852: meniscus, articular cartilage injury, knee fractures

Lateral meniscus

Circular, smaller radius, attached to ACL/PCL

Medial meniscus

Crescent shaped, larger radius, attached to MCL, less mobile

Functions of the meniscus

Force distributor

Shock absorber

Provides nutrition and lubrication to articulate cartilage

Acute to traumatic meniscal tears

Typically longitudinal or radial

Due to shearing stress from knee flexion and compression combined with femoral rotation

Degenerative meniscal tears

Result from repeated stressor to the collagen

Age related changes in collagen result in less structural support

Common types: horizontal, cleavage’s, flap, etc.

Potential pertinent history for meniscal injury

• chronic ACL tear or reporting delayed repair

• Knee twisting mechanism with foot planted

• Long standing knee pain or symptom duration

Potential predisposing factors for meniscal injury

• participating in cutting, pivoting sports

• Female

• Increased age

• Higher BMI

• Previous knee surgeries

• Knee OA

Meniscus pathology composite score

History: reports of catching or locking

Clinical Examination

• tibiofemoral joint line tenderness

• Pain with forced hyperextension

• Pain with max passive knee flexion

• Positive mcmurray test

Meniscal injury behavior

• pain with WB

• Pain with tibiofemoral joint line palpation

• Clicking, popping, locking, catching, buckling at the knee

• “Tearing” sensation at time of injury

• Delayed effusion

Symptom descriptors for meniscal injury

Mild to severe aching, can be sharp

Aggravating factors for meniscal injury

Walking, running, squatting, climbing stairs, pivoting, cutting, prolonged WB

Easing factors for meniscal injury

Rest, non WB

24 hr pattern for mensical injury

Increased pain throughout the day with increased activity

Objective exam for mensical injury

• + joint line tenderness

• + McMurrays and Thessaly

• > 3/5 of MPCS

• Pain with EROM knee flexion

• Limited knee ROM

• May have swelling

PT management for meniscal injury

• manual therapy to assist with return to pain free full ROM

• General knee and hip strengthening

• Functional activities

• Motor control exercises

• Balance and propriception

• Sport specific activities

CPG recommendations for non surgical management of meniscal injury

Supervised exercise program more beneficial than independent management

NM training, motor control exercises

Degenerative tears: supervised PT focused on knee ROM and knee strengthening for at least 8 weeks

Return to sport in non surgical mensical injury

• no effusion

• Full ROM

• Quads and hams function WNL

• No difficulty with functional exercises

• Activity specific training without subsequent symptoms

Medical management for mensical injury

Pharm: OTC NSAIDs, pain meds, corticosteroid injections

Surgery: arthroscopy, partial meniscectomy

Conservative: rehab recommended

Key differences with partial menisectomy vs repair

Repairs typically have WB restrictions and instruct on avoiding knee flex >45 early and 90 until 8 weeks post op

Removals are often WBAT and ROM is progressed as tolerated

Medical diagnosis for meniscal injury

Internal derangement of the knee

Other and unspecified derangement of the medial meniscus

Derangement of lateral meniscus

PT diagnosis for mensical injury

May be femoral adduction internal rotation

Articulate cartilage defects

Lesions occur due to acute trauma or repetitive minor trauma

Consider the post op pt who has been NWB for any length of time

4 highly structured zones of articulate cartilage

1. Superficial/tangenital

2. Intermediate/transitional

3. Deep

4. Calcified

Articulate cartilage defects

Common with ACL ruptures and medical meniscal tears

64% were less than 1 cm

Effects of ACDs

• short term: pain and swelling

• Long term: accelerates development of OA

Clinical features for diagnosing ACD

• intermittent knee pain

• History of acute trauma to the knee with hemarthrosis

• History of catching or locking

• Effusion

• Joint line tenderness

Management for ACDs

Continuous passive motion

Best achieved with low load NWB exercises

PT management for ACDs

• correction of biomechanical abnormalities

• Working to ensure symmetry of gait

• Utilizing braces to control instability

• Pool running

• Mini tramp

• Anti gravity treadmill

• Proprioceptive and strengthening exercises

Pharm management for ACDs

NSAIDS

Intraarticular hyaluronic acid injections

Intraarticular corticosteroid injections

Surgical management for ACDs

• debridement/chondroplasty

• Fixation of unstable segments

• Microfracture

• Osteochondral autograft transplantation

• Osteochondral allograft transplantation

• Autologous chondrocyte implantation

Autologous chondrocyte implantation

Articulate cartilage fragments harvested during first surgery, grown in culture, implanted into cartilage defect in second surgery

Osteochondral autograft transplantation/mpsaicplasty OAT

Involves harvesting Osteochondral plug from NWB surface of the knee and transferring it to WB chondral lesion

Medical diagnosis for ACD

Tear of articulate cartilage of knee, current

Patellar fractures

Direct: compressive force

Indirect: forceful contraction of quads in knee extension

Tibial plateau fracture

Results from either high energy or low energy trauma

Tibiofemoral joint closed pack position is terminal extension: greatest force applied here

Ottawa Knee rules

1. Age > or = 55

2. Unable to bear weight immediately after trauma or 4 steps into ED

3. Inability to flex knee to 90

4. Tenderness with palpation at patella and/or fibular head

Radiographs recommended if at least one is met following a trauma or fall

Symptoms of patellar fracture

Persistent tenderness and swelling over patella

Pain with WB

Pain with active knee motion

Symptoms of tibial plateau fracture

• severe pain locally at tibial plateau and into tibial shaft

• Limited WB

• Joint effusion

• Stiffness

Symptom descriptors for patellar fracture

Can be sharp or dull ache

Aggs and Eases for patellar fracture

Knee AROM, WB, prolonged sitting

Rest, NWB

Objective exam for patellar fracture

Follow Ottawa knee rules

Limited and painful knee AROM

Tenderness with palpation over it

Joint effusion

Symptom descriptors for tibia plateau fracture

Severe pain

Aggs and eases for tibial plateau fracture

Knee extension, WB, walking, stairs

Rest, ice, open packed position of knee

24 hr pattern for tibial plateau fracture

Activity dependent, may have night pain

Objective examination for tibial plateau fracture

• follow Ottawa knee rules

• Limited knee ROM due to stiffness, pain

• Limited ext > flex

• Gait abnormalities due to pain

• Joint effusion

Potential pertinent history for patellar fracture

• recent or past knee surgery

• Patellar instability

• Trauma

• Signs of infection

• Benign or malignant tumor

Potential predisposing factors for patellar fracture

• osteoporosis

• Obesity

• RA

• Resurfaced patella

• TKA

• Highly active

• Prolonged steroid use

Potential pertinent history for tibial plateau fracture

Recent trauma/fall

Potential predisposing factor for tibial plateau fracture

Osteoporosis

Osteopenia

Prolonged steroid use

Medical management for patellar fractures

Pharm

• Oral NSAIDs and narcotics(post op)

Surgery

• fixation of fragment with screws, wires

• Patellectomies

Conservative

• if not displaced can try an ext splint, progressive WB and ROM

Imaging

• radiographs

• CT scan

Medical management for tibial plateau fracture

Pharm: oral NSAIDs, acetaminophen, oral narcotics post op

Surgery: ORIF

Conservative: nondisplaced fractures may need 3 months of partial to NWB status

Imaging: radiographs, CT scan, MRI, MRA

PT management for patellar fractures

Initial priority: establish normal knee ROM and progress to normal WB and gait

Strengthening: isometrics, low load, progressing appropriately

PT management for tibial plateau fracture

• follow WB status

• If NWB can work AROM as tolerated

• Progress WB when appropriate

• Exercises for knee flex and extension

• Progress function and strength as appropriate

Medial diagnosis for patellar fracture

Closed or open fracture of patella

Medical diagnosis for tibial plateau fracture

Fracture of upper end of tibia and fibula, closed