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Knee

Orthopedics

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