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1
Q

What is the MC knee injury in service members?

A

Meniscal tears are 10x more common

2
Q

Which meniscus is most commonly torn?

A

Medial meniscus

3
Q

Medial meniscus shape and what is it attached to?

A

It is semilunar and adherent to MCL

4
Q

Shape and location of the lateral meniscus?

A

Circular

Covers more of the tibia

5
Q

What is the purpose of a meniscus?

A

Distributes the load of the joint via circumferential or hoop stress

6
Q

How much does lateral meniscus decrease compartment loads by>?

A

70%

7
Q

Medial meniscus decreases compartment loads by___?

A

50%

8
Q

Common tears of meniscus?

A

Vertical longitudinal (moon in the middle)

Vertical radial (a cut)

Horizontal (wear on the inside of the c)

Oblique (oblique cut)

Complex/degenerative (shit show)

Slide 8

9
Q

What is the effect of a meniscal tear?

A

It disrupts the mechanics of the knee, leading to degenerative arthritis

10
Q

Blood supply in meniscuses?

A

The more peripheral the higher the blood supply

The higher the blood supply the higher the chance of of healing

11
Q

MOA for meniscus tear?

A

Usually pivot or twist

12
Q

Meniscus warning signs

A

Joint line tenderness of medial or lateral side of knee

Pains worsens w twisting or squatting

Mechanical symptoms (locking, catching and popping)

Effusion >12hrs (slow leak)

13
Q

PE for meniscal tear?

A

Joint line tenderness

Decreased ROM (esp w locked knee)

14
Q

Special tests for meniscus tear?

A

McMurrays
Thessaly
Apley’s

15
Q

Pt has a displaced “bucket handle” meniscal tear?

A

Surgery ASAP

16
Q

What do radiographs show?

A

Eval for loose bodies/bone fragments

17
Q

What grades of meniscus tear are visible on arthroscopy?

A

III and IV

You’re getting surgery

18
Q

You get a meniscus tear and it gets fixed (or doesnt) what do you win?

A

Osteoarthritis will develop

19
Q

Who should not get surgery?

A

Conservitavie management for:

  • 40+ w pain but no mechanical symptoms
  • degenerative tears and/or middle 1/3 (avascular)
20
Q

Who should get surgery?

A
Young population
Tears between 1 and 4cm
Vertical tear
Red-red tears
Meniscal root tear
Failure of nonopp
Bucket handle/locked knee
21
Q

We decide not to get surgery how do we treat your meniscal tear?

A

The same as any other musculoskeletal inj

Acute Rehab
Subacute rehab
Bracing
Back to life

22
Q

96% of the time what are the surgeons doing for meniscus tears?

A

Debride

Only 4% repair

(Civilians)

23
Q

How does the military handle surgery for meniscal tears?

A

The military does many more repairs than the civilian sector does

24
Q

What meniscus tears get referred?

A

Trauma, mechanical symptoms or instability

Failed non-opp

All bucket handle tears

Young people

25
Q

What is an OCD?

A

Osteochondritis dissecans : osteonecrosis of subchondral bone

Usually occurs in the knee but not always

26
Q

MC location for OCD?

A

Posterolateral side of the medial femoral condyle

27
Q

What causes OCD?

A

Repetitive small stress to the subchondral bone that disrupts the blood supply to an area of bone

Osteonecrotic bone separates

Shear forces fracture the articular surface

28
Q

What happens to the osteonecrotic fragment once it breaks free?

A

It can become a loose body in the joint

29
Q

Clinical presentation of OCD?

A

Gradual onset of knee pain

Knee effusion and catching or locking symptoms

30
Q

MC site for OCD?

A

Medial femoral condyle, palpated with the knee flexed at 90*

31
Q

What is the best x-ray to view OCD?

A

Tunnel and lateral views

32
Q

What is the treatment goal for OCD?

A

Reduce shear forces allowing new bone formation

Requires creeping substitution of new bone

33
Q

How well does surgery work for OCD?

A

It may slow down the damage, but youre probably eventually getting a new knee

34
Q

Does nonoperative tx work?

A

If the cartilage is still intact
however…

Doesnt really work after skeletal maturity

35
Q

What do the surgeons do for the bone with OCD?

A

They will do microfracture
Or drilling

Can also do autograft (but thats not in the slides)

Another option is temporary internal fixation (peads)

36
Q

Does the physis matter?

A

Yes if the physis is still open the prognosis for healing is significantly higher (kids)

37
Q

What is a plica?

A

A normal fold in the synovium

There are 5 potential places for them but most are asymptomatic

38
Q

Where is the medial plica?

A

Extends from the medial joint capsule to the medial anterior fat pad

39
Q

How does plica present?

A

It becomes inflammed or thickened from trauma or overuse

Aching over anterior or anteromedial aspec of knee

Painful snapping or popping

Buckling or instability may occur

40
Q

Where are most symptomatic plicas?

A

Usually the medial plica

41
Q

How stable are plicas?

A

Though buckling or sense of instability may occur the true giving way, locking or obvious effusion is uncommon

42
Q

Can you palpate plica?

A

Sometimes you can palpate a “thickened band” with the knee flexed

43
Q

Does radiology show anything?

A

They are usually normal but you get them to r/o other stuff (i.e. to bill insurance)

44
Q

Management of plica?

A

Decrease inflammation and thickening

NSAIDS or Tylenol
Modify activities
Local anesthetic and corticosteroid

45
Q

What is diagnostic and therapeutic of plica?

A

Injection of local anesthetic and corticosteroid into the plica

46
Q

Surgery for plica?

A

Not usually but in extreme cases you can do an arthroscopic resection

47
Q

What is bipartite patella?

A

One or more secondary centers of ossification fail to fuse

Mc the superolateral pole

Basically 2 patellas

48
Q

How are bipartite patellas usually diagnosed?

A

Typically its an incidental finding

49
Q

Differentiating bipartite patella from a fx?

A

Remember fractures dont have smooth edges

50
Q

PE for bipartite patella?

A

You may feel a prominence over the superolateral pole of the patella

51
Q

5 bursal sacks of the knee?

A
  1. Pre-patellar
  2. Supra-patellar
  3. Infra-patellar
  4. Pes anserine
  5. Iliotibial tract
52
Q

What causes bursitis?

A

Chronic friction causes thickening of the synovial lining and subsequent excessive fluid formation -> localized edema and pain

53
Q

Prepatella bursa aka?

A

Housemaids knee

54
Q

Bursitis presentations?

A

Inflamed (bursitis)

Infected (septic bursitis)

55
Q

MC infection agent in prepatellar bursitis?

A

Staph aureus

56
Q

Where is the prepatellar bursa?

A

In front of the patella

57
Q

Where is the suprapatellar bursa?

A

Between anterior surface of lower part of femur and the deep surface of the quadriceps femoris

Above the knee

58
Q

Where is the infrapatellar bursa?

A

Between the upper part of the tibia and patellar ligament

Below the knee

59
Q

Where is the pes anserinus bursa?

A

Under the insertion site of the sartorius, gracilis, and semitendinosus muscles on the medial flare of the tibia just below the tibial plateau

60
Q

Who gets pes anserine bursitis?

A

Usually its pts w early osteoarthritis in the medial compartment

61
Q

What causes iliotibial tract bursitis?

A

Repetitive flexion and movement of the knee inflames it

Also causes iliotibial band friction syndrome

62
Q

How does bursitis present?

A

At first pain w activity

Gets worse after being sedentary

Localized swelling over structure

63
Q

What is pes anserine bursitis often confused with?

A

Medial meniscal pain

But pes anserine is distal to the joint line

64
Q

Difference infected bursitis from septic joint arthritis?

A

Septic knee arthritis has:

  • intense pain
  • large effusion
  • erythema
  • guarding w motion
  • limited ROM
  • low grade fever

Infected bursitis is usually not super painful or erythematous

65
Q

Which bursitis can cause numbness distal to the patella?

A

Pes anserine bursa can compress the saphenous nerve and its infrapetellar branch

66
Q

Radiographs presentation of bursitis vs septic arthritis?

A

Anterior soft-tissue swelling w prepatellar bursitis

Septic arthritis has an effusion most compressed in the suprapatellar pouch

67
Q

What needs to be done with suspected septc bursitis?

A

The slides say aspirate but dont stick the needle into the erythematous skin

He says cut them to drain and take sample

68
Q

What labs does the sample for septic bursitis need?

A

Gram stain
Culture
Crystal analysis
Synovial fluid analysis

69
Q

Treatment for bursitis?

A

NSAIDS, RICE, stretching
Corticosteroid

Ultrasound phonophoresis (prob wont help)

70
Q

Surgery for bursitis?

A

Rarely done but the slides say you can do a needle decompression or a surgical drainage

He says dont do this

71
Q

Abx for bursitis?

A

Early onset septic bursitis can be managed with oral abx

More sever gets IV abx

72
Q

What bursitis gets referred?

A

Dont respond to tx

Recurrent pes anserine bursitis

Prepatellar bursa that are recurrent

73
Q

What does a rupture of the quad or patella tendon result in?

A

It disrupts the extensor mechanism of the knee

74
Q

What causes quad and patella ruptures?

A

Trauma

Usually a fall or MVA

75
Q

Who usually gets a quad or patella ruptures?

A

Men 40-60 (weekend warriors)

Prolonged use of fluoroquinolones

76
Q

Presentation of quad and patella rupture?

A

Significant pain after acute injury

Limited walking

(Can ambulate w incomplete rupture)

77
Q

PE for quad and patella rupture?

A

Large effusion
Palpable defect

Fx is obvious but rupture may be harder to find

78
Q

What is the key to diagnosis for quad and patella ruptures?

A

Patients inability to extend the knee against gravity or perform a straight leg raise

79
Q

Diagnostic tests for quad and patella ruptures?

A

Plain radiographs
(Patella is lower or higher than it should be)

MRI can confirm rupture of the tendon but is rarely necissary

80
Q

Patella alta and patella baja?

A

Patella alta: high riding patella

Patella baja: low riding patella

81
Q

Blumensaat line?

A

Line drawn along the roof of the intercondylar notch of the femur as seen on lateral radiograph of the knee joint

82
Q

Do we need to fix quad and patella ruptures?

A

Unless you surgically fix this they will become disabled

Delay in tx is makes the outcome much worse

83
Q

What do quad and patella ruptures get? (he never gives these to anyone else)

A

Knee immobilizer

84
Q

Clinical triad for quad and patella rupture?

A
  1. Inability to actively extend knee
  2. Patella alta/baja
  3. Palpable defect
85
Q

How fast do they need surgery?

A

With in 1 week

86
Q

I awaken.
I consume oxygen, then bacon eggs and black coffee.
Then my wife
Then bacon

A

Nick offerman