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MSK > Cortex- Lower Limb: Knee > Flashcards

Cortex- Lower Limb: Knee Flashcards

1
Q

what are the compartments of the knee joint

A

medial and lateral compartments of the tibiofemoral joint

and the patellar joint

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2
Q

which part of the knee has the thickest hyaline cartilage in the body

A

retropatellar surface- reflection of the load placed on the patella

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3
Q

where are the menisci

A

tibiofemoral joint

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4
Q

what material are the menisci

A

fibrocartilage

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5
Q

what is the role of the menisci

A

ensure congruence between the concave femoral condyles and the flattish tibial plateau
shock absorbers
lubricate joint

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6
Q

what is the principle role of the ACL

A

prevent abnormal internal rotation of the tibia

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7
Q

what does the PCL prevent

A

hyperextension and anterior translation of the femur

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8
Q

what does the LCL resist

A

varus force and abnormal external rotation of the tibia

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9
Q

what can can predispose the knee to early OA

A

previous meniscal tears, ligament injuries (ACL deficiency) and malalignment (genum varum= medial OA, genum valgum= lateral OA)

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10
Q

what can influence primary knee OA

A

genetic influences, hobbies (football, distance running), occupation

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11
Q

what can predispose to the development of patellofemoral OA

A

patellofemoral dysfunction and instability

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12
Q

when can knee replacement be considered

A

in a patient with substantial pain and disability, where conservative management in no longer effective

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13
Q

what are the types of knee replacement

A

total (resurface all 3 components) or partial (unicompartmental knee replacement or patellofemoral replacement)

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14
Q

what is there less and extra risk of with TKR (when compared to THR)

A

less risk of dislocation

higher chance of unexplained pain (reliance upon the tension of soft tissues around the knee)

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15
Q

why is revision knee replacement a bigger surgery

A

often requires use of stems and a more hinged type of knee implant

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16
Q

when do meniscal injuries classically occur

A

with a twisting force on a loaded knee

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17
Q

what is the presentation of a meniscal injury

A

pain in medial (majority) or lateral joint line
effusion develops next day
mechanical symptoms- catching/ locking sensation (difficulty straightening knee with a 15 degree or so block to full extension)
may feel like knee is about to give way when walking is loose meniscal fragment caught in the knee

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18
Q

what causes true knee blocking (the mechanical block to full extension)

A

significantly torn meniscus flipping over and becoming stuck in the joint line associated with meniscal tears

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19
Q

can you have a meniscal tear without locking

A

yes

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20
Q

what is psuedo locking of the knee

A

temporary difficulty in straightening the joint (seen in other knee pathologies such as arthritis)

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21
Q

what typically causes an ACL rupture

A

a higher rotational force (turning the upper body laterally on a planted foot causing internal force on the tibia

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22
Q

what is the typical presentation of an ACL rupture

A

pop felt/ heard
development of a haemarthosis (effusion due to bleeding int he joint- vasculature of ACL) within an hour of injury
deep pain in the knee
patient will complain of rotatory instability with their knee giving way when turning on a planted foot (due to excessive internal rotation of the tibia)

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23
Q

what is typically caused by a valgus stress injury

A

torn medial collateral ligament (also potentially ACL and risking tibial plateau fracture)

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24
Q

what might a direct blow to the anterior tibia cause when knee flexed

A

rupture PCL due to hyperextension

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25
Q

what might a varus stress injury cause

A

rupture LCL (+/- PCL)

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26
Q

what can help delineate the extent of ligament injury

A

early MRI (only if exam difficult/ injury significant/ multiple ligaments injured)

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27
Q

what other tear is commonly seen with a meniscal tear

A

ACL tear

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28
Q

which might be found on clinical exam of a meniscal tear

A

effusion,
joint line tenderness,
pain on tibial rotation localised to the affected compartment (steinmann’s),
locked knee (displaced bucket handle tear) (15 degree springy block o full extension)

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29
Q

what is more common a medial or lateral mensical tear - why

A

medial (10 times)

as medial more fixed, less mobile

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30
Q

what are the patterns of meniscal tears

A

longitudinal, radial, oblique, horizontal

bucket handle tears- large longitudinal tear

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31
Q

where does the fragment of meniscus lodge to lock knee

A

into intercondylar notch

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32
Q

what causes a degenerative meniscal tear

A

meniscus weakens with age

can tear spontaneously or with a seemingly innocuous injury

first stage in many cause of knee OA

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33
Q

what are the patterns seen in degenerative meniscal tears

A

complex- horizontal, longitudinal and radial components

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34
Q

will degenerative tears be steinmanns positive

A

no

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35
Q

why does the meniscus have limited healing potential

A

as only has blood supply in its outer third

healing potential decreases with age and with increased time from injury

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36
Q

what is the surgical treatment for meniscal tears and who should get it

A

reasonable fresh longitundinal tears involving the outer 3rd in a younger patient (90% of tears not suitable)

meniscal repair- suturing the meniscus to its bed

37
Q

if meniscus doesnt heal then do symptoms go away?

A

yes, pain and inflammation settle with time

knee will smooth off its own meniscus in time

38
Q

what might help degernative meniscal tear’s early symptoms

A

steroid injection

39
Q

what is the treatment for acute meniscal tears whos symptoms do not settle in 3 months

A

arthroscopic partial menisectomy

40
Q

why is a meniscetomy not helpful in knees with degenerative change

A

as removal of menisci material will put more stress on already worn surfaces

41
Q

what is the principle complaint of ACL deficiency

A

rotator instability with giving way on turning

42
Q

what will you see on examination of an ACL rupture

A 
knee swelling (haemarthrosis or effusion)
excessive anterior translation of the tibia on the anterior drawer test and lachmans tests
43
Q

what is the ACL rule of thirds

A

1/3rd of patients will compensate well and do whatever they please (inc sports)

1/3rd will manage by avoiding certain movements, may not be able to do high impact sports

1/3rd will do poorly with frequent giving way even with normal daily activities

44
Q

why is primary repair of the torn ACL not often done

A

as is not effective and 40% will fail and need a reconstruction

45
Q

who gets ACL reconstruction as there first treatment

A

professional sport players
those who’s knees give way on sedentary activity
those who want to get back into high impact sport but cannot do so despite physiotherapy

46
Q

describe the process of ACL reconstruction

A

tendon graft, usually patellar, semitendinosis and gracilis autograft
is passed through tibial and femoral tunnels at the usual location of the ACL in the knee and secured to the bone

47
Q

how long usually after an ACL reconstruction until the patient can return to high impact sports

A

a year with intensive rehabilitation

48
Q

when in PCL reconstruction usually done

A

when there is multiple ligament injury

or if severe laxity and recurrent instability with frequent hyperextension or feeling unstable descending stairs (with anterior subluxation of the femur)

49
Q

what tendon is used in a PCL reconstruction

A

cadaveric achilles tendon allograft

50
Q

do MCL injuries heal

A

yes- majority of MCL partial and complete tears are expected to heal with little or no instability

51
Q

what what is the presentation of an MCL tear

A

laxity and pain on valgus stress with tenderness over the origin or insertion of the MCL

52
Q

how are acute MCL tears treated

A

hinged knee brace

53
Q

how can chronic MCL instability be treated

A

with MCL tightening (advancement) or reconstruction with tendon graft

54
Q

what is the treatment for an LCL tear

A

usually surgical with early repair or late construction with tendon graft

55
Q

what is the sign of an LCL tear

A

instability on rotational movement- excessive rotation of the tibia and varus

56
Q

what gives rise to an LCL injury

A

hyperextension and varus

57
Q

what ligaments are affected in a complete knee dislocation

A

all four knee ligaments rupture

58
Q

what is there high incidence of in complete knee dislocation

A

neurovascular injury

59
Q

what is the treatment for a complete knee dislocation

A

reduced as an emergency

may require external fixation for temporary stabilisation

60
Q

what is the important of an intimal tear in a knee dislocation

A

can later thrombose- regularly checks of the circulation of the foot mandatory

61
Q

what should be done if there is concern with the distal circulation

A

vascular surgery assessment

vascular stenting or by-pass nay be required

62
Q

what can happen in hyperfusion of the knee joint

A

compartment syndrome, especially after prolonged ischaemia- fasciotomies may be required

63
Q

what treatment is usually required in combined knee ligament ruptures and knee dislocarions

A

multiple ligament reconstruction

64
Q

when do osteochondral and chondral injuries occur

A

impaction or shear force of the articular surfaces/ due to a direct blow

65
Q

how should osteochondral injuries bone be treated

A

pinning fragments of bone if large

if small removed arthroscopically

66
Q

what makes up the extensor mechanism of the knee

A

tibial tuberosity, patellar tendon, quadriceps tendon and the quadriceps muscles

67
Q

what can cause a patellar or quadriceps tendon rupture

A

lifting a heavy weight,
a fall,
spontaneously in a severely degenerate tendon

68
Q

what age groups get either a ruptured patella or quadriceps tendon

A

patellar <40s

Quads >40s

69
Q

what can predispose to an extensor mechanism rupture

A

history of tendonitis, chronic steroid use/ abuse (body builders), diabetes, RA, chronic renal failure

70
Q

what antibiotic can cause tendonitis and risk tendon rupture

A

quinolone (ciprofloxacin)

71
Q

do you give steroid injections for tendonitis of the extensor mechanism of the knee

A

no- high risk of tendon rupture

NEVER INJECT A TENDON WITH STEROID

72
Q

what should be included in the assessment for all acute knee injuries

A

straight leg raise- to determine if the extensor mechanism is intact

73
Q

what is a palpable sign of extensor mechanism rupture- what is seen of this on x rays

A

a palpable gap in the extensor mechanism

x ray will shoe a high (PT) or low (quads) patella

74
Q

what might reduced extensor mechanism power suggest

A

a partial tear

75
Q

what is the treatment for extensor mechanism ruptures

A

(for both complete and partial tears)

surgery- tendon to tendon repair or attachment of the tendon to the patella

76
Q

what is patellofemoral dysfunction

A

disorder of the patellofemoral articulation resulting in anterior knee pain

77
Q

what does ‘patellofemoral dysfuction’ encompass (3)

A 
chondromalacia patellae (softening of the hyaline cartilage)
adolescent anterior knee pain 
lateral patellar compression syndrome
78
Q

in patellofemoral dysfunction what side of the knee is affected

A

lateral (as quads pull patellar to the side-plus is more common in females as wider hips= more lateral pull)

79
Q

why is anterior knee pain seen in adolescents

A

ligamentous laxity

80
Q

what are other predisposing factors for patellofemoral dysfunction

A

hypermobility, genu valgum, femoral neck anteversion

81
Q

what is the presentation of patellofemoral dysfunction

A

anterior knee pain, worse going downhill, a grinding or clicking sensation at the front of the knee, stiffness after prolonged sitting (psuedolocking)

82
Q

what is the treatment for patellofemoral dysfunction

A

90% will improve with physio
taping may alleviate the symptoms
surgery last resort

83
Q

what can cause patellar dislocation

A

with a direct blow or sudden twist of the knee

84
Q

what direction does the patella almost always dislocate

A

laterally

85
Q

can the patellar spontaneously reduce

A

yes when knee straightened

86
Q

what can happen to the surrounding structures when the patellar dislocates

A

the medial patellofemoral ligament tears

osteochondral fracture may occur (as the medial facet of the patella strikes the lateral femoral condyle)

87
Q

what type of effusion is seen in a patellar dislocation

A

lipo-haemarthrosis (medial patellofemoral ligament tear)

88
Q

what are the predisposing factors for a patellar dislocation

A 
ligamentous laxity,
female gender, 
shallow trochlear groove, 
genu valgum, 
femoral neck anteversion, 
high riding patella (patella alta)
89
Q

what can decrease the risk of patellar instability

A

risk of recurrent instability decreases with age and physiotherapy

MSK (71 decks)

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