CORTEXT 4 - Hip and Knee

Question 1

How does pain in the groin radiate to the knee?

Answer 1

Obturator nerve

Question 2

What hip pathology purely presents with knee pain?

Answer 2

SUFE

Question 3

What examination finding is usually the first sign of hip pathology?

Answer 3

Reduced range of movement

Loss of internal rotation

Question 4

What muscles are affected by Trendellenburg?

Answer 4

Gluteus medius and minimus

Question 5

What diseases cause shortening of the lower limb?

Answer 5

OA
Perthes
SJFE
AVN
Fracture

Question 6

What diseases cause groin pain?

Answer 6

Hernia
Tendonitis
Pubic symphysis dysfunction
Lumbar disc prolapse (rare)
AVN

Question 7

What treatment will be used for the following treatments:

OA, RA, Seronegative inflammatory arthropathy, AVN, dysplasia, perthes, SUFE

Answer 7

Total hip replacement/Total hip arthroplasty
(they are kind of the same, THA is a wider term and used for e.g. hip resurfacing which technically isn’t a THR as it doesn’t replace the entire femoral head)

Question 8

Why do we try to avoid THR in young patients

Answer 8

Higher risk of them needing another hip replacement later on in life (called a revision surgery) because they will put more demand on their prosthetic hip compared to the elderly
Revision surgery has more complications and less successful

Question 9

AVN

What is primary and secondary causes?

Answer 9

Primary = idiopathic 
Secondary = alcohol, steroid use, hyperlipidaemia or thrombophilia

Question 10

What do patients clinically present with when they have AVN?

Answer 10

Groin pain

Question 11

AVN

Ix (and what will you see)

Answer 11

MRI - patchy sclerosis

X-Ray - ‘hanging rope sign’

Question 12

AVN

Mx (early and late)

Answer 12

Early = Decompression by drilling holes (to relieve pressure) 
Late = THR

Question 13

What is trochanteric bursitis/gluteal cuff syndrome?

Answer 13

When the broad tendinous insertion of the abductor muscles (commonly, the gluteus medius) becomes STRAINED so is vulnerable to tendonitis and tendon tears
The trochanteric bursa also become inflamed

Question 14

Trochanteric bursitis/gluteal cuff syndrome:

Mx

Answer 14

Analgesics
Anti-inflammatories
Physiotherapy 
Steroid injection
NO SURGERY REQUIRED

Question 15

The knee joint is one big synovial joint, but what 2 smaller joints does it consist of?

Answer 15

Tibiofemoral and patellofemoral

Question 16

What do the menisci do?

Answer 16

Shock absorbers

Question 17

Name the 4 ligaments of the knee joint

Answer 17

Anterior and posterior cruciate ligaments

Medial and lateral collateral ligaments

Question 18

What movements do the 4 ligaments of the knee resist?

Answer 18

ACL = Internal rotation and anterior translation
PCL = Hyperextension and posterior translation 
MCL = Valgus force 
LCL = Varus force & External rotation

Question 19

Advantages and Disadvantages to an osteotomy compared to a total knee replacement or partial knee replacement or conservative management

Answer 19

• When subject to heavy work (manual workers), osteotomy is preferred and will last longer
• Results of osteotomy are less predictable than knee replacement
• The results of a TKR after an osteotomy are inferior to those in an unoperated knee
• Partial knee replacement = higher risk of failure than a TKR
• TKR good for when pain & disability on conservative treatment is too much

Question 20

Meniscal tears:

Clinical signs + symptoms

Answer 20

Twisting injury
Localized pain to medial/lateral joint lines
Effusion forms next day
‘Catching/locking’ sensation (difficulty straightening their leg)

Question 21

Difference between locking and pseudo-locking

Answer 21

True locking = meniscal tear
Due to the torn meniscal flipping over and getting stuck in the joint line

Pseudo-locking = Arthritis
Temporary difficulty straightening the leg (usually when standing after sitting for ages). It will spontaneously resolve or patient will describe a ‘trick manoeuvre’ that relieves issue

Question 22

Typical history of an ACL rupture

Answer 22

Occurs due to a high rotational force (football, skiing, rugby)
A ‘pop’ is heard
Deep pain in the knee
Thereafter, there is rotary instability

Question 23

O/E, what will you use in an ACL rupture and why?

Answer 23

Swelling due to a haemarthrosis (effusion due to bleeding from the vascular supply to the ACL)

Question 24

Valgus stress injuries: when do they typically occur?

And on what ligament most commonly?

Answer 24

Rugby tackle from the side

Usually MCL but could potentially also damage ACL

Question 25

What ligament would rupture from a direct blow to the anterior tibia?

Answer 25

PCL

Question 26

Varus stress injuries - what ligament is affected

Answer 26

LCL

Question 27

When is best time to examine a knee after the injury?

What imaging could you use?

Answer 27

2-7 days after

MRI - will help you see the extent of the injury

Question 28

What are the meniscal tear patterns?

Answer 28

Longitudinal, radial, oblique, horizontal tears

Question 29

What are large longitudinal tears often referred to as?

And what can happen?

Answer 29

Bucket handle tears

They can flip over and get stuck in joint line (causing incomplete extension of the leg)

Question 30

Why is the healing potential of the meniscus low?

Answer 30

It only has blood supply on it’s outer third

Question 31

Meniscal tear Mx

Answer 31

90% not suitable for surgical for repair
Pain and inflammation settles with time
Steroid injections
Arthroscopic partial menisectomy