Knee And Leg

Question 1

What are some risk factors for developing knee osteoarthritis?

Answer 1

Increasing age
Female
Obesity
Low bone density 
Previous knee injury
Occupational stresses on the knee
Joint laxity

Question 2

What imaging investigations would you do in suspected knee osteoarthritis?

Answer 2

Plain film radiographs of the knee, AP, lateral and skyline views.

Question 3

What is the classification system is used for knee osteoarthritis?

Answer 3

The Kellgren and Lawrence system.

Grade 0 - 4.

Question 4

What is the management for knee osteoarthritis?

Answer 4

Conservative management - Appropriate analgesia, topical NSAIDs, weight loss, smoking cessation, lifestyle advice, physiotherapy.

Surgical - total or partial knee replacement.

Question 5

What clinical tests do we do for ACL tear on examination?

Answer 5

Anterior drawer test - knee flexed to 90 degrees, pull forwards.
Lachman’s test - the knee is placed into 30 degrees of flexion with one hand on the femur and one on the tibia trying to pull it forwards.

Question 6

What imaging is done for a suspected ACL tear?

Answer 6

Plain film radiograph of the knee - AP and lateral views.

N.b. A Segond fracture (bony avulsion of the lateral proximal tibia) is pathognomic of ACL injury.

MRI scan is gold standard.

Question 7

What is the management for an ACL tear?

Answer 7

immediate management = RICE

Conservative treatment - rehabilitation (strengthening the quadriceps to stabilise the knee).

Surgical - Surgical repair may be done acutely by suturing the ends together or later surgical reconstruction after a period of prehabilitation. In reconstruction the surgeon will use a tendon or artificial graft.

Question 8

What is the gold standard imaging for diagnosing a PCL tear?

Answer 8

MRI scan.

Question 9

What is the management of a PCL tear?

Answer 9

They can often be treated conservatively.

Conservative - knee brace and physiotherapy.

If it is associated with other ligament injuries / the patient has knee instability then they may need reconstructive knee surgery by insertion of a graft.

Question 10

How are MCL injuries graded?

Answer 10

1-3:

Grade 1 - mild injury, no loss of integrity
Grade 2 - moderate injury, incomplete tear, increased laxity
Grade 3 - severe injury, complete tear, gross laxity of MCL

Question 11

What imaging should be done for suspected MCL injury?

Answer 11

Plain film x ray AP and lateral view of the knee to exclude any fracture.

The gold standard for diagnosis is MRI scan.

Question 12

What is the management for MCL injury?

Answer 12

Grade 1 - RICE + analgesia + rehabilitation exercises

Grade 2 - analgesia + knee brace + rehabilitation exercises

Grade 3 - analgesia + knee brace + crutches. If there is distal avulsion then surgery is considered.

Question 13

What imaging would you request for a suspected meniscal tear?

Answer 13

Plain film x ray AP and lateral view of the knee (to exclude fracture).

MRI scan is the gold standard to confirm a meniscal tear.

Question 14

How are meniscal tears managed?

Answer 14

Initial management = RICE
Most small tears will initially swell then the pain will subside over the next few days.

For larger tears / those remaining symptomatic arthroscopic surgery:

• If the tear is on the outer third of the meniscus the tear can be sutured back together as there is a good blood supply.
• If it is in the inner third the tear is often trimmed.

Question 15

What imaging should be requested for a suspected patella fracture?

Answer 15

Plain film radiographs AP, lateral and skyline view.

CT is often used in comminuted fractures.

Question 16

How are patella fractures classified?

Answer 16

By the AO foundation classification:

1 - extra-articular or avulsion
2 - partial articular
3 - complete articular

Question 17

What is the management for patella fractures?

Answer 17

Conservative if non-displaced - patients are placed in a brace or cylinder cast.

Surgical if there is significant displacement or compromise to the extensor mechanism - ORIF with tension band wiring.

Occasionally screw fixation is used or partial / total patellectomy.

Question 18

What imaging would you request for a suspected tibial shaft fracture?

Answer 18

Full length AP and lateral plain film x rays of the tibia and fibula. Also including the knee and ankle.

May also need a CT if there is intra-reticular involvement.

Question 19

How is a tibial shaft fracture managed?

Answer 19

A to E assessment.

Realignment under analgesia. Above knee backslab. Elevate the limb immediately and closely monitor for signs of compartment syndrome.

Most tibial shaft fractures are managed surgically, however some are managed conservatively with a Sarmiento cast.

Surgical management is intramedullary nailing. However fractures that extend into joints may need ORIF with locking plates.

Question 20

What imaging would you request for a suspected tibial plateau fracture?

Answer 20

Plain film radiograph AP and lateral views of the full tibia, knee and femur.

CT scanning is needed in most cases to help in surgical planning (unles the fracture is undisplaced).

Question 21

How are tibial plateau fractures classified?

Answer 21

The Schatzker classification.

Type 1 - 6.

Question 22

What is the management for a tibial plateau fracture?

Answer 22

Conservative treatment - if it is uncomplicated, typically treated with a hinged knee brace, physiotherapy and analgesia.

Operative management - ORIF, gaps can be filled with bone graft / bone substitute. Post op a hinged knee brace is fitted.

Question 23

What are the special tests for iliotibial band syndrome?

Answer 23

Nobles test - patient lies flat, slowly extend knee, place finger on lateral femoral condyle. Pain is felt at 30 degrees when the ITB passes over the femoral condyle.

Rene test - stand infront of bad knee, put pressure on lateral epicondyle, ask the patient to squat. Pain is felt at 30 degrees of flexion.

Question 24

How is ITBS diagnosed?

Answer 24

It is diagnosed clinically, however plain radiograph or MRI may be used to exclude other pathology if the history and exam are not conclusive.

Question 25

How is ITBS managed?

Answer 25

Most patients are advised to modify their activity and use simple analgesics during periods of acute pain.

Sometimes in the long-term patients are given local steroid injections to reduce inflammation + physiotherapy (stretching and strengthening the muscles).

Surgical management - surgery is only indicated if patients remain functionally limited after 6 months, despite all other non-medical treatment. Surgery involves releasing the ITB from its attachments, allowing for a greater range of movement.