Soft Tissue Knee Injuries Flashcards by Martha Innes

What are the ligaments of the knee?

Lateral collateral
Medial collateral
Anterior cruciate
Posterior cruciate

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What is extensor mechanism rupture?

Rupture of the quads tendon or patellar tendon, or patellar fracture

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What is extensor mechanism rupture caused by?

Fall onto flexed knee with quads contraction

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What are factors that predispose to extensor mechanism rupture?

Previous tendonitis
Steroids
Chronic renal failure
Ciprofloxacin

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How does extensor mechanism rupture present?

Inability to straight leg raise
Palpable gap proximal or distal to the patella
Marked weakness, disability and lack of function in late presentation

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What is the treatment for extensor mechanism rupture?

Surgical repair

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How much of the menisci have blood supply?

Outer third

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How much of the menisci have nerves?

The peripheral attachment

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What is the function of the menisci?

They distribute load from femoral condyles to articular surfaces

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Are the menisci fixed or mobile?

Medial is fixed

Lateral is more mobile

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Which meniscus is under more sheer stress?

Medial

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Who usually get meniscal tears, and how are they caused in the different groups?

Younger patients - sporting injury or getting up from squatting position
Older patients (>40) - atraumatic spontaneous degenerate tears

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How do meniscal tears present?

Pain and tenderness localised to the joint line

Positive meniscal provocation tests (not always reliable)

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Should you do investigation if you suspect meniscal tear?

Yes - MRI

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Which meniscal tears are more common?

Medial (10 times)

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What are the different patterns of meniscal tear?

Longitudinal tear
Bucket handle tear
Radial tear
Parrot beak tear

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What is a longitudinal meniscal tear?

One that follows the curve of the meniscus

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What can a longitudinal meniscal tear progress to?

Can fragment and flick out of position causing a bucket handle meniscal tear

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What are the clinical signs of a bucket handle meniscal tear?

Acute locked knee

15˚ springy block to extension (can extend it passively but it will spring back to around 15˚)

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What is the treatment for a bucket handle meniscal tear?

Surgery - arthroscopic repair

Ir irreparable needs partial meniscectomy to unlock knee and prevent further damage

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What is the best investigation to show meniscal tears?

MRI

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What is a radial meniscal tear?

A tear from the inside of the knee into the meniscus

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Will a radial meniscal tear heal by itself?

No - area is avascular

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What are the surgical options for radial meniscal tears?

Arthroscopic meniscal repair

Arthroscopic meniscectomy

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When is arthroscopic meniscal repair considered?

Acute traumatic peripheral tears in a younger patient

When is arthroscopic meniscectomy done?

Mechanical symptoms Irreparable tears Failed meniscal repair

What are degenerate meniscal tears?

A tear in the meniscus caused by the meniscus weakening with age and tearing spontaneously Common, many are asymptomatic

What do degenerate meniscal tears lead to, and how?

OA | Loss of shock absorber increases pressure on surfaces, leading to OA

What are the secondary effects of degenerate meniscal tears, and what symptom do they cause?

Bone marrow oedema, synovitis | Pain

What is the treatment for degenerate meniscal tears?

Surgery not as successful Steroid injection may help Analgesia

What is the function of the medial collateral ligament?

MCL resists valgus stress

What is the function of the lateral collateral ligament?

LCL resists varus stress

What is the function of the anterior cruciate ligament?

ACL resists anterior subluxation of the tibia and internal rotation of the tibia in extension

What is the function of the posterior cruciate ligament?

PCL resists posterior subluxation of the tibia and hyperextension of the knee

What is the posterolateral corner?

The PCL and LCL with other smaller ligaments

What is the function of the posterolateral corner?

Resists external rotation of the tibia in flexion

What is a grade one ligament injury?

Sprain - tears some fibres but macroscopic structure is still intact

What is a grade two ligament injury?

Partial tear - some fascicles disrupted

What is a grade three ligament injury?

Complete tear of a ligament

Are lateral or medial ligament injuries more likely to heal?

Medial

What does MCL rupture lead to?

Valgus instability

What does an ACL rupture lead to?

Rotatory instability

What does a PCL rupture lead to?

Recurrent hyperextension or instability descending stairs

What does a posterolateral corner rupture lead to?

Varus or rotatory instability

What is the treatment for a MCL injury?

``` Brace, early motion, physio Rarely surgery (reconstruction with tendon graft) ```

What is the presentation of an ACL injury?

Usually sports injury Classic history of 'pop', haemarthrosis and giving way on turning Positive Lachman's test Positive anterior draw test

How are ligament injuries diagnosed?

MRI

What is the treatment for ACL injuries?

Surgical reconstruction and replacement with graft | Physio

What is the prognosis for ACL injuries?

1/3 compensate and function well 1/3 avoid instability by avoiding certain activities 1/3 do not compensate, have frequent instability

What is the indication for surgery in ACL injury?

Rotatory instability or not responding to physio To protect meniscal repair from failing Rapid return to professional sport or high demand job As part of multi-ligament reconstruction

What are the downsides of surgery for ACL injury?

Does not treat pain Does not prevent arthritis Doesn't always work

What can LCL injury lead to?

Doesn't heal | Common perineal nerve palsy

What is the treatment for LCL injury?

Urgent repair if early | If later will need reconstruction

What can cause a PCL rupture?

Direct blow to anterior tibia or hyperextension injury

How does a PCL injury present?

Popliteal knee pain and bruising | May have posterior sag of the tibia and hyperextension of the knee

Do PCL injuries usually occur with other ligament injury?

Yes - isolates PCL rupture is rare

What is the treatment for PCL injury?

Surgical reconstruction as it is usually part of multi-ligament injury But doesn't need surgery is isolated

What are the complications of a knee dislocation?

Popliteal artery injury Nerve injury (common perineal nerve) Compartment syndrome

What is the difference between a knee dislocation and a patellar dislocation, and which is more common?

Knee - dislocation of the tibial femoral joint | Patellar - dislocation of the patella (more common)

Which way does the patella dislocate?

Laterally

What is a patellar dislocation caused by?

Rapid turn or direct blow

What are risk factors for patellar dislocations?

``` Females Adolescents Ligamentous laxity Valgus knee Torsional abnormalities ```

What complication can patellar dislocation cause?

Chondral or osteochondral injury if there is a dislodged bone fragemnt

What treatment can be done for patellar dislocation?

Surgical stabilisation (medial patellar femoral ligament reconstruction)

What is patellofemoral pain syndrome?

Idiopathic adolescent anterior knee pain

What can cause patellofemoral pain syndrome?

Muscle imbalance Tightness of lateral tissues Bony malalignment Flat feet

What is the treatment for patellofemoral pain syndrome?

Physio | Invasive bony surgery for most severe but results are unpredictable

What is osteochondritis dissecans?

Where an area of the surface of the knee loses its blood supply and cartilage and/or bone can fragment off

What is bone bruising/bone marrow oedema?

Impaction to articular surface leads to microscopic fracture of trabecular bone with bleeding and inflammation

What is the treatment for bone bruising/bone marrow oedema?

None - will heal with time, typically in 3 months but can take over a year

What are loose bodies?

Trauma, osteochondral dissecans and joint degeneration can cause a fragment of cartilage to detach, causing a loose body in the joint They can grow over time, getting nutrition from synovial fluid and may cause painful locking or catching

What is the presentation of loose bodies?

Mobile lump Sharp occasionaal pain (should not be constant, generalised or severe) Knee locking/catching

What are Baker's cysts and bursitis?

Common swellings around the knee

What is the treatment for baker's cysts and bursitis?

Leave alone - risk of wound problems and recurrence if remove

What does haemarthrosis indicate?

ACL or fracture

What does effusion indicate?

Meniscal or chondral injury

What injury could be caused by getting up from squatting?

Meniscal tear

What does pain at the joint line indicate?

Meniscal or chondral injury

What is the most likely diagnosis in a football injury, twist, pop, haemarthrosis, generalised pain which settles after a few days., rotatory instability?

ACL rupture

What is the most likely diagnosis in an injury when getting up from squatting, side sharp pain medial joint line, effusion, recurrent medial pain and catching +/- locking?

Meniscal tear