

Q angle?

A

ASIS-patella and the plane of the tibial tuberosity (hip form affects the femoral to tibial angle)

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21
Q

What is normal Q angle?

A

Male: 15%
Female: 20%

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22
Q

Special tests for knee?

A 
Lachman test
Apley compression test
Anterior drawer test
Lateral pivot shift test
McMurray test

Slide 19 has pics

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23
Q

Patellofemoral stability test?

A

Slide patella back and forth

Normal

  • patellar slide: 25-50%
  • patellar tilt: 15*

Just compare the knees to look for difference

Slide 20

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24
Q

What MOI causes patellar dislocation?

A

Direct trauma
Rotation over planted foot (softball swing)
Sudden cutting movement
Prior injury

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25
What radiography should be ordered for knees, why?
x ray: because its everything MRI: r/o associated injuries
26
Valgus stress test?
MCL Pull ankle laterally and push knee medically, look for laxity in MCL at 0* no laxity At 30* some laxity Slide 24
27
MCL tears and rupture prognosis?
Proximal ruptures: heal quickly but are stiff Complete ruptures: can displace joint Entire ligament: persistent laxity after non-operative tx
28
Varus stress test?
LCL Pulling ankle medial and pushing knee lateral Slide 26
29
Lachman test?
ACL Stablize thigh and pull leg toward you (w 30* flexion) and laxity = badness Slide 27
30
Pivot shift test?
ACL Push knee up and medial looking for laxity Slide 28
31
“A lachman is as good as?”
“An MRI”
32
Anterior drawer test?
ACL “These suck”
33
Lachman test sensitive and specificity? (ACL)
Sensitivity: 87% Specific: 93%
34
Anterior drawer test sensitive and specificity? (ACL)
Sensitive: 48% Specific: 93%
35
Pivot shift test sensitive and specificity? (ACL)
Sensitive: 61% Specific: 97%
36
Joint line tenderness sensitive and specific? (Meniscus)
Sensitive: 76% Specific: 95%
37
Thessaly test sensitive and specific? (Meniscus)
Sensitivity: 90ish Specific: 95%
38
McMurray test sensitive and specific? (Meniscus)
Sensitivity: 52% | Specific 97%
39
Positive McMurrays test?
Pain or pop Slide 33
40
Thessaly test
Pt stands in one foot while holding you for balance. They rotate internal and external. Positive test will get popping and clicking Conducted with foot at 5* them 20* flexion with the foot flat Slide 32
41
Posterior sag test?f
PCL Knee at 90* and the tibia is not a straight line Slide 35/36
42
Dial test?
PCL Symmetric: normal Asymmetric: abnormal Pt lying prone and feet should mirror each other when knee is flexed at 30* Slide 37
43
What is noble’s test?
(ITB) Palpate lateral femoral condyle Flex and extend knee Pos: pain at site of palpation
44
Ottawa knee rules?
When to order an x ray ``` Age >55 or <18 Unable to walk TTP on patella TTP on fibular head Unable to flex 90* ```
45
How accurate is the ottawa knee criteria?
100% sensitive Reduced radiographs by 49%
46
What to look for on lateral images of knee?
Patella alta/baja Patellar poles Fat pads/bursa Evaluate avulsion fx
47
What is patella alta/baja?
Patella Alta: high riding patella Patella baja: low riding patella Not affect knee mobility
48
What is Sunrise imaging?
Patella rising over knee like the sun over the mountains
49
Sunrise imaging assesses?
patellofemoral joint Patellar tilt Lateralization Depth of trochlear groove
50
What is a pellegrini stiega?
Avulsion fx of MCL on femur
51
What should you look for in the joint space between femur and tibial heads?
Discoid meniscus: 1. Squaring 2. Widening 3. Cupping
52
How common are ACL ruptures?
200,000 ACL rupture per yr in the US 1 in 3500 people
53
Should i fix acl ruptures?
Yes: | Reconstruction is demonstrated to reduce sequelae of chordal and meniscal injury.
54
Who is more likely to get ACL rupture? Why?
``` Females > males Wider pelvis (wide Q) Greater flexibility Less muscle development Hypoplastic vastus medialis oblique Narrow femoral notch Genu valgum External tibial torsion ```
55
ACL bundles?
2 of them AM: tight in flexion PL: tight in extension
56
What is the primary stabilizer of the knee against anterior translation?
The ACL
57
What tends to cause acl rupture?
Rotational (twisting) Hyperextension force Usually noncontact injuries
58
What is the knee terrible traid?
Concomitant injuries: 1. Meniscal tear 2. Medial collateral ligament 3. ACL rupture
59
Why is blood in the joint bad?
Blood is an irritant
60
What is a risk (uncommon) with disruption of multiple ligaments of the knee?
Popliteal artery It is a limb threatening emergency
61
Clinical presentation for ACL rupture?
Instability immediately 1/3 hear a pop Unable to continue training Immediate effusion
62
What causes joint effusion with acl rupture?
Edges of the torn ligament bleeds into the joint (hemarthrois)
63
ACL rupture PE?
Decreased ROM Effusion-hemarthrosis (immediate) Instability tests +/- MCL and meniscus test
64
What instability tests are positive with ACL rupture?
Lachman (most accurate) Pivot shift Anterior drawer
65
Do they need an MRI? (ACL)
No Clinical exam is as good as MRI
66
What is good about and MRI? (ACL)
It is sensitive and specific | Shows concomitant injuries
67
What are kissing lesions?
ACL tear MRI finding: -Anterior lat femoral condyle - Posterior lat tibial plateau Touch on MRI
68
Initial tx for ACL rupture?
RICE Early ROM and PT ROM brace is used
69
What is the key for ACL rupture management?
Early ROM exercises Full ext/flexion as soon as swelling permits
70
What will surgery not fix for ACL ruptures?
The risk of OA
71
CI for surgical repair of ACL rupture?
``` Age >40 Stiffness Response to non-operative therapy Advanced arthritis Compliance issues ```
72
What can you hope for with ACL nonoperative tx?
ROM of at least 0-120 | Strength: quadriceps and hamstring w/in 90%
73
Surgical options for ACL rupture?
Patella tendon autograft Hamstring autograft Allograft
74
Patella tendon autograft info?
Most popular (NLF uses it) Stable: late rupture is rare Anterior knee pain is common
75
Hamstring autograft info?
MC in low intensity athletes No anterior knee pain Strength/stiffness is based on fixation method
76
Allograft information?
50% strength of autograft Used to augment or when donor tissue sucks Expensive
77
What is the risk of nonsurgical tx for ACL rupture?
Recurrent instability Meniscal tears Degnerative joint disease
78
ACL surgery adverse outcomes?
Arthrofibrosis (scarring) | Numbness lateral to incision
79
Why do pts get numbness following ACL repair?
Infrapatellar branch of saphenous nerve is compressed Often spontaneously resolves
80
What is the PCL?
Posterior cruciate ligament Critical ligament in the knee and serves as the primary restraint to posterior translation of the tibia relative to the femur
81
Anatomically where is the PCL found?
Originates on the medial intercondylar wall of the femur, runs obliquely behind the anterior cruciate ligament and inserts on the posterior aspect of the tibia below the joint line
82
What is the MC cause of PCL injury?
Direct blow to the tibia such as dashboard injury in MVA
83
Why are PCL injuries often missed?
If you have an isolated PCL injury you can usually function at a near-normal level
84
Injury patterns that suggest PCL rupture?
Dashboard inj Fall onto flexed knee w foot in plantar flexion Hyperextension of knee Hyperextension strong enough to rupture ACL and PCL
85
PE for PCL rupture?
``` Effusion Posterior drawer test Posterior sag sinn False positive lachman test ACL and PCL injury ```
86
Radiographic studies for PCL?
MRI = useful for PCL and concomitant injuries to surrounding tissue
87
Adverse outcomes of PCL rupture?
Limb threatening vascular injury (dislocated knee) Permanent perineal or tibial injury and sever knee instability can occur Recurrent instability, subsequent tears and OA
88
What is the basis of PCL injury tx?
Initial: resolve swelling and restore ROM After: strengthening exercises Braces: for contact sports after return to sports
89
What is the purpose of the medial and lateral collateral ligaments?
They are outside the joint and stabilize the knee against valgus and vargus stress
90
What is the MOI for collateral ligament injury?
MC: Valgus force w/out rotation “Clipping” injury Less Common: pure vargus force to the knee
91
What other things are commonly injured with collateral ligament injuries?
``` Popliteus tendon Popliteofibular ligament Peroneal nerve (extreme case) Biceps femoris tendon (extreme case) ```
92
Can pts usually walk with collateral ligament injury?
Usually can ambulate and sometimes even return to play
93
Swelling for collateral ligaments?
Sometimes localized ecchymosis after 24-48hrs
94
PE findings with collateral ligaments?
TTP along joint line Pain +/- instability with valgus (MCL) or varus (LCL) stress Compare the sides
95
Swelling is often associated w collateral ligament injuries but what if its large effusion?
Often indicates associated intra-articular injury
96
tenderness in MCL injury?
Tender along entire course from: Medial femoral condyle to broad tibial insertion Just distal to the pes anserinus
97
Tenderness with LCL?
Tender anywhere along the course from lateral femoral epicondyle to its insertion on fibular head
98
Best position to palpate MCL?
Slight flexion
99
Best position to palpate LCL?
Figure 4 position
100
Laxity in full extension for collateral ligaments indicates?
More extensive injury to the anterior and posterior crucial ligaments plus posterior capsule rather than to just the MCL or LCL
101
Collateral ligament grades?
Measure of joint space opening: Grade I: <5mm: interstitial tear Grade II: 6-9mm: partial tear Grade III: >10: complete tear
102
Are x rays good for collateral ligaments?
Ap and lat are usually negative however: | May reveal an avulsion fx
103
When should you order an MRI?
When multilligament injury is suspected with gross laxity stress at 0 degrees
104
Why are collateral ligament injuries usually treated nonsurgically?
They are extra-articular and have good blood supply so they can heal on their own
105
Tx for isolated grade I and II collateral ligament injury?
Supportive: - RICE - Crutches - NSAIDS ROM exercises early Hinged brace
106
Grade III MCL injury tx?
Proximal and w/in midsubstance can be treated nonsurgically w hinged brace
107
Why should long term immobilization be avoided with collateral ligaments (or anything really)?
Stiffness tends to develop
108
How long will collateral ligament injuries be in a brace?
3-4 months
109
Who gets surgery (collateral ligament)?
Isolated grade III LCL injury usually involving posterolateral capsular complex and popliteus tendon
110
How are avulsions usually treated?
Usually repaired and need to be done w/in 7 days of injury
111
What is the big concern with collateral ligaments post healing?
Recurrence of injury is common especially for first 6 months
112
What collateral ligaments get to go to ortho?
Hemarthrosis Significant effusion Instability Grade III
113
What needs to be done with posterior lateral corner injuries?
Consult w/in 72hrs
114
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P-2 Ortho 3 (6 decks)

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