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Clin Med semester 2 > Lower Extremity Orthopedics- Jaynstein- Exam 2 > Flashcards

Lower Extremity Orthopedics- Jaynstein- Exam 2 Flashcards

1
Q

What is the largest joint in the body?

A

KNEE! susceptible to injury from trauma, inflammation, infection, and degenerative changes

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2
Q

The knee is stabilized by 4 ligaments: (list them)

A
  • Against anterior movement by the anterior cruciate ligament (ACL)
  • Against posterior movement by the posterior cruciate ligament (PCL)
  • Against varus strain by the lateral collateral ligament (LCL)
  • Against valgus strain by the medial collateral ligament (MCL)
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3
Q

The ACL connects the posterior aspect of the _____ _____ to the anterior aspect of the _____

A
  • femoral condyle

- tibia

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4
Q

ACL function?

A

Controls anterior translation of the tibia on the femur as well as rotational stability

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5
Q

How common is an ACL injury?

A

Common injury! - particularly in sports (3% of all athletic injuries)
Soccer, basketball, football and skiing
*Women > Men

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6
Q

MOI: ACL

A
  • Typically in a non-contact deceleration, producing valgus twisting
  • -Hyperextension
  • -Marked internal rotation
  • Or with Pure deceleration (MC mechanism is from stopping suddenly)
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7
Q

Varus?

A

think R for rum, rum makes your knees widen (Varus= knees wide apart)
-varus strain=LCL

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8
Q

Valgus?

A

think G for gum (gum makes your knees stick together)

-Valgus strain= MCL

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9
Q

ACL injury Sxs:

A
  • “pop”
  • Marked, immediate effusion
  • Difficulty/inability to weight bear
  • Knee feels “unstable”
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10
Q

ACL injury PE findings: (tests you will perform)

A
  • Lachman’s, Anterior Drawer

- Lever Sign

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11
Q

ACL injury Dx:

  • what does the Xray show?
  • ____ fractures are present in 75% of ACL tears**
  • 1st line imaging study for ACL tears?
A
  • Knee xrays often show a large effusion
  • Can demonstrate a Second fracture–> avulsion fx of the lateral tibial plateau
  • *Present in about 75% of ACL ruptures

TOC: MRI without contrast – large effusions can obscure imaging

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12
Q

ACL injury tx:

A
  • Young/active with complete tear –->surgical repair–>Autograft (own patellar or hamstring tendon) or allograph (cadaver)
  • Older/sedentary or partial tear – conservative. –>PT to strengthen the hamstrings, bracing
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13
Q

ACL injury additional tx? (specify for acute and subacute/chronic)

A
  • Bracing (debated) to protect other structures – pt at increased risk of secondary meniscus injury
  • Acute: knee immobilizer and crutches
  • Subacute/chronic: hinged brace
  • RICE, Pain control, & Ortho referral
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14
Q

What is the strongest ligament in the knee?

A

PCL (posterior cruciate ligament)

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15
Q

T/F: complete tears are more common than partial tears with the PCL

A

False! Sprains or partial tears are more common than complete tears
–Complete tears are associated with major trauma

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16
Q

Over ____% of PCL tears have assoc. injuries

A

-over 70%, ACL and MCL tears MC, or complete knee dislocation

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17
Q

MOI: PCL injury

A
  • Often due to a blow to the knee while it’s flexed
  • ie Striking the knee against the dashboard during an auto accident
  • ie Falling on the knee while it’s flexed
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18
Q

PCL injury Sxs:

A
  • Swelling is immediate and typically profound
  • Severe pain
  • Limited ROM
  • Instability, inability to ambulate
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19
Q

PCL injury Dx:

A
  • **“sag sign” – obvious set-off of the tibia posterior
  • Posterior drawer test
  • MRI WITH CONTRAST (now you’re concerned about vascular disruption)
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20
Q

PCL injury tx: (are these Pts admitted?)

-when do you opt for Physical therapy vs surgery?

A
  • Ortho referral – often admitted!
  • RICE, pain control, immobilization with crutches
  • Isolated PCL tears may be treated non-op with PT (failure = surgery)

-In combo with other injuries usually means operative treatment

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21
Q

What is the MC injured ligament in the knee?

A

MCL (medial collateral ligament). – however, not all pts with an MCL injury get seen

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22
Q

What are MCL injuries often associated with?

A

concurrent ACL injury

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23
Q

The MCL and LCL are extra-articular, and therefore ____ ______ is less common with these injuries

A

joint effusion

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24
Q

MOI MCL:

A

-Valgus stress on a partially flexed knee
-Lateral to medial impact
(Pt will say something hit the side of their knee, focal pain)

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25
Q

MCL Sxs:

A
  • Focal pain over ligament
  • Minor swelling
  • Limited ROM acutely – improves quickly! In about 2 weeks
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26
Q

MCL injury Dx:

A
  • Valgus stress exam
  • -Causes pain and laxity
  • MRI – does not need to happen acutely – may watch and wait
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27
Q

MCL injury Tx:

A
  • Graduated weight bearing as tolerated
  • Bracing (minor hinged, severe immobilizer)
  • PT
  • Allow 6-8 weeks for healing
  • Isolated MCL tears rarely need surgery
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28
Q

LCL (lateral collateral ligament injury) injury: how common?

-is there joint effusion?

A
  • less commonly injured

- The LCL is extra-articular and therefore, joint effusion is less common with these injuries

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29
Q

LCL MOI:

A
  • Varus stress on a partially flexed knee

- Medial impact

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30
Q

LCL injury Sxs:

A
  • Focal pain over ligament
  • Minor swelling
  • Limited ROM acutely – improves 2 wks
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31
Q

LCL injury dx:

A
  • Varus stress exam–>Causes pain and laxity

- MRI – does not need to happen acutely – may watch and wait

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32
Q

LCL injury tx:

A
  • Ortho referral – often surgical

- Brace

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33
Q

Meniscus injuries: how common?

A
  • “Shock absorbers” of the knee
  • **Very commonly injured
  • Can be injured acutely or suffice to degeneration
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34
Q

Meniscus MOI:

A

**multiple mechanisms, usually twisting related

-Internal rotation of femur on tibia with knee in flexion (catches posterior meniscus between femur and tibia)
-Sudden extension causes longitudinal tear (external rotation for lateral meniscal injury)
-May have partial or complete tear, posterior or anterior horn tear, longitudinal or bucket handle tear
(dont memorize these types)

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35
Q

Meniscus injury Sxs:

A
  • “catching,” “locking,” “clicking”
  • Painful walking and squatting
  • Mild to mod joint swelling
  • ** (KNOW)->Joint line tenderness**
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36
Q

Meniscus injury PE test:

-also, what do Pts complain of?

A

McMurray

-**Pts may experience “locking in extension” – piece/flap of meniscus obstruction joint

37
Q

“Pt has medial joint line tenderness”

A

think Meniscus tear!!!

38
Q

Meniscus injury Dx:

A

-Xrays usually normal but may show joint space narrowing or effusion
More helpful in pts wo h/o OA
-MRI is TOC (test of choice)

39
Q

Meniscus injury Tx:

A
  • Degenerative tears – non-operaple, PT

- Acute tears: arthroscopic meniscus repair or debridement

40
Q

Knee dislocation: dislocation of the _________ joint of the knee

A

tibiofemoral

41
Q

Knee dislocation is considered an orthopedic _______

A

EMERGENCY!!

42
Q

Stats about knee dislocation: (etiology)

A
  • The exact incidence is unknown as many present already reduced
  • Associated with multi-trauma in almost half of patients

**Ppl are screaming in pain

43
Q

How is a knee dislocation described?

A

Described in terms of the tibia’s displacement relative to the femur

44
Q

To dislocate the knee, at least __, of the ___ major knee ligaments are torn

A

3, if not all, of the 4

45
Q

Knee can dislocate in 3 ways (list 3)

A

Can dislocate anteriorly (31%) or posteriorly (25%), laterally (13%), or medially (3%)

46
Q

Which artery sustains either partial or complete disruption in 40% of knee dislocations?

A

The popliteal artery, which courses through the popliteal fossa, sustains either partial or complete disruption in 40% of knee dislocations–>** vascular emergency!!!!

47
Q

the ______ nerve is injured in 23% of knee dislocations

A

The peroneal nerve, which provides sensation to the lateral side and dorsum of the foot and controls ankle dorsiflexion

48
Q

Knee dislocation MOI:

A

MC with high-energy trauma such as hyperextension (anterior dislocation), or anterior blow to the knee (posterior dislocation) - dashboard injuries

49
Q

Knee dislocation PE findings

A

-Gross deformity (if no spontaneous reduction)
-Large effusion
-Significant pain – unable to bear weight
-**MUST evaluate for neurovascular injuries!–> Palpable distal pulses – does NOT exclude the
possibility of a vascular injury!

50
Q

What MUST you order for a knee dislocation?

A

**Obtain Ankle-Brachial Index –> assessing Popliteal vasculature

51
Q

What else should you assess in a person with suspected knee dislocation?

A
  • Assess pt sensation and strength

- -evaluating the Peroneal Nerve (provides sensation to the dorsum of the foot and controls ankle dorsiflexion)

52
Q

ABI’s: what is the cut off for ordering a CT arteriogram?

A
  • Systolic BP in LE (“ankle”) / systolic BP in the UE (“brachial)
  • ABI >0.9–> monitor with serial exams
  • ABI <0.9 –> obtain advanced imaging to evaluate the popliteal artery

**Intact distal pulses is NOT sufficient enough for acute knee injuries!

53
Q

Imaging for knee dislocations

A
  • AP and lateral knee xrays–>Obtain even if self reduced to evaluate for tibial plateau fracture
  • *CT arteriogram ( IS gold standard!!) or arterial duplex ultrasound

-**MRI later to evaluate for ligamentous derangement

54
Q

Why is CT arteriogram gold standard for eval. knee dislocations?

A
  • Evaluates for popliteal artery injury
  • Not necessarily always indicated – but do obtain if any doubt!

-Absolutes: PE consistent with decreased circulation or ABI <0.9

55
Q

Knee dislocation tx:

A
  • IV pain control – often admitted for this alone!
  • Reduce – even if pt has a vascular injury – reduce than reassess and obtain ortho/vascular consult and advanced imaging
  • Post-reduction xray
  • Splint in a long leg splint with 20-30 degree flexion
  • Admit for pain control and serial exams with ortho consult
56
Q

Knee dislocation –complications (which one is MC?)

A
  • Limb ischemia
  • Permanent nerve damage
  • Compartment syndrome
  • Arthrofibrosis (stiffness) – most common
57
Q

Knee dislocation: what must you do prior to ordering an X ray?

A

REDUCE!! then reassess and obtain ortho consult and advanced imaging

58
Q

Knee dislocation –Prognosis

A
  • Patients will require an MRI after swelling has reduced – will likely need surgical repair for ligamentous injuries
  • Patients need to know that complications are frequent and rarely does the knee return to its pre-injury state
59
Q

Knee bursitis- describe this condition

A

Bursa becomes irritated and produces too much fluid, which causes it to swell and puts pressure on the adjacent parts of the knee

60
Q

MC location for knee bursitis?

A
  • **Pre-patellar most common (KNOW!) – direct pressure on the knee
  • -“Housemaids knee”
61
Q

Knee bursitis Sxs:

A
  • Swelling and tenderness over the bursa

- May become infected – erythema, warmth

62
Q

Knee bursitis dx:

A

dx is clinical

63
Q

Knee bursitis Tx

A
  • NSAIDs
  • RICE
  • Eliminate pressure over the patella
  • Refractory – prepatellar bursa injections
64
Q

Knee osteoarthritis is ___x more common than hip osteoarthritis

A

3x

65
Q

knee OA demographic:

A
  • Affects 1/3 of those over age 65 years

- *Chronic progressive knee pain – medial compartment more commonly affected

66
Q

Knee OA Sxs:

A
  • Morning stiffness lasting < 30 minutes (KNOW!!)
  • Crepitus
  • Mild effusion
  • Pain relieved with rest

-*Severe - Genu Valgum (knock knee) or Genu Varum (bow leg)

67
Q

Knee OA dx:

A

Xrays – joint space narrowing, osteophytes

68
Q

Knee OA tx:

A
  • Conservative: Weight loss (for those with BMI >25), graded exercise (quad strengthening)
  • APAP and NSAIDs
  • Intra-articular Corticosteroid - Offers short-term relief, but does not improve quality of life, and may result in greater cartilage loss

-Synvisc (Hyaluronic acid) - Intra-articular viscosupplementation
(Mixed data)

  • Platelet-Rich Plasma Injections (Mixed data)
  • Total or partial knee replacement
69
Q

Patella Subluxation & dislocation: how common? Which direction is MC?

A
  • Very common injury

- Can go medially or lateral (laterally more common)

70
Q

MOI Patella Subluxation & dislocation

A

direct blow to the side of the knee

71
Q

Patella Subluxation & dislocation Sxs:

A
  • Pain, swelling, deformity

- Limited ROM, often locked in extension

72
Q

Patella Subluxation & dislocation dx:

A

Xray

73
Q

Patella Subluxation & dislocation tx:

A
  • Reduction – apply pressure while extending the knee
  • Immobilization short-term
  • PT – quad strengthening
  • Non-op after first, op if recurrent
74
Q

Patella Fracture MOI

A

-Direct patellar impact

ie Dashboards, fall onto flexed knee

75
Q

Patella Fracture Sxs:

A

Usually significant swelling and focal pain

76
Q

Patella Fx Dx:

A

-Xray – AP, lateral, and sunrise views (KNOW!)!

  • Multiple fracture types
  • Important to examine and document an intact extensor mechanism (patellar tendon intact)
  • SLR(straight leg raise)
77
Q

Patella fx tx:

A
  • Ortho referral, RICE, pain control
  • Non-operative: extensor mechanism intact, nondisplaced fx, vertical fracture
  • -**Extension bracing WITH weight bearing
  • Operative: extensor mechanism failure, open fx, displaced fx, comminuted fx
  • ORIF (Open reduction and internal fixation) surgery
78
Q

Bipartite patella: describe this condition and how common

A
  • In about 1 in 50 people the patella is composed of two bones
  • This is a bilateral abnormality in 50% of people
  • Correlate xray findings with PE, consider obtaining bilateral imaging
  • Weight-bearing (squatting) view demonstrates increased separation of fragments compared with non-weight views (prone)
79
Q

Patellar tendon rupture: how common? and MOI?

A

Not super common

MOI: sudden quadriceps contraction with knee in a flexed position (e.g., jumping sports, missing step on stairs)

80
Q

Patellar tendon rupture Sxs:

A

pain, swelling, elevation of patella

81
Q

Patellar tendon rupture dx:

A

Xray shows patella displacement–> MRI

82
Q

Patellar tendon rupture tx:

A
  • Ortho referral

- Complete tears are repaired operatively

83
Q

Chondromalacia /Patellofemoral syndrome aka ______

A

“runners knee”

84
Q

Chondromalacia /Patellofemoral syndrome: describe this condition

A

=Damage to the undersurface cartilage of the patella secondary to poor patellar tracking
-Women > Men, adolescents/young adults

85
Q

Chondromalacia /Patellofemoral syndrome: sxs

A
  • Chronic, progressive anterior knee pain
  • Progressive pain that is increased with going up stairs and/or squatting
  • No effusion
  • Grind test and apprehension sign
86
Q

Pts with Chondromalacia /Patellofemoral syndrome are at increased risk of ______ ______ ______

A

lateral patella subluxation

87
Q

Chondromalacia /Patellofemoral syndrome dx:

A
  • Xrays – AP, lateral, and sunrise (bilateral)
  • -Patella alta/baja, or lateral patella tilt
  • MRI – assess cartilage damage
88
Q

Chondromalacia /Patellofemoral syndrome tx:

A
  • Non-operative is mainstay
  • NSAIDs, PT (quad strengthening)
  • Operative if persistent/progressive > 1 yr and PT failed
  • -Arthroscopic debridement
  • -Patellar realignment surgery

Clin Med semester 2 (24 decks)

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