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PHTH 7212 Pathophysiology > Knee patho (ligaments and meniscus)- Dr Davies > Flashcards

Knee patho (ligaments and meniscus)- Dr Davies Flashcards

1
Q

MCL (MOI)

A

Traumatic valgus force

Twisting injury associated with an ACL injury

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2
Q

MCL (Symptoms)

A 
Pt describes the MOI
Pts may describe a "tearing" sensation
Pain
Pain with palpation over MCL
*subjective*
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3
Q

MCL (Signs)

A

*attaches to the meniscus so can injury the meniscus
Localized swelling (extra-articular)
If also affects ACL or meniscus, then will have effusion (intra-articular)
Increases c/o pain with valgus stress test
Laxity testing (depending on severity whether there is instability)
objective

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4
Q

Sprain vs Strain

A

Sprain- involves the non-contractile tissue (ligament or capsule)
Strain- involves the contractile tissue (muscle tendon unit)

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5
Q

Knee laxity testing biomechanics

A

Medial restraints at 0- MCL is only 57%
Medial restraints is 30- MCL increase to 78%
Lateral restraints at 0- LCL is 55%
Lateral restraints at 30- LCL increases to 69%
when you go to 30% you are able to target more of the LCL/MCL because the other tissues are more slackened than the LCL/MCL

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6
Q

Knee Instability Testing (Grades)

A

classification of the knee instability testing:
Grade 1: mild sprain
Grade 2: moderate sprain (partial tear of the MCL)
Grade 3: severe sprain (full tear)

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7
Q

Grade 2 1+

A

1-5 mm more laxity than the uninvolved side

  • *make sure you know that 1+ and 2+ are both under grade 2
  • *the amount of laxity is compared to the contralateral side
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8
Q

Grade 2 2+

A

6-10 mm more laxity than the uninvolved side

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9
Q

Grade 3 3+

A

> 10 mm more laxity than the uninvolved side

total rupture

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10
Q

Grade 1

A

pain, may be some swelling, NO LAXITY, some microtearing

interstitial injury to the MCL

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11
Q

If you have 3 mm of laxity on the uninvolved side and 7 mm on the involved side, what is the grade of the laxity?

A

Grade 2, 1+ because there is only 4mm different between involved and uninvolved

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12
Q

Valgus stress test in young people (what might go wrong)

A

when testing a young person (under the age of 16), you may think it is the MCL you are testing; you have to make sure you are on the joint line
there can be a lot of valgus movement at the physes (because the ligament is stronger than the physes)
*Problem can be at the physes instead of the MCL

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13
Q

what may go along with a MCL injury?

A

think about a PF subluxation also as a potential additional injury and a co-morbidity
palpate the adductor tubercle to see if there was a subluxation

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14
Q

Grade 1 MCL sprain (treatment)

A 
Treat the symptoms
MCL double upright brace
Dynamic stability exercises
Neuromuscular reactive training exercises
Functional (specificity) exercises
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15
Q

Grade 1 MCL sprain (how long until return)

A

Should be back to sports approximately 1-3 weeks (average of 2 weeks) with the MCL double upright brace
Average of 10 days
**tell them the higher end of the time; they will think you know what you are doing (don’t what to get them back too early or have to not let them back)
lie on the side of caution

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16
Q

Grade 2 MCL sprain (treatment)

A 
Treatment symptoms
MCL double upright brace
Avoid valgus stresses in rehabilitation
Dynamic stability exercises
Neuromuscular reactive training exercises
Functional (specificity) exercises
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17
Q

Grade 2 MCL sprain (how long until return)

A

Should be back to sports in approximately 3-5 weeks (average of 4 weeks) with the MCL double upright brace
Grade2 1+ (3 weeks)
Grade2 2+ (4-5 weeks)

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18
Q

Grade 3 MCL sprain (treatment)

A 
Treat symptoms
Avoid valgus stresses in rehabilitation
Drop-lock brace immediate post injury 
MCL double upright brace
Dynamic stability exercises
Neuromuscular reactive training exercises
Functional (specificity) exercise
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19
Q

why do doctors have different protocols for the MCL drop lock brace?

A

limit the extension because it stresses the ligament (screw home mechanism will stress it even more
*but if you limit extension you may lose extension ROM
limit the amount of flexion will stress the ligament
*if you limit too much flexion, you many lose the amount of flexion ROM

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20
Q

Grade 3 MCL (amount of time to return to sports)

A

should be back to sports in 8-12 weeks with a MCL double upright brace

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21
Q

Surgery vs not surgery for MCL

A

Similar outcome
few MCL have surgery if good rehab
for surgery: isolated- high performance pt, functional instability, performed within the first several days (scarring will occur after that), associated injuries (multiple-plane injuries

will use suture anchors to reattach

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22
Q

On an MRI, how can you tell if there is a meniscus tear?

A

there will be a black line in the middle of the white meniscus (the black part is the tear)

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23
Q

3 meniscus surgeries

A

Arthroscopic partial meniscetomy (most common)
Arthroscopic meniscus repair
Meniscus allograft

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24
Q

Arthroscopic Partial Meniscetomy

A

the most common in the knee (and that most surgeons do)
the doctors will go in and remove part of the meniscus when it will not heal (white section of the meniscus can be smoothed out or debrided)

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25
Q

Arthroscopic Partial Meniscetomy (problem)

A

When you remove part of the meniscus, you will increase the weight bearing in the joint
Increase in weight bearing will lead to earlier OA changes; will have chondral DJD changes
the amount of DJD/ when the onset is will depend on how much meniscus was removed

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26
Q

Vascular Zones

IMPORTANT

A 
Red-Red
Red-White
White-White
genicular arterial supply
*be able to draw and describe these*
a dye is injected into circulation; this will show where there is good circulation/blood supply
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27
Q

Red-Red Zone

A

peripheral capsular detachment with blood supply on both sides so fully vascular with excellent healing potential

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28
Q

Red-White Zone

A

junction of vascular zone blood supply peripherally, not centrally. Border of vascular supply and has a generally good healing prognosis
*transition phase

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29
Q

White-White Zone

A

avascular zone and a poor prognosis for healing (no hope)

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30
Q

Red-Red Zone (info on it)

A

peripheral 10-30% (lateral 1/3)

vascular therefore repairable (within 3 mm of vascular periphery)

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31
Q

Red-White Zone (info on it)

A

tears to this zone (avascular midsubstance) repairable if vascularity stimulated through 3 techniques

32
Q

3 techniques to help facilitate meniscus repair

A

1) fibrin clot injection
2) vascular access channel creation
3) synovial abrasion

33
Q

Fibrin clot injection

A

a fibrin clot can be injected into the meniscal lesion to promote healing through hematoma chemotactic factors
the clot will be sown into there to help the avascular transition zone go through the healing process

34
Q

vascular access channel creation

A

Vascular access channels (trephination) are tunnels created from vascular portions of the peripheral meniscus (red zone) to the more central avascular area (white zone)
Theoretically, trephination enables fibrovascular scar proliferation in the damaged meniscal section
*they make little channels in the vascular area to the non vascular area into to help with the healing

35
Q

Synovial abrasion

A

Abrasion of the synovium with a surgical rasping device activates chemotactic factors that stimulate meniscal healing
*causes bleeding/ healing

36
Q

Meniscal Repair Surgical Techniques

A 
Open repair or arthroscopically assisted
**Repairs are named by the origin of suture delivery
Inside-Out Repair
Outside-In Repair
All-Inside Repair
Meniscus arrows
37
Q

Open repair (meniscal)

A

Rarely done anymore

38
Q

Inside-Out Repair (meniscal)

A

the scope is inside and they pass the sutures outside

39
Q

Outside-In Repair (meniscal)

A

the scope and the sutures start on the outside and pass inside the joint

40
Q

All-Inside Repair (meniscal)

A

All is done inside

41
Q

Meniscus Arrow

A

they have a gun and they literally shot a dart into the meniscus; not as effective
this is not a very good procedure

42
Q

Meniscal Repair (rehab)

A

Rehabilitation is dependent on the strengthen of repair, fixation used, location of tear, and concomitant surgery

43
Q

2 types of meniscal repair rehab

A

controversy exists among clinicians in the area or rehab principles after meniscal repair
traditional versus accelerated

44
Q

traditional rehab for meniscal repair

A

Slow the pt down and do not do a lot of early weight bearing; wait a while before sending back to activities
Problem: too slow can decrease the ROM/ stiffness in the knee

45
Q

accelerated rehab for meniscal repair

A

Let the pt do things at a faster pace

Problem: don’t want to have re-injury because the 2nd surgery will not be as good as the first

46
Q

Meniscus Allograft

A

use a allograft tissue, size it, and attach it
have bone plugs at the posterior and anterior horns that will attached in the tibial plateau; will have to drill through the tibial to the contralateral side of the bone
(can also use a bone bridge and sow all the way around the new meniscus)

47
Q

when would you do a meniscus allograft?

A

good for younger individuals (do not want to remove the meniscus in younger individuals since it can lead to DJD)

48
Q

ACL MOI

A

Direct macrotrauma
pivot shift motion
the pt will have the “grab sign”

49
Q

Types of ACL Grafts

A 
Autogenous BTB (bone tendon bone)
Autogenous Hamstring/ Gracilis
Autogenous Quadriceps tendon
Autogenous Contralateral BTB
Allograft
Any of these combinations + ALL 
Synthetic Grafts (didn't work)
Tissue Engineering
50
Q

Primary Repair

A

when you take the original tissue and sow it together

51
Q

Reconstruction

A

when you remove the original tissue and replace it

want to try and leave the stumps of original (helps with the blood supply and proprioception)

52
Q

what are the two things you can do with an ACL tear

A

surgery right away (NON-COPER)- even time they move, their knee gives out on them; you will not be able to return to a high level of function without surgery
OR
try and rehab it (COPER)- hop test, etc

53
Q

Doing a contralateral harvest (positive and negative)

A

Positive- try and normalize the knees

Negative- why would you hurt a good knee; its also harder to rehab the harvest site knee

54
Q

Allograft (why you have to worry)

A

it has to go through a process to try and kill any potient diseases: Radiate, Chemicals, Freeze

worry about diseases (1 in a million); also the body may reject the tissue
higher injury of rejection in allograft

55
Q

Bundles of the ACL

A

Anteriomedial
Posteriorlateral
(sometimes say there is an intermediate)

56
Q

Tests for AM and PL bundles

A

AM is tight doing a drawer test and the PL is loose; Laucmann’s will get both the AM and PL bundles

57
Q

Surgeries for ACL

A

Single bundle

Double bundle

58
Q

Portals for the surgeries (ACL)

A

will do a standard medial and lateral portal (goes straight through the fat pads)- want the patient to do constant massage to knee from getting knots in these portals
Accessory medial portal
Tibial incision

59
Q

where to drill the trans tibial drilling for ACL?

A

Used to do at 11 or 1 o’clock which puts the graft very vertical, which makes thing rotate around it
Within a couple of years, moved the drill hole to 3 or 9 o’clock, which decreases the transverse plane motion

60
Q

Double bundle (Positive and Negative)

A

Negative: the drill hole is only a couple of mm apart. there has been collapses. No long term outcomes (only been done a few years in the US); increases the time to do the surgery
Positive: decrease the mirco transverse plane motion and stronger biomechanically

61
Q

Single vs Double (anterior translation and combined rotatory)

A

Anterior Translation- SB (89%) DB (97%)
Combined Rotatory SB (66%) DB (91%)
single helps with the sagittal plane motion
double will help more with the transverse plane motion as well as the sagittal plane motion (helps more with decreasing OA changes)

62
Q

Native ACL compared to grafts (%)

A 
Native ACL= 100%
BTB graft= 120% (as the native ACL)
semitendinosus= 70%
gracilis= 50%
Semit+G= 120%
4 strand Semit and Gr= 240%
63
Q

Cyclops Lesion in the ACL

A

scarring that occurs in the center in the notch of the knee
this develops because of all the scarring that has developed due to all the surgery, etc
the scar tissue build will cause you to not be able to regain full extension

64
Q

Rehab for the ACL (most important)

A 
most important to work on regaining physiological extension in the knee compared to the contralateral side
TERT formula (heat and weight on the knee)
range of motion limiting brace
65
Q

ALL

A

anterior lateral ligament

next to your LCL
connects between your gerdy’s tubercle and the fibula head
helps with your anterior rotatory stability

66
Q

Safety study for the ACL

A

taking the primary tear repair of the ACL and scaffold sponge filled with the patients blood and wrapping it around the ACL to help facilitate the healing
will sow the original tissue together and then the blood will help to enhance the healing
taking 10 people for this study

67
Q

Suprapatella pouch

A

the pouch goes far out the leg; need to go 10cm up the leg the pouch
*why you start the milking test so high

68
Q

the anthropometric measurements in the lower extremities

A

20 cm above jt line- the bulk of the quads and hamstrings
10 cm above jt line- about in the VMO and supra pouch
at jt line
15 cm below jt line- bulk of gastro
figure 8- fluid will go distally so need to measure distally as well

69
Q

Intra-articular swelling

A

effusion

  • the severity of the injury does not correlate with the severity of the swelling
  • if you have a 3rd degree rupture- it will move out of the capsule (which is why you always need to do you distal and proximal measurements)

*the rapidity of the swelling does correlate to the severity of the swelling; if you tear something, you will get a hemarthrosis- rapid swelling in the joint; however, if you do not have much blood flow in the area, then you will not have rapid swelling

70
Q

Extra-articular swelling

A

1) edema: fluid in the interstitial spaces
2) bursitis
3) contusion: injury to the muscles, which can lead to a 4)hematoma

71
Q

3 different variations on Intra-articular

A

Synovitis
Hemarthrosis
Hemathrosis with fatty modules

*when the doctor aspirates the knee, you will be able to tell which of these are causing the pts swelling

72
Q

Hemarthrosis

A

blood in the joint, can cause degeneration in the joint

73
Q

Two schools of thought on whether or not to aspirate the joint

A

it is an invasive procedure but there are reasons to aspirate it:

1) its appearance will give you diagnosis information
2) its easier to exam the joint (it hurts with all that swelling and gets rid of all the biomechanical crap)

74
Q

aspirating of the knee

A

this is done with a 18 gauge needle through the superior lateral capsule
provides diagnosis information; looks at the color and consistence

75
Q

Colors of aspiration of the knee (Synovitis)

A

yellow (NO RED)
will be different consistency
Viscous- (in the white part) meniscus tear
watery- chondral injury, sterile inflammatory condition
Cruddy looking- inflammatory infection

76
Q

Colors of aspiration of the knee (Hemarthosis)

A

red
Bright Red: ACL rupture (85%) of the time, peripheral meniscus tear
Dark Red: dislocated patella (tears the arterial and venous)

PHTH 7212 Pathophysiology (12 decks)

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