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Dr Ahmed Al Jabri Jan 26th 2010
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KNEEINJURIES
AhmedALJabri
outlines
• Relevantanatomy• History(focused)• KneeexaminaBon(specialtests)
• Toxrayornot?• Specificinjuries(interac0veformat).
ANATOMY/physiology
• Thekneeisthelargestandmostcomplicatedjointinthebody.
• MoBonatthekneeisacomplexinteracBonofflexion,extension,rotaBon,gliding,androlling.
• modified‐hingediarthrodialsynovialjoint.• 3bones,2meniscus,4mainligaments.• Greatstabilitymainlydependsontheintegrityoftheligamentousstructures
WhichofthefollowingisFalse?
1.FuncBonally,thekneejointcanbedividedintothreecompartments:patellofemoral,medialBbiofemoral,lateralBbiofemoral.
2.Foundwithinthepoplitealspacearethepoplitealartery,thepoplitealvein,andtheperonealandBbialnerves.
3.Thelateralandmedialfemoralepicondylesserveasimportantsitesoforiginforthemedialandlateralcollateralligaments,respecBvely
4.1&25.Noneoftheabove
WhichofthefollowingisFalse?
1.FuncBonally,thekneejointcanbedividedintothreecompartments:patellofemoral,medialBbiofemoral,lateralBbiofemoral.
2.Foundwithinthepoplitealspacearethepoplitealartery,thepoplitealvein,andtheperonealandBbialnerves.
3.Thelateralandmedialfemoralepicondylesserveasimportantsitesoforiginforthemedialandlateralcollateralligaments,respec0vely
4.1&25.Noneoftheabove
Regardingpoplitealartery?
• representsthedirectconBnuaBonofthefemoralarterybeyondtheadductorhiatus
• descendsacrosstheposterioraspectofthekneejointandterminatesattheleveloftheBbialtubercle.
• itdividesintotheanteriorandposteriorBbialarteriesattheleveloftheBbialtubercle
• Itisanchoredfirmlyattheproximalanddistalendsofthepoplitealfossa.
• Bloodsupplytothekneejointcomesfromthepoplitealarteryviathegeniculatearteries
• Alloftheabove
Regardingpoplitealartery?
• representsthedirectconBnuaBonofthefemoralarterybeyondtheadductorhiatus
• descendsacrosstheposterioraspectofthekneejointandterminatesattheleveloftheBbialtubercle.
• itdividesintotheanteriorandposteriorBbialarteriesattheleveloftheBbialtubercle
• Itisanchoredfirmlyattheproximalanddistalendsofthepoplitealfossa.
• Bloodsupplytothekneejointcomesfromthepoplitealarteryviathegeniculatearteries
• Alloftheabove
HISTRORY
IniBalAssessment:History
• Injuryhistory• Pain• Clicking• Locking• Givingway• Instability• Swelling
Injuryhistory
• High‐energytraumawithoutkneeswellingshouldraisethesuspicionofdisrupBonofthejointcapsulewithexpulsionofjointfluidandhemorrhageintothethighorlowerleg.
• Lowerenergyinjuriesaremorecommonlyassociatedwithmeniscaltears,patelladislocaBons,andlesssevereligamentinjuries.
• acBviBeswithtwisBngandturningareassociatedwithanteriorcruciatetearsandmeniscalpathology.
FocusedHistoryQuesBons
• OnsetofPain– Dateofinjuryorwhensymptomsstarted
• Loca0onofpain– Anterior– Medial
– Lateral– Posterior
FocusedHistoryQuesBons2
• MechanismofInjury‐helpspredictinjuredstructure
– Contactornoncontactinjury?• Ifcontact,whatpartofthekneewascontacted?
– Anteriorblow?– Valgusforce?– Varusforce?
– Wasfootofaffectedkneeplantedontheground?
Valgusalignment=distalsegmentdeviateslateralwithrespecttoproximalsegment.
FocusedHistoryQuesBons
• Injury‐AssociatedEvents– Popheardorfelt?
– Swellingacerinjury(immediatevsdelayed)
– Catching/Locking
– Buckling/Instability(“givingway”)
HistoricalCluestoKneeInjuryDiagnoses
Noncontact injury with “pop” ACL tear Contact injury with “pop” MCL or LCL tear, meniscus
tear, fracture Acute swelling ACL tear, PCL tear, fracture,
knee dislocation, patellar dislocation
Lateral blow to the knee MCL tear Medial blow to the knee LCL tear Knee “gave out” or “buckled” ACL tear, patellar dislocation Fall onto a flexed knee PCL tear
CommonSymptomsFactor Meniscal Cruciate MCL/
LCL Chronic Instability
Swelling + delayed
+++ early
- absent
++ recurrent
Locking yes no no yes
Clicking yes no no yes
Giving way
yes yes no yes
EXAMINATION•
1.Outlineareasoftenderness.
2.Notewhetheranyeffusionispresent.
3.CheckforrangeofmoBon,valgusstressat0and30degreesofflexion,andvarusstressat0and30degreesofflexion.
4.Evaluatethepatellarandextensormechanismoftheknee(quadricepsandpatellatendons).
5.PerformLachman's,anteriordrawer,posteriordrawer,andpivotshicteststocheckforanterolateralrotatoryinstabilityandfurtherdelineatepossibleinjurytotheanteriorcruciateligament.
6.PerformmeniscalexaminaBonwithMcMurray'sandApley'stests.
1,quadricepstendiniBs;2,prepatellabursiBs,patellapain;3,reBnacularpainacerpatellasubluxaBon;4,patellatendiniBs;5,fatpadtenderness;6,Osgood‐Schlamerdisease(Bbialtuberclepain);7,meniscuspain;8,collateralligamentpain;9,pesanserinetendiniBsbursiBs
STABILITYTESTING
• AnteriorDrawerTest.• Lachman'sTest.
• PosteriorDrawerTest.• McMurray'sTest.
• Apley'sTest.• PivotShi\.• CollateralLigamentStressTest.
AnteriorDrawerTest
• TheanteriordrawertestisatestfordisrupBonoftheanteriorcruciateligament(ACL).
• HOWTODOIT?VIDEOs\kneeinjury.flv
AnteriorDrawerTest
• AposiBvetestisdefinedastheabilityoftheBbiatomoveforwardrelaBvetothefemurcomparedwiththeotherknee.
• False‐negaBvefindingsmayoccurfromaneffusionprevenBngkneeflexionto90degrees,hamstringmusclespasmcausedbypain,orinsufficientforceappliedduringperformanceofthetest
• Afalse‐posiBvetestcanbecausedbyposteriorcruciateligament(PCL)insufficiency,whichallowstheBbiatoslipbackonthefemur,showinganabnormalamountofdisplacementwhenpulledforward
Lachman'sTest
• currentlythebestclinicaltestfordeterminingtheintegrityoftheACL;
• RELIABLEwhenthereisanacutehemarthrosis
• thekneeflexed20to30degreeswithonehandgraspingthethighandstabilizingit.TheBbiaispulledforwardwithananteriorlydirectedforce
VIDEOs\KneeExamLachmanTest.flv
Lachman'sTest:gradesofinstability
1. 1+(0to5mmmoredisplacementthanthenormalside),
2. 2+(5to10mm),
3. or3+(>10mm).
Lachman'sTest:limitaBons
• PCLmustbeintactforthetesttobevalid• false‐negaBvetestsincludehamstringspasm,meniscaltears,andthird‐degreeMCLtearswithposteriormedialextension.
• SpecificlimitaBonsofLachman'stestincludedifficultyquanBtaBngtheamountofanteriortranslaBonandinabilitytolimitmoBonofthefemur.
• Lachman'stestalsomaybedifficulmoperformiftheexaminer'shandsaresmallrelaBvetothepaBent'sthigh.
PosteriorDrawerTest
• Theposteriordrawertestremainsthe“goldstandard”forevaluaBngPCLinjury
• Howtodoit?VIDEOs\PosteriorDrawerTest‐Knee.flv
PosteriorDrawerTest
PosteriordisplacementoftheBbiamorethan5mm, or a “soc” endpoint, indicates injury tothe PCL. A normal knee should exhibit nosignificantposteriorexcursion
McMurray'sTest
• McMurray'stestisusedtoidenBfymeniscaltears
• Howtodoit?VIDEOs\McMurraystest.flv
McMurray'sTest
1. AposiBvetestoccurswhen,withtheotherhand,a“clicking”sensaBonisfeltalongthejointlineorthepaBentexperiencespainduringinternalandexternalrotaBon.
2. BytwisBngthelegintointernalrotaBon,theposteriorsegmentofthelateralmeniscusistested.
3. ExternalrotaBonteststheposteriorsegmentofthemedialmeniscus
Apley'sTest
1. Apley'stestalsoaidsindiagnosingmeniscaltears.
2. WiththepaBentprone,thekneeisflexed90degrees,andthelegisinternallyandexternallyrotatedwithpressureappliedtotheheel.
3. DownwardpressureeliciBngpainsuggestsmeniscalpathology.
4. ThepainshouldberelievedwithdistracBonofthekneeandrotaBonofthelegbacktoaneutralposiBon.
PivotShi\
• ItshouldbedonecarefullyasitmayexacerbatetheiniBalinjury.
• UsedtodetectanterolateralrotatoryinstabilityassociatedwithaninjurytotheACLorlateralcapsularstructure.
• UNCOMFORTABLE,Usuallydonepre‐operaBvely
• Howtodoit?VIDEOs\Pivotshictest.flv
CollateralLigamentStressTest
ThecollateralligamentstresstestisusedtotesttheintegrityoftheMCLandLCL.
ValgusandvarustesBngatboth0and30degreesofflexion?
ItisimperaBvethattheinjuredkneebestresstestedtodetectligamentousinjury.Whichofthefollowingstatementsdescribing
thestresstestsforthekneeisFALSE?
1. Lachman'stest:amempttomovetheparBallyflexedBbiaanteriorlyandposteriorlyonthefemur;laxityindicatescruciateinjury.
2. Applyvarusandvalgusstresswiththekneein20‐30degreesflexion.DetectsmedialorlateralligamentinjuryUNLESSthecruciatesareintact.
3. Applyvarusandvalgusstressinfullextension.Instabilityindicatesinjurytothecruciatesaswellasthemedialorlateralligaments.
4. PosteriorsagoftheupperBbiaorposteriordrawersign:ruptureoftheposteriorcruciate.
5. Anteriordrawersign:ruptureoftheanteriorcruciate.6. Lateralpivotshic:onehandappliesavalgusforcetotheextendedknee
withthethumbonthefibularheadandtheotherhandinternallyrotatesthefootwhileflexingtheknee.Near30degrees,thelateralBbiawillpalpablyreducewithlateralandanteriorcruciateinstability.
ItisimperaBvethattheinjuredkneebestresstestedtodetectligamentousinjury.Whichofthefollowingstatementsdescribing
thestresstestsforthekneeisFALSE?
Applyvarusandvalgusstresswiththekneein20‐30degreesflexion.DetectsmedialorlateralligamentinjuryUNLESSthecruciatesareintact.
(Inslightflexionthecruciatesareunstressedandvarus/valgusstresscandetectisolatedmedialorlateralligamentinjury.Infullextensionthecruciatesstabilizethekneetovarus/valgusstress)
AllofthephysicalexaminaBonfindingsareconsistentwithameniscuskneeinjuryEXCEPT:
1. Jointlinetenderness.2. Kneeorgroinpain,locking,andlimitedexcursionofthe
joint.3. Effusionthattendstodeveloprapidlyacertheinjury.4. Apleytest:flextheknee90degreesandcompressand
rotatetheBbiaonthecondyles;painimpliesatornposteriorhornofthemedialmeniscus.
5. PosiBveMcMurraytest:WiththethumbandfingerspalpaBngthelateralandmedialjointlines,extendthekneewhilerotaBngthefootexternally;repeatwhilerotaBngthefootinternallywiththeoppositehand.Pain,lockingandgrindingaresuggesBveofameniscusinjury.
AllofthephysicalexaminaBonfindingsareconsistentwithameniscuskneeinjuryEXCEPT:
1. Jointlinetenderness.2. Kneeorgroinpain,locking,andlimitedexcursionofthe
joint.3. Effusionthattendstodeveloprapidlya\ertheinjury.4. Apleytest:flextheknee90degreesandcompressand
rotatetheBbiaonthecondyles;painimpliesatornposteriorhornofthemedialmeniscus.
5. PosiBveMcMurraytest:WiththethumbandfingerspalpaBngthelateralandmedialjointlines,extendthekneewhilerotaBngthefootexternally;repeatwhilerotaBngthefootinternallywiththeoppositehand.Pain,lockingandgrindingaresuggesBveofameniscusinjury.
RadiographicEvalua0on
toxrayornot
AllofthefollowingarecomponentofOmawaKneeRule,except?
1. thepaBentis55yearsorolder2. thereistendernessattheheadofthefibula3. thereisisolatedtendernessofthepatella4. thepaBentisunabletoflexthekneeto90º5. thereiskneeeffusion6. thepaBentisunabletotakefourstepsboth
attheBmeoftheinjuryandattheBmeoftheevaluaBon
AllofthefollowingarecomponentofOmawaKneeRule,except?
1. thepaBentis55yearsorolder2. thereistendernessattheheadofthefibula3. thereisisolatedtendernessofthepatella4. thepaBentisunabletoflexthekneeto90º5. thereiskneeeffusion6. thepaBentisunabletotakefourstepsboth
attheBmeoftheinjuryandattheBmeoftheevaluaBon
OmawaKneeRule
• Morethan$1billionisspentonemergencyradiographyofthekneeeachyearintheUnitedStates,with90%‐92%ofthesestudiesshowingnofracture.
• Theruleisalmost100%sensiBveand97%specific.
PimsburghKneeRuleinbluntkneetrauma
statesthatradiographyisnecessaryonlyifthepaBentfellorsustainedblunttraumatotheknee,andeitheroftwocondiBonsispresent:
• (1)ageyoungerthan12orolderthan50or• (2)inabilitytowalkfourfullweight‐bearingstepsintheemergencydepartment.
TRUEORFALSE?
• InTraumaThetradiBonal“kneeseries”isanteroposterior,lateral,andsunriseview.
FALSE
CORRECT:InTraumaThetradiBonal“kneeseries”isanteroposterior,lateral,andtunnelviews
Tunnel”views,whichimagetheintercondylarnotch,areusedtodetectBbialspinefracturesandloosebodieswithinthenotch
Specificinjuries
Kneedisloca0onrequiresimmediateorthopedicconsulta0onduetothehighincidenceof
complica0ons,includingallofthefollowingEXCEPT:
• unstableligamentinjury• meniscusinjury
• poplitealarteryinjury• sciaBcnerveinjury• Bbialnerveinjury• peronealnerveinjury
Kneedisloca0onrequiresimmediateorthopedicconsulta0onduetothehighincidenceof
complica0ons,includingallofthefollowingEXCEPT:
• unstableligamentinjury• meniscusinjury
• poplitealarteryinjury• scia0cnerveinjury• Bbialnerveinjury• peronealnerveinjury
KNEEDISLOCATION
• 50%‐60%areanterior• poplitealarteryinjuryismostcommonlyassociatedwithposteriordislocaBons
• PeronealnerveinjuryisthemostcommonmajorneurologicalproblemassociatedwithkneedislocaBon.
• WHENTOORDERANANGIOGRAPHY?
Bi‐parBtepatella(normalvariant)
Transverseandavulsionfracturesofthepatellaaremostocenduetoexcessivequadricepstensionrupturingthepatella,whereascomminuted
fracturesarecausedbydirecttrauma.Whichofthefollowingstatementsdescribingthetreatmentofpatella
fracturesisFALSE?
1. nondisplacedtransversefracture:ankletogroincylindercast
2. transversefracturedisplaced>2‐3mmorlargeavulsion:wirefixaBon
3. minorcomminuBonwithminimalseparaBon:meBculousalignmentandwirefixaBonofthefragments
4. comminutedfracture:excisionofbonefragmentsanddirectanastomosisofthequadricepstendontothepatellarligaments
Transverseandavulsionfracturesofthepatellaaremostocenduetoexcessivequadricepstensionrupturingthepatella,whereascomminuted
fracturesarecausedbydirecttrauma.Whichofthefollowingstatementsdescribingthetreatmentofpatella
fracturesisFALSE?
1. nondisplacedtransversefracture:ankletogroincylindercast
2. transversefracturedisplaced>2‐3mmorlargeavulsion:wirefixaBon
3. minorcomminu0onwithminimalsepara0on:me0culousalignmentandwirefixa0onofthefragments
4. comminutedfracture:excisionofbonefragmentsanddirectanastomosisofthequadricepstendontothepatellarligaments
Segondfracture
• representsabonyavulsionofthelateralBbialplateau
• animportantmarkerofACLdisrupBon
TibialPlateauFractures
• BecausetheiniBalinjuryisusuallyavalgusstresswithanabducBonforceontheleg,55%to70%ofcondylarfracturesinvolvethelateralplateau
• ThemostimptaspectoftheiniBalexaminaBonistheneurovascstatus
• DisplacedfracturesofthelateralcondylemayproduceperonealnerveparalysisinaddiBontoinjurytotheanteriorBbialartery
fourfactorsdeterminetheprognosisofBbialplateaufractures:
1. degreeofarBculardepression,2. extentandseparaBonofthecondylarfracturelines,3. diaphyseal‐metaphysealcomminuBonand
dissociaBon,
4. integrityofthesocBssueenvelope(i.e.,openversusclosed)
Management
• Asarule,accuratereducBonandprolongednon–weightbearingaretheguidelinestobefollowedinBbialcondylarfractures.
• Maintechniques– compressiondressing,closedreducBonandcasBng,skeletaltracBon,andopenreducBonwithinternalfixaBon
• Ingeneral,withmoreseverelydepressed#s,operaBvetreatmenthasbemerresultsthannonoperaBvetherapy;however,nouniversalagreementexistsontheacceptableamountofarBculardepression
Osteochondri00sDissecans
• ThedisorderisfoundmainlyinadolescentsandresultsinasegmentofarBcularcarBlageandsubchondralbonebecomingparBallyortotallyseparatedfromtheunderlyingbone
• ThemanagementofthesepaBentsisbasedonthestabilityoftheosteochondralfragmentandthematurityoftheskeleton– Iftheepiphysesareopen,conservaBvetreatmentwith
protecBveweightbearingusuallyresultsinhealingofthelesion.– Oncetheepiphysesareclosed,theprognosisforhealingis
guarded.Ifthefragmentsaredetached,theloosefragmentsrequiresurgeryforremovalorfixaBon.ProtectedrangeofmoBonwithnon–weight‐bearingacBvityfor6to10weeksisgenerallyadvised
AboyhasfallenfromalowlimbofatreeorfromhisbicycleontohisrightkneeandfracturedtheanteriorBbialspine
(intercondylareminence)oftheBbia.WhichofthefollowingstatementsconcerninghisinjuryisFALSE?
1. HisexamwillrevealaposiBvedrawersignandLachman'stest,andpossiblylaxityofthemedialcollateralligamentonvalgusstress.
2. Hisx‐raywillrevealafractureoftheBbialspine.3. Usually,surgicaltreatmentwithscreworwire
fixaBonispreferred.4. Usuallyclosedtreatment(ifposiBoningcan
achieveanatomicreducBon)ispreferred;otherwiseopenorarthroscopicfixaBonmayberequired.
AboyhasfallenfromalowlimbofatreeorfromhisbicycleontohisrightkneeandfracturedtheanteriorBbialspine
(intercondylareminence)oftheBbia.WhichofthefollowingstatementsconcerninghisinjuryisFALSE?
1. HisexamwillrevealaposiBvedrawersignandLachman'stest,andpossiblylaxityofthemedialcollateralligamentonvalgusstress.
2. Hisx‐raywillrevealafractureoftheBbialspine.3. Usually,surgicaltreatmentwithscreworwire
fixa0onispreferred.4. Usuallyclosedtreatment(ifposiBoningcan
achieveanatomicreducBon)ispreferred;otherwiseopenorarthroscopicfixaBonmayberequired.
SegondfractureandBbialspineavulsionfracture
• CTimageofkneedemonstraBngSegondfractureandBbialspineavulsionfracture
FractureoftheTibialSpine(intercondylareminence)
• Thespinehastwoprominences:themedialandlateraltubercles
• TheACLandtheanteriorhornsofboththemedialandthelateralmenisciamachintheanteriorintercondylarfossa.ThePCLandtheposteriorhornsofthemenisciamachintheposteriorintercondylarfossa.
• RadiographicevaluaBonshouldincludestandardAPandlateralviews,butatunnelviewprovidesaclearerlookattheintercondylarareaandmaybenecessarytoconfirmthediagnosis
intercondylareminence:CLASSIFICATION
– TypeIinvolvesincompleteavulsionoftheBbialspinewithoutdisplacement.
– TypeII,thereisanincompleteavulsionwithminimaldisplacementoftheanteriorthirdofthefracturefragment,buttheposteriorporBonremainsadherent.
– TypeIIIischaracterizedbycompleteseparaBonofthefragmentfromitsfracturebedandhasahigherassociatedrateofcollateralligamentinjuriesandperipheralmeniscaltears
• TypeIIIA,fractureswithcompletedisplacement,
• TypeIIIB,fractureswithdisplacementandrotaBon
THANKYOU