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Musculoskeletal MBCHB > Knee and Leg Conditions > Flashcards

Knee and Leg Conditions Flashcards

1
Q

What is the aetiology of patella dislocation?

A
  • Can occur with a direct blow or sudden quadriceps contraction with a flexing knee
  • Most common in teenagers, higher incidence in females
  • Always dislocates laterally
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2
Q

What are the risk factors for patella dislocation?

A
  • Ligamentous laxity/hypermobility
  • Increased Q-angle - genu valgum, femoral neck anteversion
  • High riding patella
  • Hypoplastic lateral femoral condyle
  • Lateral quads insertions or weak vastus medialis
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3
Q

What is the presentation of patella dislocations?

A
  • Clear history of patella dislocating laterally
  • Often self-relocating
  • Pain medially (from torn medial patella retinaculum tendon)
  • Effusion (haemarthrosis)
  • Patella apprehension test positive
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4
Q

What are the investigations for patella dislocations?

A

X-ray:

  • Lipo‐haemarthrosis occurs with characteristic x-ray appearance
  • A small opacification may suggest osteochondral fracture
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5
Q

What is the management of patella dislocations?

A
  • May spontaneously reduce when the knee is straightened or rarely may require to be manually manipulated back into position (reduction with knee extension)
  • Aspiration (rarely) - if intractable pain and very swollen
  • Brace
  • Physiotherapy
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6
Q

What are the complications of patella dislocation?

A
  • When the patella dislocates, the medial patellofemoral ligament tears and osteochondral fracture may occur as the medial facet of the patella strikes the lateral femoral condyle
  • The risk of recurrent dislocation after first time dislocation is around 10%
    • Physiotherapy to strengthen the quadriceps may help
    • Patients with recurrent dislocation may benefit from surgery - lateral release, MPFL reconstruction
    • The risk of recurrent instability decreases with age
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7
Q

What is the aetiology of a complete knee dislocation?

A

Serious high energy injury (usually - can be low energy in elderly)

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8
Q

What is the pathophysiology of a complete knee dislocation?

A

Directions: posterior, anterior, medial, lateral, rotatory

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9
Q

What is the presentation of a complete knee dislocation?

A

Pain and instability of the knee

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10
Q

What are the investigations for complete knee dislocations?

A
  • Check neurovascular status
  • X-ray
  • If concern over neurovascular status - CT angiogram
  • No concern over neurovascular status - MRI
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11
Q

What is the management for complete knee dislocation?

A

Immediate

  • Emergency reduction under sedation, recheck neurovascular status
  • May need emergency fix for temporary stabilisation
  • May require theatre reduction if medial femoral condyle button-holed through the medial capsule
  • Vascular stenting or by‐pass may be required if neurovascular injury
    • Reperfusion may result in compartment syndrome especially after prolonged ischaemia and fasciotomies may be necessary

Definitive

  • Sequential ligamentous repair
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12
Q

What are the complications of complete knee dislocations?

A
  • High incidence of complications, especially neurovascular injury (popliteal artery injury, injury to the common peroneal nerve) and ligamentous injury
  • Other complications include arthrofibrosis and stiffness, and ligament laxity
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13
Q

What is the aetiology of a patellar fracture?

A

Traumatic injury - direct trauma or rapid contracture of the quadriceps with a flexed knee

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14
Q

What is the presentation of a patellar fracture?

A
  • Severe pain in/around kneecap
  • Palpable patellar defect
  • Significant hemarthrosis
  • Unable to perform straight leg raise
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15
Q

What are the investigations for a patellar fracture?

A

X-ray - AP and lateral

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16
Q

What is the management of a patellar fracture?

A
  • Conservative - knee immobilised in extension, full weight bearing
  • Operative - ORIF, partial/total patellectomy
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17
Q

What are loose bodies of the knee joint?

A

Small fragments of cartilage or bone that may move freely around the knee in joint fluid, or synovium

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18
Q

What is the aetiology of loose bodies of the knee joint?

A

Trauma, osteochondritis dissecans and joint degeneration can cause a fragment of cartilage +/- bone to detach causing a loose body in the joint

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19
Q

What is the pathophysiology of loose bodies in the knee joint?

A
  • They can grow over time getting nutrition from synovial fluid and may cause painful locking or catching
  • Some can stick to synovium or fat pad - no longer ‘loose’
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20
Q

What is the presentation of loose bodies in the knee joint?

A
  • History of mobile lump or sharp occasional pain and locking/catching suggestive of loose body
  • They should not cause constant, generalised or severe pain
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21
Q

What are the investigations of loose bodies in the knee joint?

A
  • They are commonly over diagnosed with an opacification identified on an x-ray
    • A fabella is an accessory ossicle in the lateral head of gastrocnemius (usually) commonly misdiagnosed as a loose body
  • MRI or serial x-rays can determine if a body is truly loose
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22
Q

What is the management of loose bodies in the knee joint?

A

Arthroscopic removal can help troublesome symptoms but won’t help degenerative joint pain

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23
Q

What is the aetiology of meniscal tears?

A
  • Younger patients - usually sporting injury
    • Classically twisting force on a loaded knee e.g. turning at football, squatting
  • Older patients (middle age onwards) - can get atraumatic spontaneous degenerate tears
    • Common - 20% over 50, many asymptomatic
    • Meniscus weakens with age and can tear spontaneously or with a seemingly innocuous injury
    • Probably represents 1st stage of knee OA
    • Pain from 2nd effects - bone marrow oedema, synovitis
  • 50% of ACL ruptures have meniscal tear
  • Medial meniscal tears approx. 9-10 times more common than lateral meniscal tears
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24
Q

What is the presentation of meniscal tears?

A
  • Pain and tenderness localised to joint line
    • Medial joint line tenderness = medial meniscus, lateral joint line tenderness = lateral meniscus
  • Patients knees may feel about to give way if a loose meniscal fragment is caught in the knee when walking
  • Catching or locking sensation
  • May be inflammatory effusion present
  • Positive meniscal provocation tests e.g. Steinman’s (unreliable)
  • Acute locked knee signifies displaced bucket handle meniscal tear
    • Large meniscal fragment is able to flip out of its normal position and displace anteriorly or into the intercondylar notch where the knee locks and is unable to fully extend due to mechanical obstruction from the trapped meniscal fragment
    • Patient will have 15° springy block to extension
    • Heel height asymmetry indicating fixed flexion deformity
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25
Q

What are the investigations for meniscal tears?

A

MRI

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26
Q

What is the management of meniscal tears in younger patients?

A
  • Higher proportion of peripheral or bucket handle meniscal tears which may benefit from meniscal repair
  • Consider arthroscopic meniscal repair for acute traumatic peripheral meniscal tears in younger patients
    • Involves suturing the meniscus to its bed
  • Even with careful patient selection around 25% of meniscal repairs fail requiring arthroscopic meniscectomy
  • Consider arthroscopic meniscectomy for irreparable tears with recurrent pain, effusion or mechanical symptoms (catching, clicking, locking) which fails to settle within 3 months
  • Knees with degenerate changes on x-ray (loss of joint space, sclerosis, osteophytes) or MRI (hyaline cartilage loss, bone marrow oedema) are unlikely to benefit from arthroscopic meniscectomy as removal of meniscal tissue may increase the stress on already worn / damaged surfaces
  • Young patients have a higher chance of healing with a meniscal repair
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27
Q

What is the management for buckle handle meniscal tears?

A
  • May be repairable if picked up early
  • If knee remains locked, may develop permanent fixed flexion deformity
  • If irreparable needs partial meniscectomy to unlock knee and prevent further damage
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28
Q

What is the management for degenerative meniscal tears?

A
  • Corticosteroid injection may help with symptoms in the early period
  • Healing potential also decreases with age (over about 25‐30 years of age healing rates are poor) and with increased time from the injury
  • Arthroscopic meniscectomy ineffective - only for unstable tear with mechanical symptoms, not for pain only
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29
Q

What are the classification of knee ligament injuries?

A
  • Grade 1 (sprain): some fibres torn but macroscopic structure intact
  • Grade 2 (partial tear): some fascicles disrupted
  • Grade 3: complete tear
30
Q

What ligament rupture leads to valgus instability?

A

MCL

31
Q

What ligament rupture leads to rotatory instability?

A

ACL

32
Q

What ligament rupture leads to recurrent hyperextension or instability descending stairs?

A

PCL

33
Q

What is the mechanism of injury for an MCL injury?

A

Valgus stress with possible external rotation (e.g. rugby tackling from the side)

34
Q

What is the presentation of an MCL injury?

A
  • Knee swelling with ecchymosis, pain, deformity and instability
  • Medial joint line tenderness (over origin/insertion of MCL)
  • Medial joint laxity and pain on valgus stress
35
Q

What are the investigations for an MCL injury?

A

Isolated MCL tear is a clinical diagnosis but x-rays and MRI can be used to rule out associated injuries

36
Q

What is the management for an MCL injury?

A
  • Usually heals well, even if complete tear
  • Pain can take a few to several months to settle
  • Acute tears are usually treated in a hinged knee brace
  • Chronic MCL instability can be treated with MCL tightening (advancement) or reconstruction with tendon graft (rare)
37
Q

What is the mechanism for an ACL injury?

A
  • Usually twisting sports injury
    • Higher rotational force, turning the upper body laterally on a planted foot - football, rugby, skiing
    • ACL is main stabilizer of internal of tibia
  • Higher incidence in females
38
Q

What is the presentation of an ACL injury?

A
  • Audible pop followed by deep knee pain and swelling (haemarthrosis) within an hour of the injury
  • Pain settles but leaves rotatory instability (gives way on turning on a planted foot due to excessive internal rotation of the tibia)
  • Excessive anterior translation of the tibia on the anterior drawer test and Lachman test
39
Q

What are the investigations for an ACL injury?

A
  • Joint aspiration - hemarthrosis
  • MRI to confirm
40
Q

What is the management of ACL injuries?

A
  • May cause little or no problems in some, whilst in others they can give substantial problems with function
  • Can stabilize with time and physiotherapy
  • Most have radiographic evidence of arthritis within 10 years (even those who have surgery)

ACL reconstruction (tendon graft)

  • Mainly indicated in rotatory instability not responding to physio
  • Other indications include as part of multiligament reconstruction or in professional athletes
  • Intensive rehabilitation is required and it may take up to a year to get back to high impact sports
41
Q

What is the mechanism of injury for an LCL injury?

A
  • Usually occur with varus stress and hyperextension
  • Relatively uncommon
  • Often occurs in combination with PCL or ACL injury
42
Q

What is the presentation of an LCL injury?

A
  • Knee swelling with ecchymosis, pain, deformity and instability
  • Lateral joint line tenderness
  • Varus stress test - lateral joint laxity
43
Q

What are the investigations for an LCL injury?

A

Isolated LCL tear is a clinical diagnosis but x-rays and MRI can be used to rule out associated injuries

44
Q

What is the management for an LCL injury?

A
  • Complete rupture needs urgent repair if early (within 2-3 weeks)
  • Later diagnosis - reconstruction with tendon graft
  • Tends not to heal and can cause varus and rotatory instability
  • High incidence of common fibular nerve palsy
  • High incidence early OA of the knee
45
Q

What is the mechanism of injury for a PCL injury?

A
  • Tend to occur following a direct blow to anterior tibia (e.g. dashboard, motorbike)
  • Isolated PCL rupture rare (usually occurs with other injury)
46
Q

What is the presentation of a PCL injury?

A
  • Popliteal knee pain and bruising
  • Positive posterior drawer test
  • Positive sag sign
47
Q

What are the investigations for a PCL injury?

A
  • X-ray
  • MRI
48
Q

What is the management of a PCL injury?

A
  • Most isolated cases don’t require reconstruction
  • If patient develops instability (recurrent hyperextension or feeling unstable when going down stains) consider reconstruction
  • If part of multiligament knee injury usually requires reconstruction
49
Q

What is an extensor mechanism rupture?

A

The extensor mechanism of the knee constitutes of the tibial tuberosity, the patellar tendon, the patellar, the quadriceps tendon and the quadriceps muscles

50
Q

What is the aetiology of an extensor mechanism rupture?

A
  • More common in the middle age population who play running or jumping sports
  • The patellar tendon or quadriceps tendon can rupture with rapid contractile force which can occur after lifting a heavy weight, after a fall or spontaneously in a severely degenerate tendon
  • Patellar tendon ruptures tend to occur in a younger age group (<40) with quadriceps tendon rupture in older patients (over 40)
  • Can be associated with blunt or penetrating trauma
51
Q

What are the risk factors for an extensor mechanism rupture?

A
  • Previous tendonitis
  • Steroid use/abuse
  • Chronic renal failure
  • Ciprofloxacin - quinolone antibiotics can cause tendonitis and can risk tendon ruptures
  • Diabetes
  • Rheumatoid arthritis
52
Q

What is the presentation of an extensor mechanism rupture?

A
  • Knee pain and weakness
  • Unable to straight leg raise
  • Palpable gap in the extensor mechanism
  • Partial tears can also occur which may have some extensor mechanism function but reduced power
53
Q

What are the investigations of an extensor mechanism rupture?

A
  • X-ray - may show an effusion or patella sitting in the wrong place (high in PT rupture, low lying in quads rupture)
  • USS or MRI may show partial/complete tear
  • Obese patients the gap may not be obvious and ultrasound may determine the extent of the injury
54
Q

What is the management of extensor mechanism rupture?

A
  • Requires urgent surgical repair with follow up physio to gradually increase ROM
  • Small partial tears of the quadriceps may be treated by immobilisation and physio
  • Steroid injections for tendonitis of the extensor mechanism of the knee should be avoided due to high risk of tendon rupture
55
Q

What is bone marrow oedema?

A

Impaction to articular surface leads to microscopic fracture of trabecular bone with bleeding and inflammation

56
Q

What is the presentation for bone marrow oedema?

A

A major source of pain after meniscal tear and ligament injuries

57
Q

What are the investigations for bone marrow oedema?

A

MRI

58
Q

What is the management for bone marrow oedema?

A
  • Will settle with time - typically 3 months but can take over a year
  • No treatment know to speed up resolution
  • Hyaline cartilage over area may deteriorate over time leaving a full thickness chondral defect
59
Q

What is patellofemoral dysfunction?

A

Describes disorders of the patellofemoral articulation resulting in anterior knee pain

60
Q

What is the aetiology of patellofemoral dysfunction?

A

Encompasses and in many cases is synonymous with various diagnoses including chondromalacia patellae (softening of the hyaline cartilage), adolescent anterior knee pain and lateral patellar compression syndrome

61
Q

What is the presentation of patellofemoral dysfunction?

A
  • Anterior knee pain, worse going downhill
  • Grinding or clicking sensation at the front of the knee and stiffness after prolonged sitting causing ‘pseudolocking’ where the knee acutely stiffens in a flexed position (in contrast to true locking from a bucket handle meniscal tear)
62
Q

What is the management of patellofemoral dysfunction?

A
  • At least 90% of sufferers improve with physiotherapy aimed at rebalancing the quadriceps muscles (specifically strengthening vastus medialis obliques, VMO)
  • Taping may alleviate symptoms
63
Q

What is a Baker’s cyst?

A

Ganglion cyst found in the popliteal fossa

64
Q

What is the aetiology of Baker’s cysts?

A
  • Refers to the inflammation and swelling of the semimembranosus bursa - a fluid filled sac found in the knee joint
  • It usually arises in conjunction with OA of the knee
65
Q

What is the presentation of Baker’s cyst?

A
  • Can appear as general fullness of the popliteal fossa
  • Soft and non-tender
66
Q

What is the management of a Baker’s cyst?

A

Manage OA

67
Q

What is the aetiology of a tibial shaft fracture?

A
  • Low energy injury - result of indirect torsional injury
  • High energy injury - result of direct force
68
Q

What is the pathophysiology of a tibial shaft fracture?

A
  • Multiple fracture configurations - spiral, transverse, oblique, comminuted
  • Open fractures more common
  • Higher risk for compartment syndrome
69
Q

What is the presentation of a tibial shaft fracture?

A
  • Pain
  • Inability to bear weight
  • Deformity
70
Q

What is the management of a tibial shaft fracture?

A
  • Conservative - above knee cast
    • Patient may need closed reduction in theatre before cast is fitted
  • Operative - IM nailing, ORIF

Musculoskeletal MBCHB (21 decks)

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