triage of knee issues Flashcards by VB VB

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

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what population is more prone to fractures

Younger and older pop are more prone to fracture

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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

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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

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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

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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

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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

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does the knee fracture often

Only 6% of knee injuries have fractures

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when can we start to move with a fracture

depends on how stable to the fracture is

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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

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is any training during the healing process of the fracture

“Light strengthening” allowed

Submaximal resistance that is not producing pain

body weight

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what is the point of rehab ring the immobilization phase

Goal = reduce the effects of immobilization

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what does “Toe touch”

a type of PWB

Only toes touch the ground

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what is “Touch-down”

type of PWB

Foot flat on ground

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what is swelling a good indicator of

the knee is not ready to progress

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the focus of Rehabilitation after Prolonged Immobilization

Symptom Modulation and Impairment Resolution

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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

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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

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what is the most common knee dislocation

anterior dislocation

the tibia displaced anteriorly on the femur

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when we suspect a dislocation what should we look at

Evaluate sensation and pulse to look at complications

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why are dislocations dangerous and need immediate attention

they are limb threatening because of neurovascular compromise

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what nerves are we worried about with disloction

peroneal nerve , tibial nerve

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what Arteries are we worried about with dislocations

Popliteal is primary concern; genicular anastomosis also; check all distal pulses

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what ligaments a injured with dislocation

Cruciate and collateral ligaments are injured in some combination

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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 the skin of the affected leg Red/ purple or other discolored skin in the affected leg Visible surface veins Leg fatigue

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