Q-Angle of the Knee

A well-functioning knee joint is important for mobility. The knee must be able to support the weight of the body during activities such as walking or running.

What is a Q-angle? knee anatomy

The Q Angle, or quadriceps angle, is the angle between the quadriceps tendon and the patellar tendon. An increased Q-angle is a risk factor for patellar subluxation.

How do you measure the Q-angle?

First, you will need to find the patella and its border. Then, you will need to find the center of the patella. You will then need to find the tibial tubercle and draw a line from the ASIS to the center of the patella and a second line from the tibial tubercle through the center of the patella.

normal qThe Q-angle is formed in the frontal plane by the two line segments. It is the angle formed by a line drawn from the Anterior Superior Iliac Spine (ASIS) to the center of the patella. A second line is drawn from the center of the patella to the tibial tubercle. The angle formed by the two lines is called the Q-angle. The normal Q-angle is variable. In males, the angle is usually 14° and 17° in females. A wider pelvis and an increased Q-angle in females is linked to knee pain, patellofemoral pain, and ACL injury. The alignment of the patellofemoral joint is effected by the patellar tendon length and the Q-angle. It is best to measure the Q-angle with the knee in extension as well as flexion.increased q

A larger Q-angle plus a strong quadriceps contraction can dislocate the patella. The Q-angle is increased by:

  • Genu valgum
  • External tibial torsion
  • Femoral anteversion
  • Lateral positioned tibial tuberosity
  • Tight lateral retinaculum

A CT scan study of the patellofemoral articulation is found to be very helpful.

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Sever’s Disease

Sever’s disease is a common cause of heel pain in children between the ages of 9 and 12 years. The pain is due to calcaneal apophysitis occurring due to repetitive and continuous traction on the calcaneus from the Achilles tendon. The apophysis is not part of a joint and has muscle or tendon attachments. This traction apophysitis may lead to stress fractures, pain and tenderness over the heel.

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Sever’s disease is similar to Osgood-schlatter disease of the tibial tubercle.

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Patients are usually young athletes presenting with heel pain that increases with activities. Upon examination there could be swelling, tenderness, warmth and/or redness on the back of the heel where the Achilles tendon inserts.

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Plain lateral X-rays may show sclerosis or fragmentation of the calcaneal tuberosity. Sclerosis is not specific for this condition.

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Fragmentation of the calcaneal tuberosity on the other hand, is more common in patients with Sever’s disease relative to the general population.

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Remember that Sever’s disease is a clinical diagnosis. X-rays may show other causes of pain such as tumors, fractures, infections or cysts. MRI is not commonly used, but can help rule out calcaneal stress fractures or osteomyelitis.

Sever’s disease is a self-limiting condition that usually resolves with time. Treatment usually consists of NSAID, Achilles tendon stretching exercises, and activity modifications and in severe condition a short leg walking cast can be used.

Carpal Tunnel Syndrome and Diabetes, A Challenging Problem

Approximately 20% of diabetic patients will develop carpal tunnel syndrome. Peripheral neuropathy makes the condition of the carpal tunnel worse. It is suggested that the never that already has established hypoxia caused by diabetes is more vulnerable to local compression. Other mechanisms and explanations are also involved, so it is a difficult diagnosis). Some people believe that patients with diabetic neuropathy will have a high prevalence of carpal tunnel syndrome.

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Electrodiagnostic testing (EMG and nerve studies) cannot distinguish patients with clinical carpal tunnel syndrome from patients with diabetic polyneuropathy. The decision to treat these patients should be made independently of the electrodiagnostic findings. When treating the patient, try to figure out the patient’s blood sugar level. There may be difficulty in determining if the blood sugar is under control.

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HBA1C (the glycosylated hemoglobin test) is an important blood test that shows how well the diabetes is being controlled. The test provides an average blood sugar control over the last 2-3 moths. The normal range of hemoglobin A1c is between 4% and 5.6%. When the level is 6.5% or higher, this indicated diabetes. The goal of treatment is to make sure that the patient with diabetes has hemoglobin A1c less than 7%. The higher the levels of Hemoglobin A1c, the higher the risk of developing complications. People should have the test done every three months to check and see that their blood sugar is under control. At least, the test should be done twice a year.

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The difficulty in carpal tunnel syndrome in diabetic patients is the difficulty of diagnosis, the difficulty in determining if the diabetes is being controlled or not, and if there will be surgery needed, will the patient have complications or not.

Patients who develop complications in orthopedics include: diabetics, obese patients, heavy smokers and patients taking blood thinners.

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If the condition is acute or an emergency, we have to do surgery. If the condition is elective, then surgery can wait. If the patient has poor glycemic control, then you probably don’t want to perform elective surgery on the patient such as carpal tunnel release. Remember, elective surgery can wait.

High blood sugar is linked to increased wound complications after surgery. Hemoglobin A1c is used to monitor the patient’s blood sugar level. The higher preoperative Hemoglobin A1c level, the more there is a risk factor for surgical site infection. Elective surgery can be delayed until HBA1c level becomes normal or better. Joint replacement surgery for example is delayed until HBA1c levels are less than 7%.

Since carpal tunnel syndrome is common in patients with diabetes, we need to take time to sort things out with these conditions. We need to know that the patient has better control of their diabetes. Carpal tunnel syndromes is a small surgery, but it can have catastrophic effect if we do not have a good control of the patient’s diabetes. Hemoglobin A1c will help us monitor the patient. Carpal tunnel surgery can cause complications and infection providing that high levels of HBA1c levels is a true risk factor for infection postoperatively.

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Heat Illness in Athletes

As summer approaches, athletes, coaches and other individuals will need to be aware of heat-related illnesses. Heat illnesses include a spectrum of conditions ranging from heat syncope, heat cramps and heat exhaustion to the more severe heat stroke.

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Heat Syncope (fainting) is a form of orthostatic hypotension that is related to dehydration. It occurs due to inadequate cardiac output and hypotension. It also occurs with standing quickly after sitting or lying down for prolonged durations in the heat. Symptoms include fainting, dizziness and light-headedness. Treatment includes oral rehydration (water, juice or sports drinks) and placing the patient flat on the ground in a cool area with slight elevation of the legs to push the blood back to the vital organs such as the brain.

Heat Cramps are painful muscle cramps that occur due to decreased sodium heat2.pngconcentration in the blood. The patient’s core temperature is usually not elevated. Sodium may decrease when salts are lost in sweat or with excessive water intake that does not include electrolytes leading to a situation called dilutional hyponatremia. Symptoms include painful muscle cramps occurring commonly in the abdominal muscles, arms, legs and thighs. Treatment includes rest, cooling and IV fluids or oral rehydration with fluids rich in electrolytes (sports drinks and juices) to replenish the sodium stores. Prevention could be achieved by consumption of fluids high in electrolytes before strenuous activities.

heat3Heat Exhaustion is the most common heat illness. The body temperature becomes elevated but is less than 40°C. The core body temperature is best measured rectally. The signs and symptoms of heat exhaustion include profuse sweating, core body temperature lower than 40°C, weakness and fatigue, cramping, headaches, nausea and vomiting,  fainting, hypotension, increased heart rate, and fast shallow breathing. Treatment includes rest, IV fluids or oral rehydration and rapid cooling by whole-body immersion in an ice bath.

Heat Stroke is the most severe form of heat illness. It is a medical emergency that needs immediate attention. The patient should be transported to the hospital as soon as possible. Heat strokes occur due to failure of the body’s normal thermoregulatory mechanism. If treatment is not started promptly, end-organ failure and ultimately death may occur. Heat strokes have a high mortality rate and require quick reduction of the patient’s temperature. The three characteristic features of this condition are a lack of sweating, core body temperature above 40°C (best measured rectally) and an altered mental status. Additional signs and symptoms include hot, dry skin, disorientation, confusion and hallucinations, headache and slurred speech. This is a serious medical emergency that requires rapid core body temperature reduction. The patient should have close monitoring of airway, breathing and circulation. The physician should implement basic life support and ACLS protocols. Rapid cooling by whole-body immersion in an ice bath will be utilized as well as IV fluids.

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