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The Knee Joint Rima Qudah Ahmed Al-Momtan C-2
Clinical Assessment ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Clinical Assessment ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Clinical Assessment ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Clinical Assessment ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Clinical Assessment ,[object Object],[object Object],[object Object],[object Object],[object Object]
Imaging ,[object Object],[object Object],[object Object],[object Object]
Genu Varum and Genu Valgum) ,[object Object],[object Object],[object Object],[object Object],[object Object]
Lesions of Menesci ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Patterns of meniscal tears ,[object Object],[object Object],[object Object]
Clinical features of meniscal tears ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
investigations ,[object Object],[object Object],[object Object],[object Object],[object Object]
Treatment ,[object Object],[object Object],[object Object],[object Object],[object Object]
Continue, Lesions of menisci ,[object Object],[object Object],[object Object]
Clinical features of meniscal cysts and Treatment ,[object Object],[object Object],[object Object],[object Object],[object Object]
Osteochondritis dissecans ,[object Object],[object Object],[object Object],[object Object],[object Object]
Clinical features of osteochindritis dissecans ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Investigations in osteochondritis Dissecans ,[object Object],[object Object],[object Object],[object Object]
Treatment of Osteochndritis dissecans ,[object Object],[object Object],[object Object],[object Object]
Loose bodies ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Clinically ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Imaging and Treatment ,[object Object],[object Object],[object Object],[object Object]
Tuberculosis ,[object Object],[object Object]
Clinically and on X-rays ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Diagnosis ,[object Object],[object Object]
Treatment ,[object Object],[object Object],[object Object]
Rheumatoid Arthritis ,[object Object],[object Object]
Clinically: ,[object Object],[object Object],[object Object]
Treatment ,[object Object],[object Object],[object Object],[object Object],[object Object]
Osteoarthritis ,[object Object],[object Object],[object Object],[object Object],[object Object]
Clinical Features ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
X-rays ,[object Object],[object Object],[object Object],[object Object]
Treatment ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Patellofemoral disorders
Patellofemoral disorders
Clinical features ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Treatment ,[object Object],[object Object],[object Object],[object Object],[object Object]
Operative treatment ,[object Object],[object Object],[object Object]
2- Patellofemoral overload  ( patellar pain syndrome; chondromalacia of the patella ) ,[object Object],[object Object],[object Object],[object Object],[object Object]
Clinical Features ,[object Object],[object Object],[object Object],[object Object]
Imaging ,[object Object],[object Object],[object Object],[object Object]
Arthroscopy and Differential Diagnosis ,[object Object],[object Object],[object Object],[object Object]
Treatment ,[object Object],[object Object],[object Object],[object Object],[object Object]
Osgood-Schlatter’s disease ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Swellings around the knee ,[object Object],[object Object],[object Object]
A- Acute swelling of the entire joint. ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Continue ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
B- Chronic swelling of the entire joint. ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Other joint aspect swellings ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Other joint aspect swellings ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Continue… ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Other joint aspect swellings ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Continue.. ,[object Object],[object Object],[object Object],[object Object],[object Object]
Acute knee ligament injuries ,[object Object]
Continue.. ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Continue.. ,[object Object],[object Object],[object Object],[object Object]
Clinical Features ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
On X-ray ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Treatment ,[object Object],[object Object],[object Object],[object Object]
Continue.. ,[object Object],[object Object],[object Object],[object Object],[object Object]
Continue.. ,[object Object],[object Object],[object Object],[object Object],[object Object]
Continue.. ,[object Object],[object Object],[object Object]
Complications ,[object Object],[object Object]

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orthopedic and rheumatologic disorders of the knee joint

  • 1. The Knee Joint Rima Qudah Ahmed Al-Momtan C-2
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Editor's Notes

  1. 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
  2. -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.
  3. -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
  4. 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
  5. -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.
  6. 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.
  7. 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)
  8. 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.
  9. -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)
  10. - traumatic: arising from either small horizontal tear or repeated squashing of the peripheral part of the meniscus
  11. - The lump could be firm esp if the knee is extended
  12. - 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.
  13. Herbet screws: Filling the condyler defect by cartilage transplantation, long term results are still awaited.
  14. -sometimes the locking is only momentary and usually the patient can wriggle the knee untill it suddenly unlocks. - Mouse, slips away duing palpatio
  15. Mantoux test:
  16. 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.
  17. - Rheumatoid is small proximal joint disease! (remember)
  18. -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.
  19. - 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
  20. 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
  21. -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.
  22. -patella alwys disslocate laterally. The patient may think its medially because the uncovered medial femoral condyle stands out prominantly. -apprehension test:
  23. 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.
  24. -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.
  25. Arthroscopy-- Cartilage softening is common in asymptomatic knees and painfull knees may show no abnormality.
  26. Exposed areas of subchondral bone can be drilled-in the hope that revascularization may encourage repair with fibrocartilage.
  27. Often is called “osteochondritis”, though its nothing more than a traction injury of the apophysis into which part of the patellar ligamnet is inserted.
  28. Thigh wasitng due to inhibition of quadriceps.
  29. - Wiliam morrant baker 1877, althoough he used the term to indicate tuberculousarthritis
  30. ACL and PCL also provide resistance against excessive valgus and varus angulation.
  31. -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.
  32. - A complete plaster cast is unnecessary and disadvantaginous as it inhibits movement.
  33. Th eother cases; 50% will regain suffeciently good fucntion, not to need any more t/t
  34. - 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.