Knee Problems

Question 1

What are the common acute injuries of the knee?

Answer 1

Fracture 
Acute on chronic degenerative joint disease 
Meniscal injury 
Ligament injury 
Tendon injury

Question 2

What do you need to consider when a patient presents with an acute knee injury?

Answer 2

Whether it is a flare up of a pre-existing degenerative conditions or if it is a new acute injury

Question 3

What are the important parts of the history in a patient presenting with acute knee injury?

Answer 3

Environment - sport, workplace 
Activity - sports tackle/jumping 
Energy involved at time of injury 
Systemic symptoms 
Chronology - quick or slow onset, previous injury or event 
Hear or feel a pop/crack 
Swelling - early or late onset

Question 4

What does immediate swelling suggest in acute knee injury?

Answer 4

Haemarthrosis

Question 5

What movement causes meniscal injury?

Answer 5

Twisting movement on a loaded sized knee

Question 6

What are the features of meniscal injury?

Answer 6

Painful “squelch”
Slow onset swelling, faster in young
May present with haemarthrosis in very young patients
Painful to weight bear
Locked knee - blocking fully extended position

Question 7

What are the features of ACL tear?

Answer 7

Forward momentum, leg fixed +/- rotated
Pop
Quick swelling
Often able to weight bear

Question 8

What are the features of collateral tears?

Answer 8

Lateralised pain
Feel of crack, sharp pain
No or minimal effusion
Bruising to one side

Question 9

On clinical examination, what should you look for in a patient with acute knee injury?

Answer 9

Scars
Bruising
Swelling
Joint line irregularity

Question 10

On clinical examination, what should you feel for in a patient with acute knee injury?

Answer 10

Effusion
Crepitus
Heat
Tenderness
Tissue lumps or defects 
Heat - can indicate infection but means increased blood supply to that area so can be due to just the injury

Question 11

On clinical examination, what movements should you do/ask the patient to do with acute knee injury?

Answer 11

Passive and active 
Straight leg raise
Range of movement 
Ligament testing 
Dynamic testing

Question 12

Why is it best to examine a patient with an acute knee injury immediately?

Answer 12

After a few days pain will increase, range of movement will decrease and willingness of patient to move the injured area will decrease

Question 13

What might be picked up on x-ray of a patient with an acute knee injury?

Answer 13

Fracture
Loose bodies
Ligament avulsion 
Osteochondral defect
Degenerative joint disease 
Lipohaemarthrosis

Question 14

What might be picked up on ultrasound of a patient with an acute knee injury?

Answer 14

Tendon rupture
Some meniscal tears
Swelling
Cysts

Question 15

What are the uses of MRI in acute knee injury?

Answer 15

Used for clinical confirmation, variable sensitivity and specificity
Not good for DJD or mobile pathology

Question 16

What are the indications for surgery following acute knee injury?

Answer 16

Failure of conservative treatment 
Demands of work 
Demands of sport
Problems with daily activities 
Prevention of further joint injury 
Prevention of falls

Question 17

What are the non-surgical managements of acute knee injury?

Answer 17

Restoration of function - walking, day-to-day activities 
Physiotherapy 
Analgesia 
Swelling reduction 
Range of motion 
Normal movement

Question 18

Why is the meniscus important?

Answer 18

Protects joint surface and reduces risk of degenerative changes in later life - important to preserve

Question 19

What are the surgical options for meniscal injury?

Answer 19

Partial meniscectomy
Meniscal repair
Meniscal transplantation - controversial, not widely used

Question 20

Where in the menisci are the fibroblasts and chondroblasts?

Answer 20

In matrix of type 1 collagen

Question 21

What is the fibrous structure of the menisci?

Answer 21

Circumferential hoop fibres
Superficial randomly oriented fibres
Radially oriented tie fibres

Question 22

What is the radial component of the loading force on the menisci balanced by?

Answer 22

Tensile stresses developed in the circumferentially oriented collagen fibres

Question 23

What is the vascular anatomy of the menisci?

Answer 23

Perimeniscal capillary plexus originates from branches of the inferior medial and lateral geniculate arteries
Perimeniscal plexus forms circumferential vessels and penetrating radial vessels

Question 24

Who is typically affected by meniscal injury?

Answer 24

Young, athletic people

Question 25

What are the repair techniques for meniscus injury?

Answer 25

Open technique
Outside-in
Inside-out
All inside

Question 26

Describe the Smith and Nephew Technique

Answer 26

Device passed through portal and through meniscus to a depth that enables T to be deployed
Once T is deployed, knots are tied outside the joint and a knot pusher is used to slide nots snuggly against the meniscus

Question 27

How many meniscal repairs fail/need re-arthroscopy and probable partial meniscectomy?

Answer 27

1/5

Question 28

How many meniscal repairs fail at re-scope/MRI?

Answer 28

1/5

Question 29

What needs to be considered in ACL reconstruction?

Answer 29

Acute or delayed
Effect on function
Effect on sport

Question 30

What are the indications for surgery of ACL?

Answer 30

Prevention of further injury 
Back to work 
Back to sport 
Prevention of osteoarthritis 
Patients with symptomatic instability in spite of treatment

Question 31

What are the treatment options for osteochondral injuries?

Answer 31

Debridement
Reattachment of fragment
Removal of loose bodies
Micro-fracture chondroplasty

Question 32

Osteochondral injuries carry a higher risk of what?

Answer 32

Pain, osteoarthritis and persistent loss of function