Transcript Knee & Lower Leg Injuries - Cleveland Clinic Hospital

Knee & Lower Leg Injuries
Bogdan Irimies PGY-3
June 8, 2006
Knee Anatomy:
Knee Examination


History: ask about current mechanism of
injury, prior injuries or surgeries to knee.
Inspect: pt. should be examined while
walking, note gait, muscular development,
functional ROM.
–
Inspect the knee for swelling, ecchymosis,
effusion, masses, patella location, erythema,
signs of local trauma, note leg lengths, active
range of motion.
Knee Examination



Check for neurovascular status
Palpate the knee, patella, medial and lateral
joint lines
Place the knee in various stress testing
Knee X-Rays

Ottawa Knee rules: determines the need for
x-rays, proven sensitive for fracture.
–
–
–
–
–
Age > 55
Tenderness head of fibula
Isolated patellar tenderness
Inability to flex knee 90 degrees
Inability to bear weight
Patella Fractures



Result from direct blow such as knee hitting
dashboard in MVA, fall on flexed knee,
forceful contraction of quad. Muscle.
Transverse fractures most common
PE: focal patellar tenderness, swelling,
effusion.
–
Check for extensor mechanism by doing straight
leg raising against gravity.
Patella Fracture:
Patella Fracture:
Patella Fracture

Tx: non-displaced patella fracture w/intact
extensor mechanism is treated w/knee
immobilizer, rest, ice , elevation,
NSAIDS/Opioids, then long leg cast for 6
weeks.
–
Fractures that are displaced > 3 mm or assoc.
w/disruption of extensor mechanism requires
Ortho. Referral for open reduction & internal
fixation
Femoral Condyle Fractures



These injuries secondary to direct trauma
from fall w/axial loading or blow to distal
femur.
Exam reveals pain, swelling, deformity,
rotation, shortening and inability to ambulate
Potential for popliteal artery injury, check for
ipsilateral hip dislocations or fractures
Femoral Condyle Fracture:
Femoral Condyle Fractures



Cast immobilization for stable, nondisplaced fractures
Open reduction internal fixation for displaced
fractures or any degree of joint incongruity
Complications: DVT, fat embolus, delay or
malunion, development of OA
Tibial Spine & Tuberosity Fractures

Tibial spine Fx’s:
–
–
–
–
Anterior tibial spine more commonly fractured
Painful swollen knee, inability to extend fully and
+ Lachman’s sign
If fracture is incomplete or non- displaced, it
should be immobilized in full extension w/knee
immobilizer & Ortho outpt. follow-up.
Complete, displaced fractures require open
reduction internal fixation (ORIF)
Tibial Spine Fracture:
Tibial Spine & Tuberosity

Tibial tuberosity: quadriceps mechanism
inserts on tibial tubercle
–
–
–
Sudden force to flexed knee w/quadriceps
contraction may avulse tibial tubercle
If avulsion is small or non- displaced just
immobilize.
If displaced, needs ORIF
Tibial Tuberosity Avulsion Fx:
Tibial Plateau Fractures

Produced by varus or valgus forces
combined w/axial loading which drives
femoral condyles into tibial plateau
–
–
Examples: fall from a height or leg struck by car
Painful swelling of knee, limited ROM,
ligamentous instability
Lateral Tibial Platea Fx:
Tibial Plateau Fractures


If one plateau is fractured but non- displaced,
Tx w/knee immobilizer, non-weight bearing,
outpt. Ortho follow-up for long leg cast
Complications: popliteal artery injury, DVT,
OA
Ligamentous & Meniscal Injuries






Functional instability of the knee is determined by stress testing
which can demonstrate abnormal laxity.
Medial collateral ligament: valgus or abduction applied to knee
to stress test
Lateral collateral ligament: varus or adduction applied to knee
to stress test
If there is laxity >1cm w/out firm endpoint then there is complete
rupture of MCL/LCL
If there is laxity < 1cm w/a firm endpoint then there is a partial
tear
If there is no ligamentous instability but pain w/stress testing,
then there is ligament strain
Knee Ligaments:
Anterior Cruciate Ligament



Mechanism is usually a deceleration,
hyperextension or internal rotation of tibia on
femur
May hear “pop”, swelling, assoc. w/medial
meniscal tear
Dx: Lachman’s test, anterior drawer sign ,
pivot shift
–
Displacement of > 6 mm is considered positive for
tear.
Posterior Cruciate Ligament



Less common than ACL injury
Mechanism is anterior or posterior force
applied to tibia or lower leg
DX: Posterior drawer test
Knee Ligaments Dx:


X-rays may be normal or only reveal an
effusion
MRI has approximately 90% accuracy in
detecting ligamentous or meniscal injuries
Knee Ligaments Tx:



Stable injuries involving only one ligament w/minor
strain can be treated w/knee immobilizer, ice packs,
elevation, NSAIDS, ambulation that is comfortable
for the pt.
If knee is immobilized, have pt. do daily ROM
activities to avoid contractures and maintain mobility.
Professional athletes(Kellen Winslow Jr.) w/single
ligament rupture or pts. w/more than one ligament
ruptured, need Ortho evaluation for surgical repair.
Meniscal Injuries




Mechanism is usually cutting, squatting or
twisting maneuvers.
Ask pt. if there is locking of the knee on
flexion or extension that is painful or limits
there activity.
Exam: joint line tenderness or Positive
McMurray’s test(+50% only)
Tx: partial weight bearing, NSAIDS, referral
to Ortho as outpt.
Knee Dislocation:




Result of ligamentous disruption, posterior
dislocation is most common
With posterior dislocation, ACL & PCL
injuries/disruption are common
Assoc injuries include popliteal artery injury,
peroneal nerve injury, ligamentous and
meniscal injuries
True Ortho Emergency!
Knee Dislocation




Early reduction using longitudinal traction is
essential.
Neurovascular status is important to check
pre&post-reduction
Ortho C/S & hospitalization required.
If signs of popliteal artery injury: absent
pulses, bruits, distal ischemia, C/S Vascular
surgeon for possible arteriography.
Knee Dislocation:
Patella Dislocation

Mechanism is a twisting motion on an
extended knee.
–
–
–
Patella is usually laterally displaced over lateral
condyle
May have tearing of medial joint capsule
Reduction involves conscious sedation, flexing
the hip, hyperextending the knee, and slide
patella back into place
Patella Dislocation:
Patella Dislocation:
Patella Dislocation


Check X-ray to r/o fracture
Tx: knee immobilizer, partial weight bearing,
NSAIDS, isometric quad. strengthening
exercises and outpt. F/U to Ortho.
Quadriceps/Patellar Tendon Rupture




Mechanism is forceful contraction of
quadriceps muscle or falling on a flexed
knee.
Significant pain, swelling and inability to
extend a fully flexed knee against minimal
resistance.
May see a high riding patella on lateral x-ray
view of knee
Tx: surgical repair by Ortho
Patella Tendon Rupture:
Osteochondritis Dissecans





Disorder in which a segment of articular
cartilage and subchondral bone become
separated from underlying bone
Results from acute or chronic trauma
Pts. c/o pain, swelling, cannot recall specific
injury
Dx: x-rays
Tx: protective weight bearing if epiphysis still
open.
Osteonecrosis


Bony infarction caused by disruption of blood
flow
Can be primary or secondary
–
–
Primary: etiology unknown
Secondary: steroids, SLE, ETOHism, sickle cell,
renal transplant
Osteonecrosis



Pts. Are typically elderly women who present
w/acute knee pain
X-rays are usually normal early on, MRI is
diagnostic
Tx: protective weight bearing, NSAIDS.
–
Advanced disease options include: arthroscopic
debridement, curretage,drilling of lesion, bone
grafting, tibial osteomy, osteochondral allografts,
total knee arthroplasty
Patellar Tendonitis



AKA “Jumpers Knee” b/c seen in runners,
basketball players, volleyball players and
high jumpers
Pain is in patellar tendon, worse when going
from sitting to standing position and running
up hills
Tx: Heat, NSAIDS, quadriceps muscle
strengthening
Chondromalacia Patellae



Overuse syndrome of patellar cartilage
Caused by patello-femoral malalignment
which leads to tracking abnormality of patella
putting excessive lateral pressure on articular
cartilage
Seen in young active women, pain worse
w/stair climbing and rising from a chair
Chondromalacia Patellae


Patellar compression test: push the patella
distal in trochlear groove w/knee extended
and quadriceps muscle contracted, this will
elicit pain.
Tx: rest, NSAIDS, quadriceps strength
exercises.
Penetrating Knee Injury/Joint Foreign
Body





If knee joint has been penetrated, immediate
Ortho C/S for joint irrigation in OR.
Radiopague F.B.(metal, glass) will be seen
on X-ray
F.B. in knee joint need to be removed.
Tx: IV antibiotics to cover Staph/Strep. For
penetrating wounds or foreign bodies
Don’t forget Td prophylaxis!
Fibula Fractures




Most fibula fractures are result of tibia
fractures.
Treatment is determined by injury to tibia
Fibula only bears 15% of body weight so pts.
may ambulate.
Isolated fibula fracture treated w/either knee
immobilization or elastic wrap.
Fibula Fracture:
Tibia Fractures





Mechanism usually involve torsional force, bending
force or direct blow.
Closed, minimally displaced fractures can be treated
w/reduction and immobilization
If fracture is displaced, ortho. C/S for further
reduction
Watch for compartment syndrome
Open fracture: immediate Ortho C/S, immobilize
fracture, sterile coverage of the wound, Td update,
IV antibiotics(1st gen. Ceph.), to OR for irrigation &
debridement.
Tibia Fracture:
Achilles Tendon Rupture





Mechanism is forceful plantar flexion.
Pt. may hear popping sound, difficulty
ambulating
Risk factors: quinolone use, RA, SLE, steroid
use
Dx: palpable gap in tendon, + Thompson
test, inability to walk on toes
Tx: splint in neutral position, refer to Ortho
and don’t forget the crutches.
Shin Splints





Refers to pain over medial or anterior tibia
that occurs w/exertion & relieved w/rest
Caused by micro tears of muscular fibers at
the point of bony attachment
Tenderness on exam over anterior tibia
X-rays may reveal stress fracture, bone scan
is most sensitive
Tx: stop offending activity, orthotics, strength
and flexibilty exercises
Osgood Schlatter Disease





Seen in athletic teenagers
Lesion is partial separation of tibial tuberosity
at insertion of patellar tendon
Palpation of tibial tuberosity reveals
tenderness & induration
X-ray lateral may reveal elevation of tibial
tubercle off of tibia
Tx: stop offending activities, cold
compresses, NSAIDS, Ortho referral
Do you need an xray?
Questions:






1. T or F: An ACL tear is commonly assoc. w/medial meniscal
tear as well.
2. T or F: When you prescribe a knee immobilizer, you must
instruct pt. to do daily ROM exercises.
3. T or F: Posterior knee dislocation is assoc. w/possible
popliteal artery injury.
4. T or F: For open fractures, Tx includes, Td prophylaxis.
Sterile dressing, IV ATBX, irrigation and debridement in OR.
5. T or F: RA, SLE, steroid injections, quinolone ATBX are all
risk factors for achilles tendon rupture.
Answers : ALL T!