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DPT773: MM1 > 3 - Acute Injuries to Knee Complex > Flashcards

3 - Acute Injuries to Knee Complex Flashcards

1
Q

What can joint inflammation be the result of? (5)

A
  1. Osteoarthritis
  2. Rheumatoid Arthritis
  3. Joint Sepsis
  4. Trauma
  5. Post-Surgery
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2
Q

Knee joint effusion as a result of joint inflammation causes ___

A

Arthrigenic Muscle Inhibition (AMI)

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3
Q

What does AMI cause?

A

ongoing reflex inhibition of musculature, especially the quadriceps muscle group

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4
Q

How many mL of fluid can lead to muscle inhibition?

A

60

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5
Q

What three things are assessed in the evaluation procedures of joint inflammation?

A
  1. Joint Effusion
  2. ROM
  3. Muscle Strength, Endurance, and Speed
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6
Q

What tests can be done to assess joint effusion? (2)

A
  1. Fluctuation

2. Ballotable Patella Test

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7
Q

How is ROM assessed? (2)

A
  1. Actively

2. Passively

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8
Q

When would use of a goniometer be required when doing ROM assessment?

A

to document ROM if plan to use as outcome measure

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9
Q

What test is primarily used to assess muscle strength, endurance, and speed?

A

Knee musculature MMT

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10
Q

What is the Etiology of Patellar Restrictions?

A

Usually seen after prolonged periods of immobilization, post trauma or following surgery

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11
Q

What is the primary Clinical Symptom of Patellar Restrictions and what is it due to?

A

Limitation in knee flexion most common due to lack of inferior glide.

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12
Q

What is a rare Clinical Symptom of Patellar Restrictions and what is it due to?

A

Although rare, lack of superior glide can cause extensor lag.

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13
Q

What is a key point when evaluating Patellar Restrictions?

A

If patient has restricted knee ROM, always check patellar glide first!

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14
Q

Of all knee ligaments, most common injured is the ___

A

Anterior Cruciate Ligament.

As a result, ACL has been extensively studied of all the knee ligaments.

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15
Q

Which ligament has fibers that have a direct attachment to the Medial Meniscus?

A

deep fibers of Medial (Tibial) Collateral

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16
Q

What are the two posterior ligaments?

A

Oblique and Arcuate Popliteal

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17
Q

What are the two cruciate ligaments?

A

Anterior and Posterior

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18
Q

What is the ACL divided into?

A

2 Bundles based on work by Girgis et al.

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19
Q

What are the two ACL bundles?

A
  1. Anteromedial (AMB)

2. Posterolateral (PLB)

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20
Q

How are the bundles of the ACL defined?

A

by tibial attachment

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21
Q

What other model has been defined for the number of bundles?

A

A 3-bundle model

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22
Q

What is the third bundle in the 3-bundle ACL model?

A

Intermediate Bundle

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23
Q

What is the ACL enveloped in?

A

Synovial Membrane

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24
Q

The ACL is placed (intra/extra)-articular BUT (intra/extra)synovial throughout its course.

A

The ACL is placed INTRA-articular BUT EXTRAsynovial throughout its course.

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25
Q

Knee instabilities caused by traumatic injury to either ligament or capsular tissue are classified as (2)

A
  1. Instabilities occurring in a SINGLE PLANE or STRIAGHT

2. Instabilities occurring in MULTIPLE PLANES or ROTATORY

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26
Q

Single OR Multiple Plan instabilities defined during the physical examination by

A

the direction of abnormal tibial plateau displacement

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27
Q

Initially, the medical community only recognized

A

single-plane instabilities

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28
Q

Classic definition of ligament injury in the 50’s through 70’s was the____

A

“Unhappy Triad” - Injury to the ACL, MCL, and Medial Meniscus

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29
Q

In the early 80’s, physicians began to understand that most injuries occurred in

A

multiple planes

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30
Q

What was the first instability recognized?

A

Anterior-Medial

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31
Q

What are the tissues involved with Anterior instability?

A

ACL, Anterior Capsule

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32
Q

What Clinical Tests are done for Anterior Instability?

A

Lachman’s, Anterior Drawer Test

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33
Q

What are the tissues involved with Posterior Instability?

A

PCL, Posterior Capsule

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34
Q

What Clinical Tests are done for Posterior Instability?

A

Posterior Drawer Test, Gravity Test

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35
Q

What are the tissues involved in Medial Instability?

A

MCL, Medial Capsule

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36
Q

What Clinical Tests are done for a Medial Instability?

A

Valgus Stress Test (full extension 1st; then in 25 degs of flexion)

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37
Q

What Clinical Tests are done for a Lateral Instability?

A

Varus Stress Test (full extension 1st; then in 25 degs of flexion)

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38
Q

What is the Direction of a Anteromedial multiplane instability?

A

Medial tibial plateau moves into an anterior and externally rotated direction with respect to the femur.

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39
Q

What are the Involved Structures in a Anteromedial multiplane instability?

A
  1. ACL
  2. Medial Capsule
  3. MCL
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40
Q

What Tests are done for a Anteromedial multiplane instability?

A
  1. Lachman’s Test
  2. Valgus Stress Test
  3. Anterior drawer with tibia externally rotated
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41
Q

What is the Direction of a Anterolateral multiplane instability?

A

Lateral tibial plateau moved in an anterior and internally rotated direction with respect to femur.

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42
Q

What are the Involved Structures in a Anterolateral multiplane instability?

A
  1. ACL
  2. Lateral Capsule
  3. Arcuate Ligament
  4. Posterior Aspect of IT Band
43
Q

What Tests are done for a Anterolateral multiplane instability?

A
  1. Lateral Pivot Shift, Flexion or Jerk test

2. Varus Stress test (anterior drawer with tibia internally rotated)

44
Q

What is the Direction of a Posterolateral multiplane instability?

A

Lateral tibial plateau moves in a posterior and externally rotated direction with respect to femur.

45
Q

What are the Involved Structures in a Posterolateral multiplane instability?

A
  1. LCL
  2. Posterior Capsule
  3. Acrcuate Ligament
  4. Popliteus Tendon
46
Q

What Tests are done for a Posterolateral multiplane instability?

A
  1. Posterior Drawer Test

2. Gravity or Posterior Sag Test

47
Q

Unless you actually see the injury occur, difficult to know if the injury is

A

anteromedial vs. anterolateral

48
Q

What is a KEY THING to establish in HX?

A

Was direction of injury anterior OR posterior?

49
Q

Always keep in mind - irrespective of direction - most of time instability will be ___

A

multi-directional

50
Q

How many Ligament and Capsule Injury Grades are there in the classification and what severity do they correspond to?

A

Grade I (mild)
Grade II (moderate)
Grade II+ (severe)
Grade III

51
Q

What happens in a Grade I (mild) ligament and capsular injury?

A

Microtears with no apparent laxity

52
Q

What happens in a Grade II (moderate) ligament and capsular injury?

A
  • 1/3 to 2/3’s of ligament/capsule damaged

- 0-5mm joint gapping with FIRM end-feel

53
Q

What happens in a Grade II+ (severe) ligament and capsular injury?

A

-5-10mm joint gapping with SOFT end-feel

54
Q

What happens in a Grade III ligament and capsular injury?

A
  • 2/3’s to complete rupture of ligament/capsule

- Greater than 10mm gapping with NO end-point

55
Q

What is the 1st indication for surgery?

A
  1. Acute traumatic injury with involvement of one or more ligaments and severe instability
56
Q

What is the 2nd indication for surgery?

A

Chronic knee instability secondary to old traumatic injury with poor conservative outcome

57
Q

What is the 3rd indication for surgery?

A

Buckling or “giving way” of the knee plus pain

58
Q

What are potential problems with no repairing?

A

Recurrent episodes of knee instability or “giving way” can lead to progressive osteoarthritis as well as damage to menisci and articular cartilage.

59
Q

Key question is “to repair or not to repair.” General Rule - ___

A

The younger the patient and higher the level of demand on the knee joint, the greater the risk for joint damage.

60
Q

What are surgical treatment of choice for ACL reconstruction? (2)

A

Intraarticular Reconstructive Repair

  1. Arthroscopic
  2. Arthrotomy
61
Q

What are the Tissue choice for repair types? (2)

A
  1. Autograph

2. Allograph

62
Q

What is an Autograph tissue?

A

Material obtained from the patient

63
Q

What is Allograph tissue?

A

Freeze-dried material obtained from cadaver

64
Q

What are the most common donor sites for Allograph tissue?

A

patellar tendon or semiteninosis with or without gracilis multistrand graft

65
Q

T/F: Allographs can have higher failure rates.

A

True

66
Q

What indicates that Allographs can have higher failure rates than Autographs?

A

Results from animal studies indicate delayed soft-tissue healing and graft remodeling issues not seen in autographs.

67
Q

Are Allograft failure rates higher in younger or older patients?

A

Younger (

68
Q

What are the advantages of allograft? (2)

A

elimination of graft harvest issues and decreased surgical time.

69
Q

When is the tissue graph strongest?

A

on the day of surgery

70
Q

What happens to graft material used for the repair immediately?

A

undergoes necrosis

71
Q

The graft materials will at best regain __% of original strength?

A

80%

72
Q

What implication does the graft materials only regaining a percentage of original strength have?

A

Why it is important to select materials that are initially stronger than the ACL.

73
Q

How long can it take up to for graft to attain maximum strength?

A

12 to 14 months

74
Q

What is the most commonly used autograft material that has been considered the “Gold Standard” for ACL repair?

A

Patellar Tendon (central 1/3)

75
Q

What are the advantages of using the Patellar Tendon? (3)

A
  1. High tensile strength and stiffness
  2. Can obtain rigid graft fixation as have bone on bone healing at graft sites
  3. Clinical studies indicate good, not excellent, short and long term results
76
Q

In general, patellar tendon graft bone plugs heal within ___

A

6 to 8 weeks

77
Q

What are disadvantages of using Patellar Tendon?

A

Higher incidence of Patellofemoral Joint pain post-surgery

78
Q

What are the issue withHamstring (semitendinosus) or Hamstring/Gracilis grafts?

A
  1. Biggest issue is graft fixation strength
  2. Ability of soft tissues to heal in bone tunnels
  3. Pain with contraction of hamstrings
79
Q

Soft tissues grafts can take up to ___

A

12 to 16 weeks

80
Q

To obtain comparable patellar tendon strength values, the use of Hamstring or Hamstring/Gracilis tendons require

A

multistrand grafts

81
Q

What is a multistrand graft?

A

3 and 4 stranded grafts using braided together

82
Q

Studies indicate that 4 stranded grafts are stronger and stiffer than

A

patellar tendon grafts as well as a normal ACL

83
Q

Most recently use of a double-bundle ACL replacement, initially a ___ allografts were used.

A

two tibilais anterior

84
Q

What are requirement for optimal healing?

A
  1. Controlled functional stresses to stimulate and direct collagen position during healing.
  2. Protection from excessive stresses in Phases 2 and 3.
85
Q

What are 2 major post-operative concerns for physical therapist?

A
  1. Prevent graft from being stretched

2. Protection of graft fixation sites

86
Q

What is the function of the Meniscus? (3)

A
  1. Attenuate joint reaction forced by increasing surface area (P=F/A)
  2. Increase joint congruence, thus increasing joint stability
  3. Aid the ligaments in stabilizing joint complex
87
Q

What happens to joint reaction forces from the Meniscus?

A

decreases approximately 40 to 50%

88
Q

T/F: The vascular supply is poor to the majority of the meniscus.

A

True

89
Q

What is the outer 1/3 termed?

A

The RED ZONE

90
Q

Describe the blood supply to the RED ZONE?

A

has richest blood supply

91
Q

Where does the RED ZONE get its blood supply

A

via coronary ligaments

92
Q

What is the central 1/3 termed

A

INTERMEDIATE ZONE

93
Q

Describe the blood supply to the INTERMEDIATE ZONE

A

has limited blood supply

94
Q

What is the inner 1/3 termed?

A

WHITE ZONE

95
Q

Describe the blood supply to the WHITE ZONE

A

has no blood supply

96
Q

What is classic description of injury termed?

A

Bucket-Handle tear

97
Q

T/F: Surgical Repair of a meniscal tear is a new concept.

A

False: Not a new concept, but greater awareness of saving the meniscus today, than in 60’s or 70’s

98
Q

With what age range are best results obtained for surgical repairs?

A

under 40 years

99
Q

What is the ideal length of meniscal tear to suture?

A

30mm or less

100
Q

In what zones are suturing most likely to heal?

A

If tear is in Red or Intermediate zone

101
Q

What surgical replacement option is there?

A

Meniscus allograft transplantation

102
Q

What are the current issues with Meniscal Allograft Transplantation? (4)

A
  1. Risk of disease transmission
  2. Optimal graft preservation methods
  3. Can allograft reproduce functions of meniscus
  4. Effect of sizing and fixation methods on contact mechanics
103
Q

What 4 physical exams can be done for meniscus?

A
  1. Joint Line Tenderness
  2. Bounce Home
  3. McMurray’s test
  4. Thessaly test
104
Q

What 2 tests can be done that have minimal evidence to support?

A
  1. Apley’s compression test

2. Ege’s test

DPT773: MM1 (6 decks)

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