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1
Q

Claw vs hammer vs mallet

A

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

2
Q

Important HX questions for knee injuries?

A

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

3
Q

What are the degrees of immediate dysfunction

A

Unable to ambulate
Antalgic gait
Continued to participate (sports)

4
Q

Knee anterior structures

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

Posterior knee structures

A

Meniscus
Popliteal fossa
Hamstring tendons

6
Q

Medial knee structures?

A
MCL
Meniscus
Pes anserine
Tibial plateau
Femoral condyle
7
Q

Lateral knee structures?

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

posterior lateral corner of knee injury involves what structures?

A

Lateral collateral ligament
Popliteus tendon
Popliteofibular ligament
Lateral gastrocnemius

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.

10
Q

Noncontact injury with “pop” is probably?

A

ACL tear

11
Q

Contact injury with “pop” is probably?

A

MCL, LCL tear
Meniscus tear
Fracture

12
Q

Acute effusion (<12hrs) is probably?

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

Lateral blow to the knee is probably?

A

MCL tear

14
Q

Medial blow to the knee is probably?

A

LCL tear

15
Q

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

A

ACL tear

Patellar dislocation

16
Q

Fall onto flexed knee is probably?

A

PCL tear

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%
18
Q

Genu varum vs genu valgum?

A

Varum: knees out
Valgum: knees in (gum)

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

20
Q

Q angle?

A

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

21
Q

What is normal Q angle?

A

Male: 15%
Female: 20%

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

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

24
Q

What MOI causes patellar dislocation?

A

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

25
Q

What radiography should be ordered for knees, why?

A

x ray: because its everything

MRI: r/o associated injuries

26
Q

Valgus stress test?

A

MCL

Pull ankle laterally and push knee medically, look for laxity in MCL

at 0* no laxity
At 30* some laxity

Slide 24

27
Q

MCL tears and rupture prognosis?

A

Proximal ruptures: heal quickly but are stiff

Complete ruptures: can displace joint

Entire ligament: persistent laxity after non-operative tx

28
Q

Varus stress test?

A

LCL

Pulling ankle medial and pushing knee lateral

Slide 26

29
Q

Lachman test?

A

ACL

Stablize thigh and pull leg toward you (w 30* flexion) and laxity = badness

Slide 27

30
Q

Pivot shift test?

A

ACL

Push knee up and medial looking for laxity

Slide 28

31
Q

“A lachman is as good as?”

A

“An MRI”

32
Q

Anterior drawer test?

A

ACL

“These suck”

33
Q

Lachman test sensitive and specificity? (ACL)

A

Sensitivity: 87%
Specific: 93%

34
Q

Anterior drawer test sensitive and specificity? (ACL)

A

Sensitive: 48%
Specific: 93%

35
Q

Pivot shift test sensitive and specificity? (ACL)

A

Sensitive: 61%
Specific: 97%

36
Q

Joint line tenderness sensitive and specific? (Meniscus)

A

Sensitive: 76%
Specific: 95%

37
Q

Thessaly test sensitive and specific? (Meniscus)

A

Sensitivity: 90ish
Specific: 95%

38
Q

McMurray test sensitive and specific? (Meniscus)

A

Sensitivity: 52%

Specific 97%

39
Q

Positive McMurrays test?

A

Pain or pop

Slide 33

40
Q

Thessaly test

A

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
Q

Posterior sag test?f

A

PCL
Knee at 90* and the tibia is not a straight line

Slide 35/36

42
Q

Dial test?

A

PCL

Symmetric: normal
Asymmetric: abnormal

Pt lying prone and feet should mirror each other when knee is flexed at 30*

Slide 37

43
Q

What is noble’s test?

A

(ITB)

Palpate lateral femoral condyle
Flex and extend knee

Pos: pain at site of palpation

44
Q

Ottawa knee rules?

A

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
Q

How accurate is the ottawa knee criteria?

A

100% sensitive

Reduced radiographs by 49%

46
Q

What to look for on lateral images of knee?

A

Patella alta/baja
Patellar poles
Fat pads/bursa
Evaluate avulsion fx

47
Q

What is patella alta/baja?

A

Patella Alta: high riding patella

Patella baja: low riding patella

Not affect knee mobility

48
Q

What is Sunrise imaging?

A

Patella rising over knee like the sun over the mountains

49
Q

Sunrise imaging assesses?

A

patellofemoral joint
Patellar tilt
Lateralization
Depth of trochlear groove

50
Q

What is a pellegrini stiega?

A

Avulsion fx of MCL on femur

51
Q

What should you look for in the joint space between femur and tibial heads?

A

Discoid meniscus:

  1. Squaring
  2. Widening
  3. Cupping
52
Q

How common are ACL ruptures?

A

200,000 ACL rupture per yr in the US

1 in 3500 people

53
Q

Should i fix acl ruptures?

A

Yes:

Reconstruction is demonstrated to reduce sequelae of chordal and meniscal injury.

54
Q

Who is more likely to get ACL rupture? Why?

A
Females > males
Wider pelvis (wide Q)
Greater flexibility
Less muscle development
Hypoplastic vastus medialis oblique
Narrow femoral notch
Genu valgum
External tibial torsion
55
Q

ACL bundles?

A

2 of them

AM: tight in flexion
PL: tight in extension

56
Q

What is the primary stabilizer of the knee against anterior translation?

A

The ACL

57
Q

What tends to cause acl rupture?

A

Rotational (twisting)
Hyperextension force

Usually noncontact injuries

58
Q

What is the knee terrible traid?

A

Concomitant injuries:

  1. Meniscal tear
  2. Medial collateral ligament
  3. ACL rupture
59
Q

Why is blood in the joint bad?

A

Blood is an irritant

60
Q

What is a risk (uncommon) with disruption of multiple ligaments of the knee?

A

Popliteal artery

It is a limb threatening emergency

61
Q

Clinical presentation for ACL rupture?

A

Instability immediately
1/3 hear a pop
Unable to continue training
Immediate effusion

62
Q

What causes joint effusion with acl rupture?

A

Edges of the torn ligament bleeds into the joint (hemarthrois)

63
Q

ACL rupture PE?

A

Decreased ROM
Effusion-hemarthrosis (immediate)
Instability tests
+/- MCL and meniscus test

64
Q

What instability tests are positive with ACL rupture?

A

Lachman (most accurate)
Pivot shift
Anterior drawer

65
Q

Do they need an MRI? (ACL)

A

No

Clinical exam is as good as MRI

66
Q

What is good about and MRI? (ACL)

A

It is sensitive and specific

Shows concomitant injuries

67
Q

What are kissing lesions?

A

ACL tear MRI finding:

-Anterior lat femoral condyle
- Posterior lat tibial plateau
Touch on MRI

68
Q

Initial tx for ACL rupture?

A

RICE

Early ROM and PT

ROM brace is used

69
Q

What is the key for ACL rupture management?

A

Early ROM exercises

Full ext/flexion as soon as swelling permits

70
Q

What will surgery not fix for ACL ruptures?

A

The risk of OA

71
Q

CI for surgical repair of ACL rupture?

A
Age >40
Stiffness
Response to non-operative therapy
Advanced arthritis
Compliance issues
72
Q

What can you hope for with ACL nonoperative tx?

A

ROM of at least 0-120

Strength: quadriceps and hamstring w/in 90%

73
Q

Surgical options for ACL rupture?

A

Patella tendon autograft
Hamstring autograft
Allograft

74
Q

Patella tendon autograft info?

A

Most popular (NLF uses it)
Stable: late rupture is rare
Anterior knee pain is common

75
Q

Hamstring autograft info?

A

MC in low intensity athletes
No anterior knee pain
Strength/stiffness is based on fixation method

76
Q

Allograft information?

A

50% strength of autograft
Used to augment or when donor tissue sucks
Expensive

77
Q

What is the risk of nonsurgical tx for ACL rupture?

A

Recurrent instability
Meniscal tears
Degnerative joint disease

78
Q

ACL surgery adverse outcomes?

A

Arthrofibrosis (scarring)

Numbness lateral to incision

79
Q

Why do pts get numbness following ACL repair?

A

Infrapatellar branch of saphenous nerve is compressed

Often spontaneously resolves

80
Q

What is the PCL?

A

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
Q

Anatomically where is the PCL found?

A

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
Q

What is the MC cause of PCL injury?

A

Direct blow to the tibia such as dashboard injury in MVA

83
Q

Why are PCL injuries often missed?

A

If you have an isolated PCL injury you can usually function at a near-normal level

84
Q

Injury patterns that suggest PCL rupture?

A

Dashboard inj

Fall onto flexed knee w foot in plantar flexion

Hyperextension of knee

Hyperextension strong enough to rupture ACL and PCL

85
Q

PE for PCL rupture?

A
Effusion
Posterior drawer test
Posterior sag sinn
False positive lachman test
ACL and PCL injury
86
Q

Radiographic studies for PCL?

A

MRI = useful for PCL and concomitant injuries to surrounding tissue

87
Q

Adverse outcomes of PCL rupture?

A

Limb threatening vascular injury (dislocated knee)

Permanent perineal or tibial injury and sever knee instability can occur

Recurrent instability, subsequent tears and OA

88
Q

What is the basis of PCL injury tx?

A

Initial: resolve swelling and restore ROM

After: strengthening exercises

Braces: for contact sports after return to sports

89
Q

What is the purpose of the medial and lateral collateral ligaments?

A

They are outside the joint and stabilize the knee against valgus and vargus stress

90
Q

What is the MOI for collateral ligament injury?

A

MC: Valgus force w/out rotation

“Clipping” injury

Less Common: pure vargus force to the knee

91
Q

What other things are commonly injured with collateral ligament injuries?

A
Popliteus tendon
Popliteofibular ligament
Peroneal nerve (extreme case)
Biceps femoris tendon (extreme case)
92
Q

Can pts usually walk with collateral ligament injury?

A

Usually can ambulate and sometimes even return to play

93
Q

Swelling for collateral ligaments?

A

Sometimes localized ecchymosis after 24-48hrs

94
Q

PE findings with collateral ligaments?

A

TTP along joint line
Pain +/- instability with valgus (MCL) or varus (LCL) stress

Compare the sides

95
Q

Swelling is often associated w collateral ligament injuries but what if its large effusion?

A

Often indicates associated intra-articular injury

96
Q

tenderness in MCL injury?

A

Tender along entire course from:
Medial femoral condyle to broad tibial insertion
Just distal to the pes anserinus

97
Q

Tenderness with LCL?

A

Tender anywhere along the course from lateral femoral epicondyle to its insertion on fibular head

98
Q

Best position to palpate MCL?

A

Slight flexion

99
Q

Best position to palpate LCL?

A

Figure 4 position

100
Q

Laxity in full extension for collateral ligaments indicates?

A

More extensive injury to the anterior and posterior crucial ligaments plus posterior capsule rather than to just the MCL or LCL

101
Q

Collateral ligament grades?

A

Measure of joint space opening:

Grade I: <5mm: interstitial tear
Grade II: 6-9mm: partial tear
Grade III: >10: complete tear

102
Q

Are x rays good for collateral ligaments?

A

Ap and lat are usually negative however:

May reveal an avulsion fx

103
Q

When should you order an MRI?

A

When multilligament injury is suspected with gross laxity stress at 0 degrees

104
Q

Why are collateral ligament injuries usually treated nonsurgically?

A

They are extra-articular and have good blood supply so they can heal on their own

105
Q

Tx for isolated grade I and II collateral ligament injury?

A

Supportive:

  • RICE
  • Crutches
  • NSAIDS

ROM exercises early
Hinged brace

106
Q

Grade III MCL injury tx?

A

Proximal and w/in midsubstance can be treated nonsurgically w hinged brace

107
Q

Why should long term immobilization be avoided with collateral ligaments (or anything really)?

A

Stiffness tends to develop

108
Q

How long will collateral ligament injuries be in a brace?

A

3-4 months

109
Q

Who gets surgery (collateral ligament)?

A

Isolated grade III LCL injury usually involving posterolateral capsular complex and popliteus tendon

110
Q

How are avulsions usually treated?

A

Usually repaired and need to be done w/in 7 days of injury

111
Q

What is the big concern with collateral ligaments post healing?

A

Recurrence of injury is common especially for first 6 months

112
Q

What collateral ligaments get to go to ortho?

A

Hemarthrosis
Significant effusion
Instability
Grade III

113
Q

What needs to be done with posterior lateral corner injuries?

A

Consult w/in 72hrs

114
Q

Give 100%

A

110% is impossible, only idiots recommend that

- ron swanson