- Soft tissue swelling - Periarticular osteopenia - Periarticular erosions - Severe deformity - Joint space narrowing

MSK: Hip & Knee Flashcards by Rishi Banerjee

What are the hip adductors?

GAASP

Gracilis 
Adductor longus 
Adductor magnus 
Sartorius
Pectineus

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What are some of the extra-articular manifestations of RhA?

Ocular: keratoconjunctivitis sicca (most common), episcleritis, scleritis, corneal ulceration, keratitis, steroid-induced cataracts, chloroquine retinopathy

Respiratory: pulmonary fibrosis, pleural effusion, pulmonary nodules, bronchiolitis obliterans, methotrexate pneumonitis, pleurisy

IHD: RA carries a similar risk to T2DM

Systemic:
osteoporosis, infections (e.g. septic arthritis), depression

Less common:
Felty’s syndrome (RA + splenomegaly + low white cell count), Amyloidosis

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What can cause a positive trendelenburg test and what does it test for?

Tests for hip abductor strength

Muscle weakness:
Weakness of gluteus medius minimus or Tensor Fascia Lata (TFL)

Joint issues:
Hip OA
Initially post Total Hip Replacement
Hip instability and subluxation
Lower back pain

Nerve issues:
Superior Gluteal Nerve Palsy

Chronic childhood conditions:
Legg-Calvé-Perthes Disease
Congenital hip dislocation

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X-Ray changes for OA

Loss of joint space
Subchondral cysts
Subchondral sclerosis
Osteophyte formation at the joint margin

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Clinical features of femoral nerve damage

Supplies the quadriceps and so you get weakness in knee extension

Loss of the patella reflex

Numbness of the thigh

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Features of Ankylosing Spondylosis

Anterior uveitis
Apical fibrosis
AV node block
Aortic regurgitation
Amyloidosis
Achilles tendonitis

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What are the four main types of knee replacement?

Total knee replacement (bicompartmental)
Unicompartmental (partial) knee replacement
Kneecap replacement (patellofemoral arthroplasty)
Complex/revision knee replacement

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What are some causes of apparent shortening of the leg and true shortening of leg length?

True Shortening

 e.g. NOF
 Hip dislocation
 Growth disturbance of tibia/fibula
 Osteomyelitis, #s
 Surgery: e.g. THR
 SUFE
 Perthes’ disease

Apparent (problem above the hip)

Scoliosis

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What are the features of OA in the hip?

 ± Trendelenberg gait or +ve Test
 Pain
 Stiffness
 ↓ ROM: esp. internal rotation
 Fixed flexion deformity

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What are some of the surgical options for knee OA?

Arthroscopic Washout
Realignment Osteotomy
Arthroplasty
Arthrodesis
Microfracture

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What are the types of hip arthroplasty?

THR: Replace femoral head, neck and acetabulum

Hemi-arthroplasty: Replace femoral head and neck only (can be unipolar or bipolar)

Resurfacing: replacement of the femoral head

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What techniques are used for Hip arthroplasty?

Posterior approach:

 Access joint and capsule posteriorly, reflecting of the short external rotators.
 Gives good access
 May have higher dislocation rate
 Sciatic N. may be injured → foot drop

Anterolateral Approach

 Incision over greater trochanter, dividing fascia lata.
 Abductors are reflected to access joint capsule.
 May have lower dislocation risk
 Sup. Gluteal N. may be injured → Trendelenberg gait

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Benefits and disadvantages of hip resurfacing

Advantages

 Metal-on-metal bearings wear less
 Larger head → ↓ dislocation / ↑ stability
 Preserve bone stock making revision easier

Disadvantages

 Cobalt and chromium metal ion release may cause pathology (e.g. leukaemia)
 Risk of NOF # if mal-positioned

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Indications for a hip resurfacing procedure

May be used in young (<65), active people who are expected to outlive the replacement.

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Surgical management of RA in the knee

Indicated in failed medical Mx
 Synovectomy and debridement (can be done arthroscopically)
 Removal of pannus and cartilage
 Supracondylar osteotomy
 Total knee arthroplasty

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Causes of fixed flexion deformity in the hip

 Osteoarthritis

 #NOF

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Causes of knee effusion

Synovial fluid: synovitis (inflammatory arthritis)

Blood:
 90% = ACL rupture
 PCL rupture, intra-articular #, meniscal tear
 Bleeding diathesis

Pus: septic arthritis

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Definition of osteoarthritis

Degenerative joint disorder in which there is a progressive loss of hyaline cartilage and new bone formation at the joint surface and its margin.

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X-Ray changes of RA

Soft tissue swelling
Periarticular osteopenia
Periarticular erosions
Severe deformity
Joint space narrowing

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Complications of Hip Arthroplasty

Immediate
 Nerve injury
 Fracture
 Cement reaction

Early
 DVT: up to 50% w/o prophylaxis
 Deep infection: 0.5-1.5%
 Must remove metalwork before revision.
 Dislocation (3%): squatting and adduction

Late
 Loosening: septic or aseptic
 Leg length discrepancy
 Metalosis
 Revision: most replacements last 10-15yrs
 Peri prosthetic fracture

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Complications of Knee arthroplasty

Immediate
 Fracture
 Cement reaction
 Vascular injury (superficial femoral artery + (Popliteal and genicular vessels)
 Nerve injury (peroneal nerve → foot drop (1%))

Early
 DVT
 Deep infection: 0.5-15%

Late
 Loosening: septic or aseptic
 Periprosthetic #s
 ↓ ROM and instability (due to loss of ACL)

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What are some ddx of knee locking?

 Meniscal tear
 Cruciate ligament injury
 Osteochondritis dissecans: adolescents
 Loose body

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Describe the ACL repair

 Gold-standard is autograft repair
 Usually semitendinosus ± gracilis (can use patella)
 Tendon threaded through heads of tibia and femur and
held using screws.

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What is meant by charcots joints?

 Progressive destructive joint arthropathy
 Secondary to disturbance of sensory innervation to the joint
 Painless deformed joint resulting from repetitive minor
trauma.

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What are the four phases of gait?

1. Initial contact / heel strike 2. Stance 3. Toe off 4. Swing

What are the three compartments of the knee?

Medial Lateral Patello femoral

Indications for total knee replacement

Traumatic injury OA (refractory to medical Mx) RA (refractory to medical Mx)

Hip examination: When doing active flexion which hip do you stabilise?

Ipsilateral: flexion, extension, internal and external rotation Contralateral: hip abduction and adduction

Which patients should you not perform Thomas's test in?

Hip replacement patients

What would you expect in a positive patellar tap?

Empty the suprapatellar pouch | If there is an effusion the patellar will float up and when you press down there would be a knock

How do you test meniscal damage?

McMurrays Medial rotation: lateral meniscus Lateral rotation: medial meniscus

Classification of fractures

1) Traumatic - direct - indirect (fall on out stretched hand) - avulsion (ligament pulling off bone) 2) Stress 3) Pathological

Describing an X-Ray

Patient details Location Soft tissue: open/ closed? Displacement: - translation (horizontal movement) - angulation (movement of the fracture from its normal angle) - dislocation (distally, proximally etc) Pieces: comminuted Pattern: Incomplete, transverse, oblique, spiral, impacted

When would you do an ORIF?

- Comminuted fractures - Open fractures - Intra-articular fracture (because synovial fluid contains collagenase enzymes that stop bone healing) - Failure

Complications of fractures

Early: - compartment syndrome - visceral damage - neurovascular damage Late: - avascular necrosis - malunion - OA of the joint - reduced mobility

RF for OA

Genetics Unmodifiable: female, bone density, age Modifiable: obesity Biomechanical: repetitive use of a joint

Surgical Management of OA

``` Arthroscopic washouts Arthroplasty Microfractures Osteotomy Athrodesis ```

X-ray you would request for the knee

AP Lateral Skyline (dislocated patellar)

What are the muscles used for hip abduction?

Gluteus minimus Gluteus medius Tensor Fascia Lata

How would a hip dislocation present?

Posterior dislocation: Accounts for 90% of hip dislocations. The affected leg is shortened, adducted, and internally rotated. Anterior dislocation: The affected leg is usually abducted and externally rotated.

What is a Baker's cyst?

Baker's cysts are not true cysts but distension of the gastrocnemius-semimembranosus bursa. Primary: no underlying pathology, typically seen in children Secondary: underlying condition such as osteoarthritis, typically seen in adults

Surgery in RA

Debridement Removal of pannus and cartilage Supracondylar osteotomy TKA

How would L3 nerve root compression present?

Sensory loss over anterior thigh Weak quadriceps Reduced knee reflex Positive femoral stretch test

How would L4 nerve root compression present?

Sensory loss anterior aspect of knee Weak quadriceps Reduced knee reflex Positive femoral stretch test

How would L5 nerve root compression present?

Sensory loss dorsum of foot Weakness in foot and big toe dorsiflexion Reflexes intact Positive sciatic nerve stretch test

How would S1 nerve root compression present?

Sensory loss posterolateral aspect of leg and lateral aspect of foot Weakness in plantar flexion of foot Reduced ankle reflex Positive sciatic nerve stretch test

What are you looking for from the front in a hip exam?

Scars Pelvic tilt Quadriceps wasting

What are you looking for from the side in a hip exam?

Lumbar lordosis Knee flexion Foot arches

What are you looking for from behind in a hip exam?

Scoliosis Iliac crest alignment Gluteal muscle bulk

What are you looking for from the front in a knee exam?

Quadriceps bulk Knee swelling and deformity Foot deformity

What are you looking for from the side in a knee exam?

Knee flexion Foot arches Toe deformity

What are you looking for from behind in a knee exam?

Iliac crest alignment Gluteal muscle bulk Popliteal swelling Hindfoot abnormality

What does posterior sag indicate?

Rupture of the PCL

Surgical mx of a displaced subcapital NOF?

Hemiarthroplasty or THR

Surgical mx of a non-displaced intracapsular NOF?

Cannulated hip screws | Can consider hemi or THR

Surgical mx of an intertrochanteric or basocervical NOF?

Dynamic Hip Screw (or short IM nail)

Surgical mx of a sub-trochanteric NOF?

Anterograde Intramedullary Femoral Nail

Tool to classify OA Progression?

WOMAC score

What is the Unhappy Triad of O’Donoghue

* ACL * MCL * Medial Meniscus Usually occurs at the same time

What is the normal angle of hip flexion?

120 (acute angle 60)

What is the normal angle of hip internal and external rotation?

45 degrees

What is the normal angle of hip abduction?

45 degrees

What is the normal angle of hip adduction?

25 degrees

What is the normal angle of hip extension?

20 degrees

What are the hip flexors?

``` Psoas Iliacus Sartorius Pectineus Adductor longus and brevis Rectus femoris ```

What are the hip extensors?

``` Gluteus maximus Hamstrings: - semitendinosis - semimembranosus - biceps femoris ```

What are the hip abductors?

Gluteus medius Gluteus minimus Tensor fascia lata

What are you looking for in the front for the knee exam?

Varus deformity Valgus deformity Hyperextension Fixed flexion deformity

What is the normal angle of flexion of the knee?

40 degrees acute

What is the normal angle of extension of the knee?

<10 degrees

What are the knee flexors?

- semitendinosis - semimembranosus - biceps femoris

What are the knee extensors?

Rectus femoris Vastus lateralis Vastus intermedius Vastus medialis

3 compartments of the knee?

Medial Lateral Patellofemoral

Indications for a cemented hip replacement?

Irradiated bone Osteopenic/osteoporotic bone Abnormally wide femoral canal

Kocher criteria for septic arthritis?

Non weight-bearing Temp > 38.5°C ESR >40mm/hr WBC >12,000 cells/mm3

MSK: Hip & Knee Flashcards

(75 cards)