9/26/2014

1

Kari M Komlofske, BSN, FNP-C

Orthopedics

��Describe the knee anatomy

�Review the various diagnostic tests specific to help diagnose knee disorders

�Discuss the differential diagnosis of knee pain

Objectives

�

Knee Anatomy

� Three bones articulate� Femur, tibia, patella

� Fibula is involved with support

� Main Ligaments:� Collateral

� (lateral and medial)

� Patellar

� Cruciate

� (anterior and posterior)

9/26/2014

2

�

Knee Anatomy, Continued

�Meniscus � Medial and lateral

�Muscles� Quads, hamstrings,

gastrocnemius

� Bursa � Anserine (median),

prepatellar, semimembranous(popiteal fossa)

�� Gait and stance

� Is there a Varus Deformity (bow legged), or Valgus Deformity (knocked knees)

� Pain/Tenderness� Especially important at the joint line (locate it)� Exacerbation, relief� Medications

� Range of motion � Full extension is leg flat 0 degrees� Maximum flexion is 150 degrees to your butt (you need about

120 to get up from a chair comfortably)� Visualization

� Swelling, ecchymosis, erythema, deformity

Examination of the Knee

��Other history

� Buckling or locking symptoms (hx or PE)

� Can’t lay on side with legs together in bed:� Anserine bursitis

� Associated with OA and varus deformity

� Theater sign (hx) – can’t sit through a movie without your knees aching � Patellofemoral syndrome – “J” sign

� One side of quad works harder than other

� Extend leg and contract quads

� Lateral “J” move = weak vastus medialis

Examination Continued

9/26/2014

3

�� Ballottement

� Posterior Drawer Test

�McMurray’s Maneuver

�Anterior Drawer/Lachman’s

�Varus and Valgus Stress

�Apley Grind

PHYSICAL TESTS

�

Ballottement

�Knee Effusion

� 1. Milk fluid up and down to knee cap

� 2. Reach over and push down on knee cap

It will bounce down and click against the femur

Blood vs fluid

�

Posterior Drawer Test

� Place knee at 90 degrees.

� Push the tibia backwards off femur

� Instability suggests posterior cruciate ligament (PCL) tear.

9/26/2014

4

�

McMurray’s Maneuver

�McMurray “Meniscus” tear – medial or lateral

� Extend and twist the lower leg� Inward/outward

rotation

� Stress the knee

Popping, clicking, catching – positive

May be painful

�

Anterior Drawer/Lachman’s

Anterior Drawer-Pull tibia away from the femur -ACL tear if tibia pulls forward

Sit on foot, thumbs on top tibia

Lachman’s

-Anterior drawer test done at 30 degrees to disengage quadriceps

More sensitive test

�

Varus & Valgus Stress

Varus

-Stabilize lower leg and push medial knee joint laterally– looking for

instability of LCL

ValgusStabilize lower leg and

push laterally knee joint towards midline – looking

for instability of MCL

9/26/2014

5

�

Apley Grind

�Mensicus more sensitive than McMurry’s

�Have the patient in prone position

� Place weight on foot

� Twist leg to “grind” the knee meniscus

�Clicking, catching and pain are positive

�

DIAGNOSITICS

Xray MRI

�

Diagnostics continued

CT scans – 3-D CT scans

9/26/2014

6

��X-ray – x-ray is a easy and helpful way to evaluate

bony injury or concerns. Dense materials such as bone and metal show up as white on x-rays. Air in your lungs black. Fat and muscle appear in varying shades of grey. (consider weight bearing)

�MRI – Magnetic resonance imaging (MRI) is used with a magnetic field and radio waves to create detailed images of organs and tissues (Notice: Bones are not listed here) They are 3-D images and can be viewed from various angles.

Diagnostics Continued

��CT Scans - Computerized tomography (CT)

combines a series of x-ray views from different angles and computer processing to create cross-sectional images of the bones and soft tissues inside the body. (bones here…) The images can then be sliced down to single layers to evaluate more closely the area in question. They can also be combined to create 3-D images.

Continued

��Arthritis

�Fracture

�Chondromalacia

�Patello-femoral syndrome

�Tendon Rupture

�Infection

DIAGNOSIS

9/26/2014

7

�� I was on my bike today and crashed my wrist is

killing me?

� I’m concerned the patient tore his ACL?

� The knee joint has been problematic ever since I fell last week it is killing me…I’m 23 years old?

� Every morning I wake up and my knees ache once I start moving they feel better but then they ache at night again, I’m 83 years old and still very active.

� What test should we order? Why?

QUIZ

�

Arthritis

� Involves one or more joints

� Pain and stiffness

�Worse with age

�OA and RA most common

�Gouty arthritis

� Septic arthritis

�Does this patient hurt?

�

Fracture

�Many different types and names of fractures; essentially it is a broken bone.

�Any bone in your body may be fractured.

� Tests: X-ray, possibly CT Scan

9/26/2014

8

�

Chondromalacia

�Damage to cartilage under you knee cap.

�Knee pain increases when you walk up or down stairs

� Tests: X-ray

�

Patello-Femoral Syndrome

� Pain in the front of the knee

� Caused by overuse, excess weight, kneecap isn’t properly aligned, or changes under the knee cap…called?

� Buckling or giving way, catching, popping, grinding sensations

� Teenagers, athletes, laborers

� Baseline X-rays, exam

9/26/2014

9

�

Ligament Rupture

�ACL, PCL, MCL, LCL

�ACL/PCL is anterior/ posterior drawer tests

�MCL/LCL – valgus/ varus stress

� Test: X-ray, MRI

�Repair – surgical for ACL/PCL

9/26/2014

10

�

Tendon Rupture

� Tendons attach muscles to bones. The patellar tendon attaches the bottom of the patella to the top of the tibia; quadriceps tendon attaches to the top of the patella.

� Unable to straighten leg or do a straight leg lift.

� Surgery is indicated � Can be partial as well� Tests: X-ray

�

Infection – Septic Arthritis

� Many causes but concern if native knee, hardware, total joint

� Must aspirate joint � Send for cell count,

culture, crystals� If cell count > 80,000 will

need joint washout; in total joint >5,000

� IV antibiotics with possible PO suppression

� Needs Ortho assistance

�

Septic or Gouty Arthritis?

9/26/2014

11

�

Treatment

� Treatment is dependent somewhat on diagnosis but here are a few tips to help:� PRICE (protect, rest, ice, compress, elevate)

� NSAIDS (if tolerated)

� Knee pain - in general improves with quad strengthening exercises – pushing weight - Physical therapy

� Arthritis – Off loader brace, injection, NSAIDS, TKA

� Infection – Aspiration will need surgery and IV antibiotics - Ortho

� Fracture – Operative or Non operative – Ortho

�� Ligament tear – hinged knee brace, gait training,

crutches – MRI, WB ok – Ortho

� Tendon rupture – will need surgery, Knee immobilizer, NWB – Ortho

�Consider injection to manage chronic pain issues

� Kenalog 40 mg/ml (one ml) Lidocaine 1% 4 ml Marcaine 0.25% 4ml total of 8-9 ml will take a full week for the steroid (7 days) up to three to four times per year. End stage arthritis as much as they want until TKA, younger limit three per site usually

Treatment Continued

�

QUESTIONS

9/26/2014

12

�

Brittany and Jackson

�� Sarwark, John, F. (2010). Essentials of

Musculoskeletal Care 4. Rosemont, IL: American Academy of Orthopaedic Surgeons.

� Stoller, David, W. (2008). Stoller's Atlas of Orthopaedics and Sports Medicine. Baltimore, MD: Lippincott Williams & Wilkins, a Wolters Kluwer business. Bickley, Lynn, S. (2007).

� Bates' Guide to Physical Examination and History Taking, 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins.

References