T&O: knee presentations Flashcards
What is first line (surgical) management for pre-patellar bursitis if conservative management has not been successful?
Steroid injection
What tendons hold the patella in place?
Quadriceps tendon and the patella tendon
Describe a ACL tear
Anterior cruciate ligament is torn.
What is role of ACL?
Stops tibia from sliding out in front of femur (i.e. stops anterior translation). Provides rotational stability to the knee
How does an ACL tear present?
Loss/impaired function.
Hx of twisting the knee.
Rapid joint swelling.
Pain!
Joint feels unstable.
What tests would you do for suspected ACL tear?
Lachman’s test. Anterior draw test.
How is an ACL tear managed?
RICE.
NSAIDs
Crutches, knee brace.
Rehab to strengthen quads to stabilise the know. Surgical reconstruction - tendon or artificial Grat used.
What is a complication of ACL injury?
OA
What do the menisci in the knee act as?
Shock absorbers
Stabalise knee joint
Allow for distribution of synovial fluid through joint
How do meniscal injuries/tears present?
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”
What tests would you do for suspected meniscal injury?
McMurray’s - would be positive.
How are meniscal tears managed?
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
How does quadriceps tendon rupture present?
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.
Difference in presentation of meniscal tear and ACL tear - with regard to joint swelling?
ACL = rapid joint swelling!!!
Meniscal = slow joint swelling
What imaging would you do for quadriceps tear?
XR - rule out fracture of patella. USS to measure degree of rupture.
You do an examination of a pt with suspected quadriceps tendon tear. What do you find on examination if this is true?
Can’t complete a straight leg raise. Can’t extend the knee. (or can only do these movements partially if only partially torn).
A pt has a partial quadriceps tendon tear. What is your management plan?
Immobilise knee in brace, rehab.
A pt has a complete quadriceps tendon rupture. What is your management?
Surgery needed! Then need immobilisation in brace for 6 weeks. THEN need strengthening and flexibility exercises.
How does patella fracture present?
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.
What XR is needed for patella fracture?
AP, lateral, skyline.
What surgical management options are available for patella fracture?
Open reduction and internal fixation WITH tension band wiring.
When is surgery discussed as an option for a patellar fracture?
When there is significant displacement of the patella or a compromise to the extensor mechanism.
How does patella tendon rupture present?
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.
How do presentations of patella tendon rupture and quadriceps tendon rupture differ?
Patella - defect is palpable inferior to the patella. Quadriceps - defect is palpable superior to the patella.
What imaging would you do for suspected patella tendon rupture?
XR to rule out fracture. USS to measure degree of rupture. MRI can be used.
How are patella tendon ruptures managed?
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.
Define a patella dislocation
Patella is displaced out of the patellofemoral groove, normally held in place by vistas medius obliques.
How do patella dislocations present?
Hx of high force trauma on patella/sudden forceful twisting of the knee. Laterally displaced patella
What XR would you ask for, for a patella dislocation?
AP, lateral, skyline.
How is patella dislocation managed?
Extend knee and reduce patella. Immobilise to allow healing. Physio to strengthen Vastus Medialis Obliques (VMO)
Examination findings for meniscal injury?
Reduced/restricted range of motion
Localised tenderness to the joint line
Swelling
Investigations for suspected meniscal injury?
MRI - first line for establishing Dx.
Arthroscopy - gold standard for meniscal tear.
