1
Q
What are the signs of ACL tears?
A
- Joint swelling*
- Significant pain
- Delayed: instability leg ‘giving way’.
- Lachman Test + Anterior Draw Test
2
Q
How would you investigate an ACL tear?
A
- A plain film radiograph of the knee (AP and lateral)
- Gold-standard: An MRI scan of the knee (also picks up meniscal tears)
3
Q
How is an ACL tear managed?
A
- Conservative: rehabilitation, canvas knee splint can be applied for comfort.
- Surgical repair: arthroscopic reconstruction tendon or an artificial graft
- Rehabilitation: Physio
4
Q
What is a MCL tear? Is it more common than an ACL tear?
A
- Yes
- MCL: valgus stabiliser of the knee
- Injured when external rotational forces are applied to the lateral knee, such as a impact to the outside of the knee
5
Q
How are MCL tears graded?
A
Grade I – mild injury, with minimally torn fibres and no loss of MCL integrity
Grade II – moderate injury, with an incomplete tear and increased laxity of the MCL
Grade III – severe injury, with a complete tear and gross laxity of the MCL
6
Q
How do MCL tears present?
A
- Trauma to the lateral aspect of the knee.
- Hearing a ‘pop’ with immediate medial joint line pain
- Swelling
- Increased laxity when testing the MCL*, via the valgus stress test
7
Q
How are MCL tears managed?
A
- Grade I Injury:
- RICE with analgesia (NSAIDs) as the mainstay.
- Strength training as tolerated should be incorporated
- Return to full exercise within around 6 weeks.
- Grade II Injury:
- Analgesia with a knee brace
- Weight-bearing/strength training as tolerated.
- Return to full exercise within 10 weeks
- Grade III Injury:
- Analgesia with a knee brace and crutches,
- Distal avulsion: consider surgery - reconstruction of ligament using autograft
8
Q
What is iliotibial band syndrome?
A
- The iliotibial band (also termed the iliotibial tract) is a branch of longitudinal fibres that form the shared aponeurosis of tensor fasciae latae and the gluteus maximus
- It extends from the iliac tubercle to the anterolateral tubercle of the tibia
- Inflammation of this band results in the condition termed iliotibial band syndrome (ITBS)
- Iliotibial band syndrome is the most common cause of lateral knee pain in athletes
- It is thought to be linked to repetitive flexion and extension of the knee
- Seen in runners, weight lifters and cyclers
- Common presentation when training for a marathon
9
Q
How does iliotibial band syndrome present?
A
Lateral knee pain is the classical clinical feature, which is exacerbated by exercise
10
Q
What special tests are used for iliotibial band syndrome?
A
Noble’s test and Renne’s test – positive if pain is felt at 30 degree flexion
11
Q
How is iliotibial band syndrome managed?
A
- Modification and analgesia
- Local steroid injections and physiotherapy can also be beneficial
- Surgical intervention in severe cases involves surgical release of the iliotibial band from the patella to allow a wider range of movement
12
Q
What causes tibial plateau fractures?
A
- Cause: high-energy trauma, such as a fall from height or a road traffic accident, from the impaction of the femoral condyle onto the tibial plateau.
- Typically a varus-deforming force, meaning that the lateral tibial plateau is more frequently fractured than the medial side
13
Q
What are the features and presentation of tibial plateau fractures?
A
- Features: hx of trauma, caused by injury through axial loading/ high impact
- Presentation: sudden onset pain, unable to weight bear, swelling, tenderness on medial or lateral aspects of the proximal tibia with potential ligament instability. Check peripheral NVS
14
Q
What are the characteristics of tibial plateau fractures on x ray
A
lipohaemarthrosis
15
Q
How are tibial plateau fractures managed?>
A
- Uncomplicated (no evidence of ligamentous damage, tibial subluxation, or articular step <2mm) – hinged knee brace and non- or partial-weight bearing for around 8-12 weeks + ongoing physiotherapy and suitable analgesia.
- Complicated/ open fracture/ signs of compartment syndrome: operative mx: ORIF (aim to restore the joint surface congruence and ensure joint stability)
- Significant soft tissue injury, polytrauma: External fixation with delayed definitive surgery is indicated in cases of
16
Q
How do tibial shaft fractures present?
A
- Presentation: hx of trauma, associated soft tissue injury + other fractures
- Sx: severe pain, inability to weight bear, examination: deformity, significant swelling, bruising.
17
Q
How are tibial shaft fractures ixd + mxd?
A
- Ix: ATLS – urgent bloods (crossmatch, G+S); Imaging: AP, lateral plain film radiographs, tibia, fibula. CT imaging in cases of potential intra articular extension
Managed
- Mx: realign ASAP under analgesia + sedation – should be brought approximately to length and rotation.
- Place in above knee backslab post reduction, immediately elevate the limb and monitor for signs of compartment syndrome
- Post manipulation plain radiographs + NVS of limb
- Most require surgical mx – intra-medullar nail, full weight bear post operatively
- Proximal or distal fractures extending into joint may required ORIF
18
Q
How do patella fractures arise and how do they present?
A
- Typically occur as a result of direct trauma to the patella e.g. dashboard injury in a RTA, or strong contraction of the quadriceps
- Presentation: Patients will present with anterior knee pain - worse with movement and the patient will be unable to straight leg raise, due to damage to the extensor mechanism
- Examination: affected knee will be significantly swollen and bruised
19
Q
How are patella fractures investigated and managed?
A
Ix: X-rays, including AP, lateral and skyline
Management
- Conservative management if non-displaced or minimally displaced fractures: brace, ensuring early weight bearing in extension
- Operative intervention is indicated in cases of significant displacement or compromise to the extensor mechanism - ORIF
20
Q
What is the function of the ACL?
A
21
Q
How do ACL tears present (hx, presentation and examination)?
A
- Hx: athlete with a history of twisting the knee whilst weight-bearing, sudden change of direction twisting the flexed knee
- Presentation: describe joint giving and unable to weight bear on presentation. Rapid joint swelling and significant pain
22
Q
What clinical tests are involved in diagnosing an ACL tear?
A
- Lachman’s test - place the knee in 30 degrees of flexion and, with one hand stabilising the femur, pulling the tibia forward to assess the amount of anterior movement of the tibia compared to the femu
- The anterior draw test - flex the knee to 90 degrees, placing the thumbs on the joint line and apply force anteriorly to demonstrate any tibial excursiona
23
Q
How are ACL tears ixd + mxd?
A
Ix: MRI scan of the knee is gold-standard to confirm the diagnosis
Management
- Immediate: RICE
- Conservative treatment: rehabilitation, which utilises strength training of the quadriceps to stabilise the knee - a cricket pad knee splint can be applied for comfort
- Surgical reconstruction of the ACL involves the use of a tendon or an artificial graft
- Post-traumatic osteoarthritis is a well-established complication of both ACL injury and ACL reconstructive surgery
24
Q
What is the function of the MCL?
A
25
How do MCL tears arise? How does it present?
* It is most often injured when **external** rotational forces are applied to the lateral knee e.g. impact to the outside of the knee, pushing the knee inwards
* Presentation: patient may report hearing a pop; swelling of the knee;
* Examination: increased laxity when testing the MCL, via the valgus stress test. Tenderness along medial joint line, but able to weight bear
26
How are MCL tears mxd?
* Mild tears: mx conservatively with RICE + analgesia – exercise in 6 weeks
* Moderate tears: **analgesia + knee brace** – exercise in 10 weeks
* Severe tears**: knee brace + crutches** – exercise in 12 weeks
* All patients need **physiotherapy** for strengthening exercises
27
What are the functions of the medial meniscus?
* Shock-absorbers of the knee joint
* Increase articulating surface area
28
What are the causes of a medial meniscus injury?
Causes:
* **Trauma-related injury** - young patient who has twisted their knee whilst it is flexed and weight-bearing
* **Degenerative** disease
Presentation: ‘tearing’ sensation in their knee, associated with an intense sudden-onset pain and swelling. Cause knee locking and ‘giving-way’
Examination: joint line tenderness, joint effusion, and limited knee flexion
29
What is found on examination of meniscus tear and what special test is used?
* Examination: joint line tenderness, joint effusion, and limited knee flexion
* Tests: **McMurray’s Test:** McMurrays - feeling a click or pop when your hand is over the knee, on leg extension
30
How are meniscus tears managed?
* Most small meniscal tears will heal naturally over time – need rest and elevation
* Larger tears or those remaining symptomatic: arthroscopic surgery is indicated to repair the meniscus
Year 3 - Orthopaedic Surgery
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