Soft tissue knee injuries

Question 1

Which meniscal tears are most common?

Answer 1

Medial meniscal tears

Question 2

Why are medial meniscal tears most common?

Answer 2

Medial is more fixed, less mobile

Pivoting force centred on medial

Question 3

When do meniscal injuries classically occur?

Answer 3

Twisting force on loaded knee

Question 4

Where is pain in meniscal tears?

Answer 4

Localized to medial (majority) or lateral joint line with effusion the following day

Question 5

Clinical features of meniscal tears?

Answer 5

Effusion
Joint line tenderness & pain
Pain on tibial rotation (Steinmann's test)
Locked knee 
\+ve meniscal provocation test

Question 6

Variations of meniscal tears?

Answer 6

Longitdunal
Radial
Oblique
Horizontal
Bucket handle

Question 7

“Bucket handle tear”?

Answer 7

Large meniscal fragment is able to flip out normal position and displace anteriorly or into intercondylar notch where knee locks
Unable to fully extend

Question 8

Investigations for meniscal tears?

Answer 8

MRI

Question 9

Management of meniscal tears?

Answer 9

Arthroscopic meniscal repair (only in acute, longitudinal (peripheral) tears involving outer 1/3)

Question 10

When is arthroscopic meniscectomy considered?

Answer 10

For irreparable tears with recurrent pain, effusion or mechanical symptoms (clicking, locking etc) if doesn’t settle for 3 months or if degenerate changes on radiology

Question 11

Treatment for acute locked knee from displaced bucket handle meniscal tear?

Answer 11

Urgent surgery

If irreparable -> partial meniscectomy

Question 12

Has the meniscus got good healing potential and why?

Answer 12

No

Only has blood supply in outer 1/3

Question 13

Degenerate meniscal tears?

Answer 13

As meniscus weakens with age
Spontaneous to innocuous injury
Steinmann negative

Question 14

Treatment for degenerate meniscal tears?

Answer 14

No improvement with resection and not treated with arthroscopy

Question 15

History for ACL rupture?

Answer 15

High rotational force leading to internal rotation force on tibia in high impact sport
“Pop” heard

Question 16

ACL?

Answer 16

Main stabiliser against internal rotation of tibia

Question 17

Clinical features of ACL rupture?

Answer 17

Haemarthrosis within hour of injury
Deep pain in knee
Chronic rotatory instability (knee goes way when turning on planted foot)

Question 18

Clinical examination in ACL rupture?

Answer 18

Knee swelling (haemarthrosis or effusion) 
Excessive anterior translation of tibia on anterior drawer test & Lachman test

Question 19

Management of ACL rupture?

Answer 19

Primary repair not effective

Reconstruction

Question 20

When is ACL reconstruction considered?

Answer 20

Straight away for sports people who need to get back asap
If knee gives way on sedentary activity
Strong desire to get back to high impact sport but cannot despite physio

Question 21

PCL rupture?

Answer 21

Direct blow to anterior tibia or hyperextension injury
Isolated rare (usually with another injury)

Question 22

Clinical features of PCL rupture?

Answer 22

Popilteal knee pain & bruising

Recurrent hyperextension or feeling unstable going down stairs

Question 23

Management of PCL rupture?

Answer 23

Most isolated ones do not need reconstruction

If part of multiple- ligament knee injury -> reconstruction

Question 24

MCL injuries?

Answer 24

Uncommon, MCL is a forgiving knee ligament

Healing is expected

Question 25

Clinical features of MCL tears?

Answer 25

Laxity | Pain on valgus stress with tenderness over origin or insertion of MCL

Question 26

Treatment of acute MCL tears?

Answer 26

Hinged knee brace

Question 27

Treatment of chronic MCL instability?

Answer 27

MCL tightening (advancement) or reconstruction with tendon graft

Question 28

LCL tears common or uncommon?

Answer 28

Uncommon

Question 29

Clinical features of LCL tears?

Answer 29

Marked instability on rotational movement Peroneal nerve injury Often part of multilligament injuries Vascular injury (popliteal artery. intimal or complete tear)

Question 30

Does LCL teat heel well?

Answer 30

Doesn't heal | Can cause virus and rotator instability

Question 31

Treatment for LCL tears?

Answer 31

Usually surgical with early repair or late reconstruction with tendon graft

Question 32

Combined knee ligament ruptures & dislocation?

Answer 32

Often require surgical reconstruction

Question 33

Management of complete knee dislocations?

Answer 33

Reduced as emergency External fixation for temporary stabilization Check for neurovascular injury Check feet

Question 34

If concern with distal circulation after complete combined knee ligament rupture and dislocation?

Answer 34

Vascular surgery assessment & vascular stenting or bypass may be required

Question 35

What can reperfusion cause?

Answer 35

Compartment syndrome

Question 36

What do combined knee ligament and dislocations usually require?

Answer 36

Multiple ligament reconstruction

Question 37

Complications of knee dislocation?

Answer 37

Popliteal artery injury (tear, intimal tera, thrombosis) Nerve injury - common perineal nerve Compartment syndrome

Question 38

Management of knee dislocation?

Answer 38

Emergency reduction Recheck neuromuscular status May need ex-fix for temporary stabilisation Multiligament reconstruction after