ortho 2 Flashcards
(103 cards)
1
Q
where does the quadricep insert?
A
the superior pol of the patella
2
Q
what are the risk factors for quadricep rupture?
A
increasing age CKD DM RA medications - coricosteroids and fluoroquinolones
3
Q
what are the clinical features of a quadricep rupture?
A
hearing a pop or feeling a tearing sensation
pain in anterior knee or thigh
difficulty weight bearing
localised swelling
tender palpable defect above the superior pole of the patella
if complete tear - inability to straight leg raise
4
Q
differential for quadricep rupture?
A
patella tendon rupture
patella fracture
femoral shaft fracture
5
Q
investigations for quadricep rupture?
A
XR
USS - will help to measure the degree f rupture
6
Q
how is quadricep rupture managed?
A
treatment depends on degree of rupture
partial tears - managed non-operatively - immobilisation of joint in a brace in tandem with intensive physio
complete tendon tears - surgical intervention.
7
Q
what are distal femur fractures?
A
fractures extending from the distal metaphyseal-diaphyseal junction of the femur to the articular surface of the femoral condyles.
8
Q
what is the classification of distal femur fractures?
A
The classification is commonly used to classify distal femur fractures into extra-articular (type A), partial articular (type B), and complete articular (type C).
Partial articular fractures can be further classified into sagittal fractures of lateral condyle, sagittal fractures of medial condyle, and coronal fractures.
9
Q
what is a hoffa fracture?
A
A Hoffa fracture is a specific type of type B articular distal femoral fracture in which there is a fracture of the posterior aspect of the femoral condyles in the coronal plane. Hoffa fragments are more commonly unicondylar affecting the lateral femoral condyle.
10
Q
what are the clinical features of a distal femur fracture?
A
severe pain in the distal thigh
inability to weight bear
obvious deformity on examination
swelling and ecchymosis of the distal thigh
If it is intra-articular then a knee effusion may be present
*make sure to do a full neurovascular exam
11
Q
what are the differentials for distal femure fracture?
A
tibial plataeu fractures
haemarthrosis
tibial shaft fracture
12
Q
what investigation for distal femur fracture?
A
bloods
serum calcium and a myeloma screen may be warranted
AP and lateral XR of entire femur
if there is intra articular extension then CT imaging is helpful
13
Q
how do you manage a distal femur fracture?
A
if there is significant realignment - then initial realignment in A&E
majority are managed surgically
with either retrograde nailing or open reduction internal fixation
14
Q
how does a pelvic fracture present?
A
significant pain and swelling
obvious deformity
** full neurovascular assessment is needed
15
Q
investigations for pelvic fracture?
A
XR
CT
16
Q
how are pelvic fractures classified?
A
Two classification systems are commonly used to describe pelvic ring injuries:
Young and Burgess classification – groups based on the vector of the disrupting force and the resulting degree of displacement (see Appendix) Antero-posterior compression (APC 1-3) Lateral compression (LC 1-3) Vertical shear (VS 1-2) Tile classification – fractures grouped based on the stability of the pelvic ring A-type fractures = rotationally and vertically stable B-type fractures = horizontally unstable but vertically stable C-type fractures = both horizontally and vertically unstable The Denis classification can be used to classify fractures of the sacrum; it describes the line of the fracture in relation to the sacral foramina, with type 1 = lateral to the foramina, type 2 = transforaminal, type 3 = medial to the foramina. In addition, a transverse component may result in an H-shaped or U-shaped fracture pattern.
17
Q
how are pelvic fractures managed?
A
definitive management can be conservative or operative
Indications for operative management include life threatening haemorrhage, unstable fractures, open fractures, and associated fractures with an associated urological injury. The approach and method of stabilisation can be guided by the Young and Burgess classification* and involves a combination of anterior and posterior stabilisation.
18
Q
what is the acetabulum?
A
a cup-like depression located on the inferolateral aspect of the pelvis, formed by the ilium, ischium and pubic bones.
It articulates with the head of the femur to for the hip joint
19
Q
what are the clinical features of acetabular fracture?
A
usually following high energy injury
significant pain and swelling
inability to weight bear
there are often associated pelvic fractures
20
Q
when examining someone with suspected acetabular fracture what should you do?
A
**you should check the neurovascular status of both limbs during the assessment
Check for any evidence of open fracture and assess the condition of the overlying skin for any Morel-Lavallée lesions.
21
Q
what investigations for acetabular fracture?
A
plain film XR - AP view and judet view (obtained by tilting the patient 45o laterally in both directions)
CT
22
Q
how are acetabular fractures classified?
A
using the Judet and Letournel classification:
Elementary = posterior wall, posterior column, anterior wall, anterior column, transverse Associated = posterior wall + posterior column, transverse + posterior wall, T-type, anterior column + posterior hemitransverse, both columns
23
Q
how are acetabular fractures managed?
A
Undisplaced or minimally displaced acetabular fractures can be managed conservatively with protected weight bearing for 6-8 weeks.
surgical management - in young patients with displaced fractures surgery is usually performed to restore the anatomy
24
Q
what are the two distinct areas of the neck of femur?
A
Intra-capsular – from the subcapital region of the femoral head to basocervical region of the femoral neck, immediately proximal to the trochanters
Extra-capsular – outside the capsule, subdivided into:
>Inter-trochanteric, which are between the greater trochanter and the lesser trochanter
>Sub-tronchanteric, which are from the lesser trochanter to 5cm distal to this point
25
what classification is used for intracapsular hip fracture?
the garden classification
26
what are the clinical features of NOF fracture?
pain - in the groin, thigh or referred to the knee
inability to weight bear
o/e - shortened and externally rotated with pain on pin-rolling the leg and axial loading
although neurovascular deficits are rare a full neurovascular exam should be performed
27
what are the differentials for neck of femur fracture?
pelvis - pubis ramus fractures
acetabulum fractures
femoral head and femoral diaphysis fractures
if no history of trauma - pathological fractures should be considered
28
what are the investigations for neck of femur fracture?
XR - AP and lateral views of the affected hip as well as an AP pelvis
Full length femoral XR
Basic bloods
Urine dip and CXR - especially in older patients
29
how is neck of femur fracture managed?
initial management - A-E approach to stabilise the patient
adequate analgesia - such as opioid analgesia or a regional block such as fascia-iliaca block
definitive management is surgery:
Displaced subcapital - hip hemiarthroplasty
Inter-trochanteric and basocervixal - dynamic hip screw
Non-displaced intra-capsular - cannulated hip screws
Sub-trochanteric - intramedullary femoral nail
30
post operative complications of NOF fracture management?
Immediate post-operative complications include pain, bleeding, leg-length discrepancies, and potential neurovascular damage, all of which should be consented for pre-operatively.
31
how does hip osteoarthritis present?
pain in the groin or over lateral hip or deep buttock
pain aggravated by weight bearing and improved with rest
stiffness
grinding or crunching sensation
antalgic gait
passive movement is painful
n severe OA, the range of motion is reduced. In end stage disease, the patient may have a fixed flexion deformity and walk with a Trendelenburg gait.
32
differentials for hip OA?
Trochanteric bursitis – presents with lateral hip pain radiating down the lateral leg, with associated point tenderness over the greater trochanter
Gluteus medius tendinopathy – lateral hip pain with point tenderness over the muscle insertion at the greater trochanter
Sciatica – low back pain and buttock pain, but often radiates down the posterior leg to below the knee. Diagnosis is made with the straight leg raise to produce Lasègue’s sign
Femoral neck fracture – most commonly there will be a history of trauma or known severe osteoporosis (if it is a stress fracture); the patient will be unable to weight bear due to pain and the limb will appear shortened and externally rotated
33
how is hip OA managed?
pain control with analgesic ladder
lifestyle modifications - weight loss, regular exercise, smoking cessation
phsiotherapy
hip replacement is the definitive treatment
34
who are femoral shaft fractures commonly seen in ?
High-energy trauma
Fragility fractures in the elderly (low-energy trauma)
Pathological fractures (e.g. metastatic deposits, osteomalacia)
Bisphosphonate-related fractures
35
what are the clinical features of femoral shaft fracture?
pain in the thigh and or hip or knee pain
unable to weight bear
if severe there may be an obvious deformity
assess skin and do a full neurovascular examination
36
what classification is used for femoral shaft fractures?
The Winquist and Hansen Classification can be used to classify the degree of comminution to femoral shaft fractures:
Type 0 – No comminution
Type I – Insignificant amount of comminution
Type II – Greater than 50% cortical contact
Type III – Less than 50% cortical contact
Type IV – Segmental fracture with no contact between proximal and distal fragment
37
investigations for femoral shat fracture?
Plain XR AP and lateral of the entire femur, including the hip and knee
CT may be warranted is polytrauma is suspected
38
how is femoral shaft fracture managaed?
A-E stabalise patient
pain relief with opioid or regional block
immediate reduction and immobilisation
traction splinting used in isolated fractures of the mid-shaft femur
most femoral shaft fractures will require surgery within 24-48 hours
antegrade intramedullary nail
External fixation may be used in polytrauma or open fractures
39
what are distal radius fractures caused by?
fall on an outstretched hand
40
how are radius fractures classified?
Colles fracture - extra-articular fracture of the distal radius with dorsal angulation and dorsal displacement, within 2cm of the articular surface. This type of fracture typically occurs as a “fragility fracture” in osteoporotic bone.
Smiths fracture - volar angulation of the distal fragment of an extra-articular fracture of the distal radius (the reverse of a Colles fracture), with or without volar displacement.
Bartons fracture - This is an intra-articular fracture of the distal radius with associated dislocation of the radio-carpal joint.
A Barton fracture can be described as volar (more common) or dorsal (less common), depending on whether the volar or dorsal rim of the radius is involved.
41
risk factors for distal radius fracture?
```
increasing age
female gender
early menopause
smoking
alcohol
prolonged steroid use
```
42
what are the clinical features of a distal radius fracture?
the usually present following trauma
immediate pain +/-deformity
sudden swelling around the fracture
any neurological involvement could also result in paresthesia or weakness
43
what nerves should be assessed when there has be distal radius fracture?
Median nerve: motor – abduction of the thumb; sensory – radial surface of distal 2nd digit
Anterior interosseous nerve: opposition of the thumb and index finger*
Ulnar nerve: motor – adduction of the thumb (‘Froment’s Sign’); sensory – ulnar surface of the distal 5th digit
Radial nerve: motor – extension of IPJ of thumb; sensory – dorsal surface of 1st webspace
44
what investigations for distal radial fractures?
XR - 3 measurements on a plain XR can help with diagnosis of a distal radius fracture?
Radial height <11mm
Radial inclination <22 degrees
Radial (volar) tilt >11 degrees
45
how is a distal radial fracture managed?
if displaced they will require closed reduction - this will involve ensuring sufficient traction and manipulation under anaesthetic. It can be done wit haematoma black or Bier's block
A below elbow backslab cast - repeat XR after 1 week to check for displacement
Physio and rehab once sufficient bone healing has occurred.
if significantly displaced or unstable then surgical intervention then surgery may be required.
Options for surgical management include open reduction and internal fixation with plating or K-wire fixation.
46
what can fractures of the scaphoid bone lead to?
the fractures can compromise blood supple and lead to avascular necrosis and subsequent degenerative disease.
47
how does a scaphoid fracture present?
usually following trauma
sudden onset on wrist pain and bruising
tenderness in the floor of the anatomical snuffbox, pain on palpating the scaphoid tubercle and pain on telescoping the thumb.
48
what are the differentials for radial wrist pain following trauma?
distal radial fracture, an alternative carpal bone fracture, fracture of the base of the 1st metacarpal, ulnar collateral ligament injury, wrist sprain, or De Quervains tenosynovitis
scaphoid fracture
49
what investigations for scaphoid fracture?
XR
| sometimes not seen on plain XR so MRI is sometimes indicated
50
how is scaphoid fracture managed?
if undisplaced - strict immobilisation
displaced - fixed operatively - using a percutaneous variable pitched screw
51
what is carpal tunnel syndrome?
condition involving the compression of the median nerve within the carpal tunnel of the wrist due to a raised pressure within this compartment
52
risk factors for carpal tunnel syndrome?
```
female gender
age
pregnancy
obesity
previous injury
```
it is associated with other conditions such as diabetes mellitus, RA and hypothyroidism.
53
how does carpal tunnel present?
pain, numbness and/or paraesthesia throughout the median nerve sensory distribution
The palm is often spared, due to the palmar cutaneous branch of the median nerve branching proximal to the flexor retinaculum and passing over the carpal tunnel
- symptoms worse at night
- symptoms can temporarily relived b hanging the affected arm over the side of the bed or shaking it back and forth
- in later stages there may be weakness of thumb abduction and/or wasting of the thenar eminence
54
what can tests can produce sensory symptoms in carpal tunnel?
percussing over the median nerve (Tinel’s Test) or holding the wrist in full flexion for one minute (Phalen’s Test).
55
what are the differentials for carpal tunnel?
> Cervical Radiculopathy
C6 nerve root involvement may produce pain or paraesthesia in a similar distribution however will likely have an element of neck pain or symptoms involving the entire arm length
> Pronator teres syndrome (median nerve compression by pronator teres)
Symptoms will also extend to the proximal forearm and sensation of the palm will also be reduced
> Flexor carpi radialis tenosynovitis
This can be distinguished by tenderness at the base of the thumb
56
what investigations for carpal tunnel?
usually a clinical diagnosis
| if uncertain nerve conduction studies can be useful to confirm
57
how is carpal tunnel managed?
wrist splint
corticosteroid injection
surgery is only undertaken in severely limiting cases where other treatments have failed
Carpal tunnel release surgery decompresses the carpal tunnel, involving cutting through the flexor retinaculum, in turn reducing the pressure on the median nerve. This can be done under local anaesthetic and is performed as a day case.
58
what is dupuytren's contracture?
it is a common condition involving contraction of the longitudinal palmar fascia.
Typically starting as painless nodules, fibrous cords and flexion contractures develop at the MCP and interphalangeal joints, which can severely limiting digital movement and reduce patient quality of life.
59
what is the disease pattern of dupuytrens?
1. Initial pitting and thickening of the palmar skin and underlying subcutaneous tissue, with loss of mobility of overlying skin
2. A firm painless nodule begins to form, becoming fixed to the skin and the deeper fascia, gradually increasing inside
3. A cord then develops, resembling a tendon, which begins to contract over months to years
4. Contraction of the cord pulls on the MCP and PIP joints, leading to progressive flexion deformity in the fingers
60
risk factors for dupuytren's?
smoking
alcoholic liver cirrhosis
diabetes mellitus
occupational exposures (e.g. use of vibration tools or heavy manual work)
61
clinical features of dupuytren's?
reduced range of motion
nodular deformity
complete loss of movement
The ring and little finger are most commonly involved; however, the other digits may be involved. The condition is bilateral in 45% of cases
O/E - thickened band or firm nodule adherent to the skin may be palpable. Skin blanching may occur on active extension of the affected digits
Hueston’s test is a specific test that can be performed for such patients; if the patient is unable to lay their palm flat on a tabletop, this is a positive test.
62
investigations for Dupuytrens?
usually clinical
| routine bloods to assess for potential risk factors (LFTs, random glucose/HbA1C)
63
how is dupuytrens managed?
management depends on the stage of presentation.
if early presentation with no functional disability - just monitor and treat with conservative management
conservative - hand therapy - keeping hand active with stretching exercises
Injectable collagenase clostridum histolyticum (CCM)
Surgical management:
Regional fasciectomy, whereby the entire cord is removed (the most common approach)
Segmental fasciectomy, whereby only short segments of the cord are removed
Dermofasciectomy, whereby the cord and overlying skin are removed, to be followed by a skin graft
64
what is De quervain's tenosynovitis?
De Quervain’s tenosynovitis is inflammation of the tendons within the first extensor compartment of the wrist, resulting in wrist pain and swelling.
It is most common in women between the ages of 30-50, especially in those with occupations or hobbies involving repetitive movements of the wrist.
65
what tendons does De quervain's tenosynovitis involve?
De Quervain’s tenosynovitis involves the tendons of the extensor pollicis brevis and abductor pollicis longus.
66
risk factors for De Quervain's tenosyndovitis?
Age – most common between 30 and 50 years
Female gender
Pregnancy
Certain occupations or hobbies, especially those that involve repetitive movements of the hand and wrist, also increase the risk of developing the condition.
67
what are the clinical features of De quervain's tendosynovitis?
pain near base of the thumb
swelling
Movements involving grasping or pinching are particularly painful and difficult
On examination, there will be swelling and palpable thickening over the tendon group fibrous sheath. Finkelstein’s test is often positive.
68
what is Finkelstein's test?
The examiner applies longitudinal traction and ulnar deviation to the affected thumb.
Pain specifically at the radial styloid process and along the length of the extensor pollicis brevis and abductor pollicis longus tendons is a positive test for De Quervain’s tenosynovitis.
69
Differentials for De quervain's tendosynovitis?
Arthritis of Carpometacarpal (CMC) joint – more gradual in onset, usually with a negative Finkelstein’s Test and positive Grind test.
The Grind test involves forcefully pushing thumb against CMC joint whilst also rotating it slightly, with a positive result producing pain felt on the volar side of the wrist.
Intersection syndrome – tendons of the first compartment cross over with those of the second compartment, resulting in pain felt over the second compartment.
Wartenberg’s syndrome – neuritis of the superficial radial nerve, often seen in those wearing tight jewellery.
70
how is De quervain's tendosynovitis investigated??
De Quervain’s tenosynovitis is a clinical diagnosis, with no investigations required. However, a plain hand radiograph to exclude other diagnosis
71
how is De quervain's tendosynovitis managed?
conservative
avoid repetitive actions and a wrist splint
steroid injections
for those who dont respond to conservative - surgical decompression can be used
72
what is a ganglionic cyst?
Ganglionic cysts are non-cancerous soft tissue lumps that occur along any joint or tendon. They arise from degeneration within the joint capsule or tendon sheath of the joint, subsequently becoming filled with synovial fluid
usually found in the hand and feet
73
risk factors for ganglionic cysts?
female
OA
previous joint or tendon surgery
74
clinical features of ganglionic cyst?
smooth spherical painless lump adjacent to the joint affected
he lump will be soft and will transilluminate, however may mechanically restrict the full range of motion in the affected joint.
If the cyst exerts any pressure upon an adjacent nerve(s), the patient may present with localised paresthesia, pain, or motor weakness.
75
differenatials for ganglionic cyst?
Tenosynovitis – no discrete mass, with the swelling tracking along the tendon.
Giant cell tumour of tendon sheath – the mass is solid, does not translumuniate, and is fixed to the underlying sheath (therefore less mobile than a cyst).
Lipoma – This will not be entirely spherical and does not trans-illuminate.
Osteoarthritis – usually accompanied from a long standing OA of the scaphotrapeziotrapezoid joint, presenting as a palpable, hard, non-cystic, and immobile mass that does not trans-illuminate.
Sarcoma – typically are not well circumscribed or mobile lesions.
76
investigations for ganglionic cyst?
XR
USS
Aspiration for symptomatic relief
77
management of ganglionic cyst?
If the cyst does not cause any pain, the usual recommended treatment is to simply monitor, as cysts often disappear spontaneously without further intervention.
If the cyst causes pain or severely limits range of movement, there are two main interventions that can be performed:
Aspiration +/- steroid injection*, although this is associated with infection and high rate of recurrence.
*There is only limited evidence demonstrating a clear benefit of steroid injections in ganglion.
Cyst excision, removing the cyst capsule along with a portion of the associated tendon sheath (recurrence is less than with aspiration, but still possible)
Often reserved for symptomatic cases with recurrence following aspiration.
78
what is trigger finger?
Trigger finger (stenosing flexor tenosynovitis) is a condition in which the finger or thumb click or lock when in flexion, preventing a return to extension.
It can affect one or more tendons of the hand, with most cases occurring spontaneously in otherwise healthy individuals. It has a prevalence of approximately 2 in 100 people and can be associated with other conditions, including rheumatoid arthritis, amyloidosis, and diabetes mellitus.
79
what are the risk factors of trigger finger?
The main risk factor for developing trigger finger is having an occupation or hobby that involves prolonged gripping and use of the hand.
Other risk factors include rheumatoid arthritis, diabetes mellitus, female gender, and increasing age.
80
what are the clinical features of trigger finger?
Patients with a trigger finger will often initially report a painless clicking/snapping/catching when trying to extend their finger (most commonly middle or ring finger). More than one finger can be involved at a time and it may be bilateral.
Over time, this may become painful, especially over the volar aspect of the metacarpophalangeal joint, and the digit starts to lock in flexion.
On examination, the proximal aspect of the phalanx should be palpated to assess for any clicking, pain associated with movement, and any lumps or masses.
81
differentials for trigger finger?
Dupuytren’s contracture – this differs in that the flexion is painless, fixed and cannot be passively corrected
Infection (within tendon sheath) – usually preceded with trauma and the finger becomes swollen, erythematous, and tender, with passive movement of the digit causes marked pain
Ganglion – involving a tendon sheath
Acromegaly – excessive growth hormone results in swelling of flexor synovium within tendon sheath due to increased extracellular volume, limiting both flexion and extension in the affected digit
82
investiagtions for trigger finger?
diagnosis is clinical
83
management of trigger finger?
conservative: advice regarding activities and a small spilnt
steroid injection
surgery - percutaneous trigger finger release
84
risk factors for knee OA?
Genetic factors – Estimates suggest a genetic component for hand, knee and hip OA at around 40-60%, however the specific genes involved remain largely unknown
Constitutional factors – Factors including increasing age, female gender, obesity, and low bone density (specifically in the progression of OA)
Local factors – Previous joint injury, occupational or recreational stresses on the joint, reduced surrounding muscle strength, or any joint laxity or malalignment
85
clinical features of knee OA?
pain around the knee - can radiate to the thigh and hip
exacerbated by exercise and relived by rest
often bilateral disease
joint stiffness
reduced function
reduced range of movement
crepitus in severe cases
86
what are the differentials of OA?
meniscal or ligament injury
referred pain from another joint or the back
crystal arthropathies
patellofemoral arthritis
87
investigations for knee OA?
XR
88
how is knee OA classsified?
The Kellgren and Lawrence system can be used to classify the severity of knee OA:
Grade 0 – no radiographic features of OA are present
Grade 1 – unclear joint space narrowing and possible osteophytic lipping
Grade 2 – definite osteophytes and possible joint space narrowing on AP weight-bearing views
Grade 3 – multiple osteophytes, definite joint space narrowing, evidence of sclerosis, and possible bony deformity
Grade 4 – large osteophytes, marked joint space narrowing, severe sclerosis, and definite bony deformity
89
what is the ACL?
The ACL is an important stabiliser of the knee joint, being the primary restraint to limit anterior translation of the tibia (relative to the femur) and also contributing to knee rotational stability (particularly internal). Consequently, a tear of this important ligament often results in significant functional impairment of the joint.
90
clinical features of ACL tear?
they will have a history of an athlete twisting the knee whilst weight bearing
usually occur without contact and occur from a sudden change of direction twisting the flexed knee
```
unable to weight bear
rapid joint swelling
significant pain
lachman test
anterior draw test
```
91
differentials for ACL tear?
```
roximal tibial or or distal femur fracture
a meniscal tear
collateral ligament tear
a quadriceps tendon
patellar ligament tear
```
92
investigations for ACL tear?
plain XR
MRI of the knee
50% of ACL tears will also have a meniscal tear with the medial meniscus is the most commonly affected
93
how is ACL tear managed?
RICE (rest, Ice, compression and elevation)
conservative - rehab - utilises strength training of the quadriceps to stabilise the knee
surgical reconstruction of the ACL - this involves the use of a tendon or an artifical graft
94
posterior cruciate ligament tear?
A Posterior Cruciate Ligament (PCL) tear is a less common injury to the knee join. The PCL is the primary restraint to posterior tibial translation and works to prevent hyperflexion of the knee.
PCL tears typically occur in high-energy trauma, such as a direct blow to the proximal tibia during a RTA, or less commonly in low-energy trauma when there is hyperflexion of the knee with a plantar-flexed foot.
95
clinical features and investigations for posterior cruciate ligament tear?
A torn PCL will result in immediate posterior knee pain. There will be an instability of the joint and a positive posterior draw test (with a posterior sag) on examination.
As with ACL tears, the gold-standard for diagnosis for PCL tears is via MRI scanning.
96
what is the management of posterior cruciate ligament tear?
PCL tears can often be treated conservatively in the first instance with a knee brace and physiotherapy. If the patient continues to be symptomatic and has recurrent instability of their knee joint then they may require surgery with insertion of a graft.
If it is associated with other injuries, such as meniscal tears or a multi-ligament injury, then specialist knee surgery for reconstruction is often required.
97
what is the MCL function?
| medial collateral ligaments
The MCL primary function is to act as a valgus stabiliser of the knee
98
What usually causes and MCL tear?
is most often injured when external rotational forces are applied to the lateral knee, such as a impact to the outside of the knee.
99
how is MCL tear graded?
Grade I – mild injury, with minimally torn fibres and no loss of MCL integrity
Grade II – moderate injury, with an incomplete tear and increased laxity of the MCL
Grade III – severe injury, with a complete tear and gross laxity of the MCL
100
clinical features of MCL tear?
typically occurs after trauma to the lateral aspect of the knee
usually due to a direct blow in a valgus stress direction.
may report hearing a pop with immediate medial joint line pain
swelling tens to follow a few hours later
The main clinical finding on examination will be increased laxity when testing the MCL*, via the valgus stress test. The patient will be extremely tender along the medial joint line, but may be able to weight bear.
101
differentials of MCL tear?
fractures
meniscal injury
multi-ligament tears
102
investigations of MCL tear?
Any patient following trauma with significant knee pain and swelling should have a plain film radiograph to exclude any fracture.
The gold-standard investigation to confirm the diagnosis for an MCL tear is via MRI scanning, delineating the exact extent and grade of the tear.
103
management of an MCL tear?
Grade I Injury: Rest, Ice, Compression, and Elevation (RICE) with analgesia (typically NSAIDs) as the mainstay. Strength training as tolerated should be incorporated, with an aim to return to full exercise within around 6 weeks.
Grade II Injury: Analgesia with a knee brace and weight-bearing/strength training as tolerated. Patients should aim to be able to return to full exercise within around 10 weeks
Grade III Injury: Analgesia with a knee brace and crutches, however any associated distal avulsion then surgery is considered. Patients should aim to be able to return to full exercise within around 12 weeks.
