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Year 3 - Surgery > 2.08 Trauma and Orthopaedics - The Knee > Flashcards

2.08 Trauma and Orthopaedics - The Knee Flashcards

1
Q

What muscles is the iliotibial band the aponeurosis of?

A
  • tensor fascia latae
  • gluteus maximus
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2
Q

What is the pathology of iliotibial band syndrome (ITBS)?

A
  • inflammation of the iliotibial band
  • repetitive flexion and extension of the knee, causing impingement of the band against the femoral condyle
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3
Q

What are the risk factors for ITBS?

A
  • athletes (ie. repetitive flexion and extension)
  • foot pronation
  • hip abductor weakness
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4
Q

What are the clinical features of ITBS?

A
  • lateral knee pain
  • exacerbated by exercise
  • patients take part in frequent exercise or sudden increase in intensity (e.g. training for marathon)
  • pain worsened running downhill
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5
Q

What are the special tests for ITBS?

A
  • Nobles test: patient lies supine and examiner places finger on lateral femoral condyle, with knee slowly extended. Positive test if pain is felt at 30° extension.
  • Renne test: patient asked to squat and examiner places pressure on lateral epicondyle. Positive test is pain is felt at 30° of flexion.
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6
Q

What are the differential diagnoses of ITBS?

A
  • degenerative joint disease
  • fractures
  • ligamentous injury
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7
Q

What investigations are warranted for ITBS?

A
  • MRI to exclude other pathology

Diagnosis of ITBS usually clinical. Imaging not needed to make diagnosis.

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8
Q

What is the management of ITBS?

A
  • modify activity
  • simple analgesia
  • local steroid injections
  • physiotherapy
  • surgical release of iliotibial band if severe
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9
Q

What are the risk factors for knee OA?

A
  • genetic factors
  • increasing age
  • female gender
  • obesity
  • low bone density
  • previous joint injury
  • occupation stress on joint
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10
Q

What are the clinical features of knee OA?

A
  • pain
  • radiates to hip
  • exacerbated by exercise
  • relieved by rest
  • bilateral disease
  • joint stiffness
  • reduced function
  • joint swelling

OE reduced ROM and crepitus

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11
Q

What are the differentials for knee OA?

A
  • meniscal or ligamentous injury
  • referred pain from joint or back
  • crystal arthropathies (e.g. psuedogout)
  • patellofemoral arthritis
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12
Q

What are the diagnostic features of knee OA that can be seen on lateral and AP plain film radiographs?

A

LOSS:
- Loss of joint space
- Osteophytes
- Subchondral sclerosis
- Subchondral cysts

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13
Q

Name the system used to classify knee OA.

A

Kellgren and Lawrence system.

See image.

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14
Q

What is the management of knee OA?

A
  1. Lifestyle modifications, including:
    - weight loss
    - regular exercise
    - smoking cessation
  2. Simple analgesia, ensuring ongoing mobility and quality of life.
  3. Physiotherapy to slow disease progression and improve joint mechanics.
  4. Surgical management:
    - total knee replacement (TKR) - expected to function for at least 10 years
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15
Q

What is patellofemoral OA?

A

Osteoarthritis affecting the articular cartilage along the trochlear grove and on the underside of the patella.

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16
Q

What are the clinical features of patellofemoral OA?

A
  • anterior knee pain
  • worse with activities that put pressure on the patella, for example climbing a flight of stairs
  • joint stiffness and swelling

Diagnosis confirmed using plain film radiographs using skyline view.

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17
Q

What are the functions of the menisci?

A
  • shock absorbers for the knee joint
  • increase articulating surface area
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18
Q

What is the most common cause for meniscal tears?

A
  • trauma related injury (ie. twisting of knee while flexed and weight bearing)
  • degenerative disease (more common in elderly patients)
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19
Q

What is the most common type of meniscal tear?

A

Longitudinal tear - AKA Bucket-Handle tear.

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20
Q

What are the clinical features of meniscal tears?

A
  • tearing sensation
  • sudden-onset intense pain
  • slow swelling over 6-12 hours
  • ?locked in flexion

OE joint line tenderness, significant joint effusion, limited knee flexion.

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21
Q

What special tests can be used to identify meniscal tears?

A

McMurray’s test or Apley’s Grind Test

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22
Q

What are the differential diagnoses for meniscal tears?

A
  • fracture
  • cruciate ligament tear
  • collateral ligament tear
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23
Q

What are the investigations for meniscal tears?

A
  • plain film radiograph to exclude fracture
  • MRI gold standard to confirm a meniscal tear - can also classify
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24
Q

What is the management of meniscal tears?

A
  • RICE (rest, ice, compression, elevation)
  • small (<1cm) will heal spontaneously

If tears are large or pt persists symptomatic, arthroscopic surgery is indicated.

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25
Q

What are the complications of meniscal tears?

A
  • secondary osteoarthritis

Knee arthroscopy carries a risk of DVT and damage to local structures.

26
Q

When performing knee arthroscopy, which local structures are at risk of becoming damaged?

A
  • saphenous vein
  • saphenous nerve
  • peroneal nerve
  • popliteal vessels
27
Q

What is the respective functions of:

  • ACL
  • PCL
A
  • ACL limits anterior displacement of the tibia on the femur
  • PCL limits posterior displacement of the tibia on the femur
28
Q

What are the clinical features of ACL tear?

A
  • history of twisting the knee whilst weight bearing
  • unable to weight bear
  • rapid joint swelling
  • significant pain
  • instability
29
Q

Explain the reasoning behind the difference in joint swelling in ACL verus meniscal tears.

A

Meniscus has poor vascular supply while ACL is highly vascular, hence damage to ACL results in a haemarthrosis.

ACL tear causes haemarthrosis within 30 mins.

30
Q

What special tests can be used to identify ACL tear?

A
  • Lachman test
  • Anterior Draw test

Posterior Draw test to identify PCL tear

31
Q

How are ACL tears investigated?

A
  • plain film radiograph of knee (AP and lateral) to exclude bony injuries
  • MRI scan of knee is gold standard
32
Q

What are the most common structures damaged secondary to ACL tear?

A
  • avulsion fracture of lateral proximal tibia (Segond fracture)
  • medial meniscal tear (as ACL attached)
33
Q

What is the management of ACL tears?

A
  • RICE (rest, ice, compression, elevation)

Conservative management involves rehabilitation, using strength training of the quadriceps to stabilise the knee.

Surgical reconstruction of the ACL, is patient remains symptomatic following conservative methods of treatment.

34
Q

What is the most common complication of ACL tear?

A
  • post traumatic osteoarthritis
35
Q

What is the typical MOI in PCL tear?

A
  • high energy trauma
36
Q

What is the most commonly injured ligament of the knee?

A

Medial collateral ligament

37
Q

What are the respective functions of:

a) medial collateral ligement
b) lateral collateral ligament

A

a) resists valgus forces and strain to the knee
b) resists varus forces and strain to the knee

38
Q

What are the clinical features of MCL tear?

A
  • trauma to lateral aspect of the knee
  • pop heard upon injury
  • immediate medial joint line pain
  • swelling follows after a few hours
  • increased laxity of MCL via valgus stress test
39
Q

What are the main differentials for MCL tear?

A
  • fractures
  • meniscal injury
  • multi-ligament tears (e.g. MCL and ACL)
40
Q

What are the investigations of MCL tear?

A
  • plain film radiograph (lateral and AP) to exclude fracture
  • MRI scanning gold standard
41
Q

How is MCL tear managed?

A
  • RICE (rest, ice, compression, elevation)
  • analgesia
  • strength training
  • knee brace / crutches if difficulty weight bearing
  • surgery considered if distal avulsion fracture on MRI

Patients should aim to be able to return to full exercise within around 12 weeks.

42
Q

What are the complications of MCL tear?

A
  • instability of the joint
  • damage to saphenous nerve
43
Q

What is the typical MOI of patella fractures?

A
  • direct trauma to patella (e.g. dashboard injury in RTA)
  • rapid eccentric contraction of quadriceps muscle
44
Q

What are the clinical features of patella fracture?

A
  • anterior knee pain
  • pain worse with movement
  • unable to straight leg raise (ie. damage to extensor mechanism)
  • ?unable to weight bear
  • significant swelling
  • bruising
45
Q

What are the differential diagnoses of patella fractures?

A
  • tibial plateau fracture
  • distal femur fracture
  • ligamentous injury
  • quadriceps tendon rupture
46
Q

What is a bipartite patella?

A

A congenital condition affecting 3% of the population, whereby there is failure of patella fusion, leaving two separate bony fragments of the patella joined only be fibrocartilaginous tissue.

47
Q

What investigations are used to diagnose patella fractures?

A
  • plain film radiograph (AP, lateral, skyline view)
  • CT indicated in comminuted fractures
48
Q

How are patella fractures managed?

A

Conservative management used in cases of non-displaced or minimally displaced fractures:
- leg placed in brace or cast
- early weight bearing in extension

Surgical management indicated if there is significant displacement or compromise to the extensor mechanism:
- ORIF
- screw fixation

49
Q

What are the complications of patella fractures?

A
  • reduced ROM
  • secondary osteoarthritis
50
Q

What is the most common MOI of tibial plateau fractures?

A
  • high energy trauma (e.g. fall from height, RTA)
51
Q

What are the clinical features of tibial plateau fractures?

A
  • history of trauma
  • sudden onset pain
  • unable to weight bear
  • swelling of the knee (lipohaemarthrosis)

OE: tenderness, ligament instability, ?peripheral neurovascular compromise

52
Q

What are the differential diagnoses for patella fracture?

A
  • knee dislocation
  • meniscal injuries
  • ligamentous injuries
  • quadriceps tendon rupture
53
Q

What investigations are used to diagnose tibial plateau fractures?

A
  • plain film radiograph (AP and lateral)
  • CT scanning to help with surgical planning…
54
Q

How are patella fractures managed?

A

Non-operative management trialled in uncomplicated tibial plateau fractures:
- hinged knee brace
- ongoing physiotherapy
- analgesia

Operative management:
- ORIF*
- hinged knee brace post-operatively

*External fixation with delayed definitive surgery indicated if significant soft tissue injury and highly comminuted fractures.

55
Q

What are the most common complications of tibial plateau fractures?

A
  • post traumatic osteoarthritis
56
Q

What are the clinical features of tibial shaft fractures?

A
  • trauma
  • severe pain
  • inability to weight bear
  • deformity
  • swelling and bruising
57
Q

Why are open fractures common in tibial shaft fractures?

A

Lack of soft tissue envelope anteromedially.

58
Q

Why is compartment syndrome a common complication of tibial shaft fractures?

A

Many fascial compartments in the lower leg.

59
Q

What investigations are required for tibial shaft fractures?

A

Patients presenting following major trauma, therefore follow ATLS protocol: urgent bloods incl. coagulation profile and Group & Save.

AP and lateral plain film radiographs of tibia and fibula.

60
Q

What is the management of tibial shaft fractures?

A
  • realign tibia in A&E under analgesia
  • above knee backslab
  • elevate and closely monitor limb immediately, watching for signs of compartment syndrome

Surgical fixation often needed:
- intramedullary nailing (most common)
- ORIF

Year 3 - Surgery (30 decks)

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