Orthopedics
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| Tib/fib: which one is weight bearing? | Tibia
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| Knee Hx: | MOI ( twist, blow to knee, trauma); Pain; Instability, pops, clicks, grinding; swelling; pain hip/ ankle/ foot; prior
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| Inspection: Note: | contralateral joint (compare)
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| Immediate swelling: Big 4: | ACL Tear; Patella Dislocation; Fx; Meniscus tear (not always)
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| Knee: DDx: Ant. Knee Pain | Patellofemoral dysfxn; Patellar tendinitis; Plica/ Fat Pad irritation
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| Knee: DDx: Medial | Meniscus, DJD, MCL; Pes Anserine Bursitis; Chondral lesion
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| Knee: DDx: Lateral | Meniscus, LCL, ITB; Posterolateral corner (PLC); Chondral lesion
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| Knee: DDx: Instability | ACL, PCL, PLC, ITB
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| Knee: DDx: Swelling ( immediate): | ACL, fx, dislocation, meniscus
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| Knee: DDx: Swelling (Intermittent) | Meniscus, gout, chondral lesions
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| Knee: DDx: Other | Infection, arthritis, referred pain, neoplasm
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| Knee PE: inspection | Swelling/Effusion (1+ to 3+ ; Local vs diffuse; Acute vs Chronic); Bruising; Deformity (fx; prior surg); Scars; Quad atrophy
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| Knee PE: Palpation: medial | Joint line (Menisc ); Condyle (Chondral lesion); Plica; Pes Ans bursa; MCL; Medial retinaculum (patella dislocn)
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| Knee PE: Palpation: lateral | Joint line (Menisc); LCL; Iliotibial Band (Gerdy tub.; Bursa); Condyle (Chondral lesion; Patella dislocation); Femoral head (Peroneal n. Sx); PLC (posterior)
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| Knee PE: Palpation: posterior | Bakers cyst (Menisc); Meniscus tears; Poplit art; Poplit mx; Gastrocnemius tear; Hamstring tear (distal)
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| Knee PE: ROM | Flexion (135-140; goniometer); ext 0 degree (some: 5-10 degree natl hypertext); cf to nml knee; Squat (ltd ? Menisc tear)
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| Patella Tests | Med/Lat glide; Apprehension (instability); Inhib test (PFS); Q angle; J Tracking; Poplit Angle (Hamstring tightness); Modified Thomas Test (Quad/ hip flexor tightness)
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| Q angle | angle formed by line: ASIS to ctr of patella & line fr ctr of patella thru tibial tubercle; <20 degrees = nl
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| Medial knee tests | MCL or Valgus; McMurray;
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| MCL or Valgus test | O & 20-30 degrees flexion
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| MCL or Valgus test: instability at 0 degrees = | Concomitant ACL
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| MCL or Valgus test: Concomitant ACL Grade I = | no opening, but pain
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| MCL or Valgus test: Concomitant ACL Grade II = | opening with endpoint
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| MCL or Valgus test: Concomitant ACL Grade III = | no endpoint
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| McMurray test: sensitivity = | Only 65%
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| McMurray test: medial (ME) = | Ext rotation w/ flexion & valgus
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| McMurray test: lateral | Internal rotation w/ flexion & varus
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| McMurray test: true positive = | A click (not pain)
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| McMurray test: Apleys compression = | Not usually helpful
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| Lateral knee tests | Ober; Nobles compression; PLC; reverse pivot; posterolateral drawer; dial
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| Lateral knee tests: Varus testing for LCL: grading = | Same grade as for MCL
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| IT Band tests | Obers; Nobles compression test
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| Obers | Inability for Up Leg to go down to table (= tight lateral structures)
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| Nobles compression test | Pain over lat. Fem condyle at 20 deg knee flexion
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| PLC injury usu occurs: | in ACL and/ or multi-ligament knee injuries
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| PLC tests | Recurvatum (with PCL); dial test at 30 degrees flexion; reverse pivot shift
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| ACL Tests | Lachman; ant drawer (unreliable); Pivot shift (difficult)
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| ACL Tests: gold std = | Lachman
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| PCL Tests | Post drawer & recurvatum; sag sign; quad active; dial test at 90 degrees flexion
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| PCL Tests: problem w/ dx | easily missed or mistaken for ACLs (Hx important)
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| PCL Tests: Posterior drawer | Much better than ant. drawer
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| Knee Films | AP, Lateral; Merchant; Tunnel view (look for OCD)
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| Knee Films: AP/ Lateral | Tumors; Fx; DJD; Surgeries/ Hardware
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| Knee Films: Merchant | Patella (Instability; DJD; Chondral lesions)
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| Knee DJD: Fairbanks Changes | Flattened Tib. plateau; cec. joint space; Osteophytes; Subchondral cysts
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| MRI: excellent for: | soft tissue
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| MRI in ortho: for: | ACL ( >95%); Menisc (>85%); chondral lesion (cannot quantify size); MCL,LCL,PLC,PCL; Bone Contusions/ Edema; tumors; fx?
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| CT: excellent for: | fracture characterization
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| CT: not good for: | evaluating soft tissue injuries
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| Quad active test: | When quad mx is activated, pulls tibia forward; when it relaxes, tibia sags
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| Recurvatum test: | Pulling up on toe to about 15 degrees of hyperextension, then just falling back (as if not attached properly at knee)
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| Lachman test: | At 20 degrees flexion; stabilize femur, pull up on tibia
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| Ant drawer test: | knee is flexed to 90, then pull on tibia
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| Thomas test: | If hip flexors are tight, when pull one leg up, other leg also pulls up somewhat
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| MCL: typical Hx: | Valgus injury (Soccer, ice hockey)
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| Most common lig. Tear = | MCL
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| MCL: PE: | Medial pain (on joint line, above & below); Grade I,II,III; Valgus stress
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| MCL: Tx: | conservative; NSAIDs; Ice; Rest; Bracing; PT; RTP?; Surgical: Rare
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| MCL: Tx: RTP (Gr I,II): | symptomatic tx
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| MCL: Tx: RTP (Gr III): | 4-6 weeks, start in extension
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| Medial Meniscus Tear: Hx | Twisting injury (Acute); Degenerative; Swelling +/- ; Locking/ catching
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| Medial Meniscus Tear: PE: | MJL tenderness; McMurray; Apley; Cyst
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| Medial Meniscus Tear: Tx: | conservative vs surgical
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| OCD = | Osteochondritis Dissecans
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| OCD & Chondral Defects: Hx: | Intermittent swelling after exercise, locking, catching, vague pain
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| OCD & Chondral Defects: PE: | small effusion, TTP MFC or LFC
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| OCD & Chondral Defects: Tx: | NWB, progress slowly over 6 weeks or more
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| Plica Syndrome: Hx: | snapping, esp with squats (can also be MMT)
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| Plica Syndrome: PE: | palpable plica, localized swelling; Imaging (r/o other injuries)
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| Plica Syndrome: Tx: | PT, ice post exercise; iontophoresis; NSAIDs; Injection; Surgical excision
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| Lateral Knee Pain: DDx | Lat Meniscus Tear; LCL Tear; IT Band; Patella disloc/ subluxation; PLC; OCD; Hamstring strain/ tear; PFSS
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| ITB Syndrome AKA | Runners Knee
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| ITB Syndrome Sx | Snapping knee or hip; Occasional instability
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| ITB Syndrome: Look at: | biomechanics, flexibility; Mileage
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| ITB Syndrome: Tx: | PT, local distal injection, orthotics, different shoes or surfaces
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| LCL Tear = type of injury | Varus injury (do varus stress test)
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| LCL Tear: Varus test Grade I-II: | conservative; 1-2 wks(I), 4-6 wks (II)
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| LCL Tear: Varus test Grade III: | consider surgical repair/ reconstruction; assess for concomitant injuries (PLC)
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| Patellar Dislocation: Hx: | visual sublux/ dislocation, twisting motion; previous occurrence? Brace? N/V status
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| Patellar Dislocation: PE: | Ant Knee exam; biomechanics
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| Patellar Dislocation: Radiographs: | AP/Lat, Merchant view
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| Patellar Dislocation: Tx: | extension brace 1-2 wks; quad strengthening; RTP w/ buttress brace
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| Patellar Dislocation: Tx: If multiple: | consider surgical repair
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| ACL Tx | Extension Post-op brace locked at 0 deg or knee immobilizer for very short term (until referred); mostly for protection; ACE for swelling; NSAIDs; PT (Prehab); Refer; consider brace
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| ACL: dx tests | MRI to R/O other injuries
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| ACL: recovery time if reconstructed: | 9-12 mos
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| PCL Injuries: tests | Posterior drawer; sag sign; Recurvatum; Quad active test
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| Theater sign | seated, kneecap pushes into articular cartilage (spongy, water is displaced); sit up, kneecap pushes into waterless sponge space: pain.
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| PFD Tx | PT; Short course of NSAIDs; open patella brace optional; footwear/ orthotics ; modify activity; Surgery (Last Resort)
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| PFS: Tx: PT for: | VMO (vastus medialis obliqus) (co-contract with adductors); hip abductors/ ext rotators
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| Hemarthrosis | usually due to injury (most common ACL), rapid effusion (2-4 hrs)
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| most common cause of knee pain in pts <45 yo = | PFPS; esp women
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| young pt w/ant knee pain worse w/repetitious flexion & without clear alternative cause: | PFPS
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| Local TTP, pain on motion and at rest; occasional loss of active movement; swelling, erythema, warmth: | bursitis (inflammation of synovial membrane over bony prominences)
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| Most common knee injuries | medial: anserine bursitis; MCL (most common lig); medial meniscus (most vulnerable)
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| 2nd most common knee pain site | anterior: PFPS; prepatellar bursitis; OSD; inflam arthritis
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| least common knee pain site | lateral: lat meniscus; ITB
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| Diffuse anterior knee pain w/ swelling & inflammatory change = | inflammatory arthritis (RA, gout, pseudogout) or septic arthritis
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| meniscus tear dx made by: | MRI or diagnostic arthroscopy
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| Lachman test assesses: | anterior-to-posterior laxity
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| McMurray test: | rotate foot outward to test medial meniscus; inward to test lateral; + is painful click
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| Knee pain DDx | OA, effusion, pop cyst, bursitis, ACL/coll lig, meniscus tear, PFPS, ITB, stress fx injury to ACL/PCL, meniscus, PF syndrome, bursitis, OSD, ITB, baker cyst, OA, RA
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| tests for suspected (knee & hip) OA | ESR, RF, synovial fluid analysis, imaging
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| Large joint pain. Knees w/ medial joint space narrowing, osteophytes. No erythema or warmth | Osteoarthritis (tx acetaminophen)
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| Tibial pain after running (military recruits), athletic activity (running sports) | Shin splints, stress fracture. Get bone scan if negative x-ray
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| Noncontact knee injury; pop; pivoting stress | ACL (Lachman / ant drawer test)
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| 8 – 10yo male with limp, knee pain | Legg-Calve-Perthes Disease
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| 12 – 15yo overweight male knee pain, limp, hip pain (knee XR normal) | SCFE
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| Adolescent male with knee pain, tenderness over tibial tuberosity | Osgood-schlatter disease
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| Retropatellar knee pain esp. in females | Patellofemoral pain syndrome – increased Q angle, strengthen quadriceps
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| Degenerative area at proximal end of patellar tendon | patellar tendonopathy (must distinguish from osgood schlatter)
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| Sudden pop with plantarflexion (& Pain with active plantarflexion but strength intact) = | Medial gastrocnemius tear (RICE, no surgery)
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| bucket handle tear | meniscus tear (McMurray may reduce); tx arthroscopic repair or debridement (conservative tx not helpful)
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| Tib/fib: which one is weight bearing? | Tibia
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| Immediate swelling: Big 4: | ACL Tear; Patella Dislocation; Fx; Meniscus tear (not always); Within first few hrs: Hemarthrosis
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| Patella Tests | Med/Lat glide; Apprehension (instability); Inhib test (PFS); Q angle; J Tracking; Poplit Angle (Hamstring tightness); Modified Thomas Test (Quad/ hip flexor tightness)
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| Q angle | angle formed by line: ASIS to ctr of patella & line fr ctr of patella thru tibial tubercle; <20 degrees = nl
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| Medial knee tests | MCL or Valgus; McMurray
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| MCL or Valgus test | O & 20-30 degrees flexion
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| MCL or Valgus test: instability at 0 degrees = | Concomitant ACL
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| MCL or Valgus test: Concomitant ACL Grade I = | no opening, but pain
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| MCL or Valgus test: Concomitant ACL Grade II = | opening with endpoint
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| MCL or Valgus test: Concomitant ACL Grade III = | no endpoint
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| Lateral knee tests | Ober; Nobles compression; PLC; reverse pivot; posterolateral drawer; dial
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| IT Band tests | Obers; Nobles compression test
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| Nobles compression test | Pain over lat. Fem condyle at 20 deg knee flexion
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| ACL Tests | Lachman; ant drawer (unreliable); Pivot shift (difficult)
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| ACL Tests: gold std = | Lachman
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| PCL Tests | Post drawer & recurvatum; sag sign; quad active; dial test at 90 degrees flexion
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| Quad active test: | When quad mx is activated, pulls tibia forward; when it relaxes, tibia sags
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| Recurvatum test: | Pulling up on toe to about 15 degrees of hyperextension, then just falling back (as if not attached properly at knee)
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| Lachman test: | At 20 degrees flexion; stabilize femur, pull up on tibia
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| Ant drawer test: | knee is flexed to 90, then pull on tibia
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| Thomas test: | If hip flexors are tight, when pull one leg up, other leg also pulls up somewhat
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| Most common lig. Tear = | MCL
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| Medial Meniscus Tear: Hx | Twisting injury (Acute); Degenerative; Swelling +/- ; Locking/ catching
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| OCD = | Osteochondritis Dissecans
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| OCD & Chondral Defects: Hx: | Intermittent swelling after exercise, locking, catching, vague pain
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| OCD & Chondral Defects: PE: | small effusion, TTP MFC or LFC
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| Plica Syndrome: Hx: | snapping, esp with squats (can also be MMT)
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| ACL Tx | Extension Post-op brace locked at 0 deg or knee immobilizer for very short term (until referred); mostly for protection; ACE for swelling; NSAIDs; PT (Prehab); Refer; consider brace
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| ACL: recovery time if reconstructed: | 9-12 mos
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| PCL Injuries: tests | Posterior drawer; sag sign; Recurvatum; Quad active test
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| Theater sign | seated, kneecap pushes into articular cartilage (spongy, water is displaced); sit up, kneecap pushes into waterless sponge space: pain
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| Dx given to pt who present w/traumatic knee effusion, until proven otherwise | ACL tear
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| possible graft choices in an ACL repair | bone-patellar tendon-bone, hamstring autograft, cadaver allograft
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