ORTHO 3 Flashcards
what is a meniscus?
c-shaped fibrocartilage found in the knee joint
The menisci rest on the tibial plateau
The medial meniscus is less circular than the lateral and is attached to the medial collateral ligament, whilst the lateral meniscus is not attached to the lateral collateral ligament.
what are the functions of the meniscus?
1) shock-absorbers of the knee joint
2) increase articulating surface area.
what are the causes of meniscal tear?
trauma and degenerative disease
trauma - typically young patient who has twisted their knee whilst it is flexed and weight bearing
the most common tear is longitudinal tear (bucket handle)
other tears:
- vertical
- transverse (parrot beak)
- degenerative
clinical features of meniscal tear?
often report as a tearing sensation - intense sudden onset pain
swelling
they may have locked flexion
on examination there is joint line tenderness, joint effusion and limited knee flexion.
Specific tests to identify a meniscal tear include McMurray’s Test* and Apley’s Grind Test
differentials for meniscal tear?
fracture
cruciate ligament tear
collateral ligament tear
osteochondritis dissencans
investigations for meniscal tear?
plain XR
MRI scan
how is meniscal tear managed?
rest, elevation with compression and ice
if small - the tear will heal
larger tears or if they remain symptomatic - arthroscopic surgery is indicated
what usually causes a patella fractue?
direct trauma to the patella
however less commonly can occur as a result of rapid eccentric contraction of the quadriceps muscle.
what are the clinical features of a patella fractue?
anterior knee pain
usually following a hard blow to the patella or strong contraction of the quadriceps
pain worse on movement and the patient will unable to straight leg raise
may not be able to weight bear
swelling an busing
there may be a visible and palpable patellar defect
differentials for patella fracture?
tibial plateau fractures
distal femur fractures
cruciate or collateral ligament injury
what is bipartite patella ?
Bipartite patella is a congenital condition affecting 2-3% of the population (more common in males), whereby there is failure of patella fusion, leaving two separate bone fragments of the patella joined only by fibrocartilaginous tissue.
The condition is typically asymptomatic and usually only picked up incidentally on imaging. Rarely, bipartite patella can present symptomatically, especially after exercise or overuse, with anterior knee pain.
investigations for patella fracture?
The mainstay of investigation for suspected patella fracture is plain film radiographs, obtaining three separate views (antero-posterior, lateral, and skyline*)
More advanced imaging (usually CT) is indicated in comminuted fractures or in cases not overtly apparent on plain films but clinically suggestive.
how is a patella fracture managed?
conservative - if not displaced or minimally displaced - patients will be placed in a brace or cylinder cast and ensuring early weight bearing in extension
surgical management - operative intervention is indicated in cases of significant displacement or compromise to the extensor mechanism
ORIF with tension band wiring is the most widely used method
screw fixation can be used in simple vertical or transverse fractures.
what does tibia fracture increase the risk of?
higher risk of open fractures and compartment syndrome
this is due to the lack of significant soft tissue envelope
what are the clinical features of tibial shaft fracture ?
usually present with a history of trauma
severe pain
inability to weight bear
O/E - clear deformity and significant swelling and bruising
what do you need to ensure you do with tibial fractues?
careful inspection of the skin to assess for possibility of of an open fracture
a full neurovascular exam - to assess for and vascular or peropheral nerve damage
differentials for tibial shaft fracure?
As most cases present following a fall or trauma, differentials include tibial plateau fractures, ankle fractures, fibular fractures, or soft tissue injury.
investigations for tibial shaft fracture?
Patients presenting following a major trauma should be investigated and managed as per the ATLS protocol. Urgent bloods, including a coagulation and Group and Save, should be sent.
full length AP and lateral plain XR of tibia and fibula
if there is possibility of intra-articular extension CT imaging with be need
For any suspected a spiral fracture of the distal tibia, a CT scan is also required, to assess for a fracture of the posterior malleolus.
how should tibial shaft fracture be managed?
realigned ASAP - in A&E under analgesia/sedation
following reduction an above knee backslab should be applied to control rotation.
Limb should be monitored closely for compartment syndrome
Post-manipulation plain radiographs should be performed and the neurovascular status of the limb re-assessed and documented.
most tibial fractures are managed surgically
Intramedullary nailing is most common used
Some may require ORIF (particularly proximal or distal fractures)
what is a tibial plataeu fracture?
it is from impaction of the femoral condyle onto the tibial plateau
It is typically a varus-deforming force, meaning that the lateral tibial plateau is more frequently fractured than the medial side. They are often found alongside other bony and soft tissue injuries, such as meniscal tears or cruciate or collateral ligament injury.
It is important to recognise that this is a significant injury, as there is disruption of the congruence of the articular surface that, if left, will lead to rapid degenerative change within the knee.
clinical features of tibial plataeu fracture?
history of trauma - axial loading or high impact injuries
sudden onset of pain in knee and unable to weight bear
swelling of knee
tenderness over medial or lateral aspects of the proximal tibia with potential ligament instability
**ensure to check neurovascular status of the limb
differentials for tibial plataeu fracture?
For patients presenting with knee pain following trauma, other differentials to consider are knee dislocation, other knee fractures (including patella or distal femur), meniscal injuries, ligamentous injuries, patella dislocation, or patella/quadriceps tendon rupture.
investigations for tibial plateau fracture?
plain XR (AP and lateral) CT scanning is needed in almost all cases
why is it important to recognise if there is fat in the joint?
it is important to recognise that the presence of fat in the joint indicates that there is an intra-articular fracture present (e.g. tibial plateau, patella, distal femur)
what classification is used for tibial plateau fracture?
Schatzker Classification
how is tibial plateau fracture managed?
uncomplicated - hinged knee brace an non or partial weight bearing for 8-12 weeks
physio and analgesia
operative - ORIF
what is iliotibial band syndrome?
The iliotibial band (also termed the iliotibial tract) is a branch of longitudinal fibres that form the shared aponeurosis of tensor fasciae latae and the gluteus maximus. It extends from the iliac tubercle to the anterolateral tubercle of the tibia. Inflammation of this band results in the condition termed iliotibial band syndrome (ITBS).
common cause of lateral knee pain
RF for iliotibial band syndrome?
The condition is common in those who have regular exercise involving repetitive flexion and extension of the knee, commonly runners, weightlifters, or cyclists
Anatomical risk factors include genu varum, excessive internal tibial torsion, foot pronation, and hip abductor weakness.
clinical features of iliotibial band syndrome?
lateral knee pain
exacerbated by exercise
what are the special test for iliotibial syndrome?
Nobles test – the patient lies in a supine position and the examiner places a finger on the lateral femoral condyle, with the knee slowly extends. A positive test is indicated when pain is felt at 30 degrees, when the ITB passes over the lateral femoral condyle.
Renne test – the examiner stands in front of the affected knee and puts pressure on the lateral epicondyle, with the patient then asked to squat. A positive test is indicated by the presence of pain at 30 degrees of flexion.
differentials fo rileotibial syndrome?
Main differentials include degenerative joint disease, fractures, and ligamentous injury (especially following a history of trauma and relevant findings on examination)
how is ileotibial syndrome managed?
modify their activity
simple analgesia
steroid injection
physio
Surgery is only indication if patients remain symptomatic or functionally limited after 6 months, despite all other non-medical treatment.
Surgical management involves release of the iliotibial band from its attachments from the patella, allowing for a greater range of movement. This can be done either percutaneously or via an open approach.
what is the ankle comprised of?
The ankle is comprised of the talus bone articulating within the mortise; the mortise is comprised of the tibial plafond and medial malleolus (the distal end of the tibia) and the lateral malleolus (the distal end of the fibula).
The tibia and fibula are joined at the syndesmosis, a very strong fibrous structure comprised of the anterior inferior tibiofibular ligament (AITFL), posterior inferior tibiofibular ligament (PITFL), and the intra-osseous membrane.
