Hip and Knee

Question 1

Acute painful/swollen joint - causes

Answer 1

Septic arthritis
Gout
Pseudogout
Haemarthrosis 
Reactive arthritis 
Monoarticular presentation of inflammatory arthritis
Traumatic synovitis

Question 2

Knee effusion - clinical features

specific sign of joint inflammation

Answer 2

Pain - osteoarthritis
Swelling
Stiffness
Bruising (trauma)

Question 3

Acute painful/swollen joint - assessment and investigation

Answer 3

As septic arthritis - bloods, cultures, USS guided aspiration, cytology, microscopy and culture of aspirate and X-Ray (usually normal in early disease)

Question 4

Acute painful/swollen joint - periprosthetic infections

Answer 4

Important to identify as the prosthetic joint will be need to be removed if the joint is infected - staged surgery
Stage 1
- removal of arthroplasty
- washout 
- debridement 
- antibiotic spacer
Then 6 weeks of IV antibiotics 
Stage 2
- new joint arthroplasty

Question 5

Osteoarthritis of hip and knee - clinical features

Answer 5

Functionality limiting pain
Pain at night/rest
Stiffness
Decreased range of movement 
Mechanical 
- sticking
- locking/catching sensation

Question 6

Hip pain - differentials

Answer 6

Osteoarthritis 
Rheumatoid arthritis 
Femoral neck fracture
Avascular necrosis 
Septic arthritis 
Trauma 
SCFE/Perthes - paediatrics 
Bursitis 
Labrum tear - acetabulum 
Adductor longus strain (groin strain)

Question 7

Osteoarthritis of hip and knee - non-operative management

Answer 7

NSAIDs/tramadol 
Walking stick 
Lifestyle management 
Physical therapy 
Corticosteroid joint injections

Question 8

Osteoarthritis of hip and knee - operative management

Answer 8

Total hip arthroplasty indications

• extreme functional impairment on activities of daily living
• severe osteoarthritis on X-Ray
• if conservative management inadequate

Question 9

Abnormal gait - causes

Answer 9

RA/OA
Parkinson's Disease
Multiple Sclerosis 
Stroke/TIA
Cerebral palsy 
Muscular dystrophy 
SCFE/Perthes in children

Question 10

AVN of hip - pathophysiology

Answer 10

Vascular occlusion occurs due to the coagulation of the intraosseous microcirculation

• leads to intraosseous hypertension and decreased blood flow to the femoral head
• lack of blood causes osteocyte death and femoral AVN

Question 11

AVN of hip - causes

Answer 11

Idiopathic
Trauma - femoral neck fracture 
Irradiation 
Haematological disease
Dysbaric disorders
Marrow-replacing disease

Question 12

Slipped capital femoral epiphysis - presentation

Answer 12

Dull pain in thigh, knee, groin or hip
Sudden limp
Hip held in passive external rotation 
Boys aged 1-16 (during period of rapid growth)
Restricted range of movement - reduced internal rotation and abduction 
Unstable SCFE - can't walk
Weakness
Abnormal leg alignment

Question 13

Slipped capital femoral epiphysis - diagnosis

Answer 13

X-Ray
- AP and frog lateral
AP findings
- Klein’s line - reduced intersection of lateral femoral head in SUFE (drawn along the superior border of the femoral neck)
- epiphysiolysis
- blurring of proximal femoral metaphysis

Question 14

Developmental dysplasia of hip - risk factors

Answer 14

Family history
Firstborn
Female
Breech position
Oligohydramnios

Question 15

Developmental dysplasia of hip - clinical signs

Answer 15

Barlow's test 
- dislocates a dislocatable hip 
- adduction and depression 
- exit click
Ortolani's maneuver 
- reduces a dislocated hip 
- elevation and adduction of fixed femur 
- entry click
Galeazzi sign
- apparent limb length discrepancy due to unilateral hip dislocation

Question 16

Developmental dysplasia of hip - management

Answer 16

Abduction splinting/bracing if reducible

No-operations until 18 months

Question 17

Developmental dysplasia of hip - clinical features in older infants (3 months - 1 year)

Answer 17

Limited hip abduction
Leg length discrepancy
Klisic test - line points to pelvis rather than umbilicus

Question 18

Developmental dysplasia of hip - treatment in older infants (3 months - 1 year)

Answer 18

Abduction splinting/bracing if reducible (<6 months)

Closed reduction and spica casting (6-18 months)

Question 19

Developmental dysplasia of hip - clinical features in children >1 year

Answer 19

Pelvic obliquity
Lumbar lordosis
Trendelenburg gait - abductor insufficiency
Toe-walking (compensation for leg length discrepancy)

Question 20

Developmental dysplasia of hip - treatment in children >1 year

Answer 20

Closed reduction and spica casting (<18 months)
Surgical
- open reduction and spica casting
- open reduction and femoral/pelvic osteotomy

Question 21

Quadriceps and patella tendon rupture - importance

Answer 21

Very subtle and easy to miss
Physiotherapy needs to be started early to prevent stiffness
- loss of knee flexion

Question 22

Quadriceps and patella tendon rupture - clinical features

Answer 22

Supra/infra patellar pain
Popping sensation
Hard to weight-bear
Bruising 
Droop/elevated patella
Tenderness
Cramping
Indentation
Can't actively straight leg raise or maintain passive extension
Reduced range of movement due to pain

Question 23

Quadriceps and patella tendon rupture - acute management

Answer 23

Non-surgical (small or partial tears)
- immobilisation in extension
- physiotherapy after initial pain and swelling
Surgical
- primary repair (fully torn)
- tendon reconstruction (severe partial tear)
Rehabilitation
- weight-bearing with brace and physiotherapy

Question 24

Meniscal tears - clinical features

Answer 24

History of axial load and rotation with a fixed foot 
Joint effusion - delayed, slow onset 
Pop, click or locking on maneuver
Localised pain
- medial or lateral 
Joint line tenderness

Question 25

Ligament knee injuries - clinical features

Answer 25

History of valgus stress and internal or external rotation
- internal rotation = medial or anterior ligament affected
- external rotation = lateral ligament affected
Joint effusion - rapid onset
Absent popping sensation
Localised pain
Positive ligament test