Hip and Knee Conditions (Week 4--Module and Fish) Flashcards
Hip and Knee conditions
Bones: fractures and dislocations (acetabular fracture, avascular necrosis–femoral head, posterior hip dislocation, femur intertrochanteric fracture, toddler’s fracture, patellar fracture, tibial stress fracture), Legg-Calve-Perthes disease, Osgood Schlatter disease
Joints: hip OA, developmental hip dysplasia, slipped capital femoral epiphysis, toxic synovitis, knee OA, palletofemoral syndrome, tibial torsion
Muscles/tendons: trochanteric bursitis, pes anserine bursitis, meniscal tear, knee ligament tear
Nerves/vessels: compartment syndrome, peripheral neuropathies (lateral femoral nerve syndrome, piriformis syndrome, common peroneal nerve entrapment)
Acetabular fracture
Less common hip fracture
Occur due to high-energy auto collision, fall, or in elderly patients due to osteoporosis
Avascular necrosis-Femoral head
Avascular necrosis is cell death of bone components due to interruption in blood supply
Secondary to trauma, diabetes, sickle cell anemia, SLE, chronic corticosteroid use
Initially, patient may be asymptomatic and thus disease progresses further into collapse of bone structure and destruction of hip joint
Treatment usually requires total hip replacement
“Crescent sign” of dead bone on MRI
Posterior hip dislocation
Either developmental or traumatic (high-energy blunt force trauma)
Posterior hip dislocation more common than anterior hip dislocation
Lower extremity internally rotated and adducted
Sciatic nerve commonly compressed by dislocated femoral head
Femur intertrochanteric fracture
In elderly patients because of osteoporosis or traumatic event like a fall
Damage to circumflex femoral artery branches account for common posttraumatic complication of avascular necrosis of the femoral head (extracapsular, so bleeds more?)
Will present externally rotated?
Treat with NSAIDS and opioids, reduction and internal fixation in young people and older people w/osteoporosis may require hip replacement
Toddler’s fracture
Mid-shaft oblique fracture of tibia in a toddler (1-3 years old)
Caused by twisting or torsional injury to lower extremity
Commonly mistaken for abuse
Patellar fracture
1% of all skeletal injuries in adults and children
Most common type is transverse fracture
Initial event usually jumping or something that involves eccentric contraction of quadriceps muscle, but also can be due to fall on anterior knee
Cannot flex knee
Surgery recommended if patient unable to perform Straight Leg Raise test, but full recovery expected
Tibial stress fracture
Tibia most common location for stress fracture, which is when repair process unable to keep up with repetitive trauma
Pain over medial aspect of tibia (shin splints)
Gradual onset of pain that then becomes constant localized, deep aching pain; reproducible with jumping; pain increases after weight-bearing activity and decreases with rest, ice, NSAIDs
ROM is normal
MRI is gold standard for diagnosis but X-ray is helpful
Legg-Calve-Perthes Disease
Pathophysiology: idiopathic avascular necrosis of femoral head; usually only one hip affected; almost exclusively in young white boys 3-12 with no hx trauma
Clinical presentation: mild hip or knee pain, limp, unilateral or diff stages bilaterally; initial phase radiographs normal, degenerative phase is flattened femoral head, regenerative phase is re-ossification of femoral head so does not fit in acetabular cavity normally; ROM decreased internal rotation and abduction of hip joint; worse with activity
Management/prognosis: brace and bedrest to keep femoral head in place, avoid weight bearing; good prognosis
Osgood Schlatter Disease
Pathophysiology: common in adolescents who jump/play sports because of repetitive pulling by patella’s tendon at insertion to tibial tubercle
Clinical presentation: anterior knee pain increases with time; prominent tibial tubercle with effusion, tenderness, warmth, normal ROM but some may avoid excessive knee flexion bc of pain; X-ray not helpful
Management/prognosis: NSAIDs, quadriceps and hamstring stretching and strengthening, ice, surgery is rare; resolves within 1 year or with skeletal maturity
Hip OA
Pathophysiology: involves head of femur and acetabulum; caused by previous fracture which changes hip alignment, undiagnosed developmental hip dysplasia, avascular necrosis of femoral head
Clinical presentation: pain in groin can be dull aching to throbbing, sharp and stabbing; antalgic gait (limp), ROM decreased internal rotation and abduction of hip; tender inguinal area; X-ray shows non-uniform joint space narrowing, bone sclerosis, osteophytes
Management/prognosis: (Tylenol first b/c this isn’t an inflammatory problem), NSAIDs, opioids, PT to strengthen muscles that cross hip joint, corticosteriod injections; prognosis only fair to poor
Developmental hip dysplasia
Pathophysiology: unbalanced fit of femoral head into acetabulum causes easy posterior subluxation of femoral head (uni or bilateral); genetics involved; more common in girls, found in physical exam of infants; due to mechanical factor in utero
Clinical presentation: asymmetry of gluteal region, thigh, labial folds, ROM limited abduction, ortolani and Barlow maneuver (abduct hip with anterior pressure to induce dislocation and positive is a click); X-ray shows DDH
Management/prognosis: Pavlik harness to prevent adduction and extension, 1-2 weeks of traction or surgery if diagnosed later; prognosis is fair if treated within first few weeks of life but if not treated then develop hip OA at young age
Slipped capital femoral epiphysis
Pathophysiology: displaced, Salter-Harris Type I fracture of epiphyseal plate for head of femur (uni or bilateral); change in orientation of epiphyseal growth plate (physis) for femoral head during early adolescence causes greater disruptive shear forces during daily activity and mechanical stress on growth plate and hormonal imbalances predispose white boys 11-16 to this; associated with obesity, radiation; doesn’t usually lead to avascular necrosis of femoral head but does predispose to premature hip OA
Clinical presentation: sharp severe pain in groin radiating to buttocks or knee that increases with movement and weight-bearing activities, leg in external rotation, ROM decreased intrenal rotation and abduction; pain on palpation; X-ray shows this
Management/prognosis: NSAIDs, surgical pinning then strength training rehab; after surgery most patients are functional but may have accelerated joint degeneration later in life
Toxic synovitis
Pathophysiology: unknown cause but affects boys between 3-7; AKA transient synovitis
Clinical presentation: acute pain, limp, appears in morning, patient not sick, CBC and ESR normal; ROM limited internal rotation by pain; no pain on palpation; lasts 3-5 days; frog leg x-ray helpful
Management/prognosis: NSAIDs, rest; resolves on its own
Knee OA
Pathophysiology: usually older patients >55 or previous trauma; medial compartment most common of 3 affected (more than patellofemoral and lateral compartments); bilateral but dominant pain on one side; degeneration of medial femorotibial articulation produces varus deformity of knee (bow-legged); associated with meniscus tear, ligament tear, prior fractures
Clinical presentation: gradual intermittent pain progresses to constant; idiopathic, obesity, hx trauma, instability from ligament tear can contribute; stiffness after inactivity; pain increases with weight bearing and decreases with rest; antalgic gait, ROM restricted flexion and extension w/pain at end; tender over joint line, crepitus palpated with ROM; X-ray for osteophytes, bone sclerosis, non-uniform joint space narrowing
Management/prognosis: NSAIDs, opioids, exercise and weight loss, PT to strengthen knee, brace to maintain stability, cane on contralateral side, shoe wedges for varus or valgus, corticosteroid injection, knee replacement; prognosis only fair to poor
Patellofemoral syndrome
Pathophysiology: changes in pallatofemoral joint resulting from overuse, overload or muscular/biomechanical problems cause patella not to glide smoothly over femoral condyles (poor tracking); repetitive grinding of retropatellar surface on femur can lead to pain
Clinical presentation: gradual onset anterior knee pain that is dull aching; clicking of patella; pain increased while ascending stairs, walking, running, sitting a long time, standing up from sitting and decreases with rest; decreased strength of quadriceps, offset patella, swollen knee joint; atrophy of vastus medialis muscle; ROM limited knee flexion; crepitus and tenderness of lateral patella; special test to evaluate tracking of patella
Management/prognosis: NSAIDs, rest, ice, braces/tape, quadriceps strengthening, surgery rarely; prognosis good
Tibial torsion
Pathophysiology: AKA toeing-in or pigeon toe where tibia turns inward; due to familial tendency or positioning of leg in uterus
Clinical presentation: no pain, “toeing-in” gait, may trip and fall, ROM normal, measure angle between thigh and foot (<10 degrees normal)
Management/prognosis: observation, nighttime splint, surgery if doesn’t resolve; most cases resolve by age 2
Trochanteric bursitis
Pathophysiology: painful inflammation of bursa between greater trochanter and insertion of gluteus maximus tendon; iliotibial band (IT band) becomes tight and puts pressure on bursa; caused by acute repetitive trauma (runners)
Clinical presentation: gradual lateral hip pain progresses to constant; discomfort lying, walking, running; may have bruising or swelling over lateral hip, normal ROM, pain on palpation, stretching IT band reproduces pain
Management/prognosis: NSAIDs, rest, ice, stretching of IT band, for chronic cases apply deep heat (ultrasound), correct gait abnormalities (cane, walker, orthotics, knee braces), corticosteroid injection into bursa; prognosis good with rehab
Pes Anserine Bursitis
Pathophysiology: irritation or inflammation of pes anserine bursa at medial knee
Clinical presentation: pain reproducible with passive knee extension, may be mild swelling below joint line of medial knee, normal ROM, tendeness on palpation at pes anserine bursa but not joint line or patella
Management/prognosis: NSAIDs, ice, lower extremity stretching after activity, corticosteroid injection; good prognosis
Meniscal tear
Pathophysiology: when foot planted while knee twisting, from football, basketball and skiing or older adults secondary to degenerative changes
Clinical presentation: acute injury then mild swelling (occurs hours to days after injury) and pain lasting more than 24 hours OR gradual onset increasing in adults with degenerative changes; sharp pain with twisting or bending; popping, clicking or catching with joint effusion; effusion and tenderness on joint line with possible atrophy of vastus medialis muscle; ROM limited extension, full flexion is painful; McMurray test, assess ACL, PCL, MCL, LCL to rule out ligamentous injury
Management/prognosis: NSAIDs, initially restrict activity and ice, crutches, quadriceps and hamstring strengthening, if locking or ACL then consider surgery; prognosis good to fair
Knee ligament tear
Pathophysiology: ACL tear most common and from jumping, twisting (basketball, skiing, football tackle) and can hear audible “pop” then swelling within an hour; PCL tear in “dashboard” injuries when hit tibia from front while knee bent; LCL tear from excessive varus; MCL tear from excessive valgus; combined MCL, ACL and medial meniscus tear is “unhappy triad” or “terrible triad injury”
Clinical presentation: immediate pain on high impact twisting while foot planted, immediate swelling, initially sharp and severe pain then softens to dull ache, knee instability, hemarthrosis, effusion, ROM limited flexion and extension, effusion and tenderness, Lachman and anterior drawer test for ACL tear; posterior drawer test for PCL tear; valgus and varus stretch for LCL and MCL tears; MRI is gold standard to view ligament tear
Management/prognosis: NSAIDs, ice, proprioception and ROM exercises, quad and hamstring strengthening, surgical reconstruction (patellar or hamstring tendon from cadaver); good prognosis with PCL, MCL, LCL tear but fair prognosis for ACL tear bc risk for knee instability, accelerated joint degeneration
Compartment syndrome
Pathophysiology: limb-threatening, life-threatening condition occurs when perfusion pressure is below tissue pressure in closed anatomical space; pressure from swelling/bleeding builds up in compartment, most commonly lower leg; associated with trauma, tight casts; usually acute but may be chronic due to repeated low-intensity trauma; can lead to tissue necrosis, permanent functional impairment, rhabdomyolysis (excessive tissue damage) which can progress to renal failure and death
Clinical presentation: acute or recurrent and progressive pain if chronic; significant pain after injury due to nerve impingement, burning, tightness, pain with movement and nothing helps; swollen with or without pallor, pain with passive stretching, warm or cold, tense/hard bc filled with fluid
Management/prognosis: IV hydration, O2 for ischemia, no elevation, do fasciotomy; prognosis good if fasciotomy within 6 hours of onset but necrosis if after 6 hours of ischemia
Lateral femoral cutaneous nerve syndrome
Lateral femoral cuteneous nerve courses deep to lateral edge of inguinal ligament and is compressed there
Burning, numbness, paresthesias down proximal-lateral aspect of thigh
Peripheral neuropathy
(AKA meralgia paresthetica?)
Piriformis syndrome
Sciatic nerve enters gluteal region through greater sciatic foramen deep to piriformis muscle; if piriformis muscle tight it can compress sciatic nerve
Pain referred to gluteal region and posterior compartment of thigh, described as deep pain
Peripheral neuropathy
(sciatica?)
Common peroneal nerve entrapment
Most common peripheral nerve injury in lower extremity
Common peroneal nerve can be injured at any location along thigh down to fibular head region from trauma but most occur at fibular head (at front); common peroneal nerve wraps around fibular head and can be compressed or injured there
Compression from habitual leg crossing, compression against bed railing or hard mattress, prolonged immobility if patient under anesthesia
Where might patients point to when they’re really having HIP pain?
Lateral and anterior thigh
Buttocks
Groin
Hip “short” external rotators
Piriformis
Gemellus superior
Obturator internus
Gemellus inferior
Obturator externus
Quadratus femoris
Hip internal rotators
Anterior fibers of gluteus medius and minimus
Adductor longus and brevis
Pectineus
Medial hamstrings (semitendinosus and semimembranosus)
Tensor fascia lata
Thomas test
Tests for flexion contractures of the hip
Internal rotation load/grind test
Acetabular labral tears
Ober’s test
Tightness in iliotibial band (IT band)
Clinical entities that have been associated with avascular necrosis of the hip
Corticosteroid use, alcohol, trauma, rheumatoid arthritis, sickle cell disease, myeloproliferative disorders, Gaucher’s disease, radiation, chronic pancreatitis, decompression sickness (Caisson’s disease, the bends), SLE
Hallmark of avascular necrosis (AVN) of the femoral head
“Crescent sign” caused by discrepancy in densities of femoral head due to subcondral bone collapse
(AVN with crescent of dead bone appearing white on MRI)
Meralgia pareshetica
Entrapment of lateral femoral cutaneous nerve
People who wear weight belts, belt too tight when working, overweight people
Different types of fractures of the hip (proximal femur)
Subcapital neck
Transcervical neck
Intertrochanteric
Subtrochanteric
Greater trochanter
Lesser trochanter
Adverse outcomes of hip fracture
Inability to walk
Thrombophlebitis (deep vein thrombosis)
Pressure ulcer
Pneumonia
Painful nonunion of the fracture
Death
Purpose of each ligament of the knee
ACL prevents anterior tibial translation
PCL prevents posterior tibial translation
MCL protects agains valgus (bowtie) stress
LCL protects against varus (bowlegged) stress
Meniscal vascular zones
Red Zone: (vascularized) heal well in most cases
Red/White Zone: may or may not heal without surgery
White Zone: (not vascularized) usually require surgery
Outer zone is fine because well vascularized but inner zone needs surgery
What is the first rotation lost in someone with OA of the hip?
Internal rotation
Which spinal level nerve root problem mimics hip problem?
L1-3 nerve root problem mimics hip problem
Which muscle is the big hip flexor?
Psoas major (which attaches to lesser trochanter)
(what about iliopsoas??)
Which knee compartment is the first degenerated in OA?
Medial compartment (because meniscus less round/C shaped and tears instead of moving!)
What spinal level are you testing by having patient walk on tip toes?
S1?
Tear in gastruc or achilles?
History of pain after sitting/stair climbing
Patellofemoral etiology
History of locking/pain with squatting
Meniscal tear
History of noncontact injury with “pop”
ACL tear
Patellar dislocation
History of contact injury with “pop”
Collateral ligament (MCL, LCL?)
Meniscus
Fracture
History of acute swelling
ACL
Peripheral meniscus tear
Osteochondral fracture +/- capsule tear
History of knee “giving way”
Ligamentous laxity
Patellar instability
History of anterior force on dorsiflexed foot
PCL or patellar injury
Which spinal level could knee pain be coming from?
Lumbar spine
Which knee ligament is compromised in planted foot with twisting/lateral force?
ACL
With OA, is it easy/hard to reduce pain/slow down disease progression?
Easy to reduce pain
Hard to slow disease progression
