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Sub-Acute > Week 1: Knee & Ankle > Flashcards

Week 1: Knee & Ankle Flashcards

1
Q

Do ACL injuries generally occur as a result of contact or non-contact mechanisms?

A
  • Non-contact
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2
Q

What other concomitant knee pathology generally occurs with an ACL injury?

A
  • Meniscus
  • Chondral injury ie damage to the articular cartilage
  • Collateral ligament
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3
Q

To what extent does an ACL injury increase the risk of future knee OA?

A

40-70% increased risk of knee OA

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4
Q

What signs on an MRI would suggest an ACL tear? 5*

A
  • Increase in fluid around the ACL (subsequently there is increased T2 signalling)
  • Fibre discontinuity
  • Abnormal ACL orientation (ie if the ACL is less steep)
  • Empty notch signal: ACL will still attach to tibia but won’t attach to the lateral femoral condyle (generally this area fills with fluid as a result)
  • Bone contusions
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5
Q

An ACL rupture should always be suspected if the patient reports (3):

A
  • An injury mechanism that involves deceleration/acceleration in combination with a knee valgus load eg a lateral movement with the knee bending in
  • Hearing or feeling a “pop” at the time of injury
  • hemarthrosis within 2 h of injury (bleeding into a joint space)
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6
Q

Do males or female have a higher incidence of ACL injury?

A

Males (higher participation rate in soccer, AFL, etc)

Although this rate is growing particularly in young females (aged 5-14)

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7
Q

What is the most common traumatic knee injury?

A

ACL

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8
Q

Do males or females have a higher risk of ACL injury?

A

3.4 fold greater risk in females than males

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9
Q

Modifiable risk factors for ACL injury

A
  • Earlier/more intense and more frequent participation in sport
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10
Q

Non-modifiable risk factors for ACL injury

A

Variation in bone morphology
Neuromuscular control
Genetic eg amount of knee extension
Hormonal

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11
Q

KANON trial:
- Early rehab + early ACL repair
- Early rehab + optional delayed ACL repair

What were the findings (also 5 year follow-up findings?)

A

Rehabilitation plus early ACL reconstruction was not superior to a strategy of rehabilitation plus optional delayed ACL reconstruction.

At 5 years the results didn’t differ better surgically reconstructed early vs late. Note: KOOS was used as the primary outcome measure.

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12
Q

Compare trial
- Randomised to early ACL reconstruction
- Rehabilitation followed by optional delayed ACL reconstruction after a three-month rehab period

A

Larger improvement at two-years in the early surgical reconstruction group that was statistically significant but unclear if the difference was clinically meaningful.

50% of patients randomised to three-months of rehab did not need surgery.

Note: IKDC subjective knee form

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13
Q

SNAPP trial
- Initial rehabilitation
- ACL reconstruction

A

This trial found better 18-month outcomes in participants assigned to ACL reconstruction than in those assigned to rehabilitation and optional delayed reconstruction

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14
Q

ACL cross bracing protocol results

Why is the knee flexed?

A
  • 90% of patients had evidence of healing on 3-month MRI (continuity of the ACL).
  • More ACL healing on 3-month MRI was associated with better outcomes.
  • Longer-term follow-up and clinical trials are needed to inform clinical practice

The more flexed the knee is the more likely the ACL is to mesh & recover. Knee is braced and held at 90 degrees (NWB)

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15
Q

When are allografts used in ACL repair? Benefits/consequences?

A

Most commonly used for revision ACL surgery
- No pain occurs in autografts
- Decreased surgery time, incision, stronger bone fixation
- Increased risk of infection and increased risk of failure

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16
Q

Benefits/consequences of using a patella tendon graft?

A
  • increase in patellofemoral knee pain
  • Increase in post-op stiffness
  • Decreased knee laxity compred to other methods

Note: middle 1/3rd of tendon is utilised

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17
Q

Benefits/consequences of using a hamstring tendon graft?

A
  • Decreased knee pain stiffness
  • Decreased hamstring strength
  • Decreased incision and faster recovery
  • Increased laxity/potential graft lengthening

Note: Easy surgery to perform

18
Q

Benefits/consequences of using a patella tendon graft?

A
  • Fixation not as solid
  • Increased knee pain post op
  • Decreaed laxity compared to other methods
19
Q

ACL: post management

  • Continuous passive motion …. improve long term motion.
  • Early (Immediate) weightbearing …… patellofemoral pain, prevent …… & return the ….-…. mechanism (E)
  • Postoperative rehabilitative bracing did not improve ….., pain, ……, or safety.
A
  • Did not
  • Decreases patellofemoral pain
  • Prevents atrophy
  • Returns the screw-home mechanism
  • Swelling & ROM
20
Q

What is the most significant meniscal damage that can occur? What will happen to the knee as a result?

A

Bucket handle
- Knee will be completely locked and unable to extend (emergency MRI will likely be needed)

Big hole in the actual meniscus as opposed to most others that are generally tears

21
Q

What are the types of meniscal tears?

A
  • Vertical
  • Transverse
  • Peripheral
  • Bucket-handle
  • Parrot beak
  • Flap
22
Q

General presentation of a meniscal tear - what are the symptoms?

A
  • Pain, stiffness & joint effusion
  • Catching/locking/ROM restriction
  • Instability
23
Q

What is involved in meniscus surgery?

A
  • Arthroscopy + meniscectomy: damage cartilage is trimmed away
  • Arthroscopy + meniscus repair: sutured together. Depends on type of tear, location of tear (outer not inner - outer is more likely to heal?, condition of meniscus and time for recovery is longer than meniscectomy

Note: arthroscopy involves using a camera to look at the knee joint.

24
Q

Is criteria or time based progression preferred in traumatic knee injury?

A

Combination of both but must definitely being criteria based goals

25
Q

What is the focus of meniscus rehab in weeks 1-2?

  • WBAT as tolerated ……
  • By day ….. full weight bearing
  • Emphasising full ….. ….. & flexion ROM close to ….-….. deg?
  • Exercises?
A
  • WBAT as tolerated initially
  • By day 5 full weight bearing
  • Emphasising full knee ext & flexion ROM close to 90-100 deg?
  • Exercises: straight leg raise, hip abd/add, 1/4 squats, hamstring curls
26
Q

What is the focus of meniscus rehab in weeks 2-4?

A

Isometric quad exercises (start with short arc, progress to long arc)

27
Q

What is the focus of meniscus rehab in weeks 4-8?

A

Increase resistance & range in exercises
Running program may be initiated eg jogging on spot/trampoline, increase distance, begin to jog overground + low intensity functional and agility training

28
Q

What is the focus of meniscus rehab in weeks 8-12?

A

Once patient can run 4-5km in a straight line add agility drills and sport specific activities

29
Q

Results from: Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear

A

No difference 12 months post surgery

30
Q

Results from: Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline

A

The panel believes that almost everyone would prefer to avoid the pain and inconvenience of the recovery period after arthroscopy, since it offers only a small chance of a small benefit.

31
Q

Weber A fracture is….
- Stable or unstable
- ……. to syndesmosis
- Syndesmosis intact/not intact
- Deltoid ligament intact/not intact
- Medial malleolus fracture?

A
  • Stable
  • Inferior
  • Intact
  • Intact
  • +/- medial malleolus (may occur/may not occur)
32
Q

Weber classification is to categorise fractures to what bone?

A

Fibula ie lateral malleolar fractures

33
Q

Weber B fracture is….
- Stable or unstable
- ……. to syndesmosis
- Syndesmosis intact/not intact
- Deltoid ligament intact/not intact
- Medial malleolus fracture?

A
  • In between (stability varies)
  • Fracture is at level of syndesmosis
  • Syndesmosis intact or partially torn
  • +/- medial malleolus/deltoid ligament damage
  • May require ORIF
34
Q

Weber C fracture is….
- Stable or unstable
- …… …… of ankle joint
- Syndesmosis intact/not intact
- Deltoid ligament intact/not intact
- Medial malleolus fracture?

A
  • Unstable
  • Above level of ankle joint
  • Syndesmosis damaged with widening of joint
  • Usually deltoid ligament injury and/or medial malleolus
  • ORIF required
35
Q

Management of Weber A fracture
- Typically do/don’t need to be casted
- Treated in …… …… ……
- Focus on…..
- Syndesmosis ……
- ….. exercises as tolerated

A
  • Don’t need to be casted
  • Treated in stabilising ankle orthoses
  • Early function & weight-bearing
  • Intact
  • ROM
36
Q

When are follow-up x-rays needed following stable non-displaced Weber fracture?

A

Follow-up X-rays 4, 7, 11 and 30 days after trauma

37
Q

Article: Immobilising ankle fractures. How long should casts or orthoses be used to restrict movement

Study details: * 247 skeletally mature patient (16 – 85 years) with an isolated, stable Weber B Type fibula were included. 51% were male.
* 80 received 3 weeks of orthosis, 84 received 6 weeks in a cast, 83 received 3 weeks in a cast.

A
  • A shorter 3 week period of immobilization proved non-inferior to traditional 6 weeks of cast immobilization.

Indicates the benefit of early weightbearing!!

38
Q

What is the most important factor in determining how an achilles rupture is managed?

A
  • Early detection is key –> try to catch within the first 2 days, foot can enter plantar grade in a boot/with heel raise and then blood flow will help with recovery (> 5 days is likely to require surgery)
39
Q

What is the risk of re-rupture in conservative vs surgical management of achilles rupture?

A

Increased risk of re-rupture (4/100 in conservative vs 2/100 for surgical)

40
Q

Complication rate for surgical vs non-surgical management of achilles rupture?

A

2 per 100 treated will have complications over 2 years such as infection, nerve injury and scarring from non-surgical.

5 per 100 treated will have complications over 2 years such as infection, nerve injury and scarring in the surgical group.

Sub-Acute (4 decks)

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