Adult Hip + Knee Problems Flashcards
what can go wrong in the hip
altered mechanics block to movement failure of bone degeneration injury
what can be causes of block to movement
Perthes Disease
what are the 4 types of hip joint
normal
CAM - high demand more at risk
Pincer - high demand more at risk
Mixed
what can cause failure of bone
avascular necrosis
what can be an uncommon complication of RA and Perthes disease
Protrusio acetabuli
intrapelvic displacement of the acetabulum and femoral head, so that the femoral head projects medial to the ischioilial line
Surgical management of arthritic hip joint
Total Hip Replacement (THR)
Surgical management of Pethes hip joint
osteotomy
what are the indications for THR in people over 65 y/o
Reduced walking distance Pain not controlled by analgesics Night pain Impairment of activities of daily living Impairment of hobbies
complications/risks of THR
Blood loss DVT / PE Nerve damage Dislocation Medical complications
what is the history for Trochanteric bursitis
sharp, localised pain
Tx for Trochanteric bursitis
usually self limiting
treated conservatively +/- injections
what factors are indicative of referral of hip pain from GP
pain at night
loss of function
age of pain
common causes of hip pain
OA RA AS Fracture Referred from back Malignancy
rare causes of hip pain
Soft tissue
Paget’s disease
Infection
AVN
what is the role of the menisci in the knee
distribute load from convex femoral condyles to relatively flat tibial articular surfaces
why are medial meniscal tears more common
medial meniscus is fixed whilst lateral meniscus is more mobile
medial meniscus under greater amount of sheer stress
what are the roles of the ligaments in the knee
MCL resists valgus stress
LCL resists varus stress
ACL resists anterior subluxation of the tibia and internal rotation of the tibia in extension
PCL resists posterior subluxation of the tibia ie anterior subluxation of the femur and hyperextension of the knee
which is the only ligament we expect to heal
the medial collateral ligament
what would a rupture of the MCL, ACL and PCL cause separately
MCL rupture - valgus instability
ACL rupture - rotatory instability
PCL rupture - recurrent hyperextension or instability descending stairs
what does posterolateral corner or multiligament ruptures cause
PL corner - various and rotatory instability
Multi - gross instability
what are the patterns of meniscal tear
longitudinal - along longitudinal fibres
radial - from the centre (will not heal)
parrot beak - flaps about, folds underneath its self
bucket handle - flicks in and out, catches in inter-condyle notch
what is a sign of a bucket handle tear
knee cannot go straight
what causes meniscal tears in younger patients
sporting injury
getting up from squatting position
what causes meniscal tears in older patients
atraumatic spontaneous degenerate tears
what are 50% ACL ruptures associated with
meniscal tears
how are meniscal tears investigated
MRI
Tx of meniscal tear issues
limited healing potential
only peripheral 1/3 has blood supply
Tx of meniscal tear
arthroscopic repair in acute peripheral tears in younger patients
arthroscopic menisectomy for mechanical symptoms (locking) or failed meniscal repair
what are the signs of a bucket handle tear and Tx
acute locked knee
springy block to extension
urgent surgery required - arthroscopic repair
if that does not work - partial meniscectomy
what can happen if knee remains locked in bucket handle tear
fixed flexion deformity
surgery helps in degenerate tears - true or false
false
steroid injection may help
what are the grades of knee ligament injuries
grade 1 - sprain
grade 2 - partial tear
grade 3 - complete tear
MCL injury prognosis
usually heals well unless combined with ACL or PCL rupture
Tx for MCL
brace, early motion, physic
pain can take several months to settle
rarely requires surgery - advancement or reconstruction with tendon graft
ACL function and mechanism for rupture
main stabiliser against internal rotation of tibia
usually sporting injury
Tx for ACL rupture
Physio - to help stabilise knee
ACL repair does not work - reconstruction only
Autograft - patellar tendon or hamstrings
Allograft - achilles
Can stick ACL to PCL for stability
rule of 1/3rds for ACL rupture
1/3 compensate and are able to function well
1/3 can avoid instability by avoiding certain activities
1/3 do not compensate and have frequent instability or can’t get back to high impact sport
when is surgery indicated for ACL rupture
rotatory instability not responding to physio
return to high intensity sports
multiligament reconstruction
surgery can treat pain and prevent arthritis in ACL rupture - true or false
false
does not treat pain or prevent arthritis
what does LCL injury cause
varus and hyperextension
rotatory instability
complication of LCL injury
common peroneal nerve palsy
what does LCL injury often occur in combination with
PCL/ACL injury
Tx of LCL
Complete rupture needs urgent repair if early (within 2-3 wks) Later reconstruction (hamstring or other tendon)
MOI of PCL rupture
Direct blow to anterior tibia, (Dashboard / Motorbike) or hyperextension injury
what can be seen in a PCL rupture
popliteal knee pain
brusing
isolated PCL rupture common - true or false
false
usually with other injury
complications post PCL rupture
instability – recurrent hyperextension/feeling unstable when going down stairs
MOI of knee dislocation
high energy injury
complications of knee dislocation
Popliteal artery injury
Nerve injury - common peroneal nerve
Compartment syndrome
Tx of knee dislocations
emergency reduction
recheck neurovascular status
vascular surgery if needed
multi-ligament reconstruction
MOI of patellar dislocation
rapid turn to direct blow
who is more likely to get patellar dislocation and why
females adolescents
ligamentous laxity
valgus knee
torsional abnormalities
how many get recurrent patellar dislocations
10%
what happens when you fall onto flexed knees with quads contraction
extensor mechanism rupture
risk factors for extensor mechanism rupture
previous tendonitis
steroids
chronic renal failure
drugs e.g. Ciprofloxacin
signs of extensor mechanism rupture
unable to straight leg raise
palpable gap
what type of swelling are ACL and fractures associated with
haemarthrosis - blood, immediately swells
what type of swelling is associated with meniscal or chondral injury
effusion - next day swelling
what does pain on the joint line suggests
meniscal/chondral, generalised haemarthrosis
football injury, twist, pop, haemarthrosis, generalised pain, pain settles after a few days, rotatory instability - injury?
ACL rupture
Getting up from squatting, sudden sharp pain medial joint line, effusion, recurrent medial pain & catching +/- locking
Meniscal tear
what is hyaline cartilage comprised of
water, collagen, proteoglycans and chondrocytes
what do chondrocytes secrete
collagen
PGs
Enzyme
Regulate ECM
how does hyaline cartilage get nutrition
synovial fluid and subchondral bone
what are defects of articular cartilage
trauma - ligament injury, dislocation
atraumatic - Osteochondritis dissecans, Osteoarthritis, Inflammatory arthritis
what type of cartilage injuries heal
only full thickness injuries - healing still not perfect
why is healing in cartilage injuries not perfect
healing with fibrocartilage
greater friction
less wear resistant
what is Osteochondritis dissecans
when An area of the surface of the knee loses its blood supply and cartilage +/- bone can fragment off
most common in teens
can heal spontaneously
how is Osteochondritis dissecans TX if detachment is seen on MRI
can pin in place with internal fixation
what are cartilage regeneration techniques
Drilling / microfracture - simplest + cheapest
Osteochondral autograft or allograft - for larger defects
Mosaicplasty
MACI – membrane induced autologous chondrocyte implantation
early OA non operative treatments
Weight loss, stick, exercise, analgesics, activity modification
Hyaluronic acid injections
Steroid injection - acute flare ups
who gets knee replacement
elderly patients with end stage arthritis
TKR lasts 15-20 years
Sx of Osteochondritis dissecans
Pain after exercise
Intermittent knee swelling
Locking may occur
Seen in ages 13-21 commonly
