50. Knee and lower leg

Question 1

3 compartments of the knee

Answer 1

1. patellofemoral
2. medial tibiofemoral
3. lateral tibiofemoral

Question 2

2 rules for knee #

Answer 2

Ottawa
Pittsburgh
- higher sense

Question 3

What is most urgent concern in knee dislocation

Answer 3

popliteal artery injury

Question 4

5 directions of knee dislocation and most common one

Answer 4

In order
o	anterior
o	posterior
o	medial
o	lateral 
o	rotary

Question 5

2 nerves to assess in knee dislocation and how to test

Answer 5

peroneal most common
	dorsum of foot sense
	dorsiflexion
posterior tibial nerve
	plantar sense
	plantar flexion

Question 6

3 methods to assess popliteal injury

Answer 6

Pulses NOT enough

• ABI
• CTA
• duplex US

Question 7

MGMT of knee dislocation

Answer 7

-	reduce ASAP
o	before imaging
o	simple traction-countertraction
-	immobilize in long splint
-	assess artery
-	open joint – ancef
-	watch for compartment syndrome

Question 8

MGMT of distal femoral #

Answer 8

• femoral blocks very effective
• splint
• emergency ortho
  o ORIF

Question 9

What is secondary sign of tibial plateau #

Answer 9

Segond

- avulsion at lateral capsular ligament

Question 10

4 xray signs of plateau #

Answer 10

o look for fat-fluid level
o also fat globules on joint tap
o look for bone avulsions
o joint space widening

Question 11

MGMT of plateau

Answer 11

splint and no WB until ortho

Question 12

What is # of tibial spine

Answer 12

of intercondylar eminence

Question 13

MGMT of # of tibial spine

Answer 13

• immobilize knee
• non-weight bearing
• ortho in 3-7 days

Question 14

What is Osteochondritis dissecans

Answer 14

• partial or total separation of articular cartilage from underlying bone

Question 15

MGMT of osteochonditis dissecans

Answer 15

NWB until ortho

Question 16

5 possible locations of extensor mechanism injury

Answer 16

1. quad muscles
2. tendon
3. medial and lateral retinaculae
4. patella
5. patellear tendon and tibia tubercle

Question 17

4 signs of extensor injury on xray

Answer 17

o Obliteration of quads tendon
o Poorly defined supra-patellar mass
o Soft tissue calcific densities
o Displaced patella

Question 18

MGMT of extensor injury

Answer 18

• any partial or complete tear should get ortho referral

- if only partial, probably immobilize in extension for 4-6wks

Question 19

5 types of patella #

Answer 19

o	transverse
o	stellate
o	comminuted
o	longitudinal
o	proximal or distal pole

Question 20

MGMT of patellar #

Answer 20

• initially knee immobilizer
• crutches with initial WBAT
• ortho in 1 week

Question 21

MGMT of patella dislocation

Answer 21

• reduce
• post-reduction xray
• immobilize in full extension

Question 22

3 xray findings to suggest ligament tear

Answer 22

 Losse bodies
 Segond
 Lateral capsular sign

Question 23

MGMT of ligament tear

Answer 23

• RICE and NSAIDS
• Minimal WBAT
• Fu othro 1 week

Question 24

test for patellofemoral syndrome

Answer 24

• compression of patella against femur elicits pain

Question 25

MGMT for patellofemoral syndrome

Answer 25

o strengthen quads o brace support o limit flexion actives o NSAIDS

Question 26

What is plica syndrome

Answer 26

- redundant folds of synovium | - repeated synovitis

Question 27

MGMT of plica

Answer 27

rest | NSAIDS

Question 28

What is Popliteus tendinitis

Answer 28

- small flat muscle passes beneath lateral head of gastroc - usually in athletes - running and walking down hill makes it worse - tenderness to medial insertion point of gastroc

Question 29

MGMT of Popliteus tendinitis

Answer 29

rest, | nsaids

Question 30

2 main locations of bursitis

Answer 30

``` 1. prepatellar o repetitive kneeling on hard surface o also common site of septic bursitis 2. anserine bursitis o pain at proximal medial tibia o obese women with OA ```

Question 31

MGMT of subcondylar #s

Answer 31

o Long leg posterior splint | o Comminuted or intraarticular need ortho

Question 32

Watson classification for tibial tubercle #

Answer 32

Proximal anterior border • Type 1 – hinged up without displacement • 2 – small portion avulsed but no articular surface involved • 3 – extend into articular surface

Question 33

MGMT of tibial tubercle #

Answer 33

o 1 – immobilize in extension o 2 – same if can be reduced by external maneuvers o 3- ORIF

Question 34

Nerve injured in tibial shaft #

Answer 34

peroneal

Question 35

MGMT of tibial shaft #

Answer 35

1. immobilize in long leg posterior splint in 10-20 deg flexion 2. if pain persists, think about compartment syndrome

Question 36

What is only really important proximal fibula #

Answer 36

Maissoneuve o medial ankle disruption with tearing of ligament o fibula floats free relative to the tibia  unstable ankle mortise

Question 37

MGMT of most proximal fib #

Answer 37

- ice, rest, analgesia - non-weight bearing - don’t need long leg cast, but may help with comfort - progress WBAT with no pain - if severely displaced, then ortho

Question 38

3 types of tib/fib dislocations

Answer 38

``` 1. Anterolateral  Most common  Fall on flexed leg 2. Posterior  Direct blow to flexed knee  Peroneal injury 3. Superior  Ankle #s common ```

Question 39

MGMT of of tib/fib dislocations

Answer 39

- closed reduction o flex knee to 90, evert ankle, apply direct pressure to fib - immobilize knee and ortho