Knee-膝关节运动损伤.ppt

Click to edit Master title style,*,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Knee Problems,MS3 Family Medicine,Anatomy Review,Femur,Medial&lateral,Condyles,Epicondyles,Trochlear groove,Intercondylar notch,Patella,Superior pole(base),Inferior pole(apex),Medial&lateral facets,Tibia,Medial&lateral,Condyles,Gerdys tubercle,Pes anserine area,Tibial tuberosity,Tibial plateau,Tibial spines,Fibula,Head,Neck,ACL and PCL,Iliotibial band(ITB),Anatomy Menisci of the Knee,Medial meniscus,Lateral meniscus,Meniscal ligaments,Functions of the menisci,Meniscal zones,White-white,Red-white,Red-red,Knee Exam Overview,Inspection,Palpation,Range of Motion,Strength,Neurovascular,Special Tests,Case 1 Medial Right Knee Pain,16yo HS soccer player,previously healthy,Tackled from right side while running,Immediate onset of medial jt line pain,Delayed onset local medial edema,stiffness,Able to bear weight,Key Questions in the History,Mechanism of Injury?,Acute or Chronic?,Location and level of pain?,Able to walk?,Mechanical Symptoms?(Locking,popping,catching?),Associated instability?,Swelling?,Previous injuries or surgeries?,Case 1-Exam,Inspection:Mild medial knee edema,Palpation:+ttp medial knee,ROM:cant bend 80d,Strength:mildly decreased,Neurovascular:normal,Special tests:,Neg Lachman,Anterior Drawer,McMurray,varus stress,+mild increased gap on valgus stress(compared to left)with good endpoint,Special Tests-ACL Injury,Lachman Test,Special Tests-PCL Injury,Posterior Drawer Test,Sag Sign,Quad-Active Test,Varus/Valgus stress for LCL and MCL Injury,Features that should prompt an xray after acute knee injury include:,Unable to bear weight,Cant flex 90d,Patella TTP,Fibular head TTP,Age 55,All of the above,5 Ottawa Knee Rules,i.e.When to order a knee xray after acute injury,Age 55 or R knee pain,Former parachutist,no specific trauma,No previous knee surgeries,Stiffness worse in morning,Pain is worse with activity,better with rest,Case 2 Key Questions,Mechanism of Injury?,Acute or Chronic?,Where/how bad is pain?,Mechanical Symptoms?(Locking,popping,catching?),Associated instability?,Swelling?,Previous injuries or surgeries?,What makes it worse?,What makes it better?,Insidious Onset,Chronic,Difficult to localize;mild,No,None,Occasional,Lots of“Bad Landings”No surgery,Activity,Rest,Case 2 Physical Exam,Inspection:,Genu varus,Bony enlargement at Med/Lat joint lines,Palp:Posterior medial joint line ttp,ROM:Decreased flexion,110 deg,mild crepitus,Strength:normal,Neurovascular:normal,Special Tests:no ligamentous laxity,neg meniscal tests,Special Tests-Meniscal Injuries,Joint line tenderness,McMurray Tests,Thessaly test,Bounce-home test,Full Squat,Case 2 Plain Films,Joint space narrowing,Subchondral Sclerosis,Osteophytes,Subchondral Cysts,What is your diagnosis?,10,Meniscal tear,Plica syndrome,Osteoarthritis,Bone tumor,Osteoarthritis,Nonpharmacologic Treatment:,Nonpainful aerobic activity,Weight loss,Physical Therapy,Improve ROM,increase strength,Bracing,Pharmacologic Treatment:,APAP,Supplements,Glucosamine and Chondroitin,NSAIDs,COX-2s,Tramadol,Viscosupplementation,Intrarticular Steroids,Case 3,31 year old female,L knee pain,Recreational runner,Localizes pain to front of knee,No trauma,insidious onset,Localizes pain“around kneecap”,Worse with stairs,Worse after prolonged sitting,Knee occasionally“gives out”,Case 3 Key Questions,Mechanism of Injury?,Acute or Chronic?,Where is the pain?,Mechanical Symptoms?(Locking,popping,catching?),Associated instability?,Swelling?,Previous injuries or surgeries?,What makes it worse?,What makes it better?,Insidious Onset,Chronic,Anterior knee,No,but sometimes gives out,None,None,None,Running,Stairs,Multiple days of rest,Physical Exam,Inspection:mild genu valgus,Palpation:TTP lateral medial patellar facets,ROM:full w/o pain,Strength:normal,Neurovascular:normal,Special Tests:,+patellar grind,Decreased patellar glide,Inflexible hamstrings(Popliteal angle),Patellofemoral Joint Exam,Patellofemoral Joint Exam,Patellar Grind Test,Case 3 Plain Films,AP,Lateral,Case 3 Plain Films,Tunnel,Sunrise,Whats your diagnosis?,Patellar tendinopathy,Patellar instability,Patellofemoral syndrome,Plica syndrome,Patellofemoral Syndrome,Treatment:,Relative rest;non-painful aerobics,Physical Therapy,Improve Quad/Hamstring flexibility,Quad,Hip abductor strengthening,Core strengthening,Patellar stabilization brace/taping,Foot orthotics,Surgery(last-ditch effort),Case 4,34 yo Army MAJ training for 1,st,marathon,Atraumatic onset of R lateral knee pain 1 week ago after 10 mile run,Sharp burning pain,Better with rest,returns with running,Case 4 Key Questions,Mechanism of Injury?,Acute or Chronic?,Where is the pain?,Mechanical Symptoms?(Locking,popping,catching?),Associated instability?,Swelling?,Previous injuries or surgeries?,What makes it worse?,What makes it better?,Insidious Onset,Acute,Lateral knee,No,but sometimes gives out,None,None,None,Running,Multiple days of rest,Physical Exam,Inspection:normal,Palpation:TTP over lateral femoral condyle,ROM:full,Strength:normal,Neurovascular:normal,Special tests:,+Noble test,Tight on Ober test,Ober testNoble test,Whats your diagnosis?,Osteoarthritis,Meniscal tear,Iliotibial band syndrome,LCL sprain,Iliotibial Band Syndrome,Treatment:,Ice massage,pain meds,Relative Rest;nonpainful activity,Physical Therapy,Specific ITB stretches,Hip abductor strengthening,Core strengthening(Gluteus Medius),Slow return to activity,Extrinsic factors:shoes,running surface,training errors,What the heck is a Plica?,Congenital thickening of joint capsule,Redundant meniscus,Loose piece of intra-articular cartilage,Figment of my imagination,Plica Syndrome?,Questions?,Before we break for hands-on,Special Tests-ACL Injury,Lachman Test,Knee flexed to 15-30 degrees,Stabilize distal femur,Anteriorly translate tibia on femur,Watch&feel for amount of translation&end point,Pivot Shift,Special Tests-PCL Injury,Posterior Drawer Test,Knee flexed to 90 degrees,Posteriorly translate tibia on femur,Watch&feel for amount of translation&end point,Sag Sign,Knees flexed,quads relaxed,compare both sides,Look for tibial posterior“sag”relative to femur,Quad-Active Test,Knee flexed;hamstrings,fully,relaxed,Slide foot along table(quad active),Observe for anterior relocation,Special Tests-MCL Injury,Valgus Stress Testing,Knee flexed to 30 degrees,Relax ACL/PCL&joint capsule,Valgus stress applied to knee,Look and feel for translation and endpoint,Compare to uninjured side,May repeat with knee in full extension,Special Tests-LCL Injury,Varus Stress Testing,Same test as valgus stress testing,Except applying a varus stress instead,LCL,IT band,&PLC are tested,Special Tests-Meniscal Injuries,Joint line tenderness,Full Squat,McMurray Tests,Thessaly test,Bounce-home test,McMurray test for Meniscal injury,Test Med and Lat meniscus separately,3 concurrent maneuvers:,Grind,it(Rotate tibia AWAY from it),Crunch,it(varus or valgus),Pinch,it(flex/extend knee),Positive:Painful“pop”,Special Tests-Meniscal Injuries,Thessaly Test,Pt stands on affected leg,Knee bent at 20 degrees,Examiner holds pts hands and rotates pt to both sides,Meniscal grind,Positive test:pain,painful click.,Anterior Knee Exam,Palpation of patellar facets,Glide and lift patella medially&laterally,Palpate undersurface of patella for tenderness,Patellar Exam,Patellar Glide,Knee in extension,relaxed,Medial&lateral patellar displacement,Measured in quadrants,Normal:1-2 quadrants,Patellar Apprehension,Lateral patellar displacement,patient apprehension,or guarding,Anterior Knee Exam,Patellar Grind Test,Knee 10 deg flexion,Glide patella distally,and firmly compress patella against trochlear groove,Active quadriceps contraction,pain,Special Tests Obers Test,Lateral decubitus with testing side up,testing knee flexed,Adduct and fully flex hip,Abduct,externally rotate,&extend hip,Slowly release support against gravity from leg,allowing gravity to take leg towards table,Positive test:leg remains abducted despite examiner releasing leg,Special Tests,Nobles test,Palpate lateral femoral condyle,Flex and Extend Knee,+Test is pain at site of palpation,