Hip and Knee

Question 1

when is genu varum normal?

Answer 1

in children for 1-2 yrs after starting to walk

Question 2

when is genu valgum normal?

Answer 2

in children 2-4 yrs of age

Question 3

what is genus varum?

Answer 3

reduced Q angle= angle between the femur and the tibia, with a medial angulation of the leg in relation to the thigh (bowleg).
puts excess pressure on medial aspect of knee joint, and overstresses the fibular collateral ligament.

Question 4

what is Lachman’s test?

Answer 4

used to test for injury to ACL

displacement of femur and tibia assessed

Question 5

benefits of a unicompartmental (partial) knee replacement?

Answer 5

quicker recovery
better function
same level of pain relief as TKR, but with less scarring and bruising
range of movement often better than with TKR

Question 6

why is a unicompartmental knee replacement not suitable for everyone?

Answer 6

need strong healthy ligaments in knee
disease affecting >1 compartment
more likely to need knee revised than with TKR

Question 7

red flag symptoms in ptnt presenting with hip pain?

Answer 7

unable to bear weight
severe night pain
history of malignancy and hip pain
rapid worsening of symtoms

Question 8

considerations in site of hip pain?

Answer 8

radiation to groin- likely to be hip

greater trochanter- ?trochanteric bursitis, NOF#

Question 9

how can intensity of hip pain be assessed?

Answer 9

how far can ptnt walk?- also assess loss of function, do they need a walking aid?- stick, or walker?
scale of 1-10
night pain

Question 10

how can aggravating factors to hip pain be asked about?

Answer 10

pain at night?
exercise?- mechanical pain, biological-rest
walking up and down stairs?
pain post sitting down for long periods, getting out of a chair?- start-up pain?

Question 11

how is stiffness asked about in hip pain?

Answer 11

can they reach their feet, can they put socks and shoes on?

how difficult is it to get into and out of a car, or bath?

Question 12

what does start-up pain indicate?

Answer 12

OA

Question 13

why does start-up pain occur with OA?

Answer 13

articular cartilage has been lost, and during inactivity, there is a reduction in fluid film, so bone ends up grinding on bone, causing pain when ptnt first moves.

Question 14

other than assessment of hip pain and secondary symptoms, what else is it important to ask in history of ptnt with hip pain?

Answer 14

drug history- pain relief?- has it helped?
PMH: cancer?
FH: arthritis?
SH: occupation?- can they still do this?
exercise, activities enjoyed- how have they been disrupted? how are they managing at home, live alone? stairs? house adjustments e.g. lowered seats, bars?

Question 15

**classical history of ptnt with greater trochanteric pain syndrome (GTPS)?

Answer 15

terrible, constant pain over lateral hip, can’t sleep on that side

Question 16

what are you looking for when ptnt on bed in hip exam?

Answer 16

symmetry, scars, muscle wasting- indicate not been walking on that side? erythema, hernias
limb length- can assess by feeling medial malleoli

Question 17

what do you palpate in hip exam.?

Answer 17

distal pulses- must ensure good blood supply intact if thinking of operating
iliac crest, ASIS, PSIS, greater trochanter, ischial tuberosity
tenderness?

Question 18

types of extracapsular hip fractures?

Answer 18

trochanteric- inter- and reverse oblique

subtrochanteric

Question 19

how does a tibial osteotomy work for tment of knee OA?

Answer 19

a wedge of bone is removed from the outside of the tibia, under the healthy side of the knee
on closing the wedge, the leg is straightened, which brings the bones on the healthy side of the knee closer together, creating more space between the bones on the damaged side.

Question 20

3 goals of knee osteotomy?

Answer 20

transfer weight from arthritic part of join to healthier area
correct poor knee alignment
prolong lifespan of knee joint

Question 21

hip blood supply?

Answer 21

mainly medial lateral circumflex femoral artery, also lateral circumflex, both give rise to retinacular arteries
also artery of ligamentum teres
and nutrient (medullary) artery

Question 22

how does avascular necrosis of hip joint appear on radiograph?

Answer 22

appears white as loss of stability causes compression

rough

Question 23

what provides nourishment of articular cartilage?

Answer 23

synovial fluid

Question 24

why must a hip infection be treated quickly?

Answer 24

to stop progression to septic arthritis in which lost cartilage will result in hip pain for life
requires urgent decompression*

Question 25

comparisons regarding benefits and risks associated with THR and hemiarthroplasty for treating hip fractures?

Answer 25

both assoc. with lower reoperation rates and better function than internal fixation in ptnt with displaced IC hip fractures THR may be assoc. with lower reoperation rates and better function than hemi but THR has slightly higher risk of dislocations and general comlications- tnt must be fitter?

Question 26

how do bone edges appear in a hip fracture in contrast to smooth edges normally seen?

Answer 26

raggedy

Question 27

where is apparent leg length measured?

Answer 27

from umbilicus or xiphisternum to medial malleolus

Question 28

where is true leg length measured?

Answer 28

from ASIS to medial malleolus

Question 29

inspecting ptnt from a far in hip exam., what are you looking for?

Answer 29

look at hips, any pelvic tilting? are they symmetrical look at spine- any scoliosis? look at knees can observe muscle wasting e.g. from disuse, infection, polio can look for a rotational deformity- common in OA*

Question 30

ptnt must be inspected from front, side and behind. what are we looking for from the side and back?

Answer 30

increased lumbar lordosis- suggestive of fixed flexion deformity of hip- tested in Thomas test back- scoliosis- may be secondary to pelvic tilting, gluteal muscle wasting e.g. from disuse, infection, and sinus scars- e.g. secondary to TB

Question 31

what to look at 1st when inspecting gait of an individual?

Answer 31

look at heel strike

Question 32

why does limb appear short in apparent shortening?

Answer 32

adduction contracture of hip, which is compensated for by tilting of pelvis

Question 33

how might a ptnt noticeably compensate for limb shortening?

Answer 33

plantarflexion of foot on affected side flexion of knee on unaffected side pelvic tilting, may compensate for by development of a lumbar scoliosis

Question 34

in true limb shortening, what will be notes when ptnt supine?

Answer 34

heels will not be level, but pelvis will not be tilted

Question 35

where does iliopsoas insert?

Answer 35

lesser trochanter of femur

Question 36

origin of hamstrings?

Answer 36

ischial tuberosity | except short head of biceps femoris- posterior aspect of femur

Question 37

a loss affecting hip extension only is often 1st detectable sign of what?

Answer 37

hip joint effusion

Question 38

normal hip extension range?

Answer 38

5-20 degrees

Question 39

normal range of hip flexion?

Answer 39

120 degrees

Question 40

normal range of hip abduction?

Answer 40

40 degrees

Question 41

how can the faber sign be elicited?

Answer 41

both hips and knees flexed, place (L) foot on opp. knee and gently press down on knee of (L) leg (Patrick's test)

Question 42

normal range of hip adduction?

Answer 42

25 degrees

Question 43

normal range of internal rotation of hip at 90 degrees flexion?

Answer 43

45 degrees

Question 44

normal range of hip external rotation at 90 degrees flexion?

Answer 44

45 degrees

Question 45

normal range of hip internal rotation in extension?

Answer 45

35 degrees

Question 46

normal range of hip external rotation in extension?

Answer 46

45 degrees

Question 47

causes of coxa vara?

Answer 47

``` congenital rickets paget's disease osteomalacia fracture ```

Question 48

causes of coxa valga?

Answer 48

polio | neurological disturbances

Question 49

what is Perthe's disease?

Answer 49

condition in which blood supply to epiphysis of femoral head is disturbed, so a portion undergoes avascular necrosis commonly presents between ages of 4 and 6, and commoner in boys than girls assoc. with anteversion of femoral neck usually presents with a limp, and vague pains in hips, thighs or knees

Question 50

tment of acute symptoms in perthe's disease?

Answer 50

bed rest and traction | followed by physio

Question 51

what happens in a SUFE (slipped upper femoral epiphysis) of hip?

Answer 51

attachment of femoral epiphysis to femoral neck loosens, so head appears to slide downwards on femoral neck, eventually producing a coxa vara hip deformity. may be history of preceding may be hormonal disturbance disease of adolescence, more common in boys

Question 52

late complications of SUFE?

Answer 52

femoral head avascular necrosis | chondrolysis

Question 53

presentation of SUFE?

Answer 53

pain in groin or knee may be impossible to weight bear internal rotation and abduction of affected hip restricted

Question 54

tment of SUFE?

Answer 54

internal fixation of epiphysis without reduction if large amount of acute displacement, may reduce before fixation, but this may increase risk of AN osteotomy of femoral neck if longstanding may do prophylactic pinning of other hip if not bilateral, but only if high risk

Question 55

swelling should be noted on knee observation, what might be indicated if swelling extends beyond limits of joint cavity?

Answer 55

infection- of joint, femur or tibia tumour major injury

Question 56

what might be cause of swelling in joint line of knee?

Answer 56

meniscus cyst

Question 57

importance if noting knee bruising?

Answer 57

indicates trauma | not usually seen with meniscus tears

Question 58

why is evidence of psoriasis important to note in looking at the knee? e.g. red, scaly patches, may have nail changes- nail pitting and onycholysis (nail plate separation from nail bed)

Answer 58

may be a psoriatic arthritis

Question 59

why might knee be warm and foot cold?

Answer 59

popliteal artery block

Question 60

normal knee flexion range?

Answer 60

135 degrees or more

Question 61

with what disease is genu valgum most commonly assoc. with in adults?

Answer 61

RA

Question 62

what is a Girdlestone procedure?

Answer 62

an excision arthroplasty of the hip

Question 63

indications for a Girdlestone procedure?

Answer 63

peri-prosthetic infection aseptic loosening recurrent dislocation failed internal fixation of femoral neck fractures

Question 64

benefits of SA over GA in THR operation?

Answer 64

reduced blood loss during surgery- reduce need for blood transfusion, as reduction in arterial and venous pressure with sympathetic blockage decreased bleeding at operative site, improved cement bonding and reduced surgical time reduce VTE incidence avoid -ve effects on pulmonary function of GA good early PO analgesia lower cost

Question 65

what do the cruciate ligaments lie within?

Answer 65

the intercondylar notch of the femur

Question 66

why do meniscal tears involving central portion have poor healing?

Answer 66

only peripheral edges of menisci have an appreciable blood supply

Question 67

describe Apley's test and Thessaly's test?

Answer 67

used to test for meniscal tears

Question 68

origin of rectus femoris?

Answer 68

AIIS

Question 69

difference between locking and pseudolocking of the knee?*

Answer 69

locking- mechanical obstruction to knee joint being extended e.g. a loose body in the joint, torn meniscus pseudolocking- knee is being prevented from being moved due to pain, but no physical obstruction

Question 70

how much time should be left if repeat steroid injections into joint?

Answer 70

must be given at least 3 mnths apart

Question 71

what name is given to the condition producing knee pain often in young athletes due to wearing away of cartilage on the undersurface of the patella?

Answer 71

chondromalacia patellae