triage of knee issues Flashcards
Ottawa Knee Rules
Age 55+
Isolated tenderness of the patella
OR
Tenderness over fibular head
Unable to flex the knee past 90
Unable to bear weight immediately, or in the ED for 4 steps
what population is more prone to fractures
Younger and older pop are more prone to fracture
Pittsburgh Knee Rules
Blunt trauma or a fall as MOI plus one of the following:
Age under 12
Age over 50
Unable to bear weight in the ED for 4 steps
how do you use Ottawa Knee Rules
and pittsburgh knee rule
IF ANY ONE OF THE CRITERIA ARE PRESENT AFTER AN ACUTE INJURY, RADIOGRAPHS SHOULD BE ORDERED
with a knee injury when should we send pt to the ED
Open Injury
Neurovascular Injury with
Diminished or absent distal pulses
Absent sensation
Obvious fracture OR
Positive Ottawa Ankle/Knee Rules - high index of suspicion
Gross misalignment of limb
knee issue - Continue Exam;
Refer out when finished:
Positive Ottawa Ankle/Knee Rules - low index of suspicion
Tibiofemoral or Patellofemoral Dislocation
No neurovascular issues
Normal alignment (spontaneous reduction)
No tendon ruptures
proximal tibias into articular surface is the biggest problem for what population
more a problem in younger pt because of growth plates, can lead to weird growth
does the knee fracture often
no
Only 6% of knee injuries have fractures
when can we start to move with a fracture
depends on how stable to the fracture is
normal treatment for a fracture
Treat non-operatively
Closed reduction
Immobilize for 4-6 weeks
NWB or PWB for 4-6 weeks
Usually has a 0-90° ROM restriction
is any training during the healing process of the fracture
“Light strengthening” allowed
Submaximal resistance that is not producing pain
body weight
what is the point of rehab ring the immobilization phase
Goal = reduce the effects of immobilization
what does “Toe touch”
a type of PWB
Only toes touch the ground
what is “Touch-down”
type of PWB
Foot flat on ground
what is swelling a good indicator of
the knee is not ready to progress
the focus of Rehabilitation after Prolonged Immobilization
Symptom Modulation and Impairment Resolution
what impairment do we see with prolonged immbolization
joint effusion and edma
Improve Muscle Activation and Decrease Atrophy
Restore Limited Motion, Decrease Joint Stiffness
Restore Normal Movement Patterns
Wolff’s Law
do not use it you will lose it, the bone response to load (stress), this has to be controlled and progressive with time – weightbearing ease into it
what is the most common knee dislocation
anterior dislocation
the tibia displaced anteriorly on the femur
when we suspect a dislocation what should we look at
Evaluate sensation and pulse to look at complications
why are dislocations dangerous and need immediate attention
they are limb threatening because of neurovascular compromise
what nerves are we worried about with disloction
peroneal nerve , tibial nerve
what Arteries are we worried about with dislocations
Popliteal is primary concern; genicular anastomosis also; check all distal pulses
what ligaments a injured with dislocation
Cruciate and collateral ligaments are injured in some combination
treatment for dislocation
immobilization, likely surgical reconstruction of any structures that have torn
Prognosis for dislocations
long rehab to return to function, continued instability is common. Not good…
Long term complications of knee dislocations include
Quadriceps atrophy
Joint stiffness
Osteoarthritis
Avascular necrosis of femoral or tibial condyles
Posterior knee joint dislocation can impact what artery
popliteal artery
Check posterior tibial pulse
Posterolateral knee joint injury can impact supply to what artery
anterior tibial artery
Check dorsalis pedis pulse
what is Deep Vein Thrombosis
Clotting/Blockage of a distal vein
what procedure increases the occurrence of DVT
More common after surgery (hip, knee, leg/calf, abd, chest)
Some of the reasons why surgery can increase DVT risk:
Tissue debris, protein, and fats may move into veins following surgery.
Vein walls can become damaged, which may also release substances that promote blood clotting.
Prolonged bed rest is common following surgery.
where do we check for the Dorsalis Pedis Pulse
Top of the foot, lateral to EHL tendon
Distal to navicular
where do we check for the Posterior Tibial Pulse
Posterior to medial malleolus
Risk of deep vein thrombosis increases
age
especially after age 60
what lifestyles lead to a higher risk of DVT
Sitting or inactivity for a long time
Extra weight/obesity
Current use of hormonal contraceptive pills or patches
Smoking
Signs and Symptoms of DVT
Swelling in one or both legs
Pain or tenderness in one or both legs, which may occur only while standing or walking
Warmth in theskinof the affected leg
Red/ purple or other discolored skin in the affected leg
Visible surface veins
Legfatigue
result of wells score
3 points: high risk (75%);
1 to 2 points: moderate risk (17%)
;<1 point: low risk (3%).
Common Peroneal Nerve Motor Function
Ankle DF
Great toe extension
Toe extension
Common Peroneal Nerve Sensory Function
1st web space
Dorsal surface of toes
Tibial Nerve Motor Function
Plantarflexion
Toe flexion
~Inversion
Tibial Nerve Sensory Function
Plantar aspect of calcaneus
Plantar aspect of 5th toe
what is Antalgic Gait
pain when they are walking and are showing it when they are walking
- limbing
Flexed Knee Gait
Avoids terminal knee extension
potential reasons for flexed knee gait
Quadriceps avoidance gait
Co-contraction of the quadriceps and hamstrings to limit motion
Limited passive extension ROM
what strutures for Lateral Joint Line (meniscus) and Tibial Plateau
Fibular head, LCL,
Biceps fem Tendon, lateral Gastrocnemius
ITB & Gerdy’s Tubercle
what structures for Medial Joint Line (meniscus) and Tibial Plateau
MCL, medial hamstring tendons & gastroc (posteriorly), pes anserine (bursa and muscle)
what strutures for Patella
Superior patella and quadriceps tendon
Medial patella and vastus medialis
Lateral patella, lateral retinaculum, vastus lateralis
what structure for Tibial Tubercle
Patellar tendon, fat pads, distal patella
Empty end-feel
pain before the restriction
Indicates high irritability
Pain pushing into the restriction indicates
Usually indicates low symptom irritability
Pain at the point of restriction
Capsular end-feel
Indicates moderate irritability
Can likely handle some loading
Boney changes cause what kind of end feel
hard end feel
strong and painless
normal
strong and painful
Minor Muscle Injury
(Contractile Tissue)
weak and painless
Nerve lesion or
“complete muscle tear”
weak and painful
“Serious Pathology” or
significant muscle injury
when we are doing a quad set what are we looking for
Should see a full tetanic contraction with evidence of VMO contraction
Should see evidence of a superior patella glide
what are we looking at with a SLR
Lift 6” off of bolster for goniometer
What is Joint Effusion
Fluid contained WITHIN a body/joint cavity
what is the largest synovial cavity in the body
the knee joint
what would lead to an intra-articular injury
Intra-articular injury
not a extra-articular injury
Joint Edema in relation to effusion
All effusions are edemas, not all edemas are effusions
this is general term for swelling
