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Surgery 6th year, Tutorial (Dr. Ali A. Nabi)


Published on

Jan. 4th, 2012

Surgery 6th year, Tutorial (Dr. Ali A. Nabi)

  1. 1. The diseases of the knee joint
  2. 2. Anatomy of the knee <ul><li>Joints: there are two joints in the knee: </li></ul><ul><ul><li>Patellofemoral joint </li></ul></ul><ul><ul><li>Tibiofemoral joint (the joint that is usually referred to as 'the knee joint') </li></ul></ul>
  3. 3. Anatomy of the knee <ul><li>Patella: the patellar tendon (also called patellar ligament) passes anteriorly to the patella. </li></ul>
  4. 4. <ul><li>Ligaments: stability to the tibiofemoral joint is provided by various ligaments: </li></ul>Anatomy of the knee
  5. 5. Anatomy of the knee <ul><li>Anterior cruciate ligament (ACL) - controls rotational movement and prevents forward movement of the tibia in relation to the femur. Runs between attachments on the front (hence anterior cruciate) of the tibial plateau and the posterolateral aspect of the intercondylar notch of the femur </li></ul>
  6. 6. Anatomy of the knee <ul><li>Posterior cruciate ligament (PCL) - prevents forward sliding of the femur in relation to the tibial plateau. Runs between attachments on the posterior part (hence posterior cruciate) of the tibial plateau and the medial aspect of the intercondylar notch of the femur. </li></ul>
  7. 7. Anatomy of the knee <ul><li>Medial collateral ligament - prevents lateral movement of the tibia on the femur when valgus (away from the midline) stress is placed on the knee. Runs between medial epicondyle of the femur and the anteromedial aspect of the tibia. Also has a deep attachment to the medial meniscus </li></ul>
  8. 8. Anatomy of the knee <ul><li>Lateral collateral ligament - prevents medial movement of the tibia on the femur when varus (towards the midline) stress is placed on the knee. Runs between lateral epicondyle of the femur and head of the fibula. </li></ul>
  9. 9. <ul><li>Menisci: the medial and lateral menisci are located within the knee joint, attached to the tibial plateau. They help to protect the articular surfaces by absorbing some of the forces transmitted through the knee. They also help to stabilise and lubricate the knee. </li></ul>Anatomy of the knee
  10. 10. Anatomy of the knee
  11. 11. Anatomy of the knee
  12. 12. History <ul><li>Was onset of pain gradual or acute? OA comes on over years; ACL injuries cause immediate pain. </li></ul><ul><li>If acute, was there trauma? </li></ul>
  13. 13. History <ul><li>If there was trauma, what exactly happened? If injury occurred in sport or an accident get a precise history of the mechanism. Was there a direct blow causing vulgus or varus stress? Was there a twisting motion? </li></ul>
  14. 14. History                                                                   Figure 5                                               Figure 1                                                                                   Figure 3                                                                              Figure 2
  15. 15. History <ul><li>Was there any sound? A 'popping' or 'snapping' sound may suggest rupture of a ligament. </li></ul><ul><li>Did the knee swell immediately, gradually, or not at all? Rapid swelling (0-2 hours) suggests haemarthrosis which may be due to e.g. ACL or PCL rupture, patellar dislocation. Gradual swelling (6-24 hours) suggests an effusion which may be due to meniscal injury. </li></ul>
  16. 16. History
  17. 17. History <ul><li>What was the degree of pain and disability at the time of injury? How does this compare to the current situation? </li></ul><ul><li>Does the knee lock or click? Suggests a loose body and may be due to meniscal injury. </li></ul>
  18. 18. History <ul><li>Does the knee give way? Suggests instability (e.g. ACL injury) or muscle weakness. </li></ul><ul><li>Does the patient have a previous history of knee injury? </li></ul><ul><li>What are the patient's past medical history, occupation and level of exercise? </li></ul>
  19. 19. Symptoms <ul><li>pain: causes of knee pain could be due to: </li></ul><ul><ul><li>Inflammatory. </li></ul></ul><ul><ul><li>Degenerative. </li></ul></ul><ul><ul><li>Mechanical. </li></ul></ul><ul><ul><li>Trauma. In which the mechanism is useful. </li></ul></ul>
  20. 20. Symptoms <ul><li>Stiffness. Due to trauma or arthritis. </li></ul><ul><li>Locking. Differs from stiffness in which the knee suddenly cannot straightened fully, although flexion is still possible like in torn meniscus. </li></ul><ul><li>Deformity like knock knee and bow leg. </li></ul>
  21. 21. Symptoms <ul><li>Swelling which could be localized or diffused, it may appear suddenly like in haemoarthrosis or after few hours like in torn meniscus. </li></ul><ul><li>Giving way due to mechanical disorder or as a result of muscle weakness. </li></ul><ul><li>Limp due to pain or instability. </li></ul>
  22. 22. Signs <ul><li>Look </li></ul><ul><li>Valgus or varus deformity. </li></ul><ul><li>Wasting. </li></ul><ul><li>Swelling and lump. </li></ul>
  23. 23. Signs
  24. 24. Signs
  25. 25. Signs
  26. 26. signs
  27. 27. Signs <ul><li>Feel </li></ul><ul><li>Temperature. </li></ul><ul><li>intra-articular fluid in which can be tested by: </li></ul><ul><ul><li>Cross-fluctuation test can test large amount of fluid. </li></ul></ul><ul><ul><li>The patellar tap test can test moderate amount of fluid. </li></ul></ul><ul><ul><li>The bulge test can test small amount of fluid. </li></ul></ul><ul><ul><li>The patellar hollow test can test very small amount of fluid. </li></ul></ul>
  28. 28. Signs
  29. 30. signs <ul><li>Tenderness over soft tissue and bony outlines. </li></ul><ul><li>Synovial thickening. </li></ul>
  30. 31. Signs <ul><li>Move </li></ul><ul><li>Flexion and extension normally the range 0 - 150°. Hyperextension should be recorded as minus degree. </li></ul><ul><li>Rotation normally the knees can be rotated internally and externally for 10° if the hip and knee are 90° flexed. </li></ul>
  31. 32. Signs
  32. 33. Tests for stability <ul><li>In testing for stability it is essential to compare the normal with the abnormal knee. </li></ul>
  33. 34. Tests for stability
  34. 35. Tests for stability <ul><li>The medial and lateral collateral ligaments (MCL and LCL) </li></ul><ul><li>are tested by stressing the knee into valgus and varus: this is best done by tucking the patient’s foot under your arm and holding the extended knee firmly with one hand on each side of the joint; the leg is then angulated alternatively towards abduction and adduction. This is called valgus and varus stress tests. </li></ul>
  35. 36. Tests for stability <ul><li>The test is performed at full extension and again at 30 degrees of flexion. Sideways movement in full extension is always abnormal: it may be due to either </li></ul><ul><li>Torn or stretched ligament. </li></ul><ul><li>Loss of articular cartilage or bone. </li></ul>
  36. 38. Tests for stability
  37. 39. Tests for stability <ul><li>The cruciate ligaments </li></ul><ul><li>are tested by examining for abnormal gliding movements in the antero-posterior plane. With both knees flexed 90 degrees and the feet resting on the couch, the upper tibia is inspected from the side; if its upper end has dropped back, or can be gently pushed back, this indicates a tear of the posterior cruciate ligament (the 'sag sign'). </li></ul>
  38. 41. Tests for stability <ul><li>With the knee in the same position, the foot is anchored by the examiner sitting on it (provided this is not painful): then, using both hands, the upper end of the tibia is grasped firmly and rocked backwards and frontward to see if there is any antero-posterior glide ( the drawer test ) </li></ul>
  39. 42. Tests for stability <ul><li>an excessive posterior movement ( a positive posterior drawer sign ) signifies posterior cruciate laxity </li></ul>
  40. 44. Tests for stability <ul><li>Excessive anterior movement </li></ul><ul><li>( a positive anterior drawer sign ) denotes anterior cruciate laxity </li></ul>
  41. 46. ACL <ul><li>Lachman test- is more sensitive but this is difficult if the patient has big thighs (or the examiner has small hands). The patient’s knee is flexed 30 degrees; with one hand grasping the lower thigh and the other the upper part of the leg, the joint surfaces are shifted backwards and forwards upon each other. If the knee is stable, there should be no gliding. </li></ul>
  42. 49. McMurray’s test <ul><li>This is the classic test for a torn meniscus and is based on the fact that the loose tag can sometimes be trapped between the articular surfaces and then induced to snap free with a palpable and audible click. The knee is flexed as far as possible; one hand steadies the joint and the other rotates the leg medially and laterally while the knee is slowly extended. The test is repeated several times with the knee stressed in valgus or varus feeling and listening for the click. </li></ul>
  43. 52. The patellofemoral joint <ul><li>The patellofemoral joint is examined separately: The size, shape and position of the patella are noted. The bone is felt first on its anterior surface and then along is edges and at the attachments of the quadriceps tendon and the patellar ligament. Much of the posterior surface is accessible to palpation if the patella is pushed first to one side and then to the other: tenderness suggests synovial irritation or articular cartilage softening moving the patella up and down while pressing it lightly against the femur (the friction test') causes painful grating if the central portion of the articular cartilage is damaged. </li></ul>
  44. 53. KNEE SPECIAL TESTS <ul><li>Apprehension Test </li></ul><ul><li>(Assessment for Patella Subluxation or Dislocation) </li></ul><ul><li>Athlete is sitting with the affected leg extended (straight). </li></ul><ul><li>Place thumbs along medial or lateral edge of patella. </li></ul><ul><li>Gently move patella in opposite direction. </li></ul><ul><li>(+) = athlete voices apprehension to you doing test OR pain on movement </li></ul>
  45. 54. Do not forgot to examine the patient in prone position <ul><li>These signs might be found: </li></ul><ul><li>Bulging capsule (midline swelling). </li></ul><ul><li>Semi membranous bursa ( above joint line). </li></ul><ul><li>Baker’s cyst (below joint line). </li></ul>
  46. 55. Tests to be done from posterior aspect are: <ul><li>Apley’s test </li></ul><ul><li>Lachman's test can be readily, performed with the patient prone </li></ul>
  47. 56. Imaging <ul><li>Antero-posterior, lateral and sometimes patello-femoral (or skyline) and intercondylar or tunnel views are needed. The antero-posterior view should be taken with the patient standing. Stress films in valgus and varus are essential for diagnosing collateral ligament tears. Loose bodies also can e detected. </li></ul>
  48. 57. Imaging <ul><li>Arthrography and MRI are useful in doubtful Meniscal or ligament injuries. </li></ul><ul><li>Radioisotope Scans may show increased activity in the sub articular bone which indicates early sign of osteoarthritis. </li></ul>
  49. 58. Arthroscopy <ul><li>Arthroscopy is useful: </li></ul><ul><li>(1) To establish or refine the accuracy of diagnosis. </li></ul><ul><li>(2) To help in deciding whether to operate, or to plan the operative approach with more precision. </li></ul><ul><li>(3) To record the progress of a knee disorder. </li></ul><ul><li>(4) To perform certain operative procedures. </li></ul>