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By C. Nerusul. University of Pittsburgh at Bradford.

Repeating the maneuver with the leg in external rotation should tighten the posteromedial portion of the capsule discount kamagra effervescent 100 mg mastercard. If the patient’s tibia glides forward as much as it did with the leg in the neutral position generic 100mg kamagra effervescent amex, an MCL tear may be accompanying the potential ACL tear. Repeating the test with the leg in internal rotation tightens the posterolateral capsule. If the patient’s tibia again glides forward as much as it did with the leg in the neutral position, an LCL tear may be accompanying the poten- tial ACL tear. To test for a posterior cruciate ligament (PCL) tear, the examiner stays seated on the patient’s foot as for the anterior drawer test. However, instead of pulling the patient’s tibia toward the examiner, the tibia is pushed posteriorly (Photo 8). If the patient’s tibia glides posteriorly on the femur, it is likely torn, although the PCL is rarely torn. In this sign, the patient’s hip is flexed to 45° and the knee is flexed to 90°. The examiner supports the limb by holding the patient’s ankle (Photo 9). In a patient with a PCL tear, the tibia will posteriorly translate on the femur. Tenderness to palpation at the joint line (which you have already assessed) is a good indication that Knee Pain 101 Photo 9. The McMurray test was designed to diagnose a tear in the posterior medial meniscus because the posterior horn of the medial meniscus is difficult to palpate. To perform the McMurray test, the examiner instructs the patient to lie supine with legs extended. The examiner then takes hold of the patient’s heel and fully flexes the leg. Using the ankle as a fulcrum, the examiner rotates the patient’s leg internally and externally to loosen up the knee joint. With the knee joint loose and fully flexed, the examiner continues to use the ankle as a fulcrum and puts the leg into external rotation at the same time as the examiner uses the other hand to push the patient’s knee medially, applying a valgus stress. The examiner then slowly extends the knee, maintaining the leg in external rotation and under valgus stress (Photo 10). If this maneuver elicits a palpable or audible click in the patient’s knee, the posterior half of the medial meniscus is probably torn. Another good test to help differentiate between a meniscus tear and a collateral ligament tear is the Apley compression and distraction test. To perform this test, the patient is instructed to lie in the prone posi- tion. The examiner stabilizes the thigh with one hand and flexes the patient’s knee to 90° with the other hand. The examiner then applies downward pressure to the patient’s heel as the examiner internally and 102 Musculoskeletal Diagnosis Photo 10. When this maneuver elicits medial pain, the patient may have a medial meniscus or ligament tear. When this maneuver elicits pain on the lateral side, the patient may have a lateral meniscus or ligament tear.

Nambu T proven 100 mg kamagra effervescent, Gasser B order 100mg kamagra effervescent overnight delivery, Schneider E, Bandi W, Perren SM (1991) Defor- mation of the distal femur: a contribution towards the pathogen- Signs and symptoms Treatment esis of osteochondrosis dissecans in the knee joint. Nehrer S, Spector M, Minas T (1999) Histologic analysis of tissue Mild symptoms, no effusion, Sports ban, poss. Clin Orthop 365:149–62 no suspicion of dissection on »hindering« splint or cylinder 28. O’Connor MA, Palaniappan M, Khan N, Bruce CE (2002) Osteo- the x-ray cast. J Bone Joint Surg Br 84:258–62 Clear clinical symptoms MRI or arthroscopy, if dissec- 29. O’Driscoll SW (1999) Articular cartilage regeneration using perios- and/or radiological signs of tion confirmed, refixation with teum. Clin Orthop Suppl 367: 186–203 dissection (polyglycolic acid) screw(s) or 30. Paget J (1870) On production of some of the loose bodies in the fragment removal and defect joints. Peterson L, Minas T, Brittberg M, Nilsson A, Sjogren-Jansson E, Habitual dislocation of the patella: The patella can be Lindahl A (2000) Two- to 9-year outcome after autologous chon- dislocated laterally at will and only remains in the drocyte transplantation of the knee. J Bone Joint Surg (Am) 78: 439–53 Chronic dislocation of the patella: The patella dislocates 34. Slawski D (1997) High tibial osteotomy in the treatment of adult during the course of childhood and is then perma- osteochondritis dissecans. Clin Orthop 341: 155–61 nently dislocated, the extensor mechanism is displaced 35. Slough JA, Noto AM, Schmidt TL (1991) Tibial cortical bone peg laterally (usually combined with genu valgum). Clin Orthop 267: ▬ Congenital dislocation of the patella: The patella is 122–7 dislocated at birth and the extensor mechanism is dis- 36. Twyman RS, Desai K, Aichroth PM (1991) Osteochondritis dis- secans of the knee. J Bone Joint Surg (Br) 73: placed laterally (usually combined with genu valgum). Wilson N (1967) A diagnostic sign in osteochondritis dissecans of ally permanent) dislocation of the patella caused by the knee. J Bone Joint Surg (Am) 49: 477–80 abnormal traction on the vastus lateralis muscle. Wirth T, Rauch G, Schuler P, Griss P (1991) Das autologe Knorpel- ▬ Iatrogenic dislocation of the patella: Medial subluxation Knochen-Transplantat zur Therapie der Osteochondrosis disse- cans des Kniegelenkes. Z Orthop 129: 80–4 or dislocation of the patella after surgery to correct a lateral dislocation of the patella. A proportionate level of trauma is needed to produce an acute dislocation of the patella. The injury usually Classification occurs when the knee is in a position of flexion, valgus We distinguish between the following: and external rotation. This is the same mechanism that ▬ Acute traumatic dislocation of the patella: Lateral most commonly leads to rupture of the anterior cruciate dislocation of the patella caused by proportionate ligament in adults. Other concomitant injuries are dislocation of the patella in the presence of predis- also often observed, for example disruption of the medial posing factors. Usually progresses to the recurrent retinacula and shear fractures of the medial patellar facet form. Acute traumatic dislocation ▬ Recurrent dislocation of the patella: Repeatedly occur- of the patella without any predisposing factors is rare in ring lateral dislocations of the patella in the presence children and adolescents.