Significance of acute effusion Knee exam case #1: Inspection Intra - PDF document

7/23/2013 Learning objectives: Common Knee Problems: in 50 minutes you will be able to… What You “Knee’d” to Know 1. List the organizational scheme for any musculoskeletal work ‐ up 2. List the 3 key knee history questions 3. Generate a differential diagnosis for acute knee injury with effusion 4. Generate a differential diagnosis for chronic anterior knee pain 5. Treat a patient with knee OA and meniscus tear 6. QUIZ UCSF Essentials of Primary Care August 8, 2013 Carlin Senter, M.D. Musculoskeletal work ‐ up Knee history • Acute vs. Subacute ‐ • H istory Chronic • Mechanism of injury • I nspection – Direct fall onto patella • Patellar fracture or • P alpation cartilage damage – Varus or valgus force to the knee • R ange of motion • MCL or LCL – Noncontact with a pop • ACL • O ther T ests http://www.ski-injury.com/kneeanat.gif, • Location of the pain Accessed 10/04/05. Accessed 10/4/05 1

7/23/2013 3 key knee injury questions Case #1: House of Air 1. Locking = meniscus or intra ‐ articular loose • 35 y/o woman on trampoline half ‐ pipe. body Jumped down and felt a pop with immediate knee pain and swelling. 2. Instability = ligament • Went to ER: placed in knee immobilizer and 3. Swelling = intra ‐ articular derangement given Vicodin for pain relief. 1. Immediate: due to blood (ACL, fracture, patellar dislocation) • Now, 3d later, has posterior pain and tightness with bending. 2. Subacute: 8 ‐ 24 hours, due to synovial inflammation (meniscus, MCL) • Knee feels unstable if not in the brace. Ddx acute traumatic knee injury with Musculoskeletal exam order effusion • H istory • Intra ‐ articular derangement • I nspection – (+) instability  ligament • P alpation – (+) locking  meniscus – Dislocation • R OM • Patella • Knee • O ther – Cartilage damage – Patellar or quad tendon • T ests rupture http://www.ski-injury.com/kneeanat.gif, Accessed 10/04/05. Accessed 10/4/05 2

7/23/2013 Significance of acute effusion Knee exam case #1: Inspection • Intra ‐ articular derangement • You will likely be ordering xray +/ ‐ MRI • The patient will not be returning to sport today Knee exam case #1: Palpation Palpation: patellar facet Ballottement Video courtesy of Dr. Anthony Luke 3

7/23/2013 Knee exam case #1: Palpation Knee exam case #1 • Supine, knee fully extended • ROM: 5 ‐ 90, limited due – Ballotement to evaluate for effusion to pain (normal 0 ‐ 135) – Medial patellar facet (patellar dislocation) – Determine if knee is – Patellar apprehension (patellar dislocation) • Straight leg raise intact locking or if ROM is limited due to effusion – If not ‐ Quad tendon or patellar tendon rupture ‐ > urgent ortho • Knee flexed to 90 degrees – Locking: think bucket – Joint line (meniscus) handle meniscus. – Lateral femoral condyle (patellar dislocation) • Urgent xrays, MRI – Above and below medial and lateral joint lines (MCL, LCL) • Urgent referral to sports • Our patient: tender medial joint line, can do straight leg surgeon for arthroscopy raise – Rules out patellar dislocation, LCL, tendon rupture Knee exam case #1 Other Tests: Lachman to evaluate ACL • Strength 5/5 hip flexion, knee extension, PF, DF. – (+) active knee extension rules out quad or patellar tendon rupture • 2+ dorsalis pedis pulses bilaterally • Sensation intact to light touch over legs bilaterally • Reflexes 2+ at patella and achilles bilaterally Video courtesy of Dr. Anthony Luke 4

7/23/2013 PCL: Sag sign PCL: Posterior Drawer Video courtesy of Dr. Anthony Luke Meniscus: McMurray MCL and LCL Sensitivity medial 65%, Specificity medial 93% Video courtesy of Dr. Anthony Luke Magee, DJ. Orthopaedic Physical Assessment, 5 th ed. 2008. 5

7/23/2013 Meniscus: Thessaly Meniscus: squat Video courtesy of Dr. Anthony Luke Case #1 special tests Case #1 diagnosis 1. Patellar tendon • (+) pain with medial McMurray, ( ‐ ) lateral rupture • (+) Thessaly – medial pain 2. Quad tendon • (+) Squat – medial pain rupture • ( ‐ ) laxity to varus or valgus at 0 and 30 3. PCL tear • (+) Lachman without endpoint 4. ACL tear • ( ‐ ) Posterior drawer 5. MCL tear 6. Fracture http://www.ski-injury.com/kneeanat.gif, 7. Meniscus tear Accessed 10/04/05. Accessed 10/4/05 6

7/23/2013 Traumatic knee effusion red flags  Case #1 treatment urgent ortho referral • Knee brace +/ ‐ crutches • Locked knee: unable to fully extend compared depending on pain and to other side instability • Xrays to r/o fracture – Bucket handle meniscus • MRI to confirm diagnosis – Make non weight bearing w/crutches • Pain medication • Fracture (tibial plateau, patella) • PT to restore normal ROM, decrease swelling, • Unable to extend knee against gravity strengthen quad • Orthopaedic surgery – Patellar or quadriceps tendon rupture referral to discuss +/ ‐ – Needs urgent surgical repair reconstruction Segond fracture – avulsion of lateral tibial plateau in ACL tear Case #2: Sketcher Shape ‐ Ups Subacute knee history 40 y/o woman presents with sharp anterior • 3 key questions knee pain x 1 month. Might have some swelling. – Swelling No locking but the knee is popping. Feels – Locking unstable when walking down stairs. Pain worse – Instability up/down stairs. Painful when gets up from • Exercise and activity history: squats, lunges, sitting. Exercise: started a walking program for new training program, marathon? New Year’s resolution, wearing new Sketcher • Shoes: how old, what type Shape ‐ Up shoes. No squats/lunges. Doesn’t • Orthotics: how old, why wearing them wear orthotics. 7

7/23/2013 Ddx subacute ‐ chronic anterior knee Case #2: Inspection pain 1. Patellofemoral pain syndrome 2. Patellar chondromalacia 3. Osteochondral lesion 4. Osteoarthritis of patellofemoral joint Patellofemoral pain syndrome: Palpation miserable malalignment syndrome • Effusion: none • Femoral anteversion • Joint line, patellar facets (inward rotation of – Tender medial and femur) lateral patellar facets • Squinting patella • Patella alta • Increased Q ‐ angle • Excessive outward tibial rotation http://www.kneeguru.co.uk/KNEEnotes/node/763 http://www.gla.ac.uk/ibls/US/fab/tutorial/biomech/akp3.html 8

7/23/2013 ROM Other tests • 0 ‐ 135 • Ligaments – Lachman • (+) crepitus with flexion and extension as patella moves across articular surface of femur – Posterior drawer – MCL – LCL • Meniscus – McMurray Other tests: Ober part 1 identify tightness and weakness • Ober (too tight?) • Hip abduction strength (weak?) • One ‐ legged standing squat (weak? Pain?) Passive hip abduction and extension. Hip extension  ITB positioned over greater trochanter of femur. http://www.youtube.com/watch?v=A0C0WBw4l4s&feature=player_detailpage 9

7/23/2013 Ober part 2 Hip abduction strength Lower the upper limb. If tight ITB then hip will not adduct past neutral. Compare side to side. http://www.youtube.com/watch?v=9Iy ‐ QrcuGno&feature=player_detailpage http://www.youtube.com/watch?v=A0C0WBw4l4s&feature=player_detailpage One ‐ legged standing squat One ‐ legged standing squat • Patient standing on unaffected leg • Do 3 slow 1 ‐ legged squats • Watch for stability, valgus angulation of knee, ask about pain • Switch and perform on affected leg • Sign of weak hip abductors, weak core • Can bring out pain of patellofemoral pain 10

7/23/2013 Case #2: Sketcher Shape ‐ Ups One ‐ legged standing squat Physical exam • Valgus angulation of the knees • No effusion • Tender medial and lateral patellar facets • ROM 0 ‐ 135, crepitus • No laxity with lachman, posterior drawer, varus or valgus at 0 and 30 degrees • (+) Ober bilaterally • 4/5 hip abductor strength bilaterally • Unstable 1 ‐ legged squat with valgus knee angulation Case #2 diagnosis Case #2 treatment 1. Patellofemoral pain syndrome • Physical therapy rx – Strengthen hip abductors 2. Patellar chondromalacia – Strengthen quadriceps 3. Osteochondral lesion – Stretch ITB, quads, hamstrings 4. Osteoarthritis • Correct alignment: consider OTC orthotics with arch support if pes planus • Activity: avoid running, squats, lunges, stair ‐ running, downhill hiking until improved. 11

7/23/2013 Case #3 Radiographs • 55 y/o man with R knee h/o lateral meniscus surgery. • Lateral ‐ sided pain and swelling of the R knee since hiking last week. • No locking, no instability • Exam: effusion, tender lateral joint line and above/below lateral joint line, (+) lateral knee irritation with lateral McMurray, (+) lateral pain with squat and Thessaly, no ligamentous laxity • He brings with him xrays and MRI for your review MRI Diagnosis Lateral Medial Lateral Medial A. Lateral meniscus tear B. ACL tear C. Osteoarthritis D. Patellar dislocation E. Septic arthritis 12