knee clinical conditions pt 1 (DFF to Patellofemoral Pain) Flashcards by JOANN ENRICKE BALBOA

includes both supracondylar and condylar regioms

distal femur fractures

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zone between femoral condyles and the junction of metaphysis w femoral shaft

comprises the distal 10 to 15 cm of femur

supracondylar area

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extends more distally and is mire convex than lateral femoral condyle

physiologic valgus of femur

medial condyle

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this flexes distal fragment, causing posterior displacement and angulation

gastrocnemius

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they exert proximal traction, resultimg in shortening of lower ex

quads and hamstrings

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mechanism of injury of distal femur fractures

severe axial load w varus, valgus, rotational force

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mechanism of injury of distal femur fracture in young adults

high energy trauma like motor vehicle collision or fall from a height

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mechanism of injury of distal femur fracture in elderly

minor slip or fall onto a flexed knee

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general principles of dff treatment

restore articular congruity
rigid stabilization of articular fracture
indirect reduction of metaphyseal component to preserve vascularity of fractyre fragments
stable (not necessarily rigid) fixation of articular block to shaft
early knee ROM

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intervention of stable non operative fractures of dff

hinged knee brace w partial weight bearing

full time bracing for 6-8 wks, closed chain rom at 3-4 wks

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non operative intervention of displaces fractures in dff

6-12 wks period of skeletal traction followed by bracing

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complication of skeletal traction

varus and internal rot deformity, knee stiffness, prolonged hospitalization and bed rest

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indications of non operative treatment of dff

nondisplaced or incomplete fractures, impacted stable fractures in elderly pts, severe osteopenia, advanced underlying medical conditions, gunshot injuries

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operative treatment. indicated for extra articular fractures and simple intra articular fractures

retrograde intramedullary (im) nail

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operative treatment, indicated when associated with pre existing joint arthroplasty and select cases when stable internal fixation not achievable

arthroplasty (metal implant)

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uncommon injury that may be limb threatening, orthopedic emergency

knee dislocation

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significant soft tissue injury of knee dislocation

ruptures of at least three or four major ligamentous structures of the knee

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most common knee dislocation

posterolateral

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complications if knee dislocation

vascular injury, neurologic injury, stiffness/ligament, ligamentous laxity

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nerve affected if neurologic injury of knee dislocation occurs

peroneal nerve, fibular nerve

+ foot drop if there is injury

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most common complication of knee dislocation

stiffness/arthrofibrosis

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treatment for knee dislocation

emergent reduction if pt did not present reduced

revascularize within 6 hrs if there is significant arterial injury

care for soft tissue injuries (open knee dislocations)

ligament reconstruction

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largest sesamoid bone in body, articular cartilage may be up to 1cm thick

patella

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articular facets of patella

7 articular facet, lateral facet is largest

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most common type of patellar dislocation

lateral dislocation

ensures that the resultant vector of pull with quadriceps action is laterally directed

Q angle

Q angle in women is ______ degrees greater than men

4.6 deg

lateral moment is normally counterbalanced by

patellofemoral patellotibial retinacular structures patellar engagement within the trochlear groove.

predisposes to patella dislocation increases tendency of patellar dislocation because it can move more lateral

Increased/wider Q angle

Why is Lateral patellar dislocation more common in Women

Women have higher Q angle Ligaments of women are lax

functions of patella

increase the mechanical advantage and leverage of the quadriceps tendon aid in nourishment of the femoral articular surface protect the femoral condyles from direct traum

Reduction and casting or bracing in knee extension - Usually for first time dislocation may ambulate in locked extension for 3 weeks, at which time progressive flexion can be instituted with physical therapy for quadriceps strengthening - Isometrics, no aggressive ROM after 6 to 8 weeks, patient may be weaned from the brace as tolerated

Non-operative treatment for Patellar Dislocation

primarily used with recurrent dislocations no single procedure corrects all patellar malalignment problems patient’s age, diagnosis, level of activity, and condition of the patellofemoral articulation must be taken into consideration

Operative treatment for Patellar dislocation

Surgical interventions for Patellar disloc

Lateral release Medial plication Proximal patella realignment Distal patellar realignment

Test for patellar disloc

+ apprehension test

hemarthrosis (there’s bleeding inside) inability to flex the knee displaced patella on palpation patients with reduced or chronic patella dislocation may demonstrate a positive apprehension test

Clinical evaluation for Patellar Disloc

Not common Represent 1% of all skeletal injuries Male-to-female ratio (2:1) Most common age group 20 to 50 years old Bilateral injuries (uncommon)

Patellar Fracture

Trauma to the patella may produce incomplete, simple, stellate, or comminuted fracture patterns. minimal displacement owing to preservation of the medial and lateral retinacular expansions abrasions over the area or open injuries are common active knee extension may be preserved

Direct mechanism of injury for Patellar fracture

most common secondary to forcible quadriceps contraction while the knee is in a semiflexed position (e.g., in a a stumble or a fall) intrinsic strength of the patella is exceeded by pull of the musculotendinous and ligamentous structures transverse fracture pattern active knee extension is usually lost

Indirect mechanism of injury for Patellar Fracture

Most common mechanism of injury for Patellar fracture

Indirect

Classification of Patellar fracture

Undisplaced Transverse Lower or upper pole Multifragmented undisplaced Multifragmangted displaced Vertical Osteochondral

cylinder cast or knee immobilizer for 4 to 6 weeks early weight bearing to FWB with crutches as tolerated early SLR and isometric quadriceps strengthening exercises should be started within a few days After radiographic evidence of healing, progressive active flexion and extension strengthening exercises are begun with a hinged knee brace initially locked in extension for ambulation

Non operative treatment for Patellar fracture

Indications for Non operative treatment for Patellar fracture

nondisplaced or minimally displaced (2- to 3-mm) fractures with minimal articular disruption (1 to 2 mm) requires an intact extensor mechanism

Techniques - tension band wiring - screws - circumferential cerclage wiring retinacular disruption should be repaired postoperatively, patient should be placed in a splint for 3 to 6 days until skin healing, with early institution of knee motion AAROME, progressing to partial and full weight bearing by 6 weeks

Operative treatment for Patellar Fracture

Indications of operative treatment for patellar fracture

>2-mm articular incongruity >3-mm fragment displacement open fracture

major weight-bearing bone of the leg (85% load)

Tibia

composed of the articular surfaces of the medial and lateral tibial plateaus, separated by the intercondylar eminence (nonarticular, attachment of the cruciate ligaments) 10-degree posteroinferior slope

Tibial plateau

larger and concave

medial plateau

extends higher and convex

lateral plateau

3 bony prominences 2 to 3 cm distal

tibial tubercle: patellar tendon pes anserinus: medial hamstrings Gerdy’s tubercle : iliotibial band)

More common tibial plateau fracture

Lateral Plateau fractures

tibial tubercle: patellar tendon pes anserinus: medial hamstrings Gerdy’s tubercle : iliotibial band)

Medial plateau fractures

Mechanism of Injury for Tibial Plateau fractures

Varus or valgus forces coupled with axial loading bicondylar split fracture results from a severe axial force exerted on a fully extended knee

MVA split fractures + ligamentous disruption

Mechanism of injury for Younger Indiv

Falls depression and split-depression fractures lower rate of ligamentous injury

Mechanism of injury for Elderly px w osteoponic bone

Associated Injuries of Tibial Plateau fractures

Meniscal tears (50%) Cruciate or collateral ligament injuries (30%) Peroneal nerve or popliteal neurovascular lesions

Young adults: highest risk of collateral or cruciate ligament rupture

Cruciate or collateral ligament injuries (30%

Medial tibial plateau fractures Peroneal nerve injuries are caused by stretching (neurapraxia) which usually resolve over time Arterial injuries

Peroneal nerve or popliteal neurovascular lesions

traction induced intimal injuries presenting as thrombosis (transection injuries secondary to laceration or avulsion is rare)

Arterial injuries

caused by stretching (neurapraxia) which usually resolve over time

Peroneal nerve injuries

AP and lateral views supplemented by 40-degree interna

lateral plateau

external rotation oblique views

medial plateau

useful for delineating the degree of fragmentation or depression of the articular surface

3D CT Scan

useful for evaluating injuries to the menisci, the cruciate and collateral ligaments, and the soft tissue envelope

MRI

Avulsion of the fibular head Segond sign Pellegrini-Steida lesion

Signs of associated ligamentous injury

lateral capsular avulsion - ACL injury

Segond sign

calcification along the insertion of the medial collateral ligament

Pellegrini-Steida lesion

Classification for Tibial Plateau Fracture

Schatzker Classification Type I: Lateral plateau, split fracture Type II: Lateral plateau, split depression fracture Type III: Lateral plateau, depression fracture Type IV: Medial plateau fracture Type V: Bicondylar plateau fracture Type VI: Plateau fracture with separation of the metaphysis from the diaphysis

are low-energy injuries

Types I to III

are high-energy injuries

Types IV to VI

usually occurs in older individuals

Type III

usually occurs in younger individuals and is associated with medial collateral ligament injuries

Type I

for nondisplaced or minimally displaced fractures and in patients with advanced osteoporosis protected weight bearing and early ROM in a hinged fracture-brace isometric quadriceps exercises and progressive passive, active-assisted, and active ROM exercises Partial Weight Bearing (PWB) (30 to 50 lb) for 8 to 12 weeks is allowed, with progression to FWB

Non operative treatment for Tibial Plateau fracture

articular step-off >2mm Instability >10 degrees of the nearly extended knee compared to the contralateral side Split fractures more unstable than pure depression fractures Open fractures Compartment syndrome Associated vascular injury

Operative treatment for Tibial plateau fracture

Postoperative: non-weight bearing with continuous passive motion and AROM Weight bearing is allowed at 8 to 12 weeks

Rehab for Tibial Plateau Fracture

Knee stiffness Infection Compartment syndrome Malunion or nonunion (Schatzker VI) Post-traumatic arthritis Peroneal nerve injury - Causing foot drop deformity Popliteal artery laceration Avascular necrosis of small fragments (results to loose bodies)

Complications of Tibial Plateau Fracture

characterized by pain in the vicinity of the patella that is worsened by sitting and climbing stairs, inclined walking and squatting

Patellofemoral Pain

Incidence of Patellofemoral pain

F > M if non athletic M > F if athletic

4 classic factors implied in the genesis of the instability

trochlear dysplasia patella alta Increase in Q angle patellar tilt (excessive patellar tilt with medial ligamentous disruption)

The single most important factor implied in the genesis of patellar instability The femoral sulcus is not sufficient to provide the osseous restraint capable of avoiding patellar dislocations

Femoral trochlear dysplasia

Moving of patella causes friction, will cause pain

Patellar morphology and the amount of congruence of the patellofemoral joint

Position can be baja (below) or up (alta)

The positioning of the patella (alta or baja)