by mtoom

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  • What are the knee menisci?
  • What is their function? 
Fibrocartilaginous pads that function as shock absorbers between the femoral condyles and tibial plateaus.
What injury occurs sometimes with meniscal tears?
ACL injury
  • What are 2 types of injury to the menisci?
Give a mechanism of each.
  • Traumatic/acute: Twisting injury to knee
  • Older: Degenerative tears with time, patient can tear meniscus after rising from squatting position
What are symptoms of meniscal tears?
  • Knee swelling (leads to limited ROM)
  • Knee stiffness
  • Mechanical Sx (locking, catching, popping)
  • Pain with twisting/squatting
  • "Locked knee" if large pieces of cartilage get stuck in knee joint
What do you see on physical exam for meniscal tears?
  • Tenderness over medial or lateral joint line (most common)
  • Hemarthrosis (if acute)
  • Knee effusion (if acute)
  • Limited ROM (due to pain or effusion)
  • Positive McMurrary Test (i.e. painful click)
How do you diagnose a meniscal tear?
  • MRI (specific, sensitive)
  • X-ray: AP, lateral, axial patellofemoral views (if history of trauma, effusion; if chronic, AP and lateral should be weight-bearing)
  • Knee aspiration (to r/o crystal arthropathy)
What happens if treatment delayed for meniscal tear?
  • Recurrent episodes of locking and damage to adjacent cartilage
  • Subsequent osteoarthritis
  • Loss of chance to do surgical repair
What is treatment for mensical tear?
  • Locked knee, Loss of ROM, young patients → surgery
  • Degenerative tear or no mechanical symptoms →  RICE protocol, analgesics
  • Restrict sports
  • Early controlled movement
What are adverse outcomes in meniscal tear?
  • Renal/gastric NSAID complications
  • Failure of meniscectomy (10% to 30%)
  • Persistent pain or osteoarthritis after meniscectomy
What are referral decision or red flags in meniscal injuries?
  • Traumatic effusion
  • Mechanical symptoms
  • Ligamentous instability
  • Non-response to non-surgery

  • Persistent effusions 
What is primary job of ACL?
Stabilize knee against anterior translation
Tear in ACL results from what?
  • Rotational/twisting
  • Hyperextension
Are ACL injuries mostly contact or non-contact injuries?
An ACL tear is often accompanied by what injuries?
  • Often a meniscal tear
  • Sometimes an MCL tear 
What is the concern if a knee injury disrupts multiple ligaments?
Instability, leading to potential limb loss if popliteal artery is affected
What are the symptoms of an ACL tear?
  • Sudden pain
  • Knee "gives out" from twisting or hyperextension-type injury
  • Cannot continue with activity due to instability or pain
What happens if ACL tear is left untreated for long term?
  • Recurrent instability
  • Further meniscal and articular cartilage damage
  • Degenerative arthritis 
What is the most sensitive test for an ACL tear?
Lachman (Knee flexed to 30 degrees)
What diagnostic tests can be ordered for ACL?
  • X-rays (AP, lateral, tunnel) → usually only show effusion, avulsion fractures of lateral capsular margin
  • MRI → sensitive for ACL tears
How is an ACL tear treated?
  • RICE
  • Aspiration (If hemarthrosis knee effusion)
  • Brace (for comfort)
  • Early ROM exercises (maintain ROM)
  • Muscle-building exercises (for stability)
  • Surgery → ACL reconstruction
What are risks of treatment options for ACL tear?
  • Non-surgery → instability, mensical tears, degenerative disease
  • Surgery → infection, phlebitis, pulmonary emboli, neurovascular insult, scarring, possibility of re-tear, failure of ACL graft to incorporate, excessive laxity
What are referral decisions and red flags in ACL injuries?
  • Post-traumatic knee effusions
  • Suspected ACL tears 
What are symptoms of an ankle fracture?
  • Marked tenderness
  • Swelling
  • Palpable gap on medial side
  • External rotation or lateral displacement of foot from tibia
What is a bimalleolar fracture?
Describe what is presumed to be a bimalleolar fracture.
  • Bimalleolar is when both medial and lateral malleolus are fractured
  • Fracture of distal fibula (lateral malleolus) with tenderness over medial deltoid ligament is presumed to be an unstable bimalleolar injury
  • What is a Maisonneuve fracture?
  • How do you check for it? 
  • Fracture of proximal fibula
  • Tenderness in proximal fibula and swelling of medial ankle
  • Unstable external rotation injury that includes fracture of the proximal fibula, tear of medial deltoid ligament, disruption of tibiofibular syndesmotic ligaments
How do you diagnose an ankle fracture?
  • X-rays: AP, lateral, mortise (AP view with ankle internally rotated 15 degrees); also AP/lateral of proximal fibula and tibia when tenderness there; minimally displaced fractures not evident on initial x-rays; must repeat in 10 to 14 days
What happens to the medial clear space (MCS) in the mortise view with a lateral fibular fracture with deltoid disruption?
MCS widens to beyond 5mm
What fracture can happen to the talus?
Osteochondral fracture of the lateral articular surface (best seen on mortise view)
How do you treat ankle fractures?
  • Stable fractures of distal fibula → Weight-bearing case for 4 to 6 weeks
  • Unstable, non-displaced fractures → Non-weight-bearing short or long leg cast
  • Unstable, displaced fractures → Closed or open reduction
What do you do with osteochondral fragments of the talus?
Remove them, unless it's a young person then you can try to screw them back
What are referral decisions and red flags in ankle fractures?
  • Unstable fractures
  • Osteochondral fractures
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