ASSESSMENT AND MANAGEMENT OF THE KNEE AND LOWER LIMB

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ASSESSMENT AND MANAGEMENT OF THE KNEE AND LOWER
LIMB
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Overview

• History
• Examination
• X-rays
• Fractures and Dislocations.
• Soft Tissue Injuries
• Other Knee/Lower limb Problems

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Anatomy of the Knee
Femur
Quads insertion
Patella
Ligamentum patellae
Meniscus
Medial Collateral Ligt
Tibia
Fibula
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ACL
PCL
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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?

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KNEE EXAMINATION

• Look
• Wasting,swelling,deformity
• ,redness,scars
• Feel
• Temp,Effusion,crepitus
• Move
• Passive,Active
• Resting position,SLR,Extension,flexion,collateral
  ligaments, cruciates menisci

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X-RAYS
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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 AE
• Exceptions

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Knee

• 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

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Fracture of lateral tibial plateau
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Patella Facture
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Patella

• Patella Fracture
• Direct blow, Fall, Violent flexion, Quadriceps
  contraction.
• Pain/Swelling, Crepitus, Pain on extension
• Straight leg raise.
• Haemarthrosis
• X-ray
• Treatment
• Vertical
• Transverse

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High Patella
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Patella

• Dislocation
• Medial stress gt Lateral dislocation
• Knee in flexion. Dislocation usually obvious.
• Entonox
• Medial reduction with knee extension.
• Obtain X-rays, cylinder POP, Analgesia, and
  orthopaedic follow up.

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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

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Knee

• Tibia Plateau Fracture
• Treatment
• Long POP backslab
• Orthopaedic referral
• Elevation
• ORIF/Bone grafting

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Haemarthrosis

• Acute haemarthrosis
• Onset of swelling following injury
• Warm, tense, painful
• Causes
• Cruciate ligament damage, tibial avulsions,
  fractures
• Orthopaedic opinion

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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

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ACL Rupture
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PCL Rupture (tibial sag)
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Avulsion fracture of ACL insertion
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Meniscal Injury

• Usually twisting injury
• History crucial
• McMurrays Test

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Collateral Ligament Injury

• Examination
• Tenderness, stress testing
• Grading
• Grade I
• Local tendernessslight or no laxity
• Grade II
• Local tendernesslaxity with endpoint.
  Orthopaedic follow up
• Complete rupture
• No endpoint. POP cylinder. Analgesia, Crutches.
  Orthopaedic referral

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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.

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Soft Tissue Injury

• Locked Knee
• Full extension blocked. Degree of which can vary.
• Possible meniscal injury.
• X-ray for loose body.
• Requires arthroscopy.

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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.

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Prepetellar and Infrapatellar Bursitis
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Knee problems not to be missed

• Bakers Cyst
• Osteoarthritis
• Septic Arthritis
• Osteomyelitis
• Referred pain
• NB other lower limb problems
• DVT
• Compartment Syndrome

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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.

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