Knee&Foot Part1.pdf

Knee & Foot Part 1 Dr.Sarkawt S.Kakai Orthopedic surgeon Knee Learning objectives • Knee deformities, terms, causes and treatment • Meniscal lesion, osteochondritis dissecans and anterior knee pain Foot • • • • Club foot, Arch problems: pes cavus & congenital vertical talus, Big toe: hallux va...

Knee & Foot Part 1 Dr.Sarkawt S.Kakai Orthopedic surgeon Knee Learning objectives • Knee deformities, terms, causes and treatment • Meniscal lesion, osteochondritis dissecans and anterior knee pain Foot • • • • Club foot, Arch problems: pes cavus & congenital vertical talus, Big toe: hallux valgus &hallux rigidus, Deformities of lesser toes. Knee deformities Mnemonic The L of "lateral" is also in valgus, but not in varus. When also remembering that the direction of the distal part is key: distal (more) lateral means valgus and distal (more) medial means varus. Up to 4 years old are so common that they are stages of normal development. Physiological bow-legs and knock-knees Bow-legs: measuring the distance between the knees with the child standing and the heels touching; it should be less than 6 cm Measuring Knock-Knees: knock-knee can be estimated by measuring the distance between the medial malleoli when the knees are touching with the patellae facing forwards; it is usually less than 8 cm Operation: hemi-epiphyseodesis Indication: If the age is >10 years, and the deformity persist This is done by inserting a staple or small plate on the side of the physis (the convex side of the deformity) that needs growth restriction Staple or plate is removed when the correction achieved A unilateral deformity is likely to be pathological Pathological bowlegs and knockknees in children Operative correction by osteotomy should be delayed until near the end of growth lest the deformity recur with further growth Usually Progressive Eccentric growth from the physis of the distal femur or proximal tibia Causes: rickets, injury, infection, or an inherent growth disorder A progressive form of genu varum deformity Blount's Disease Cause • posteromedial part of the proximal tibia abnormal growth (dyschondrosis) • More common in children of black African Two forms: Infantile and Adolescent forms • Adolescent form: Child is overweight and walks with outward thrust Radiographs: • The proximal tibial epiphysis is flattened medially and the adjacent metaphysis is beak shaped. Treatment: • Spontaneous resolution is rare. • Hemiepiphyseodesis may not always work and correction by osteotomy is usually needed. Lesions of the menisci The meniscus is a Cshaped piece of tough, rubbery cartilage Gross Shape • Acts as a shock absorber between the shinbone and the thighbone • Medial meniscus • C-shaped with triangular cross section • Lateral meniscus • is more circular (the horns are closer together and approximate the ACL) • covers a larger portion of the articular surface Functions • Improving articular congruency • Stability: Controlling the complex rolling and gliding actions of the joint • Force transmission: Distributing load during weightbearing If the menisci are removed or torn, their functions are jeopardized. • Because it is less mobile than the lateral meniscus, the medial meniscus is more vulnerable to tearing when subjected to aberrant forces. Pain Clinical features • Sever following activity, relived by rest Swelling • Variable degrees depend on type of the tear and the force of injury • Rest will subside it Locking • (The sudden inability to completely extend the knee) signals a tear in the bucket handle. • Sometimes, the patient Knew how to fully bend or rotate their knee in order to "unlock" it Giving way In individuals over 40 • Spontaneously and this is again followed by pain and swelling • The initial damage may not be noticeable and the primary complaint is persistent "giving way" or "locking." 01 02 03 04 The joint may be held slightly flexed and there is often an effusion. Quadriceps wasting in late presentation may be noticed The joint line, often on the medial side, is where tenderness is centered. Flexion is usually full but extension is often slightly limited. Physical exam McMurray’s test Special tests • Flex the knee and place a hand on medial side of knee, externally rotate the leg and bring the knee into extension. • A palpable pop / click + pain is a positive test and can correlate with a medial meniscus tear. Thessaly test • Standing at 20 degrees of knee flexion on the affected limb, the patient twists with knee external and internal rotation with positive test being discomfort or clicking. Radiographic features On plain radiographs, meniscal tears are not visible MRI Is the modality of choice when a meniscal tear is suspected, with sagittal images being the most sensitive Arthroscopy As a diganostic tool and tretment Nonoperative Treatment Operative • Rest, NSAIDS, Rehabilitation • Partial meniscectomy • Meniscal repair • Peripheral in the red-red zone (vascularized region) • Vertical and longitudinal tear Osteochondritis Dissecans OF the Knee Is a pathologic lesion affecting articular cartilage and subchondral bone Well-demarcated, avascular fragment of bone and overlying cartilage, sometimes separates and appears as a loose body in the joint Posterolateral aspect of medial femoral condyle (70% of lesions in knee) Knee (most common) Bilateral in 25% of cases Anatomic location Capitellum of humerus Talus Symptoms • Pain activity related pain that is vague and poorly localized Physical exam • localized tenderness • Wilson’s test • pain with internally rotating the tibia during extension of the knee between 30°and 90°, and then relieving the pain with tibial external rotation Imaging • Radiographs • Recommended obtain tunnel (notch) view • knee bent between 30 and 50 degrees • MRI: Best method • size of lesion • status of subchondral bone and cartilage • presence of loose bodies Treatment Nonoperative: Restricted weight bearing and bracing • stable lesions in children with open physes • asymptomatic lesions in adults • Outcomes: 50-75% will heal without fragmentation Operative • Diagnostic arthroscopy • Failed non-operative management • Subchondral drilling with K-wire or drill • Fixation of unstable lesion • unstable lesion seen on arthroscopy or MRI >2cm in size • Chondral resurfacing • Large lesions, >2cm x 2cm • Knee arthroplasty • patients > 60 years Is pain that occurs in the Front and central aspect of the knee Anterior Knee Joint Pain Causes • Patella abnormalities: Chondromalacia Patellae • Muscular imbalances or weakness: Quadriceps tendinopathy, liotibial band syndrome • Joint: Plica Syndrome, OA, Tumors, Bursitis • Systemic : Infection, Gout • Referred pain: Hip & LSS • Truma Diagnostic procedure Evaluation of anterior pain is challenging as it can be non-specific and differential diagnosis is extensive. Symptoms: • Pain (location and type) or instability problems • Swelling: Mild? Diffuse? Alignment: • Of the entire lower extremity: Squinting patella? Genu valgus? • Patellar position: Patella alta? Patella baja? Muscles and soft tissues: An imbalance between VM and VL? Weakness of knee extensors Knee function: Locking? Lab Investigations • CBP, CRP.. Imaging: • Radiograph • U/S • MRI Depends on the underlying cause Treatment Non-operative treatment: RICE, NSAID, Physiotherapy Operative treatment • Correctable anatomical abnormalities • Ligament reconstruction or release References • • • • • Solmon, L., & Warwick, D. (2014). The Knee. In Apley and Solomon's Concise System of Orthopaedics and trauma (Fourth, pp. 265–285). essay, CRC PRESS. El-Feky, M. (2022, July 9). Meniscal tear: Radiology reference article. Radiopaedia Blog RSS. Retrieved December 25, 2022, from https://radiopaedia.org/articles/meniscal-tear “Meniscus Tears - OrthoInfo - AAOS.” Meniscus Tears - OrthoInfo - AAOS, 1 Mar. 2021, www.orthoinfo.org/en/diseases--conditions/meniscus-tears. MD, Mark Karadsheh. “Osteochondritis Dissecans - Knee and Sports - Orthobullets.” Osteochondritis Dissecans - Knee & Sports - Orthobullets, 26 Feb. 2022, www.orthobullets.com/knee-andsports/3028/osteochondritis-dissecans. Tuerlinckx, M. (2022). Anterior knee pain. Physiopedia. Retrieved December 25, 2022, from https://www.physio-pedia.com/Anterior_knee_pain