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*Orthopaedic Surgery > Lower Extremity Disorders: THE KNEE: WORK-UP AND TREATMENTS > Flashcards

Lower Extremity Disorders: THE KNEE: WORK-UP AND TREATMENTS Flashcards

1
Q

DDx of Knee pain in the following pts:

  1. Teen pt under 20? 4
  2. Adult pt 20-48 YO? 5
  3. Older pt >48? 3
A
  1. Teen patient (under 20 yrs)
    - Patellofemoral syndrome (PFS) 95%
    - Tendinitis (patellar)
    - Osgood-Schlatters
    - Osteochondritis Dissecans (OCD)
  2. Adult patient (20-48 yrs)
    - PFS
    - Meniscus tear
    - Ligament tear
    - Bursitis (prepatellar)
    - Tendinitis (IT band friction)
  3. Older patient (>48 yrs)
    - Meniscus tear
    - Arthritis
    - Bursitis (pes)
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2
Q

Injury Associated Events we should ask about on Hx for knee injury?

4

A
  1. Pop heard or felt
  2. Swelling after injury (immediate vs delayed)
  3. Catching/Locking
  4. Buckling/Instability
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3
Q

HISTORICAL CLUES TO
KNEE INJURY DIAGNOSES

  1. Noncontact injury with “pop”? 1
  2. Contact injury with “pop”? 3
  3. Acute swelling? 5
  4. Lateral blow to the knee? 1
  5. Medial blow to the knee? 1
  6. Knee “gave out” or “buckled”? 2
  7. Fall onto a flexed knee? 1
A
  1. ACL tear

2.

  • MCL or LCL tear,
  • meniscus tear,
  • fracture

3.

  • ACL tear,
  • PCL tear,
  • fracture,
  • knee dislocation,
  • patellar dislocation
    4. MCL tear
    5. LCL tear

6.

  • ACL tear,
  • patellar dislocation
    7. PCL tear
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4
Q

12 year old female presents with nonspecific anterior knee pain. Worse with activities like running, squatting, and jumping. May have some swelling. Losing confidence. No injury. Occasional popping.

  1. What special tests do you want to do? 3
A
  1. Medial and Lateral Patellar Glide
  2. Patellofemoral Grind
  3. Patellar apprehension test
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5
Q
  1. What is the Patellofemoral Grind?
  2. Whats a positive sign for it?
  3. Whats the Patellar apprehension test?
  4. Whats a positive sign?
A
  1. Pressure on superior patella as patient fires quads
  2. Pain is positive exam
  3. Apply medial forces to patella- forcing it laterally
  4. Apprehension is positive exam indicating previous subluxation or dislocation
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6
Q

12 year old female presents with nonspecific anterior knee pain. Worse with activities like running, squatting, and jumping. May have some swelling. Losing confidence. No injury. Occasional popping.

  1. Dx?
  2. How common is this?
  3. How to make the Dx? 4
  4. Tx? 3
A
  1. PFS/ Chondromalacia
  2. VERY COMMON!
  3. Dx-
    - look for muscle imbalance,
    - flexibility issues,
    - feet
    - alignment

4.

  • Tx- NICER
  • Patellar stabilizing brace
  • PHYSICAL THERAPY to correct deficits
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7
Q

18 year old female basketball player on breakaway layup goes down under the basket with no one around – ends up on the floor holding her knee and screaming in pain.

Felt a “pop”. Unable to continue. Experienced instability and increased stiffness.

Dx?

A

ACL TEAR

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8
Q

18 year old female basketball player on breakaway layup goes down under the basket with no one around – ends up on the floor holding her knee and screaming in pain.

Felt a “pop”. Unable to continue. Experienced instability and increased stiffness.

Special Tests

Assess stability of 4 knee ligaments via applied stresses

The stabilizing roles of each ligament include:

  1. The medial collateral ligament (MCL) prevents the knee from what?
  2. The lateral collateral ligament (LCL) prevents the knee from what?3. The anterior cruciate ligament (ACL) prevents what?
  3. The posterior cruciate ligament (PCL) prevents what?
A
  1. buckling inwards (valgus injury)
  2. buckling outwards (varus injury)
  3. the tibia from sliding forward under the femur
  4. the tibial from sliding backward under the femur
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9
Q

KNEE LIGAMENTS

Valgus and Varus at ________ flexion then ______ extension

A
  1. 30 degrees
  2. full
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10
Q

Knee ligaments: What is the Bohler test?

A

Valgus stress for MCL

Varus stress for LCL

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11
Q

COLLATERAL LIGAMENT INJURIES

Tx? 3

Timeline? 2

A
  1. Tx- NICER
  2. Brace
  3. Pain free activity

Time

  1. 2-8 weeks based on grade
  2. 1 year for full maturation of scar in complete tear
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12
Q

Special tests for the ACL?

3

A
  1. Lachman
  2. Anterior Drawer
  3. Pivot Shift

Don’t do- causes pain and isn’t necessary. Difficult exam. Insensitive and inaccurate while awake.

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13
Q

Describe how to accomplish the following tests:

  1. Lachman? 2
  2. Anterior Drawer? 2
A
  1. Lachman
    - Supine, knee at 20-30 degrees flexion, & RELAXED
    - >5mm anterior translation of tibia positive
  2. Anterior Drawer
    - Supine, hip at 45 degrees, knee at 90 degrees
    - Tibia directed toward examiner
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14
Q

ACL tear

  1. Contact or non?
  2. Gender?
  3. Cause?
  4. Dx? 4
  5. Tx depends on? 3
A
  1. Most noncontact
  2. Females higher prevalence
  3. Muscle imbalance and mechanics- valgus load

4.

  • Hx,
  • exam,
  • aspiration
  • MRI
    5. Surgical vs Non-op
  • Age,
  • activity,
  • concomitant injury
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15
Q

SPECIAL TEST- LIGAMENT

PCL? 2

A
  1. Sag Sign
  2. Posterior drawer
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16
Q

Describe the following and what makes them positive:

  1. Sag sign?
  2. Posterior Drawer?
A

Sag Sign

1.

  • Same position as anterior drawer
  • Thumb slides medial to patella into tibial condyle
    2. Positive sign is lacking condyle

Posterior Drawer

1.

  • Position as for anterior drawer
  • Posterior pressure on tibia
    2. Positive is posterior translation of tibia
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17
Q

PCL TEAR

  1. Cause?
  2. Dx? 3
  3. Tx? 3
A
  1. Hyperextension or posterior load (dashboard)

2.

  • Hx,
  • exam,
  • +/- aspiration

3.

  • Tx- PT- quad strengthening
  • Bracing
  • Occasionally surgery
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18
Q

54 year old male construction worker steps off ladder onto uneven ground and has his knee twist and experiences immediate medial pain. Develops some swelling. Is now having trouble with squatting, kneeling and climbing ladders.

Dx?

A

MENISCUS INJURY

19
Q

Special Tests for Meniscus?

6

A
  1. Full Flexion- Sensitivity 55-85%, Specificity 29-67%
  2. Joint line tenderness - Sensitivity 76%, Specificity 29%
  3. McMurray- Specificity 97% and Sensitivity 52%
  4. Apleys Compression Test
  5. Bounce Test
  6. Duck Walk
20
Q

MCMURRAY’S TEST

Medial Meniscus?

Lateral?

21
Q

MENISCUS INJURY

  1. Which injury is more common?
  2. Which is worse?
  3. Symptoms? 3
  4. Confirm with?
  5. Tx? 2
A
  1. Medial common,
  2. lateral worse

3.

  • Mechanical symptoms
  • Pain
  • swelling
    4. Confirm w/ MRI
    5. Tx: arthroscopy with meniscectomy vs repair
22
Q

14 year old male soccer player presents to clinic with insidious onset of anterior knee pain. Localizes the pain to the patellar tendon. No swelling. No injury. Progressive in nature

Dx?

A

PATELLAR TENDONITIS (TENDINOSIS/TENDINOPATHY)

Jumper’s Knee

Affects participants in “explosive” sports involving quick movements

Basketball players are most commonly affected

Commonly in hikers/ backpackers on hills and unpredictable terrain

23
Q

PATELLAR TENDONITIS (TENDINOSIS/TENDINOPATHY)

Causes? 4

A

Causes

  1. Excessive activity
  2. Especially a rapid increase in frequency/intensity of training
  3. Improper mechanics of training
  4. Excessive weight on person with a weight bearing exercise lifestyle
24
Q

TENDINOPATHY

  1. Acute tx? 4
  2. Preventative? 2
  3. Severe?
A
  1. Treatment- Acutely:
    - Ice,
    - NSAIDs

Physical therapy

  • Flexibility
  • Eccentric exercises
    2. Treat mechanics:
  • Heel lift or orthotic to control pronation,
  • change activity stimulus
    3. Immobilize if necessary- Cam walker for severe cases achilles tendonopathy
25
Q

CHRONIC TENDINOPATHY TX

  1. What makes this different than acute? 2
  2. Why is this hard to treat? 3
A
  1. Not an inflammatory condition
    - Traditional therapies may not be best approach

2.

  • NSAIDs have no role except analgesia
  • Steroid injections decrease pain short term
  • No inflammation so mechanism in questionNo benefit with long term pain relief. Consider for therapy to break the pain cycle

Possible effects on neovascularization and accompanying nerves as sclerosing agent or as vasoconstrictor/hypoxia

26
Q

CHRONIC TENDINOPATHY TX

Injury may be red flag to associated factors such as?

6

A
  1. Nutrition
  2. Malalignments- Q angle, hyperpronation/

supination, limited ROM of nearby joint, pes cavus,

pes planus, ankle instability, impingement

  1. Muscle problem- muscle weakness/imbalance, inflexibility
  2. Training errors- poor technique, excessive force, repetitive loading, fast progression with high intensity, poor or inadequate equipment
  3. Medication association- esp fluoroquinolones, doxycycline, steroids
  4. Systemic disease- psoriasis, SLE, hyperthyroid, DM, etc.
27
Q

Describe the Iceberg theory of tendinosos

28
Q

CHRONIC TENDINOPATHY TX

5

A
  1. Relative Rest
  2. Discontinue painful activities
  3. Avoid immobilization if possible
  4. Too much rest is bad!
  5. Progress through passive and active stretching to PROM to progressively increasing loads of AROM
29
Q

CHRONIC TENDINOPATHY TX

Why is too much rest bad? 3

A
  1. Regeneration and Remodeling of collagen requires protected loading of tendon
  2. New collagen aligns along lines of stress
  3. Rest results in poorly aligned collagen and healing
30
Q

ECCENTRIC MUSCLE TRAINING

Eccentric muscle training- multiple studies of chronic patellar and Achilles tendinopathy show efficacy

12 week program

Improvement in pain and function results from 3-18 months…not quick

Histopathologic review shows normal tissue

-What does it do? 3

A
  1. Induces cell activity and remodeling
  2. Induce inflammatory response and repair?
  3. Prevention strategy?
31
Q

40 year old male roofer presents with acute onset of knee swelling. Diffuse pain. Knee feels warm to touch. No injury. This happened 5 years ago as well. Resolved with time. Currently unable to work.

Dx?

A

ATRAUMATIC SWOLLEN KNEE

32
Q

When should you needle a knee? 2

A
  1. Diagnostic tool
  2. Therapeutic tool
33
Q

ATRAUMATIC SWOLLEN KNEE

  1. What is it?
  2. Want to rule out what?
  3. Tx?
A
  1. No Injury, Positive Effusion
  2. Want to rule out:
    - Infection (hematogenous/post- op/post-inj)
    - Inflammation (RA, psoriasis, etc)
    - Reactive (meniscus, DJD)
  3. ASPIRATE!!!
34
Q

ATRAUMATIC SWOLLEN KNEE

  1. Joint Fluid: Send for? 4
  2. Blood tests? 3
  3. Radiographs? 3
A

1.

  • cell count and differential,
  • crystals,
  • culture and gram stain.
  • Microbiology and Special forms (aerobe/anaerobe/fungal/TB).
    2. Blood tests: CBC with diff, ESR, CRP.
    3. Radiographs: AP/Lat/Merchant
35
Q

ATRAUMATIC SWOLLEN KNEE

Situation Specific tests you can order? 6

A
  1. Lyme titer
  2. PPD
  3. Echo for a murmur
  4. RF/ANA
  5. Rashes/mouth ulcers/back symptoms, eye symptoms
  6. MRI and/or bone scan

(or leave it to the rheumatologist)

36
Q

ATRAUMATIC SWOLLEN KNEE

What would your cell count, culture, and ESR be for the following:

  1. Reactive?
  2. Inflammation?
  3. Infection?
A
  1. Reactive 0-20K (-) less than 30
  2. Inflamm 20-50K (-) less than 50
  3. Infection >50K + >100
37
Q

SEPTIC BURSITIS 4 vs SEPTIC ARTHRITIS 2

A
  1. Bursitis is red and angry looking.
  2. There is an area of fluctuance.
  3. The knee moves pretty well.
  4. Don’t aspirate joint through the cellulitis.
  5. Septic joint doesn’t look red, just swollen.
  6. It is very tender and any motion causes severe pain.
38
Q

THERAPEUTIC INJECTIONS for joints?

2

A
  1. Corticosteroid delivery for advanced OA, and other noninfectious inflammatory arthritides (gout)
  2. Delivery of viscosupplementation
39
Q

Glucosamine and Hyaluronate injections

2

A
  1. Studies show a weak benefit in pain relief with glucosamine +/- chondroitin. No harm except $.
  2. Studies have not supported benefit of hyaluronate injections (multiple) over single cortisone injection, however have shown pain relief.
40
Q

KNEE INJECTION

Injection

  1. 3 injection?
  2. What type of needle?
  3. Aspiration use what?
A

1.

  • 40-80 mg Kenalog
  • 4 cc 1% Lidocaine
  • 4cc 0.5% Marcaine
    2. 1 ½ inch 25 gauge needle
    3. 18 gauge needle and 30-60 cc syringe
41
Q

FIBULAR SHAFT FRACTURE

Tx? 3

Referral when? 4

A

Treatment based on patients comfort

  1. Splint, cast, or walking boot for 3-4 weeks
  2. Then gradual return to activities
  3. Complete healing about 6-8 weeks

Referral

  1. Comminuted
  2. Significantly displaced
  3. Associated tibial fracture
  4. Neurovascular injury
42
Q

TIBIAL PLATEAU FRACTURE tx?

A

Refer!

Splint, NICER,

non-weightbearing

43
Q

KNEE PAIN IMAGING

If arthritis or fracture is on your list or you are going to refer a patient, order what?

4

A
  1. (Standing) AP both knees,
  2. both laterals and
  3. Merchant/Sunrise view radiographs.
  4. For arthritis, standing 30 degree AP also

*Orthopaedic Surgery (28 decks)

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