knee_pres_1[1]

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knee eassessment

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  • Brief intro
  • Bakers cyst
  • Medial condyle of femur Most patients are athletic Direct blow is more common cause than a rotational injury Most common cause of an intra-articular loose body The separation of articular cartilage and subchondral bone fragment from a joint surface was misnamed as osteochondritis dissecans in the nineteenth century in the false belief that there was an underlying inflammatory pathology. 1 We know now that this is not the case but the name has stuck. The separated fragment may become avascular and exist as a loose body within the joint. It is the most common cause of a loose body in the joint space of adolescent patients. There are two main types of osteochondritis dissecans: Adult form (after the physis has closed) Juvenile form (occurring with an open epiphyseal plate) Some believe that the adult form represents undiagnosed, persistent disease from childhood. The aetiology is uncertain but thought to be due to a multifactorial combination of: Epidemiology Prevalence This is a rare disorder - affecting the knee, there are 3-6 cases per 10,000 adult population. 2 Always consider the diagnosis, as early pick-up is vital. Clinical findings can be subtle so have a low threshold for ordering X-rays or requesting an orthopaedic opinion. Juvenile lesions are typically stable, with an intact articular surface, and thus have the potential to heal with conservative management if detected early. 6 Differential diagnosis Alternative causes of the symptoms should be sought where there is no radiological confirmation of osteochondritis dissecans. Consider: In children and adolescents, traction apophysitis , e.g. Osgood-Schlatter's disease , may cause similar symptoms but the pain is usually localised to the relevant tendinous insertion with overlying tenderness and swelling. Investigations Staging Staging of Osteochondritis Dissecans 3 StageAppearance on MRIStability of lesionI Thickening of articular cartilage and low signal changesStable II Articular cartilage interrupted, low-signal rim behind fragment showing that there is fibrous attachmentStable III Articular cartilage interrupted, high signal changes behind fragment and underlying subchondral bone.Unstable IV Loose bodyUnstable Management Non-drug Conservative measures should be used to treat stable (Grade I and II) lesions and younger patients with open epiphyses. Many cases will resolve with this regimen including: Drugs Simple analgesics or NSAIDs may be used to treat pain. NSAIDs will not affect the disease course as there is no significant inflammatory component. Surgical Surgery is usually undertaken when: Surgical approaches include 1 : Complications Prognosis Prognosis depends on the age of the patient, the affected joint and stage of lesion at presentation. Younger patients with small, stable medial femoral condyles have the best prognosis. 8 Unstable lesions can heal after stabilisation, but long-term prognosis is not clear. Chronic loose fragments can be difficult to fix and tend to heal poorly. Excision of large lesions from weightbearing zones also tend to give poor results. 6
  • Oblique, horizontal, radial , complex, bucket handle ORIGINALLY DESCRIBED BY Karachalios in 2005 213 pts did 4 tests 90 % accurate Associated ACLR less accurate
  • Eges test described by Akeski et al 2005 Accuracy = JLT and supreior to that of McMurrays
  • Bounce Home Test
  • 60-80% menical injuries have JLT 84 % sensitive but only 31% specific Found that JLT higher diagnostic accuracy , sednsitivity and specificity for LM than MM
  • Contractile tissue Hamstring/Quads strain matches up with palpation
  • 12 bursa in knee Most common roofers, plumbers
  • Anteromedial proximal tibia Sartorius, gracilis and semi tendinous = ‘goose’s foot’ Lies superficial to tibial insertion of MCL Overuse hamstrings (Runners) with tight hamstrings Direct trauma Patients with OA (50-80 yrs), genu valgum or flat footed
  • Infra patella area Generally post traumatic Hoffas test- flex knee press both thumbs deep alongside patella tendon- extend knee=pain +ve
  • Cruciates are thick as a pencil ACL stabilises through range
  • MM more mobile attatched to MCL
  • PCL is twice as strong as ACL
  • MCL: strong, flat, broad ligt; origin at medial femoral epicondyle, inserts 5cm below joint line at shaft of upper tibia LCL: shorted, cord-like ligt; 5cm long, size of half a pencil. Origin at lateral femoral condyle and inserts at head of fibula
  • The McMurray test is the most widely used test first described 1940, and it is found to be positive in 58% of knees with a torn meniscus19 JLT Others believe that joint-line tenderness is the most accurate clinical sign of meniscal tears, as it is present in 77% to 85% of such cases11,18,19. The joint-line tenderness sign only can be safely used for the detection of lateral meniscal tears1 The Thessaly test at 20° of knee flexion had a high diagnostic accuracy rate of 94% in the detection of tears of the medial meniscus and 96% in the detection of tears of the lateral meniscus, and it had a low rate of false-positive and false-negative recordings. Other traditional clinical examination tests, with the exception of jointline tenderness, which presented a diagnostic accuracy rate of 89% in the detection of lateral meniscal tears, showed inferior rates. Conclusions: The Thessaly test at 20° of knee flexion can be used effectively as a first-line clinical screening test
  • Chondromalacia patellae (also known as CMP , Patellofemoral Pain Syndrome and Runner's Knee ) is a term that goes back eighty years. "soft cartilage under the knee cap,“ pain at the front of the knee from just about any cause. BIPARTITE PATELLA 1% population. In some people who have a bipartite patella, the fibrous tissue that connects the pieces of bone can become inflamed and irritated. The tissue that connects the two parts of bone is called a synchondrosis
  • ? Sky line view
  • In some people who have a bipartite patella, the fibrous tissue that connects the pieces of bone can become inflamed and irritated. The tissue that connects the two parts of bone is called a synchondrosis -type I: inferior pole of the patella;           - type II: lateral margin type;           - type III: superolateral type
  • Flow chart Advice and education for those pts with mild pain or longer term condition: Pain ladder; relative rest, move as pain allows; ice 10-15 mins each hour; tubigrip?, elevate
  • CRS Osteo sarcoma ? Case for imaging in patients with persistant unilateral knee pain > 6 weeks 20-30 yrs age
  • knee_pres_1[1]

    1. 1. Knee Assessment Amanda Adams Donna Abraham 8 th March 2010
    2. 2. Subjective History <ul><li>knee problems diagnosed by good subjective examination </li></ul>80%
    3. 3. Subjective Examination <ul><li>Onset- Insidious or sudden </li></ul><ul><li>Mechanism of injury- </li></ul><ul><li>Weight bearing ? Which direction force? </li></ul><ul><li>Open/Closed? </li></ul><ul><li>Audible sounds- &quot;pop&quot; or &quot;snap&quot; = ACL . </li></ul><ul><li>A clicking noise on movement = meniscal injury . </li></ul><ul><li>Pain location - Localized or diffuse ? </li></ul>
    4. 4. <ul><li>Severity of Pain - ACL Vs MCL </li></ul><ul><li>Swelling - Haemarthrosis = ACL , PCL, tibial plateaux fractures . </li></ul><ul><li>Gradual swelling (6-24 hours) effusion =meniscal injury. </li></ul>
    5. 5. Special Questions <ul><li>Locking Cannot fully extend passively </li></ul><ul><li>? True or pseudo ? Spasm locking </li></ul><ul><li>? Stiffness </li></ul><ul><li>? Osteochondritis dissecans </li></ul><ul><li>loose bodies ? X-ray ? </li></ul><ul><li>Giving way ? Reflex inhibition or pain? </li></ul>
    6. 6. Objective Assessment Observation / Palpation ROM / Muscle strength & Special tests
    7. 7. Observation <ul><li>Swelling – generalised (joint inflammation/ OA) or specific (?bursitis) </li></ul><ul><li>Deformity – valgus/ varus (long standing condition) </li></ul><ul><li>Muscle wastage – quads bulk (long standing condition) </li></ul><ul><li>Redness - ?infection </li></ul>
    8. 8. Swelling/Effusion <ul><li>Patella tap : extend the knee and empty the suprapatellar pouch by applying pressure from the palm of your hand above the knee. This will push fluid underneath the patella, lifting it. Maintain this pressure. Next, press down on the patella with the fingers of the other hand and the patella will be felt to move down and touch ('tap') the underlying bone </li></ul><ul><li>Sweep : again, with the knee in extension, use the palm of your hand to massage any fluid in the anteromedial compartment of the knee into the suprapatellar pouch. Next, stroke the lateral side of the joint and the lateral side of the suprapatellar pouch. This will push any fluid present back into the anteromedial compartment. Look for a fluid impulse. 2 </li></ul>
    9. 9. Thessalys Test <ul><li>Karachalios T, Hantes M, Zibis AH, Zachos V, Karantanas AH, Malizos KN. Diagnostic accuracy of a new clinical test (the Thessaly test) for early detection of meniscal tears.  J Bone Joint Surg Am.  2005;87(5):955-962. </li></ul>
    10. 10. Ege’s Test <ul><li>The patient's feet are turned outwards to detect a medial meniscus tear, and turned inwards to detect a lateral meniscus tear. </li></ul>AkeskiD, OzcanO, Boya H. PinarH. A new weight bearing Test & Comparison with McMurrays test and Joint line Tenderness. Arthroscopy 2005 20:951-958
    11. 11. Functional/ Range of movement (ROM )
    12. 12. ROM <ul><li>Compare active and passive </li></ul><ul><li>Capsular Pattern </li></ul><ul><li>End feel – spongy or hard? </li></ul>
    13. 13. Palpation <ul><li>Medial/lateral joint lines </li></ul><ul><li>Patella mobility and tendon </li></ul><ul><li>Posterior aspect knee </li></ul><ul><li>Muscle attachments </li></ul><ul><li>Bursa </li></ul>
    14. 14. <ul><li>Pain ? </li></ul>Muscle Strength
    15. 15. Pre Patella Bursitis
    16. 16. Pre Patella Bursitis
    17. 17. Pes Anserine Bursa <ul><li>Pes Anserinus Bursitis </li></ul>
    18. 18. HOFFA s Syndrome /Anterior impingement
    19. 19. Special tests
    20. 20. ACL – anterior drawer test <ul><li>Usually history of twisting injury to knee with foot/tibia fixed/ ‘pop’ </li></ul><ul><li>+ve test = excess forward translation of tibia </li></ul><ul><li>Plan: Referral to physio +/-Orthopaedics via CRS </li></ul>
    21. 21. ACL – Lachman test <ul><li>Usually history of twisting injury to knee with foot/tibia fixed/ ‘pop’ </li></ul><ul><li>+ve test = excess forward translation of tibia </li></ul><ul><li>Plan: Referral to physio +/-Orthopaedics via CRS </li></ul>
    22. 22. <ul><li>MCL+ACL+medial meniscus tear = O’Donoghue’s (unhappy) triad </li></ul>
    23. 23. PCL – posterior drawer test <ul><li>Usual history: ‘dashboard’ injury </li></ul><ul><li>+ve = excessive posterior tibial movement </li></ul><ul><li>Sag sign </li></ul><ul><li>Plan: Referral to physio +/-Orthopaedics via CRS </li></ul>
    24. 24. MCL and LCL stress testing <ul><li>Direct impact to lateral/medial aspect of knee </li></ul><ul><li>Plan: Refer to physio </li></ul>
    25. 25. Meniscal testing – McMurray scoop <ul><li>History of locking +/- giving way </li></ul><ul><li>Medial and lateral rotation of tibia from flexion into extension </li></ul><ul><li>Pain +/- ‘clunk’ </li></ul><ul><li>Joint line pain </li></ul><ul><li>Plan: refer to Orthopaedics via CRS (then post-op physio) with information of obj examination </li></ul>
    26. 26. Anterior Knee Pain <ul><li>Billateral </li></ul><ul><li>Middle aged woman ? other joint involvement </li></ul><ul><li>? inflammatoy arthopathy </li></ul><ul><li>Chondromalacia Patella/ Patello femoral dysfunction/ Patella maltracking </li></ul>
    27. 27. AKP-Tests Patello-femoral compression test/Clarkes
    28. 28. AKP-Tests McConell Critical Test
    29. 29. Bipartite patella
    30. 30. Advice and education <ul><li>(P)RICE </li></ul><ul><li>Review after 1/52 in the surgery, reassess objectively: refer to physio or secondary care </li></ul><ul><li>Borderline cases, ring Team Lead Physio to discuss </li></ul>
    31. 31. Triage Knee pain Mild Soft Tissue injury/ minimal symptoms Mod/severe soft tissue injury/ Structural compromise Long term conditions Eg. OA Suspicion of red flag pathology Managed by GP: Advice + Analgesia Review 2-3/52 Refer to PHYSIO If surgical intervention required, refer to Secondary care/CAS Refer to PHYSIO Onward referral/ Send to A&E Managed by GP. If poorly controlled, refer to PHYSIO

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