Knee - Bursitis & Ligaments Flashcards
Keys to PE
- pt supine on table
- everything bilateral
- perform same routine every time
Testing acronym
HOPS
- history
- observation
- palpation
- special tests
Observation
- deformity
- open wounds/abrasion
- 3 Es: edema, effusion, ecchymosis
- loss of contour
- color change
Palpation
- effusion vs. edema
- crepitus during ROM
- mechanical sx: catching, locking, popping
- pain over anatomic landmark
what is dx until proven otherwise if mechanical sx on knee exam
meniscal tear
Special tests
- Patellar apprehension
- Meniscal injury (Apley’s, McMurray’s, Deep squat/Duck walk)
- Ligamentous Laxity (Varus/Valgus stress, Lachman, ant/post drawer, pivot shift)
Bursitis
- describe
Inflammation of small, fluid-filled sacs at points of high-friction where tendon passes over bony prominence
Bursitis
- locations
many on knee
MC:
- pre-patellar
- Anserine (very common)
Bursitis
- classic presentation
- someone who kneels on floor a lot - construction
Bursitis
- presentation
- swelling
- traumatic or chronic/insidious
- little loss of fn
What is a baker’s cyst commonly associated with?
meniscal tear
Bursitis
- PE
- “watery” feeling of swelling
- extra-articular pain/swelling (except Anserine does not swell)
- pain with active ROM
Bursitis
- work up
- usually clinical dx
- may need MRI
- XR not helpful unless calcific
Bursitis
- Tx
Conservative:
- RICE
- abs if septic (gram+)
Invasive
- Aspiration for pre-patellar
- injection for anserine
- bursectomy: recalcitrant swelling, infection, pain
Knee ligament Injuries
- four ligaments
- Medial collateral ligament (MCL)
- Lateral collateral ligament (LCL)
- Anterior cruciate ligament (ACL)
- Posterior cruciate ligament (PCL)
Ligament injury scale
I: stretching of fiber without tearing (intrasubstance or attachment)
II: partial tearing (usually intrasubstance)
III: complete rupture of ligament intrasubstance or avulsion from origin/insertion
MCL
- classic case
- description of injury force
- how common?
- football player struck on lateral aspect of knee when foot planted
- valgus force placed on knee
- most common ligament injury of knee
MCL
- presentation
- medial-sided knee pain
- effusion w/in 1-4 hrs
- inability to bear weight or instability with weightbearing
- “knee gave way” or “knee buckled”
MCL
- PE
- medial pain at origin (MC), mid-substance, insertion (least common)
- laxity during valgus stress testing
What is the common knee injury triad?
ACL
MCL
Medial meniscus
MCL
- how to grade
- grades
- always compare to contralateral side
I: slight medial joint space opening, firm end point
II: marked medial joint space opening, ed point present but not firm
III: gross medial opening, no end point not medial soft tissue restraint
MCL sprain
- workup
- AP and lateral XR (look for avulsion which = sx)
- MRI (**PANCE answer)
MCL sprain
- Tx Grade I-III
- Tx overall
I-II: WBAT, ? crutches, hinged knee brace II+ or III: WBAT, crutches, straight leg immobilizer - RICE - acetaminophen (no NSAIDs) - narcotics? - ortho referral - mostly non-surgical - PT - 4-10 weeks disability
When might an MCL sprain need sx?
- multi-ligament injury
- MRI evidence of distal/insertional injury
ACL
- what is its purpose
- classic case
- rotational stability to the knee, prevents excess anterior tibial translation on the femur
- “coming down from a jump and landed awkwardly”, “fell skiing and one ski stayed on”, “made a cut playing sport and knee buckled” and I felt/heard a POP
ACL
- presentation
- lrg effusion, onset w/in 4 hours
- feeling unstable, “giving way” if can bear weight
- loss of ROM in flexion/extension/both
ACL special tests
- Lachman (most sensitive and specific)
- Anterior drawer
*there is grading in lecture but, personally, i’m ignoring it
ACL
- workup
XR
- often shows no injury
- may see tibial spine avulsion
- r/o tibial plateau fx, esp trauma cases
MRI
- GS
- best seen on sagittal view
ACL
- Tx
- Aspiration of hemarthrosis (risk infection)
- WBAT on crutches
- knee immobilizer brace
- early ROM
- PT: restore ROM or severe effusion
- Ortho referral
- ACL reconstruction (sx)
What should you do if a pt declines nonoperative tx of ACL injury?
Counsel pt it can cause future damage to menisci and articular cartilage
ACL reconstruction
- why?
- ACL does not heal on own (lack of clot formation, insufficient vasculature, impaired cell migration)
- return stability for athletic endeavors
- maintain articular cartilage and meniscal viability = prevent OA
PCL
- purpose in body
- classic case
- 95% of resistance force to posterior tibial translation relative to femur
- more vertical than ACL = provides less rotational stability, usually uninjured in rotational injury
- front seat passenger in MVA and knee hit dashboard
PCL
- presentation
- same as ACL
Which cruciate ligament is most commonly injured due to direct trauma?
- PCL
- ACL is usually non-contact
- key to differentiating prior to exam is mechanism of injury!!
PCL special tests
- Posterior drawer
- Sag test/Godfrey’s 90-90 test
PCL
- imaging
MRI is GS
PCL
- Tx
- Acute tx is same as ACL
- Much less sx
- brace in immobilizer for 4-6 weeks with PT
When does PCL injury have a surgical indication
- young and athletic
- multi-ligament injury
- chronic with symptomatic instability
LCL
- how common
- mechanism of injury
- classic case
- least common of the 4 ligaments
- varus load on knee: (uncommon bc physically hard to get to medial knee…)
- football running back has lateral knee pain and swelling. Was hit on inside of knee when mid-stride
LCL
- presentation
- very similar to MCL sprain
- knee effusion w/in four hours
- lateral knee pain to palpation, proximal or distal to joint line
LCL
- special test findings
- laxity with varus stress test
- ligament pain to palpation with figure four position (book test)
LCL
- imaging
- MRI
- Best seen on coronal view
LCL
- Tx
- WBAT
- Early PT and mobilization Grade I
- Hinged knee brace grade II-III
When is sx indicated for LCL sprain?
Other structures compromised or significantly retracted
