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Musculoskeletal > Knee Problems > Flashcards

Knee Problems Flashcards

1
Q

what is role of ACL

A

prevents abnormal internal rotation of tibia (twisting is either ACL or meniscal)

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2
Q

what is role of PCL

A

prevents hyperextension and anterior translocation of femur

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3
Q

what is role of MSL

A

resists valgus force

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4
Q

what is role of LCL

A

resists varus force

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5
Q

what have you injured if you get up from squatting

A

meniscal tear

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6
Q

what is a grade 1 knee ligament injury

A

sprain

tear some fibres but macroscopic structure intact

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7
Q

what is grade 2 knee ligament injury

A

partial tear

some fascicles disrupted

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8
Q

what is grade 3 knee ligament injury

A

complete tear

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9
Q

what surgery may help in younger patients with medial OA

A

osteotomy of proximal tibia (HTO) to shift load to lateral compartment
esp useful for heavy manual workers as knee replacement would fail early

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10
Q

when would knee replacement be considered and what are different kinds

A

patient with substantial pain and disability where conservative management no longer works
resurface all 3 compartments (total knee replacement) or partial knee replacement (UKR, or patellofemoral replacement)

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11
Q

what kind of knee replacement is failure incidence higher in

A

higher in partial since arthritis can progress in the unresurfaced compartments

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12
Q

by which movement will a meniscal tear occur

A

twisting force on loaded knee (eg turning at football, squatting)

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13
Q

what may a large longitudinal meniscal tear result in

A

bucket handle tear where a large meniscal fragment is able to flip out of its normal position and displace anteriorly or into the intercondular notch where the knee locks and if unable to fully extend due to obstruction from fragment

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14
Q

what is a degenerate tear

A

occurs as meniscus weakens with age - can be a horizontal, longitudinal or radial tear

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15
Q

how to tell difference between bucket handle tear and degenerate tear

A

degenerate will be steinmanns negative

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16
Q

what are the symptoms of a meniscal tear

A

patient localises pain to the medial (majority) or lateral joint line and effusion develops by following day
knee locking and feeling like it will give way

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17
Q

what is cause of knee locking in meniscal tear

A

15o or so block to full extension ie cant straighten properly = caused by significantly torn meniscus flipping over and becoming stuck in joint line
however, possible to not have this if torn meniscus not unstable enough to flip

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18
Q

what causes knee feeling like its going to give way in meniscal tear

A

if loose fragment is caught in knee when walking

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19
Q

what does an acute locked knee signify and what surgery does this urgently require

A

displaced bucket handle tear
arthroscopic repair
if irrepairable = needs menisectomy to unlock knee and prevent further damage

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20
Q

how is a meniscal tear diagnosed

A

clinical = effusion, joint line tenderness, pain on tibial rotation (steinmann’s test)
MRI will confirm suspicion

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21
Q

why are >90% of meniscal tears not suitable for repair

A

only blood supply in outer third of meniscus so limited healing
only fresh longitudinal tears involving outer 1/3 of meniscus in young patient should be considered

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22
Q

what is initial treatment

A

pain and inflammation may settle and knee may smooth off own meniscus
steroid injection in degenerate tears may help symptoms in early period

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23
Q

what happens if pain from acute tear do not settle within 3 months

A

arthroscopic partial menisectomy

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24
Q

why shouldn’t meniscectomy be considered in patient who also has OA

A

if degenerative xray (loss of joint space, sclerosis, osteophytes) or MRI (hyaline cartilage loss, bone marrow oedema) then the removal of meniscal tissue may increase stress on already worn / damaged surface

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25
Q

what force causes an ACL rupture

A

high rotational force, turning the body laterally on a planted foot leading to internal rotation on tibia
usually occurs at football, rugby, skiing etc

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26
Q

what are symptoms of ACL rupture

A

pop usually felt/heard and haemarthrosis (effusion due to bleeding in joint) within an hour
chronically = rotatory instability with knee giving way on planted foot

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27
Q

what is found in clinical examination of ACL rupture

A

knee swelling (haemarthrosis or effusion) with excessive anterior translation of the tibia on the anterior drawer test and Lachman test

28
Q

how is ACL rupture treated

A

physio, surgery if don’t respond

29
Q

what % of primary repair of ACL need a reconstruction

A

40%

30
Q

in what case would you progress straight to ACL reconstruction

A

professional sportsmen

those whose knees give way on sedentary activities

31
Q

what does ACL reconstruction involve

A

tendon graft (usually patellar tendon or semitendonosis and gracilis autograft) being passed through the tibial and femoral tunnels at the usual location of ACL in knee and secured to bone

32
Q

why is it known as a disease of 1/3rds in terms of complication

A

1/3 = compensate well
1/3 = manage by avoiding certain movements and sport
1/3 = do poorly with frequent giving way with normal activities
physio of quadriceps and hamstrings may help compensation

33
Q

what force causes MCL rupture

A

valgus stress injury (ie rugby tackle from side)

higher forces may also damage ACL and risk lateral tibial plateau fracture

34
Q

what is symptoms of MCL rupture

A

may have laxity and pain on valgus stress with tenderness over the origin or insertion of MCL

35
Q

how is MCL treated

A

heals quite well
acute tears = hinged knee brace
chronic instability = MCL tightening (advancement), or reconstruction with tendon graft

36
Q

what force causes PCL rupture

A

direct blow to anterior tibia with knee flexed (eg motorcycle crash) or hyperextension

37
Q

when is PCL reconstruction performed

A

when reconstructing multiple ligament injured knee

38
Q

when only time reconstruction of PCL rupture in isolation (not common) take place

A

only those with severe laxity and instability with frequent hyperextension or feeling unable descending stairs
reconstruction here usually with cadaveric achilles tendon allograft

39
Q

what force causes LCL rupture

A

varus stress injury, can occur with or without injury to PCL

40
Q

what other bad things can happen when you tear your LCL

A

high incidence of common peroneal nerve injury from excessive stretch
LCL injuries often part of multiple knee ligament injuries with high incidence of vascular injury (popliteal artery intimal or complete tear)

41
Q

what is symptoms of LCL rupture

A

patients usually have marked instability on rotational movement (excessive external rotation of tibia and varus)

42
Q

how is LCL ruptures treated

A

usually surgical with early repair or late construction with tendon graft

43
Q

with higher degrees of force, some injuries can involve rupture or more than one of four knee ligaments, how do you treat this

A

surgical reconstruction (multiple ligament) due to degree of instability

44
Q

complete knee dislocations should be reduced as emergency, why?

A

high incidence of neurovascular injury

as well as reduction, may require external fixation for temporary stabilisation

45
Q

why are regular checks on the circulation of food mandatory after a complete knee dislocation

A

intimal tears can occur which later thrombose

46
Q

what is an osteochondral / chondral injury and how do they occur

A

injury to articular cartilage +/- the bone underneath it
occur due to impaction or shear of the articular surface
or due to direct blow

47
Q

when would osteochondral / chondral injury be suspected

A

ongoing pain and effusion after a knee injury warrant further investigation with xray, MRI and with arthroscopy

48
Q

how is osteochondral / chodral injury treated

A

acute involving large osteochondral fragments with substantial bone should be fixed with pins
if they are from non-weight bearing area or have little bone attached they are usually removed arthroscopically

49
Q

what type of cartilage fills a defect in surface of knee

A

fibrocartilage (scar type hyaline cartilage) not as good as hyaline

50
Q

what is microfracture

A

process where by if a defect has bare bone at its base it can be drilled to induce bleeding to promote fibrocartilage formation from stem cells differentiating into chondroblasts

51
Q

what does the extensor mechanism of the knee constitute

A 
tibial tuberosity 
patellar tendon 
patella
quadriceps tendon 
quadriceps muscle
52
Q

what can cause patellar tendon (<40 yo) or quadriceps tenon (>40 yo) rupture

A

rapid contractile force which can occur after lifting a heavy weight, after a fall or spontaneously in a severely degenerate tendon

53
Q

what are the risk factors for extensor mechanism ruptures

A 
history of tendonitis, chronic steroid use, diabetes, RA and chronic renal failure 
Quinolone antibiotics (eg ciprofloxacin) can cause tendonitis and risk tendon ruptures
steroid injections for tendonitis of extensor mechanism should be avoided due to risk of rupture
54
Q

how is extensor mechanism rupture diagnosed

A

straight leg test to determine if extensor mechanism intact
may also have palpable gap in extensor mechanism = may not be obvious in obese patients so US to determine extent of injury
xray = reveal high (PT rupture) or low lying (quads rupture) patella

55
Q

how is extensor mechanism rupture treated

A

surgical with tendon to tendon repair or reattachment of tendon to patella
do not inject steroids!

56
Q

what conditions does the term “patellofemoral dysfunction” cover

A

disorders of the patellofemoral articulation resulting in anterior knee pain
chondromalacia patellae (softening of hyaline cartilage)
adolescent anterior knee pain
lateral patellar compression syndrome

57
Q

what are the risk factors for patellofemoral dysfunction

A

females (due to wider hips resulting in more lateral pull of quadriceps)
joint hypermobility
genu valgum
femoral neck anteversion

58
Q

what are symptoms of patellofemoral dysfunction

A

anterior knee pain, worse going downhill, a grinding or clicking sensation at front of knee and stiffness after prolonged sitting
stiffness causes “pseudolocking” = acutely stiffens in flexed position

59
Q

what is treatment of patellofemoral dysfunction

A

physio aimed at rebalancing quadriceps (esp vastus medialis)
taping may alleviate symptoms
surgery last resort - either releasing tight lateral retinaculum or if there is relatively lateralised tibial tubercle then a tubercle transfer to aid patellar tracking

60
Q

what side does patella mostly always dislocate to

A

laterally

61
Q

how to fix patella dislocation

A

may spontaneously reduce when knee straightened or rarely may require manual manipulation

62
Q

what happens when patella dislocates

A

the medial patellofemoral ligament tears and osteochondral fracture may occur as the medial facet of the patella strikes the lateral femoral condyle

63
Q

what is seen on xray in patellar dislocation

A

small opacification on xray (the osteochondral fracture)

lipo-haemarthrosis occurs which is also seen on xray

64
Q

what % risk of recurrent dislocation after first time

A

10

65
Q

how is patellar instability treated

A

risk of recurrence decreases with age and physio to strengthen quadriceps may help
if dislocation frequent = tibial tubercle transfer or medial patellofemoral ligament (MPFL) reconstruction may help

Musculoskeletal (55 decks)

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