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Orthopaedics > knee > Flashcards

knee Flashcards

1
Q

direct blow to the front of the knee will usually cause

A

PCL injury

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2
Q

blows to the side of the knee will usually cause

A

collateral injury

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3
Q

twisting injuries will usually cause

A

cruciate rupture or meniscal injury

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4
Q

swelling immediately after injury usually suggests

A

haemarthrosis

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5
Q

recurrent swelling with normal periods in between usually suggests

A

chronic internal derangement such as inflammatory arthritis or an old meniscal tear

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6
Q

locking

A

limitations in extension although flexion is still possible
commonly caused by torn meniscus or loose body caught between articular surfaces
patient may describe being able to manipulate the knee around to unlock it

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7
Q

instability

A

usually sugests ligamentous injury, but could also be capsular or muscle weakness

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8
Q

how should you start the knee examination

A

patient standing
exposed joint above and below
exposed contralateral side for comparison

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9
Q

knee examination - look

A

skin - scars, erythema, lacerations
soft tissue
- effusion most easily detected by absense of the dimple on the medal side of the patella
- muscle wasting of the quadriceps
alignment
- varus and valgus deformities
- genu ricavatum: knee hyperextension
- back of the knee: bakers cysts or popliteal anaeurysms
gait
- antalgic gait: short stance phase on affected side may be a commonn finding

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10
Q

varus deformity may be due to

A

medial side of the joint affected by osteoarthritis

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11
Q

fixed flexion deformity

A

position of comfort for the joint, may be due to acute infection

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12
Q

knee examination - feel

A

sensation, palpating pulses and cap refil time
palpate soft tissue
palpate tibial crest, tibial tuberosity, patella tendon, patella margin, quadriceps insertion, collateral ligaments and joint capsule
palpate the popliteal fossa for swelling or palpable cyst
palpate along the medial joint line to assess for tenderness along the medial colateral ligament
palpate along the lateral joint line for tenderness along the lateral colateral ligament

temperature of the joint
stroke test for effusion: fluid is milked from the medial side of the knee up to the suprapatellar pouch, watch to see if the fluid returns

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13
Q

knee examination - move

A

active and passive movement comparing both sides
proceed to special tests

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14
Q

lag test

A

lift leg 10cm off the bed
bend knee 20 degrees and straighten again
if the quadriceps is weak they wont be able to straighten it again

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15
Q

checking for posterior sag

A

compare the two tibial tuberosities with knees bent
if they’re not at the same level and there is posterior sag on one side, suspect PCL injury

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16
Q

ACL draw test

A

after ensuring the patient has no foot pain, sit on the patients foot
place fingers in the popliteal fossa and thumbs on the ischial tuberosity
try to bring the tibia forward
repeat on the other joint and compare laxity

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17
Q

lachman’s test

A

alternative to anterior draw test
knee flexed to 30 degrees
draw tibia upwards

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18
Q

cruciate injury summary

A
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19
Q

testing the stability of the collateral ligaments

A

bend knee at 30 degree angle
apply varus and valgus test

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20
Q

which test is used to test for meniscal tears

A

McMurry’s

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21
Q

McMurry’s test

A

flex knee to 90
medial: apply valgus stress, externally rotate and extend. Palpated or audible click indicates a medial meniscal tear
lateral: apply varus stress, internally rotate and extend. Palpated or audible click indicates lateral meniscal tear
poor sensitvity and can be painful

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22
Q

test for propensity of patellar dislocation

A

patellar apprehension test

23
Q

patients with lax ligaments

A

more susceptible to patellar dislocation
knee is usually swollen, painful and may be difficult to examine
examine the normal knee to test for propensity to dislocate

24
Q

patellar apprehension test

A

test on normal knee for propensity to dislocate/lax ligaments
leg is held over the edge of the bed in an extended position
flexed while patellar is pushed laterally
patella may be encouraged to dislocate laterally, pateint will become veery anxious and the test should be stopped

25
Q

appley’s test

A

patient lies prone
tibia is compressed down and rotated into the examination table
if there is more pain with compression than distraction the pathology is likely meniscal
more pain with distraction is likely ligamentous

26
Q

special tests

A

lag test for quadriceps weakness
check for posterior sag for PCL injury
anterior draw test for ACL injury
Lachman’s test for ACL/PCL stabilty
valgus/varus stress tests for stability of the collateral ligaments
mcmurry’s test for meniscal injury
patellar apprehension test
apley test for meniscal injury

27
Q

acute swelling ddx

A

post-traumatic haemarthrosis = immediate swelling, blood in the joint, painful warm and tense
bleeding disorders
acute septic arthritis
traumatic synovitis
aseptic non-traumatic synovitis (gout, pseudo gout, inflammatory arthropathy)

28
Q

chronic swelling ddx

A

intraarticular - osteoarthritis or inflammatory arthritis, synovil disorders eg. synnovial chondromatosis
bony swelling - osteochondroma, osgood-schlatter, maligancy

29
Q

posterior knee swellinng ddx

A

baker’s cyst - usually presents in older people with OA, occasionally will rupture and produce pain
semimembranosus bursa
popliteal aneurysm (there will be pulsation in the lump unless thrombosed

30
Q

baker’s cyst

A

bulging of the posterior capsule and synovial herniation
seen in the midline
presents in older people with OA
occasionally ruptures and causes pain

31
Q

semimembranosus bursa

A

bursa between semimembranosus and gastrocnamius
resolves with time

32
Q

pulsation in posterior knee lumb

A

popliteal aneurysm will have pulsation unless thrombosed

33
Q

anterior knee swelling ddx

A

prepatellar bursitis
infrapatellar bursitis
other bursae

34
Q

prepatellar bursitis

A

front of the patella, often seen in workers who are often on their knees
treatment consists of bandaging and avoiding kneeling
occasionally aspiration is needed
lump may need to be excised in chronic cases
secondary infection is not uncommon

35
Q

ACL injury

A

most common knee ligament injury
often ruptured playing sport
commonly occurs when suddenyl changing direction or landing or twisting from a jump
rare for the ACL to heal satisfactorily

36
Q

what does the ACL do

A

limits forward movement of the tibia on the femur
also important for rotational stability

37
Q

why is it rare for the ACL to heal satisfactorily

A

because the synovial fluid around the ligament prevents formation of a clot required to promote healing response in the ligament

38
Q

examination of ACL injury

A

presents with haemarthrosis
anterior draw test
lachman’s test
pivot shift test

39
Q

ACL injury is confirmed with

A

MRI scan

40
Q

management of ACL

A

depends on age and activity
younger patients under 22 - reconstruct everyone
patients over 35 - try to treat non-operatively

41
Q

non operative management of ACL injury

A

conscious control over the knee to minimise rotational instability
risk of repeated damage which can cause irreversible damage to the meniscus

42
Q

operative management of ACL injury

A

reconstruction
hamstring tendon autograph hervesting
common orthopaedic procedure with good success rate
most common complication is re-rupture of the ligament
this is reduced by diligent post operative rehabilitation and delaying return to sport by 9-12 months post-surgery

43
Q

surgery for meniscal teaar

A

if patient has mechanical symptoms of locking or catching
repair or tear or menisectomy
of the joint is locked and cannot be unlocked, this is an indication for semi urgent surgery

44
Q

predisposing factors of patellar dislocation

A

generalised ligamentous laxity
underdevelopment of the lateral femoral condyle and flattening of the intercondylar groove
maldevelopment of the patella, which may be too high or too small
valgus deformity of the knee
external tibial torsion
a primary muscle defect

45
Q

initial management for patella dislocation

A

petella reduction - urgent because it is extremely painful
RICE
physiotherapy

46
Q

recurrent patella dislocation

A

first time dislocation is generally treated non operatively
first episode is followed in 15-20% of cases with recurrent dislocation or subluxation after minimal stress

47
Q

management for recurrent patella dislocation

A

non-operative management
- knee brace: not ideal for long ter due to quadriceps wasting
- physiotherapy
- patella taping
operative treatment
- repair/reconstruct

48
Q

osteoarthritis

A

knee is the commonest of the large joints to have OA
often bilateral

49
Q

4 cardinal signs of OA on radiography

A

loss of joint space
osteophyte formation
subchondral sclerosis
subchondral cysts

50
Q

non operative management of OA

A

activity modification, weight reduction
using a stick or walker
physio
anti-inflammatory
corticosteroid injections

51
Q

operative treatment of OA

A

knee replacement
may be total or partial (unicompartmental knee replacement)

52
Q

unicompartmental knee replacements

A

advantage of preserving the ligaments
patients feels the knee is more natural
however if the artritis progresses to the other compartment it may need to be revised to total knee replacement to these surgeries have a higher revision rate

53
Q
A

Orthopaedics (26 decks)

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