T&O: knee presentations

Question 2

What is first line (surgical) management for pre-patellar bursitis if conservative management has not been successful?

Answer 2

Steroid injection

Question 3

What tendons hold the patella in place?

Answer 3

Quadriceps tendon and the patella tendon

Question 4

Describe a ACL tear

Answer 4

Anterior cruciate ligament is torn.

Question 5

What is role of ACL?

Answer 5

Stops tibia from sliding out in front of femur (i.e. stops anterior translation). Provides rotational stability to the knee

Question 6

How does an ACL tear present?

Answer 6

Loss/impaired function.
Hx of twisting the knee.
Rapid joint swelling.
Pain!
Joint feels unstable.

Question 7

What tests would you do for suspected ACL tear?

Answer 7

Lachman’s test. Anterior draw test.

Question 8

How is an ACL tear managed?

Answer 8

RICE.
NSAIDs
Crutches, knee brace.
Rehab to strengthen quads to stabilise the know. Surgical reconstruction - tendon or artificial Grat used.

Question 9

What is a complication of ACL injury?

Answer 9

OA

Question 10

What do the menisci in the knee act as?

Answer 10

Shock absorbers
Stabalise knee joint
Allow for distribution of synovial fluid through joint

Question 11

How do meniscal injuries/tears present?

Answer 11

Knee twisted while flexed or weight bearing. Sensation of tearing. Intense sudden onset pain. Swells slowly. Tender along joint line. Effusion in the joint. Limited knee flexion.

Z2F:
Young patient - sports related injury
“pop” sound or sensation
Pain
Swelling
Stiffness
Restricted range of motion
Locking knee
Instability - knee “gives way”

Question 12

What tests would you do for suspected meniscal injury?

Answer 12

McMurray’s - would be positive.

Question 13

How are meniscal tears managed?

Answer 13

RICE. Small tears <1cm- heal by themselves. Large, symptomatic tears - need arthroscopic surgery. Sutures may be needed if tear is in outer 1/3rd. Sutures need to be trimmed if in inner third, as can cause locking of the knee.

Z2F:
RICE
NSAIDs
Physio after initial pain and swelling settled
Surgery may be needed - arthroscopy - repair meniscus or remove affected part of meniscus

Question 14

How does quadriceps tendon rupture present?

Answer 14

Hx of landing from jump/height and putting excessive load on quads - hear popping sensation/tearing.
Pain in anterior knee or thigh. Hard to weight bear. Swelling. Palpable defect over superior patella.

Question 15

Difference in presentation of meniscal tear and ACL tear - with regard to joint swelling?

Answer 15

ACL = rapid joint swelling!!!
Meniscal = slow joint swelling

Question 16

What imaging would you do for quadriceps tear?

Answer 16

XR - rule out fracture of patella. USS to measure degree of rupture.

Question 17

You do an examination of a pt with suspected quadriceps tendon tear. What do you find on examination if this is true?

Answer 17

Can’t complete a straight leg raise. Can’t extend the knee. (or can only do these movements partially if only partially torn).

Question 18

A pt has a partial quadriceps tendon tear. What is your management plan?

Answer 18

Immobilise knee in brace, rehab.

Question 19

A pt has a complete quadriceps tendon rupture. What is your management?

Answer 19

Surgery needed! Then need immobilisation in brace for 6 weeks. THEN need strengthening and flexibility exercises.

Question 20

How does patella fracture present?

Answer 20

Hx of direct trauma to patella/strong contraction of the quadriceps. Anterior knee pain, which is worse on movement. Patella defect is palpable. Swollen and bruised.

Question 21

What XR is needed for patella fracture?

Answer 21

AP, lateral, skyline.

Question 22

What surgical management options are available for patella fracture?

Answer 22

Open reduction and internal fixation WITH tension band wiring.

Question 23

When is surgery discussed as an option for a patellar fracture?

Answer 23

When there is significant displacement of the patella or a compromise to the extensor mechanism.

Question 24

How does patella tendon rupture present?

Answer 24

Direct blow or jumping action which is followed by a tearing or popping sensation. There is a palpable defect interior to the patella. Swelling. Pain in anterior knee.

Question 25

How do presentations of patella tendon rupture and quadriceps tendon rupture differ?

Answer 25

Patella - defect is palpable inferior to the patella. Quadriceps - defect is palpable superior to the patella.

Question 26

What imaging would you do for suspected patella tendon rupture?

Answer 26

XR to rule out fracture. USS to measure degree of rupture. MRI can be used.

Question 27

How are patella tendon ruptures managed?

Answer 27

Depends on degree of rupture. If partial = immobilise in brace and rehab. If complete = surgical intervention followed by immobilisation in brace for 6 weeks before strengthening and flexibility exercises.

Question 28

Define a patella dislocation

Answer 28

Patella is displaced out of the patellofemoral groove, normally held in place by vistas medius obliques.

Question 29

How do patella dislocations present?

Answer 29

Hx of high force trauma on patella/sudden forceful twisting of the knee. Laterally displaced patella

Question 30

What XR would you ask for, for a patella dislocation?

Answer 30

AP, lateral, skyline.

Question 31

How is patella dislocation managed?

Answer 31

Extend knee and reduce patella. Immobilise to allow healing. Physio to strengthen Vastus Medialis Obliques (VMO)

Question 32

Examination findings for meniscal injury?

Answer 32

Reduced/restricted range of motion
Localised tenderness to the joint line
Swelling

Question 33

Investigations for suspected meniscal injury?

Answer 33

MRI - first line for establishing Dx.
Arthroscopy - gold standard for meniscal tear.