WK9 - Acute Knee and Below Knee Injuries Flashcards

Question

What is the Tx for meniscal injuries?

Answer 1

Operative intervention, arthroscopy especially for younger athletes *Meniscectomy  Partial resection (removal) 6-8 weeks recovery Create a smooth margin so weight-bearing does not cause pain *Meniscal repair (preferred) Recovery 2x of resection, 12-16w First 4 weeks non-weight bearing in knee splint Week 5-8, knee brace allows 0-90 degrees *Avoid extreme movements (hyperflexion/extension) but allow strength building --> After 8 weeks, agility training then another 4-6 weeks to get up to prior level

Answer 2

Females 10x more likely Usually have an underlying predisposition Mechanism -Flexed knee under valgus loading (jumping) Signs -may stick out -May reduce spontaneously *Looks normal but swell afterwards *Important to look at Hx/observation/patient description -Lump visible on LAT side *Patella does not naturally/usually displace MED ALWAYS LAT -Knee flexed to about 20deg -Tender MED side of patella *When patella dislocates, tears MED patella retinaculum -Knee swells rapidly *Other cause of big swollen knee after injury (other one is ACL)

Answer 3

-May reduce with passive extension *Eg if pick up leg while being carried off field -Knee splint *Only leave it on until they feel comfortable again *Long term splinting is bad -Should have early movement -X-ray for loose fragment (or MRI) *If a piece of patella gets knocked off during displacement *Will need arthroscopic removal -Commence quads drill early

Answer 4

- 50% chance after single dislocation of having another one - 90% chance of redislocation after 2nd one

Answer 5

- realignment is effective - tibial tubercle transfer --> move tibial tubercle (from LAT position) to change forces --> align mechanism of patellofemoral joint --> low rate of redislocation

Answer 6

1 in 5 players sustains an injury every season - most common hamstrings, ankle, knees - at least 1 previous injury/reduced lower limb function score has a significant increased risk of sustaining new injury of same kind during 8month follow-up period *Important for us to RECOGNISE and REMOVE

Answer 7

OA Rules - pain on dorsal side of 1 or both malleoli - palpation pain at base of metatarsal 5 - palpation pain of navicular bone -inability to walk at least 4 steps - rule out fractures and reduce need for x-rays Sensitivity --> 86-99% specificity --> 25-46%

Answer 8

- more POS than ANT, around where ligament attaches - various attachments to one could cause periosteal disruptions and thus pain on palpation but may not be due to fracture

Answer 9

pain with axial compression is similar to putting weight on foot --> get xray - swelling -inability to weight bear - deformity, instability, crepitating RULES 4 - deformity, instability, crepitating 2 - inability to weight bear, axial compression pain 2 - tibia palpation pain and swelling 1 - fibula palpation pain and swelling 1- Achilles tendon palpation pain and swelling 1 - base of 5th metatarsal 1 - haematoma/haemarthrosis Age divided by 10 Radiography required if >8 when added up Sensitivity = 59% Specificity = 84%

Answer 10

LAT aspect of knee! Maisonneuvre fracture (prox fibula) - usually accompanies unstable ankle injury --> force enters through ankle and travels up to fibular - likely not weight-bearing, as it is a significant injury

Answer 11

- controls AP draw, taut during PF (restrain against PF) - primary restraint against pathologic PF - 2 parts - 1 part is within synovium, usually does not heal well - if there is no pain on palpation of ATFL, unlikely there is actue LAT ligament rupture

Answer 12

Calcaneofibular ligamnet - runs below subtalar joint, holds subtalar joint - controls inversion, taut in DF

Answer 13

- comes into play with ankle dislocation Does not have a lot to do with PF?

Answer 14

-60% of patients with acute LAS have pain on level of medial malleolus -40% of patients with acute LAS have pain over AITFL without rupture of ligament (anterior inferior tibiofibular ligament) -Delayed physical examination (4-5 days) is more reliable than physical examination within 48 hours *In terms of specificity and sensitivity in diagnosing *Allow for everything to settle -Only ~50% of individuals who have a LAS will seek medical attention for it -40% of individuals who sustain LAS will develop chronic ankle instability (CAI) and may not be able to RTP

Answer 15

-ATFL disrupted = excessive anterior movement compared to other side  positive anterior draw test -Forward translation of talar dome relative to tibia *Could potentially be due to old injuries -Compared to healthy ankle -Combination with other tests allows for degree of laxity to be determined *Eg. Prone anterior draw test

Answer 16

-Positive anterior drawer test + pain on palpation of ATFL and hematoma discoloration *98% Sensitivity *84% Specificity -May not need expensive tests like MRI, CT, x-ray etc -Ultrasonography has similar sensitivity (92%) but lacks specificity (64%) compared with delayed examination

Answer 17

Inflammatory phase (immediate) Proliferative (6WKs-3months) Remodelling phase (up to 1y post-trauma)

Answer 18

- PRICE/RICE/POLICE - bracing // casting

Answer 19

*No evidence that RICE alone/cryotherapy/compression therapy alone has any positive influence on pain, swelling or patient function -No role for RICE alone in treatment of acute LAS *Joint cooling does not adversely affect muscle reaction time or muscle amplitude provided you don’t leave it on too long *Cooling doesn’t affect other specific components of neuromuscular control such as joint position sense *Ice can be applied before ankle rehab without adversely affecting dynamic control -Effects should be limited to 10 minute applications of either wet-ice application or cold-water immersion

Answer 20

Lancet 2019 study on simple ankle strains *The ones who did the best were those in plaster casts -Min. 4wks in lower leg cast following acute LAS = less optimal outcomes compared with functional support and Ex strategies for 4-6wks *Maybe max. 10-14 days immobilization, allow other professionals to determine recovery course of action -Use lace-up or semi-rigid ankle brace = better outcomes compared to other functional types of treatment like sports tape or kinesiotape *Good for immobilization and preventing reinjury

Answer 21

*Copers are those who suffered ankle sprains and have no residual symptoms *Non-copers are those who suffer from CAI

Answer 22

- ankle corrects for small errors in faulty foot placement - hip corrects for larger errors in faulty foot placement - poor hip ADB/errors in hip mechanics will alter the way you land and increase likelihood of stress and inversion --> CAI --> shows how instability or problems at 1 level can affect the ankle --> injury at 1 level --> can't control at subtalar joint --> need to work harder at hip but if can't control at hip then leads to more ankle instability

Answer 23

- ANT tibialis works less than half compared to healthy people - CAI people overuse the peroneus longus, MED gastroc and glute medius muscles compared to healthy people ** fibularis longus compensating for lack of ankle stability --> LAT compartment pain, fibularis longus tendonitis ** if muscles are not activating at the right time (e.g. too early in the swing phase) --> potentially more fatigue-aggravated ankle instability/laxity ^^ could be normalised with ankle bracing or taping

Answer 24

-Achieving an equilibrium between the combined goals of stopping downward velocity of body and preventing collapse of lower extremity -Increase hip flexion is one component of a preparatory strategy for CAI group to attempt to reduce risk of impact -Eg jumping and landing on soft surface --> bend more to compensate for lack of ankle instability and balance -Even if they don’t have pain but you notice them doing ^, may indicate CAI

Answer 25

LAT/Talar Dome Injuries (Mortise and Tenon Joint) "OCD" fracture * inversion with PF or atraumatic - small piece that wasn't fused on and is jamming/getting caught - if people complain ankle is giving way but do not have hypermobility/ligamentous laxity, potentially have OCD

Answer 26

- inversion with PF or atraumatic (MED side) - inversion with DF - forced PF jamming (people who are consistently "on pointe" - point tenderness over LAT process (ANT and INF to the LAT malleolus) due to fracturing - fracture at neck of talus - fracture of ANT calcaneal process (articulates with cuboid) - not common - Jones fracture - overuse traction apophysitis

Answer 27

*Tenderness to deep palpation anterior to Achille’s tendon over posterolateral talus instead of over Achille’s *10% of population will experience, may be asymptomatic until plantarflexion *Plantar flexion may reproduce pain

Answer 28

"Snowboarders ankle" due to forces going through the area in the common snowboarding position - may require surgical incision if there is non-union

Answer 29

Chopart Joint -Between talonavicular and calcaneocuboid midfoot joint/Bifurcate joint between calcaneus, cuboid and navicular ?? -Part of joint process that holds up arch -Many ligaments in this area -Dorsal ligaments between cuboid and calcaneus If ligaments are stretched, could cause disruption and an avulsion fracture If ligaments are compressed, could cause compression fracture – fracture depends on joint movement ^ may be good to brace

Answer 30

* TN - talonavicular (top bony structure) * bifurcate ligament (middle) * DCC - Dorsal Calcaneocuboid Ligament (slightly below bifurcate ligament

Answer 31

*Involves 4th and 5th metatarsal articulation *Tendon of fibularis tertius and brevis are pulling in opposing directions *Typically a stress fracture leading to a fracture *If you miss this fracture, little chance of healing well *Vascular considerations -Zone 1 – avulsion not a big deal -Zone 2 – articulating btw 4th and 5th, differential forces, poor blood supply, don’t heal very well -Zone 3 – likely overuse, will break

Answer 32

*Growth plate and avulsion in different directions -Avulsion horizontal but growth plate is vertical *Traction apophysitis of 5th MT *Usually no surgical options, just conservative in boot *Can take some time to show evidence of healing -Clinical signs but radiologically not filled in yet

Answer 33

T! MED collateral (deltoid) ligament attaches to the POS tibiotalar, tibiocalcaneal, tibionavicular and ANT tibiotalar

Answer 34

* ANT deltoid under max. tension when PF * mid portion of deltoid tension when hyperpronated * EXT ROT = deep deltoid ligament * ABD/Eversion = superficial deltoid ligament

Answer 35

tibia down to talus, navicular and sustentaculum tali spring ligament ST to navicular --> sitting underneath, supporting talus/talonavicular head * creates socket and support for head of talus * most essential ligament in maintaining MED longitudinal arch

Answer 36

1. Spring ligament 2. Short plantar ligament 3. long plantar ligament 4. plantar aponeurosis

Answer 37

- Provide med stability to tibiotalar joint by providing a firm fixation between tibia and talus - Prevent talus shifting into a valgus position or to move anterolaterally or externally rotate - Prevent talus (med) shifting more than 2mm laterally, even if lat structures aren’t in place - Pos tibiotalar ligament restricts int rot of talus (deep fibers) - Sequential cutting of superficial ligament still results in ankle stability - Gross instability of ankle develops if deeper fibers of ligaments are cut (surgically) - Difficult to surgically repair

Answer 38

- Without deltoid ligament forces go through ankle and fracture fibula (Maisonneuve) - Isolated deltoid ligament injuries are rare (3-4%) * Usually with deltoid involved, other structures are injured as well

Answer 39

*47 ankles with chronic lateral ankle instability with no medial ankle pain, deltoid ligament injuries were observed in 72% of ankles *In subgroup of patients with MRI evidence of lateral ligament injury, incidence of deltoid injury was 35% signs: tenderness at MED gutter of ankle joint

Answer 40

-Movement into supination-external rotation -Eversion-pronation ^ stress deltoid ligament -Single heel raise is not indicative or diagnostic for deltoid ligament (test for tibialis posterior or lateral ligaments)

Answer 41

Think about the line around the pos side of the med ankle bone!! -Posterior tibial tendonitis *Unsteady gait *Difficulty pointing toes inwards *Failed heel raise Test for ^: -Squeeze tennis ball between medial ankles and raise up on toes -From valgus heel position to varus -Activation of tibialis posterior ^ excess bit of bone which can be a source of injury, kind of sticks to navicular and can be disrupted during injury  pain over navicular

Answer 42

-Planted foot, pronating + externally rotating then blow at knee -Rotational forces at mortise and tenon joint – major stress - EXT ROT mechanisms - longer recovery - occurs in sports such as Hockey and Skin

Answer 43

DF: talus snug in joint between malleoli and against trochlear surface PF: not snug

Answer 44

-Widening the ankle mortise by 1mm decreases the contact area of tibiotalar by 42%  instability and early arthritis (severe) *Bracing may be a good idea because every time you walk, the tibio-fibular joint springs apart and could cause it to heal in a widened position, leading to instability after recovery

Answer 45

External rotation test * Place knee at 90 degrees with ankle at neutral * Apply an external rotation force Squeeze test * Compress proximal tibia and fibula * Positive test occurs at level of ankle joint * Pain more proximally should alert suspicion of proximal fibula fracture Crossover test * Pressure applied to externally rotate ankle  Patient pushes down on foot * Pain will be felt with disruption of syndesmosis (not seen with LAS) * Patient lead, will stop if pain is too bad

Answer 46

-Bracing -Tight-rope (surgical correction) *Rope holding pieces together *Tighten rope until it can’t be tightened anymore *Rope will break eventually but scar tissue should be able to hold it together -Screw *But will need to have surgery again to come out, not preferred because ankle should have some degree of mobility

Answer 47

Compartment syndrome Acute * Direct trauma or fracture * Compromise neurovascular bundles  Muscles may not be receiving adequate perfusion  Irreversible damage * Not very common * Signs:  Pain and swelling in shin, numbness in foot and toes Chronic * Fascia thickening  Continuous running can cause muscle hypertrophy but compartment doesn’t expand as well, trigger stimulus to fascia (muscle attaches to it)  can cause fascia to thicken  Can be congenitally thicker * Pressure can decrease after rest * Exertional compartment syndrome more likely to happen on anterior side  Back of leg is less contained than anterior

Answer 48

Important: - Ask about patient history * Friis’ example – creatine caused increase in muscle size due to water retention causing chronic compartment syndrome Tests: - Pressure testing

Answer 49

Fasciotomy *Pressure can build up again *May do fasciectomy instead Removes attachment site of anterior compartment muscles Reduces recruitment ability of these muscles

Answer 50

Fasciotomy *Pressure can build up again *May do fasciectomy instead Removes attachment site of anterior compartment muscles Reduces recruitment ability of these muscles

Answer 51

-Pain when tapping over the shin -Do not heal properly and can take a very long time Mechanism: -Tibial Vara -Overstriding when running *Contact/lead foot in front of center of mass -Others

Answer 52

-Pain when tapping over the shin -Do not heal properly and can take a very long time Mechanism: -Tibial Vara -Overstriding when running *Contact/lead foot in front of center of mass -Others

Answer 53

-Change technique for running -Center of mass over the foot -Forefoot landing so less forces going through heel *Reduce stride length, increase step rate -Nail

Answer 54

-Direct trauma to lateral calf -Initial x-rays normal -Torsional stress aggravates periosteal damage *Particularly in jumping sports -Serial radiology may be necessary -Early rest for better long term results -Presents/diagnosed as calf strain or peroneal tendonitis (associated with lateral ankle ligament injury)

Answer 55

L (always lateral side of calf) If you don't stop torsional forces going through fibular then it will progress to a full fracture.

WK9 - Acute Knee and Below Knee Injuries Flashcards

(79 cards)