• Share
  • Email
  • Embed
  • Like
  • Save
  • Private Content
orthopedic and rheumatologic disorders of the knee joint
 

orthopedic and rheumatologic disorders of the knee joint

on

  • 4,365 views

 

Statistics

Views

Total Views
4,365
Views on SlideShare
4,365
Embed Views
0

Actions

Likes
5
Downloads
0
Comments
2

0 Embeds 0

No embeds

Accessibility

Categories

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel

12 of 2 previous next

  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment
  • Pain: The most common knee symptom, can be due to inflammatory, degenerative  diffused pain, or traumatic  localized The mechanism I the pt remember is extremely usefull Maybe it is a referred pain Swelling: Can be localized or diffused. Is it immediate  suggestive of haemiarthrosis, or after some hours  typical for torn lemniscus, chronic  synovitis or arthritis Stiffnes: common, is it flactuant??when better or worse?, early morning  inflammatory Stifness after periods of inactivity  typical osteoarthritis Locking Doesn’t mean the joint is immovable at all (ambigous term) 1 minute it moves perfectly,later can flex but incomplet extension Due to something jammed the articulation surfaces (torn meniscus for eg Unlocking  the object is removed Deformity If new onset  early detected, unilateral vs bilateral: valgus, varus, fixed flexion, or hyperextension Knock knees and bandy legs are common in children  spontanuous resolution as the child grows up Giving way -This term is used to describe the sensation of the knee suddenly failing to provide proper support, especially when walking on uneven ground - Caused usually by mechanical disorder such as torn meniscus, or faulty patellar extension mechanism Can be due to muscle weakness, Loss of function Progressively diminishing walking distance Inability to run or going up stairs
  • -valgus or varus->best seen in upright position -symmetrical knock-knee and bow legs -  can be normal variation -unilateral may e more significant esp if progressive -ask the pt to walk  look for instability or limbing.
  • -position may be in valgus or varus, partially flexed or hyperextended - Wasting is a sure sign of joint diorder, visual impression must be confirmed by measuring the girth of thigh at the same level
  • warmth  compare two knees, normal gradient (warmer proximally-colder distally) Outlines and tendrness best apreciated if u let the patient bend his knee  and the examiner sits on the edge of the couch facing the knee (notice:anatomical outlines of joint, patellar ligament,collteral ligament, pes arserinus) -synovial thickining Is best apreciated if the patient places his knee in extension, the examiner grasps the patella by thumb and middle finger pull it forward, -if easy  no thicking if slip  thickened. (move): Normally knees flex till calf meets ham, extend completely with a snap Slight loss of extension or springness  important While moving the knee, feel for crepitus  sign of patellofemoral degeneration or wear
  • -swelling; is in the mdline (bulging capsule), to one side (possibly bursa), backer’s cyst?, popliteal aneurysm abley’s test: knee is flexed 90 degrees and rotated while applying first compression force an then distraction force. (pain and/or clicking on compression  meniscal lesion.
  • Arthroscopy is usefull to: 1- establish or refine the accuracy of Dx. 2- in deciding whether to operate or to plan the operative approach with more precision 3-to record the progress of knee disorder 4-to perform certain operative procedures - It is not substitute for clinical examination.
  • Theoretically anything more or less than 5-7 is considered as deformity, it doesn’t bother anybody unless is unilateral Examination of the pt while in standing. Bilateral genu varum can be recorded by measuring the distance between the knees and the legs straight and the medial malleoli just touching it, it should be less than 6 cm Genu valgum can be estimated by measuring the distance between medial malleoli when the knees are held touching with the patellae facing forward, it is usualy less than 8 cm In children these deformities are so common, mostly auto resolution occurs by the age of 10-12 In children parents reassurance and visits in intervals 6 months If present at 10 years of age, operative correction is advised (epiphyseodesis/stapling one side of physes to slow growth of that side ) or later stage (osteotomy) Bone dysplasia and rickets are associated with intractable deformities which are likely to need operative correction Blount’s disease is a progressive bow-leg deformity associated with abnormal growth of posteriomedial proximal part of tibia, children sually overweight, and start walking early, usually the deformity is bilateral, it nay include rotational movement. Needs operative management, x-rays show characterstic features such as abnormal flattening of the medil half of the epiphysis In adults, varus and valgus; esp if unilateral or asymetric, is likely to disorders such as joint injury (RA-valgus), (osteoarthritis-varus)  If intolerable, joint reconstruction or osteotomy (supracondylar femoral or for valgus deformity and proximal tibia for varus)
  • Bucket-Bundle tears: when split is vertical but runs along part of the circumference of the meniscus, creating a loose silver still attached ant and post. The torn silver sometimes displaces towards the centre of the joint, and becomes jammed between the articulating surfaces  locking (to extension) Horizontal tears: are usually degenerative, or due to repetitive minor trauma, some are associated eith meniscal cysts.
  • -swelling occurs hour up to a day! Locking to extension, locked in flesxion position Activity should be avoided!! With rest symptoms subside, bt returns after twists or strains In patient of 40 y/o or above,the initial injury maybe unremarkable! And the main comlaint: recurrent giving away or lock Locked knee-inability to fully extension  bucket handl tear! Sometimes the patient knows how to unlock by bending fully or by twisting from side to side Tenderness is localized to joint line, in most cases (medial side)
  • - traumatic: arising from either small horizontal tear or repeated squashing of the peripheral part of the meniscus
  • - The lump could be firm esp if the knee is extended
  • - Intracondyler x-rays show line of demarcation around a lesion; on the lateral part of the medial femoral condyle. If detached, the empt hollow may be seen and possibly a loose body elsewhere in the joint.
  • Herbet screws: Filling the condyler defect by cartilage transplantation, long term results are still awaited.
  • -sometimes the locking is only momentary and usually the patient can wriggle the knee untill it suddenly unlocks. - Mouse, slips away duing palpatio
  • Mantoux test:
  • Swelling resolves, x-rays of the joint surfaces are intact, then the patient is mobilized and allowed to start walking Arthrodesis; in children it is deferred untill growth ceases, in adults is done as soon as the disease is inactive.
  • - Rheumatoid is small proximal joint disease! (remember)
  • -Stage 2 on X-rays: show loss of joint space and marginal erosions, can be easily differentiated from osteoarthritis by complete absence of osteophytes. - Stage 3 on X-rays: bone destruction characterstic of advanced disease.
  • - There is usually a predisposing factor; an injury to the articular surface, a torn meniscus and ligamentous instability or pre-existing deformity of the knee Cartilage breakdown usually starts in an area of excessive loading. Thus with long standing varus the changes is most marked in the medial compartment
  • Pain is worse after use of the joint, or (if the patellofemoral joint is affected ) going up stairs. After rest, the joint feels stiff and it hurts to ‘get going’ after sitting for any length of time
  • -Arthroscopic washouts: with trimming of degenerative meniscal tissu and osteophytes may give temorarily relief, it is a usefull measure when there is a contraindication to reconstructive surgeries. -realignment osteotomy: typically an upper tibial valgus osteotomy for medial compartment disease in young pnt is often successful in relieving symptoms and staving off the need for ‘end-stage surgery’ - Replacement arthroplasty: is indicated in older pnt with progressive joint destruction. This is usually a resurfacing knee replacement; with modern techniques and meticulous attention to anatomical alignment of the knee, the results are excellent.
  • -patella alwys disslocate laterally. The patient may think its medially because the uncovered medial femoral condyle stands out prominantly. -apprehension test:
  • If recurrences are few and far between, conservative treatment is enough as when the child gets older, patellar mechanisms tends to stabilize. - However in bout 15% of children with patellar instability suffer repeated and distressing episodes of dislocation and for these patients, surgical reconstruction is needed.
  • -patellofemoral pain is elicited by pressing the patella against the femur and asking the patient to contract the quadriceps- first with central pressure, then compressing the medial facet and then lateral. - If in addition, the apprehension test is positive, this suggest previous subluxation or dislocation.
  • Arthroscopy-- Cartilage softening is common in asymptomatic knees and painfull knees may show no abnormality.
  • Exposed areas of subchondral bone can be drilled-in the hope that revascularization may encourage repair with fibrocartilage.
  • Often is called “osteochondritis”, though its nothing more than a traction injury of the apophysis into which part of the patellar ligamnet is inserted.
  • Thigh wasitng due to inhibition of quadriceps.
  • - Wiliam morrant baker 1877, althoough he used the term to indicate tuberculousarthritis
  • ACL and PCL also provide resistance against excessive valgus and varus angulation.
  • -swelling –immediately in contrast to meniscal injury. Partial tears permit no abnormal movement. If there’s any doubt, examination under anaesthesia is mandadtory with side titling if the knee angulates only in slight flexion, there’s probably an isolated tear of the collteral ligamnets. If it angulates in full extension, there’s probably rupture of the capsule, the cruciates, the collaterals! ! The patient should be supine with the hips flexed to 45 degrees, the knees flexed to 90 degrees and the feet flat on table. The examiner sits on the patient's feet and grasps the patient's tibia and pulls it forward (anterior drawer test) or backward (posterior drawer test). If the tibia pulls forward or backward more than normal, the test is considered positive. Excessive displacement of the tibia anteriorly (more than 5 mm) indicates that the ACL is likely torn, whereas excessive posterior displacement of the tibia indicates that the PCL is likely torn. The Lachman test is a variation on this test in which the knee is in thirty degrees flexion Drawer test; +ve test is diagnostic for tear, if –ve doesn’t exclude tear.
  • - A complete plaster cast is unnecessary and disadvantaginous as it inhibits movement.
  • Th eother cases; 50% will regain suffeciently good fucntion, not to need any more t/t
  • - adhesions>> the knee ‘gives way’, with catches of pain, localized tenderness is present, the pain occurs on medial or lateral roatation, R/O mediscal injury by Arthroscopy or grinding test.

orthopedic and rheumatologic disorders of the knee joint orthopedic and rheumatologic disorders of the knee joint Presentation Transcript

  • The Knee Joint Rima Qudah Ahmed Al-Momtan C-2
  • Clinical Assessment
    • History:
      • Pain
      • Swelling
      • Stiffness
      • Locking/unlocking
      • Deformity
      • Giving way
      • Loss of function
  • Clinical Assessment
    • Signs: upright, supine, lying prone
    • Upright:
      • Valgus or varus deformity
      • Symmetrical knock-knee
      • Bow-legs
      • Unilateral vs bilateral
      • Obeservation while walking.
  • Clinical Assessment
    • Lying Supine
      • (look):
        • Position of knees.
        • Swelling
        • Old scars, sinuses or small lumps
        • quadriceps muscle wasting
  • Clinical Assessment
      • (Feel):
        • Increased warmth.
        • Soft tissue and bony outlines palpation
        • Tenderness
        • Synovial thickening.
      • (move)
    • Tests and maneuvers:
      • tests for intra-articular fluid
        • Cross fluctuations
        • Patellar tap
        • Bulge test
        • Patellar hollow test
      • Patellar tests
        • Patellar friction test
        • The apprehension test
      • Tests for ligamentous stability
  • Clinical Assessment
    • Lying Prone
      • (look):
        • Scars or lumps in the popliteal fossa.
        • Swelling
        • Abley’s test
  • Imaging
    • AP- and lateral views are standard.
    • Patellofemoral (skyline) and intracondylar or (tunnel) views are needed.
    • MRI-if doubtful meniscal or ligament injuries.
    • Arthroscopy.
  • Genu Varum and Genu Valgum)
    • By end of growth, knees are normally in 5-7 degrees of valgus.
    • In children are considered as a stage of development
    • Bone dysplasia?
    • Blount’s disease?
    • Valgus and varus in adults.
  • Lesions of Menesci
    • 1- Meniscal tears:
      • Common in young adults
      • Caused by forced grinding it between the femur and tibia
      • In the young, occurs when weight is being taken on the flexed knee and there was twisting strain simultaneously common in footballers.
      • In middle age,fibrosis has restricted mobility of meniscus, tears occur with relatively little force
      • Medial meniscus is more affected, because of its attachmet to the capsule  less mobile.
  • Patterns of meniscal tears
    • a) Bucket-handle tears
    • b) Horizontal tears
    • Most of the meniscus is avascular  spontaneous repair doesn’t occur unless the tear is in the outer third
  • Clinical features of meniscal tears
    • 1- History:
      • From Hx, the patient is young, who sustains a twisting injury to the knee on the sports field
      • Pain
      • swelling
      • Locked-knee
      • “ giving way”
    • 2- P/E:
      • Joint is held slightly flexed, there’s often an effusion,
      • In late presentations, quadriceps will be wasted
      • Tenderness
      • Felxion-extension lock
      • Apley’s test +ve!
  • investigations
    • 1- Imaging:
    • Plain x-rays (normal),
    • MRI is reliable
    • 2-Arthroscopy:
    • Can be Diagnositic and therapeutic!
  • Treatment
    • t/t in the past is by open operation.
    • now; is by arthroscopic surgery
      • For peripheral tears, operative repair is feasible
      • In case of displaced portion clean excision.
      • PostOp: physiotherapy.
  • Continue, Lesions of menisci
    • 2- Meniscal cysts
      • Can be linkened to a ganglion: fibrous tissue containing gelatinous fluid!.
      • Its probably traumatic in origin!
  • Clinical features of meniscal cysts and Treatment
    • History and P/E
      • Pain
      • Lump (seen and felt)-usually on the lateral side of joint
      • Treatment:
        • Either decompression or removal arthroscopically, and if any meniscal lesion, can be dealt with at the same time
  • Osteochondritis dissecans
    • Is an escape of a small, well demarcated, avcascular fragment of bone and overlying cartilage and sometimes separates; from one of the femoral condyles and appears as a loose body in the joint.
    • Most likely cause is trauma
      • Either single impact with the edge of the patella
      • Or repeated contact with adjacent tibial ridge
    • More than 80% of lesions occur on the lateral side of the of the medial femoral condyle, 25% have the lesion bilaterally.
  • Clinical features of osteochindritis dissecans
    • History:
      • Usually a male patient, aged 15-20 y/o
      • Intermittent ache or swelling
      • Giving way (later)
      • Lock from time to time
    • P/E
      • quadriceps is wasted
      • Little swelling-will small effusion
      • Plus Two important signs
        • tenderness localized to one femoral condyle.
        • Wilson’s sign: if the knee is flexed to 90 degrees, rotated medially and the gradually straightened, pain is felt, if the test is repeated with the knee is rotated laterally, the patient feels no pain.
  • Investigations in osteochondritis Dissecans
    • Imaging:
      • Plain X-rays esp (tunnel) veiws – show a line of demarcation around a lesion.
      • Radionuclide-increased activity around the lesion
      • MRI-hypointensity in T1 images
  • Treatment of Osteochndritis dissecans
    • In earliest stage, cartilage is intact and the lesion is stable  no t/t is needed but activities must be curtailed for 6-12 months, small lesions often heal spontaneously.
    • If the fragment is unstable (i.e. surrounded by a clear boundary with sclerosis of the underlying fibrocartilage  large fragment (> 1 cm in diameter) can be shaped to fill the crater and should be fixed in situ with pins or Herbett screws.
    • If one the above was done, after 6 weeks, encourage movement! But not weight-bearing activities.
    • New approches?
  • Loose bodies
    • Knee is relatively capacious with large synovial folds, so it’s a haven for loose bodies.
    • Loose bodies can be produced by:
      • Injury (a chip of bone or cartilage)
      • Osteochondritis dissecans (may produce one or two fragments
      • Osteoarthritis (piece of cartilage or osteophyte).
      • Charcot’s disease (large osteocartligenous bodies are separated by repeated trauma in ajoint that has lost sensation).
      • Synovial chondromatosis (carilage metaplasia in the synovium sometimes producing hundred of loose bodies.
  • Clinically
    • May be asymptomatic!.
    • Sudden “locking” without Hx of injury.
    • Feeling of something ‘popping’ in and out of joint.
    • Sometimes, esp after the 1 st attack, the knee swells up, due to synovitis
    • Try to find underlying cause!
    • “ joint mouse” when palpated for..
  • Imaging and Treatment
    • Most of the loose bodies are radio-opaque.
    • Sometimes you may find the underlying joint pathology!
    • Treatment
      • removal! (arthroscopic), unless the joint is severely osteoarthritic.
  • Tuberculosis
    • Is increasing world wide!
    • Tuberculosis of the knee may appear at any age, but more common in children.
  • Clinically and on X-rays
    • Clinically:
      • early: pain and limp
      • Swollen joint and low grade fever.
      • Thigh muscles are wasted
      • The knee is warm, and there is synovial thickening
      • Movement is restricted and often painful.
      • Mantoux test +ve, ESR is high!
    • X-rays:
      • Periatricular osteoporosis
      • In children, enlarged bony epiphyses
      • Joint space narrowing and progressive erosion are late signs.
  • Diagnosis
    • DDx: monoarticular rheumatoid arthritis or juvnile chronic arthritis.
    • A synovial biopsy may be necessary to establish the diagnosis.
  • Treatment
    • Anti-Tb therapy.
    • Knee is rested in a splint (during therapy)
    • If joint surfaces are destroyed, the knee is stiff, arthrodesis is recommended.
  • Rheumatoid Arthritis
    • Chronic monoarticular synovitis
    • Sooner or later other joint become involved
  • Clinically:
    • Stage 1: (synovitis); the patient complain of pain and chronic swelling. There is some wasting, there maybe a large effusion and the thickened synovium is easily palpable.
    • Stage 2: (articular erosion); increasing instability of the joint, marked muscle wasting, some loss of flexion and extension.
    • Stage 3: (deformity): pain and disability are usually sever, in some patients the joint has only a jog of painful movement, in others. It becomes increasingly unstable and deformed.
  • Treatment
    • General rheumatoid treatment plus: local splintage and injection of triamsonolone will usually reduce the synovitis.
    • More prolonged effect can be achieved by injection of tadiocolloids such as yttrium-90 ( 90 Y).
    • Synovectomy (rare), if other measures fail.
    • If deformity is marked, femoral or tibial osteotomy may improve funcion and relieve pain.
    • If there was bone distruction and joint is unstabel  total joint replacement.
  • Osteoarthritis
    • Knee is one of the most common sites for OA.
    • Usually There is a predisposing factor;
    • In many cases, no obvious cause can be found and here the condition is often bilateral and has strong association with Heberden’s nodes.
    • Cartilage breakdown usually starts in an area of excessive loading.
    • Characterstic features; cartilage fibrillation, sclerosis of the sub-chondral bone and peripheral osteophyte formation are usually present.
  • Clinical Features
    • Patients are usually >50 y/o, tend to be overweight, may have long standing bow-leg deformity.
    • Hx:
      • Pain: is the leading symptom
      • Swelling
      • ‘ Giving way’
      • Locking
    • P/E:
      • ranges: obvious deformity (usually varus)
      • Scar if a previous operation
      • Quadriceps is usually wasted.
      • And DURING exacerbations only: warmth and synovial membrane thickining.
      • Movement is somewhat limited and is often accompanied by patellofemoral creapitus .
  • X-rays
    • Weight bearing view is essential.
    • Tibiofemoral joint space is diminished (often only in one compartment)
    • Sub-chondral sclerosis
    • Osteophytes and sub-chondral cysts are usually present and sometimes there is soft-tissue calcification in the suprapatellar region in the joint itself (chondrocalcinosis)
  • Treatment
    • If symptoms are not very sever, t/t is conservative (analgesics, quadriceps exercises, and application of warmth, joint loading is lessened by using a walking stick).
    • Operative T/T is indicated if:
        • Persistent pain irresponsive to conservative t/t
        • Progressive deformity and instability
      • Arthroscopic washouts
      • Realignment osteotomy
      • Replacement arthroplasty
  • Patellofemoral disorders
  • Patellofemoral disorders
  • Clinical features
    • Girls are affected more commonly than boys, and the condition is often bilteral.
    • Acute pain
    • Stuck knee in flexion, may cause the patient to fall.
    • Patella is dislocated!
    • Tenderness on the medial side of the joint
    • The joint swells (later) and aspiration may reveal a blood-stained effusion.
    • Apprehension test +ve
  • Treatment
    • If still dislocated, push it back into place while the knee is gently extended.
    • A plaster cylinder or splint id applied and retained for 2-3 wks
    • Isometric quadriceps-strengthening excercises are encouraged and the patient is allowed to walk on crutches.
    • Exercises should be continued for at least 3 months concentrating on strengthening the vestus medialis muscle.
    • If recurrences are few and far between, conservative treatment is enough as when the child gets older, patellar mechanisms tends to stabilize.
  • Operative treatment
    • Principles of treatment are:
    • To repair or strengthen the medial patellofemoral ligaments. And
    • To re-align the extensor mechanism as to produce a mechanically more favourable angle of pull.
  • 2- Patellofemoral overload ( patellar pain syndrome; chondromalacia of the patella )
    • Ant. Knee pain is common among active adolscents and young adults
    • Often associated with softening and fibrillation of the acrticular surface of the patella- chondromalacia patellae .
    • The basic disorder is probably repetitive mechanical overload of the patellofemoral joint due to either:
      • Malcongruence of the patellofemoral surfaces because of some abnormal shape of the patella or intercondylar groove. Or
      • Malalignment of the extensor mechanism, or relative weakness of the vesus medialis, which causes the patella to tilt, or subluxate or bear more heavily on one facet than other during flexion or extension
  • Clinical Features
    • The patient often a teenage girl or an athletic young adult.
    • Pain over the front of the knee ‘underneath the knee-cap’
    • Aggravated by activity, climbing stairs or when standing up after prolonged sitting.
    • Quadriceps wasting.
  • Imaging
    • X-ray Should include skyline views of the patella.
    • May show abnormal tilting or subluxation.
    • Lateral view with the knee partly flexed to see if the patella is high or small.
    • Most accurate way of showing and measurement of malposition is by CT or MRI with the knees in full extension and farying degrees of flexion.
  • Arthroscopy and Differential Diagnosis
    • Arthroscopy:
      • Arthroscopy is useful in excluding other causes of ant knee pain.
    • Differential diagnosis:
    • - Table page 234
  • Treatment
    • Most cases respond to adjustment of stressful activities and physiotherapy.
    • Excercises are directed specifically at strengthening the medial quadriceps to counterbalace the tendency to lateral subluxation or tilting of the patella.
    • If Symptoms persist; surgery can be considered-lateral release or lateral release cobined with the realignment procedures (20.22 p 235)
    • If there is any sign of fibrillated cartilage is sometimes performed, but its efficacy is questionable.
    • Exposed areas of subchondral bone can be drilled.
  • Osgood-Schlatter’s disease
    • Painful swelling of the tibial tubrcle.
    • Common in adolscents, particularly those engaged in strenous sports.
    • Often called “osteochondritis”
    • On P/E; the tibial tubrosisty is unusually prominent and tender.
    • Sometimes active active extension of the knee against resistance is also painful.
    • X-rays; show displacement or fragmentation of the tibial apophysis.
    • T/T: Spontaneous recovery is usual but takes time, its wise to restrict such activities as cycling and football.
  • Swellings around the knee
    • Fairly common complaint.
    • Could involve the entire joint, or asymmetrically on one or other aspect of the joint.
    • Can be acute or chronic.
  • A- Acute swelling of the entire joint.
    • Post-traumatic haemiarthrosis:
      • Swelling immediately after injury means blood in the joint.
      • Painful, warm, tense and tender knee.
      • Restricted movement.
      • X-rays are essential to cheque for fractures, if there was no, suspect a tear of the ACL.
    • Non-Traumatic haemiarthrosis:
      • In patients with bleeding disordes, it is the most common site to bleed.
      • If the clotting factor is available, aspirate, splint and give the deficient clotting factor.
    • Acute septic arthritis:
      • swollen, painful, and inflammed joint.
      • WBCs, ESR are elevated.
      • Send aspirate for culture (including anaerobic).
      • Most common organism is Staph. Aureus.
      • In adult, gonococcus is as common!
      • t/t drainage, IV Antibiotics
  • Continue
    • Traumatic Synovitis:
      • Injury stimulates reactive synovitis.
      • The swelling appear only after some hours vs haemiarthrosis.
      • Subsides spontanuously over period of days.
      • Thigh wasting.
      • Fluid aspiration hastens muscle recovery.
    • Aseptic non-traumatic synovitis:
      • Acute swelling.
      • With no Hx of trauma or signs of infection  gout? Pseudogout.
      • Aspiration of fluid (resembles pus but sterile).
      • microscopy reveals crystals (using polarized light).
      • Treatment with anti-inflammatory drugs is usually effective.
  • B- Chronic swelling of the entire joint.
    • Arthritis:
      • Most common causes are OA, and RA.
      • Other signs: deformity, loss of movement, or instability.
      • X-ray will usually show characteristic features
    • Synovial disorders:
      • Most important is to exclude TB
      • It is considered when no obvious alternative Dx.
      • Invetigations: mantoux testing, synovial biopsy and microbiological studies
      • The ideal is to start anti-TB before joint destruction occurs
  • Other joint aspect swellings
    • A- Swellings in front of the joint.
      • Prepatellar bursitis “house maid’s knee”.
        • Flactuant swelling confined to the front of patella.
        • The joint itself is normal.
        • It is an uninfected bursitis due to constant friction between skin and bone.
        • Seen in carpet layers, paving workers, floor cleaners who don’t use knee pads.
        • T/T; firm bandaging and avoidance of kneeling, occasionally aspiration is needed.
        • In chronic cases, the lump is best excised.
      • Infrapatellar bursitis “clergyman’s knee”:
        • The swelling is bellow the patella and superfacial to the patellar ligament.
        • More distal to prepatellar bursitis.
        • t/t is the same.
  • Other joint aspect swellings
    • B- Swellings at the back of the joint.
      • Semimembranous bursa :
        • Between the semimebranosus and the medial head of gastrocnemius.
        • May enlarge in children or adults.
        • Presents as a painless lump behind the knee, slightly to the medial side of the midline.
        • Best seen while the knee is straight.
        • Fluctuant, trasilluminant.
        • Normal knee joint
        • t/t is ‘waiting policy’ even if causes some ache, it disappears with time.
      • Popliteal Cyst (Baker’s cyst”:
        • Bulging from the post capsule and the synovial herniation may produce a swelling in the popliteal fossa.
        • Most likely cause by RA or OA.
        • t/t is the same.
  • Continue…
      • Popliteal Cyst “Baker’s cyst”:
        • Bulging from the post capsule and the synovial herniation may produce a swelling in the politeal fossa.
        • Most likely caused by RA or OA.
        • Sometimes it ruptures and its content descend down the calf muscle, causing pain, may be mistaken for a DVT.
        • It may diminish following aspiration, and injection of hydrocortisone.
        • Excision is not advised  recurrence rate is high unless the underlying pathology is treated.
  • Other joint aspect swellings
    • C- Swellings at the side of the joint:
      • Meniscal cyst:
        • Small, tense, tender, swelling, usually at the lateral side at or just bellow the joint line.
        • Sometimes, can be soo tense, can be mistaken for a bony lump.
      • Calcification of the collateral ligament:
        • Acutely painful swelling, suddenly appear on the medial side of the joint.
        • Rubbery in consistancy and acutely tender.
        • Operative decompression confirms the Dx. And provide immediate relief.
        • The calcific material is extruded like toothpaste.)
  • Continue..
      • Bony swellings
        • Arises in long-bone metaphyses
        • Visible and palpable swelling in the vicinity of a joint.
        • If large, non-discrete and painful this could suggest a tumour.
        • Diagnosis can be made of by an X-ray, confirmed by tissue biopsy.
  • Acute knee ligament injuries
    • The bony structure of the knee is inherently unstable!, where it not for the strong capsule, intra-articular, extra-articular ligaments and controlling muscle, the knee wouldn’t be able to function effectively as a mechanism for support, balance and thrust.
  • Continue..
    • Valgus stresses are resisted by:
      • Fascia lata.
      • Pes anserinus.
      • Superfacial and deep layers of medial collateral ligament (MCL).
      • The tough posterimedial part of the capsule.
    • Varus stresses are resisted by:
      • Iliotibial tract.
      • Lateral collateral ligamnt (LCL).
    • Anteroposterior and rotatory stability by:
      • Anterior cruciate ligament (ACL).
      • Posterior cruciate ligament (PCL).
  • Continue..
    • Injuries to these ligament are common particularly in sporting pursuits.
    • Maybe associated with fractures or dislocations.
    • Vary in degree, from simple sprain to complete rupture.
    • These injuries are seldom unidirectional >> involve more than one structure so; we refer to them by functional terms like “anteromedial instability” or anatomical “torn MCL and ACL”.
  • Clinical Features
    • Hx of twisting or wrenching, and may claim to have heard a ‘pop’ as the tissue snapped.
    • The knee is painful.
    • Swelling appears immediately.
    • Tenderness is maximal on the torn ligament.
    • Stressing on one side of the joint, produces excoriating pain.
    • Sideways tilting (valgus, varus) is examined; first with the knee flexed to 30 degrees, then with the knee straight. Compare both sides.
    • Anteroposterior stability is assessed first by placing the knees at 90 degrees with the feet resting on the couch and looking from the side for post. Sag of the proximal tibia, if +ve, this is a reliable sign of PCL instability.
    • Drawer test?
    • Lachman test; more reliable, anteroposterior glide is tested with the knee flexed 15-20 degrees.
  • On X-ray
    • Stress x-rays of the knee provide evidence of instability.
    • Plain X-rays may show that the ligament is avulsed a small piece of bone;
      • The MCL, usually from the femur.
      • The LCL from the fibula.
      • The ACL from the tibial spine.
      • The PCL from the back of the upper tibia.
  • Treatment
    • Sprains and partial tears:
    • - The intact fibers splint the torn ones >> spontaneous healing. Active excecises are prescribed from the start.
      • Aspirating the haemiarthrosis and applying of ice-packs intermittently relieves the pain.
      • Weight bearing is allowed, but the knee is protected from angular or rotational movement by heavily padded bandage or a functional brace.
  • Continue..
    • Complete tears:
      • Isolated tears of MCL or the LCL can be treated as partial tears.
      • Isolated tears of the ACL may be treated by early operative reconstruction.
      • In all other cases, it is more prudent to follow the conservative regimen, the cast-brace is only worn until symptoms subside.
      • Isolated cases of PCL tears are usually treated conservatively.
  • Continue..
    • Avulsion fractures of the tibial intercondylar eminence.
      • Caused by sever strain, instead of rupturing a cruciate lig, results in avulsion fracture of the insertion.
      • Maybe partially displaced  difficult to detect on X-ray.
      • If the fragmment can be manipulated back into position, and allow full extension of the knee  immobilization in plaster cylnder for 6 weeks.
      • Full movement is usually regained within 3 months.
  • Continue..
    • Combined injuries:
      • ACL and collateral ligament injury, treat the joint bracing and physiotherapy in order to restore a good range of movement before following in with ACL reconstruction; the collateral doesn’t need reconstruction!
      • Similar approach is adopted for combined injuries involving the PCL, but here all damaged structures need to be repaired.
  • Complications
    • Adhesions; if the knee is not exercised, torn fibers stick to intact fibers and to the bone.
    • Instability  gets worse and predisposes to OA  reconstruction before the onset of degenerative changes.