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Sem 2 - MSK > The Knee > Flashcards

The Knee Flashcards

1
Q

What leg bone is not involved in the knee joint?

A

The fibular

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2
Q

What bony surfaces are involved in the knee joint?

A
  • Condyles of femur
  • Condyles of Tibia
  • Patellar surfaces of Femur
  • Articular surfaces of patella
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3
Q

What are the femoral condyles?

A

Medial is larger than lateral as it takes more weight

Between the condyles

  • Anteriorly - shallow depression for patella articulation
  • Posteriorly - Deep notch - intercondylar fossa (this contains the cruciate ligamnents which are attatched to the inner aspect of the condyles)
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4
Q

What is the tibial surface?

A

Tibial plateau

Medial surface is slightly concave

Lateral surface is slightly convex

There are separated by the intercondylar eminence (rough and attatch stuff)

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5
Q

What is the patella?

A

Largest sesamoid bone (develops within a tendon)

Provides mechanical advantage to quadriceps tendon.

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6
Q

What is the problem with the shape of the knee joint?

A

The Knee isn’t very stable

Mismatch of shapes.

“Like two balls on a table top”

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7
Q

How is the knee joint made more stable?

A

Deepen the articular surface of the tibial element - Menisci (crescent shapes bits of fibrous cartilage that are thicker on the edges than the middle.)

Support the joint by various structures:

  • Ligaments
  • Capsule
  • Muscles
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8
Q

What are the menisci of the knee?

A
  • Deepen the surface of articulation
  • Crescent plates of fibrocartilage
  • Shock absorbers
  • Thicker at edges - wedge shapes
  • Attached to intercondylar areas
  • Are attatched to joint capsule via Coronary ligaments
  • Anteriorly connected by transverse ligament of the knee
  • Lateral meniscus is more mobile than the medial one
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9
Q

What ligaments are involved in the knee?

A

Cruciate ligaments (intra-capsular)

Oblique popliteal ligament (Ligaments that strengthen the capsule)

Collateral ligaments (extracapsular)

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10
Q

What are the cruciate ligaments?

A

Anterior - stops anterior displacement of the tibia on the femur. (The anterior passes posterior and inserts laterally)

Posterior - Stops posterior is placement of the tibia on the femur. (Posterior passes anterior inserts medially)

(If femur is reference point, swap it over)

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11
Q

What is the difference between the anterior cruciate ligament and the posterior cruciate ligament?

A

ACL is weaker of the two with a poor blood supply. It limits the anterior movement of Tibia on Femur.

Whereas, PCL is the stronger of the two. It limits the posterior movement of tibia on femur. In weight bearing, it flexes the knee. PCL is the main stabiliser.

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12
Q

What is the joint capsule?

A

Surrounds sides and posterior aspect of the joint.

  • -It is deficient anteriorly
    • Allows the synovial membrane to extend up beneath patella (supra-patellar bursa)
  • Strengthened laterally
    • Inferior fibres of Vastus lateralis / medialis
  • Strengthened posteriorly
    • Oblique popliteal ligament
    • Expantion of semimembranosus
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13
Q

What are the extra-capsular ligaments?

A

Medial (Tibial) collateral ligament

  • Medial Femoral epicondyle to Tibia

Lateral collateral ligament

  • Lateral Femoral epicondyle to lateral surface of Fibular head
  • Also reinforced by illiotibial tract

The medial tibial collateral ligament attaches to the medial meniscus at its medpint.

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14
Q

What are the movements of the knee?

A

Flexion - Hamstrings (Gastrocnemius)

Extension - Quadraceps (rectus femoris, vastus medialis, vastus intermedialis, vastus lateralis)

When knee is flexed you can get some rotation.

Medially - Semitendinosus

Laterally - Biceps Femoris

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15
Q

What muscles have a stabilising effect in the knee?

A

Most important is the quadriceps femoris.

Especially inferior fibres of

  • Vastus medialis
  • Vastus lateralis

Also the iliotibial tract laterally

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16
Q

What are the hamstrings?

A

These are at the back of the thigh. They are the semimembranosis, semitendinosis and the biceps femoris.

17
Q

What is the femoral trangle?

A

The femoral triangle is an anatomical space in the upper inner thigh.

It is bound:

  • superiorly by the inguinal ligament.
  • medially by the lateral border of the adductor longus muscle.
  • laterally by the medial border of the sartorius muscle.

It is important because many important structures pass through it:

  • Femoral nerve and its (terminal) branches.
  • Femoral sheath and its contents:
  • Femoral artery and several of its branches.
  • Femoral vein and its proximal tributaries (e.g., the great saphenous and deep femoral veins).
  • Deep inguinal lymph nodes and associated lymphatic vessels.
18
Q

What is locking of the knee?

A
  • So it is less effort to stand
  • Femur rotates internally over Tibia to lock
  • In this position the knee joint can be help in position
  • To ‘unlock’ -Popliteus helps to rotate the femur externally.
19
Q

What are bursa?

A

Synovial sacs that cushion the interface between tendons and bones and other attachments.

There are three important ones:

  • Supra-patellar bursa
  • Pre-patellar bursa
  • Superficial infra-patellar bursa
20
Q

What people commonly get knee problems?

A

Young with sport injuries

Middle age with early onset arthritis

Old people with arthritis

And others..

21
Q

Why are knee disorders important?

A

Major weight baring joint

Required for walking - Critial for health and fitness

Reduces mobility -predisposition to falls -Weight gain

Disability

Inability to work

Psychological issues -Depression -Social isolation

22
Q

What are femoral shaft fractures?

A
  • Usually High energy injuries
    • Road Traffic Accident
    • Falls from height
  • Low velocity e.g fall if if:
    • Osteoporitic
    • Metastases
    • Other bone lesions eg cyst
  • Site
    • Poximal
    • Mid-shaft
    • Suprcondylar
  • Blood loss (if closed fracture)
    • 1500ml (1.5L)
    • Hypovolaemic shock (physiological response to trauma.)
  • If fracture is open then blood loss may be double
  • Traction splint
  • Surgical fixation
23
Q

What are tibial plateau fractures?

A
  • High energy injury
  • Axial loading and angulation
  • Uni / Bi-condylar
  • Lateral tibial condyle fractures most common
  • Articular cartilage damage
  • Instability
  • Asociated with meniscal tears and ACL injury
  • Accurate joint surface reduction
  • Fix articular segment to shaft
  • CT scan -Identify anatomy to piece back together
  • Post traumatic osteoarthritis
24
Q

What are Patella Fractures?

A

Direct or Indirect force

Is the extensor mechanism intact?

  • (can you lift your leg off the floor / straight leg raise)

Displaced

  • Reduce and Fix

Undisplaced

  • Splint and protect

Lever arm for quadriceps

Pos traumatic OA

Blood supply via the inferior pole

Palpaple defect in patella and joint swollen due to blood (haemotharosis)

Beware of bipartite Patella (patella in two parts) which can be mistaken for a fracture.

25
Q

What are Patella Dislocations?

A

Lateral direction

Twisting actions is small knee bend

Falls on bent knee

Predispositions are common

  • Ligamental laxity
  • Shallow patella groove in femur
  • Long patella tendon
  • Previous dislocations
  • Patellofemoral joint hypermobility
  • Weakness of quadriceps muscles, espicially VMO (vastus medialis obliquus)

Reduce and Immobilise

Giving way

Soft tissue reconstruction.

26
Q

What are meniscal injuries?

A

Twisting injury in high flexion

Localised pain

Swelling

Mechanical symptoms -

catching, jamming, ‘locking’

MRI

Traumatic - Meniscetomy / Meniscal repair

Degenerative - Leave alone and rehabilitate

27
Q

What infuences knee (any) joint stability?

A

Static

  • Bones and ligaments

Dynamic

  • Muscles and Tendons

Knee stability

  • Bones (ish)
  • Menisci
  • 2 collaterals
  • 2 Cruciates
  • Posterior Capsule
  • Quadriceps
  • Hamstrings
28
Q

Collateral Ligament Injuries

A

Contact / Direct bow - Sport

Medial - VaLgus strain (Lateral angulation of the distal segment)

Lateral - Varus strain (varus = medial angulation of the distal segment)

Pain and or instability (instability more by LCL as medial tibial plateau forms deeper and more stable socket for the femoral condyle.)

Brace and rehabilitation

Associated injuries - ‘Terrible triad”

Surgical repair / reconstruction

29
Q

What us the unhappy triad?

A

This is when there is injury to:

  • Anterior cruciate ligament
  • Medial collateral ligament
  • Medial meniscus

It results from a strong force applied to the lateral aspect of the knee. The medial meniscus is firmly adherent to the medial collateral ligament which is why it is also injured.

30
Q

What are cruciate ligament injuries?

A

Anterior (ACL)

  • Non contact - Landing or direction change
  • Anterolateral rotatory instability
  • Popping sensation
  • Recurrent instability -Giving way -Twisting / Turing /sudden stops
  • Rehabilitation +/- surgical reconstruction

Posterior (PCL)

  • Contact - Fall onto flexed knee or hyperextension (dashboard injury)
  • Brace and rehabilitation

Detected using Draw tests. Lachmans tests can also be used to detect ACL injuries.

31
Q

What is knee joint dislocation?

A
  • Uncommon
  • High energy trauma
  • 3 out of 4 ligaments ruptured
  • Vascular injury
    • Popliteal artery tethers
    • Angiography / MRA
  • Reduce and stabilise
  • Late stiffness and instability
32
Q

What could cause swellings around the knee?

A
  • Bony
    • eg Osgood-Schlatters disease
  • Soft tissue
    • Local or generalised.
    • Mass?
  • Knee effusion
    • Never normal
    • Acute - Haemarthosis (bleeding into the joint, dangerous)
      • Need to be treated in under 6 hours
    • Sub-acute - Reactive synovitis
      • Next day / Variable
33
Q

Whar are some types of acute knee infusion?

A

Haemarthrosis - ACL fracture until proven otherwise. Fluid and blood look same as soft tissue on injury.

Lipohaemarthrosis - Fracture until proven otherwise. Fat into knee joint so appear black on x-ray

34
Q

What is bursitis and what types are there?

A

Bursae are fluid filled sacks protecting bony prominences.

Bursitis - Inflammaion (and fibrosis) of a bursa

Chronic mechanical irritation.

Pre-patella bursitis - ‘Housemaids knee’. History of repetive trauma and difficulty walking.

Infra-patella bursitis - ‘Clergymans knee’. Reteated microtrauma by kneeling.

Supra-patella bursitis - knee joint effusion. Sign of pathology in the knee joint.

Semimemnranosis bursitis - Popliteal (bakers) cyst

35
Q

What is Osgood-Schlatter’s disease?

A

OSD is inflammation of the patellar ligament at its insertion into the tibial tuberosity.

In teenagers who play sport

Localised pain and swelling Bilateral in 20-30% cases

Resolved with rest and ice.

Physio after initial symptoms have resolved.

36
Q

Knee arthritis

A
  • Osteoarthritis - wear and tear
  • Inflammatory arthritis - Sero-positive (rheumatoid) /Sero-negative / Crystal (gout)
  • Joint surface / Chondral damage -Diffuse -Limited capacity to repair
  • Synovits (swelling)
  • Pain / Stiffness / Loss of function
  • Deformity - Varus / Valgus / Fixed flexion
  • Uni- / Bi- / Tri-compartmental.
  • Prevelence - 12% population, 35% > 75yrs
  • Fluctuating symptoms - Proviked by activity and relased by rest
  • Predispositions -age/sex/weight/post-trauma/genetics
  • Treatment - Strengthening/Analgesia/weight losss/ activity modification or surgery
37
Q

What is osteoarthritis?

A

Symptoms:

  • Knee pain - may follow a pattern
  • Swelling
  • Stiffness
  • Some feel knee giving way when going down stairs -muscle weakness

Loss of articular cartilage leads to friction as bone rubs on bone. This can be felt as crepitus (grating sound or cracking sensation on movement of joint)

This is joint space narrowing, Osteophytes, Sclerosis, Subchondral cysts.

38
Q

What is septic arthritis?

A

Septic arthritis is the innervation of the joint space by micriorganisms, usually bacteria (commonly staphylococcus aureus) (but occasionally viruses, mycobacteria and fungi). It differs from reactive arthritis, which is a sterile inflammatiory process that can result from extra-articular infection e.g. gastroenteritis.

Prothetic joints are at particular risk due to intra-operative contamination or haemotogenous spread from a distant infective focus.

Consequences include damage to articula cartilage due to pathogenic properties and host response.

Patients present with:

  • Fever
  • Pain
  • Reduced range of motion

If septic arthrits suspected, aspiration of joint should be carried out imediately and aspirate should be sent for urgent microscopy, culture and sensitivites.

It has high morbidity.

Sem 2 - MSK (22 decks)

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