Hip and Knee Flashcards
Presentation of child with hip disease
Not necessarily hx of pain or trauma but normally with unexplained limp
Also unexplained thigh or knee pain should raise suspicion because of referred pain
6 important causes of childhood hip pain
Congenital dislocation of the hip Perthe's disease Slipped upper femoral epiphysis Septic arthritis Transient synovitis or "irritable hip" Other arthrtides
Presentation of congenital dislocation of the hip
Physical exam or US should pick it up
Usually present before age 5 with delay in walking, limp or discrepancy in leg length
What can missed cases of congenital dislocation of the hip lead to?
Non-congruent joint and early OA degeneration in adulthood
What is Perthe’s disease?
Disintegration of femoral head with subsequent healing and deformity of the hip
Who does Perthes disease usually occur in?
Boys age 5-10 years
Most likely cause of Perthe’s disease
Segmental avascular necrosis of femoral head probably responsible
Symptoms of Perthe’s disease?
Limp, hip pain or knee pain
Examination shows limitation of all movements of hip
Treatment aims with Perthe’s disease
To contain the femoral head in the acetabulum to reduce risk of future OA (40 years post diagnosis and 40% have hip replacement)
Who does slipped upper femoral epiphysis normally occur in?
Overweight, hypogonadal boys (can occur in girls)
Aged 10-16 years
How does SUFE often present?
With knee pain - referred pain
Also limping and pain in groin and anterior thigh
Management of SUFE?
Surgical stabilisation is needed urgently to prevent further slippage of the disc
Also be wary as risk of it occurring in contralateral hip too
Child who is ill, toxic and unable to walk and can’t move hip joint from pain
Suspect septic arthritis - it is rare but dangerous
What is “irritable hip”
Chief cause of hip pain in children
Transient synovitis which can occur due to reactive effusion in association with systemic viral illness
Usually self-limiting and responds to NSAIDs
Where is hip pain in adults felt?
Usually in groin or lateral/anterior thigh
Can also be referred to knee
What is one of the most common causes of hip pain in adults?
OA
Management of hip OA
Rest, analgesia, ROM and strengthening exercises and a walking stick
These relieve the pain
What can develop in patients with hip OA
Trendelenburg gait due to weakened hip abductors
Common cause of hip pain in elderly women
Hip fracture - inability to bear weight and short ex.rotated leg
What is trochanteric bursitis?
Self-limiting inflammation of bursa between greater trochanter and fascia lata
frequently accompanies other MSK problems such as spinal stenosis that alter gait and attendant muscle forces across greater trochanter
What is iliopsoas bursitis?
Bursa deep to psoas muscle and anterior to hip joint - pain in groin and across thigh
Occasionally infectious aetiology
What is snapping iliopsoas tendon?
Painful clunk when hip goes from extension to flexion - hip is otherwise normal
Surgical release may be needed
What is ischial bursitis?
Inflammation of bursa separating glut.max from ischial tuberosity - comes from prolonged sitting or trauma to bursa
What is meralgia paraesthesia?
Local compression of lat.cut.femoral nerve at inguinal ligament
Numbness and burning pain in anterior thigh
Arises from direct compression eg. obesity, pregnancy, tight clothes
What is anterior knee pain syndrome?
Pain in anterior knee, either directly behind the patella or in the medial/lateral retinaculum
Who does anterior knee pain syndrome typically occur in? X3
People who engage in repetitive athletic activity, those with abnormalities in extensor mechanical alignment or overweight patient
When do patients with anterior knee pain syndrome complain of accentuated pain?
Accentuated by climbing and descending stairs. Squatting, kneeling and sitting for long periods of time
Treatment of anterior knee pain syndrome? x4
Activity modification, weight control if necessary, physio to strengthen the quadriceps muscles and core musculature
Pain meds
What is pes anserine bursitis?
Inflammation of bursa overlying insertion of semitendinosus, gracilis and sartorius on anterio medial aspect of proximal tibia
Where is pain in pes anserine bursitis?
Medial aspect of the knee, distal to the medial joint line
Management of pes anserine bursitis
Activity modification, strengthening exercises and anti inflammatories - it chronic may respond to corticosteroid injections
Where is pain with iliotibial band friction syndrome?
It’s inflammation of iliotibial band which is the distal portion of tensor fascia lata which inserts on anterolateral aspect of proximal tibia
Who normally gets iliotibial band friction syndrome?
Runners or cyclists who complain of activity-related knee pain
Management of iliotibial band friction syndrome
Activity modification, stretching and strengthening
Ice and anti inflammatories
Relation of clinical symptoms with knee OA and radiological findings?
Often not correlated, can have lots of pain with nothing on X-ray and vice versa
What is arthritis of the knee commonly associated with?
Peri articular soft tissue problems which can often be a major source of knee pain eg. Pes anserine bursitis
Non pharmacological management of knee OA x6
Weight loss, aerobic exercise, knee strengthening exercises, patellar taping, acupuncture and knee bracing
Pharmacological management of knee OA
Paracetamol NSAIDs not indicated Nutraceuticals use is still debated NSAID gels short term use Injections of steroids and hyaluronans can be very effective (hyaluronans longer lasting effect but more expensive)
When do you use surgical management of knee OA
Arthroscopic treatment is reserved for mechanical symptoms such as catching, locking or instability due to loose bodies or a meniscal tear
When is knee replacement done in knee OA? What sort
Poorly controlled symptoms - can be total or can do unicompartmental - eg. Just medial compartment
What causes most knee injuries in sport
Indirect trauma such as twisting motion
What is most commonly injured in indirect trauma to the knee causing twisting motion?
Menisci, collateral ligaments and cruciate ligaments
What is o’donoghues triad?
Injury of medial meniscus, medial collateral and anterior cruciate
What does direct trauma to the knee usually cause?
Bone contusions, fracture or dislocations - can affect either tibiofemoral joint or patellofemoral joint
What is usually required for dislocation of the tibiofemoral joint? And what usually occurs
High energy trauma - neurovascular damage usually occurs as well
When do the majority of meniscus tears occur in young people?
Mild to moderate twisting injuries - usually occur alone or with collateral
Ligament strain
What does high energy twisting motion usually cause In the knee?
Anterior cruciate injury with acute haemarthroses and inability to bear weight
What are symptoms of meniscus tear?
Focal tenderness over joint line
May have catching and locking
Joint effusion and pain
When can you do arthroscopic repair in meniscus injury?
If it is acute tear (can also get chronic condition) in well-vascularised peripheral portion of the meniscus
What is done to manage chronic meniscus tears?
They are typically vascular and degenerative therefore will not heal if repair
Only do arthroscopic resection on torn parts because total resection leads to early onset OA
What causes articular cartilage injury in the knee?
Often result of traumatic injury that involves impact injury to cartilage surface
Symptoms of articular cartilage injury?
Focal pain, joint effusion and mechanical catching symptoms
Treatment of articular cartilage injury in knee?
Graduated physiotherapy or arthroscopic repair if there’s displaced osteochondral fragments
What is osteochondritis dissecans?
Occult episodes of trauma to the knee which result in separation of cartilage from the subchondral bone due to subchondral bone becoming avascular - fragments of bone break away to form loose bodies - causes poorly localised pain and pain after exercise with intermittent knee swelling
What does haemarthrosis development imply?
Significant articular injury such as anterior cruciate ligament tear, osteochondral fracture or patellar dislocation - develops immediately
What does delayed knee effusion after injury imply?
Meniscus tear or posterior cruciate ligament injury - developing over hours
What is patella tendonopathy?
Overuse syndrome - especially in explosive athletes such as jumping
Symptoms of patellar tendonopathy
Pain and soft tissue swelling around patellar tendon usually at proximal attachment to patella
Treatment of patella tendonopathy?
Ice, pain medication, activity modification and strengthening exercises focusing on eccentric loading of the tendon
What is the most commonly affected large joint in RA?
the knee
How are knees usually affected in RA?
Usually bilateral - symptom onset usually occurs early in course of the disease
Other chronic inflammatory arthritides which affect the knee? x2
Psoriatic arthritis and ankylosing spondilitis
Treatment of knee pain in inflammatory arthritides
Treated with the management of the systemic disease - lifestyle modification, physiotherapy, disease-modifying agents, NSAIDs etc
What is the most commonly affected joint?
The knee
How does knee joint infection present?
Red, swollen, hot knee with difficulty in weight bearing and a limitation in passive ROM
What is the common infecting organism in septic arthritis
Staphylococcus aureus
Management of septic arthritis - in knee
Joint aspiration for microbiological culture and looking for crystals
Systemic antibiotics
Serial joint aspiration or arthroscopic assisted washout
What is Reiters disease?
Reactive arthritis with conjunctivitis and urethritis
Tumours in knee
Knee is one of the most commonly affected sites for benign tumours - including osteoid osteoma, enchondroma and chondroblastoma
Also malignant tuours which as osteosarcoma and chondrosarcoma
Red flags indicating possible bone tumour as cause of knee pain
Unexplained pain, worse at night, unexplained swelling, systemic symptoms
What is Galeazzi test
Test for DDH
Child lies supine on examination table, hips flexed and feet flat on table with ankles touching buttocks -+ve test if knees are at different heights
If both legs are dislocated test will be -ve
Other signs of DDH
Unequal leg length
Asymmetrical groin creases
Widened perineum and buttock flattening on affected side
If >3 months, limited abduction of hip whilst in flexion may be the most sensitive test
Sign of bilateral DDH
Increased lumbar lordosis
What is bipartite patella?
Congenital fragmentation of the patella - usually incidental radiographic finding but may give pain if superolateral fragment is mobile with tenderness over the junction
If pain - extra fragment excision may relieve it
What is recurrent patella subluxation
A tight lateral retinaculum causes the patella to sublux laterally - giving medial pain
Knee may give way
Commoner in girls and with those with valgus knees
What is housemaids knee?
Prepatella bursitis - swelling anterior to the patella - typically following trauma or overuse
What is clergymans knee?
Infrapatellar bursitis - swelling inferior to patella
Treatment of knee bursitis
Friction bursitis can aspirate
If suppurative bursitis then needs drainage and antibiotics
Immediate knee haemarthrosis
ACL ligament damage because ACL is very vascular
Investigation of ACL injury
Xray to exclude evulsion
MRI
Knee locking
Meniscus tear
Swelling after medial meniscus tear
After hours
Treatment of medial meniscus tear
Analgesia, arthroscopy for locking or persisting symptoms
Swelling with unhappy triad
Immediate
Partial ACL tear swelling
Still immediate even if partial
DDH investigation
Ultrasound
