{"id":5422,"date":"2011-07-14T20:26:24","date_gmt":"2011-07-14T20:26:24","guid":{"rendered":"http:\/\/crashtext.org\/misc\/5422.htm\/"},"modified":"2019-05-20T12:10:37","modified_gmt":"2019-05-20T16:10:37","slug":"knee-lower-leg","status":"publish","type":"post","link":"https:\/\/crashingpatient.com\/trauma\/knee-lower-leg.htm\/","title":{"rendered":"Knee and Lower Leg"},"content":{"rendered":"

<\/span>Proximal Tibia Fx<\/span><\/h3>\n

Plateau fractures or condylar, spine, tuberosity, subcondylar, epiphyseal<\/p>\n

AP\/LAT\/Oblique<\/p>\n

<\/span>Proximal Fibula<\/span><\/h3>\n

Indicative of significant knee injury, also associated c medial malleolar fx.\u00a0 Common peroneal or anterior tibial art injury<\/p>\n

\"\"<\/a><\/p>\n

\"\"<\/a><\/p>\n

<\/h3>\n

<\/span>TIB\/FIB Shaft Fxs<\/span><\/h3>\n

Consider Compartment Syndrome<\/p>\n

Long Leg Splint-2 slabs<\/p>\n

 <\/p>\n

<\/span>Patella Fxs<\/span><\/h3>\n

Assoc c soft tissue disorders of knee<\/p>\n

Jumper\u0092s Knee<\/p>\n

Patella tendonitis<\/p>\n

Baker\u0092s Cyst<\/p>\n

Swelling behind knee, if ruptures, can get swelling of lower legs appears like a dvt.\u00a0 If sx of coincident arthritis of knee and thrombophlebitis of calf should have baker\u0092s cyst ruled out by arthrogram<\/p>\n

<\/span>Knee<\/span><\/h3>\n

Exam<\/a><\/p>\n

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\"\"<\/a><\/p>\n

\"\"<\/a><\/p>\n

Thorough history<\/p>\n

Examine good leg first<\/p>\n

Inspection-examine quads for atrophy<\/p>\n

Palpation:\u00a0 \u00a0for temperature, An effusion can be detected by noticing the loss of the peripatellar groove and by palpation of the fluid. Smaller effusions may be detected by compressing the medial and superior aspects of the knee, then pressing or tapping the lateral aspect to create a fluid wave. A perceptible bulge on the medial aspect suggests a small effusion; this sign may not be present with larger effusions. Ballottement of the patella may also be a useful technique for detecting an effusion. The examiner quickly pushes down on the patella. In the normal knee joint with minimal free fluid, the patella moves directly into the femoral condyle and there is no tapping sensation underneath the examiner’s fingertips. However, in the knee with excess fluid, the patella is “floating”; thus, ballottement causes the patella to tap against the femoral condyle. This sensation is transmitted to the examiner’s fingertips. Localized swelling over specific knee structures, such as the MCL or LCL, can also be noted. Crepitus, a palpable grating sensation, may be produced during certain motions in joints with cartilage disruption The maneuvers producing crepitus, the location of the crepitus, and any pain elicited should be recorded. Joint line tenderness can also be detected by palpating medial and lateral to the patella in the groove between the femoral condyle and the tibia.<\/p>\n

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Lachman-is typically performed while the patient lies supine with the knee flexed to 20\u00b0 to 30\u00b0 The examiner stands to the side of the patient’s leg with the patient’s heal on the examination table. The femur is grasped with one hand just above the knee. While the examiner grasps the femur firmly to prohibit motion of the upper leg and to relax the hamstrings, the other hand grasps the proximal tibia. The lower leg is then given a brisk forward tug and a discrete end point should be felt. A positive test is one in which the end point is not discrete or there is increased anterior translation of the tibia.<\/p>\n

 <\/p>\n

Finally, meniscal integrity is assessed using several specific examination maneuvers, including McMurray test, the Apley compression test, and the medial-lateral grind test (Figure 2<\/a>). McMurray test is performed with the patient supine. The examiner stands on the side of the affected knee and places one hand on the heel and another along the medial aspect of the knee, providing a valgus force. The knee is extended from a fully flexed position while internally rotating the tibia. The test is repeated while externally rotating the tibia. A positive sign is indicated by a “popping” and sensation of symptoms along the joint line, often accompanied by an inability to fully extend the knee.<\/p>\n

 <\/p>\n

The Apley compression test is performed with the patient laying in a prone position on a low examination table. The examiner applies his\/her knee into the posterior thigh of the leg to be examined, then flexes and externally rotates the tibia while gripping the ankle. The examiner then compresses the tibia downward. If this compression produces an increase in pain, the test is considered positive.<\/p>\n

 <\/p>\n

The medial-lateral grind test is performed with the patient supine on the examination table. The examiner cradles the affected leg’s calf in one hand and places the index finger and thumb of the opposite hand over the joint line. Valgus and varus stresses are applied to the tibia during flexion and extension. If a grinding sensation is palpated by the hand placed over the joint line, the medial-lateral grind test is deemed positive.<\/p>\n

(JAMA 286:13 Oct 2001 JB24<\/strong>)<\/p>\n

 <\/p>\n

Medial Collateral Ligament Testing is done by applying valgus stress with the knee in full extension and then in 30 of flexion.\u00a0 If there is laxity in full extension, then there is a complete rupture of the MCL.<\/p>\n

<\/span>Ottawa Knee Rules<\/span><\/h2>\n

Age>55<\/p>\n

Fibular Head Tenderness<\/p>\n

Isolated Tenderness of Patella<\/p>\n

Inability to flex 90 degrees<\/p>\n

Inability to weight bear for four steps after injury and in the ED<\/p>\n

 <\/p>\n

Validated in children age 2-16 (Annals EM 42:1, 2003)<\/p>\n

 <\/p>\n

<\/span>X-Rays<\/span><\/h3>\n

AP\/LAT<\/p>\n

Sunrise to better evaluate the patella<\/p>\n

Tunnel view for the intercondylar notch for tibial spine fractures or loose foreign bodies<\/p>\n

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KNEE<\/strong>Plain radiographs of the knee usually include an AP and lateral view.\u00a0 With this two-view imaging protocol, the sensitivity of detecting knee fractures is only 79%.\u00a0 The addition of two oblique views for a four-view imaging protocol increases this sensitivity to 85% (22).\u00a0 To reduce the number of overlooked knee fractures, consider obtaining oblique plain radiographs and possibly even CT imaging for high-risk patients.\u00a0 The normal AP and lateral anatomy of the knee is shown in Figures 19 and 20.Figure 18.\u00a0 AP radiograph and diagram of normal right knee \"\"<\/a>\u00a0 \"\"<\/a> Figure 19.\u00a0 Lateral radiograph and diagram of normal right knee \"\"<\/a>\u00a0 \"\"<\/a><\/strong>Using the \u0093DOH\u0094 mnemonic again, a knee \u0093D\u0094islocation is not a clinically or radiographically subtle diagnosis (Figure 20).\u00a0 The radiographic pitfall is not considering an associated popliteal artery injury.\u00a0 They occur in 23-60% of knee dislocations (23-25).Figure 20.\u00a0 Anterior dislocation of knee (Lateral view) \"\"<\/a> \"\"<\/a><\/strong>There are three high-risk, \u0093O\u0094ccult fractures of the knee.\u00a0 The first is a tibial plateau fracture, which alone accounts for one-third of all knee fractures.\u00a0 These fractures usually occur after a valgus force is applied with axial loading, such as when a pedestrian is struck by the bumper of a car.\u00a0 Because of the relative insensitivity of two-view plain radiographs, if a high-risk patient is unable to bear weight on the affected knee, two additional oblique views will help elucidate the injury.\u00a0 Figure 21 radiographically appears grossly normal on the two-view series but one can appreciate the impressive fracture pattern through the medial tibial plateau on one of the oblique views.\u00a0 CT imaging is necessary to evaluate the extent of any tibial plateau fracture and should be considered in the rare high-risk patient who has a normal four-view radiographic series.\u00a0 Such a high-risk patient might be a pedestrian struck in the knee by a car, has significant point-tenderness over the medial or lateral joint line, and is unable to bear any weight on the leg.Figure 21.\u00a0 Tibial plateau fracture of left knee (A) AP view, (B) Lateral view, (C) Oblique view, (D) Diagram<\/strong><\/p>\n

A<\/strong> \"\"<\/a> B<\/strong>\"\"<\/a> C<\/strong>\"\"<\/a> D<\/strong>\"\"<\/a><\/p>\n

The second \u0093O\u0094ccult knee fracture is a Segond fracture\u0097a proximal lateral tibial avulsion fracture (Figure 22).\u00a0 The fractured piece was the insertion site of the lateral capsular ligament.\u00a0 Although the fracture piece appears clinically insignificant, be wary that Segond fractures have a significant concurrent risk for anterior cruciate ligament (ACL) tears.\u00a0 These patients should be discharged with a knee immobilizer and urgent follow-up with an orthopedist.\u00a0 Figure 22.\u00a0 Segond fracture of the left knee (AP view) \"\"<\/a>\u00a0 \"\"<\/a><\/strong>For further images of a Segond fracture visit the EMedHome.com Archives for the clinical case discussing this injury.<\/p>\n

And the third \u0093O\u0094ccult fracture is a patella fracture, which comprises 40% of all knee fractures.\u00a0 It is usually the result of direct blunt trauma to the patella.\u00a0 Because of the overlapping femoral condyles, the AP view is poor in detecting patellar fractures.\u00a0 The best radiographic perspective is the lateral view.\u00a0 Figures 23 and 24 show the AP and lateral views of a patella fracture, respectively.\u00a0 Additional images such as the \u0093sunrise view\u0094, which is a tangential view of the patella with the knee flexed approximately 60 degrees, may be helpful especially in visualizing vertical patella fractures.Figure 23.\u00a0 Left transverse patella fracture (AP view)<\/strong> \"\"<\/a>\u00a0 \"\"<\/a> Figure 24.\u00a0 Left transverse patella fracture (Lateral view)<\/strong> \"\"<\/a>\u00a0 \"\"<\/a><\/p>\n

The primary \u0093H\u0094alf pathology for the knee is a Maisonneuve fracture (Figures 25 and 26).\u00a0 In this injury, a fracture of the proximal fibula is associated with a fracture of the medial malleolus or deltoid ligament of the ankle.\u00a0 Often the ankle mortise is widened, and the tibiofibular syndesmosis is disrupted.\u00a0 Finding a proximal fibula fracture necessitates the need for an ankle exam and radiograph, and conversely finding a medial malleolus fracture and\/ or widened mortise necessitates the need for a tibia-fibular exam and radiograph.Figure 25.\u00a0 Maisonneuve fracture: Right knee proximal fibula fracture (AP view of knee)<\/strong><\/p>\n

\"\"<\/a>\u00a0 \"\"<\/a> \u00a0<\/strong><\/p>\n

Figure 26.\u00a0 Maisonneuve fracture: Right ankle medial malleolus fracture (AP view of ankle)<\/strong><\/p>\n

\"\"<\/a><\/p>\n

\"\"<\/a> \u00a0<\/strong><\/p>\n

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<\/span>The following proposed algorithm is a very reasonable approach (1):\u00a0 When the patient is first seen, if the peripheral circulation in the extremity is deficient, the dislocation should be reduced as quickly as possible and the circulatory status of the limb carefully re-assessed.\u00a0 Arteriography is routine for any patient having questionable circulation or absent peripheral pulses either before or after reduction of a dislocated knee. Arteriography should be done in an extremity that originally has no pulses, even though satisfactory pulses are restored after reduction, because intimal tears may be present even though the patency of the popliteal artery is sufficient for satisfactory circulation.\u00a0\u00a0 An arteriogram is not routinely done when there is no sign of peripheral circulatory embarrassment before or after reduction.\u00a0 During the first 48 to 72 hours after injury, the extremity is closely monitored for an intimal tear that may progress and cause thrombosis. Selective arteriography is becoming the standard, as stated in a recent study:\u00a0 In the group of patients who present with knee dislocations and normal peripheral vascular examination arteriograms are not helpful. Most now recommend early ligament repair or reconstruction of the knee and aggressive rehabilitation, especially in young, active patients (1). References: (1)\u00a0 Canale: Campbell’s Operative Orthopaedics, Ninth Edition, Copyright 1998 Mosby, Inc. Selective arteriography is becoming the standard, as stated in a recent study: In the group of patients who present with knee dislocations and normal peripheral vascular examination arteriograms are not helpful. Most now recommend early ligament repair or reconstruction of the knee and aggressive rehabilitation, especially in young, active patients (1). References: (1) Canale: Campbell’s Operative Orthopaedics, Ninth Edition, Copyright 1998 Mosby, Inc. (2) Roberts DM Emergency department evaluation and treatment of knee and leg injuries Emerg Med Clin North Am 2000 Feb; 18: 67-84 (3) Martinez D, et. al. Popliteal artery injury associated with knee dislocations Am Surg 2001; 67:165-7 \"\"<\/a><\/span><\/h3>\n

<\/h3>\n

<\/h3>\n

<\/span>Osgood Schlatter<\/span><\/h3>\n

8-15 y\/os<\/p>\n

Pn\/swelling at tibila tuberosity<\/p>\n

<\/span>Dislocation of the Knee<\/span><\/h3>\n

Box the peroneal nerve-get foot drop<\/p>\n

Anterior disloc-popliteal injury<\/p>\n

Posterior-can be reduced<\/p>\n

Medial\/Lat\/Rotational-must go to OR<\/p>\n

Patellar Dislocation-can be easily reduced, do patella apprehension test, push patella laterally, if pt reacts or tenses quad then positive<\/p>\n

 <\/p>\n

Ankle\/Brachial pressure ratio less than 0.8 (using doppler) requires arteriography.<\/p>\n

 <\/p>\n

The presence of pulses and equal ankle-brachial indices is nearly 100% sensitive in excluding operative vascular injury (Am J EM, 2\/07, pg. 241)<\/p>\n

<\/span> \"\"<\/a>(Injury 2008;39:710)<\/span><\/h3>\n

<\/h3>\n

<\/span>Quadriceps Tendon Rupture<\/span><\/h3>\n

Can not do straight leg raise.\u00a0 Need surgical repair within 58-72 hours.\u00a0 Put in immobilizer<\/p>\n

<\/span>Osteoarthritis<\/a><\/span><\/h3>\n

<\/span>Popliteal (Baker’s) Cyst<\/span><\/h3>\n

there is no way to differentiate it from DVT on clinical grounds, get an ultrasound.<\/p>\n

if the cyst is ruptured and you give heparin, can get massive bleeding and even one case of posterior compartment syndrome<\/p>\n

may see hemorrhagic ring surrounding ankle<\/p>\n

you almost never will feel a mass<\/p>\n

since the cyst contains inflammatory fluid, if it ruptures, entire calf will get red, swollen and painful.\u00a0 Knee pain which gets relieved but then the calf begins to hurt is classic<\/p>\n

Differential:\u00a0 thrombophlebitis, baker’s cyst, muscle tear (gastroc), plantaris tendon rupture, cellulitis, fasciitis, compartment syndrome, popliteal aneurysm, ganglia, neural tumors, sarcoma, hemangioma<\/p>\n

 <\/p>\n

\"\"<\/a><\/p>\n

 <\/p>\n

<\/span>Shin Splints<\/span><\/h2>\n

Here are my tips re shin splints and exhaustion: 1) While you can usually acutely double your short duration exercise time, a marathon does not “scale” the same way for many, if not most people. Next time take your training up to 2\/3rds of the marathon distance. 2) Shin splints and stitches usually come either early or late in a run. If early it is usually because you haven’t warmed up properly or are trying to increase the pace to fast. They also are almost universal in new runners or reconditioning ones. In both cases slowing down and running or walking through them is fine. When they occur late in the run they usually indicate an acute electrolyte disturbance. I had good results with continuous supplementation with magnesium (oxide) which most diets (including middle class Indian ones) are sorely deficient in and which is associated with atherosclerosis and SCD. Trying to maintain a fairly constant sodium in addition to hydration level is also important. Some runners with persistent problems report relief with Mg++ plus 400 IU q.d. vitamin E and at least 100 mg q.d. of CoQ10. If, as you say, you were completely drained and exhausted you may want to not only increase the length of your training runs (and take the supplements I list above), but also consider tanking up your muscle fuel reserves with p.o, creatine supplementation. I once employed a guy who was both a superb athlete and did consulting with big name athletes on nutrients. I can tell you that ALL world class athletes are stuffed full of legal performance enhancing nutrients and that these nutrients do make a positive difference. Creatine supplementation can have a dramatic effect on muscle mass and endurance and seems very safe (and also to reduce injury). While I realize you are not aspiring to be a professional athlete, I think that improving adaptation and tolerance for training through good nutrition (including judicious use of supplements) is both good sense and good for the body. It is interesting to note that superb athletes rarely live to anywhere near the maximum lifespan for humans. There are no great centenarian athletes, yet. One clue as to why this is the case is to look at the T-Bar levels and free radical adducts in the urine and serum of athletes after a good workout: they are astronomical — often higher than seen after 10 minutes of global systemic ischemia! Years before it was being considered as a marker of ischemia-reperfusion injury the cytochrome C levels of conditioned athletes after exercise were shown to be elevated. Runners also get a blast of Fenton reaction mediated radicals as a result of the release of free hemoglobin due to hemolysis (in part from foot impact on the pavement).<\/p>\n

 <\/p>\n

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|\u00a0\u00a0 \u00a0\u00a0 |\u00a0\u00a0 \u00a0\u00a0 |<\/p>\n","protected":false},"excerpt":{"rendered":"

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