9/26/2014

Kari M Komlofske, BSN, FNP-C Orthopedics

Objectives t w Describe the knee anatomy w Review the various diagnostic tests specific to help diagnose knee disorders w Discuss the differential diagnosis of knee pain

Knee Anatomy t w Three bones articulate t Femur, tibia, patella w Fibula is involved with support w Main Ligaments: t Collateral w (lateral and medial) t Patellar t Cruciate w (anterior and posterior)

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Knee Anatomy, Continuedt w Meniscus t Medial and lateral w Muscles t Quads, hamstrings, gastrocnemius w Bursa t Anserine (median), prepatellar, semimembranous (popiteal fossa)

Examination of the Knee t w Gait and stance t Is there a Varus Deformity (bow legged), or Valgus Deformity (knocked knees) w Pain/Tenderness t Especially important at the joint line (locate it) t Exacerbation, relief t Medications w Range of motion t Full extension is leg flat 0 degrees t Maximum flexion is 150 degrees to your butt (you need about 120 to get up from a chair comfortably) w Visualization t Swelling, ecchymosis, erythema, deformity

Examination Continued t w Other history t Buckling or locking symptoms (hx or PE) t Can’t lay on side with legs together in bed: w Anserine bursitis w Associated with OA and varus deformity t Theater sign (hx) – can’t sit through a movie without your knees aching w Patellofemoral syndrome – “J” sign w One side of quad works harder than other w Extend leg and contract quads w Lateral “J” move = weak vastus medialis

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PHYSICAL TESTS t w Ballottement w Posterior Drawer Test w McMurray’s Maneuver w Anterior Drawer/Lachman’s w Varus and Valgus Stress w Apley Grind

Ballottement t w Knee Effusion t 1. Milk fluid up and down to knee cap t 2. Reach over and push down on knee cap

It will bounce down and click against the femur Blood vs fluid

Posterior Drawer Test t w Place knee at 90 degrees. w Push the tibia backwards off femur w Instability suggests posterior cruciate ligament (PCL) tear.

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McMurray’s Maneuver t w McMurray “Meniscus” tear – medial or lateral w Extend and twist the lower leg t Inward/outward rotation t Stress the knee Popping, clicking, catching – positive May be painful

Anterior Drawer/Lachman’st Anterior Drawer Lachman’s -Pull tibia away from the femur -Anterior drawer test -ACL tear if tibia pulls forward done at 30 degrees to disengage quadriceps Sit on foot, thumbs on top tibia More sensitive test

Varus & Valgus Stress t Varus Valgus -Stabilize lower leg and Stabilize lower leg and push medial knee joint push laterally knee joint laterally– looking for towards midline – looking for instability of MCL instability of LCL

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Apley Grind t w Mensicus more sensitive than McMurry’s w Have the patient in prone position w Place weight on foot w Twist leg to “grind” the knee meniscus w Clicking, catching and pain are positive

DIAGNOSITICS t Xray MRI

Diagnostics continued t CT scans – 3-D CT scans

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Diagnostics Continued t w 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) w 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.

Continued t w 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.

DIAGNOSIS t wArthritis wFracture wChondromalacia wPatello-femoral syndrome wTendon Rupture wInfection

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QUIZ t w I was on my bike today and crashed my wrist is killing me? w I’m concerned the patient tore his ACL? w The knee joint has been problematic ever since I fell last week it is killing me…I’m 23 years old? w 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. t What test should we order? Why?

Arthritis t w Involves one or more joints w Pain and stiffness w Worse with age w OA and RA most common w Gouty arthritis w Septic arthritis w Does this patient hurt?

Fracture t w Many different types and names of fractures; essentially it is a broken bone. w Any bone in your body may be fractured. w Tests: X-ray, possibly CT Scan

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Chondromalacia t w Damage to cartilage under you knee cap. w Knee pain increases when you walk up or down stairs w Tests: X-ray

Patello-Femoral Syndromet w Pain in the front of the knee w Caused by overuse, excess weight, kneecap isn’t properly aligned, or changes under the knee cap…called? w Buckling or giving way, catching, popping, grinding sensations w Teenagers, athletes, laborers w Baseline X-rays, exam

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Ligament Rupture t w ACL, PCL, MCL, LCL w ACL/PCL is anterior/ posterior drawer tests w MCL/LCL – valgus/ varus stress w Test: X-ray, MRI w Repair – surgical for ACL/PCL

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Tendon Rupture t w 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. w Unable to straighten leg or do a straight leg lift. w Surgery is indicated w Can be partial as well w Tests: X-ray

Infection – Septic Arthritist w Many causes but concern if native knee, hardware, total joint w Must aspirate joint w Send for cell count, culture, crystals w If cell count > 80,000 will need joint washout; in total joint >5,000 w IV antibiotics with possible PO suppression w Needs Ortho assistance

Septic or Gouty Arthritis? t

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Treatment t w Treatment is dependent somewhat on diagnosis but here are a few tips to help: t PRICE (protect, rest, ice, compress, elevate) t NSAIDS (if tolerated) t Knee pain - in general improves with quad strengthening exercises – pushing weight - Physical therapy t Arthritis – Off loader brace, injection, NSAIDS, TKA t Infection – Aspiration will need surgery and IV antibiotics - Ortho t Fracture – Operative or Non operative – Ortho

Treatment Continued t w Ligament tear – hinged knee brace, gait training, crutches – MRI, WB ok – Ortho w Tendon rupture – will need surgery, Knee immobilizer, NWB – Ortho w Consider injection to manage chronic pain issues t 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

QUESTIONS t

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Brittany and Jackson t

References t w Sarwark, John, F. (2010). Essentials of Musculoskeletal Care 4. Rosemont, IL: American Academy of Orthopaedic Surgeons. w 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). w Bates' Guide to Physical Examination and History Taking, 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins.

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