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MM I > Acute Knee > Flashcards

Acute Knee Flashcards

1
Q

What is the difference between structural instability and functional instability?

A

Structural: jt instability based on TESTING ONLY, not pt function

Functional: jt instability that affects FUNCTION

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2
Q

For a patient with a suspected single ligament injury to the knee, would you expect them to have SINGLE plane instabilities or MULTIPLANAR instabilities?

A

Single plane Instabilites: excessive ant/post glide or varus/valgus rotations

*Result of single lig injury

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3
Q

For a patient with suspected multiple ligament injuries to the knee, would you expect them to have SINGLE plane instabilities or MULTIPLANAR instabilities?

A

Multiplanar instabilities (rotary instability)

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4
Q

What is a common combination of injuries to the knee? (3 structures)

A
  1. ACL
  2. MCL
  3. Lateral meniscus
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5
Q

What is the involved lig for anterior instability?

A

ACL

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6
Q

What is the involved lig for post instability?

A

PCL

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7
Q

What is the involved lig for medial instability?

A

MCL

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8
Q

What is the involved lig for lateral instability?

A

LCL

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9
Q

What are 3 clinical tests for ANTERIOR instability? (ACL = involved lig)

A
  1. Lachman’s
  2. Anterior Drawer sign
  3. Lever sign
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10
Q

What are 3 clinical tests for POSTERIOR instability? (PCL = involved lig)

A
  1. Posterior drawer
  2. Posterior sag sign
  3. Quad active
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11
Q

What is a clinical test for MEDIAL instability (MCL = involved lig)

A

Valgus stress test

*Test in full ext 1st, and then 25 deg flex

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12
Q

What is a clinical test for LATERAL instability (LCL = involved lig)

A

Varus stress test

*Test in full ext 1st, then 25 deg flex

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13
Q

Which of the ACL clinical tests has the highest diagnostic accuracy?

A

Lachman’s

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14
Q

Which 2 of the PCL clinical test have the highest diagnostic accurary?

A
  1. Posterior sag sign
  2. Posterior drawer
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15
Q

When performing a valgus stress test to test the integrity of the MCL, you find that at 0 deg, there is medial joint line gapping, suggesting a positive test. You therefore suspect a combined lig injury. What lig(s) do you suspect are injured?

A
  1. MCL
  2. LCL
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16
Q

When performing a valgus stress test to test the integrity of the MCL, you find that at 0 deg, there is no medial joint line gapping, indicating a neg test. You go on to test at 25 deg and there is medial joint line gapping, indicating a positive test. What lig(s) do you suspect are injured?

A
  1. MCL
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17
Q

When performing a varus stress test to test the integrity of the LCL, you find that at 0 deg, there is medial joint line gapping, suggesting a positive test. What lig(s) do you suspect are injured?

A
  1. LCL
  2. ACL
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18
Q

When performing a varus stress test to test the integrity of the LCL, you find that at 0 deg, there is no medial joint line gapping, indicating a neg test. You go on to test at 25 deg and there is medial joint line gapping, indicating a positive test. What lig(s) do you suspect are injured?

A
  1. LCL
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19
Q

Rotatory instability involves ___ rotation around an abnormal ___ axis.

A
  1. Tibial
  2. vertical
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20
Q

What are the 5 possible injured structures involved with ANTEROLATERAL instability?

A
  1. ACL
  2. ALL
  3. Lateral capsule
  4. LCL
  5. Posterolateral complex (PLC)
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21
Q

What abnormal movement is demonstrated with anterolateral instability?

A

Lateral tibial plateau moves in an ANTERIOR and INTERNALLY ROTATED direction w/ respect to femur

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22
Q

What 4 clinical tests could you do for anterolateral instability?

A
  1. Lachman’s
  2. Lateral pivot shift test
  3. Varus stress test
  4. Anterior drawer w/ tibia INTERNALLY rot
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23
Q

What are the possible injured structures involved with anteromedial rotary instability?

A
  1. ACL
  2. Medial capsule
  3. MCL
  4. OPL (oblique popliteal lig)
  5. POL (Posterior oblique lig) - post to MCL
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24
Q

What abnormal movement is demonstrated with ANTEROMEDIAL instability of the knee?

A

The MEDIAL tibial plateau moves in an ANT and EXT ROT direction w/ respect to femur

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25
Q

What are 3 clinical tests for ANTEROMEDIAL instability of the knee?

A
  1. Lachman’s
  2. Valgus stress
  3. Anterior drawer w/ tibia ext rot
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26
Q

What are the 4 possible injured structures involved with Posterolateral rotary instability?

A
  1. PCL
  2. LCL
  3. Post Capsule
  4. PLC (Posterolateral corner)
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27
Q

What are 3 clinical tests you can perform for POSTEROLATERAL instability of the knee?

A
  1. Posterior drawer test
  2. Posterior sag sign
  3. Varus stress test
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28
Q

What abnormal movement is demonstrated with POSTEROLATERAL instability of the knee?

A

Lat tibial plateau moves in a POST and EXT ROT direction w/ respect to femur

29
Q

What are the 5 possible injured structures involved with POSTEROMEDIAL rotary instability?

A
  1. PCL
  2. MCL
  3. Post Capsule
  4. OPL (oblique popliteal lig)
  5. POL (post oblique lig)
30
Q

What abnormal movement is demonstrated with POSTEROMEDIAL instability of the knee?

A

The medial tibia plateau moves in a POST and INT ROT direction w/ respect to the femur

31
Q

What are 3 clinical tests you can perform for POSTEROMEDIAL instability of the knee?

A
  1. Posterior drawer
  2. Posterior sag sign
  3. Valgus stress test
32
Q

Assign a grade classification to the lig/capsule injury described below:

Microtears in lig w/ no apparent change in laxity compared to opposite knee. Still painful!

A

Grade I (mild)

33
Q

Assign a grade classification to the lig/capsule injury described below:

  • 33-66% of the lig is torn and capsular damage
  • 0-5 mm greater jt gapping than opp limb w/ FIRM end-feel
A

Grade II (moderate)

34
Q

Assign a grade classification to the lig/capsule injury described below:

  • 66-99% of lig is torn and capsular damage
  • 5-10 mm greater jt gapping than opp side w/ SOFTENED end-feel
A

Grade II+ (severe)

35
Q

Assign a grade classification to the lig/capsule injury described below:

  • 100% lig torn and damage to capsule
  • > 10mm gapping compared to opp side, w/ NO end-point
A

Grade III

36
Q

What are 5 non-surgical indications for knee ligament injuries?

Basically, what are reasons that would indicate that surgery is not a good option?

A
  1. Little exposure to high risk activities (cutting, pivoting, jumping)
  2. > 40 yo
  3. Severe OA
  4. Unwillingness to comply w/ surgical rehab
  5. Being a “potential coper”
37
Q

What are 3 indications that you WOULD perform surgery on someone w/ ligamentous injury to the knee?

A
  1. Functional instability: repeated episodes of giving way (non-coper)
  2. Desire to return to high ACL demand activity
  3. Multiple structures involved in injury
38
Q

What is a potential problem of pursuing the non-surgical route for knee ligament injuries?

A

Recurrent episodes of knee instability/ “giving way” can lead to progressive OA and damage to menisci and articular cartilage

39
Q

What is the general rule of the key question: “to do surgery or not to do surgery?”

A

The younger the pt & the higher level of demand on knee jt, the greater risk for future joint damage w/o surgery.

40
Q

What is the difference between arthroscopic surgery and arthotomy?

A

Arthoscopic surgery is completed w/ a scope into the joint

Arthrotomy surgery is completed through open incision

41
Q

What are potential tissue options for an AUTOgraft ligament reconstruction of the knee?

A

patellar tendon, HS tendon, quad tendon (from SELF)

42
Q

What are potential tissue options for an ALLOgraft ligament reconstruction of the knee?

A

Freeze-dried material obtained from cadaver: patellar/HS/quad/achilles tenodn, fascia lata

43
Q

T or F: Current evidence (2016, 2017, 2018) shows that autografts are superior to allografts w/ respect to graft failure, pt reported outcomes, and return to sport in YOUNG, ACTIVE, HS/COLLEGE STUDENTS.

A

True.

44
Q

T or F: evidence indicates that allograft failure rates are higher in pts < 40 yo

A

True.

45
Q

What is the GOLD STANDARD for ACL reconstruction AUTOgrafts?

A

Patellar tendon (central 1/3)

46
Q

Compare the advantages and disadvantages for using a patellar tendon as an autograft for ACL reconstruction.

A

Advantages:
- high tensile strength & stiffness
- can obtain a rigid graft fixation on both graft ends
- bone plugs heal w/in 8 weeks
- clinical studies indicate GOOD, not excellent short & long-term results

Disadvantages:
- higher incidence of ant knee pn post-surgery
- higher rate of arthrofibrosis (build-up of scar tissue)

47
Q

Compare the advantages and disadvantages for using a hamstring tendon autograft for an ACL reconstruction.

A

Advantages:
- No disruption to extensor mechanism of the knee, like with patellar tendon
- decreased surgical time

Disadvantages:
- BIGGEST issue is less graft fixation strength on the femoral graft end (QUIZ Q)
- Soft tissue healing in bone tunnel: up to 12-16 wks
- Pn/weakness of hamstrings (recall that hamstrings are ACL agonists)

48
Q

Compare the advantages and disadvantages for using a QUADRICEPS tendon autograft for an ACL reconstruction.

A

ADVANTAGES:
- less disruption to knee extensor mechanism
- less harvest site morbidity
- larger graft cross-sectional area
DISADVANTAGES:
- possible suprapatellar pouch injury
- requires proper tensioning
- pain/weakness of quads

49
Q

T or F: When a patellar tendon is used as an autograft for ACL reconstruction, it is ~ 37% stronger than native ACL when implanted

A

True.

50
Q

T or F: A quadrupled HS tendon graft is ~91% stronger than native ACL and ~ 39% stronger than patellar tendon autograft

A

True.
HS graft is multistrand (3-4 strands braided together)

Quad tendon graft has larger cross-sectional area and higher ultimate load to failure than patellar tendon graft

51
Q

Identify 4 functions of the meniscus

A
  1. Attenuate joint reaction forces between femur and tibia by inc SA (pressure = force/area)
  2. Increase joint congruence, thus inc joint stability
  3. Lubrication
  4. Guide knee motion
52
Q

T or F: Removing meniscus increases contact forces by 230%

A

True.

Meniscus removal can lead to OA.

53
Q

Describe the vascular supply to the meniscus

A

Outer 1/3 (Red zone): richest blood supply via coronary ligs
Central 1/3 (Intermediate zone): limited blood supply
Inner 1/3 (white zone): NO blood supply

Decreases w/ age!

54
Q

What is the MOI for a meniscus injury?

A

Rotation of flexed knee over a planted foot

*Often combined with lig injury

55
Q

What are the 6 types of meniscus tears?

A
  1. Radial: most common
  2. Horizontal: typically not repairable
  3. Flap: tx depends on location & size
  4. Parrot beak: typically unstable, requires surgery
  5. Longitudinal: can heal if in outer 1/3, if large enough than surgery is required to repair or remove since it can become bucket-handle
  6. Bucket-handle: results in knee locking
56
Q

What is the most common type of meniscus tear?

A

Radial

**Usually NOT repairable

57
Q

What are the KEY FINDINGS during the time of possible MENISCUS injury?

A
  1. “Pop” (may)
  2. Pn localized to jt line
  3. “Catching” or “locking”, cannot fully straighten/bend
  4. Some swelling, but NOT rapid onset
  5. After few days, pts will often be able to perform ADLS w/o pn, BUT will have pn esp w/ ROT over fixed foot
58
Q

What would you include in your physical exam if you suspect a meniscus injury?

A
  1. Joint line tenderness
  2. McMurray’s
  3. Thessaly
  4. Meniscus Cluster Exam:
    • Joint locking
    • Joint line tenderness
      • McMurray’s
    • Pn w/ flex
    • Pn w/ hyperextension
59
Q

T or F: suturing following a meniscus tear is most likely to heal if tear is in RED or INTERMEDIATE zone

A

True.

60
Q

What are 2 reasons that a pt would need a meniscetomy?

A
  1. tear is too long
  2. tear is in region of poor vascularity
61
Q

When would a meniscus allograft transplantation be indicated?

A

Total meniscectomy

62
Q

What direction is post common for a patellar dislocation?

A

Lateral

63
Q

What age range and sex are patellar dislocations most common?

A

10-17 yo
Females

64
Q

What are the MOIs for patellar dislocations?

A
  • Contact OR Non-contact
  • Often assoc w/ medial rot/add of femur over fixed foot

*May be related to trochlear dysplasia (shallow or absent trochlear groove)

65
Q

What are clinical sxs of a patellar dislocation?

A
  • Acutely, patella will likely be LATERAL to lateral femoral condyle and knee flexed
  • Patella will often self-relocate w/ ext (causes “pop”)
  • Rapid onset of hemarthrosis (bleeding into jt) following relocation
  • Pain
66
Q

What knee structures could be injured as a result of patellar dislocation?

A
  • Medial patellofemoral lig (MPFL)
  • Medial retinaculum
  • Osteochondral injury (need proper imaging: merchant view)
67
Q

What should tx consist of for a pt with acute patellar dislocation?

A
  • Typically immobilized initially (2-4 wks) in knee immobilizer brace
  • WBAT on crutches
  • Early ROM = important in maintaining articular cartilage health
  • Progression to patella-stabilizer bracing as soon as comfort permits
  • Progression to strengthening exercises based on impairments
  • Movement retraining
68
Q

What are surgical intervention options following patellar dislocation?

A

Soft tissue procedures:
- MPFL reconstruction (often gracilis or semitendinosis)
Bony procedures:
- Trochleoplasty: deepening on trochlea (if trochlear dysplasia)
- Distal realignment
- Medializing tibial tubercle (Elmsie-Trillat)
- Elevating tibial tubercle (macquet)
- Medializing and elevating tibial tubercle (fulkerson)

69
Q

What are the 5 criteria included in the CPG for determining when to order radiographs following an acute knee injury?

A

ONE or > of the following:
1. > 55 yo
2. Isolated patellar tenderness w/o other bone tenderness
3. Fibular head tenderness
4. Cannot flex to 90 deg
5. Unable to WB immediately and in ED for 4 steps

MM I (9 decks)

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