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MSK Exam 3 > LE: Knee > Flashcards

LE: Knee Flashcards

1
Q

Palpation of the knee - Posterior

A
  • Popliteal fossa
    – *Popliteal artery is only palpable structure
    normally in this area
  • Abnormal bulges
  • Popliteal artery aneurysm
  • Popliteal thrombophlebitis
  • Baker’s cyst
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2
Q

Distal Femoral Fractures etiology

A

Trauma

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3
Q

Distal Femoral Fractures clinical presentation

A
  • Severe pain, distal thigh
  • Acute trauma in the history
  • Unable to ambulate
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4
Q

Distal Femoral Fractures diagnosis

A
  • Assess distal neurovascular status
    – Ankle-Brachial Index obtained if any vascular injury
    suspected
  • Abnormal results = (ABI < 0.9)
  • X-ray
    – Femur: AP & lateral
    – Knee: AP, lateral
  • Possibly Oblique or tunnel view of the knee
  • Consider CT or MRI if high suspicion for an occult knee
    fracture despite (–) X-ray
    – CT angiography can be performed concurrently, if vascular
    injury suspected.
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5
Q

Distal Femoral Fractures
Management

A
  • ER
  • Hospital admission
  • ORIF
  • If the fracture is non/minimally displaced
    could be managed non-surgically
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6
Q

Distal Femoral Fractures complications

A
  • Early
    – Neurovascular injury
    – Compartment syndrome
    – Infection
  • Late
    – Chronic pain
    – Nonunion or malunion
    – Infection
    – Thromboembolic disease
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7
Q

Tibial Plateau Fractures etiology

A
  • Low energy injuries
    – patients > 50 years old > 50% of
    tibial plateau fractures
  • High energy injuries
    – Any age
  • MVA, Fall from height
  • 1.3% of all fractures
  • 8% of fractures in the elderly
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8
Q

Tibial Plateau Fractures
Clinical Presentation

A
  • Proximal tibia pain & swelling
  • Abrasions, lacerations from trauma
  • Open wounds
  • Unable to bear weight
  • Joint effusion
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9
Q

Tibial Plateau Fractures diagnosis

A
  • X-ray – AP, Lateral, Oblique
  • CT – Aids in surgical decision making and planning
  • MRI – When ligament or meniscus injury also suspected
  • Assess for compartment syndrome
    – perform serial leg compartment exams for
    minimum 24 hours
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10
Q

Tibial Plateau Fractures management

A
  • Stable, minimally displaced fractures may be treated conservatively with splint, long
    leg cast, or cast brace for 8-12 weeks
  • Surgical management
    – Intra-articular fractures with > 2 mm joint depression or separation
    – Significantly displaced metaphyseal components or angulated > 5°
    – Fractures with vascular injury
    – Fractures with associated ligamentous injuries requiring stabilization
  • Open fractures
    – Antibiotic prophylaxis
    – Update tetanus status
    – Consider deep vein thrombosis prophylaxis
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11
Q

Tibial Plateau Fractures
Complications

A
  • soft tissue bruising or swelling
  • compartment syndrome
  • knee stiffness (may be due to initial injury, surgery, scarring, or immobilization)
  • infection
  • osteoarthritis (2° to initial chondral damage, residual articular discontinuity, or
    postoperative disrupted mechanical axis)
  • malunion or nonunion
  • wound dehiscence
  • deep vein thrombosis (DVT)
  • peroneal nerve injury
  • avascular necrosis of articular fragments
  • loss of limb
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12
Q

Patella Fracture etiology

A
  • Direct blow- Trip and fall
    landing on knee
  • Fall onto knee
  • Forceful contraction of the
    quadriceps
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13
Q

Patella Fracture
Clinical Presentation

A
  • Focal patellar pain
  • Soft tissue swelling anterior to & around patella
  • Knee joint effusion (typically = hemarthrosis)
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14
Q

Patella Fracture diagnosis

A
  • X-ray
    – AP, Lateral, Sunrise
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15
Q

Patella Fracture
Management

A
  • Isolated patellar fractures can be managed as an outpatient
    – nondisplaced fractures (< 3 mm of fragment of fracture separation & < 2 mm of
    articular incongruity) with intact knee extensor mechanism
    – except open fractures
  • Consult ortho for patellar fractures needing potential operative repair
    – Including comminuted & open fractures
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16
Q

Patella Fracture
Complications

A
  • Patella tendon rupture
  • Quadriceps tendon rupture
  • Non- & mal-union
  • Delayed union
  • Posttraumatic patellofemoral joint arthritis
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17
Q

Knee Dislocation etiology

A
  • High Energy Trauma
    – MVA, Pedestrian v auto, Fall from height
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18
Q

Knee Dislocation presentation

A
  • Significant deformity
  • Significant instability
  • Non-ambulatory
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19
Q

Knee Dislocation
Diagnosis

A
  • Check distal neurovascularity
    – Assess popliteal artery
    – Vascular injuries requiring operative repair- Can be a vascular emergency
  • Evaluate of ligamentous injury
    – Anterior drawer, Lachman, Varus/Valgus, Posterior Drawer
  • X-ray
    – AP, Lateral
  • CT + CT angiography - Angiography added to look at the vasculature
    – However, do not delay operative repair to perform CT angiography
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20
Q

Knee Dislocation
Management

A
  • Orthopaedic & potential a vascular emergency
  • Closed reduction with procedural sedation (←Click for link) 1:55
  • Posterolateral dislocations typically will require open reduction
  • Once reduced, immobilize the lower extremity in a hinged knee brace/splint at 20
    degrees of flexion to prevent further injury
  • It is estimated that up to 50% can self reduce- Knee can look OK, but damage is
    already done, thus making it easy to miss
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21
Q

It is estimated that up to 50% can self reduce

A

Knee dislocation

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22
Q

Knee Dislocation
Complications

A
  • Vascular injury occurs in 5%-43% of knee dislocations
    – Popliteal artery injury
  • Posterior knee dislocations
  • Other vessels that may be affected:
    – medial genicular artery, anterior tibial artery, posterior tibial artery, superficial
    femoral artery, & common femoral artery
  • Thrombosis, particularly deep vein thrombosis
  • Arterial limb ischemia
  • Peroneal nerve injury
  • Compartment syndrome
  • Instability
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23
Q

Patella Dislocation etiology

A
  • patella dislocates laterally in response to force or blow
  • indirect trauma is usual cause
    – typically occurs as femur rotates internally while leg is in valgus & foot planted
    – tension applies lateral forces on patella
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24
Q

Patella Dislocation
Clinical Presentation

A
  • History of trauma with sensation of slippage &
    intense pain
    – typically occurs during sports or other intense
    physical activity
  • Unable to bear weight & ↓ range of motion
  • May have impaired muscle activation & strength
  • “catching” or “locking” of knee suggests presence
    of loose bodies
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25
Q

Patella Dislocation
Diagnosis

A
  • History
  • Clinical
    – Patellar hypermobility & apprehension when shifted laterally
    – Bassett’s sign FYI
    – Moderate to severe effusion
  • X-ray, CT, or MRI to help identify contributing anatomic conditions or potential
    complications, including medial patellofemoral ligament (MPFL) tear
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26
Q

Bassett’s sign

A
  • Pain on palpation of medial patellofemoral ligament (MPFL), patellar, &
    peripatellar areas
  • Pain at full extension, and then resolves when knee at 90 degrees
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27
Q

Patella Dislocation
Management

A
  • Manual closed reduction may be performed under mild sedation by applying gentle force to the lateral aspect (medial direction) of patella while gradually extending the knee
  • RICES
  • Immobilize patients for 4 weeks in straight knee brace; use knee brace to stabilize
    affected area as soon as pain allows
  • Physical Therapy with increase gentle ROM
  • Surgery
    – Typically not required
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28
Q

When may surgery be indicated for a patella dislocation?

A
  • disrupted medial patellofemoral ligament (MPFL)
  • continued instability & poor outcomes following
    conservative management
  • osteochondral defects
  • ≥ 1 risk factors for instability in uninvolved knee
  • aged < 15 years old with desire to return to
    high-level sports or physical activities
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29
Q

Patella Dislocation complications

A
  • recurrent patellar dislocation
  • patellofemoral osteoarthritis
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30
Q

Medial Collateral Ligament Sprain etiology

A
  • Common in sports
  • Direct valgus stress from a blow to the lateral aspect of the knee
    – Direct blows typically cause more severe injury
  • Indirect stress through abduction or rotation of the lower leg
    – Twisting & torque of the lower extremity
31
Q

MOST COMMON KNEE INJURY

A

Medial Collateral Ligament Sprain

32
Q

Medial Collateral Ligament Sprain presentation

A
  • Many able to ambulate
  • Medial swelling & ecchymosis
  • Joint stiffness
  • Pain
33
Q

Medial Collateral Ligament Sprain diagnosis

A
  • History
  • Physical Exam
    – + Valgus stress test
    – Focal tenderness over medial joint line
  • MRI
    – Definitive Diagnosis
  • Grade 1, 2, or 3
34
Q

Medial Collateral Ligament Sprain
Management

A
  • RICES
  • Temporary bracing, but avoid long term immobilization
  • Physical Rehabilitation
    – Early ROM
    – Weight bearing to tolerance
  • Surgery is rarely necessary
    – Usually reserved for multiple injuries (ie Unhappy triad)
35
Q

Medial Collateral Ligament Sprain
Complications

A
  • Persistent instability
  • Residual pain
    – Rarely Complex Regional Pain Syndrome
  • Arthrofibrosis- stiffening of the knee from excessive collagen production, adhesion
    and scar tissue build up of a joint
36
Q

Lateral Collateral Ligament Sprain etiology

A
  • Associated with injuries to the posterolateral corner (PLC), posterior cruciate ligament (PCL), &/or anterior cruciate ligament (ACL)
  • Most common mechanism of injury involves a high energy force that combines hyperextension & varus forces
  • Injury may occur with an isolated varus hyperextension or external tibial rotation
    force
  • Typically, an isolated LCL injury, especially of lower grade, is caused by a primarily varus force (eg, knee forced laterally from a blow to the medial side
37
Q

Lateral Collateral Ligament Sprain clinical presentation

A
  • Patients typically present following a blow to the medial or anteromedial aspect of
    their knee while it was fully extended, & report lateral or posterolateral knee pain.
  • Swelling
  • “Locking or catching” (if meniscus is involved)
  • Knee buckling
38
Q

Lateral Collateral Ligament Sprain diagnosis

A
  • History
  • Physical exam
    – + Lateral collateral ligament tenderness
    – + Varus stress test
  • MRI
    – Definite diagnosis
  • Grade 1, 2, & 3
39
Q

Lateral Collateral Ligament Sprain
Management

A
  • RICES
  • Grade 1 – Crutches for ~week prn for pain control; hinged bracing 4-5 weeks
  • Grade 2 – Crutches & knee immobilizer for 1-3 weeks for pain control
    – A hinged brace may be used once the patient is partial-weight-bearing, usually at
    two to three weeks.
  • Grade 3 – Immobilization, non-weight-bearing with crutches, & consultation with an
    orthopedic surgeon.
    – Immobilization will likely be maintained until surgery is performed, preferably
    within two weeks of injury.
  • Acute lateral collateral ligament (LCL) partial tears with functional instability or injuries
    of the posterolateral corner should be referred to an ortho within 2 weeks
  • Acute, mid-portion, complete LCL tears
40
Q

Lateral Collateral Ligament Sprain
Complications

A
  • Functional instability
  • Peroneal nerve injury
41
Q

Anterior Cruciate Ligament Sprain etiology

A
  • Contact injuries account for ~30% of ACL injuries
  • Noncontact injuries account for ~70% of ACL injuries
42
Q

Anterior Cruciate Ligament Sprain
Clinical Presentation

A
  • Patients report a “pop” at time of injury,
    immediate pain & swelling of knee
  • Joint effusion
43
Q

Anterior Cruciate Ligament Sprain
Diagnosis

A
  • Assess neurovascular status
  • Joint line tenderness
  • Effusion
  • Varus & Valgus laxity (0°, 30° of flexion)
    • Lachman test
      – 86% sensitivity
      – 91% specificity
    • Pivot shift (typically most accurate under
      anesthesia because it hurts)
      – 97-99% specificity
  • MRI
44
Q

Anterior Cruciate Ligament Sprain
Management

A
  • Acute Phase
    – RICES
  • Surgical Management
  • Knee bracing
45
Q

Anterior Cruciate Ligament Sprain
Complications

A
  • ↓ knee function
  • Sports “disability”
  • Arthrosis
  • Osteoarthritis, early onset
46
Q

Posterior Cruciate Ligament Sprain etiology

A
  • Isolated PCL injury is rare
    – Commonly associated with posterior lateral corner injuries, ACL injuries & MCL
    injuries.
  • High energy trauma
    – MVA
  • Dashboard injury (posterior force)
  • Sports, falling on the knee with a plantar flexed ankle
47
Q

Posterior Cruciate Ligament Sprain
Clinical Presentation

A
  • Pain
  • Swelling/Effusion
  • Knee instability
  • Posterior Drawer (or Sag sign)
48
Q

Posterior Cruciate Ligament Sprain
Diagnosis

A
  • History
  • Physical exam
    – + Posterior Drawer
  • MRI
  • Arthroscopy
49
Q

Posterior Cruciate Ligament Sprain
Management

A
  • RICES
  • Hinged knee brace
    – Locked in full extension x 2 weeks
  • Physical Rehabilitation
  • Surgical management
50
Q

Surgical management for PCL sprains

A

– Grade 3 PCL injuries – Anterior border of medial tibial plateau can be displaced
posteriorly beyond the anterior border of the medial femoral condyle (posterior
displacement >10 mm
– PCL injuries associated with any fracture or any additional soft tissue injuries of
significance (eg, posterolateral corner, ACL injury, meniscal tear).
– PCL disruption involving avulsion of the ligamentous insertion at the tibia

51
Q

Posterior Cruciate Ligament Sprain
Complications

A
  • Generally good prognosis in isolated tears
  • Degenerative joint disease
  • Pain
52
Q

Meniscus Injury
Etiology

A
  • Acute meniscal tears = shearing/compressive forces on a meniscus
    – Most often due to noncontact forces, involving sudden acceleration or deceleration coupled with a directional change
    – Contact injuries, with varus or valgus forces acting on knee
    – Tibial displacement, due to injury to anterior cruciate ligament (ACL) &/or medial collateral ligament, leading to undue stress on meniscus
  • Degenerative meniscal tears
    – With age menisci become stiff, & have ↓ compliance
    – Result from repetitive normal forces on a deteriorated meniscus
53
Q

Meniscus Injury
Clinical Presentation

A
  • Knee pain
    – especially with deep knee flexion
  • Effusion (acute)
  • Patient reports ”locking, popping, catching, or buckling”
    – Especially with using stairs
  • Persistent focal joint line tenderness
  • ↓ ROM
54
Q

Meniscus Injury
Diagnosis

A
  • History
  • Physical Exam
    – + McMurray Test
    – Sensitivity = 22-70%, Specificity = 29-96%
    – +Thessaly Test (Thessaly Test Video)
  • Medial meniscus
    – Sensitivity = 89%, Specificity = 97%
  • lateral meniscus
    – Sensitivity = 92%, Specificity = 96%
  • MRI
55
Q

Meniscus Injury
Management (conservative)

A
  • Conservative (no associated ligament tears)
    – Degenerative meniscal tears
    – Nonsymptomatic, nondisplaced meniscal tears
    – Poor surgical candidates (multiple comorbidities or advanced age)
    – Acute traumatic meniscal body tears
  • Modify activity, & utilize crutch ambulation
  • Simple knee sleeve may be used to manage swelling
  • Physical Rehabilitation
    – Bracing in patients with meniscal root tears
    – NSAIDS &/or corticosteroid injections
56
Q

Meniscus Injury
Management- Surgical

A

– Younger patients
– Bucket Handle Tears lend themselves to surgery sooner rather
than later (eg. Often meniscus surgery is done after PT)
– Failure of conservative management of up to 6 weeks
– Symptomatic &/or displaced meniscal body tears, in knees free
from severe degenerative knee osteoarthritis
– Symptomatic meniscal root tears, with goal of
preventing/slowing progression of osteoarthritis
– Absent or nonviable meniscus (previous meniscectomy)

57
Q

Meniscus Injury
Complications

A
  • arthrofibrosis
  • infection
  • septic arthritis
  • deep vein thrombosis
  • patella fracture
  • neurovascular damage
  • failure to heal
  • hardware irritation or suture irritation
  • cyst formation
  • retear
  • need for reoperation
  • allograft rejection with meniscal transplant
58
Q

Prepatellar Bursitis etiology

A
  • Cumulative microtrauma
  • Acute trauma
  • Infection
    – Staph aureus (80-90% of cases), usually by direct inoculation
59
Q

Prepatellar Bursitis clinical presentation

A
  • localized swelling of soft tissue over patella
  • bursal fluctuance
  • painless or only slightly painful joint range of motion (except at extreme flexion)
  • septic prepatellar bursitis
    – suspected with warmth, erythema, skin abrasion, or cellulitis over patella
    – Fever possible
60
Q

Prepatellar Bursitis
Diagnosis

A
  • Clinical
  • Septic bursitis
    – Confirmed with isolation of pathogen from culture of bursal aspirate
61
Q

Prepatellar Bursitis
Management

A
  • RICES
  • If septic prepatellar bursitis suspected
    – affected bursa should be aspirated & sent for immediate culture analysis
    – corticosteroid injection contraindicated if bursa infected or inflamed
    – oral antibiotics targeting staphylococci & streptococci
  • IV administration reasonable if infection severe
    – incision & drainage may be considered for severe septic bursitis
  • Bursectomy reserved for refractory cases
62
Q

Prepatellar Bursitis
Complications

A
  • Infection of associated joint or underlying bone if patient immunocompromised or
    delay in starting antibiotics
  • Rarely, bacteremia after prolonged septic bursitis, possible if patient
    immunocompromised
  • complications of treatment
63
Q

Patellofemoral Syndrome etiology

A
  • Exact cause unknown
    – likely due to abnormal tracking of patella over the femoral condyles &/or
    patellofemoral joint overload
64
Q

Most common cause of anterior knee pain

A

Patellofemoral Syndrome

65
Q

Patellofemoral Syndrome
Clinical Presentation

A
  • Patient c/o anterior knee pain described as being behind, around, or underneath
    patella
    – usually gradual onset (could be acute, if associated with trauma)
    – worse with prolonged sitting (theatre sign) or going down stairs
    – may be exacerbated by running, jumping, or climbing stairs
66
Q

Patellofemoral Syndrome
Diagnosis

A
  • History + Clinical exam
    – suspect patellofemoral pain syndrome in patients with anterior knee pain
    exacerbated by long periods of sitting or descending stairs
    – Painful resisted knee extension
    – Painful squatting
  • X-ray may be helpful to r/o other conditions
  • MRI (usually not necessary)
67
Q

Patellofemoral Syndrome
Management

A
  • RICES
  • Activity modification
  • NSAIDS
  • Corticosteroid injection
  • Physical rehabilitation
  • Patellar taping, bracing &/or foot orthoses may be helpful
  • Surgery reserved for cases refractory to conservative measures x 6-12 months
68
Q

Iliotibial Band Syndrome etiology

A
  • combination of repetitive stress & biomechanical factors
    – tightness of ITB
    – weakness of knee extensors, flexors, & hip abductors
    – low hamstring strength compared to quadriceps strength on same side
    – femoral external rotation
    – angle of knee flexion (ITB rubs against underlying structures at position of 20-30°)
    – leg length discrepancy (injury to longer leg)
    – abnormal foot & ankle mechanics (rear foot pronation, internal tibial rotation)
    – excessive hip adduction
    – narrow step width
69
Q

Iliotibial Band Syndrome
Clinical Presentation

A
  • Patient may describe:
    – Progressive tenderness over lateral femoral
    epicondyle &/or Gerdy tubercle
    – In less severe cases, pain may initially subside
    upon cessation of activity
    – Pain worsened on stairs
70
Q

Iliotibial Band Syndrome
Clinical Presentation

A
  • Pattern of pain typical for runners
    – Initially occurs after completion of a run with
    progressively earlier occurrence during running
    sessions, & eventually progressing to pain when
    at rest
    – Occurs while lengthening stride
    – Worsens after running long distances, while
    running downhill, or outside
71
Q

Iliotibial Band Syndrome
Diagnosis

A
  • History of lateral knee pain associated with
    repetitive weight-bearing motion;
  • Physical exam
    – + Noble compression test
    – + Ober test
    – + Modified Thomas test to assess for tightness
    of the ITB, iliopsoas, & rectus femoris
  • Consider magnetic resonance imaging to rule out
    other causes if clinical exam unclear
72
Q

Iliotibial Band Syndrome
Management

A
  • Activity modification
  • RICES
  • NSAIDS
  • Corticosteroid injection (between lateral femoral condyle & ITB)
  • Physical rehabilitation
  • Surgical intervention if conservative measures fail
    – Debridement
    – ITB release
    – ITB bursectomy
73
Q

Iliotibial Band Syndrome
Complications

A
  • Pain
  • Biomechanical compensation
  • ITB rupture (with corticosteroid rupture)

MSK Exam 3 (6 decks)

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