Lower Extremity Evaluation Lecture > Knee > Flashcards

Knee Flashcards

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1
Q

Femur

A
  • Longest and strongest bone in body
  • Distal portion forms medial and lateral condyles & epicondyles
  • Features Linea Aspera
    ~ Posterior and serves as attachment
    site
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2
Q

Tibia

A
  • Proximal portion forms medial and
    lateral Tibial Plateaus
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3
Q

Fibula

A
  • Fibular head serves as attachment site
    for numerous soft tissue structures
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4
Q

Patella and its purpose

A
  • Classified as Sesamoid bone due its
    shape
  • Improves mechanical function of quads
    ~ Acts as a pully
  • Protects anterior portion of knee
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5
Q

Bursae

A
  • Act as padding and reduce friction
  • Suprapatellar
  • Prepatellar: On top of Patella
  • Infrapatellar (2)
  • Pretibial: On top of Tibia
  • Popliteal
  • Anserine: Medial
  • Iliotibial: Lateral
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6
Q

Tibiofemoral Joint

A
  • Articulation between condyles of femur
    and tibial plateaus
  • Condyles are covered with articular
    (hyaline) cartilage
  • Tibial plateaus are covered by medial
    and lateral menisci
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7
Q

Menisci and purpose

A
  • Made of fibrocartilage
  • Act as shock absorbers, increase joint
    congruency (bones fit better = stability),
    and decrease friction
  • Gets most of its resources from Synovial
    Fluid
    ~ Not supplied by blood very well; outer
    1/3 has the best blood supply and
    therefore better at healing
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8
Q

Tibiofemoral Joint Movements During Functional Loading/Pronation

A
  • Sagittal: Flexion
  • Frontal: Abduction
  • Transverse: Internal Rotation
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9
Q

Tibiofemoral Joint Movements During Functional Unloading/Supination

A
  • Sagittal: Extension
  • Frontal: Adduction
  • Transverse: External Rotation
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10
Q

What bone is relative to what bone at the Tibiofemoral Joint?

A

Tibia is relative to Femur

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11
Q

Patellofemoral Joint

A
  • Articulation between the patella and the
    medial and lateral condyles of femur
  • Both surfaces are covered by articular
    cartilage
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12
Q

Patellofemoral Joint Movements

A
  • Gliding along femoral condyles during functional loading and functional unloading of knee
  • During extension the patella rests superior to femoral groove (out of joint)
  • During flexion the patella enters the femoral groove (20-30 degrees)
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13
Q

When is the Patella most stable?

A

During flexion (loading): there’s no room for injury

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14
Q

Superior Tibiofibular Joint & Its Movements

A
  • Articulation between tibia and head of fibula
  • Movements:
    ~ Superior/Inferior Gliding
    ~ Anterior/Posterior Gliding
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15
Q

What Muscles Move the Knee?

A
  • Vastus Lateralis
  • Vastus Medialis
  • Vastus Intermedius
  • Rectus Femoris
  • Sartorius
  • Gracilis
  • Semitendinosus
  • Biceps Femoris
  • Semimembrabosus
  • Popliteus
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16
Q

Pes Anserine contains what Muscles?

A
  • Common tendon formed by Sartoius, Gracilis, and Semitendinosus
  • Insertion: Superior aspect of medial surface of Tibia near Tibial Tuberosity
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17
Q

Vastus Lateralis

A
  • Origin: Lateral lip of Linea Aspera &
    Intertrochanteric Line
  • Insertion: Lateral Border of Patella
  • Nerve: Femoral
  • Action: Knee Extension
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18
Q

Vastus Medialis

A
  • Origin: Medial lip of Linea Aspera &
    Intertrochanteric Line
  • Insertion: Medial Border of Patella
  • Nerve: Femoral
  • Action: Knee Extension
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19
Q

Vastus Intermedius

A
  • Origin: Superior 2/3 of anterior and
    lateral surfaces of femur
  • Insertion: Superior Border of Patella
  • Nerve: Femoral
  • Action: Knee Extension
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20
Q

Rectus Femoris

A
  • Origin: Anterior Inferior Illiac Spine &
    Superior to Acetabulum (Socket)
  • Insertion: Superior Border of Patella
  • Nerve: Femoral
  • Action: Knee Extension & Hip Flexion
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21
Q

Quadriceps Function: During functional loading at the Knee, the Quadriceps muscles…

A

Decelerate Flexion, Internal Rotation, & Abduction

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22
Q

Sartorius

A
  • Origin: Anterior Superior Iliac Spine
  • Insertion: Pes Anserine
  • Nerve: Femoral
  • Action: Knee Flexion; External Rotation &
    Flexion of the Hip
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23
Q

Gracilis

A
  • Origin: Inferior Ramus of Pubis & Ramus
    of Ischium
  • Insertion: Pes Anserine
  • Nerve: Obturator
  • Action: Flexion & Internal Rotation of
    Knee; Adduction of Hip
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24
Q

Semitendinosus

A
  • Origin: Ischial Tuberosity
  • Insertion: Pes Anserine
  • Nerve: Tibial
  • Action: Flexion & Internal Rotation of
    Knee; Hip Extension
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25
Semimembranosos
- Origin: Ischial Tuberosity - Insertion: Medial Condyle of Tibia - Nerve: Tibial - Action: Flexion & Internal Rotation of Knee; Hip Extension
26
Biceps Femoris
- Origin: Ischial Tuberosity (long) & Linea Aspera (short) - Insertion: Head of Fibula - Nerve: Tibial - Action: Flexion & External Rotation of Knee; Hip Extension
27
Biceps Femoris Function: During functional loading at the knee, the Biceps Femoris…
Decelerates Internal Rotation
28
Popliteus
- Origin: Lateral Condyle of Femur - Insertion: Posterior, Proximal Tibia - Nerve: Tibial - Action: Internal Rotation of Knee
29
Tibialis Posterior Function: During functional loading at the knee, the Tibialis Posterior…
Decelerates Flexion
30
Soleus Function: During functional loading at the knee, the Soleus…
Decelerates Flexion
31
What should be noticed during Anterior Inspection?
- Knee Alignment - Patella Position - Quadriceps Girth and Contour - Patellar Tendon - Tibial Tuberosity - Edema or Effusion?
32
Knee Alignment & What structures get more stress due to these alignments?
- Genu Valgum (“Knock Knee”) ~ Knees touch, ankles don’t ~ Lateral meniscus, MCL, and ACL get more stress - Genu Varum (“Bowleg”) ~ Knees apart with ankles touching ~ Medial meniscus and LCL get more stress
33
Patella Position
- Normal should be in the middle - Grasshopper Eye: Tilt Outward - Squinting Eye: Tilt Inward - Patella Alta: High Position - Patella Baja: Low Position
34
Edema vs. Effusion
- Edema ~ Swelling that’s all over and outside the joint - Effusion ~ Swelling that’s localized and inside the joint
35
Sweep/Brush/Stroke Test: Edema vs. Effusion Test
- Positive test indicated by observation of fluid movement from lateral to medial ~ Indicates Effusion
36
Patellar Tap/Ballotable Patellar Test: Edema vs. Effusion Test
- Positive test indicated by behavior of patella: ~ If patella sinks = Edema ~ If patella rebounds = Effusion
37
Fluctuation Test: Edema vs. Effusion Test
- Positive test indicated by fluid passing from superior to inferior ~ Indicates Effusion
38
What should be noticed during lateral inspection?
- Knee Alignment ~ Genu Recurvatum (“Hyperextended Knee”) > Needs to be seen bilateral to be normal
39
What should be noticed during posterior inspection?
- Knee Alignment - Calf Girth and Contour - Hamstring Girth and Contour - Popliteal Fossa
40
ROM Testing
- AROM ~ Depends on muscle girth and body size ~ Flexion: 135-145 degrees > Pt. needs to be supine to take Rectus Femorus out of the equation ~ Extension: 0 degrees > Pt. needs to be supine to take Rectus Femorus out of the equation > Leg slightly elevated to allow knee to fully push down - PROM - RROM
41
Neurological Assessment
- Very important due to orientation of the nerves around the knee and the possibility of nerve injury along with other soft tissue injury - Nerve injuries follow the MOI of ligaments - Common Peroneal: Sensory & Motor - Tibial: Sensory & Motor - Saphenous: Sensory
42
Ligamentous and Capsular Testing: Tibiofemoral Joint
- Joint Capsule ~ Fibrous connective tissue capsule which surrounds the circumference of knee joint - Medial & Lateral Collateral Ligaments
43
Medial Collateral Ligament
- Provides medial stability & resists valgus - Originates just below the Adductor Tubercle, crosses the medial joint line - Inserts 7-10 cm below joint line (Junction of Tibiofemoral Joint) - Strong and thick because it’s used all day, every day
44
Medial Collateral Ligament Test
- Valgus Stress Test ~ Positive test indicated by increased laxity at the medial joint line > Full Extension = MCL & Medial Joint Capsule > 25 degrees of Flexion = MCL
45
Lateral Collateral Ligament
- Provides lateral stability & prevents Varus - Originates from lateral femoral epicondyle, crosses the lateral joint line - Inserts on the Fibular head - Small and wimpy because it’s not used all the time. The knees natural reaction is to go into Varus and not Valgus
46
Lateral Collateral Ligament Test
- Varus Stress Test ~ Positive test indicated by increased laxity at the lateral joint line ~ Full Extension = LCL & Lateral Joint Capsule ~ 25 degrees of Flexion = LCL
47
Medial Collateral Ligament Signs & Symptoms
- Pain medially - Will hear/feel a pop - A lot of effusion - Instability
48
Lateral Collateral Ligament Signs & Symptoms
- Pain laterally - Will hear/feel a pop - Effusion or Edema or both - Instability
49
Anterior Cruciate Ligament (ACL)
- Origin: Anteromedial intercondylar eminence of Tibia, runs superior & lateral - Insertion: Medial wall of lateral femoral condyle - Provides stability in all 3 planes: ~ Abduction ~ Anterior tibial translation ~ Internal Rotation - Anterior Bundle: Tightest at full Flexion - Posterior Bundle: Tightest at full Extension
50
ACL Tests
- Anterior Drawer Test (easier) ~ Positive test indicated by increased anterior translation of Tibia relative to Femur ~ Determines grade: 1-3 ~ False negatives can occur due to hamstrings muscle guarding > hamstrings need to be relaxed and no extension - Lachman’s Test (favored) ~ Positive test indicated by increased anterior translation of Tibia ~ Hamstrings aren’t able to muscle guard
51
Segond Fracture
- Piece of bone off of Tibia - High correlation to ACL injury and same MOI - Thought to be due to excess Internal Rotation - Appears to be an avulsion fracture, possibly associated with tension on posterlateral capsule, or LCL
52
Posterior Cruciate Ligament (PCL)
- Origin: Posterior aspect of Tibia, runs superior and medial - Insertion: Lateral wall of medial femoral condyle - Works with Popliteus to prevent posterior translation and external rotation of Tibia on Femur - Anterior Bundle: Tightest between 40-120 degrees - Posterior Bundle: Tightest beyond 120 degrees
53
PCL Tests
- Posterior Drawer Test ~ Positive test indicated by increased posterior translation of Tibia ~ Will appear normal, once posterior force is applied, will look abnormal - Godfrey’s Test ~ Positive test indicated by unilateral posterior displacement of Tibial Tuberosity ~ Knees flexed in air, gravity will make Tibial Tuberosities appear unilateral ~ Quads need to be relaxed - Posterior Sag Test ~ Positive test indicated by unilateral posterior displacement of Tibial Tuberosity ~ Knees flexed with feet on table, gravity will make Tibial Tuberosities appear unilateral
54
The Anterior & Posterior Tibiofibular Ligaments support…
The Proximal Tibiofibular Joint: head of Fibula against Tibia
55
Proximal Tibiofibular Joint Ligament Tests
- Tibiofibular Translation Test ~ Positive test indicated by increased movement of Fibula on Tibia ~ Excess Anterior Translation = Posterior Tibiofibular Ligament ~ Excess Posterior Translation = Anterior Tibiofibular Ligament
56
Meniscus Tear and S&S
- Often paired with ligament injury ~ Any MOI that causes ligament tear - Impingement of meniscus between Femoral Condyles and Tibial Plateau - Remember! Meniscus’ main job is stability - S&S: ~ Not much swelling due to lack of blood supply, unless severe ~ Pain ~ Clicking, locking, & popping
57
Meniscus Tear Tests
- McMurray’s Test (best for posterior) ~ Positive test indicated by popping, clicking, or locking of knee ~ Positive with Internal Rotation = Lateral Meniscus posteriorly ~ Positive with External Rotation = Medial Meniscus posteriorly - Apley’s Compression Test (not that good) ~ Positive test indicated by pain during compression and not during distraction > If pain with distraction indicates other structure
58
Anterolateral Rotary Instability
- Describes the direction the Tibia translates on Femur as a result of injury ~ Anterior & Lateral - Possible injury to ACL and any combination of Anterolaterl/ Posterolateral Capsule, and or LCL
59
Why is instability worse than laxity?
- Instability requires surgery - Laxity is rehabilitatable
60
Anterolateral Rotary Instability Tests
- Slocum 1 Drawer Test ~ Internal Rotation ~ Positive test indicated by increased amount of anterior tibial translation relative to straight drawer - Lateral Pivot Shift Test ~ Internal Rotation ~ Positive test indicated by anterolateral subluxation of Tibia at around 20 degrees & reduction greater than 30 degrees - Slocum Anterolateral Rotary Instability Test ~ Internal Rotation ~ Positive test indicated by anterolateral subluxation of Tibia ~ Can be used for ACL and Capsule
61
Anteromedial Rotary Instability
- Possible injury to ACL and any combination of Anteromedial/ Posteromedial capsule, and or MCL
62
Anteromedial Rotary Instability Test
- Slocum 2 Drawer Test ~ External Rotation ~ Positive test indicated by increased amount of anterior Tibial translation relative to straight drawer
63
What does excess laxity internally, externally, or the same internally and externally indicate?
- Excess laxity internally = LCL - Excess laxity externally = MCL - Excess laxity internally & externally = ACL
64
Posterolateral Rotary Instability
- Possible injury to PCL and Posterolateral Capsule and or LCL
65
Posterolateral Rotary Instability Tests
- Hughston’s Posterolateral Drawer Sign Test ~ External Rotation ~ Positive test indicated by increased posterior translation of Tibia relative to straight drawer - External Rotation Recurvatum Test ~ External Rotation ~ Positive test indicated by hyperextension of knee & external rotation of Tibia
66
Posteromedial Rotary Instability
- Possible injury to PCL and Posteromedial Capsule and MCL
67
Posteromedial Rotary Instability Test
- Hughston’s Posteromedial Drawer Sign Test ~ Internal Rotation ~ Positive test indicated by increased posterior translation of Tibia relative to straight drawer
68
Plica Syndrome and Cause
- Normal fold in joint capsule that’s enlarged and becomes inflamed ~ Usually medial and superior to patella ~ Can also be superior, inferior, or lateral - Can be due to trauma or anatomical variation
69
Plica Syndrome Signs, Symptoms, and Management
- S&S: ~ Snapping and/or locking with knee Flexion/Extension > occurs due to patellar movements ~ Minimal swelling ~ Appears the same as Meniscus tear > Pt. will say weird MOI for Meniscus tear - Management: ~ RICE ~ NSAIDS ~ Surgical Excision > Last resort; needs to be severe > Causes scar tissue
70
Plica Syndrome Tests
- Mediopatellar Plica Test ~ Positive test indicated by pain with medial movement of patella - Plica “Stutter” Test ~ Positive test indicated by jerking motion of patella during knee extension > Jerking is caused by patella getting stuck and will forcefully glide
71
Osgood-Schlatter’s Disease
- Apophysitis at Tibial Tubercle ~ Causes prominent bump at Tibial Tubercle - Common in boys and girls between 8-15 years old
72
Sinding-Larsen Johansson’s Disease
- Apophysitis at Infrapatellar pole (patellar tendon attachment site) ~ Causes prominent bump at patellar tendon attachment site - Common in boys and girls between 8-15 years old
73
Osgood-Schlatter & Larsen-Johansson Diseases Cause, Signs, Symptoms, & Management
- Cause: ~ Excess stress or tension on bony attachment ~ Age; Adolescents - S&S: ~ Pain just below attachment ~ Swelling over attachment - Management: ~ Decrease activity level ~ RICE ~ Patellar Tendon Strap > Changes angle of tendon pull (bows in and cheats) > Not a fix, but helps ~ Time
74
Patellar Tendonitis (“Jumpers Knee”)
- Chronic inflammation due to overuse - Common in sports requiring explosive movements involving Flexion/Extension of Knee
75
Patellar Tendon Rupture
- Excess tension of patellar tendon - Usually preceded by Tendonitis or Osgood’s - Not common in adolescents
76
Patellar Tendon Rupture Signs, Symptoms, & Management
- S&S: ~ Complaint of sudden snap/pop ~ Swelling = Edema ~ Tenderness ~ Discoloration ~ Deformity ~ Diminished/absent active knee Extension - Management: ~ Splint/brace to immobilize ~ Crutches (non-weight bearing)
77
Patellofemoral Joint: Soft Tissue that keep Position Maintenance
- Bony Geometry ~ Patella is built and set up to stay in femoral groove - Retinaculum ~ Medial: originates from Vastus Medialis and Patella and inserts on Tibia ~ Lateral: originates off of Vastus Lateralis and Patella and inserts on Tibia - Patellofemoral & Patellotibial Ligaments - Muscles ~ Vastus Medialis ~ Vastus Lateralis ~ Vastus Intermedius ~ Rectus Femoris
78
Knee Conidtions
- Patella Femoral Stress Syndrome ~ Normal activity can cause it so ask if any trauma to knee, if no suspect this - Chondromalacia Patellae ~ Caused by Patella Femoral Stress Syndrome ~ Breakdown of patella - Patellar Subluxation/Dislocation ~ Easy to see
79
Patellar Subluxation/Dislocation Test
- Patellar Apprehension Test ~ Positive test indicated by patient apprehension ~ Subluxation usually goes lateral and this test mimics that
80
Neurovascular Injury
- Emergent - Usually as a result of a Subluxation - Same force of soft tissue MOI can injure nervous and vascular structures - Nerves involved ~ Tibial: Dislocation or hyperextension ~ Common Peroneal: LCL ~ Saphenous: MCL
81
Tibial Nerve (Posterior)
- Sensory ~ Back of thigh ~ Lateral lower leg ~ Sole of foot - Muscles Innervated ~ Soleus ~ Gastrocnemius ~ Tibialis Posterior ~ Flexor Hallicus Longus ~ Flexor Digitorum Longus ~ Hamstrings
82
Common Peroneal Nerve
- Split from the Sciatic Nerve - Splits into Deep and Superficial after crossing the knee
83
Common Peroneal: Deep Peroneal (Anterior)
- Sensory ~ 1st web of foot - Muscles Innervated ~ Tibialis Anterior ~ Peroneus Tertius ~ Extensor Hallicus Longus ~ Extensor Digitorum Longus
84
Common Peroneal: Superficial Peroneal (Lateral)
- Sensory ~ Lateral lower leg ~ Lateral portion of dorsum of foot - Muscles Innervated ~ Peroneal Longus ~ Peroneal Brevis
85
Saphenous Nerve (Medial)
- Split from Femoral Nerve - Sensory ~ Medial knee ~ Lower leg
86
Signs of Vascular Injury
- Expanding hematoma - Absent distal pulse ~ Dislocation can cause an artery to tear - Cold and pale limb
87
Why is a Vascular injury worse than a Neurological injury?
- A vascular injury causes the lack of blood flow to tissue resulting in tissue death - It’s very important to call EMS and refer immediately if suspected
88
Q-Angle
- Angle of hips relative to lower leg ~ Abduction/Valgus - Women have larger Q-Angle due to having wider hips - Larger Q-Angle predisposes you to ACL, MCL, and Lateral Mensicus tear
89
Obturator Nerve
Innervates the upper/medial thigh
90
What does NSAIDs stand for?
Non Steroidal Anti Inflammatory Drugs
91
Patellar Bursitis “Housemaid’s Knee”
- Patellar Bursa becomes too inflamed due to excess friction
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