knee conditions part 2

COMPARTMENT SYNDROME

• cross sections of the main compartment of the lower leg 

  • common on lower leg but can happen in upper ex or hands

  • tibia usually has trauma

  • Direct contact with a lot of things (e.g. soccer ball hitting tibia) 

• occurs as a results of increased pressure within a closed osteofascial compartment leading to occlusion of blood flow- nerve ischemia- and eventually necrosis

• generally a clinical diagnosis

  •  can measure intracompartmental pressure (>30 mmhg)  less than 10 is normal, more than 10 - must be monitored for observation)

  • most common loc: anterior compartment of the leg

    • CAN OCCUR IN THE FASCIAL COMPARTMENT OF THE FOREARM, THIGH, BUTTOCKS, SHOULDER, HAND AND FOOT

ETIOLOGY & PATHOPHYSIOLOGY COMPARTMENT SYNDROME

• Increased fluid content in the compartment

  • bleeding d/t trauma

    • direct trauma to the area

    • open or closed fracture

• burns

• muscle swelling

  • over exertion (muscle swelling due to excessive exercises)

• exogenous fluid infiltration

• external compression of the compartment

  • prolonged use of compression garments/air splints

  • tight casts or dressings

  • prolonged compression of limb

  • crush injuries

• MALES> FEMALES

• most common

  •  tibial shaft fracture patient s with non-traumatic causes are more likely

• Patients with non traumatic causes are more likely to have complications due to delayed treatments

• COMPARTMENT SYNDROME IS A SURGICAL EMERGENCY

MOI AND PATHOPHYSIOLOGY OF COMPARTMENT SYNDROME

Prolonged compression of the compartment
I
due to impaired vascular supply and venous outflow
I
ischemia of the muscle and nerves
I
Tissue necrosis
Early diagnosis is essential in order to restore blood flow and prevent ischemia

CLINICAL MANIFESTATIONS (COMPARTMENT SYNDROME)

• Deep, unrelenting and progressive pain
  out of proportion to the injury
  exacerbated by passive stretch of the involved muscles
  usually unilateral
  

• Skin is tight, shiny, and cannot be wrinkled
  feels hard or tense to touch "wood-like"y
  Observe skin for lesions, swelling or colour changes
  

• Palpate of temperature, tension, tenderness
  

• Check Pulses
  

• Sensory evaluation
  

• Motor Testing

6 P's of Compartment Syndrome

Pain
Pallor
Paresthesia*
Paralysis
Pulselessness*
Poikilothermia* - cannot adjusted to temp, cold to touch bc no more blood flow to the area

DIAGNOSTIC MODALITIES (compartment syndrome)

Acute Setting
Radiographs if suspecting a fracture
Ultrasound to check for fluid accumulation
Manometer on Slit Catheter to measure intracompartmental pressure
Normal intracompartmental pressure <10 mmhg
Diagnostic of compartment syndrome >30 mmhg

TREATMENT (compartment syndrome)

Immediate Surgical Management ideally within 6 hours of injury
Fasciotomy not recommended >36 hours
Escharotomy- ideally within 6 hrs if more than 6 hours= ischemia
Amputation= more than 36 hours kay amputee na kay patay na huhu
Remove any restrictive casts, dressings, bandages
Prevent hypoperfusion to the area
Manage complications:
Pain
Contractures
Rhabdomyolysis
Acute Renal failure
Muscle Weakness
Sensory deficits
Infection

MYOSITIS OSSIFICANS

benign self limiting process wherein bone or bone tissue formation takes place within a bone skeletal muscle
common in the quads, brachialis, and adductors of the hip
post traumatic MO occurs in about 20% of cases reported with large muscle hematoma associated with contusion or trauma
lasts for an average 1.1 years
it may also due to repetitive injury to the same area
initial stretching can help, ROM and gentle exercises (isometric quadriceps, contraction and terminal knee extension)

MOI AND PATHOPHYSIOLOGY OF MYOSITIS OSSIFICANS

Myositis Ossificans
Occurs after trauma to the muscle or broken bone
l
Formation of a new bone cells between the torn muscle fibers
|
presents with painful, tender enlarging mass, local signs of inflammation and loss of motion

GENU VARUM (BOW-LEGGED)

Normal appearance of varus: neonate - 2 years old
Patella and knee - outward
Tibia - inward
Genu valgum - vice versa of genu varum
Most resolve spontaneously with normal development
Night bracing may be done
Osteotomy if persistent and beyond 15 degrees
Often obscene deformity during toddler years
Abnormal outward bowing of legs
Etiology:
Blount's Disease (unilateral, epiphyseal plate problem)
Rickets (Vitamin D deficiency)
Skeletal dysplasia
Trauma
Due to alternating of hip-knee-ankle mechanics, can lead to gait abnormalities & muscle imbalances.

BLOUNT DISEASE (TIBIA VARA)

Acquired genu varus deformity due to disrupted cartilage growth at the proximal medial tibia metaphysis

MOI & PATHOPHYSIOLOGY OF TIBIA VARA

excessive compressive forces on the medial aspect of the medial tibial physis
|
altered endochondral bone formation, inhibition of growth on the medial side
|
genu varus deformity

3-DIMENSIONAL DEFORMITY OF TIBIA VARA

Varus deformity
Procurvatum
Internal tibial rotation
Leg length discrepancy

TWO TYPES OF TIBIA VARA

Infantile (Age 1-5 years old)
Commonly bilateral and exacerbates after initiating of walking
Adolescent
Presents later, usually unilateral
Often associated with pain and kids are often obese

FINDINGS SUGGESTIVE OF BLOUNT DISEASE (SEEN IN X-RAY)

Medial breaking of epiphysis
Widened and irregular medial physis
Irregular ossification
Medial slope of the epiphysis and metaphysis in varus deformity

TIBIOFEMORAL ANGLE

Angle formed when the line that forms the femoral shaft axis is extended through the distal femur to form an an angle between the femoral shaft axis and the tibial shaft axis
5-7 degrees = normal valgus angle
More = valgus
Less = varus

METAPHYSEAL-DIAPHYSEAL ANGLE

Used to predict progression of Blount Disease
Interaction between:
Line from most distal point on the medial and lateral breaks of tibial metaphysis
Line that is perpendicular to long-axis of tibial diaphysis
Cutoff (normal): 16 deg
>16 deg - 95% chance of progression
<10 deg - likely physiologic
11-16 deg - for close observation

LANGENSKIÖLD CLASSIFICATION

Indicates severity and metaphyseal collapse

Stage I LANGENSKIÖLD CLASSIFICATION:

Irregularity of metaphyseal zone

Stage II LANGENSKIÖLD CLASSIFICATION:

Medial metaphyseal beaking

Stage III LANGENSKIÖLD CLASSIFICATION:

Development of "step" in the metaphyseal beak

Stage IV LANGENSKIÖLD CLASSIFICATION :

Epiphysis beaking and occupies a pit in the medial metaphysis

Stage V LANGENSKIÖLD CLASSIFICATION :

Double epiphyseal plate

Stage VI LANGENSKIÖLD CLASSIFICATION:

Bony bar formation

MANAGEMENT OF TIBIA VARA & GENU VARUM

Orthotic Bracing
KAFO are a potential treatment option for children diagnosed before age 4 and with langenskiold stage 1 or 2 disease
apply valgus force to correct the deformity
Guided Growth
Via hemiepiphysiodesis, a surgical procedure involving pinning/plating of the lateral growth plate
Osteotomy
fuse the bone
last option,kai maka LLD

GENU VALGUM (KNOCK KNEES)

Normal valgus appearance at ages of 2-4 years
Gradually corrected as the child grows and increases weigh-bearing forces
Normal adult valgus: 5-10 degrees
Majority are asymptomatic and live with no functional limitation
Majority are asymptomatic and live with no functional limitations

Etiology of GENU VALGUM:

Rickets
Skeletal dysplasia
Trauma
Surgical management if persisting >10 years old
Often preceded by flat-foot
May lead to ligamentous instability

MOI & PATHOPHYSIOLOGY

Increased weight bearing on the medial side
|
Medial foot and knee pain

LIGAMENT TEARS

Extracapsular Ligaments
Collateral Ligaments
Intracapsular Ligaments
Cruciate Ligament
Note: mahirap itreat because u really have to open up during the surgery cause u need to repair the ligament but might affect other structures

COLLATERAL LIGAMENT INJURIES

Isolated MCL sprain due to direct impact on the lateral aspect of the knee that applies valgus forces without rotation
More likely to have injury to adjacent structures (ACL and Meniscus) due to its attachments
Isolated LCL sprain are less common and occur with high-energy blow with excessive varus forces to a hyperextended knee

CLINICAL PRESENTATION OF LIGAMENT INJURIES

Acute Pain,swelling and ecchymosis
Tenderness on the lateral/medial aspect of the knee
Knee instability on direction of affected ligament
(+) Varus/ Valgus stress tests
don't just focus on these special tests, also do other special tests like anterior drawer, lachman, etc to rule out other conditions such as meniscus injury
Varus/Valgus thrust during gait assessment

LIGAMENTOUS LAXITY GRADING

Grade 1 = 0-5 mm displacement
Grade 2= 5-10 mm displacement
Grade 3= >10 mm displacement
Fully torn ligament with torn capsule/retinaculum
in history taking, pt will say there is an audible pop = torn ligament
Ligament testing should be done after the initial pain and swelling have subsided as they can mask the degree of injury

ACL TEARS

ACL sprain is the most commonly injured ligaments without contact by a decelerating valgus angulation and external rotation force
Can occur due to contact and noncontact injuries
They occur most frequently in those who play sports involving pivoting (e.g football, basketball netball, soccer, european team handball, gymnastics, downhill skiing)
Players lands with the knees in hyperextension and the tibia internal rotation
Hyperextension : Tibia moves anteriorly → ACL injury
Hyperflexion: Tibia moves posteriorly → PCL injury
Lateral trauma to the knee can cause torn medial collateral ligaments, cruciate ligament injury as well as meniscus injury
O'Donoghue Unhappy triad : ACL, MCL, Medial meniscus

Direct contact
30 % from direct contact injuries
70% from Non-contact injuries

EPIDEMIOLOGY OF ACL INJURY:

Females > Males
Bony characteristics
Increased Q Angle
Greater ligamentous laxity
Greater Valgus collapse due to positioning

Clinical Presentation OF ACL

Acute pain, marked effusion and ecchymosis
Audible pop followed by knee instability on direction of affected ligament
(+) Lachmann Test, Anterior Drawer test
Lachmann is the gold standard because of the position of the knee because u can see talaga the displacement

POSTERIOR CRUCIATE LIGAMENT (PCL) Tears

Isolated PCL injuries occur with knee flexion but may be secondary to hyperextension injury.
More commonly occurs along with injuries to other structures
MC: motor vehicular accidents (dashboard injury)
Isolated Injuries:
Vague and minimal ssx
Minimal swelling, pain, and instability
Combination Injuries
Differ according to the extent of the knee injury
Swelling, pain, instability and LOM
Persistent or recurrent instability suggest concomitant meniscal tear

DEGREES OF SEVERITY (ACL & PCL)

GRADE 1: Microscopic tears in the ligament, mostly as the result of an overstretch
It is still able to function and stabilize the knee
There is a little tenderness and swelling
GRADE 2: The ligament is partially torn
There is a feeling of instability
Increased translation during special tests
GRADE 3: Complete tear or rupture, accompanied by a sprain of the outer cruciate and/or collateral ligaments.
Note: Surgery is not really required if the patient wants to do nonoperative treatment so it really depends on a criteria as well as lifestyle or occupation of the patient. (ex. an elderly bat ka pa magopera? athlete ofc yeah )

GRADE 1 (DEGREE OF SEVERITY):

Microscopic tears in the ligament, mostly as the result of an overstretch
It is still able to function and stabilize the knee
There is a little tenderness and swelling

GRADE 2 (DEGREE OF SEVERITY):

The ligament is partially torn
There is a feeling of instability
Increased translation during special tests

GRADE 3 (DEGREE OF SEVERITY):

Complete tear or rupture, accompanied by a sprain of the outer cruciate and/or collateral ligaments.

TREATMENT OF ACL

Radiographic X-ray
to rule out other structures affected
MRI of the KNEE
Gold standard
To confirm diagnosis and degree of injury prior to operative treatment (pre-operative)
Non- Operative
Isolated Grade I and Grade II
Cruciates do not heal
Higher risk for recurrent instability
Greater participation restriction
Muscle strengthening and improving ROM
Operative Treatment
Factors influencing decision for surgical reconstruction:
Ligament injuries
Localization and size of the lesion
Degree of instability
Presence of concomitant pathology (meniscal tear, other ligamentous tear, articular cartilage damage)
Potential for achieving desired level of function.
Reconstruction
Intra-articular bone-tendon-bone
Hamstring/Patellar tendon autograft
Semitendinosus/ Gracilis tendon autograft

Chronic Instability

can lead to early degeneration of articular cartilage, hence, early onset OA.

PCL TREATMENT

CRITERIA for Conservative Treatment:
Posterior drawer <10 mm
Decrease in posterior drawer excursion with internal rotation on the femur
<5 degrees abnormal rotary laxity and/or no significant increased valgus-varus laxity

The Risks of ACL Reconstruction include but are not limited to

:
Permanent numbness in the front of the knee: 100%
Other nerve injuries: 0.5%
Patellofemoral pain (Knee cap): 15%
Stiffness or reduced motion of the knee: 10%
Reinjury: 5-10%
Superficial infection: 1%
Deep infection: 0.5%
Blood Clots: 2-3%
Delay in regaining motion: 5%

Permanent numbness in the front of the knee:

100%

Other nerve injuries:

0.5%

Patellofemoral pain (Knee cap):

15%

Stiffness or reduced motion of the knee:

10%

Reinjury:

5-10%

Superficial infection:

1%

Deep infection:

0.5%

Blood Clots:

2-3%

Delay in regaining motion:

5%

RELATIVE CONTRAINDICATIONS TO ACL RECONSTRUCTION

Relatively inactive individual with little to no exposure to work, sport, and recreational activities that place high demands on the knee
Inability to make lifestyle modifications that eliminate high-risk activities
Inability to cope with episodes of instability
Advanced arthritis of the knee
→ total knee arthroplasty
Poor likelihood of complying with postoperative restrictions and adhering to a rehabilitation program

Advantages: COMPLICATIONS OF THE BONE-PATELLAR TENDON-BONE AUTOGRAFT

High tensile strength/stiffness, similar or greater than the ACL
Secure and reliable bone-to-bone graft fixation with interference screws
Rapid revascularization/biological fixation (6 weeks) at the bone-to-bone interface permitting safe, accelerated rehabilitation
Ability to return to preinjury, high-demand activities safely

DISADVANTAGES/COMPLICATIONS OF THE BONE-PATELLAR TENDON-BONE AUTOGRAFT

Anterior knee pain in area of graft harvest site
Pain during kneeling
Extensor mechanism/patellofemoral dysfunction
Long-term quadriceps muscle weakness
Patellar fracture during graft harvest (rare, but significant adverse effects)
Patellar tendon rupture (rare)

ADVANTAGES AND DISADVANTAGES/ COMPLICATIONS OF THE SEMITENDINOSUS GRACILIS AUTOGRAFT

ADVANTAGES OF THE SEMITENDINOSUS GRACILIS AUTOGRAFT

High tensile strength/stiffness greater than ACL with quadrupled graft
No disturbance of epiphyseal plate in skeletally immature patient
Evidence of hamstring tendon regeneration at donor site
Loss of knee flexor muscle strength remediated by 2 years postoperatively

DISADVANTAGES/ COMPLICATIONS OF THE SEMITENDINOSUS GRACILIS AUTOGRAFT

Tendon-to-bone fixation devices (particularly tibial fixation) not as reliable as bone-to-bone fixation
Longer healing time (12 weeks) at tendon-bone interface
Hamstring muscle strain during early rehabilitation
Short- and long-term knee flexor muscle weakness (not associated with functional limitation)
Possible increased anterior knee translation (not associated with functional limitations

GENERAL TREATMENT (ACL)

Period of immobilization (6 weeks)
Restricted Weight Bearing
due to extensive tissue disruption during open knee surgery and poor healing qualities of ligamentous tissue
Complications:
Post-immobilization contractures
Patellofemoral dysfunction (Preoperative treatment)(
Muscle weakness
Rerupture
Check page 812-813 of KISNER

EXERCISE PRECAUTIONS AFTER ACL RECONSTRUCTION

Resistance Training—General Precautions
Closed-Chain Training
Open-Chain Training

Resistance Training—General Precautions

Progress exercises more gradually for reconstruction with hamstring tendon graft than bone-patellar tendon-bone graft.
Progress knee flexor strengthening exercises cautiously if a hamstring tendon graft was harvested and knee extensor strengthening if a patellar tendon graft was harvested.

Closed-Chain Training

When squatting in an upright position, be sure that the knees do not move anterior to the toes as the hips descend because this increases shear forces on the tibia and could potentially place excess stress on the autograft.
Avoid closed-chain strengthening of the quadriceps between 60° to 90° of knee flexion.*

Open-Chain Training

During PRE to strengthen hip musculature, initially place the resistance above the knee until knee stability and control is established.
Avoid resisted, open-chain knee extension (short-arc quadriceps training) between 45° or 30° to full extension for at least 6 weeks or as long as 12 weeks.
Avoid applying resistance to the distal tibia during quadriceps strengthening.*
*Contraction of the quadriceps in these positions and ranges causes the greatest anterior tibial translation and can create potentially excessive stress to the graft during the early stage of healing

KNEE DISLOCATION

Occurs secondary to multiple ligament injuries: ACL, PCL, M/LCL
From high-energy or isolated sports accidents
MC Direction: Anterior Dislocation of tibia
Dangerous ang Posterior
Limb -threatening due to the neurovascular structures at the popliteal fossa.

MENISCAL TEAR

common injury: rotational forces
Traumatic Tears vs Degenerative Tears
Occurs with concomitant injuries to adjacent structures due to its manny attachments (common in adolescent age groups)
Medial meniscus >>> Lateral Meniscus
Males (bucket-handle tears) >> Females (peripheral tears)
*Meniscus- both avascular and vascular depends on what structure
Periphery meniscus- vascular
Inner meniscus- avascular
MOI: foot is fixed and the femur is rotated internally (medial meniscus) or Lateral rotation of the femur on a fixed tibia (lateral meniscus)
IR of the tibia + Varus stress = lateral meniscus
ER of the tibia + Valgus stress = medial meniscus
Pivoting, getting out of the car, receiving a clipping injury
Often accompanies an ACL injury due to medial meniscus
Osteoarthritis can also lead to a spontaneous meniscal tear through breakdown and weakening of the meniscal structure there is ...kulang

CLINICAL MANIFESTATIONS OF MENISCAL TEAR:

Swelling and effusion
Pain at the joint line
During forced hyperextension or maximum flexion
LOM due to pain in acute phases
Inability to weight-bear
Acute locking of the knee → chronic intermittent catching/locking
(+) Mcmurray Test, (+) Apley's Compression and Distraction Test
don't do this on acute kay ma false positive ka

MENISCAL TEAR TREATMENT

Partial Meniscectomy
Meniscal Repair

.Partial Meniscectomy

Small Incisions are made and saline is injected inside to distend the knee
The torn meniscus is identified, grasped, and divided endoscopically by knife or scissors and removed by vacuum
Indications for Surgery for Partial Meniscectomy:
A displaced tear of the meniscus that is associated with pain and locking of the knee sustained by an older, inactive individual
A tear extending into the central, less vascular third of the meniscus that is not determined repairable when arthroscopically visualized and probed
A tear localized to the avascular inner third of the meniscus

Meniscal Repair

Arthroscopic examination is done to see if the meniscus is suitable for repair
Small incisions are made to introduce the needed instruments and the knee is distended with saline solution
Debridement is performed to remove any unstable tissue fragments.
The edges of the tear are approximated and sutures and placed to ensure complete closure
Indications for surgery :
: A lesion in the vascular outer third of the medial or lateral meniscus
A tear extending into the central, relatively avascular third of the meniscus of a young (younger than age 40) or physically active older (older than age 50) individual

DISCOID MENISCUS

a rare congenital disorder where the lateral meniscus remains around instead of its usual cupped shape leading to instability of the lateral compartment
This condition is EE