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Knee pain (무릎 통증)

The Root of Ambulatory Care (외래 진료 지침서) 전체 목록 보기
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The Root of Ambulatory Care

The Root of Ambulatory Care

  • 저 자 : 이진우
  • 출 판 : 군자출판사
  • 페이지수: 543면

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KEYWORDS: ..무릎 통증은 일차의료 의사가 흔히 접하는 문제이며, 주의 깊은 병력 청취, 자세한 진찰로 원인을 진단할 수 있는 경우가 많다. ..Acute Knee pain -Traumatic - Medial collateral ligament sprain (most common) - Anterior cruciate ligament sprain - Medial meniscus tear - Subluxed or dislocated patella - Contusions - Traumatic bursitis ..Acute Knee pain- Nontraumatic - Arthritis - Gout - Calcium pyrophosphate dihydrate(CPPD) crystal deposition disease - Referred pain : In adults ; herniated disk, muscle sprain, hip injury In children ; hip pathology commonly refers pain to knee Knee pain Femur Anterior Cruciate Ligament(ACL) Medial Meniscus Anterior Ligament of Head of Fibula Fibula Tibia Lateral Meniscus Posterior Cruciate Ligament(PCL) ▶ Ligaments of the Knee ..Chronic Knee pain - Arthritis - Patellofemoral pain syndrome(PFPS) : 10대~20대 - Patellar tendonitis : jumper’s knee - Iliotibial band syndrome : runner's knee - Meniscal tears - Pes anserine bursitis - Osgood-Schlatter disease (traumatic apophysitis of the tibial tubercle) : 사춘기 - Quadriceps tendinitis 1. Onset of injury Sudden vs gradual onset Associated change in training pattern, Intensity, or activities Ability to continue activities after injury 2. Mechanism of injury → Varus/Valgus contact : ligament sprains, patellar subluxation, meniscal tear, fracture → Direct blow : patellofemoral joint injuries, PCL sprain, fracture → Hyperextension injury : ACL sprain, PCL sprain, fracture → Deceleration injury : ACL sprain → Rotational injury : meniscal injury, ligament injuries, osteochondral fracture, patellar dislocation or subluxation → Dashboard injury (by TA) : fracture, ligament and capsular injuries 3. Pop or snap? → may indicate rupture of ligament, tendon, or muscle or a fracture 4. Swelling? → how quickly occurred : bloody effusion immediately (1~2hrs) after injury indicates a high probability of ACL rupture 5. Pain : location,radiation pattern, and → Sharp, stabbing pain : more likely to be associated with mechanical problems → Dull, aching pain : more likely to be associated with degenerative and overuse problems 6. Buckling : → be associated with ACL injury 227 The Root of ambulatory care Key questions Key test Knee pain 7. Pseudobuckling : a feeling of giving way but without actual giving way of knee ; associated with ACL injury, PFPS, arthritis 8. Locking : knee getting caught in specific positions ; associated with meniscal injury, loose bodies, osteochondritis dissecans, patellar dislocation 9. Pseudolocking : knee feels like it catches without actually locking ; associated with PFPS, arthritis, patellar subluxation The Ottawa Knee Rule for the use of radiography in acute knee injuries 1. Age 55 years or older 2. Isolated tenderness of patella 3. Tenderness at head of fibula 4. Inability to flex to 90 degrees 5. Inability to bear weight both immediately and in the emergency department (4 steps) 1. Knee AP/lateral (weight bearing) and bilateral/axial (Merchant) views 2. MRI : useful for evaluation of ligaments, menisci, bone bruise 3. CT : good for evaluation of osteochondritis dissecans and other bony pathology 4. Joint aspiration : if indicated ; aspiration of tense effusion will also provide some pain relief. ..Apprehension sign - patellar instability ..McMurray circumduction test - Meniscal tear ..Valgus stress test - medial collateral ligament ..Varus stress test - lateral collateral ligament ..Lachman test, Thumb sign, Anterior and posterior drawer test - ACL/PCL 229 The Root of ambulatory care ▶ Apprehension sign : With the patient supine and the quadriceps relaxed, place the knee in extension. Displace the patella laterally and then flex the knee to 30。With instability, this maneuver displaces the patella to an abnormal position on the lateral femoral condyle. The patient often perceives pain and becomes apprehensive. ▶ McMurray circumduction test : Flex the knee to the maximum pain-free position. Hold that position while externally rotating the foot, and then gradually extend the knee while maintaining the tibia in external rotation.This maneuver stresses the medial meniscus and often elicits a localized medial compartment click and/or pain in patients with a posterior horn tear. The same maneuver performed while rotating the foot internally will stress the lateral meniscus. Pain-free flexion beyond 90 is necessary for this test to be useful. ▶ Valgus stress test : With the patient in the supine position, place the knee at 20 to 30 degrees of flexion with the thigh supported. Stabilize the femur and palpate the medial joint line with one hand. Place the other hand on the distal tibia - Place the joint surface in the starting position and abduct the tibia on the femur, restricting axial rotation. Estimate the medial joint space and evaluate the stiffness of motion. Laxity is graded on a 1 to 4 scale: 1+, 5mm of medial joint space opening with a firm but abnormal endpoint; 2+, 10mm medial opening with a soft endpoint; 3+ (15mm) and 4+ (20mm) may be indicative of an assosiated cruciate ligament injury and must be carefully examined. ▶ Varus stress test : Place the patient in the supine position, with the knee at 20 to 30 degrees of flexion with the thigh supported. Stabilize the femur and palpate the lateral joint line with one hand. Place the other hand on the distal tibia - begin with the joint in the starting position and adduct the tibia on the fumur, restricting axial rotation. Estimate the joint space and evaluate the stiffness of motion. Grading is similar to that described above for the valgus stress test. Key treatment Knee pain Cf) Thumb sign - with the patient supine, flex the knee to 90 with the foot supported on the table. Normally, the anterior tibial plateaus sit 1cm anterior to the femoral condyles, and you may place your thumbs on top on the medial and lateral tibial plateaus. If the posterior cruciate ligament(PCL) is injured, the proximal tibia falls back and the area available to place your thumbs decreases. When the tibial plateaus are flush with the femoral condyles, there is 10mm or more of posterior laxity, consistent with a complete tear of the PCL. - mechanical cause PRICED 1. Protect : splinting is the safest and most effective 2. Rest from pain-producing activities : Weight bearing is allowed as tolerated. 3. Ice : recommended for 24~48hours after an acute injury 4. Compression : if swelling is noted 5. Elevation above level of heart to reduce edema 6. Drug : NSAIDs ..기계적 손상 후 재활 기간은 관절 고정 시간의 두 배가 되어야 한다. ▶ Lachman test (left knee) : The patient is in the supine position, with the knee flexed at 20 to 30 degrees. Grasp the femur in one hand and the tibia in the other, and examine the anteroposterior motion of the knee by displacing the tibia on the femur. Grade the motion from 0 to 4+ (1+, 5mm; 2+, 10mm; 3+, 15mm; 4+, 20mm). In addition, examine the endpoint of the ligament and grade it as firm, marginal, or stiff. A soft endpoint is usually indicative of a positive ACL tear. 231 The Root of ambulatory care -Arthritis 1. Acetaminophen ..Tylenol ER.. 650mg 1T, 2T tid 2. NSAIDs ..Brufen.. 200-600mg tid ..Naxen-F.. 500mg 1T bid~tid ..Voltaren 25mg 1T, 2T tid → 1T tid 3. Muscle relaxants ..Lioresal.. 1T tid ..Orpheryl.. 50mg 1T tid 4. Analgesics ..Tridol.. 50mg 1T tid ..Tridol.. SR 100mg 1T bid 5. Intralesional steroid injection ..Triamcinolone 40mg + Lidocaine 2cc ..Naxen-F..- naproxen ..Voltaren..- diclofenac ..Lioresal.. - Baclofen ..Orpheryl..- orphenadrine ..Tridol..- tramadol ▶ Neurovascular compromise ▶ Suspected complete ligamentous disruption ▶ Locked knees-unable to be manipulated place ▶ Fractures : Patellar(complete), Femoral condylar, Tibial plateau, Any compound fracture ▶ Severe injury with limited examination (examination under anesthesia may be indicated) Key treatment Knee pain 참고 문헌 양윤준 : 무릎통증, in 가정의학 임상편. 서울, 계측문화사, 2002, P 1175-1181 Craig C. Young: Knee pain, in Saunders Manual of Medical Practice, 2nd ed, Robert E. Rakel(ed). Philadelphia, Saunders, 2000, P 986-988 Walter B. Greene, M.D.(ed) : Anterior cruciate ligament tear, Arthritis of the knee, Collateral ligament tear, Meniscal tear, in Essentials of Musculoskeletal Care. Rosemont, American Academy of Orthopaedic Surgeons, 2001, P 360-362, P 363-365, P 373-375 P 379-381 Mitchell A. Kaminski, M.D., MBA : Knee complaints, in A Lange clinical manual Family Medicine Ambulatory Care & Prevention, 4th ed, Mark B. Mengel, M.D., L. Peter Schwiebert M.D. (ed). United States of America, The McGrwa-Hill Companies, Inc., 2005, P 244-251