ORTHO BULLETS Orthopaedic Surgeons & Providers The knee joint is … instability, locking, catching sensation; Physical exam inspection body habitus; gait. Over a 10-year period, 85 consecutive patients presented to the Accident and Emergency Department with an acutely locked knee and were all treated by manipulation under anaesthesia. (OBQ11.13) She denies constitutional symptoms. A clinical image of the left leg in the supine position is shown in Figure A. it is completely stuck in position and cannot be moved whether due to pain or a mechanical block. A 12-year-old skeletally immature female presents with a several year history of bilateral knee pain and lower extremity deformity with her knees rubbing together while she runs. Copyright © 2021 Lineage Medical, Inc. All rights reserved. Recovering From Locked Knee Surgery. Most people make an excellent recovery from locked knee surgery. 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. If pulses do not return, perform popliteal artery exploration. Meniscal Injury. Function. His exam is completely normal and symmetric to his left knee. Xrays are normal. Crossref, Medline, Google Scholar Metaphyseal comminution also demands treatment with a fixed angle device or a locked intramedullary nail and is therefore amenable to locking plate treatment. What is the next step in treatment? increasing congruency. In the past you have had conflicting advice regarding the management of these injuries so discuss with the Orthopaedic SHO how he should be further managed. Tearing your meniscus or having loose fragments in your joint can cause a “locked knee,” which painfully limits the motion of the knee joint. A locked knee may only last a few seconds, it may last longer. A standing alignment radiograph is shown in Figure B with the mechanical lateral distal femoral angle measured at 73° (mLDFA 88°, range 85°-90°), an mechanical medial proximal tibial angle of 87° (mMPTA 87°, range 85°-90°), and a tibial femoral angle of 25°(range 5°-10°). A locked knee is a knee that cannot be bent or straightened — i.e. 3 Fracture of Tibia or Fibula at knee joint can cause knee locking or locked knee joint. Locked knee to a lesser extent can be managed conservatively but in severe cases it needs surgery. There are four basic surgical approaches: 1) open (rarely used in contemporary practice), 2) inside-out suture techniques, 3) outside-in suture techniques, and 4) all-inside techniques. Knee & Sports Pediatrics Recon Hand Foot & Ankle Pathology Approaches Search Cases; Trauma; Spine; Shoulder & Elbow; Knee & Sports; Pediatrics; Recon; Hand Sometimes the patient may have to visit emergency room if the condition is sudden and severe. Knee & Sports Pediatrics Recon Hand Foot & Ankle Pathology Approaches Search Cases; Trauma; Spine; Shoulder & Elbow; Knee & Sports; Pediatrics; Recon; Hand A recent MRI revealed that most of the medial meniscus was removed (apparently this was just before arthroscopic surgery). An 18-year-old girl presents with a deformity of the left leg that limits her ability to play basketball and volleyball. effect on walking distances; pain at night or rest . Osteotomy procedures around the knee can alter the biomechanical axis of the knee, thereby shifting the load from one compartment to another. This can be used to unload an arthritic painful compartment or to decrease the weight experienced by a cartilage restoration procedure. Open reduction through an anteromedial approach, spanning external fixation. Causes Of Locking Of Knee Joint. may resolve spontaneously or with the maneuvering of the leg) or permanent. the threshold of deformity that leads to future degenerative changes is unknown, deformity after a proximal metaphyseal tibia fracture (Cozen) should be observed, as it almost always remodels, genu valgum <15 degrees in a child <6 years of age, > 15-20° of valgus in a patient <10 years of age, if line drawn from center of femoral head to center of ankle falls in lateral quadrant of tibial plateau in patient > 10 yrs of age, to avoid physeal injury place them extraperiosteally, to avoid overcorrection follow patients often, growth begins within 24 months after removal of the tether, insufficient remaining growth for hemiepiphysiodesis, perform a peroneal nerve release prior to surgery, Pediatric Pelvis Trauma Radiographic Evaluation, Pediatric Hip Trauma Radiographic Evaluation, Pediatric Knee Trauma Radiographic Evaluation, Pediatric Ankle Trauma Radiographic Evaluation, Distal Humerus Physeal Separation - Pediatric, Proximal Tibia Metaphyseal FX - Pediatric, Chronic Recurrent Multifocal Osteomyelitis (CRMO), Obstetric Brachial Plexopathy (Erb's, Klumpke's Palsy), Anterolateral Bowing & Congenital Pseudoarthrosis of Tibia, Clubfoot (congenital talipes equinovarus), Flexible Pes Planovalgus (Flexible Flatfoot), Congenital Hallux Varus (Atavistic Great Toe), Cerebral Palsy - Upper Extremity Disorders, Myelodysplasia (myelomeningocele, spinal bifida), Dysplasia Epiphysealis Hemimelica (Trevor's Disease), therefore it is critical to differentiate between a physiologic and pathologic process, distal femur is the most common location of primary pathologic genu valgum but can arise from tibia, between 3-4 years of age children have up to 20 degrees of genu valgum, after age 7 valgus should not be worse than 12 degrees, after age 7 the intermalleolar distance should be <8 cm, ineffective in pathologic genu valgum and unnecessary in physiologic genu valgum. Out of 69 patients who could be adequately followed up, 46 (67 per cent) subsequently required arthrotomy for an internal derangement. Knee locking is when the leg gets stuck in one position, making it impossible to bend or straighten the knee. increases contact area leads to decreased point loading. She is neurovascularly intact in the bilateral lower extremities. If pulses do not return, perform on-table angiogram. He denies fevers or mechanical knee symptoms. MB BULLETS Step 1 For 1st and 2nd Year Med Students. Historically, the saline load test has been the diagnostic test of choice for assessing traumatic arthrotomy; however, CT has recently been shown to have excellent sensitivity and specificity for detecting open knee joint injuries. Injury to ACL, PCL, PMC, and PLC (4 ligaments), rate of vascular injury (5-15%%) based on Schenck classification, Multiligamentous injury with periarticular fracture, measure Ankle-Brachial Index (ABI) on all patients with suspected KD, if pulses are still absent following reduction, imaging contraindicated if it will delay surgical revascularization, assess sensory and motor function of peroneal and tibial nerve as nerve deficits often occur concomitantly with vascular injuries, (Segond sign - lateral tibial condyle avulsion fx), fracture identified on post reduction plain films, obtain post reduction CT for characterization of fracture, tibial eminence, tibial tubercle, and tibial plateau fractures may be seen, after acute reduction but prior to hardware placement, patients can be placed in a knee immobilizer until treated operatively, anterior dislocation - traction and anterior translation of the femur, posterior dislocation - traction, extension, and anterior translation of the tibia, medial/lateral - traction and medial or lateral translation, rotatory - axial limb traction and rotation in the opposite direction of deformity, KD IV injuries have the highest rate of vascular injuries, emergent vascular repair and prophylactic fasciotomies, avoid stiffness with early reconstruction and motion, 25% occurrence of a peroneal nerve injury, neurolysis or exploration at the time of reconstruction, nerve repair or reconstruction or tendon transfers if chronic nerve palsy persists, dynamic tendon transfer involves transferring the posterior tibial tendon (PTT) to the foot, Adult Knee Trauma Radiographic Evaluation, Proximal Humerus Fracture Malunion and Nonunion, Distal Radial Ulnar Joint (DRUJ) Injuries, treatment is generally emergent reduction and assessment of limb perfusion, high energy is usually from MVC, crush injury, fall from a height, or dashboard, hyperextension injury leads to anterior dislocations, the knee is a ginglymoid joint and consists of tibiofemoral, patellofemoral and tibiofibular articulations, PCL, ACL, LCL, MCL, and PLC are all at risk for injury, main stabilizers of the knee given the limited stability afforded by the bony articulations, popliteal artery injuries occur often due to tethering at the popliteal fossa, proximal - fibrous tunnel at the adductor hiatus, geniculate arteries may provide collateral flow and palpable pulses masking a limb-threatening vascular injury, the normal range of motion of 0-140 degrees with 8-12 degrees of rotation during flexion/extension, posterolateral is most common rotational dislocation, based on a pattern of multiligamentous injury of knee dislocation (KD), history of trauma and deformity of the knee, may present with subtle signs of trauma (swelling, effusion, abrasions, ecchymosis), reduce immediately, especially if absent pulses, indicative of an irreducible posterolateral dislocation, a contraindication to closed reduction due to risks of skin necrosis, priority is to rule out vascular injury on exam both before and after reduction, palpate the dorsalis pedis and posterior tibial pulses on injured and contralateral side, does not indicate the absence of arterial injury, collateral circulation can mask a complete popliteal artery occlusion, then monitor with serial examination (100% Negative Predictive Value), perform an arterial duplex ultrasound or CT angiography, if arterial injury confirmed then consult vascular surgery, confirm that the knee joint is reduced or perform immediate reduction and reassessment, if pulses present after reduction then measure ABI then consider observation vs. angiography, may see recurvatum when held in extension, post reduction AP and lateral of the knee, required to evaluate soft tissue injury (ligaments, meniscus) and for surgical planning, pulses are absent or diminished following reduction, if arterial injury confirmed by arterial duplex ultrasound or CT angiography, successful closed reduction without vacular compromise, most cases require some form of surgical stabilization following reduction, worse outcomes are seen with nonoperative management, prolonged immobilization will lead to loss of ROM with persistent instability, obesity (may be difficult to obtain closed), obese (if difficult to maintain reduction), instability will require some kind of ligamentous repair or fixation, midline incision with a medial parapatellar arthrotomy, the medial capsule may need to be pulled over medial condyle if buttonholed, acute associated soft tissue injuries (patellar tendon rupture, periarticular avulsion, or displaced menisci) may benefit from acute repair, periarticular fractures may be fixed acutely or spanned with external fixator depending on surgeon preference, place knee-spanning external fixator in 20-30 degrees of flexion with knee reduced in AP and sagittal planes, arthroscopic may not be possible if large capsular injury and creates a risk of fluid extravasation and compartment syndrome, PLC and PMC require open reconstruction given subcutaneous nature and proximity to neurovascular structures, arthroscopic reconstruction of ACL and/or PCL, address intraarticular pathology (menisci, cartilage defects, capsular injury), open repair versus reconstruction of collateral ligaments, acute reconstruction (<3 weeks) has been shown to lead to improved clinical and functional outcomes.

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