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phase iii orthopaedics > knee > Flashcards

knee Flashcards

1
Q

what does turbid knee effusion suggest?

A

gout, infection

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2
Q

what does straw colored knee effusion suggest?

A

ra

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3
Q

what does clear knee effusion suggest?

A

normal

RA

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4
Q

which view is the best to visualise loss of medial joint space?

A

rosemberg view (30-40deg flexed weight bearing view with XR beam tilted caudally to profile joint line)

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5
Q

WBC raised: gout or RA?

A

Gout

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6
Q

normal foot progression angle

A

6-10 deg externally rotated

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7
Q

intoeing foot progression angle

A

negative 20-30 deg

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8
Q

describe the physiological evolution of leg alignment at various ages

A

0-18 months: genu varus
- tibial intorsion

2-6 years: genu valgum

  • laxity of ligaments
  • valgus max at 4yo
  • management: reassure parents and measure child intermalleolar distance every 6 months

6-7 yo: straight

  • tightening of ligaments
  • operative correction advised if marked deformity persists past 10 yo
  • note: slight valgus of 5-7 deg is normal
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9
Q

define rickets

A

failure of mineralisation of physes or bone due to vit D deficiency

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10
Q

define blount’s disease

A

infantile growth disorder with idiopathic arrest of growth plate on medial side of tibia

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11
Q

presentation of blount’s disease

A
  • progressive genu varum + medial rotation of tibia

- often bilateral

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12
Q

mechanism of intoeing in CHILD

A

hip: femoral anteversion
- excessive internal rotation
- usually bilateral
- history of W sitting

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13
Q

management of intoeing in child

A
  • conservative: cross legged sitting

- surgical when intoeing interferes with walking/running > derotational osteotomy

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14
Q

mechanism of intoeing in toddler

A

leg: medial tibial torsion

- commonest cause of bow leggedness in 1yo

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15
Q

mechanism of intoeing in infant

A

foot: metatarsus adductus (curved foot)

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16
Q

consequence of genu valgus (accept valgus till about 5-7yo)

A
  • inhibition of lateral growth plate > OA of lateral compartment
  • callosities
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17
Q

knee deformity seen in RA

A

genu valgum

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18
Q

knee deformity seen in OA

A

genu varum

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19
Q

symptoms in osteochondritis dissecans

A
  • locking (loose body)
  • giving way
  • intermittent ache or swelling
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20
Q

exact site usually affected by osteochondritis dissecans

A

lateral part of medial femoral condyle

- wilson’s sign: pain when knee flexed 90, internal rotation, gradually straightened

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21
Q

management of osteochondritis dissecans

A

1) conservative: lifestyle modification (decrease activity)
2) surgery for unstable fragments
- small fragments: arthroscopic removal of fragment
- large fragments (>1cm): fixation with pins or herbert screws

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22
Q

causes of loose body in knee

A

1) trauma
2) OA
3) synovial chondromatosis
4) charcot’s joint

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23
Q

causes of charcot’s joint

A

1) diabetes
2) peripheral neuro
3) tertiary syphillis
4) tabes dorsalis
5) syringomyelia
6) myelomeningocele
7) cauda equina

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24
Q

differential diagnosis for anterior knee pain

A
  • osteochondritis dessicans (young male, post trauma)
  • patella maltracking > CMP (esp young females)
  • patella subluxation
  • patella tendinosis (jumper’s knee)
  • plica syndrome
  • hoffa syndrome: inflammation of infra patellar fat pad
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25
Q

management of osgood schlatter’s disease

A

conservative

  • ice
  • NSAIDs (pain relief + reduce inflamm)
  • rest
  • physiotherapy (quadriceps strengthening > reduce tension on tibial tuberosity)
  • orthotic devices (brace)
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26
Q

etiology of acute joint swelling

A

1) haemarthrosis (trauma - ACL!/bleeding dyscrasias)
2) acute septic arthritis
3) gout/pseudogout

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27
Q

differentials for swelling at back of knee

A

1) skin
- lipoma
- sebaceous cyst

2) artery
- popliteal artery aneurysm

3) vein
- saphena varix
- dvt

4) nerve
- neuroma

5) enlarged bursae
- semimembranosus bursae

6) cyst
- baker’s cyst (associated with OA)
- popliteal cyst

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28
Q

what is a baker’s cyst

A

posterior herniation of knee joint capsule

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29
Q

what conditions is a baker’s cyst associated with?

A
  • OA
  • RA
  • charcot’s joint

TRO dvt

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30
Q

signs of baker’s cyst

A
  • swelling BELOW joint line (semimembranosus bursa is above)
  • fluctuant
  • may be transilluminable
  • non tender
  • positive slip sign
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31
Q

complications of baker’s cyst

A
  • increased risk of dvt

lateral deviation of popliteal vein > compression> venous stasis

32
Q

investigation of baker’s cyst

A

U/S

33
Q

popliteal cyst vs semimembranous cyst

A

popliteal cyst empties on flexion of knee joint, semimembranosus cyst does not

34
Q

risk factors for patella maltracking

A

1) malalignment of extensor mechanism/weakness of VMO
2) tight lateral retinaculum/ITB
3) lax/torn MPFL
4) large Q angle

35
Q

causes of increased Q angle

A

1) genu valgum
2) femoral anteversion
3) external tibial torsion
4) laterally positioned tibial tuberosity
5) tight lateral retinaculum
6) larger pelvis

36
Q

why is q angle not accurate in extension

A

laterally dislocated patella > false impression that Q angle is normal

37
Q

management of patellofemoral overload

A

1) conservative
- analgesics
- physiotherapy: strengthen VMO, stretch ITB
- taping/knee brace

2) surgery
- lateral retinacular release
- anteromedial tibial tuberosity transfer

38
Q

associated injuries/complications of tibial plateau fracture

A
  • compartment syndrome (esp type 5 and 6)
  • popliteal artery injury
  • ligament/meniscal tear (contralateral side)
  • malunion
  • joint stiffness
  • secondary OA
39
Q

classification for tibial plateau fractures

A

schatzker’s classification

40
Q

describe the types of tibial plateau fractures according to schatzker’s classification

A

1: simple split of lateral condyle
2: split of lateral condyle with more central area of depression
3: depression of lateral condyle with intact rim
4: fracture of medial condyle
5: fractures of both condyles but central portion of metaphysis still connected to tibial shaft
6: combined condylar and subcondylar fracture (split extending to metaphysis)

41
Q

management of tibial plateau fractures by fracture type

A

lateral condylar fracture undisplaced/minimally displaced: conservative
- aspirate haemarthrosis + compression bandage > hinged cast

lateral condylar fracture markedly displaced/comminuted
- ORIF (plate + screws)

medial condylar fracture
- ORIF +/- lateral ligament repair

bicondylar fracture
- ORIF

osteoporotic condylar fracture
- ORIF or TKR

42
Q

types of patellar fractures

A

1) undisplaced crack
2) comminuted/stellate
3) transverse fracture with gap between fragments

43
Q

mechanism of injury for undisplaced patellar crack

A

direct blow

44
Q

mechanism of injury for comminuted/stellate patellar crack

A

fall or direct blow in front of kidney

45
Q

mechanism of injury for transverse fracture with gap

A

indirect traction injury due to forced, passive flexion of knee while quads muscle contracted

  • torn extensor mechanism
  • inability to actively extend knee
46
Q

main complication of patella fractures

A

PFOA

47
Q

management of patellar fractures

A

aim for early ROM for all

1) undisplaced/minimally displaced crack
- aspirate haemarthrosis
- protection with plaster cylinder holding knee extended

2) comminuted fracture
- aspirate haemarthrosis
- acceptable displacement: backslab
- severe displacement: complete/partial patellectomy

3) displaced transverse fracture
- ORIF: tension band wiring + K wires
- repair extensor tendons

48
Q

common position preceding patellar dislocation

A

sudden contraction of quadriceps while knee stretched in valgus + external rotation

49
Q

management of first instance of patellar dislocation

A

reduction + backslab + physiotherapy

50
Q

risk factors for recurrent patella dislocation

A

1) generalised ligamentous laxity
2) underdevelopment of lateral femoral condyle
3) maldevelopment of patella (too high/small/lateral
4) genu valgus
5) tibial tubercle malalignment
6) primary muscle defect
7) more common in girls

51
Q

management of recurrent patella dislocation

A

1) conservative
- reduction & backslab
- physiotherapy: isometric quad strengthening exercises (focus on vastus medialis to counterbalance lateral tilt/subluxation)

2) surgical
- repair patellofemoral ligaments
- realignment of extensor mechanism
- lateral release if lateral retinaculum too tight

52
Q

complications of knee dislocation

A

1) early
- vascular injury: popliteal artery
- nerve injury: posterior tibial, common peroneal nerves
- capsular/meniscal injuries
- compartment syndrome

2) late
- reperfusion injury
- joint instability
- joint stiffness

53
Q

management of knee dislocation

A

1) conservative
- quadriceps muscle exercises

2) surgery
- reduction + backslab in 15deg flexion
- unstable or vascular repair: external fixator

54
Q

stabilisers of the knee

A

1) strong capsule
2) intraarticular ligaments: ACL, PCL
3) extraarticular ligaments: MCL, LCL
4) quadriceps

55
Q

what is the unhappy triad (o’donoghues triad)

A

ACL + MCL + medial meniscus

note: classically described as MCL + medial meniscus but can be any collateral ligament + meniscal injury

56
Q

grades of ligamentous sprain in knee

A

grade 1:

  • ligament mildly damaged
  • slightly stretched but able to keep knee joint stable
  • PCL step off 0-5mm

grade 2:

  • partial tear of ligament
  • stretched to the point where it becomes loose
  • PCL: 5-10mm of posterior translation

grade 3:

  • complete tear of ligament
  • knee unstable
  • PCL: >10mm of posterior translation
57
Q

management of ligamental injury of knee

A

1) conservative
- aspirate haemarthrosis
- pain relief: ice packs/nsaids
- physiotherapy: strengthen hamstrings & quads

2) surgical
- ACL reconstruction by grafting (hamstring/bone-patella tendon- bone)

58
Q

indications for conservative management in knee ligament injuries

A

1) sprains & partial tear
2) isolated MCL, LCL, PCL tears
3) isolated ACL in non-sportsman

59
Q

function of ACL

A

1) prevent anterior translation of tibia on femur

2) resist internal rotation of tibia

60
Q

name the two bundles of the ACL

A

1) anteromedial > taut in flexion

2) posteriolateral > taut in extension

61
Q

mechanism of acl injury

A

1) internal rotation on hyperextended knee
2) indirect varus blow to knee
- patients with greater Q angle > greater chance of ACL tear

62
Q

history in acl injury

A

1) audible pop
2) giving way > inability to continue activity
3) immediate haemarthrosis

63
Q

why does ACL not have ability to heal

A

1) synovial fluid keeps both ends apart
2) synovial fluid produces proteolytic enzymes exacerbating damage
3) synovial fluid prevents formation of fibrin platelet clot at wound site

64
Q

mechanism of injury of PCL

A
  • dashboard injury
65
Q

mechanism of injury of LCL

A

varus force

66
Q

mechanism of injury of MCL

A

valgus force

67
Q

why is medial meniscus more commonly injured than lateral

A

1) medial meniscus LESS mobile (due to attachment of MCL)

2) popliteus muscle pulls lateal meniscus into more favourable position during suden movements

68
Q

etiology of meniscal pain

A

synovitis; not due to innervation of meniscus

69
Q

symptoms of meniscal tear

A

1) severe pain over joint line
2) knee locked in partial flexion
3) delayed swelling (unlike ligament tear)
4) giving way

70
Q

what is locking of knee suggestive of?

A

bucket handle tear of meniscus

71
Q

management of meniscus injury

A

aim for meniscus preservation

1) conservative
- analgesia
- physiotherapy
- glucosamine + supplements (controversial but can offer)
- bracing + orthosis
- H&L injections, PRP

2) surgery
- microfracture therapy
- menisectomy (outer 1/3: good vascular ss from capsule > attempt repair; mid 1/3: intermediate vascular ss and healing; inner 1/3 avascular and poor healing > total/subtotal menisectomy)
- cartilage work (scaffold/implants)

72
Q

what type of collagen is articular cartilage of meniscus made of?

A

type II collagen

73
Q

risk factors for patella/quadriceps tendon rupture

A
  • DM
  • SLE
  • RA
  • streroid use`
74
Q

blood supply of ACL

A

medial geniculate artery

75
Q

lateral meniscus or medial meniscus more associated with ACUTE ACL tear

A

lateral meniscus

76
Q

outerbridge classification of cartilage lesions

A

grade 1: chondromalacia
grade 2: fibrillation <1/2
grade 3: fragmentatino to subchondral bone
grade 4: erosion to bone

phase iii orthopaedics (6 decks)

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