Knee/Leg Flashcards
Degenerative Joint Dz AKA
Arthritis of knee
DJD patho
progressive (irreversible) degeneration of articular cartilage of femoral condyles and tibial plateau surfaces
DJD is associated with
aging
obesity
repetitive wear and tear
previous trauma
types of knee arthritis
Osteoarthritis (MC)
rheumatoid
psoriatic
pain in DJD
pain and stiffness (worse when getting out of bed in AM)
progressively worse over months to years
relieved with rest
endstage DJD pain
pain at all times (worse with weight bearing)
instability
loss of AROM, PROM
PE of knee arthritis
tenderness of joint line
decreased AROM/PROM
valgus or varus deformity (late stage)
dx studies in DJD
AP an Lateral XRAY
loss of joint space, sclerosis, subchondral cyst, osteophytes @ joint
if hip is affected = AP pelvis
non rx tx of knee arthritis
non weight bearing exercise
weight loss
maintain AROM
refer when pt unable to cope or advanced deformity
rx tx of OA knee
NSAID
steroid injection
Hyaluronic acid
bursa
fluid filled sac lying between bony prominence and tendon, ligaments, skin or muscles
three major bursa of knee
pre patellar
infrapatellar
pes anserine
bursitis knee
bursa become inflamed and irritated due to chronic pressure or friction = thickening and swelling
pre patellar bursa
anterior aspect of knee
superficial, lies between knee and skin
infra patellar bursa
anteroinferior knee and lies between patellar tendon and tibia epiphysis
pes anserine bursa
MEDIAL knee
under SGT
bursitis of knee history
insidious onset
pain present with activity or direct pressure and worse after resting then resuming activity
+/- swelling
pre patellar bursitis history
bursa swell to size of tennis ball
common in carpet layers or wrestlers
pes anserine history
over use or improper warm up
MC in obese patients, early warning of medial joint DJD
PE of bursitis of knee
swelling and redness then palpate for tenderness, ROM
infected - red ness and tenderness more marked and AROM more painful
diagnostic tests of bursitis
AP and Lateral Xray to r/p tumor
characterized by nighttime pain
infection = aspiration and culture of synovial fluid
non rx tx of bursitis
ice, decreased activity
PT, u/s. phonphoresis
rx tx of bursitis
NSAIDs, steroid injection
Plica
fold of joint lining that is remnant of tissue from embryologic development
NML fold
infrequently causes symptoms
plica syndrome
inflammation and thickening of the bands that cause various symptoms in a subset of the population
history of plica syndrome
activity related aching in anterior or anteromedial aspect of knee
“snapping or popping” or buckling sensation (NOT actually buckling)
PE of Plica
tenderness to palpation MC mediosuperiro knee next to patella and medial femoral condyle
feel a pop at 60 degrees while extending
diagnosis of plica (images)
radiographs of patella to r.o. pathology
MRI to definitively diagnose
ddx of Plica
meniscal tears
non rx tx of Plica
physical therapy for modality and stretching rehab
MAY do arthroscopic resection
rx tx of Plica
NSAID
steroid injection
patellofemoral pain etiologies
maltracking (grind along surface causing destruction of patella and cartilage) MC
patho of patellofemoral pain
patella articulates with femoral trochlea between condyles
history of patellofemoral pain
insidious onset
diffuse anterior knee pain worse with prolonged sitting, climbing stairs, jumping, squatting
instability or catching sensation
PE of patellofemoral pain
women = increased Q angle
maltrackingn of patella
diagnostic tests of patellofemoral pain
AP, lateral X ray
non rx tx of patellofemoral pain
quad strengthening
referral for failure of conservative tx
menisci of the knee
cartilaginous tissue that serve to fusion joint and provide additional stability
which menisci is fixed? mobile?
lateral is mobile
medial is fixed = more likely to be torn
hx of meniscus tear
injury pain, that subsided, 2 days later - effusion
pain is worse with forced flexion (I.e. squatting)
buckling or catching sensation
traumatic meniscus tear
occurs when knee is subjected to a twisting type motion
bucket handle tear
buckling or catching sensation that causes tear to flip over and block knee from full extension
immediate ortho referral
PE of meniscus tear
inspect/palpate for effusion and joint line tenderness
McMurry test +
Dx studies meniscus tear
lateral and merchant view plain films (r/o fracture)
MRI is sensitive for tear
non rx tx of meniscus tear
rest, ice, compression, PT, elevation
refer for sx if conservative tx fails
meniscus tear sx and physical therapy
PT prior to sx will allow surrounding muscles to be strengthened therefore improving results post op
ACL fxn
major stabilizer of the knee
limits ration and anterior translation of tibia on femur
able allow for sudden change in direction (I.e. in sports)
hx of ACL tear
sudden pain giving way of knee from twisting on a bent, hyperextended knee
“pop” followed by effusion immediately (vascular tear as well)
PE of ACL tear
inspection and palpate
LACHMAN TEST, anterior drier
diagnostic tests ACL tear
Xray (AP, lateral, tunnel view)
MRI (not necessary in complete tear)
Rx tx of ACL tear
NSAID of choice
opioids are not preferred due to long term pain control needed
non rx tx ACL tear
rest, ice, crutches
PT with ROM strengthening and bracing
surgery (referral for suspected ACL tear, following MRI)
joint aspiration of blood effusion for pain relief
MCL and LCL tear fxn
give stability to knee against valgus and varus stress
MCL protects against (valgus/varus) stress
VALGUS
LCL protects against (valgus/varus) stress
VARUS
MCL and LCL tear hx
direct force applied to lateral or medial side causes sprain or tear of ligament
pain, swelling, stiffness
may have localize ecchymosis and swelling 2nd day
PE MCL and LCL tear
look for edema and ecchymosis
Tenderness on bone - avulsion of ligament from bone
special test: valgus and varus
diagnostic tests MCL and LCL tear
XR to r/o fracture then MRI
tx of MCL and LCL tear
PT, bracing, ice
joint effusion, complete tear of LCL - orate referral
NSAID
patellar/quad tendon
connects the quad femoris muscle group to tibial tubercle on anterior proximal tibia
two spots for patellar/quad tendon tear
< 55 = distal to patella
>55 = proximal to patella
patellar/quad tendon tear hx
fall on partially flexed knee
patellar/quad tendon tear PE
palpable defect superior or inferior to patella
Inability to fully extend against gravity
patellar/quad tendon tear dx tests
r/o fracture AP/Lateral XR
MRI (not needed)
patella alta XRAY
indicative of patella tendon rupture
patella baja
indicative of quad tendon rupture
patellar/quad tendon tear tx
surgical repair early
partial tear = immobility, ALL REFERRED to ortho
long leg locked hinge brace post op
patellar/quad tendon tear and NSAIDS
AVOID NSAIDS due to decreased tissue healing
tibial plateau consist of
articular surface
epiphysis
metaphysis of proximal tibia
tibial plateau fracture common from
jumping from a hight landing on knocked nee
severe forceful valgus or varus stress on stationary thigh
hx tibial plateau fracture
MCV hit from side can result in medial fracture
direct blow to distal lateral high with planted foot
tibial plateau fracture PE
palpation - tender tibial rim
asses NV distally
radiographs of tibial plateau fracture
AP and lateral
CT recon for surgical planning
tibial plateau fracture tx
ORIF for displaced and intra-articular fracture
referral for all patients
MC will also have meniscal or ligament injury as well
increased likelihood of developing OA
patella fxn
seasomoid bone embedded within quad tendon
serves as fulcrum on femur to improve effectiveness of vector force on quad contraction during extension of knee
patella fracture hx
direct blow by fall or object
pain, swelling, inability to extend the knee
patella fracture PE
AROM (decreased or absent to to pain or lack of extension mechanism intact)
XR Ap and Lateral
patella fracture tx
long leg cylinder cast or long leg hinged brace
complete and or extensor mechanism not intact, surgical fixation req
Osgood Schlatter Dz
overuse injury of growing child that results from repetitive stress when too tight quad drops pulls on apophysis of tibial tuberosity (11-13 y/o)
Osgood Schlatter Dz when pain Is b/l
no need for XRAY
if unilateral, need one to r/o tumor
when do you need sx for Osgood Schlatter Dz
avulsion of ossification center
Sinding larsen Johansson syndrome
similar to osgood except occurs at junction of PATELLAR TENDON and DISTAL POLE of patella
(pain at inferior pole of patella)
