Term
| A sprain is stretching or partial tear of a __. |
|
Definition
|
|
Term
| Most common ligaments sprained include: |
|
Definition
Medial Collateral Ligament
Lateral Collateral Ligament
Anterior Cruciate Ligament (often complete tears)
Posterior Cruciate Ligament (often complete tears) |
|
|
Term
| The medial collateral ligament gives __ stability to the knee. |
|
Definition
|
|
Term
| The lateral collateral ligament gives __ stability to the knee. |
|
Definition
|
|
Term
| Dx of collateral ligament sprain/tear: |
|
Definition
Valgus stress is applied to the MCL – if there is pain or laxity this suggests a sprain/tear to the ligament
Varus stress is applied to the LCL – if there is pain or laxity this suggests a sprain/tear to the ligament
Tender to palpation at the ligament of concern, either proximal or distal insertion or centrally (if centrally, think about meniscal tear, especially at the MCL)
The knee is tested at 0 degrees of extension and at 30 degrees of flexion for both stress tests
Testing at 30 degrees isolates the ligament in question
Testing at 0 degrees includes the posterior medial corner with the MCL and the posterior lateral corner of the LCL |
|
|
Term
| When testing for a collateral ligament sprain of the knee, you test at __ __ to isolate the ligament in question. You also test at 0 degrees extension to include the __ __ corner of the __ and the __ __ corner of the __. |
|
Definition
- 30 degrees flexion to isolate ligament in question
- 0 degrees extension to include posterior medial corner of MCL and posterior lateral corner of LCL |
|
|
Term
| Treatment for medial/lateral collateral ligament sprain: |
|
Definition
- weight bear as tolerated (WBAT)
- crutches for comfort
- hinge knee brace if laxity and/or increased pain
- come out of brace to work on PROM and AROM
- refer to orthopedics to make sure no other problems |
|
|
Term
| The anterior cruciate ligament gives stability to prevent __ translation of the __. |
|
Definition
| - anterior translation of the tibia |
|
|
Term
| The posterior cruciate ligament gives stability to prevent __ translation of the __. |
|
Definition
| - posterior translation of the tibia |
|
|
Term
| Are ACL or PCL tears more common? |
|
Definition
|
|
Term
| Mechanism of injury for ACL/PCL tear: |
|
Definition
- pivoting on planted foot with flexion/extension of the knee
- sometimes with a varus/valgus force applied |
|
|
Term
| With ACL/PCL tears, the patient will complain of a __ and __ __ episodes. |
|
Definition
- pop
- giving way episodes |
|
|
Term
| Pts sometimes try to treat ACL/PCL tears on own thinking its just a sprain, but when they return to sports that require __, their knee __ __ or feels __. |
|
Definition
- cutting
- gives way
- feels unstable |
|
|
Term
| Cruciate ligament tears (ACL/PCL) and meniscal tears all increase the pts risk of __ in the future. |
|
Definition
|
|
Term
| Lachman's test is used to test for a __ __. |
|
Definition
|
|
Term
| What is a positive lachmans? |
|
Definition
|
|
Term
| If really can't tell if Lachmans is positive or not, you can order an ___. |
|
Definition
|
|
Term
|
Definition
- Lachman's test: 30 degrees flexion (best)
- Anterior Drawer test: 90 degrees flexion
- Pivot-shift test |
|
|
Term
|
Definition
Same tests as the ACL but you apply posterior translation during the Lachmans and posterior drawer test
Posterior sag sign may also be seen, which is another test for a PCL tear |
|
|
Term
|
Definition
| - sagging of the proximal tibia with knee flexed, seen with PCL tears |
|
|
Term
| __ is the best diagnostic technique short of surgery (arthroscopy) for dx of a cruciate ligament tear. |
|
Definition
|
|
Term
Athletes who play cutting/pivoting sports almost always have their ACL reconstructed in order to return to their sport.
The ACL is not required for straight away activities, such as running. However, a young person is generally advised to have the ACL reconstructed if they are active.
Most of the time patients above 39 years of age do not get their ACL reconstructed, unless they are physically fit and still participate in cutting/pivoting sports.
A patient can rehab the hamstrings, which can give anterior translation stability of the knee in the absence of an ACL. Although, the hamstrings will not replace the full strength of an ACL. |
|
Definition
|
|
Term
| A pt with a torn ACL who is older and does not need surgery, can rehab the __ to give knee stability in the absense of an ACL. |
|
Definition
|
|
Term
| Patients who sustain an ACL tear, and even a meniscal tear, have already set the cascade to develop osteoarthritis (OA) in the future. I have had patients who sustain an ACL tear and within 10 years have advancing OA. This does not happen to all patients, though. But, keep in mind, patients who come to you complaining of knee pain and have a history of a knee injury (ie. ACL tear, meniscal tear) despite surgery may have OA. Four view radiographs are important in this case (we will talk about more about radiograph views during the osteoarthritis section). |
|
Definition
|
|
Term
| Cruciate ligament tear treatment: |
|
Definition
- if choose surgery> at least 6 months of rehab
- not cleared to run until 4-5 months after surgery
- cannot return to pivoting/cutting sports for 6-7 months |
|
|
Term
| Stretching or partial tear of a muscle: |
|
Definition
|
|
Term
| Muscles at the knee that are commonly strained: |
|
Definition
Anterior thigh muscles including:
- Rectus femoris
- Vastus medialis oblique (VMO)
- Vastus lateralis
Posterior thigh muscles:
- Biceps femoris |
|
|
Term
| Anterior thigh muscles commonly strained at the knee: |
|
Definition
- Rectus Femoris
- Vastus medialis oblique
- Vastus lateralis |
|
|
Term
| Posterior thigh muscles commonly strained around the knee: |
|
Definition
|
|
Term
|
Definition
- tender to palpation
- possible local swelling
- hematoma/bruising may occur |
|
|
Term
|
Definition
- Rest
- Ice for first 72 hours
- Heat/ice after 72 hours
- Gentle AROM, and as the strain improves gentle PROM
- Gradual return to activities as tolerated |
|
|
Term
| Contusions occur due to a __ __ to __ __ or __. |
|
Definition
| - blunt force to soft tissue or bone |
|
|
Term
|
Definition
| Hematomas may occur with ecchymosis. Sometimes a hematoma is large enough that an aspiration may be needed. Blood is usually aspirated |
|
|
Term
|
Definition
| Often very painful. It can occur outside or inside a joint. Sometimes feels like a fracture, and can take longer to be pain free than a fracture. May have an effusion requiring an aspiration (usually bloody) |
|
|
Term
| If you aspirate a joint and there are fatty deposits in the aspirate, you have to assume there is a ___. If the x-rays are negative, make the pt __ __ __ and __ the knee joint. Get an __ or __ __. If these are negative then the pt can weight bear as tolerated and work on range of motion. |
|
Definition
- fracture
- non-weight bearing and immobilize the knee
- MRI or CT scan |
|
|
Term
| Dx and tmt of contusions: |
|
Definition
- tender to palpation
- swelling
- ecchymosis
- negative radiographs
- tmt similar to strain tmt: rest, ice, ice/heat, gentle AROM then PROM, gradual return to activity |
|
|
Term
| Tendonitis may affect what three tendons of hip/knee: |
|
Definition
- Quadraceps tendonitis
- Iliotibial Band tendonitis(IT band)
- Patellar Tendonitis |
|
|
Term
| Mechanism of injury of tendonitis: |
|
Definition
|
|
Term
| Pts with quadriceps and/or patellar tendonitis complain of pain with __ activies or pain with __ of the knee, especially with __ range of motion. They also complain of pain with __ motion. |
|
Definition
- explosive
- flexion of the knee
- active range of motion
- eccentric |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
| With quadriceps/patellar tendonitis, if the pt pushes through the pain or continues activity is __ __. |
|
Definition
|
|
Term
| If a pt rupture the quad/patellar tendon, you may palpate a defect in the tendon and cannot __ the knee. |
|
Definition
|
|
Term
| Most of the time the mechanism of injury is when a patient falls (ie. Fall going down stairs with the knee flexed on the step below, putting a pull on the tendon with the quad contracted). |
|
Definition
|
|
Term
| IT band tendonitis is most commonly seen in __. The __ just __ or __ to the tendon can get swollen, red, and painful. Sometimes ___is palpated with the IT band with range of motion. |
|
Definition
- runners
- bursa just behind or medial
- crepitus |
|
|
Term
| Dx and tmt of tendonitis: |
|
Definition
- tender to palpation at the tendon
- sometimes swelling
- pain with stretching or movement of the tendon |
|
|
Term
|
Definition
- similar to strains
- steroid shots are ok for IT band tendonitis, but NOT patellar/quad tendon |
|
|
Term
| You can inject __ tendonitis, but not __ or __ tendonitis. |
|
Definition
- IT band tendonitis
- NOT quad or patellar tendonitis |
|
|
Term
|
Definition
- steroid flare
- infection
- de-pigmentation of skin
- fat atrophy
- tendon rupture |
|
|
Term
| with persistent biceps tendonitis (long head of the biceps in the shoulder joint at the superior labrum)we often will inject the tendon to cause it to rupture, because persistent biceps tendonitis treatment is a biceps tenotomy (surgically cutting the biceps tendon and let it fly). That way the patient can avoid surgery. However, you can see why we do not inject the quad tendon or patella tendon. Rupture of the quad tendon or patella tendon is devastating. Rupture of these tendons require immediate surgery. |
|
Definition
|
|
Term
| Patellofemoral pain syndrome is pain in the __ or ___ areas secondary to physical or biomechanical changes in the patellofemoral joint. |
|
Definition
| - peripatellar or retropatellar |
|
|
Term
| Pts with patellofemoral syndrome have inflammation behind and around the __. The pain is excaberbated by __, especially with weight bearing. Pts most commonly complain of pain with increased periods of __ with the knees __ and then when they move to a standing position. Some pts will complain of __ behing the patella.You may palpate __ at the patellofemoral joint. |
|
Definition
- patella
- bending
- sitting with the knees bent
- popping
- crepitus |
|
|
Term
| Patellofemoral syndrome demographics: |
|
Definition
- more common in females
- wide age range
- most of the pts have valgus in their knees
- usually DENY swelling, locking, giving way, and injury
- gradual in onset, unlness from fall
- patella may subluxate
- occurs with repetitive bending activities |
|
|
Term
| Reasons for PF (patellofemoral) pain may be multi-factorial: |
|
Definition
- Overuse/overload- overweight, repetitive activities
- Biomechanical- increased valgus, laterally tilted patella, pes planus at foot
- Muscular dysfunction- atrophy/weakness of the vastus medialis oblique (VMO) |
|
|
Term
| Increased __ of the knees, __ tilted patella, and __ __ can all cause PF pain. Also, weakness of the __ __ __ muscle can cause this. |
|
Definition
- valgus
- laterally tilted
- pes planus
- weakness of the vastus medialis oblique |
|
|
Term
| most commonly diagnosed knee problem in orthopedics: |
|
Definition
|
|
Term
| Osgood-Schlatters is an ___, which occurs at the __ __ in a growing child. It occurs at the __ of the __ tendon at the __ __. |
|
Definition
- apophysitis
- growth plate
- insertion of the patellar tendon ath the tibial tubercle |
|
|
Term
| Osgood-Schlatters occurs b/c the child's __ grows faster than the __, so the __ pulls on the tibial tubercle causing pain at its insertion. Often this occurs __ and is better with __. |
|
Definition
- bone grows faster than the tendon
- tendon pulls
- bilaterally
- rest |
|
|
Term
| The child that complains of Osgood-Schlatter is usually an __ that performs repetitive __ and __activities with the knees. |
|
Definition
- athlete
- jumping and flexing |
|
|
Term
| Osgood-Schlatters pts will be to tender to palpation at the __ __ and inspection will show a pronounced __ __. |
|
Definition
- tibial tubercle
- tibial tubercle |
|
|
Term
| Tmt of Osgood Schlatters: |
|
Definition
- avoid aggravating activities
- ice
- gentle stretching
- usually resolves when pt stops growing (if it does not its b/c pts formed ossicles which will need to be surgically removed) |
|
|
Term
| Prepatellar bursitis is inflammation of the bursa __ to the patella. These occur with repetitive __ or ___ to the anterior knee or a __ to the knee. May only present with __, but sometimes there may increased __, __, and __ to palpation. With these findings must rule out infection. |
|
Definition
- anterior
- kneeling or pressure
- contusion
- warmth, erythema, and pain |
|
|
Term
This is an infected pre-patella bursa, which most likely has caused a septic knee (we will talk about septic knees later on in this lecture). Notice the swelling and obvious erythema with well marked edges. This may have started as cellulitis and has become something more (an infected prepatella bursa and/or sepsis of the knee). Check vitals and labs (discussed under septic knee). If this was straight forward cellulitis you would mark the circumference of the erythematous edges with a good marker and have the patient return the next day to see how they respond to your treatment for cellulitis. However, in the above knee you would need to work it up for sepsis, before assuming this is a straight forward cellulitis.
***Always give the patient ER precautions (worsening symptoms, redness expanding beyond the marker, fever/chills/night sweats, and just all in all worse – go to ER)*** |
|
Definition
|
|
Term
| Treatment of bursitis when not infected is to avoid kneeling and repetitive bending. For prepatellar bursitis a __ or __ will help reduce swelling. It will usually resolve on its own. If there is significant swelling an ___ with help reduce swelling and pain. |
|
Definition
- sleeve or wrap
- aspiration |
|
|
Term
| Tmt of infected bursitis: |
|
Definition
If there is an infection, patient should still avoid repetitive bending and kneeling.
If cellulitis treat with oral abx, but if worse, possibly IV antibiotics (Abx).
I do not apply a sleeve or wrap with patients who have an infection.
An aspiration on a suspected infected pre-patella bursitis can help determine the abx of choice by running labs on the aspirate, but also reduce pain.
Do not put a patient on an Abx until you get a good aspirate
Generally, if you suspect a sepsis then you must REFER the patient immediately to the orthopedic specialist (the patient most likely will need an irrigation and debridement) |
|
|
Term
The knee has a medial and a lateral meniscus.
These menisci may tear with a ___ force to the menisci.
The mechanism of injury (MOI) that tears a meniscus is usually ___on a ___ foot with ___ or ___ of the knee, also with a valgus or varus force.
The patient will often report feeling/hearing a __.
The above MOI and ‘pop’ usually is reported with an __ __, as well. |
|
Definition
- shearing force
- pivoting on a planted foot with hyperextension or flexion of the knee
- pop
- ACL tear |
|
|
Term
| Dx this: Pts will complain of immediate swelling and pain with pivoting motions. Sometimes their knee will lock and they will be unable to fully extend. They will either point to the medial or lateral joint line as their source of pain. |
|
Definition
|
|
Term
| Osteoarthritis in the elderly may be mistaken as a __ __, don't do this. |
|
Definition
|
|
Term
| Pts who get mesical tears are at an increased risk for __. |
|
Definition
|
|
Term
| Tests used to dx meniscal tear: |
|
Definition
- McMurray Test
- Apley Test |
|
|
Term
| A positive McMurray test is pain at the __ __ while performing the test and feeling/hearing a __ __ under your finger at the joint line in question. This is used to dx __ __. |
|
Definition
- pain at the joint line
- clunk/click
- meniscal tears |
|
|
Term
| A positive Apley test for a meniscus tear is __ at the joint line. |
|
Definition
|
|
Term
| Radiographic image of choice for dx meniscal tears: |
|
Definition
|
|
Term
| To isolate a medial meniscal tear (MMT), flex the knee __ degrees and rotate it with a __ stress. |
|
Definition
- 90 degrees
- varus
(think you want to pinch the meniscus with McMurrays test, so a varus stress would pinch the medial meniscus) |
|
|
Term
| To isolate a lateral meniscus tear (LMT) you flex the knee __ __ and rotate it with a __ stress. |
|
Definition
- 90 degrees
- valgus stress
(this is McMurrays test) |
|
|
Term
| To perform Apleys test the patient is ___ with the knee __ __ __. The provider rotates the __with a compressive downward force. |
|
Definition
- prone
- 90 degrees
- tibia |
|
|
Term
| An MRI helps in determining the extent of a mensical tear, the best way to determine extent of injury is by __ __ __ of the meniscus via ___. |
|
Definition
| - direct visual inspection of the mensicus via arthroscopy |
|
|
Term
| Pt has a locked meniscal tear: |
|
Definition
| REFER TO ORTHO IMMEDIATELY FOR SURGERY |
|
|
Term
|
Definition
If true mechanical symptoms like locking and catching are occurring the patient will most likely need an arthroscopy to remove the torn portion of the meniscus
Some patients may tear the meniscus in an area of good blood supply and may do well with a repair of the meniscus. Often times you do not know if the meniscus is repairable until you actually perform the arthroscopy and take a direct look into the knee.
A torn meniscus generally does not heal, unless it is torn in the periphery in the younger patient (ie adolescent) where there is generally a good blood supply. The older the patient, the less likely you can repair a torn meniscus. |
|
|
Term
| A torn meniscus generally does not heal unless it is torn in the ___ in a __ patient. The older the pt, the less likely it is to heal. |
|
Definition
|
|
Term
| Post-op treatment of an arthroscopy only requiring removal of the torn portion of the meniscus is different than that of a meniscal repair. A menisectomy without repair will allow the patient to return to activities as tolerated faster and they are weight bearing immediately following surgery. However, a meniscal repair requires a patient to be non-weight bearing (toe-touch weight bearing only) for 6 weeks with a hinge knee brace locked from 0 to 90 degrees for 6 weeks to reduce shearing force on the repaired meniscus. This helps prevent a re-tear of the meniscus |
|
Definition
- arthrscopy> immediate weight bearing, activities as tolerated
- meniscal repair> no weight bearing for 6 weeks, hinge knee brace locked from 0 to 90 degrees for 6 weeks |
|
|
Term
| Do NOT order an __ on a pt who is bone on bone at the knee joint for x-ray. This means they likely have __. |
|
Definition
- NOT order an MRI
- osteoarthrits
(to determine joint space of knee have to order weight bearing x-ray views) |
|
|
Term
| YOU MUST GET WEIGHT BEARING FILMS TO HELP IN DECIDING HOW MUCH JOINT SPACE A PATIENT HAS IN THEIR KNEE JOINTS. (We will talk about weight bearing views for the knees in this lecture in a moment) |
|
Definition
|
|
Term
|
Definition
- Old Uncle Arther
- Degenerative Joint Disease |
|
|
Term
| Osteoarthritis is __ of __ __ and __ __. |
|
Definition
- degeneration of joint cartilage and underlying bone
It can occur due to normal wear and tear over years, and/or trauma |
|
|
Term
| OA pts complain of __ knee pain in their knee that is gradually getting worse. The pain comes and goes with __ and __. They complain of a __ __ __ around their knee. The knee may __ intermittently. |
|
Definition
- increasing knee pain
- activity and weather
- diffuse dull ache
- swell intermitenly |
|
|
Term
| If there is a diffuse effusion consider other dx besides OA. |
|
Definition
|
|
Term
| I had a 52 year male complaining of swelling in his knee. He was sent to me for knee arthritis. When I examined the knee it was severely swollen. I aspirated over 300 cc of fluid out of this patient’s knee. His x-rays showed degenerative changes, but when I reviewed more of his history I found out he had ankylosing spondylitis (a diagnosis that falls into rheumatology). This patient most likely was not going to improve with repeated aspirations (the swelling will continue to return, even with a steroid shot following the aspiration). He needed to have his ankylosing spondylitis treated by a rheumatologist requiring medicines that orthopedic providers do not prescribe. His knee pain and swelling may just improve with the rheumatology medications, and if not, he would then possibly need a knee replacement by an orthopedic surgeon. There are a lot of rheumatology problems that cause destruction of joints that lead to degenerative findings on radiographs, so always think about this in patients who have a history of something like rheumatoid arthritis, Lupus, and other autoimmune disorders. Sometimes just taking care of the disease producing the degenerative knee takes care of the joint pain and effusions. |
|
Definition
|
|
Term
| factors that suggest knee replacement necessary in an OA pt: |
|
Definition
- pain while sleeping
- affecting daily activities
- radiographs show advancing OA |
|
|
Term
| Best candidate for knee replacement: 65 years or older, minimal medical problems, already weight bearing (not wheelchair bound due to another problem), and the patient is emotionally, socially, and mentally ready and educated about the procedure |
|
Definition
|
|
Term
| Knee radiographs to dx arthritis should include what 4 views? |
|
Definition
- AP standing
- Lateral
- Sunrise/Merchant
- PA standing at 30-40 degrees flexion (aka PA flexion view) |
|
|
Term
| weight bearing knee views: |
|
Definition
AP standing
PA flexion standing |
|
|
Term
| Bowlegged patients may get ___ __ __. |
|
Definition
| - medial compartment osteoarthritis |
|
|
Term
| Knock kneed patients will moslty likely get __ __ __. |
|
Definition
| - lateral compartment osteoarthritis |
|
|
Term
| Terms used to describe arthritic knee on x-ray: |
|
Definition
Degenerative
Sclerotic
Loss of joint space
Bone spurs
Osteophytes
Bone cysts (usually subchondral)
Varus/Valgus deformity
Joint collapse |
|
|
Term
| With OA tmt don't jump to surgery, usually a long time before surgery needed. If the patient is less than __ years old still has greater than __ __ of space, an __ may help, but generally a knee replacement is inevitable. |
|
Definition
- 65 years old
- 2 mm
- arthroscopy
Most surgeons will not perform arthroscopies (less invasive, more like a clean-up job) on patients with osteoarthritis, unless they experience mechanical symptoms like locking and catching. |
|
|
Term
| Once an OA pt has knee joint space of __ __ or less, they are considered to have advanced stages of OA. |
|
Definition
|
|
Term
|
Definition
- watch and wait
- oral anti-inflammatories
- physical/aquatic therapy- cain, walker (NO WHEELCHAIR)
- Steroid shots
- Viscosupplementation injections (Supartz, Synvisc, hyaluronic acid injections)
- surgery eventually |
|
|
Term
| Remember a patient must have functional __ to be able to use anti-inflammatorires. |
|
Definition
|
|
Term
| For anti-inflammatory use, if pt is on warfarin need to have a good INR. If its __ than __, its ok to give steroid shot. |
|
Definition
|
|
Term
| In order to use viscosupplementation for tmt of OA, pt must not have __ or __ allergies. |
|
Definition
|
|
Term
| Avascular necrosis (AVN) is aka __. |
|
Definition
|
|
Term
| AVN occurs when the ___ supply is no longer supplied to the end of __ bones, which leads to __ __. |
|
Definition
- blood
- long bones
- bone death |
|
|
Term
| Knee osteonecrosis can occur at the __ __, the __ __, or both. |
|
Definition
- distal femur
- proximal tibia |
|
|
Term
| Radiographic image of choice for suspected AVN: |
|
Definition
|
|
Term
| AVN can ultimately lead to __ __. |
|
Definition
|
|
Term
|
Definition
|
|
Term
| AVN radiographs may show __ __ surrounding ___. These are early findings of AVN. |
|
Definition
| - subchondral lucency surrounding sclerosis |
|
|
Term
| look at slides 70,71, and 72 of Hip and Knee ppt for more AVN pictures. |
|
Definition
|
|
Term
| If AVN is caught early, before x-ray changes are seen but with changes on MRI, a surgery to improve __ __ can be performed. If this does not work, the bone progressively dies. |
|
Definition
|
|
Term
| The pt with AVN generally presents with the same complaints as the pt with __. Advanced AVN tmt is the same as ___ tmt. |
|
Definition
- osteoarthritis
- osetoarthritis |
|
|
Term
| ___ is a common surgery used on the knee with AVN. It is performed by drilling mulitple holes into the affected portion of the osteonecrotic knee. This is supposed to draw __ to the affected area to help __ and __. |
|
Definition
- Micro-fracturing
- blood to the affected areas to help the bone revascularize and heal |
|
|
Term
|
Definition
- 50% no known reason
- some AVN pts have a h/o EtOH use
- HIV pts are more susceptible
- long term use of steroids can lead to AVN |
|
|
Term
| In pts with AVN what 2 history questions should you always ask? |
|
Definition
- steroid use?
- alcohol use? |
|
|
Term
If a patient has been diagnosed with AVN in one joint, and then another joint starts to bother that patient, your suspicion should be that this new joint pain is also AVN
If this is the case, then get an MRI of this second joint to rule out AVN, especially if radiographs are negative, and you know the other joint has AVN |
|
Definition
|
|
Term
| Pts with AVN should be educated that their other joints may develop AVN. Holse has seen AVN in shoulders, hips, knees, wrists, and ankles. The most common AVN joints are __ and __. |
|
Definition
|
|
Term
| Osteochondritis Dissecans (OCD) is death of the __ bone causing __ of the bone and cartilage, which may become a __ body joint. This is most common in ___, but can occur in any age group. |
|
Definition
- subchondral bone
- fragmentation
- loose body joint
- adolescents |
|
|
Term
| With OCD, pts complain of __ __ at the lesion. Sometimes they will complain of __ __. This is a rare contributer to __ and __in patients complaining of mechanical symptoms. |
|
Definition
- point tenderness
- recurrent effusion
- locking and catching |
|
|
Term
| The osteochondral lesion with OCD is usally located at the __ aspect of the __ condyle. |
|
Definition
| - lateral aspect of the medial condyle |
|
|
Term
| With OCD, there is potential for a __ __ to break off in the joint and cause __ symptoms. |
|
Definition
|
|
Term
|
Definition
| Osteochondritis Dissecans |
|
|
Term
|
Definition
|
|
Term
|
Definition
- avoid activity that increases symptoms
- protective weight bearing
- sometimes will heal with time (3 months) with conservative measures |
|
|
Term
| When can OCD pts return to activities: |
|
Definition
- no pain
- negative physical exam findings
- lesion healed on x-ray
(when x-rays show healing this is a good thing b/c these pts may fully heal and slowly return to physical activity) |
|
|
Term
| Older pts with OCD __ to heal and requires ___. |
|
Definition
- fails to heal
- requires surgery |
|
|
Term
| Factors that make one susceptible to sepsis of the knee: |
|
Definition
- total knee repalcements
- other knee surgeries
- trauma
- HIV
- autoimmune disorders
- comorbidities
- open wounds
- h/o of STD |
|
|
Term
| If suspect a septic knee, and lab findings are positive, what do you? |
|
Definition
|
|
Term
| Pt complaining of diffuse knee pain. The knee is swollen, erythematous, and hot. The pt may or may NOT have a fever. What do you suscpet and what steps do you take? |
|
Definition
- suspect knee sepsis
- run labs
- aspirate knee
- refer if positive findings |
|
|
Term
| Labs that should be run if sepsis of the knee is suspected: |
|
Definition
- CBC with differential
- Sed Rate
- CRP
- Fungal
- Acid fast bacilli (Tuberculosis)
- Anaerobic and aerobic
- Gram stain
- Gonorrhea
- Uric Acid level |
|
|
Term
| Most common isolated organism from a septic knee? |
|
Definition
|
|
Term
|
Definition
- IV antibiotics to cover isolated organism
- Irrigation and Debridement (I&D) of joint via arthroscopy (less often with an open procedure) |
|
|
Term
| Pts with septic knees are put on IV antibiotics. They also have __ of the knee via ___. However,if they have an infected prosthetic knee, an __ __ is performed. |
|
Definition
- I&D via arthroscopy
- prosthetic knee> open I&D |
|
|
Term
| Most common location for gout? |
|
Definition
- great toe at the MCP joint
(also occurs at knees and other joints) |
|
|
Term
| Gout can often be mistaken as an __. |
|
Definition
infection
A gout pt is usually afebrile, however, the ACUTE gouty knee is hot to palpation; swollen; painful to touch; painful with any range of motion (ROM)
Patients often will give a history of gout |
|
|
Term
|
Definition
|
|
Term
| Gout tmt and preventative med: |
|
Definition
- Indomethocin
- Colchicine
- +/- pain meds
- Allopurinol is preventative med |
|
|
Term
| Do NOT immobilize a knee joint unless you suspect a __ of if the patient has a __ __, such as the __ or __ __ (these three instances all need immediate referral). |
|
Definition
- fracture
- tendon rupture
- patellar or quad tendon |
|
|
Term
| Patients who need surgery b/c of an __ __ or __ __ have to have FULL RANGE OF MOTION prior to doing surgery. The one exception is the pt with a __ knee due to a __ tear. |
|
Definition
- ACL tear or meniscal tear
- locked knee due to a mensical tear |
|
|
Term
| 2 most common hip injuries Holse sees: |
|
Definition
1. "groin pull"
2. flexor tendon strain |
|
|
Term
| Make sure to rule out possiblity of __ with hip pain patients, especially if they deny injury. |
|
Definition
|
|
Term
| Hip sprain/strain treatment: |
|
Definition
- rest
- ice
- possibly anti-inflammatories and acetominophen
- gentle stretching as it heals
- slow return to activities as symptoms improve |
|
|
Term
| A Hip Pointer is a __ __/___ to the __ __ __ __. It is common in __ sports and may occur from a __. Can be very painful. Both the __ __ and ___ are bruised. |
|
Definition
- direct blow/contusion to the anterior superior iliac spine (ASIS)
- contact sports
- fall
- soft tissue and bone are bruised |
|
|
Term
| Side note: bruised bones are sometimes more painful than fractured bones. |
|
Definition
|
|
Term
|
Definition
- rest
- ice
- gentle stretching
- gradual return to activities
- anti-inflammatories and acetominophen |
|
|
Term
| With Greater Trochanteric Bursitis the patient complains of pain at the __ aspect of their hip and says that it hurts to _ on that side. Patients are tender to palpation at the __ __ where the bursa is located. |
|
Definition
- lateral
- hurts to lie on that side
- greater trochanter |
|
|
Term
| The bursa is like a pillow filled with fluid to help the __ glide more smoothly over the __ __ __. |
|
Definition
- tendons
- greater trochanteric prominence |
|
|
Term
| With bursitis is there swellling? |
|
Definition
|
|
Term
| If a direct blow is the cause of greater trochanteric bursitis, ecchymosis may be present. |
|
Definition
|
|
Term
| The bursa is b/w the bone and muscle and allows the tendons to move smoothly. |
|
Definition
|
|
Term
| Greater Trochanteric Bursitis tmt: |
|
Definition
- physical therapy
- ice
- stretching
- anti-inflammatories
- acetominophen
- steroid shot |
|
|
Term
| With Greater Trochanteric Bursitis, a steroid shot may be done after the __ phase b/c most patients with improve with time. If there is no improvement in __ to __ weeks, then do a steroid shot. |
|
Definition
- after the acute phase
- 6-8 weeks |
|
|
Term
| A steroid shot for Greater Trochanteric Bursitis is performed with the patient in __ __ position. Then locate the __ __ spot at the greater trochanter. Then advance the needle to bone and then back up __ __. Then inject. |
|
Definition
- lateral decubitus
- most tender
- 2 mm |
|
|
Term
| Pts with hip dysplasia may not even know they have it. They may just come in with __ pain and then you find this on x-rays. They may also have a __ __ __. |
|
Definition
- groin pain
- leg length discrepancy |
|
|
Term
|
Definition
- Developmental Dysplasia of the Hip (DDH)
- Congenital Dysplasia of the Hip (CHD)
- Developmental Dislocation of the Hip (DDH) |
|
|
Term
| Hip dysplasia is __ of the hip. This predisposes the hip to abnormal function over time and over time the hip will wear out. This is when they come to see you with ___ secondary to hip dysplasia. |
|
Definition
- malalignment
- osteoarthritis |
|
|
Term
| Hip dysplasia pts present with __ and __ pain and generally develop __. |
|
Definition
- hip and groin pain
- osteoarthritis |
|
|
Term
| Pts with hip dsyplasia may have __ hip sockets. |
|
Definition
|
|
Term
| In infants you want to catch hip dysplasia early because you can avoid surgery and treat with conservative options |
|
Definition
|
|
Term
| Hip dysplasia conservative treatment options; |
|
Definition
- anti-inflammatories
- physical therapy
- steroid injections (sometimes under fluoroscopy) |
|
|
Term
| Hip dysplasia surgical options: |
|
Definition
- Arthroscopy if NO OA (pt may have labral tear)
- Osteotomies (realignment of the joint)
- Total hip arthroplasty (hip replacement) |
|
|
Term
| Second most common joint to get OA: |
|
Definition
|
|
Term
| radiographic findings of OA of the hip: |
|
Definition
- loss of joint space
- osteophytes
- spurring
- sclerosis |
|
|
Term
| pain in the groin that is radiating to the knee: |
|
Definition
|
|
Term
| The specialists will often x-ray both the knee and hip if the patient c/o of knee pain with normal radiographic knee films, and then find out it is hip OA (or some other problem at the hip) that is causing the patient’s pain |
|
Definition
|
|
Term
| To determine if you are dealing with a hip or knee problem, rotate the hip __ and __ with the patient __ and __ and with the hip and knee __ at __ __ each. If the hip is the pain source, pt will complain of __ pain instead of knee pain. |
|
Definition
- hip internall and externally
- seated and supine
- hip and knee flexed at 90 degrees each
- groin/hip |
|
|
Term
| You are trying to determine if a pts pain is from their hip or knee. You are internall and externally rotating the hip when the pt cups their hip with their knee. What is this? |
|
Definition
| "C-sign"- tells you its a hip problem |
|
|
Term
| Subchondral cyst formation and osteophytes are x-ray findings of patients with ___ and __ __. |
|
Definition
- osteoarthritis
- avascular necrosis |
|
|
Term
|
Definition
- nothing at all
- oral antiinflammatories
- physical therapy
- steroid shot
- THA (total hip arthroplasty)- hip replacement |
|
|
Term
| You can do steroid injection in __ pts with hip OA, but most doctors feel best doing these shots under __. |
|
Definition
|
|
Term
| A fluoroscopy machine is like an x-ray, but it allows you to visualize you actually injecting the patient and maneuvering the needle in position for the joint injection |
|
Definition
|
|
Term
| When doing a hip steroid shot w/o floroscopy, mark one centimeter __ and one centimeter __ to the __ tip of the __ __ while the patient is supine. Place the needle perpendicular to the skin and parallel to floor, advance till you hit bone, then back up 2 mm. Beofre you inject, you should __ to make sure you're not in a vessel. If not, then inject. |
|
Definition
- superior
- anterior
- greater trochanter
- aspirate |
|
|
Term
| Fractures of the __ __ predispose the hip to AVN. Even after these are healed on xrays, specialists need to monitor. |
|
Definition
|
|
Term
| An early sign of AVN may be the __ sign, which is a fracture b/w the __ __ and __ __. |
|
Definition
- Crescent sign
- subchondral bone and necrotic bone |
|
|
Term
| A __ ___ of the hip is similar to the microfracturing surgery for the knee. It is a single __ __ made through the __ __ to promote blood flow and healing of AVN. |
|
Definition
- core decompression
- drill hole
- proximal femur |
|
|
Term
| AVN and OA can often present the same. But AVN hip pts tend to have pain __ in their ___. Also AVN patients are/are not tender to palpation and say the pain is more deep. Sometimes they will have pain with passive ROM, but not always. |
|
Definition
- deep in their butt
- AVN pts are NOT tender to palpation |
|
|
Term
Even if radiographs are normal, but you have a high suspicion of AVN you will want to get an MRI
If the MRI is positive for AVN, and the radiographs show no evidence of AVN, the patient may benefit from a core decompression surgery, and avoid a THA altogether
A total hip arthroplasty is the surgical treatment for advanced AVN of the hip
Do not order an MRI of the hip joint if there is x-ray evidence of AVN |
|
Definition
|
|
Term
| You suspect AVN but the x-rays dont show anything.Should you order an MRI? |
|
Definition
|
|
Term
| You suspect AVN but the x-rays dont show anything.Should you order an MRI? |
|
Definition
|
|
Term
| You suspect AVN and the x-rays show evidence of ANV. Should you order an MRI? |
|
Definition
|
|
Term
| Remember, if a patient has AVN in one joint and then complains of pain in another joint (ie. the opposite joint, knees, shoulders), you must think that AVN is occurring in those joints, as well. |
|
Definition
|
|
Term
| If MRI is positive for AVN but x-rays are negative, pt may benefit from a __ __ surgery. |
|
Definition
|
|
Term
| If x-rays show advanced AVN you can treat with ___, __ __, and __ __. Ultimate tmt is __. |
|
Definition
- anti-inflammatories
- physical therapy
- steroid injections
- Total Hip Arhtroplasty |
|
|
Term
| Holse sees AVN most commonly in pple in their 40s |
|
Definition
|
|
Term
| Slipped Capital Femoral Epiphysis (SCFE) is problem seen mostly in __ ___. It occurs when the epiphyseal plate slides off the __ __ of the femur(metaphysis),displacing the position of the ___. |
|
Definition
- heavier adolescents
- epiphyseal plate slides off the long bone of the femur
- position of the femur |
|
|
Term
| DO NOT MISS SLIPPED CAPITAL FEMORAL EPIPHYSIS(SCFE) IN PRIMARY CARE. IF YOU MISS IT, YOU WILL LIKELY BE IN LEGAL TROUBLE. |
|
Definition
|
|
Term
| SCFE if caught early can save a kids __ and prevent further damage. |
|
Definition
|
|
Term
| A pt with SCFE syndrome has to be made ____ immediately and __ for __. |
|
Definition
- NON- WEIGHT BEARING IMMEDIATELY
- REFERRED FOR SURGERY |
|
|
Term
| see slide 121 of hip and knee ppt for SCFE pictures |
|
Definition
|
|
Term
| Pts with SCFE (slipped capital femoral epiphysis) usually walk with their leg __ rotated due decrease pain. ___ for __ rotation will cause pain. MAKE THESE PATIENTS NON-WEIGHT BEARING AND REFER. |
|
Definition
- externally rotated
- PROM for internal rotation will cause pain |
|
|
Term
| Legg-Calve-Perthes Disease (LCP) is a disorder is idiopathic ___ of the __ __ epiphysis of the __ __. It is seen in the __. |
|
Definition
| - idiopathic osteonecrosis of the capital femoral epiphysis of the femoral head (similar to AVN) |
|
|
Term
| If Legg-Calve-Perthes is caught early you can preserve the hip joint without advancing deformities and problems in adulthood (OA). |
|
Definition
|
|
Term
| LCP (Legg-Calve-Perthes) is treated conservatively if caught early. Usually affects kids between ages __ and __. The __ the pt the better the results. |
|
Definition
|
|
Term
| Legg-Calve-Perthes (LCP) pts are usually brought in by parents b/c they have a ___. The pt does NOT always have pain. Must get __. If high suspcision of LCP and xrays are negative, get an MRI. This is generally a ___ problem. |
|
Definition
- limp
- x-rays
- unilateral |
|
|
Term
| LCP is usually unilateral/bilateral? |
|
Definition
|
|
Term
| young kid brought in by parents b/c limping. pt not in pain. what do you suspect and what do you order? |
|
Definition
- Legg-Calves-Perthes Disease
- x-rays, if x-rays normal but really think they have LCP order MRI |
|
|
Term
|
Definition
Legg-Calves-Perthes Disease (LCP)
Notice the pts left hip epiphysis- loss of bone here is indicative of the epiphysis dying |
|
|
Term
|
Definition
| Legg-Calves-Perthes on the right- collapse of the epiphysis |
|
|
Term
| Treatment for Legg-Calves-Perthes (LCP) Disease: |
|
Definition
- anti-inflammatories
- physical therapy for ROM
- crutches for non-weight bearing
- bracing may allow for healing
- surgery (osteotomy)for the pt that does not heal |
|
|
