Knee 1 Flashcards
Condition?
- Friction irritation due to repetitive A-P movement of the iliotibial band over the lateral femoral condyle (e.g. cross country running, cycling)
- Faulty biomechanics
Iliotibial Band “Friction” Syndrome
ITB Friction Syndrome
- Inflammation of the ITB at the point wher it passes over what?
Passes over lateral epicondyle of the femur
3 predisposing factors to ITB “Friction Syndrome”
- Tight IT band
- Genu varum (bowlegged)
- Foot pronation → internal tibial rotation
Clinical Presentation of what?
- Localized tenderness over lateral femoral condyle (esp. w/ palpation at 30˚ knee flexion)
- Pain with active knee flexion / extension (walk with “stiff” knee)
- No limitation of end range active or passive knee flexion/extension
- No weakness with resisted knee range of motion
- No pain or instability with collateral ligament laxity testing
Iliotibial Band “Friction” Syndrome
What test? / For what Condition?
- Pt supine
- Knee is flexed to 90°
- Pressure applied to lateral femoral condyle
- Knee is passively extended
- c/o pain at 30° similar to that during activity
Noble Compression Test
Tx for ITB “Friction” syndrome?
- NSAIDs
- Ice WITH motion
- Activity Modification
-
Therapy:
- improve gluteal & iliotibial band flexibility
- gluteal (hip abductor strength)
- evaluate biomechanics
- If fail conservative –> corticosteroid injection (risky bc/ tendon rupture)
Which condition?
- MC from repetitive contact/trauma
- Repetitive contact
- Carpet / tile layers
- Grappling sports (wrestling)
- Trauma
- Fall
- Forceful contact with hard object (coffee table)
Prepatellar Bursitis
Prepatellar Bursitis
- Tightness at end range of active & passive knee flexion
- Restricted ROM should be pain free
- Should not have pain w/ _____ of the patella
- What special test will be positive?
- lateral compression of the patella
- Patellar Ballotement is +
Tx for Prepatellar Bursitis
- Aspiration/injection
- Compression
- Ice
- NSAIDs
- Surgical excision (if recurrent problems)
- Prevention (Knee pads)
Aspiration / Injection for Prepatellar Burisitis Treatment
- 3 things you do to eval for Infection?
-
Post aspiration care:
- no direct water exposure for ___ hours
- Continuous compression for __ hours/ day for ___ days
-
During the first 7 days:
- ice daily
- avoid pressure/contact
- No repetitive LE exercise
- Visualize fluids for clarity, color, viscosity
- Leukocyte count
- Culture & gram stain
- no water: 48-72 hours
- compression: 48 hrs / 5 - 7 days
2 types of Infectious Arthritis
- Non-gonococcal acute bacterial arthritis (septic)
- Gonococcal arthritis
Infectious Arthritis - Non-gonococcal
- MC etiology?
- MC organism?
- RFs? (7)
- MC etiology: Hematogenous
- Organism: Staph aureus
-
RFs:
- •Immunosuppression
- Diabetes Mellitus
- Sickle cell anemia
- Prosthetic joint
- Previous or pre-existing arthritis
- Trauma
- Bacteremia
Clinical Px of what condition?
- Acute onset of monoarticular inflammatory arthritis (knee MC)
- Erythema, swelling/effusion, warmth and pain
- Limited function
- +/- fever
- +/- leukocytosis
Infectious Arthritis - Non-gonococcal
Infectious Arthritis - Non-gonococcal
- Mainstay of dx?
- Analysis consistent w/ what?
- Blood cultures positive in what %?
- Imaging?
- Mainstay: synovial fluid analysis w/ wide bore needle (16 G)
-
Analysis: Bacterial Infection
- >50,000 WBCs
- >75% PMNs
- Low glucose
- culture
- 50% of blood cultures are +
- Imaging usually NOT very helpful
Which condition?
- > 60 years
- High prevalence of RA
- Average of 4 joints (Knee, elbow, shoulder and hip predominate)
- Staph and Strep most common (Blood cultures positive in 75%)
- Synovial fluid culture positive in 90%
- Poor prognosis (32% mortality (compared to 4% with monoarticular disease)
Polyarticular infectious arthritis (Non-gonococcal)
IV drug users w/ Non-gonoccoal Infectious Arthritis
- What 3 joints are affected?
- # 1 MC organism?
- # 2 MC organism?
- sternoclavicular, costochondral, pubic symphysis
- #1: S. aureus
- #2: pseudomonas
Tx for Non-Gonococcal Infectious Arthritis?
- Joint aspiration and irrigation
- Start IV antibiotics - do not wait on culture results
•Empiric = Vancomysin + 3rd generation cephalosporin (Ceftriaxone)
Targeted:
- MSSA = Nafcillin
- MRSA = Vancomysin
•Serial synovial fluid analysis are utilized to confirm clearance of infection
Gonococcal - Infectious Arthritis
- Infection w/ what organism?
- Occurs in otherwise healthy people
- ____ arthritis in sexually active adult
- Greater in men or women?
- More common during menses & pregnancy
- Neisseria gonorrhoeae
- migratory
- Women
Clinical Px of what Condition?
- Migratory non-symmetric polyarthralgias of wrist, knee, ankle, elbow for 1-4 days
- Tenosynovitis
- Necrotic pustules on palms and soles
- Fever occurs in less than half
- Less than one fourth have GU symptoms
- <50% develop purulent arthritis (knee MC)
Gonococcal Infectious Arthritis
Labs of Gonococcal Infectious Arthritis
- Elevated WBC in less than 1/3 of cases
- Synovial fluid analysis
- elevated ___
- Gram stain positive in 25%
- Culture + in 50%
- Blood cultures positive in 40-70% of cases
- Cultures of what 4 locations need to be done? And are often + w/o sxs
- Imaging?
- elevated WBCs
-
4 locations for cultures:
- urethra
- throat
- cervix
- rectum
Tx for Gonococcal Infectious Arthritis?
- Azithromycin 1 g orally as single dose + third gen cephalosporin (Ceftriaxone)
- After improvement in 24-48 hours, patient must complete 7-14 day course of ceftriaxone IM daily
Prognosis: rapid response to abx
Which condition?
- Overuse / repetitive stress (e.g. jumping activities)
- Microtrauma / chronic inflammation of the patellar / quadriceps tendon
- Common in athletes who repeatedly jump or place eccentric stress on the knee
- Imbalance between frequent patellar tendon loading and short-term healing ability
Patellar / Quadriceps Tendonitis (-osis)
Clinical Px of what condition?
- Localized pain / tenderness on palpation
- Persistent aching after activity
- Pain with resisted knee extension (+/- weakness)
- Pain / tightness at end range of active and passive knee flexion
Patellar / Quadricepts Tendonitis (osis)
Tx for Patellar / Quad Itis or Osis?
- Activity modification
- NSAIDs
- Ice
- Patellar tendon strap
- PT if not improving w/ self mgmt
Tendonitis
Tx for Patellar / Quad Itis or Osis?
- Activity modification
- Physical therapy
- Patellar tendon strap
- NSAIDs NOT beneficial for long term management
Tendonosis
Which condition?
- 30-60 years old
- MOA: Rapid eccentric overload – fall on partially flexed knee
- MOA: Rapid concentric overload – basketball player jumping
- Sensation of instability or “giving way”
- Feel and/or hear a “pop”
Patellar / Quadriceps Tendon Rupture
Clinical Px of what?
- Significant pain at the time of injury but during exam they may have minimal to no pain with quadriceps contraction
- Rapid large effusion
- Defect indicating area of rupture may be palpable
- Key to diagnosis is inability to extend knee against gravity or perform straight-leg raise
- DO NOT assess prone passive knee flexion ROM
Patellar / Quadriceps Tendon Rupture
Patellar / Quadriceps Tendon Rupture
- R/o what with imaging?
-
Location of patella?
- Patella tendon rupture?
- Quadriceps tendon rupture?
- r/o patellar fx
- Patella: patella higher than usual
- Quad: patella lower than usual
What imaging do you order to confirm dx of Patellar/Quad Tendon Rupture?
MRI
Tx for Patellar / Quaddriceps Tendon Rupture?
- Straight leg immobilizer
- Non-weight bearing
- Partial tears <50% may be treated non-surgically
- Surgical repair treatment of choice for complete rupture
- Marked disability will develop secondary to deficient extensor mechanism
Which condition?
Repetitive activity w/ faulty biomechanics
- Vastus medialis oblique (VMO) weakness
- Increased Quadriceps angle (Q angle)
- Hyperpronation
- Poor technique
Patellofemoral Pain Syndrome
(Overuse condition affecting the patellofemoral joint)
Term? Condition?
- Pathologic changes involving articular surface of patella and femoral condyle
Chondromalacia
- Patellofemoral Pain Syndrome
Patellofemoral Pain Syndrome - Quadriceps Angle (Q-angle)
- Line from the ___ –> ____
- 2nd line transects the center of the patella and the ____
- Females: ___ in full extension
- Males: ___ degrees in full extension
- ASIS –> center of patella
- tibial tuberosity
- F: <22 degrees
- M: <18 degrees
Which condition?
- “Movie theater sign”
- Pain w/ ascending and descending stairs
- Pain w/ repetitive deep knee flexion
- Pain at end range of active and passive knee flexion
- Pain with resisted knee extension (+/- weakness)
- J sign
- patellar grind
Patellofemoral Pain Syndrome
PFPS (patellofemoral pain syndrome) Treatment?
- Activity modifications
- NSAIDs
•Weight loss if obese****
- VMO strengthening
- Gluteal strengthening
- Evaluate / correct technique
Which condition?
- Most commonly due to twisting injury to knee.
- Only 10 % caused by direct trauma
- Subluxation and dislocation may occur with minimal stress (e.g. minor twist with foot planted)
Patellar Dislocation
4 RF of Patellar Dislocation?
- Shallow patellofemoral articular groove
- Patella alta
- Excessive Q angle
- Generalized ligamentous laxity
Patellar Dislocation
- Avg age range?
- Rare over what age?
- Which sex has higher incidence?
- Avg: 16 - 20 yrs
- Rare: >30 yrs
- Females
Patellar Dislocation
- Severe pain, sometimes a “pop”
- Pain and position of the patella contribute to patient being extremely uncomfortable
- Knee held in a ____ position with a prominent _____ condyle
- Reduced by gentle extension of the tibia, forceful ____ pressure on the patella is avoided
- After reduction the patient has diffuse peri-patellar tenderness
- flexed position / medial femoral
- forceful medial
Patellar Dislocation
•Subluxation or dislocation of the patella causes tearing of restraining _______ and ________, leading to pain, significant hemarthrosis, and loss of knee motion
- medial retinacular tissue & medial patellofemoral ligament
What test? What condition?
- Knee in 30° flexion & gently displace patella laterally
- Observe for guarding (reflexive quad contraction and/or reaching towards the knee) and visible apprehension
Patellar Apprehension Sign / Patellar Dislocation
Patellar Dislocation
- Post reduction x-rays may show____ or _____ of patella
- ____should be ordered to assess severity of soft tissue injury & screen for osteochondral injury
- lateral tilt or subluxation of patella
- MRI
Tx for Patellar Dislocation?
- Knee Immobilizer after reduction
- Stabilization brace post immobilization
- PT to address biomechanical risk factors
- Surgery if there is evidence of loose body on imaging studies or if patient has a history of recurrent dislocations
MCL / LCL injuries
- Which has greater incidence?
- MC in males or females?
- Result from what 2 mechanisms?
- Use what 2 tests?
- MCL > LCL
- Males
- Valgus or Varus mechanisms
- Valgus/Varus stress tests (grade 1, 2, or 3)
MCL Injury
- Force directed to ___ aspect of knee leads to injury of medial collateral ligament
lateral
Clinical Eval of which injury?
- Instability - Abnormal opening of medial joint space
- Valgus stress test knee fully extended
- Valgus stress test knee flexed 30°
MCL injury
What is the “unhappy triad” and what injury?
MCL injury
- Medial collateral ligament tear
- Medial meniscal tear
- Anterior cruciate ligament tear
What is the name of the MCL avulsion fx?
Steida’s Fracture
LCL injury
- Force directed to the ___ aspect of the knee
- Results in injury to the lateral collateral ligament
- Rare
medial
Clinical eval of which injury?
- Abnormal opening of lateral joint space
- Varus stress test knee fully extended
- Varus stress test knee flexed 30°
- Check neurological function
LCL injury
Collateral Ligament Tears
- Pain w/ palpation
- Swelling
- ROM loss varies based on severity/amt of swelling
- Is loss of knee flexion or extension more pronounced?
Loss of flexion is more pronounced
Which grade of Collateral Ligament Tear?
- Pain with stress testing but no laxity
- RICE, short term NSAIDs and crutches as needed
Grade 1 (Interstitial)
Which grade of Collateral Ligament Tear?
- Pain and mild laxity with stress testing
- Hinged brace and weight bearing as tolerated
- Therapy
Grade 2 (Partial)
Which grade of Collateral Ligament Tear?
- Significant laxity and +/- pain with stress testing
- Orthopedic surgery consult
- Hinged brace and gradual return to full weight bearing over 4-6 weeks
- Therapy
Grade 3 (complete)
