Disorders and conditions of the knee

What xrays should you order for the knee?

-AP -weight bearing 45 degrees posterioranterior -lateral view -merchant or laurin view of patella (sunrise)

what xrays would you get for tibial shaft fracture?

-AP and lateral tibia (include joint distal and proximal)

What is the tx for a multiple ligament injury?

-IMMEDIATELY reduce the knee -determine neurovascular status (vascular injury to popliteal artery common) -surgery (for compartment syndrome, open dislocation, popliteal injury, irreducible dislocations)

what are the 5 nonoperative tx for DJD of the knee?

-activity modification -NSAIDs -joint injections (corticosteroids or viscosupplementation) -unloading brace (bets for exercise) -assistive device like a cane or crutches (use in opposite to affected knee)

Whats the presentation of ACL injury?

-acute swelling or an effusion/hemoarthrosis (immediate or within 2 hours) -audible pop at time of injury -sense of instability (specifically with lateral or twisting motion, going down stairs)

what are the indications for a total knee arthroplasty (TKA)?

-advanced arthritic changes -debilitating pain affecting ADLs -pain not well controlled with conservative therapy -medically fit for surgery -no infection (anywhere)

Atraumatic and idiopathic AVN (osteonecrosis)

-alcoholism, steroid, divers -more typically in elderly women

how would you treat an articular cartilage injury?

-arthroscopy -debridement -chondroplasty -microfracture -graft

what are the 3 operative tx for DJD of the knee?

-arthroscopy- palliative tx only -Osteotomy- best indicative for active pts under 50 -total knee arthroplasty

in djd of the knee in arthroscopy success is _______ related to severity of mechanical symptoms; ________ related to severity of arthritis

-directly -inversely

when would you do a tension band wiring for patellar fracture?

-extensor mech disrupted -more than 2 mm separation or incongruent articular surfaces

what is the presentation of osteomyelitis?

-extremity pain, warmth, fever, elevated ESR, CRP and cell count- need aspiration for C&S

when would you go for surgery in tiabial plateau fractures?

-greater than 3 mm articular step off -knee unstable -condylar widening > 5mm

name the complications of a TKA?

-infection -peroneal nerve palsy resulting in foot drop -vascular injury ie. popliteal artery -transection of the lateral genicular artery -> necrosis of the patella -patella fracture -intraoperative MCL injury -post operative flexion contraction -osteolysis (recurrent pain/swelling) typically 8-12 years after surgery

Patellar dislocation is typically _____ and injuries _______ ligament

-laterally -patellofemoral

when would you chose nonoperaive tx for tibial plateau fractures?

-less than 3mm articular step off -knee stable -cast bracing, delayed weight bearing 4-6 weeks

Grade 1 collateral ligament injury

-ligament is strained and has continuity -still able to help keep the knee joint stable

what are the complications of tibial shaft fracture?

-non union- rule out infection -malunion- most common with proximal 1/3 fractures, more difficult to hold with casting/fixation -delayed union- seen in transverse pattern and open fractures -infection- related to severity of soft tissue injury -compartment syndrome -anterior knee pain

what is the presentation of DJD of the knee?

-pain with weight bearing, activities -worse with inclines, sit to stand change -later finding- bowing deformity and instability

Pigmented villonodular synovitis

-pain, swelling, possible palpable mass -nodular or diffuse type -tx both with arthoscopic synovectomy- diffuse type tends to reoccur

what is the tx for patellar dislocation?

-reduction and immobilization, minimal movement X 6 weeks

Tx for Osgood-schlatter disease

-self limiting -activity modification -possible immobilization -ICE and quads stretching -NSAIDs

what is the most common organism in ped acute osteomyelitis? how about if the pt has sickle cell?

-staph aureus -slamonella

what is the tx for prepatellar bursitis?

-supportive -intermittent steroid injection -bursal excision-rare -aspiration to rule out infection

how do you tx ICP?

-symptomatic -extensive PT -steroid injections

what are some complications of patellar fracture?

-symptomatic hardware -loss of reduction -nonunion -infection -arthrofibrosis/ stiffness

Plicae

-synovial folds, embryologic remnants -occasionally pathological- abrasion of medial femoral condyle

What are common causes of compartment syndrome?

-tibial or forearm fractures -ischemic reperfusion following injury -IV drug use -prolonged limb compression -hemorrhage -vascular puncture -casts -crush injuries and burns

what is the tx for a meniscal tear?

1-conservative- typically for older pts with no swelling, catching, locking or give away symptoms 2-partial menisectomy- almost everything but peripheral longitudinal tear 3- meniscal repair-should be done in all peripheral longitudinal tears also if ACL repair is needed

What is the normal amount of movement that should be present when doing an anterior drawer test?

6 mm

what percent of ACL injuries have meniscal tear?

75%

what is the most common cause of acute hemarthrosis?

ACL tear

what test would you use if you are looking for bony tumors, fractures?

CT

What is the main ACL injury tx?

Conservative and PT

if you compress the patella pain increases

ICP

Tx for osteomyelitis

IV abx, possible surgical I and D

isolated injuries of _____ are UNCOMMON

LCL

what is the most sensitive examination for ACL injury?

Lachman test

Valgus stress on the knee is the MOI for?

MCL injury

what is the test of choice for ligament injuries, meniscal disease, osteonecrosis (AVN), articular cartilage defects, occult fractures?

MRI

what kind of imaging can confirm the diagnosis of meniscal tear?

MRI

What is ESSENTIAL to confirm an ACL injury?

MRI- most sensitive and specific

if the pt has normal capillary refill and palpable pulses, does that rule out compartment syndrome?

NO

what is the tx of quads tendinitis?

NSAIDs and PT

what is the tx for patellar tendinitis?

NSAIDs, PT, patellar tendon strap (no steroids)

posterior sag test

PCL injury

Patellofemoral disorders Quadriceps tendon rupture vs patellar ligament/tendon rupture

Quads- more common, indirect trauma, pts >40 patellar- direct and indirect trauma, pts <40

what test would you use if you are looking for soft tissue lesions including hematomas, fluid?

US

what is the MOI of injury in iliotibial band friction syndrome?

abrasion btw iliotibial band and lateral femoral condyle- pain worse with knee flexion

what happens if osteochondritis dissecans is left untreated?

arthritis

how do treat plicae?

arthroscopic shaving or release

what is often difficult to distinguish from osteochondritis dissecans?

articular cartilage injury

Idiopathic chondromalacia pattelae (ICP)

articular damage and inflammation of the patella

how do you examine a patellar fracture?

assess the ability to extend knee or complete a straight leg raise

Popliteal (baker) cyst

associated with meniscal disorders

where do MCL injuries most commonly occur?

at the femoral insertion of the ligament

who would commonly suffer from patellar tendinitis?

athletes who jump like basketball and volleyball (but check training)

What kind of fracture is associated with disruption of ACL?

avulsion fracture of the knee that involves the lateral aspect of the tibial plateau

what is typically the result of a knee dislocation?

both ACL and PCL torn

what is the tx for nondisplaced distal femur fractures?

bracing and immobilization 1-2 months

distal femur fractures

can be supracondylar or intracondylar

high energy tibial shaft fracture?

comminuted, tibia and fibula at the same level, transverse, diastasis between tibia and fibula

Swelling with pain out of proportion to injury, not relieved by immobilization or analgesics?

compartment syndrome

in who would you commonly see PCL injuries?

defensive line backers, tackles

MOI for PCL injury

direct blow to anterior tibia with -knee flexed (think dashboard injury) -hyperflexion- less common -hyperextension- more common

what is the MOI for patellar dislocation?

direct injury

MOI for patellar fracture

direct trauma

which MCL injuries have less healing potential?

distal injuries

what is more common than ligament injuries in children?

epiphyseal separation (fracture related to trauma)

who is at increased risk of patellar instability?

females- genu valgus

when is PCL repair recommended?

for functionally unstable or combined injuries

what is most commonly referred to as a complete tear of the collateral ligament?

grade 3 -knee joint unstable -possible surgery

Tx of MCL injuries

hinged knee brace and PT

what is housemaid's knee most commonly associated with?

history of prolonged kneeling

what typically affects runners and cyclists?

iliotibial band friction syndrome

meniscal tears occur typically?

in sports, traumatic can also happen I the older population (degenerative tears)

Apley compression test

increased rotation compared to normal side= ligamentous injury decreased rotation= meniscus injury

what is the MOI for ACL injury?

jumping, pivoting, decelerating sometimes rotatory (non contact) injury

Rehabilitation of a PCL injury focuses on strengthening of?

knee extensors er. quadriceps

in internal tibial torsion, is the left or right side more affected?

left

Surgical criteria of ACL injury

look at slide 37

which meniscus is more likely to tear?

medial

Toe-in gate due?

medial (internal) rotation of tibia

Pain, clicking, locking sensation, difficulty squatting, effusion and joint line tenderness on the knee and a positive McMurray sign?

meniscal tear

what is the most common injury of the knee that requires surgery?

meniscal tear

what is internal tibial torsion associated with?

metatarsal adductus

how do you treat a meniscal cysts?

needling along with a partial meniscectomy

when would you go for nonsurgical tx for a patellar fracture?

nondisplaced with intact extensor mech

how do you examine iliiotibial band friction syndrome?

ober test- estend and abduct the hip then release the knee support, failure of the knee to ADDUCT is a positive test meaning the IT band is tight=pain

people that have a meniscal tear and a meniscectomy have an increased risk of?

osteoarthritis

what is the common presentation of MCL injury?

pain but able to ambulate, possible swelling

what is the common presentation of quads tendinitis?

painful superior border of the patella

Grade 2 collateral ligament injury

partial tear of ligament

patella alta

patella may not articulate with the sulcus

what is known as jumper's knee?

patellar tendinitis

what is more common patellar tendinitis or quads tendinitis?

patellar tendinitis

what would present as pain and tenderness near the inferior border of patella that worsens with extension?

patellar tendinitis

Oscood-schlatter disease

peds -fatigue failure of tibial tubercle apophysis -seen in growing active children -males -pain and swelling over tibial tubercle

what kind of meniscus tear is more common with tibial plateau fracture?

peripheral

what is osteochondritis dissecans?

piece of cartilage and bone may come loose from bone beneath but stay in place

what is another ACL injury test that will cause the tibia to sublux and pop?

pivot shift

Housemaid's knee?

prepatellar bursitis

what presents as warm, swelling, tender, fluid fill mass over patella?

prepatellar bursitis

synovial condromatosis

proliferative disease of synovium, leads to intraarticular loose bodies

what is the surgical tx for patellar instability if needed?

proximal and distal realignment

what are late findings of compartment syndrome?

pulselessness, paresthesia and pallor

what is the major complication of patellar dislocation?

redislocation

what is often curative for patellar instability?

rehab and bracing

patella baja

result of fat pad and tendon fibrosis

MOI of articular cartilage injury

rotational force

spontaneous AVN of knee

self limiting- limited weight bearing

what is a complication of osteomyelitis in infants < 1 year?

septic arthritis

when are symptoms worse for ICP?

sitting, knee flexed or descending stairs

tibial shaft fractures are often associated with ____ injury

soft tissue

low energy tibial shaft fracture?

spiral oblique, tibia and fibula at different levels, closed fracture

Tx for internal tibial torsion in extreme cases?

supramalleolar osteotomy, most cases improve with growth

what is the most common surgical repair?

tension band wiring

Posterior drawer sign

testing for PCL injury

where is the most common place for osteochondritis dissecans?

the knee- medial femoral condyle

what is the most common long bone fracture?

tibial shaft fracture

how does LCL injuries appear on exam?

varus instability at 30 degrees of flexion

What xray is most sensitive for revealing early osteoarthritis ?

weight bearing 45 degrees posterioranterior view

what imaging would you get for DJD of the knee?

weight bearing AP, lateral, merchant view, lateral flexion and extension view

when do meniscal cysts occur primarily?

with horizontal cleavage tears of the lateral meniscus

who has higher rate of injury for ACL?

women

who most frequently suffer from patellar dislocations?

young adults and adolescents

who would typically suffer from osteochondritis dissecans?

young men (50% of adolescents), after injury to the joint