The knee

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111 the absence of a history of trauma, the complaint of a relatively sudden onset of pain and swelling suggests diagnoses such as sepsis, crystal arthropathy (gout or pseudogoul) or reactive arthritis (Fig. 8.20AI. An insidious onset of chronic knee pain and swelling with stiffness, which is worse in the morning and after inactivity, is more typical of chronic monoarthritis. Fnquiry about other joint symptoms, extra-articular features and family history will help with the diagnosis. A long hisiory of painful knee, often with relatively little swelling, which is exacerbated by activity and causes progressive disability over months and years is more typical of degenerative disease. Night pain is an important feature of established degenerative disease. Pain in the knee which the patient has difficulty localising may be referred from the hip or, occasionally, the lumbar spine.

In the patient presenting after trauma, it is important lo try lo establish how the injury occurred and speed of onset of the swelling, since this information often assists in

Fluid in suprapatellar pouch secondary to active synovitis

Osteochondritis dtssicans with separated fragment forming loose body

Metaphyseal focus of Infection

Osgood Schlatter disease

Fluid in suprapatellar pouch secondary to active synovitis

Osteochondritis dtssicans with separated fragment forming loose body

Metaphyseal focus of Infection

Osgood Schlatter disease

Lateral compartment arthritis

Fig. 8.20 S Non-traumatic lesions about the knee. IB Traumatic lesions about the knee.

making the diagnosis (Fig. H.20B). For example, rotation on a flexed knee, as when kicking a football is a typical cause of meniscal injury. The meniscus is avascular and when torn is associated with a slowly developing effusion. Abduction-adduction stresses across the knee, for example while skiing, are more likely to damage the collateral ligaments. Cruciate ligament injuries are also common and may be associated with a variety of mechanisms, such as hyperextension of the knee. Ligaments arc vascular structures - thus after a tear of the collateral ligament there is bruising at the site of the injury, while after a cruciate ligament tear, a haemarthrosis rapidly develops. The patient should also be asked to try to identify the site of pain, which is usually localised to the site of injury or pathology.

Sometimes a knee effusion is associated with pain and swelling in the popliteal fossa. This is caused by synovial fluid passing through a one-way valvular system in the posterior capsule into the popliteal fossa producing a popliteal (Baker's) cyst. This may be asymptomatic but on occasions it can give rise to local pain. The history of a cyst, followed by an episode of acute pain in the calf, with a reduction in the size of the cyst is highly suggestive of a rupture of the cyst. This is sometimes misdiagnosed as a deep venous thrombosis.

The complaint of the knee 'giving way' is common. Such instability can occur as a result of inability to fully straighten the knee (locking), and this is often associated with a displaced segment of torn meniscus. Mobile loose bodies wiLhin the joint tend to produce intermittent locking when the knee suddenly gives way under the patient, and just as rapidly the obstruction frees and the knee returns to normal. A careful history may be required to distinguish between the complaint of locking and the sensation of stiffness and restriction felt in the degenerative knee, which is particularly noted hy the patient after silling.

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