Goals. Our Real Goals. Michael H. Boothby, MD Southwest Orthopedic Associates Fort Worth, Texas. Perform a basic, logical, history and physical exam

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1 Michael H. Boothby, MD Southwest Orthopedic Associates Fort Worth, Texas Goals Our Real Goals Perform a basic, logical, history and physical exam on a patient with knee pain Learn through cases, some common knee injuries and their associated treatments Know when to acutely refer a patient for further orthopaedic care 1

2 Knee Injury Overview I. Evaluation History Physical Exam Radiographic Exams II. Treatment of common knee injuries Patellofemoral Syndrome Collateral ligament injury (MCL v LCL) Meniscus injury Cruciate ligament injury (ACL v PCL) Case History Patient is a 25yo male professional basketball player Patient was playing basketball and had a fall which resulted in knee pain and deformity with immediate effusion YOU, are asked to evaluate the patient courtside and render appropriate care Case History- Video 2

3 Knee Evaluation History 6 Questions for Every Patient Acute or Chronic Mechanism of injury Varus or Valgus Rotation or Hyperextension Pain nature and location Swelling (when and how long) Locking or catching Buckling or giving way Knee Evaluation Physical Exam 6 Exam Points for Every Patient Skin Effusion Alignment Range of motion Stability Tenderness to Palpation Physical Exam Breakdown Points Skin: Open/Closed Warm/Cool Effusion Swelling inside joint capsule Traumatic, Hematologic, Infectious, Pathologic Alignment Varus/Valgus Procrevatum/Recrevatum 3

4 Range of Motion Passive versus Active Typically Degrees Loss of extension Meniscus tear ACL tear Loss of flexion may be only due to effusion May be posterior meniscus injury Beware the arthritic patient Stability- Cruciate Ligaments Evaluate at 30 and 90 of flexion Lachman is most sensitive test to isolate ACL rupture Anterior Drawer requires relaxation Posterior Drawer may not be positive if Tibial Sag Pivot Shiftis hf useful lfor ACL rupture, but difficult Stability- Collateral Ligaments Evaluate at 0 and 30 of flexion In extension laxity indicates injury to posterior capsular structures C i t i j i l it i t i Cruciate injury may increase laxity in extension Laxity at 30 isolates the MCL and LCL 4

5 Tenderness to Palpation Medial Joint Line Lateral Joint Line Medial/Lateral Femoral Condyle Medial/Lateral Tibial Plateau Proximal/Distal Pole Patella Patella-femoral Grind Be Systematic! Radiographic Evaluation Three views of the knee AP Lateral Sunrise Case Study- Break 25 yo professional football player seen on the field after a tackle with the following physical exam That s an Orthopaedic consultation!! 5

6 Cases and Treatments for Difficult Knee Injuries Patelofemoral Syndrome Collateral Ligament Injury MCL LCL Meniscus Injury Medial meniscus tear Lateral meniscus tear Cruciate Ligament Injury ACL PCL Case #1 16 yo girl with 2 month history of worsening bilateral knee pain. She can t describe when or where it bothers her the most, but says she has trouble bending her knee with soccer, and has significant pain during gym workouts. Audience Responsea. Refer to Orthopaedics b. X-ray c. More specific H & P d. MRI Answer C. More specific H & P 6

7 Case #1 Continued After further specific history you find Pain worse with stairs, car rides, leg kept in bent position Pain located in the front of the knee, not on either side Pain worse with when squatting or lifting activities in the gym After physical exam you find Pain with full flexion anterior knee No pain along medial or lateral joint line, or either pole of patella No ligamentous instability Positive patella femoral grind test Audience Response: A. Medial meniscus injury B. Patella Femoral Syndrome C. Patellar Tendinitis (Jumpers knee) D. Anterior Cruciate Tear Correct Answer B. Patellar Femoral Syndrome 7

8 Patellofemoral Syndrome The Patient: Typically young women Pain in the anterior knee Stairs, Airplanes, Movies Instability Lateralization of patella with increased Q angle Crepitance: functionally and on exam Patellofemoral Syndrome The Reason: 4-5 x s your body weight in force between the patella and femur during stair climbing or squatting Lateralization of the patella multiplies this force by localizing it over a smaller area of the patella The Treatment: NSAIDS, Therapy, Taping, Bracing Surgery?? Case #2 36 yo man with pain on the outside of his knee after being checked in to the boards at his father/son floor hockey game. Knee did not swell up immediately. Now with continued pain despite OTC NSAID use and crutches. 8

9 Case #2 Continued After further questioning and an organized examination you learn... Pain to palpation is limited to lateral aspect of knee No feeling of locking or catching, although knee feels alittle loose Pain and slight instability with varus stress to the knee Negative Lachman and Posterior drawer testing Your thoughts??? Audience Response A. Lateral meniscus tear B. Hamstring Strain C. Loose Body in Knee D. Lateral Collateral Ligament Injury Correct Answer D. Lateral Collateral Ligament Injury 9

10 Collateral Ligament Injury Grade 1 Tenderness Grade 2 Increased laxity solid end point (5-10mm opening) Grade 3 Complete disruption (>10mm opening) Collateral Ligament Injury Medial Collateral Ligament Superficial; deep portions 80% of valgus stability at 25 flexion Non-isometric i insertion i Pain along ligament, but mostly at the condyles Collateral Ligament Injury MCL Injury Treatment Non-operative Improved collagen and strength with motion Ice: NSAIDS Reestablish ROM Brace grade 2 and 3 10

11 Collateral Ligament Injury Lateral Collateral Ligament Injury Varus stability Difficult to diagnose Isometric insertion Grade 3 injuries require reconstruction or repair Associated injury common PCL Posterolateral corner Case #3 54 yo man had a twisting injury to the L knee when he stumbled in a hole mowing his lawn. He had significant pain but was able to finish mowing his yard. He now has continued pain for 4 weeks even though he has tried ice, rest, and some antiinflammatories. Case #3 Continued On further evaluation you note The patient reports inability to completely straighten out the leg Has worsening pain with twisting activities Has periods of exquisite pain and then periods of relative comfort Pain to palpation directly over the medial joint line Positive McMurray s Test 11

12 Audience Response A. ACL Tear B. Meniscus Tear C. Baker s Cyst D. Gout Correct Answer B. Meniscus Tear Meniscus Injury Joint line tenderness Localized pain with full flexion Tibial rotation- McMurry Loss of extension (locked) Effusion- worse with exercise 12

13 Meniscus Function Load transmission Shock absorption Joint stability Joint lubrication Proprioception Meniscus Tears Non-operative Indications Surgical Indications Restriction of ADLs or sports Confirmatory exam Absence of other causes of knee pain Failed conservative management Activity modification Physical therapy Meniscus Tears Surgical Management Location of tear Age of patient ACL tear? 13

14 Meniscus Tears Operative Management: Bucket Handle Meniscus Tear Meniscus Tears Operative Management: Degenerative Meniscus Tear Meniscus Tears Operative Management: Meniscus Repair Special Thanks to Dr. Alan Barber for this arthroscopic footage 14

15 Menisectomy Normal 50% of load in extension 85% of load in flexion Menisectomy Increase in contact stress related to amount of tissue removed Case #4 18 yo running back for your local HS football team twists awkwardly through the line and sustains a twisting injury to his R knee. He is unable to ambulate without assistance and his knee swells immediately. After suffering though a night of ibuprofen and ice he meets you the office the following day Case #4 continued After examining the patient and speaking with his parents you find Difficulty with complete terminal extension Unable to ambulate without crutches X-rays are negative for fracture Has equivocal lachman test that is difficult to perform Mild medial joint line pain Neurovascular intact throughout extremity IDEAS??? 15

16 Audience Response A. Knee Dislocation B. Medial Meniscus Tear C. Patella Fracture D. ACL Rupture Correct Answer D. ACL Rupture Cruciate Injury: PCL Often missed Confused with ACL tear due to increased tibial translation from posterior starting position Posterior sag of tibial tubercle (90 ) Most likely treated with Rehabilitation because of ligaments broad insertion and ability to heal Maybe reconstructed surgically in cases of multiple ligament injury 16

17 PCL Injury: MRI Cruciate Injury: ACL Large effusion immediately after injury Anterior drawer Watch for hamstring spasm May diminish 2-7 days after injury Lachman 30 flexion Degree of anterior tibial translation End point?? (soft, firm, none) ACL Tests 17

18 ACL Injury: MRI ACL Reconstruction When to refer. Uncomfortable with anatomy/diagnosis Continued stiffness Failure to progress MRI evidence of meniscus or cruciate injury Multiple ligament injury ACL- PCL Knee Dislocations 18

19 Lets Review- What did we learn? History Duration, Mechanism, Where is the pain, Locking, Giving way or buckling Physical Exam Skin, Effusion, ROM, Stability, Tenderness Basic Knee Injuries Patellofemoral Syndrome, Collateral Ligament Injury, Meniscus Injury, Cruciate Ligament Injury When to Refer Unsure of anatomy or diagnosis, failure to progress, radiographic confirmation of injury, any question about patient

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