Ortho: Block 3 Flashcards
Hip impingement is AKA ?
What causes this injury
Femoral acetebular impingement
Bone malformation at acetabulum rim or femoral head/neck
What are the two different types of hip impingements
How do PTs w/ hip impingement present?
Cam- deformity on femoral neck
Pincer: deformity on acetabulum rim
C-sign
Hip abductor weakness
Dec flexion/internal rotation
+ FADDIR test
What is the adverse outcome of non-Tx hip impingement?
What will be seen on x-ray of a hip impingement?
OA
Dec femoral head/neck distances
Cam= bump impinging on labrum w/ flexion, causes lateral tears/cartilage wear
Pincer: focal over coverage/protrusio
Cross over sign: anterior wall more lateral than posterior wall
What images are taken for surgical consideration on PTs w/ hip impingement
What are the non-op/op Tx plans for these PTs?
3D recon MRI
Non: RICE, NSAID, PT w/ muscle balance goal
Op: arthroscopy, Osteotomy
What would be seen on x-ray of OA in the hip?
How is it Tx w/ non-op/op
What is the adverse outcome of these Tx options
Dec joint space
Osteophytes
Subchondral Cyst/Sclerosis
Non: RICE, NSAID, injections
Op: Total HA, Osteotomy
Osteonecrosis
What risk factors can lead to osteonecrosis of the hip?
How will these PT present?
Steroid use Lupus Alcohol abuse Prior trauma Sickle Cell RA
Non specific pain, dec ROM and + straight leg raise
What is the unique radiographic finding for osteonecrosis of the hip?
How is it Tx?
What is an adverse outcome of this Tx
White Crescent sign
No non-surg Tx
Hip replacement
Femur Fx
Hip strains usually involve ? and are made worse w/ ?
When is imaging ordered?
Single muscle- hamstring
Resisted ROM
MRI of extreme athlete
How can trochanteric bursitis be Tx non-op?
How can it be Tx w/ surgery?
What is the adverse outcome of this Tx?
Injections
Rehab- stretch ITB, piriformis, and tensor fascia latate
Abductor strengthening
Bursectomy
Infection
What mechanism of injury causes an ACL tear?
What is unique about this knee injury?
Rotation +/- hyperflexion
Intrarticular location results in significant pain (hemarthrosis), PT won’t continue to play
What tests are done during PE for an ACL tear?
What type of Fx can come w/ an ACL tear?
Lachman test- more sens/spec test
Anterior drawer test- least sen/spec test, can be negative in 50% of tears
Lateral capsule sign
Segond Fx- avulsion of lateral tibia
How are ACL tears Tx non-surgically?
When are ACL tears red flagged for immediate referral?
Aspirate hemarthrosis
Early ROM
Elderly PT- rehab w/ goal to dec pain/inflammation w/ RICE and inc stability
Gross instability= limb vascularity threatening
Continued laxity
What are the 4 types of arthritis that can occur in the knee?
How will PTs w/ 1/2 present complaining of?
How would they present if it was a crystalline dz?
Primary OA- MC
2* OA- Hx of trauma
RA- symmetric
Crystalline- unilateral, single joint
Buckling/giving way- dz of extensor mechanisms
Pseduo gout w/ rhomboid crystals causing episodic, debilitating episodes
What two knee compartments are effected by arthritis of the knee?
What are the 3 compartments of the knee?
Genu Varum- MC
Genu Valgum
Lat: ACL to PCL, laterally
Medial: ACL to PCL, medialy
Patella: back of patella, front of trochlear femur surface
Which knee compartment supports the majority of the weight bearing?
What are the x-ray finding words for OA and RA?
Medial
Cysts Narrowing Sclerosis
Osteopenia Symmetric Erosion
How are knee arthritis’ Tx non-surg?
How are they Tx w/ surgery and what are the risks?
Injection, brace
NOT arthroscopy
Arthroplasty
Adv: infection, cartilage destruction, transient synovitis
What are the two major bursitis of the knee that are affected?
What lab tests are done to differentiate knee aspiration from bursal fluid or synovial fluid?
Prepatellar- a/septic from Staph or Strep
Pes anserine- OA, medial osteophytes on tibial plateau
Gram stain
Culture
Cell count
Microscopy for crystals
How are bursitis of the knee Tx non-surgically?
When are these PTs referred to Ortho
PO ABX if mild
IV ABX if severe
Septic bursitis
Bursitis secondary to OA
What is the difference of presentation between neuro/vascular claudication?
Neuro: not immediately resolving
Improves w/ stationary bike, prox to distal
Worse w/ walking down hill
Vascular: immediately resolves
Worse on stationary bike
Distal to proximal
On MRI, what are the black dots within the white spinal column space?
How is knee claudication Tx non-operatively?
What is the definitive Tx?
Nerves
Spine Tx
Feet Tx- similar to diabetic, avoid support hose
Spinal fusion
When are knee claudication PTs referred?
What type of force causes a valgus or varus force?
How do these PTs present differently?
Neuro- Ortho spine/neurosurgery
Vascular- to vascular surgery
MCL- valgus
LCL- varus
Return to activity/sport game
How are knee collateral ligament tears graded?
What could be seen on x-ray of an MCL tear?
What could be seen on x-ray of an LCL tear?
Varus/Valgus tests
1: <5mm
2: 5-10mm
3: >20mm
Medial femur avulsion Fx
Lateral fibia head avulsion Fx
Which collateral knee tears can be managed w/out surgery?
Which ones need surgery?
LCL 1 and 2
MCL 3
LCL-3 w/in 7 days
MCL avulsion Fx off of tibia
What types of injuries can cause compartment syndrome of the knee?
What compartment if more likely to collect fluids and swell?
Traumatic tibia Fz or Crush injury
Anterior chamber
How much internal pressure causing exertional force is needed to cause compartment syndrome in the knee?
What is the major presenting issue for this emergency?
> 40mmHg
Pain out of proportion to exam
Main test= passive stretch of muscles in compartment
What is the limit indicating acute compartment pressure
What are the adverse outcomes if the syndrome is not Tx?
Within 30mmHg of diastolic BP
>30mm post-exercise
>20mm 5min post-exercise
Amputation
Kidney failure from rhabdo
What muscles are passively stretched to isolate which knee compartment is involved w/ compression?
Anterior= paresthesia in 1st dorsal web space
Weak dorsiflexion
Passive great toe flexion
Lateral= ankle inversion stretching peroneus longus/brevis
Deep posterior= great toe extension
Superficial posterior= dorsiflexion ankle
What is the name of the tool used to measure compartment pressures?
How can chronic compartment syndrome be Tx w/out surgery?
Striker tool
Retrain how they run
How are compartment syndromes Tx w/ surgery?
What is the adverse outcome of this Tx?
Fasciotomy- surgical emergency
Scars
When are leg contusions red flagged for referral?
What two structures does the ITB connect to?
Coagulopathy
Compartment syndrome
Ileum
Tibia
Crosses both hip and knee joint, on outside of femoral condyle
What 2 PT populations develop ITB Syndrome?
What is the name of the tubercle that the ITB inserts on?
Distance runners
Cyclists
Gerdy’s tubercle
Where are gastrocnemius tears more likely to occur?
What are adverse outcomes of this injury?
Medial head in +30y/o
Shortened tendon
DVT
Where do knee meniscal tears occur?
What is an adverse outcome of this injury?
Anterior horn of medial meniscus
OA
What exams are done during PE for meniscal tears?
What type of tear is severe?
McMurray- audible/palpable click
Apley- pain test
Thessaly- pain test, specific
Bucket handle- posterior fragment flips anterior, causes locked leg and beyond rehab ability
How are meniscus tears managed non-operatively?
What types are Tx w/ surgery?
Rehab w/ early ROM goals
Peripheral- repair
Large- debridement
When are meniscus tears referred to Ortho?
Where does osteonecrosis of the femoral condyle occur?
What can cause this?
Mechanical Sxs
Peripheral tears
Weight bearing medial condyle
Systemic steroids
Systemic dzs- Gaucher
Renal transplant/Sickle cell
MC: female +60y/o
Since osteonecrosis of the femoral condyle can’t be fixed w/out surgery, what operative Txs can be done?
When are these PTs referred?
Arthroscopy
Osteomies
Arthroplasty
ALL PTs are referred
Patellar/Quad tendonitis is AKA ?
What do PTs complain of in clinic?
Jumper’s knee
Infer/Superior pole of patella
Pain w/ quad exercise inc w/ resisted extension
What is different about patellar/quad tendon ruptures?
What would be seen of an early case of this tendonitis?
No precursor of tendonitis is req’d
Spurs
If at tibial tuberosity- Hx of O-S
What are the 3 phases of non-surgical management of Patellar/Quad tendonitis?
What is the adverse outcome of this management?
Rest
Pain free ROM, flexibility and strengthening
Resume activities- heat before, ice after
Persistent functional impairment
How does the PT population differ between quad tendon and patellar tendon tears?
What is the clinical triad at presentation?
Quad: white male, 40-60y/o
Patella: black male, 40-60y/o
Palapable defect
Inability to extend
Change in patella height on x-ray
What will be seen on PE of PT w/ patella/quad tendon rupture?
What will be seen on x-ray and how is it quantified?
Palpable defect
Effusion
No extension
Patella alta= patellar tendon rupture, patella is higher
Patella baja= quad tendon rupture, patella is lower
Quantify w/ MRI
What are the adverse outcomes of knee/quad tendon repair surgery?
All of these tears need to be surgically repaired w/in ? time frame?
Thromboembolism
Retearing of tendon
1wk
Patellofemoral maltracking usually occurs in ? direction but can be due to laxity of ?
How are these dislocations reduced?
Laterally
Medial patellofemoral ligament
Spontaneously w/ knee bending
What is seen on exam of PTs w/ patellofemoral maltracking?
What type of x-ray view is used to assess?
Retropatellar knee pain
J-sign: abnormal lateral tracking of knee
Apprehension test
Sunrise- Merchant or Laurin view
How are patellofemoral maltracking PTs managed non-operatively?
How are they repaired surgically?
What adverse event can occur even w/ treatment?
Acute= Brace, NSAID Chronic= quad exercise, brace
MPFL repair
Osteotomy
Recurrent Sxs
Patellofemoral pain is characterized by the ? sign and presents w/ pain during ?
How does PT pinpoint their pain?
Theater sign- pain w/ prolonged sitting
Quad activities
Circle around patella
How is patellofemoral pain Tx w/out surgery?
Which plica is more likely to be affected?
Hamstring/Quad strength
Full AROM
Medial
What is an adverse outcome of plica syndrome
How can this be Tx w/out surgery?
What surgical Tx option is available
Erosion of femoral condyle
Injection into plica
Arthroscopy
Popliteal cysts are AKA ?
PTs will pinpoint their pain to be between what two structures?
Baker cysts
Synovial cyst- similar to ganglion cyst
Medial gastrocnemius
Semimembranous
What imaging modality is preferred for popliteal cysts?
How can these be Tx w/ non-surgical and surgical methods?
US, also r/o DVT
Non: US guided aspiration
Surg: Tx
What is the function of the PCL?
What type of injury force causes a tear?
Keeps tibia from tracking back/behind femur
Forces applied to tibia and pushing it posterior (dashboard accidents)
Knee dislocation, posterior direction is MC
What will be seen on exterior exam of PT w/ posterior shin splints?
Where will PTs point their pain to be at which is also the hallmark of this condition?
Tibialis posterior muscle causing over pronation (pes planus) of ankle
Distal 1/3 of posterior medial crest, origin site of tibialis posterior
How are kids w/ anterior knee pain Tx w/out surgery
Which ones can be Tx w/ surgery but only when ?
Rest, Strength, Lengthen/Stretch
Plica/Bipartite- after 3-6mon of PT
What risk factors can lead to developmental hip dysplasia?
This deformity is associated w/ ? 3 issues
FamHx Breech birth Oligohydramnios First born Swaddling Female
Metatarsus adductus
Congenital muscular torticolis
Hyperextension of knee
What is the first inidcator a child has developmental dysplasia of the hip?
W/out Tx, this issue can develop into ?
Walking creates pain
Degenerative joint dz
Secondary OA
Pain w/ activity
Every child under 1yr old gets what two tests?
What two additional tests can be done for further info?
Barlow- attempt to displace femur head posteriorly while pressing/adducting femur
Ortolani- relocation maneuver w/ hip abduction,
Galeazzi- leg length
Dec abduction= hip out of socket
What is the preferred imaging modality for assessing developmental dysplasia of the hip in Peds?
How is this Tx w/out surgery?
US
Modified swaddling
Concentric reduction= normal acetabulum
Pavlik harness until 6mon
How is developmental hip dysplasia in Peds Tx w/ surgery?
What are adverse events that can occur in this d/o?
Closed reduction- cast
Surgical reduction
Femoral nerve palsy
Osteonecrosis
When do Peds hip dysplasias need to be referred to Ortho?
When arethe rules for ordering x-rays for a child w/ a limp?
What labs are ordered?
+ Ortolani- hip can be popped in
+ Barlow w/ US en route
More than 2 views
More than x-rays if >6wk
MRI + contrast
CBC w/ diff
ESR/CRP
What degree of Genu Valgum in Peds is normal for their age
Most of these cases are ?
Birth: 10-15* varus
12-18mon: neutral
2-4yr: 10-15* valgus
11y/o: 5-7* valgus
ASx
What two angles are measured when assessing for Genu Valgum
What x-ray images are used for measurement?
Tibiofemoral angle
Intermalleolar distance
Full length hip to ankle film
Non-operative Tx is used for Genu Valgum if the PT is what age?
What surgical procedures are used for surgical Tx?
3-4y/o or,
ASx
Hemi-epiphysiodesis
Osteotomy
When are Peds w/ Genu Valgum referred to Ortho?
What two angles are used for measuring Genu Varum PTs?
Asymmetric
Short stature
After 12mon
Tibofemoral angle
Intercondylar distance
What 3 criteria indicate the need for x-rays in a PT w/ Genu Varum
What surgical procedure is done to correct this?
At 2y/o
<25th height percentile
Asymmetric
Osteotomy at 4y/o
When are Genu Varum cases referred to Ortho/
What are 3 causes of intoeing?
What are 2 causes of outtoeing?
> 5y/o
Worsening condition
Foot deformity
Inward tibial rotation
Inward femur rotation
Outward rotation of femur or Tibia
How to Pts w/ in/out toeing present?
What needs to be assessed on PE?
No pain
Tripping/inability to keep up
Assessment of femur, tibia, foot
How are in/out toeing Tx non-surgically or surgical?
When are they referred?
Non: reassurance
Op: osteotomy
Assymetric
No improvement
Complaints of other issues
Define Legg-Calve Perthes Dz
What PT population does this occur in?
Osteonecrosis of femoral head
Boys 4-8y/o
What are the Sxs of Legg-Calve Perthese Dz
What are the adverse outcomes of this Dz?
Limp + groin pain
Secondary OA
Discrepancy in leg length
What is seen on PE of Legg Calve Perthes Dz
What will be seen on x-ray
Dec abduction and internal rotation
Pelvic shift when standing on one leg
Crescent sign= subchondral Fx
What does it mean if a Legg Calve Perthes Dz x-ray shows a smaller epiphysis?
What does it mean if there are angular changes?
Fragmentation stage
Reossification stage
How is Legg Calve Perthes Dz Tx non-operative
What is the only surgical Tx when the femoral head is misshapen?
Bed rest
NSAID
ROM therapy
Joint replacement- means multiple surgeries through out life
When do LCP Dx PT need to be referred?
Define Osgood Schlatter Dz
Define Sinding Larsen Johansen
<6y/o w/ great involvement or
<40* abduction
>6y/o
Apophysitis at tibia tubercle
Apophysitis at patella
What causes Sxs in Peds w/ OS or SLJ Dz
What will be seen on x-rays
Quad activities
Theater sign
TTP at tibial tubercle OR distal patella pole
Heterotropic ossification
Unfused apophysis
How is OS/SLJ Dz Tx non-surgically
When are they referred to ortho?
RICE Stretch
Inability to perform straight leg raise
Slipped capital femoral epiphysis is AKA ?
What PT population does it occur in?
Saltar Harris Type 1 femur Fx
Over weight, black males 13-15y/o or girls 11-13y/o
How do PTs w/ slipped capital femoral epiphysis present?
What body mechanic is changed due to these Sxs?
Pain and limp worse w/ activity
External rotation (unstable Fx, non-weight bearing) Dec internal rotation
What is the name of the imaginary line used to asses Peds x-rays for slipped capital femoral epiphysis
How is this Tx w/ surgery?
When are they referred to Ortho?
Klein line- superior femoral neck into joint
Stabilization of physis w/
screw fixation
All are referred
What type of issue is transient synovitis of the hip in Peds?
What do these PTs present complaining of?
Sterile effusion
Groin pain
What motions have dec ROM in transient synovitis?
What Labs/Rads are ordered?
Dec ROM w/ abduction or internal rotation
US*, x-ray
CBC w/ Diff- norm
ESR/CRP- elevated
Hip dislocations usually occur in which direction?
What adverse outcome can occur after these injuries?
Posterior
Osteonecrosis
Define Posterior/Anterior hip dislocations w/ words
Post: short, flexed, adducted/internal rotated w/ sciatic nerve palsy
Ant: flexed, aBducted and externally rotated; femoral nerve palsy
How do ant/posterior hip dislocations look differently on x-rays?
What other injury is common with these dislocations and what imaging is used to assess them?
Ant: femoral head larger
Post: femoral head smaller
Acetabular Fx- CT
What is the sequence of events for hip dislocation on-surgical management?
If it is a non-complicated dislocation/Fx, how long are they non-surgically managed?
NV exam Rad Sedate Reduction NV exam Rad + CT
Weight bearing as tolerated x 4wks
When are hip dislocations considered candidates for surgery?
What must be included when x-raying femurs after Fx?
Unable to reduce
Acetabulum Fx on posterior edge
Femoral neck
What is the difference between a stable/unstable pelvis Fx?
What PE findings indicate immediate refferals?
Stable- one Fx/disruption to the ring
Unstable: poly trauma, more than one Fx/disruption to the ring
Blood in perineal- do not cath, call Urology
What images are used to assess a pelvic Fx?
If there is a suspected Fx of the acetabulum, what needs to be ordered to assess the pelvis?
Inlet/Outlet views
CT
How are low energy pelvis Fxs treated w/out surgery?
What type of injuries are Tx w/ surgery
WBAT x 6wks
High energy
Hip joint capsule attaches on what structures of the femur?
Proximal femur Fx includes Fxs where?
Ridge between trochanters
Inside joint capsule and disrupts blood supply leading to multiple complications
What are the risk factors for a proximal femur Fx?
White female Dementia >50y/o Smoke/alcohol Osteoporosis Urban setting Psychotropic use Sedentary
What is the mechanisms of injury in a proximal femur Fx?
What will be seen on PE?
Fall from standing height
Affected limb shorter Externally rotated Abducted leg \+ log roll test No straight leg raise
What important x-ray image can NOT be taken for proximal femur Fxs?
When are these types of Fx Tx non-surgically?
Frog leg lateral- will displace Fx more
Non ambulatory,
transfer only PTs
When are proximal femur Fx referred?
What are the two types of stress Fxs of the femoral neck?
Emergency when <60y/o
Tension- superior side in older PTs
Compression- young/active PT on inferior side of femur neck
What type of stress Fx in the femur neck are pressed apart by weight bearing?
Which type is more likely to complete and displace?
Tension
Tension
What are the adverse outcomes of femoral neck stress Fxs?
What will be seen on PE?
Only issues if it’s a complete Fx
Dec ROM w/ IR
Pain w/ straight leg raise
What time frame are which images ordered for stress Fx of femoral neck?
What caution is needed when assessing these images?
2-4wks= plain x-ray 24-48hrs= bone scan 72hrs= MRI* preferred
Radiographic healing lags behind true healing by 10-14 days
How are compression Fx stress Fxs of the femoral neck Tx non-surgically?
How are tension Fxs Tx w/ surgery?
No training
NWB x 8wks w/ serial x-rays to monitor progression
All Tx surgically w/ internal fixation
When are stress Fx of femur neck referred to Ortho?
Distal femur Fx are usually ?
Tesnsion
Compression >8 wks of compliance
Supracondylar
Intra-condylar
Periprosthetic
What type of force usually causes a Fx at the tibial plateau?
What tests need to be done for Fxs about the knee?
Valgus force- lateral femur compresses weaker lateral tibial plateau
NV exam w/ ABI
<0.9 is bad
What image is ordered for any intra-articular or displaced Fx about the knee?
When can these Fxs be Tx non-surgically?
When are they emergent for surgery Tx?
CT
W/ angiography if ABI <0.9
MRI if non-displaced
Non-displaced: toe touch x 6wks
Vascular/Compartment syndrome
What is the difference between anterior/posterior stress Fxs?
How are these types of Fxs treated non-surgically?
Ant: tension side
Post/Medial: compression side
Pain w/ walking= cast and NWB x 6wks
Less pain= swim/bike PT, no run x 6wks
What type of surgery can be done for anterior stress Fxs as prophylaxis?
When are they referred to Ortho?
Prophylactic nail
All anterior
No improvement x 2wks
How are peds femur Fxs Tx non-operative?
When are they Tx w/ surgery?
6mon-5yrs: casting if non-displaced Fx and intertrochanteric, shaft Fx
> 6y/o, displaced, trochanteric, distal femur
When are peds w/ diphyseal femur Fxs referred w/ red flags?
What image is ordered for Peds w/ tibia Fxs?
When are these Fxs Tx w/ surgery?
<36mon w/ abuse suspicion
Tibia is common site for abuse related Fxs
CT articular
Displaced <5*
Intra-articular/physeal
Open
When are Peds tibia Fxs referred to ortho?
Angulation >10*
Physeal
Articular
Open
Hip arthritis prevalence is highest in ? systemic Dz populations?
End stage arthritis is commonly seen in PTs w/ ? systemic dz
RA
Ankylosing spondylitis
Lupus
What types of gaits can be observed in PTs w/ inflammatory hip arthritis?
What is the most sensitive PE finding for adults w/ hip joint dz?
Antalgic- short step phase on affected side
Trendelenbur gait- develops w/ loss of articular cartilage
Restricted hip ROM w/ loss of internal rotation
How is synovial inflammation detected in PTs w/ inflammatory arthritis of the hip?
What is seen on x-rays of early/late inflammatory arthritis?
PT prone, knee flexed, gentle “rolling pin”
Early: osteopenia, effusions
Late: symmetric loss of space, erosion
Why are flexion contractures so problematic in hip OA PTs?
What two abnormalities can this problem be seen as?
Affected gait, compesation w/ inc lumbar extension
Antalgic- short stride on painful leg
Abductor lurch- swaying trunk over affected hip
Why would a PT be a candidate for hip fusion due to OA?
Osteonecrosis of the femur usually presents at ? age and is often ?
Young PT who has to return to work as manual laborer or lives vigorously active life
3-5th decade
Bilateral
When does the ITB sublux?
PTs w/ ITB syndrome will point to their pain being ?
Walking
Hip rotation
Trochanter region
PTs w/ snapping iliopsoas usually feel pain ? when they do ? motion
How are these snapping movement replicated during a PE?
Groin
Hip extends from flexed position (rising from chair)
ITB: stand and rotate hip w/ it held in adduction; tightness assessed w/ Ober test
Ilio: hip extension from flexed position
Weakness of ? muscles is common in PTs w/ painful ITB syndrome
Hip strains can encompass what 5 muscles?
Hip abductors
Abdominals
Hip flexor- iliopsoas, sartorius, rectus femoris
Hip adductors
What is the usual mechanism of injury for hip strains?
How is a strained abductor isolated on PE?
Vigorous muscle contraction while muscle is stretched- kicked ball and leg is blocked
Groin pain w/ passive abduction
What are the 5 phases of hip strain rehab
1: 48-72hrs; RICE, crutches
2: 72hrs-7days; PROM, heat, electric stimulation, US
3: isometric exercises, sport related training to inc strength/flexibility
Origin and insertion of hamstring?
Transient osteoporosis of the hip is AKA ?
Ischial tuberosity
Tibia/fibula
Bone marrow edema syndrome
How long does it take for transient osteoporosis to self resolve?
What type of gait do they adopt?
6-12mon
Atalgic
What non-leg sourced issues can lead to trochanteric bursitis?
Where can this pain radiate to?
Lumbar spine dz
Leg, butt, or knee, NOT to foot
What is the essential PE finding for trochanter bursitis?
How is pain replicated?
What is the issue if PT pin points pain to being above greater trochanter?
Point tenderness over trochanter
Hip abduction
Adduction w/ internal rotation
Glutues medius tendon
What PT movements are essential when Tx trochanter bursitis w/ physical rehab?
The main job of the ACL is prevention of knee ?
Hip abduction strengthening
Anterior translation
What knee injury is most commonly from non-contact injuries?
This injury can be accompanied by other knee injuries but rarely w/ injuries to ?
ACL tears
LCL or PCL
What PT population is more likely to have tibial eminence Fxs w/ an ACL tear?
How are older PTs Tx non-surgically?
PTs w/ open physes
PT w/ goal of controlling instability
Most ACL repair surgeries are not actual repairs, but instead are ?
OA of medial or lateral compartments lead to ?
Grafts using patellar tendon, hamstring/quad tendon or cadaver tissue
Medial: Genu varum
Lateal: Genu valgum
Isolated patellofemoral OA can exist, especially in ? PT population?
This is more frequently found in PTs w/ ?
Patellar subluxation
Patella baja
Tibiofemoral OA
RA of the knee usually involves ? compartment
Gout causes knee destruction via ? while pseudogout causes destruction via?
Genu valgum, lateral
Uric acid
Calcium pyrophosphate
OA usually affects what 3 PT populations?
It is not uncommon for knee OA PTs to present w/ ? bilateral knee malformity?
> 55y/o
Obese
FamHx of Dz
Windswept deformity- one knee valgus, one knee varus
What type of x-rays are taken to measure the degree of joint space loss?
What adjunct can PT use to decrease swelling and improve movement by keeping the oint warm?
Weight bearing AP w/ full extension
Knee sleeve/elastic bandage
What is as effective as NSAIDs for OA Tx?
What type of management/Tx is NOT done in knee OA PTs?
PT w/ strength, gait and balance focused plans
Arthoscopic exams
What do osteotomy do for knee OA issues?
Bursitis of the prepatellar bursa is AKA ?
Unloading tibial/femoral osteotomy can improve alignment, dec pain x 5-10yrs
House maid knee
The pes anserinus burs lies between what structure landmarks?
This form of bursitis can occur from overuse but is usually due to ?
Beneat insertion of sartorius, gracilis and semitendinous muscle on medial flare of tibia
Early OA in medical compartment
How is pes anserinus bursitis differentiated from medial meniscus pathology?
If this bursa swell, what neurological finding can be seen?
Pes anserine is distal to joint line
Saphenous nerve and infrapatellar branch compression, numbness distal to patella
What therapeutic modalities can help w/ non-infected knee bursitis?
What is the underlying issue of neurogenic claudication?
US and Phonophoresis
Spinal stenosis causing Ischemia to clauda equina
What is the underlying issue of vascular claudication?
Neurogenic claudication
Peripheral vascular dz and compromised vascular flow
Buttocks and spreads while walking, inc w/ down hill waking
Improved w/ bike riding
Prox to distal
Vascular claudication
Neurogenic claudication may have a normal exam at rest, what can be done to cause Sxs?
Pain stops w/ stopping activity
Worse w/ bike riding
Pain starts distally, works proximal
Weakness/reflex changes after provocation exercises
What findings may be seen on PE in PTs w/ arterial insufficiency induced claudication?
What two knee tendons are intra/extra articular?
Diminished pulses below waist
Extremities are cool
Ulcerations on toes
Inc erythema/pallor w/ elevation
Intra: ACL PCL
Extra: LCL, MCL
What is the mechanism of injury in a MCL tear
What is the mechanism of the less common LCL tear
Valgus, abduction
Varus, adduction
What additional findings when examining a MCL injury should increase suspicion of a lateral meniscus tear?
How is the LCL and MCL best examined?
Mechanical Sxs
Lateral joint line tenderness
MCL- knee in slight flexion
LCL- leg in figure 4 position
What knee PE findings are considered knee dislocations w/ spontaneous reduction
What tests are done after this discovery?
Valgus/Varus laxity in full extension= ACL/PCL disruption and posterior capsule involvement
Neuro
ABI
How can the knee be wrapped to expedite recovery after a severe quad contusion?
Normally the ITB sits ? and bending the knee more than ?* moves the ITB in which direction?
Hyperflexion w/ elastic bandage
Anterior to LatFemCon
30*
Moves posterior to lateral femoral condyle
Athletes w/ ? pre-existing risk factors can develop ITB syndrome?
What functional test can be done after an Ober test to confirm ITB syndrome?
Genu Varum
Internal tibia rotation
Excessive foot pronation
One legged hop causing lateral knee pain
What 4 areas are focused on when PTs w/ ITB go to rehab?
What 3 activities usually precede a gastrocnemius tear in ? population
Hamstring
Tensor fasciae latate
Hip external rotator flexibility
Hip abductor weakness
Tennis
Hill running
Jumping
+30y/o
What test can be positive in a PT w/ a gastrocnemius tear that can also signify Achilles tendon tear?
What movement modifiers are used when Tx this injury non-surgically?
- Thompson test- passive plantar flexion of the foot when calf is squeezed
CAM boot
0.5” hell lift
Calf sleeve/compression hose
Crutches
What type of PT presentation is a warning of a non-functioning meniscal tear?
What imaging needs to be done on all suspected meniscal tears prior to MRI?
Obese PT w/ pop followed by pain at posterior knee
Weight bearing x-rays
When are arthroscopic surgical debridement surgeries indicated for meniscal tears?
What x-ray findings indicate if femoral condyle osteonecrosis is early or late?
Young PT w/ substantial tear
Locked knee
Non-surgical Tx failure
Early: sclerosis, flattened condyle
Late: narrowing, osteophytes
What is the hallmark Sx of Jumper’s Knee
When do PTs say the pain is most noticeable
Anterior knee pain
Right after exercise or,
While sitting down after exercise
What adverse MSK issue can develop in long lasting Jumper knee?
What would be seen on x-ray
Atrophy of Vastus Medialis Obliques
Calcification at tendon insertions
Heterotopic ossification at upper/lower poles
When assessing a knee for a quad/patella rupture, how is the knee placed for x-rays
Medial patellar instability is rare but can occur in ? setting
30* flexion to assess angle between inferior pole and Blumensaat line
Surgical lateral retinacular release
If PT can’t recall a knee injury/dislocation, the Sxs usually mimic what other knee injury?
What is the hallmark Sx of PT w/ malalignment
ACL tear
Retropatellar pain
Why is gait assessed in PTs complaining of patellofemoral pain?
What foot issue can increase/be present in this knee d/o?
What muscle circumference needs to be measured and compared to contralateral side?
Patellar squinting- patella point towards each other during amublation, sing of femoral anteversion/weakness of glute medius)
Foot pronation- flat foot
Vastus medialis obliques
When assessing patellofemoral pain, examiner can bend knee to 30* and move the patella how far in each direction?
What does a patellar tilt indicate?
One quadrant medial
Two quadrants laterally
Lateral retinacular tightness
What is the hallmark Tx of patellofemoral pain?
What type of mechanical assistance can be used during rehab?
PT rehab
McConnell taping
What is a pilca and how many are there?
Which ones are more prominent and where are they located?
Fold of synovium in the knee, 5
Suprapatellar- under quad tendon to medial/lateral capsule
Infrapatellar- ligamentum mucosa, ant/post and over ACL
Medial- medial capsule to medial anterior fat pad
Why do inflamed plica cause issues?
What complaint/Sx is rare w/ these inflammations?
Patholocial plicas may pop when bent to __*
Bowstring over femoral condyle
Locking, giving away, effusions
60*
How are pathological plicas Tx?
What is the most common benign synovial cyst of the knee
Arthroscopic resection
Popliteal/Baker’s
Popliteal cysts are associated w/ ? 2 underlying conditions?
What Sx may PTs complain of?
What PT population usually experience a burst cyst?
RA
Degenerative meniscus tears
Numb plantar surface
+40y/o w/ RA or degenerative joint dz
What are the red flags of a popliteal cyst?
Where does the PCL originate and insert
CA like Sxs
Pulsatile cysts may be popliteal aneurysms
Medial intercondyle of femur, behind ACL inserts on posterior tibia below joint line
What 4 clinical patterns suggest a torn PCL
What two nerves can be damaged by this injury if left un treated?
Dashboard injury
Fall on flexed knee w/ plantar flexed foot
Pure hyper flexion injury to knee
Hyper extension knee injury after ACL ruptures
Peroneal or Tibial nerves
What is the most common location for osteochondritis dissecans in the knee to occur?
What is required to make a Dx of chondromalacia
Lateral aspect of medial femoral condyle
Arthroscopy
Genu Varum can be caused by ? Dz
What image is used to assess distal tibial Fxs in a child?
What causes anterior knee pain in Peds PTs?
Blount Dz
CT
Repetitive stress
MC= patellar maltracking
Where is pain localized in Peds w/ painful plica or bipartite patella?
What other exam needs to be done in these PTs?
Plica: medial side
Bipart: superolateral pole
Hip- SCFE or Legg-Calve Dz
How are Peds w/ Sx Plica Tx
The Ortolani maneuver becomes negative w/ age at ?
What is the only modifiable risk factor of hip dysplasia?
7-10 days in knee rest in extended position
3mon
Swaddling, avoid in new borns
Internal tibial torsion is the most common diagnosis in ?
Inc femoral anteversion is most common in ?
What is used to quantify in/out toeing of a child?
Toddlers
Peds +4y/o
Foot angle progression
What hip measurement w/ PT prone is indicative of tibial torsion?
What condition can develop as result of out toeing?
What additional test is performed for tibial out torsion?
Great than 10-15*
Pes Planovalgus
Ober test
If Peds PT requires surgery to correct in/out toeing, what ages can they have the surgery?
Tibial torsion usually presents ? while femoral presents /
Tibia: 6-8y/o
Femur: 10-12y/o
Tibial: asymmetric
Femur: symmetric
Male Peds w/ LCPD, 90% present w/ ? while another 1/3 tend to have ? and the smallest percent have ?
What are the 3 phases of LCPD
What is a common x-ray finding in PTs w/ LCPD
Delayed bone age
ADHD
Transient synovitis
Crescent sign- subchondral fx
Fragmentation- epiphysis collapse
Resossification- healing starts
Coxa magna
Bilateral cases in different stages of dz
If Peds presents w/ bilateral LCPD, what additional lab test needs to be done after imaging?
What is seen on radiographs of OS/SLJ dz?
Peds w/ OS need to have parents educated that sports are to be avoided for ?
Hypothyroid
OS: heterotopic ossification on tuberal tuberosity
SLJ: elongation of inferior pole of patella
2-3mon
What is the MC presenting Sx of a SCFE?
What finding is the most sensitive and specific on PE?
How are these Dx’s confirmed
Pain
Loss of IR of hip
AP and Frog-lateral x-rays
Klein line front superior femoral neck doesn’t intersect w/ lateral capital femoral epiphysis
What is the immediate next piece of info after the Dx of a SCFE is given?
What is a common cause of childhood limping between 2-7y/o?
What lab tests is added to imaging for these PTs?
No weight bearing at all
Transient synovitis, b>g x3
Anti-strep O Ag test
What are the 3 most significant adverse outcomes from femur Fxs?
PTs w/ open femur Fxs get what two things?
Fat embolism
ARDS
Multisystem organ failure
Tetanus
Systemic ABX
What meds are given prophylactically for Fxs about the knee?
What is the draw back for taking x-rays to assess stress Fxs
Anticoags
Fx may not be visible for 3wks or more after injury
How are non-displaced neck and intertrochanteric Fxs Tx in Peds
How are femoral shaft Fxs Tx?
Cast immobilization
Spica casting or early splint/bed rest/cast
