Knee problems acute and chronic

1. Knee problems acute and
chronic
How to diagnosis, treat and refer
Chris Parfitt MD, FRCS(C)

2. Disclosures
• None

3. Rural Orthopedics: Travelling
• People travel
from all over
the world to
see these
views

4. Rural Orthopedics
• This is what you end
up looking at a lot of
the time

5. Knee problems: Evaluation
• Most common
problem joint
• 3 separate joint
compartments,
menisci, internal and
external ligaments

6. Knee problems: History
If injured, ask :
1. Mechanism of injury
2. Immediate result of
injury i.e. Swelling,
crutches
3. Symptoms since the
injury

7. Knee problems: history
• Pain
• Instability(giving way)
• Locking
• Swelling
• Acronym PILS

8. Knee problems: Pain
Pain, ask:
1. Where the pain is
(one finger PLEASE)
2. What brings the pain
on (twisting, going
up or down stairs,
pain at night etc.)

9. Knee pain: instability
• Almost always
remembers an injury
• Knee”gives way”
• Ask what activities
cause instability

10. Knee Pain: Locking
Locking, can be
1. Torn meniscus,
classically in flexion,
particular in squat
2. Chondral lock can
occur at any angle
3. Patellar lock occurs
near extension
4. Loose bodies

11. Knee conditions: physical exam
• Acronym LAP the
patient (look at the
part)
• Assess limp as they
walk in
• Examine them on an
examining table

12. Knee problems: physical exam
ONE FINGER EXAM
• Muscle wasting
• Effusion!!!!
• Range of motion
• Ligament tests
• McMurrays test

13. Knee problems: physical signs
• Muscle wasting
• Sometimes can see
• Sometimes have to
measure
• Important for
medicolegal and WCB

14. Knee problems: physical signs
• Effusion
• Large effusions easy
to see
• Smaller effusions are
demonstrated with
fluid wave
• Bakers cyst a
posterior effusion

15. Knee Effusions
• ALWAYS A SIGN OF PATHOLOGY
• Detectable fluid in the knee is always a
sign of something wrong
• May be asymptomatic
• Once again helps sort out secondary gain
situations

16. Knee Ligament examination
• Stop!!
• Get an xray with
acute injury

17. Knee: ligament tests
• Drawer test
• Not that helpful in
comparison to
Lachmans test

18. Knee problems: ligament tests
• Drawer test is a little
better for posterior
cruciate
• However, posterior
sag is a very good
sign of posterior
cruciate laxity

19. Knee problems: ligament tests
• In this case, dramatic
posterior sag

20. Knee problems: ligament tests
• Lachmans test best
for Anterior cruciate
assessment
• MCL and LCL tested
at same time
• Pivot shift helps
confirm acl deficiency

21. Knee problems: Mcmurrays test
• This will be positive
with both torn
meniscii and with
arthritis

22. Knee problems: check hip
• Since you have the
leg in your hand,
always do a rotational
test on the hip
• Knee pain can be
caused by hip
problems at all ages

23. Knee problems: circulation
• Always check the
pulse at the foot as
part of the knee exam

24. Knee problems: dynamic tests
• Kneel beside the
patient as they go
into a squat
• You can hear and feel
crepitus and
sometimes lock up
the knee

25. Knee problems: investigation
• Plain Xrays
• Necessary if you are
going to refer the
patient
• In any patient past 45
years of age get
weight bearing AP

26. Knee problems: Xrays
• Previous slide was
non weight bearing
• This slide is weight
bearing

27. Single stance
• Stork view

28. Knee problems: investigation
• In any person you
suspect
patellofemoral disease
order a skyline view

29. Knee Pain: skyline view
• Skyline view helpful in
this case!

30. Knee problems: MRI
• MRI shows meniscal
and ligament injuries
well
• However it misses
most chondral lesions
• Chondral lesions are
the most common
lesions we find

31. Knee problems: MRI
• MRI is less accurate in
most studies than
arthroscopy
• I ask patients to
answer the question “if
the MRI is negative will
you be satisfied and
not want surgery?”
• WCB and ICBC cases
are good ones for MRI

32. Knee problems: MRI
• MRI is required by
many insurance
companies in the US
• In the future this may
be more of a
requirement before
considering surgery

33. Mystery slide
• What is the
diagnosis?
• Elderly man with
Parkinsons disease
has trouble walking

34. General advice on Referrals
• Nuisance knee means
no disability
• Disability means can’t
do desired activities
• Hurts every day
• Not improving
• Conservative therapy
finished

35. Management:Acute swollen
knee
• Can be torn
meniscus(i)
• Can be ligamentous
injury
• Can be flareup of
arthritis
• Or combination of all
.

36. The acute knee injury referral
• Don’t miss rupture of
extensor mechanism
• Refer urgently lateral
collateral injuries
(controversial)

37. Acute Knee Injury
• If extensor
mechanism intact and
Xray normal
• Do your best
assessment
• Crutches, ice and
follow up closely
within one week

38. Acute knee injury followup
• Getting better, re-
examine, follow
up again
• Not getting
better, refer
• MRI if available
(not usually)

39. acute knee injury follow up
• Can make better
diagnosis at follow up
• ?ACL
• ?MCL
• ? Locked meniscus
• Don’t wait too long

40. Acute knee injury MCL
• Examine at 30
degrees of flexion
• Grade 1
• Grade 2-endpoint
• Grade 3 no endpoint

41. Medial Collateral injury RX
• Grade l, Grade 2 and
Grade 3 can be
treated conservatively
with hinge brace,
protected weight and
physio
• Bony avulsion and
maybe tibial avulsion
Grade 3 for surgery

42. Grade 3 MCL with ACL tear
• Treat the MCL tear
conservatively
• Then reconstruct the
ACL
• Regain ROM and
strength before
reconstruction

43. Bucket handle tear meniscus
• If knee staying locked
in flexion refer early
• i.e. call the surgeon

44. Arthroscopy
• Arthroscopic
debridement doesn’t
help arthritis
• Arthroscopic
menisectomy not
helpful in presence of
arthritis (not always
true)

45. Acute knee injury
• If improving, get
some physio therapy
if available
• But still follow them
up

46. Knee ligament Surgery
• Mostly ACL
• PCL, posterolateral
reconstruction and
MCL reconstruction
all possible
• Only for symptoms
of instability

47. Children Acute knee injury
• Watch for physeal injuries, may need
stress XRays
• If ligamentous injuries present as well,
or in isolation can be treated as adults
• CT helpful (MRI too)

48. Question Period-knee problems