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<Provider Id="sundheddkcms"> <Item Id="{F2C8E77F-2902-423D-8C07-0B3C91AEEBE6}" Name="knaesmerter" Type="LHContentPage" ParentProviderId="sundheddkcms" ParentItemId="{0DC18AC1-8322-42DA-BF54-C4D06C1501CE}" SortOrder="700" PublishDate="2009-02-16T14:47:00" DeleteDate="2999-12-31T00:00:00" PotItemType=""> <Content> <HtmlField Name="PageContent"><![CDATA[<h2>Basisoplysninger</h2> <h3>Definition</h3> <ul> <li>Smerter i knæet kan have årsag i sygdomme i og omkring selve knæleddet</li> <li>Knæsmerter kan også være projicerede smerter fra hofte og lårben eller tegn på mere generaliseret sygdom</li> </ul> <h3>Forekomst</h3> <ul> <li>De fleste mennesker vil opleve knæsmerter i en periode af deres liv. Ofte er smerterne med kendt årsag og forsvinder hurtigt, og i disse tilfælde søger patienten ikke læge</li> <li>Læge kontaktes, hvis smerterne er kraftige, langvarige og har betydning for arbejde, fritidsaktiviteter eller daglige funktioner</li> </ul> <h3>Diagnostisk tankegang</h3> <ul> <li>Knæsmerter kan have mange årsager og disponerende faktorer </li> <li>Det kan være overbelastningstilstande som tendinit, bursit, patellofemoralt syndrom </li> <li>Degenerative tilstande i brusk og meniskvæv som kan være artrose ved udtalte forandringer</li> <li>Inflammatoriske tilstande som artritis og systemsygdomme </li> <li>Traumer i form af ligamentskader, meniskskader, frakturer </li> <li>Patientens alder har betydning for de forskellige tilstandes hyppighed <ul> <li>Knæsmerter hos børn kan være projicerede smerter fra hoften </li> <li>Knæsmerter hos yngre er ofte overbelastningsrelaterede </li> <li>Knæsmerter hos midaldrende kan være menisklæsion </li> <li>Knæsmerter hos ældre kan ofte være på degenerativ/artrose baggrund</li> </ul> </li> </ul> <h3>Diagnostiske faldgruber</h3> <ul> <li>Hoftelidelser - specielt hos børn </li> <li>Osteosarkom og <a href="~/link.aspx?_id=0D90FE5F7EC44E09BDFF3752CCB7BB0A&_z=z">Ewings sarkom</a> hos børn </li> <li>Artralgi på grund af leukæmi hos børn </li> <li><a href="~/link.aspx?_id=BF43C438F520402F9003F17299AD1C05&_z=z">Dissemineret sclerose</a></li> </ul> <h3>ICPC-2</h3> <p>[ICPC]</p> <h3>ICD-10/SKS-koder</h3> <p>[ICD10]</p> <h2>Differentialdiagnoser</h2> <h3>Generelle knæsmerter</h3> <h4> <a href="~/link.aspx?_id=E7B85CC9D28B472D86648FCEFCA56E58&_z=z">Gonartrose</a><a href=" " data-type="journal-reference" data-value="Greene MA, Loeser RF, Aging-related inflammation in osteoarthritis. Osteoarthritis Cartilage 2015;23(11): 1966-71" data-value-piped="Greene MA, Loeser RF|Aging-related inflammation in osteoarthritis|Osteoarthritis Cartilage|2015|23(11)|1966-71" data-url="reference-link" title="Greene MA, Loeser RF, Aging-related inflammation in osteoarthritis. Osteoarthritis Cartilage 2015;23(11): 1966-71">1</a> </h4> <ul> <li>Primære, eller sekundære til knæskade </li> <li>Smerter i knæet ved og efter belastning, startsmerter kan være fremtrædende. Hvilesmerter og natlige smerter ses ved fremskreden sygdom </li> <li>Der kan påvises hydartron, låsninger i knæet </li> <li>Medial artrose er hyppigere end lateral <ul> <li>Varusdeformitet kan forekomme ved medial artrose </li> <li>Valgusdeformitet kan forekomme ved lateral artrose</li> </ul> </li> <li>Røntgen af knæet giver diagnosen artrose</li> </ul> <h4> <a href="~/link.aspx?_id=1FB7C3A0532247DFB565FF6E022EC89F&_z=z">Patellofemoral artrose</a> </h4> <ul> <li>Almindelig ved alder over 40 år </li> <li>Smerter fortil i knæet som fremprovokeres ved gang opad og nedad bakker, samt ved at sidde med knæet bøjet</li> </ul> <h4> <a href="~/link.aspx?_id=7ABAD738D35E4753AD6FFAF512DA3AFD&_z=z">Osteochondritis dissecans</a></h4> <ul> <li>Subkondral knoglefragment med tilhørende brusk løsner fra ledfladen og danner et frit legeme i ledhulen (mus) </li> <li>Tilstanden kan ramme mange led, men er hyppigst i knæet (75 %) </li> <li>Patienterne er som regel mellem 12 og 20 år </li> <li>Rammer oftest meget idrætsaktive børn og unge</li> <li>Patienten oplever aflåsningstilfælde, knæsmerter, følelse af knæsvigt, hævelse</li> <li>Diagnose stilles ved MR scanning</li> <li>Mistanke om diagnosen skal anføres på røntgenrekvisition mhp. "musebillede"</li> </ul> <h4>Ligamentskader</h4> <ul> <li>Skade på korsbånd (<a href="~/link.aspx?_id=31F9C6A28890445699188E01DB594781&_z=z">forreste</a>, <a href="~/link.aspx?_id=4B554278A79E44D79F2886879D8340D6&_z=z">bagerste</a>) og sidebånd (<a href="~/link.aspx?_id=9420D9657893433B8111575746FEFE68&_z=z">laterale</a>, <a href="~/link.aspx?_id=DA3912A90F2E435AA19D76D8A598C79A&_z=z">mediale</a>) er almindelige idrætsskader </li> <li>Smerte og følelse af at knæet svigter efter kendt traume, ofte med rotation på låst fod </li> <li>Instabilitet kan ofte påvises med forskellige kliniske test </li> <li>MR-scanning eller artroskopi bekræfter diagnosen </li> </ul> <h4>Andre årsager</h4> <ul> <li>Traume og frakturer </li> <li>Muskelsenerupturer </li> <li>Forskellige tendinitter og bursitter </li> <li>Artritter </li> <li>Tumores </li> <li> <a href="~/link.aspx?_id=CE4CD19F704045BCA94389A5385DB2A8&_z=z">Vokseværk</a></li> </ul> <h3>Forreste knæsmerter</h3> <h4> <a href="~/link.aspx?_id=91264DC3F44944CE80E4D1D28E14FE76&_z=z">Patellatendinit (patella periostit)</a> </h4> <ul> <li>Relativt almindelig hos idrætsfolk, specielt i idræt hvor hop og spring er almindelig, som atletik, fodbold, basketball, volleyball og alpint skiløb </li> <li>Gradvis tiltagende smerter lokaliseret til patellas nedre pol, mindre hyppigt til den øvre pol <ul> <li>Fremprovokeres af aktivitet, gang op ad trapper, rejsning fra en stol og fra hugsiddende stilling </li> <li>Forsvinder i hvile</li> </ul> </li> <li>Normalt ømhed ved patellas nedre (evt. øvre) pol, evt. også senefortykkelse </li> <li>Isometrisk ekstension er positiv, giver smerter </li> <li>Ultralydsscanning er bedste billeddiagnostiske modalitet</li> </ul> <h4> <a href="~/link.aspx?_id=44A9335675024C01914A956FF40C0A75&_z=z">Patellofemoralt smertesyndrom</a> </h4> <ul> <li>Eksklusionsdiagnose med forreste knæsmerter uden pato-anatomiske fund </li> <li>Meget almindelig tilstand, især blandt idrætsaktiv ungdom og motionister i alle aldre</li> <li>Patofysiologisk årsag er usikker og omdiskuteret </li> <li>Habituel patellaluksation og svaghed i vastus medialis kan disponere til tilstanden, f.eks. efter en knæskade med hydartron </li> <li>Forreste knæsmerter, stivhed, låsningstendens og følelse af at knæet kan svigte <ul> <li>Smerterne er værst ved gang op og ned af trapper og bakker, ved hugsiddende stilling og ved rejsning efter langvarig siddende stilling (biograf syndrom)</li> </ul> </li> <li>Ofte få kliniske fund; i de fleste tilfælde let quadricepsatrofi og kraftnedsættelse (sekundær), af og til krepitationer ved fleksion og ekstension, og følelse af låsning</li> </ul> <h4>Patella instabilitet</h4> <ul> <li>Tilbagevendende (recidiverende) <a href="~/link.aspx?_id=6E86B798A51F41E3A88A9B31E4F8976B&_z=z">luksation af patella</a>, næsten altid lateralt, som opstår ved aktiviteter med vrid af knæet</li> <li>Skyldes primært dysplasia i patellofemoral leddet kombineret med hypermobilitet og højtstående patella (Patella Alta)</li> </ul> <h4> <a href="~/link.aspx?_id=79E5B3CB1017436C8E88340305A546E9&_z=z">Knæbursit</a> </h4> <ul> <li>Præpatellar og infrapatellar bursit er hyppigst </li> <li>Årsagsmekanismen er ofte langvarigt knæliggende arbejde, som skuring og polering af gulv, eller evt. et enkelttraume </li> <li>Hævelse, ømhed, varme og rødme foran eller nedenfor patella <ul> <li>Begrænset fleksion på grund af smerte </li> <li>Øm, fortykket bursa hvis kronisk</li> </ul> </li> <li>Aspiration kan bekræfte og skelne diagnosen fra septisk bursit </li> <li>Den vigtigste differentialdiagnose er ansamling og infektion i selve knæleddet</li> </ul> <h4>Traktions apofysitis</h4> <ul> <li>Osteokondroser </li> <li>Traktionsapofysitis på henholdsvis tuberositas tibiae (<a href="~/link.aspx?_id=C7C444B82BE44C7BB92EA22FF337EEEA&_z=z">Osgood-Schlatters</a> sygdom) og apex patellae (<a href="~/link.aspx?_id=B01D8B5825074615AF19FA2EB7CE86C0&_z=z">Sinding-Larsens sygdom</a>) </li> <li>Osgood-Schlatters sygdom optræder i 10-15 års alderen, Sinding-Larsens sygdom nogle år tidligere. Begge sygdomme er hyppigere hos drenge end hos piger </li> <li>Aktivitetsrelaterede smerter i de angivne områder </li> <li>Tuberositas tibiae eller apex patellae er palpationsøm, og der foreligger ofte hævelse </li> <li>Røntgen af knæet bekræfter diagnosen</li> </ul> <h4> <a href="~/link.aspx?_id=1EBD426D921244BBB95D80384151BC23&_z=z">Todelt patella</a> (Patella bipartitia)</h4> <ul> <li>Nogle patellae har et separat fragment i det superolaterale hjørnet, ofte bilateralt </li> <li>Tilstanden giver hos nogle forreste knæsmerter </li> <li>Røntgen kan bekræfte diagnosen</li> </ul> <h3>Laterale, mediale og bagerste knæsmerter</h3> <h4><a href="~/link.aspx?_id=86801C3859394AA28C52056243376B8F&_z=z">Anserinus tendinit</a> </h4> <ul> <li>Hyppigst hos midaldrende og ældre, men ses også hos idrætsfolk </li> <li>Ofte traume eller uvant langvarig belastning fortil i knæet </li> <li>Subakutte eller akutte, intense værkende smerter bagtil og medialt på knæet </li> <li>Lokaliseret ømhed over sene og bursa, af og til med hævelse</li> </ul> <h4> <a href="~/link.aspx?_id=F0FEB09C89344B52AF0D4BD8BC71C87D&_z=z">Meniskdegeneration</a> </h4> <ul> <li>Regulære skader på menisken ses primært hos voksne sportsudøvere</li> <li>Hos 30-50 årige vil skader kunne opstå ved mindre traume, da vævet ikke har samme elasticitet og styrke </li> <li>Akutte eller subakutte smerter, følelse af knæsvigt og tendens til låsning, recidiverende hydartron </li> <li>Positive meniskprovokationstest, ømhed lateralt eller medialt langs ledlinjen </li> <li>MR scanning er bedst til at bekræfte diagnosen</li> </ul> <h4> <a href="~/link.aspx?_id=A6D988B893B24EE883F68BEE2D0EBC55&_z=z">Langdistanceknæ</a> </h4> <ul> <li>Tractus iliotibialis friktionssyndrom (Runner's knee) </li> <li>Inflammation af bursaen under tractus iliotibialis ved den laterale femurkondyl </li> <li>Almindeligst hos langdistanceløbere </li> <li>Tilstanden giver laterale knæsmerter efter kort tids løb </li> <li>Lokaliseret ømhed</li> </ul> <h4> <a href="~/link.aspx?_id=718D9D615421410D88FF5AC04EDCE26C&_z=z">Popliteustendinit</a> </h4> <ul> <li>Årsagen er usikker men kan muligvis skyldes hyperpronation af foden ved løb </li> <li>Tilstanden giver bagerste knæsmerter </li> <li>Ømhed ved palpation af popliteussenen </li> </ul> <h4> <a href="~/link.aspx?_id=2CEE72AC17744091A46C4235932C4A5E&_z=z">Popliteacyste (Bakercyste)</a> </h4> <ul> <li>Forstørret bursa bagtil i knæleddet </li> <li>Associeret med inflammatoriske tilstande i knæleddet, patienter med <a href="~/link.aspx?_id=939AB6BE2EA74C2890648DEA4AF5E6C6&_z=z">RA</a> stærkt overrepræsenteret </li> <li>Ruptur af cysten kan give pludselige stærke smerter i knæhasen, som kan minde om DVT (dyb venetrombose) </li> <li>Palpation af fluktuerende hævelse i knæhasen </li> <li>Ultralyd kan bekræfte diagnosen, men giver sjældent den bagvedliggende årsag, som hos voksne ofte er intraartikulær </li> <li>Hos børn forsvinder cysten oftest af sig selv</li> </ul> <h4>Andre årsager til knæsmerter</h4> <ul> <li> <a href="~/link.aspx?_id=BA77007FD5454D78BF5B5701D82C0135&_z=z">Iskias</a> <ul> <li>L4-affektion; forreste knæsmerter </li> <li>L5-S1-affektion; bageste knæsmerter</li> </ul> </li> <li>Hoftelidelser <ul> <li>Hofteleddet er innerveret af L3, og overført smerte vil lokaliseres på de forreste mediale dele af låret ned mod knæet</li> </ul> </li> </ul> <h2>Sygehistorie</h2> <h3>Generelt</h3> <h4>Har du tidligere været udsat for skader, fald eller skader?</h4> <ul> <li>Ja, tænk <ul> <li>Ligamentskader </li> <li>Meniskskader </li> <li>Sekundær artrose</li> </ul> </li> <li>Nej, tænk <ul> <li>Overbelastningsproblem <ul> <li>Bursit </li> <li>Tendinit </li> <li>Patellofemorale smerter</li> </ul> </li> <li>Artrose </li> <li>Artrit </li> <li>Svulst</li> </ul> </li> </ul> <h4>Har du knæliggende arbejde?</h4> <ul> <li>Tænk knæbursit</li> </ul> <h4>Har du fritidsaktiviteter som boldspil eller løb?</h4> <ul> <li>Vurder <ul> <li>Ligamentskader </li> <li>Meniskskader </li> <li>Belastningsskader</li> </ul> </li> </ul> <h4>Har du smerter i andre led end i knæet?</h4> <ul> <li>Artrit </li> <li>Artrose</li> </ul> <h4>Er det nogen i din slægt som har reumatiske sygdomme (leddegigt)?</h4> <ul> <li>Artrit</li> </ul> <h4>Har du selv haft reumatiske sygdomme eller andre sygdomme?</h4> <ul> <li>Kortlægge risikofaktorer for krystalartrit </li> <li>Reaktiv artrit </li> <li>Sygehistorie med forudgående uretrit, vaginit, eller halsinfektion og/eller konjunktivit og ledsmerter</li> </ul> <h4>Er det vanskeligt at gå op og ned ad trapper?</h4> <ul> <li>Ofte patellofemorale smerter</li> </ul> <h4>Er det vanskelig at hoppe?</h4> <ul> <li>Patellartendinit</li> </ul> <h4>Aktivitetsrelaterede smerter som forsvinder i hvile hos børn mellem 10 og 15 år?</h4> <ul> <li>Osteokondrodritis dissecans</li> <li>Patellofemorale smerter</li> </ul> <h4>Har du andre symptomer?</h4> <ul> <li>Hævelse, stivhed</li> </ul> <h3>Knæskade</h3> <h4>Har du været udsat for en knæskade eller et fald?</h4> <ul> <li>Tyder på ligamentskade eller meniskskade </li> <li>Patienterne husker som regel skadetidspunktet ved en ligamentskade, men ikke ved en meniskskade</li> </ul> <h4>Var det en ikke-kontakt skade?</h4> <ul> <li>Ofte er forreste korsbånd eneste skadede ligament</li> </ul> <h4>Var det en kontaktskade?</h4> <ul> <li>Mulig multiligamentskade, tænk <ul> <li>Forreste korsbånd og mediale kollaterale ligament </li> <li>Forreste korsbånd og laterale kollateralligament </li> <li>Begge korsbånd og et af kollateralligamenterne</li> </ul> </li> </ul> <h4>Følte eller hørte du et smæld?</h4> <ul> <li>Forekommer ofte ved forreste korsbåndskade</li> </ul> <h4>Hvor lang tid tog det, før hævelsen kom?</h4> <ul> <li>Ved forreste korsbåndskade sker det indenfor få timer </li> <li>Ved meniskskade sker det gerne over natten</li> </ul> <h4>Låser knæet sig?</h4> <ul> <li>Ægte låsning skyldes løse legemer i ledhulen <ul> <li>Meniskskader (buckethandle menisklæsion)</li> <li>Osteochondritis dissecans </li> <li>Korsbåndskader</li> </ul> </li> <li>Pseudolåsninger <ul> <li>Svær hydrops </li> <li>Smertefulde tendinitter </li> <li>Muskelspasmer</li> </ul> </li> <li>Følelse af låsning <ul> <li>Osteochondritis dissecans </li> <li>Patellofemoral artralgi</li> </ul> </li> </ul> <h4>Spænder knæet?</h4> <ul> <li>Uspecifik oplysning <ul> <li>Quadricepssvaghed </li> <li>Løst legeme </li> <li>Ligamentinstabilitet </li> <li>Patellaluksation </li> <li>Smerteudløst</li> </ul> </li> </ul> <h4>Er det svært at springe til siden?</h4> <ul> <li>Forreste korsbåndsinstabilitet</li> </ul> <h4>Er det vanskeligt at sidde på hug?</h4> <ul> <li>Meniskskade </li> <li>Artrose</li> </ul> <h4>Hvor gør det ondt?</h4> <ul> <li>Mediale ledlinje <ul> <li>Skade af mediale menisk </li> <li>Medial artrose</li> </ul> </li> <li>Mediale kollaterale ligament <ul> <li>Skade af ligamentet</li> </ul> </li> <li>Mediale tibia <ul> <li>Anserinustendinit eller -bursit</li> </ul> </li> <li>Laterale ledlinje <ul> <li>Lateral meniskskade </li> <li>Lateral kollateralbåndskade </li> <li>Langdistanceknæ</li> </ul> </li> <li>Popliteustendinit</li> </ul> <h2>Klinisk undersøgelse</h2> <h3>Generelt</h3> <ul> <li>Patienten skal være afklædt kun iført trusser, så bækkenhældning og lænd kan ses </li> <li>Patienten skal observeres, når han/hun går og står </li> <li>Det raske knæ bør undersøges først </li> <li>Sammenlign knæene </li> <li>Udeluk fraktur før stabiliteten testes ved akutte skader (anvend Knee-rules: Direkte patella og kaput fibula ømhed, manglende evne til at gå 4 skridt, alder over 55 år og manglende evne til at flektere over 90 grader skal udløse røntgen af knæ)</li> </ul> <h3>Specielt</h3> <h4>Inspektion</h4> <ul> <li>Gående <ul> <li>Se efter halten </li> <li>Fodstilling og fodafvikling</li> </ul> </li> <li>Stående <ul> <li>Tegn til seneruptur, ændringer i konfiguration? </li> <li>Fodstilling</li> </ul> </li> <li>Siddende <ul> <li>Vurder patellas position</li> </ul> </li> <li>Liggende <ul> <li>Se efter muskelatrofi, rødme, hævelse</li> </ul> </li> </ul> <h4>Palpation</h4> <ul> <li>Temperatur <ul> <li>Tegn til øget varme?</li> </ul> </li> <li>Hævelse <ul> <li>Vurder konsistens - knogle, bløddele, væske?</li> </ul> </li> <li>Ømhed <ul> <li>Vurder patella, ledlinjer, periartikulært</li> </ul> </li> </ul> <h4>Test, oversigt<a href=" " data-type="journal-reference" data-value="Lubowitz JH, Bernardini BJ, Reid JB 3rd., Current concepts review: comprehensive physical examination for instability of the knee. Am J Sports Med 2008;36(3): 577-94" data-value-piped="Lubowitz JH, Bernardini BJ, Reid JB 3rd.|Current concepts review: comprehensive physical examination for instability of the knee|Am J Sports Med|2008|36(3)|577-94" data-url="reference-link" title="Lubowitz JH, Bernardini BJ, Reid JB 3rd., Current concepts review: comprehensive physical examination for instability of the knee. Am J Sports Med 2008;36(3): 577-94">2</a></h4> <ul> <li>Fleksion og ekstension <ul> <li>Normalt kan knæet flekteres 135-145 grader fra fuld ekstension</li> </ul> </li> <li>Hyperekstension <ul> <li>5-10 grader fra retstilling er almindelig</li> </ul> </li> <li> <a href="~/link.aspx?_id=6D3C4FFA8F3B43519BE1BA2333ED26C6&_z=z">Korsbånd</a> <ul> <li>Lachmans test (forreste korsbånd)</li> <li>Pivot shift </li> <li>Bagerste skuffetest (bagerste korsbånd)</li> </ul> </li> <li>Kollateralligamenter <ul> <li><a href="~/link.aspx?_id=E6AB24834CC644928EEAB2D18537A3AF&_z=z">Sidestabilitet</a></li> </ul> </li> <li>Menisker <ul> <li><a href="~/link.aspx?_id=6628DF904B7A4790B4B11125020B0677&_z=z">Menisk provokationstest</a> </li> <li>Generelt vurderes testene som positive ved smerteangivelse<strong></strong></li> </ul> </li> </ul> <h4>Menisklæsion</h4> <ul> <li><a href="~/link.aspx?_id=6628DF904B7A4790B4B11125020B0677&_z=z">McMurrays test</a><br> <ul> <li>Under vridning/rotation og samtidig fleksion/ekstension af knæet kan den skadede menisk afklemmes med smerte eller klik til følge</li> </ul> </li> <li><a href="~/link.aspx?_id=6628DF904B7A4790B4B11125020B0677&_z=z">Thessaly test</a><br> <ul> <li>Undersøgeren støtter patienten ved at holde patientens udstrakte hænder, mens patienten står på en ben og roterer i knæet indad og udad 3 gange, mens knæet holdes flekteret 20° </li> <li>I et studie fandt man, at sensitivitet var 89 %, og specificitet var 97 % for mediale meniskskader, og tilsvarende 92 % og 96 % for laterale meniskskader<a href=" " data-type="journal-reference" data-value="Olsen OE, Myklebust G, Engebretsen L, Holme I, Bahr R, Exercises to prevent lower limb injuries in youth sports: cluster randomised controlled trial.. BMJ 2005;330: 449" data-value-piped="Olsen OE, Myklebust G, Engebretsen L, Holme I, Bahr R|Exercises to prevent lower limb injuries in youth sports: cluster randomised controlled trial.|BMJ|2005|330|449|15699058" data-url="reference-link" data-pubmedid="15699058" title="Olsen OE, Myklebust G, Engebretsen L, Holme I, Bahr R, Exercises to prevent lower limb injuries in youth sports: cluster randomised controlled trial.. BMJ 2005;330: 449">3</a> </li> </ul> </li> </ul> <h4>Ruptur af forreste korsbånd<a href="EditorPage.aspx?da=core&id=%7BF2C8E77F-2902-423D-8C07-0B3C91AEEBE6%7D&ed=FIELD1004023341&vs&la=da&fld=%7B850D32D3-55A1-49E4-9CDF-F0C88D91563C%7D&so=%2Fsitecore%2Fsystem%2FSettings%2FHtml%20Editor%20Profiles%2FRich%20Text%20LHPH&di=0&hdl=H1004023397&us=sitecore%5Cmacl&mo&pe=0&fbd=1" data-type="journal-reference" data-value="Lubowitz JH, Bernardini BJ, Reid JB 3rd., Current concepts review: comprehensive physical examination for instability of the knee. Am J Sports Med 2008;36(3): 577-94" data-value-piped="Lubowitz JH, Bernardini BJ, Reid JB 3rd.|Current concepts review: comprehensive physical examination for instability of the knee|Am J Sports Med|2008|36(3)|577-94" data-url="reference-link" title="Lubowitz JH, Bernardini BJ, Reid JB 3rd., Current concepts review: comprehensive physical examination for instability of the knee. Am J Sports Med 2008;36(3): 577-94">2</a></h4> <ul> <li><a href="~/link.aspx?_id=6D3C4FFA8F3B43519BE1BA2333ED26C6&_z=z">Lachmans test</a><br> <ul> <li>Med knæet 20-30 grader flekteret trækkes tibia fremad i forhold til femur <ul> <li>Både translation og kvalitet i stop vurderes </li> </ul> </li> </ul> </li> <li> <ul> </ul> <a href="~/link.aspx?_id=6D3C4FFA8F3B43519BE1BA2333ED26C6&_z=z">Pivot shift-test</a><br> <ul> <li>Knæet flekteres til 50 grader, hvor der holdes på fod og proximalt på crus, der påvirkes med mindre indadrotation og valgus belastning. Herefter ekstenderes langsomt. Ved positiv test ses og fornemmes pludselig posterior subluksation ved 10-12 grader ekstension</li> </ul> </li> </ul> <h4>Ruptur af bagre korsbånd<a href="EditorPage.aspx?da=core&id=%7BF2C8E77F-2902-423D-8C07-0B3C91AEEBE6%7D&ed=FIELD1004023341&vs&la=da&fld=%7B850D32D3-55A1-49E4-9CDF-F0C88D91563C%7D&so=%2Fsitecore%2Fsystem%2FSettings%2FHtml%20Editor%20Profiles%2FRich%20Text%20LHPH&di=0&hdl=H1004023397&us=sitecore%5Cmacl&mo&pe=0&fbd=1" data-type="journal-reference" data-value="Lubowitz JH, Bernardini BJ, Reid JB 3rd., Current concepts review: comprehensive physical examination for instability of the knee. Am J Sports Med 2008;36(3): 577-94" data-value-piped="Lubowitz JH, Bernardini BJ, Reid JB 3rd.|Current concepts review: comprehensive physical examination for instability of the knee|Am J Sports Med|2008|36(3)|577-94" data-url="reference-link" title="Lubowitz JH, Bernardini BJ, Reid JB 3rd., Current concepts review: comprehensive physical examination for instability of the knee. Am J Sports Med 2008;36(3): 577-94">2</a></h4> <ul> <li>Bagerste skuffetest <ul> <li>Med knæet 90 grader flekteret undersøges, om tibia kan presses bagud i forhold til femur, således at det normale anteromediale tibia-"step-off" (afstanden mellem tibias forkant og mediale femurkondyl i sagittalplanet) reduceres eller ikke mere kan palperes </li> </ul> </li> <li>Tyngdekraft tegn, gravity eller Sag sign <ul> <li>Med knæet i 90 graders fleksion synker tibia bagover pga. tyngdekraften. Sag-tegn</li> </ul> </li> <li>Ekstern rotation recurvatum-test <ul> <li>Tibia udadroteres, og knæet strækkes maksimalt </li> <li>Ved ruptur kan ses recurvatium-fænomen, dvs. overstrækning med bagudglidning af tibia og samtidig tibia vara</li> </ul> </li> </ul> <h4>Ruptur af mediale kollaterale ligament<a href="EditorPage.aspx?da=core&id=%7BF2C8E77F-2902-423D-8C07-0B3C91AEEBE6%7D&ed=FIELD1004023341&vs&la=da&fld=%7B850D32D3-55A1-49E4-9CDF-F0C88D91563C%7D&so=%2Fsitecore%2Fsystem%2FSettings%2FHtml%20Editor%20Profiles%2FRich%20Text%20LHPH&di=0&hdl=H1004023397&us=sitecore%5Cmacl&mo&pe=0&fbd=1" data-type="journal-reference" data-value="Lubowitz JH, Bernardini BJ, Reid JB 3rd., Current concepts review: comprehensive physical examination for instability of the knee. Am J Sports Med 2008;36(3): 577-94" data-value-piped="Lubowitz JH, Bernardini BJ, Reid JB 3rd.|Current concepts review: comprehensive physical examination for instability of the knee|Am J Sports Med|2008|36(3)|577-94" data-url="reference-link" title="Lubowitz JH, Bernardini BJ, Reid JB 3rd., Current concepts review: comprehensive physical examination for instability of the knee. Am J Sports Med 2008;36(3): 577-94">2</a></h4> <ul> <li><a href="~/link.aspx?_id=E6AB24834CC644928EEAB2D18537A3AF&_z=z">Valgusløshed</a><br> <ul> <li>Undersøges dels på strakt og dels på 20 grader flekteret knæ <ul> <li>Positiv valgus-test nær fuld ekstension tyder yderligere på posteromedial kapselskade </li> <li>Positiv valgus-test i fuld ekstension tyder på samtidig skade af forreste korsbånd</li> </ul> </li> </ul> </li> </ul> <h4>Ruptur af laterale kollaterale ligament (og posterolaterale kapselhjørne)<a href="EditorPage.aspx?da=core&id=%7BF2C8E77F-2902-423D-8C07-0B3C91AEEBE6%7D&ed=FIELD1004023341&vs&la=da&fld=%7B850D32D3-55A1-49E4-9CDF-F0C88D91563C%7D&so=%2Fsitecore%2Fsystem%2FSettings%2FHtml%20Editor%20Profiles%2FRich%20Text%20LHPH&di=0&hdl=H1004023397&us=sitecore%5Cmacl&mo&pe=0&fbd=1" data-type="journal-reference" data-value="Lubowitz JH, Bernardini BJ, Reid JB 3rd., Current concepts review: comprehensive physical examination for instability of the knee. Am J Sports Med 2008;36(3): 577-94" data-value-piped="Lubowitz JH, Bernardini BJ, Reid JB 3rd.|Current concepts review: comprehensive physical examination for instability of the knee|Am J Sports Med|2008|36(3)|577-94" data-url="reference-link" title="Lubowitz JH, Bernardini BJ, Reid JB 3rd., Current concepts review: comprehensive physical examination for instability of the knee. Am J Sports Med 2008;36(3): 577-94">2</a></h4> <ul> <li><a href="~/link.aspx?_id=E6AB24834CC644928EEAB2D18537A3AF&_z=z">Varusløshed</a><br> <ul> <li>Undersøges dels på strakt og dels på 20 grader flekteret knæ</li> </ul> </li> <li>Posterolateral eksternal rotations-test <ul> <li>Med knæet flekteret 90 grader roteres tibia udad og skubbes frem og tilbage, mens det registreres om tibia bevæger sig unormalt meget i forhold til femur</li> </ul> </li> </ul> <h2>Supplerende undersøgelser</h2> <h3>I almen praksis</h3> <h4>Blodprøver</h4> <ul> <li>Ekskludere reumatiske lidelser og septisk artrit <ul> <li>SR, CRP, LD (Leukocyt- og diff tælling), rheumaserologi</li> </ul> </li> </ul> <h4>Ledpunktur</h4> <ul> <li>Med aspiration af ledvæske under streng hygiejne ved hydartron </li> <li>Se efter bakterier, leukocytter, krystaller mv.</li> </ul> <h3>Andre undersøgelser</h3> <h4>Røntgenundersøgelser</h4> <ul> <li>Er ikke rutinemæssig indiceret ved fravær af låsning eller bevægelses indskrænkninger </li> <li>Kan afdække artrose, brud, aksetilstande (varus, valgus), frit knoglesegment </li> <li>Hos børn bør man også rekvirere røntgenundersøgelse af hofter ved knæsmerter</li> <li>På mistanke og artrose skal røntgen foretages før MR scanning</li> </ul> <h4>MR-scanning</h4> <ul> <li>Kan give god information om alle former for bløddelspatologi </li> <li>Kan være nyttigt præoperativt når man vurderer, hvad der skal foretages af artroskopiske procedurer</li> <li>Tilstande som kræver kirurgisk intervention</li> <li>Uklare langvarige symptomatiske tilstande hvor hverken klinisk vurdering eller MR scanning har givet diagnose</li> </ul> <h2>Tiltag og råd</h2> <h3>Henvisninger</h3> <ul> <li>Akut henvisning til ortopædkirurg ved mistanke om infektion eller brud</li> <li>Subakut henvisning ved mistanke om instabilitet eller ved aflåsning</li> </ul> <h3>Klinisk retningslinje</h3> <ul> <li>National klinisk retningslinje - "<a href="https://www.sst.dk/da/nyheder/2016/ny-national-klinisk-retningslinje-for-meniskskader-i-knaeet">Retningslinje for meniskskade i knæet</a>", Sundhedssstyrelsen</li> </ul> <h3>Råd </h3> <ul> <li>Ofte behov for aflastning fra uhensigtsmæssige arbejds- og sportsbelastninger</li> <li>Instruktion om quadricepsøvelser </li> <li>Smertestillende middel <ul> <li>[DliActiveSubstance;6381;Paracetamol] er oftest førstevalg, evt. <a href="http://pro.medicin.dk/Laegemiddelgrupper/Grupper/213010">NSAID</a></li> </ul> </li> <li>Vægtreduktion ved overvægt </li> <li>Kontrol <ul> <li>Aftal kontrol 1-2 uger efter knæskader for evt. ny vurdering af ligamenter og menisker</li> </ul> </li> <li>Forebyggelse <ul> <li>Et struktureret program for opvarmningsøvelser har vist at kunne forebygge knæ- og ankelskader blandt unge mennesker som dyrker idræt<a href=" " data-type="journal-reference" data-value="Olsen OE, Myklebust G, Engebretsen L, Holme I, Bahr R, Exercises to prevent lower limb injuries in youth sports: cluster randomised controlled trial. BMJ 2005;330: 449" data-value-piped="Olsen OE, Myklebust G, Engebretsen L, Holme I, Bahr R|Exercises to prevent lower limb injuries in youth sports: cluster randomised controlled trial.|BMJ|2005|330|449|15699058" data-url="reference-link" data-pubmedid="15699058" title="Olsen OE, Myklebust G, Engebretsen L, Holme I, Bahr R, Exercises to prevent lower limb injuries in youth sports: cluster randomised controlled trial. BMJ 2005;330: 449">4</a></li> </ul> </li> </ul> <h2>Illustrationer</h2> <h3>Billeder</h3> <ul> <li> <a href="~/link.aspx?_id=B5D70A93124A4AF9900236407A542F33&_z=z">Knæ, normalbillede, rtg. front</a> </li> <li> <a href="~/link.aspx?_id=0B16EB31CCDF4AEDA756590C6BE5B352&_z=z">Knæ, normalbillede, rtg. side</a> </li> </ul> <h3>Plancher eller tegninger</h3> <ul> <li> <a href="~/link.aspx?_id=3CB8CB200E74425886B51B853CBCDA78&_z=z">Korsbånd, tegning</a> </li> <li> <a href="~/link.aspx?_id=FBAC6CE005CF4F7695CFFD3FCE8C2F4E&_z=z">Mediale kollateralligament, tegning</a> </li> <li> <a href="~/link.aspx?_id=090B5530022A474D93B1210958779BD0&_z=z">Menisker</a> </li> </ul> <h2>Patientinformation</h2> <h3>Hvad du bør informere patienten om</h3> <ul> <li>Lægens arbejdshypoteser </li> <li>Hvilke aktiviteter patienten bør afstå fra </li> <li>Hvilke bevægelser og aktiviteter som er gunstige </li> <li>Omtrentlig ventetid ved evt. henvisning eller rekvirering</li> <li>Se <a href="~/link.aspx?_id=C73B900DE9C446C7A5A0A612CD36960C&_z=z">film med øvelser for knæ</a></li> </ul> <h3>Træningsfilm for knæet</h3> <ul> <li><a href="~/link.aspx?_id=F8EA408AB9F34E268A9A6A0FDA9E796E&_z=z">Øvelsesprogram, 3 øvelser</a><br> <br> <a href="~/link.aspx?_id=C73B900DE9C446C7A5A0A612CD36960C&_z=z"><img alt="" src="AEEAFCA4C1CF41FBB5EF216AC4268EA8-135-84" style="height: 84px; width: 135px;" height="84" width="135"></a></li> </ul> <ul> <li><a href="~/link.aspx?_id=D7AA1E606E0843E7829CD08F050580B5&_z=z">Øvelsesprogram, 3 øvelser med arabisk tale - فيديوهات تمارين رياضية باللغة العربية</a><br> <br> <a href="~/link.aspx?_id=7AF5525A96704D8985657CA6EB334FD7&_z=z"><img alt="" height="84" width="135" src="985525327CA5433980B8954F35E047EA-135-84" style="height: 84px; width: 135px;"></a></li> </ul>]]></HtmlField> <HtmlField Name="PageReferences"><![CDATA[<div> </div>]]></HtmlField> <LinkListField Name="Spot2"> <LinkField 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]]></Media> 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