Hip and Knee Flashcards
What should you always do when someone presents with a sore joint?
Think a joint up- is a sore hip coming from the back (particularly if buttocks). Is a sore knee coming from the hip.
Why are X-rays not good to do always?
Should only do them if it will change management as many people may show OA of hip but actually have not symptoms.
5 common causes of hip pain?
Osteoarthritis Rheumatoid arthritis Fracture Referred from back Malignancy
5 less common causes of hip pain?
Soft tissue e.g. trochanteric bursitis
Paget’s disease
Infection e.g. septic, TB
Avasular necrosis
What are knee problems often related to?
Trauma- even trauma that has occurred years ago can affect the knee
Describe two features of knee pain?
Commonly anterior and usually well localised.
What is osgood schlatters syndrome?
Osteochondritis of tibial tubersity (inflammation and swelling of the growth plate)
4 common causes of knee pain?
- LIGAMENT STRAIN OFTEN MEDIAL COLLATERAL
- BURSITIS
- OSGOOD-SCHLATTER’S
- OSTEOARTHRITIS (PATELLO-FEMORAL>KNEE)
6 less common causes of knee pain?
CHONDROMALACIA PATELLAE MENISCUS INJURY CRUCIATE DAMAGE GOUT RHEUMATOID ARTHRITIS PATELLAR SUBLUXATION/DISLOCATION
What are menisci?
Partially flat fibrocartilage that stabilise the rounded femoral condyle on the flat tibial plateau.
How can meniscal tears occur?
They can be torn by injury commonly in sorts that involve twisting. Can also get degenerate meniscal tears in early OA.
What meniscal tears are more common?
Medial
Some ACL ruptures can cause _____ tear
meniscal tear
Presentation of meniscal tear?
history of twisting injury slow to form effusion joint line tenderness positive Steinmanns test complain of feeling of locking and knee giving way
Exam of meniscal tear?
Effusion, joint line tenderness and positive Steinman test
What is a positive Stienman’s test?
joint line tenderness and pain on tibial rotation localizing to the affected compartment
medial pain in external rotation- medial meniscus
lateral pain in internal rotation- lateral meniscus
Treatment of meniscal tears?
Immediate treatment is ice
Only consider arthroscopic repair in young patients with peripheral tears. Lots of these surgeries still fail
More than 90% not suitable for repair, they do not heal but can settle over time. Can do meniscectomy.
Steroid injections for degenerate tears may help symptoms.
Degenerate tears unlikely to benefit from meniscectomy as increases the stress on a joint.
Why do menisci have limited healing potential?
The meniscus only has an arterial blood supply in its outer third. Healing potential also decreases with age. Those 25-30 have poor healing potential.
Describe what MCL, LCL, ACL and PCL in the knee do?
MCL resists valgus stress
LCL resists varus stress
ACL resists anterior subluxation of the tibia and internal rotation of the tibia in extension and hyeprflexion
PCL resists posterior subluxation of the tibia ie anterior subluxation of the femur and hyperextension of the knee
Describe what injury to MCL, LCL, ACL and PCL can lead to?
MCL rupture may lead to valgus instability
ACL rupture may lead to rotatory instability
PCL rupture may lead to recurrent hyperextension or instability descending stairs
Posterolateral corner rupture leads to varus and rotatory instability
What usually causes ACL rupture?
Sports injury- football, rugby, skiing.
Presentation of ACL rupture?
history of rotatory injury on a planted foot
at time of injury may have felt a pop and knee give way
quick development of effusion (massive haemarthrosis as ACL as large blood supply)
complain of rotatory instability and feeling of knee giving way
Clinical examination of ruptured ACL?
Knee swelling (haemarthosis or effusion) with excessive anterior translation of the tibia on the anterior drawer test and Lachman test
What is the rule of 3 with ruptured ACLs?
1/3 will compensate and can function well, 1/3 will manage by avoiding certain activities and 1/3 will do poorly
Treatment of ruptured ACL?
Primary repair is not effective so reconstruction done (only 40%). Usually sports or active people who physio is not working on. Reconstruction is usually from a tendon graft and need rehabilitation (1 yr).
What type of isolated ligament rupture is rare?
Ruptured PCL
Treatment of ruptured PCL?
Most isolated cases don’t need reconstruction
If part of multi ligament knee injury reconstruction is usually needed.
Complaint in ruptured PCL?
Instability- recurrent hyperextension
Rupture/ tear of what ligament usually heals well?
MCL
If combined with ACL or PCL injury it does not heal as well
Presentation of MCL tear?
history of valgus stress injury e.g. a rugby tackle from the side
pain and laxity on valgus stress and along the ligament
What ligament is relatively uncommon but will cause varus and hyperextension? Does it heal?
LCL rupture or tear
It doesn’t heal and causes varus and rotatory instability
LCL rupture or tear has incidence of _________
common peroneal nerve palsy (AKA common fibular nerve!!)
Define knee dislocation?
Entire alignment of femur and tibia is moved out of place. There is rupture of all four knee ligaments and have a high incidence of neurovascular injury.
Complications of complete knee dislocation?
Popliteal artery injury, common peroneal (fibular) nerve injury, compartment syndrome.
Treatment of complete knee dislocation?
Emergency reduction, recheck neurovascular status.
Any concerns with vascular status needs vascular surgery
May require external fixation for temporary stabalisation
Need multi ligament surgery
What can cause patellar dislocation? Where does the patella virtually always dislocate?
Can occur with direct blow or sudden twist of the knee. Virtually always dislocates laterally and may spontaneously reduce when the knee is straightened or rarely may require manual manipulation back into position.
What ligament tears in patellar dislocation, what does this cause?
Osteochondral fracture may occur and can get lipo- haemarthosis on X-ray.
Predisposing factors to patellar dislocation?
Ligamentous laxity, females gender, shallow trochlear groove, genu valgum, femoral neck anteversion and high riding patella.
Describe risk of recurrent patellar dislocation?
Risk of recurrent instability decrease with age and physio to strengthen the quads may help. Risk of recurrent dislocation after 1st dislocation is 10%.
What does the extensor mechanism of the knee consist of?
tibial tuberosity, the patella tendon, the patella, the quadriceps tendon and the quadriceps muscles
Describe mechanisms for extensor mechanism rupture?
The patellar tendon or quads tendon can rupture with rapid contractile force e.g. fall, lifting heavy weight or spontaneously in a degenerate tendon. More likely for it to be patellar tendon in under 40 and quadriceps tendon in over 40.
Predisposing factors to extensor mechanism rupture?
Tendonitis history, chronic steroid use, diabetes, RA and kidney failure. Quiniolones too and they can cause tendonitis.
Presentation of extensor mechanism rupture?
Unable to do straight leg raise
Palpable gap
Treatment of extensor mechanism rupture?
Surgical- tendon to tendon repair or reattachments of the tendon to the patella.
Compare swelling in a meniscal tear and a ACL rupture?
although both will cause swelling due to the good blood supply ACL rupture will swell almost immediately but meniscal tear will swell over a few hours.
Describe where pain from the hip is typically felt?
Hip pathology typically produces pain in the groin which may radiate to the knee (due to the obturator nerve supplying both joints and referred pain). Hip pathology may also result in buttock pain however lumbar spine and SI joint problems can also give rise to buttock pain. Hip pathology can also present purely with knee pain, particularly in SUFE.
What is one of the commonest sites of avascular necrosis?
The hip
Treatment of hip avascular necrosis?
If the condition is detected early enough (pre‐collapse), drill holes can be made up the femoral neck and into the abnormal area in the head in an attempt to relieve pressure (decompression), promote healing and prevent collapse. Once collapse has occurred, the only surgical option is THR.
Explain trochanteric bursitis
(often related to gluteal cuff syndrome)
Repetitive trauma caused by iliotibial band tracking over trochanteric bursa causing inflammation of the bursa.
Predisposing factors to trochanteric bursitis?
More common in females, can happen in runners. Can also cause inflammatory arthritis.
Presentation of trochanteric bursitis?
Pain on the lateral aspect of the hip and pain on palpation of the greater trochanter.
Diagnosis of trochanteric bursitis?
Clinical diagnosis: radiographs are usually unremarkable, it is visible on MRI but this isn’t usually needed.
Treatment of trochanteric bursitis?
No proven benefit from surgery
NSAIDs and Analgesia
Physio
Steroid Injections
Why does hip pathology often radiate to the knee?
The obturator nerve supplies both joints
