ASSESSMENT AND MANAGEMENT OF THE KNEE AND LOWER LIMB www.fisiokinesiterapia.biz
Overview History Examination X-rays Fractures and Dislocations. Soft Tissue Injuries Other Knee/Lower limb Problems
Anatomy of the Knee Femur Quads insertion Patella Ligamentum patellae Meniscus Tibia Fibula Medial Collateral Ligt
ACL PCL
HISTORY Mechanism of injury is vitally important. Flexed/Twisting Forced flexion/hyperextension Falls/Direct Blow Swelling Rapid/Gradual Previous Knee Problems No Injury or Previous Problems?
Look KNEE EXAMINATION Wasting,swelling,deformity,redness,scars Feel Temp,Effusion,crepitus Move Passive,Active Resting position,slr,extension,flexion, collateral ligaments, cruciates menisci
X-RAYS
Ottawa Knee Rules Xrays are only required if the following are present. Isolated bony tenderness of the patella. Bony tenderness of the fibula head. Patient cannot flex knee to 90 Patient cannot weight bear (4 steps) after injury or in A&E Exceptions
Tibia Plateau fracture Fall extended leg,compression # proximal tibia. Valgus stress, # lateral tibia plateau Varus stress, # medial tibia plateau Proximal tibia examination reveals tenderness. Swelling, haemarthrosis, ligament damage. X-ray Knee
Fracture of lateral tibial plateau
Patella Facture
Patella Fracture Direct blow, Fall, Violent flexion, Quadriceps contraction. Pain/Swelling, Crepitus, Pain on extension Straight leg raise. Haemarthrosis X-ray Treatment Vertical Transverse Patella
High Patella
Patella Dislocation Medial stress > Lateral dislocation Knee in flexion. Dislocation usually obvious. Entonox Medial reduction with knee extension. Obtain X-rays, cylinder POP, Analgesia, and orthopaedic follow up.
Dislocation of the Knee Dislocation Serious ligamentous and soft tissue damage. Assess above and below knee. Vascular and Nerve damage. Reduction Adequate analgesia Traction/Reduction of deformity Check Pulses and Sensation POP backslab Admission
Knee Tibia Plateau Fracture Treatment Long POP backslab Orthopaedic referral Elevation ORIF/Bone grafting
Haemarthrosis Acute haemarthrosis Onset of swelling following injury Warm, tense, painful Causes Cruciate ligament damage, tibial avulsions, fractures Orthopaedic opinion
Cruciate Ligament Rupture Examination Anterior Look for medial collateral and menicus damage Anterior draw Avulsion of anterior tibial spine. Posterior Sagging of tibia Avulsed posterior tibial spine. Both require referral
ACL Rupture
PCL Rupture (tibial sag)
Avulsion fracture of ACL insertion
Meniscal Injury Usually twisting injury History crucial McMurray s Test
Collateral Ligament Injury Examination Tenderness, stress testing Grading Grade I Local tenderness+slight or no laxity Grade II Local tenderness+laxity with endpoint. Orthopaedic follow up Complete rupture No endpoint. POP cylinder. Analgesia, Crutches. Orthopaedic referral
Soft Tissue Injuries Ruptured Quadriceps Unable to straight leg raise Possible palpable defect. Surgical repair Ruptured Patellar Tendon Unable to straight leg raise Possible palpable defect. Displaced patella Avulsion of tibial tuberosity Surgical repair.
Soft Tissue Injury Locked Knee Full extension blocked. Degree of which can vary. Possible meniscal injury. X-ray for loose body. Requires arthroscopy.
Bursitis Typically from kneeling Prepatellar In front of patella Infrapatellar Below patella Treatment Rest, NSAIDS, stop kneeling Pyrexia and/or Cellulitis Fluid aspiration. Cultures. Antibiotics.
Prepetellar and Infrapatellar Bursitis
Knee problems not to be missed Baker s Cyst Osteoarthritis Septic Arthritis Osteomyelitis Referred pain NB other lower limb problems DVT Compartment Syndrome
Summary When a patient complains of a painful knee the initial differential diagnoses are multiple A good history will rapidly clarifyreduce this and examination should confirm the diagnosis Special investigations may still be required.