Hip and Knee Conditions Flashcards
What are the risk factors for bursitis?
Occupation that causes mechanical stress on bursa Rheumatoid arthritis Gout or pseudogout Penetrating injury Osteoarthritis of the hip Infection in a nearby joint Lower limb length discrepancy Iliotibial band contracture Lumbar spondylosis Valgus knee deformity Low-riding shoes Anatomical or functional impingement within the Coracoacromial arch Muscle wasting following surgery
What are the symptoms of bursitis?
Pain
Tenderness
Limited movement
low-grade temperature (septic bursitis)
swelling
erythema (septic bursitis)
warmth of overlying skin (septic bursitis)
painful arc on shoulder abduction (subacromial)
lateral hip pain (trochanteric)
pain at the extremes of hip rotation, abduction, or adduction (trochanteric)
pain of contraction of the hip abductors against resistance (trochanteric)
pseudoradiculopathy: pain radiating down the lateral aspect of the thigh (trochanteric)
impalpable patella (prepatellar)
palpable bump over heel (retrocalcaneal)
What investigations should be carried out for bursitis?
X ray MRI US Gram stain of fluid aspirate Crystal analysis
What is the management for bursitis?
NSAIDs Relative rest / Activity modification Physiotherapy Correct posture, abnormal movements Stretching Strengthen muscles around joint Injection Corticosteroids Surgery Bursectomy- rarely done as risks are too high US guided needle aspiration
What is avascular necrosis?
Death of bone due to loss of blood supply
If have end artery supply and have fracture or something blocking it then can get AVN
What are the risk factors for AVN?
Trauma-fracture, dislocation, iatrogenic or irradiation Idiopathic Hypercoagulable state Steroids Haematological Alcoholism Caisson's disease
What are the symptoms of AVN?
Pain that is insidious in groin Pain on incline Limp Stiffness Reduced motion esp internal rotation
What investigations should be done for AVN and what is seen on imaging?
X ray MRI See crescent sign-micro trabecular structures collapse but cartilage is still fine Then head of femur flatten off Then see arthritis type patterns Then head breaks off
What is the management for AVN?
Reduce weight-bearing NSAIDs Bisphosphonates Anticoagulants-improve flow of blood Physiotherapy Maintain range of motion Surgical -Restore blood supply -Core decompression -Core decompression and vascularised graft -Move the lesion away from the weight-bearing area -Rotational Osteotomy -Total Hip Replacement
What is Femoroacetabular Impingement?
In younger patients get impingement of femoral neck against anterior neck of acetabulum
Excess bone
Aspherical head
What are the two categories of FAI?
Cam lesion-extra bone on femur head
Pincer-acetabulum problems with more bone, more common in females
What are the associated injuries with FAI?
Labral tear
Cartilage damage and flap tears (secondary arthritis)
What is the presentation of FAI?
Groin pain worse with flexion
Mechanical symptoms-get to a certain point of passive movement and get stuck
Reduced flexion and internal rotation
FADIR test-flexion, adduction and internal rotation
What imaging should be used for FAI?
X ray to see bones
MRI to look at surrounding structures
What is the management for FAI?
Activity modification
NSAIDs
Physiotherapy
Arthroscopy-shave down bone and deal with labrum and cartilage
Open surgery-resection
Hip Replacement or resurfacing (take away a lot less bone and leave acetabulum)
What is the most common labral tear?
anterosuperior tear
Are labral tears more common in females or males?
Females
What are the causes of labral tears?
FAI Trauma OA Dysplasia Collagen diseases – Ehlers-Danlos
What is the presentation of labral tears?
Groin or Hip Pain
Snapping sensation
Jamming or locking
Positive FABER test-Flexion, Abduction, External Rotation
What investigations should be done for labral tears?
X ray
MRI arthrogram-fluid goes up to cleft of tear
Diagnostic injection-local anaesthetic into area and see if pain reduces
What is the management of labral tears?
Activity modification NSAIDs Physiotherapy Injection of Steroids Arthroscopy Repair Resection
What are the risk factors for a meniscal tear?
Acute trauma (twisting injury) Knee joint arthritis Knee instability FH of anterior cruciate ligament injury Malalignment of the knee joint Rough or uneven playing surface Poor ground/weather conditions Construction work and manual labour jobs Discoid meniscus
What is the presentation of a meniscal tear?
Intermittent Knee swelling
Sensation of knee instability or buckling/catching
Knee pain
Tenderness at joint line and joint line crepitation
Positive McMurray’s test
Positive Apley’s test
Positive hyperextension test
Popliteal (Baker’s) cyst in chronic cases
Limited range of motion
Positive Thassaly’s (Bend knee at 20 degrees with one leg raised and get them to twist, recreate injury pattern)
Effusion (do patellar tap)
Mechanical block to movement
Cant do deep squat
What is the McMurray test?
Patient is supine with knee in flexion. Examiner flexes the hip and, with one hand on the joint line, rotates the foot internally and externally. Pain with rotation suggests a meniscal tear. (Click is more suggestive of meniscal tear) This test has low sensitivity and high specificity for diagnosing a meniscal tear.
What is the Apley’s test?
Patient is prone with knee flexed at 90°. Examiner places axial load on the lower leg while rotating the foot. Patient often feels pain in the affected compartment.
What is the management for meniscal tear?
Unlikely to heal due to poor blood supply
NSAIDs
Rest
Physiotherapy-quadriceps strengthening so don’t put as much pressure on mensicus
Arthroscopy (can also be diagnostic)
What are the risk factors for an anterior cruciate ligament injury?
Acute trauma Female sex (after puberty) Poor technique for landings History of previous ACL injury Use of cleats or spikes Rough or uneven playing surface Ground condition/weather Fatigue Adolescence Athlete with higher skill level
What is the presentation of an ACL tear?
Audible pop Rapid knee swelling from haemarthrosis Inability to return to activity Sensation of knee instability or buckling Pain Positive Lachman's test Positive pivot shift manoeuvre Tenderness at lateral femoral condyle, lateral tibial plateau Positive anterior drawer test Had a non contact pivot injury
What is Lachman’s test?
Lachman’s test involves putting the patient supine and while placing one hand behind the tibia and the other on the patient’s thigh, the knee is at about 20 to 30 degrees in flexion. With the clinician’s thumb on the tibial tuberosity, the tibia is pulled anteriorly. If the ACL is intact, a firm end point is found. If a soft end-point is found, and there is more than 2 mm of anterior movement compared with the uninjured knee, the test is positive, suggesting a torn ACL.
What is a pivot shift manoeuvre?
The patient is in the lateral decubitus position and the examiner holds the patient’s leg with both hands. The knee is at 20 degrees of flexion and the patient is asked to relax the muscles. The examiner then places the knee in full extension and internally rotates the tibia. Then the knee is pushed from the lateral side and flexed. If a clunk is felt at 30 degrees, the test is positive for ACL rupture.
What is the management for ACL injury?
Focussed quadricep programme
ACL reconstruction
What is the presentation of an MCL tear?
Heard a ‘pop’ or ‘crack’ Pain Medial side Unable to continue playing Bruising medial knee Localised swelling Tender medial joint line Tender femoral insertion of mcl Painful in full extension Opening on valgus stress
What is the management for an MCL tear?
Rest Physiotherapy Brace for comfort NSAIDs Repair or reconstructions
What is osteochondritis dissecans?
Osteochondritis dissecans is an acquired, potentially reversible idiopathic lesion of subchondral bone resulting in delamination and sequestration with or without articular cartilage involvement and instability.
AVN of the knee
Can get juvenile and adult
What are the risk factors for OD?
Repetitive throwing/valgus stress Gymnastics/weight-bearing on upper extremity Ankle sprain/instability Competitive athletics Family history Vascular problems
What is the presentation of OD?
Pain is exacerbated by activity
Location of pain anteromedial aspect of the knee with the knee flexed to 90 degrees
Location of pain lateral aspect of elbow
Location of pain posteromedial aspect of dorsiflexed ankle or anterolateral aspect of plantar-flexed ankle
Effusion present
Locking of joint
Catching of joint
Decreased range of motion
Antalgic gait in osteochondritis dissecans involving the knee or talus
External rotation gait in osteochondritis dissecans involving the knee
Crepitus
Quadriceps atrophy
Wilson’s test
What is Wilson’s test?
Pain with tibial internal rotation and extension of the knee from flexion of 90 degrees to 30 degrees may be elicited from impaction of the medial tibial eminence on the lateral aspect of the medial femoral condyle
What is the management of OD?
Restricted weight-bearing Rom brace Arthroscopy Subchondral drilling Fixation of loose fragment Open fixation
