Bones made up of four main bones- femur, tibia, fibula & patella The main movements of the knee joint occur between the femur, patella & tibia. Joints.. - 3 joints within a single synovial cavity :
1) Patellofemoral joint -Between patella & the patellar surface of femur -Planar joint (gliding)
- aka tibiofemoral joint - Between femur & tibia - Hinge joint (uniaxial) Anatomical components of knee Components Capsule Ligaments Extracapsular Intracapsular Capsule Surrounds sides & posterior aspect of knee joint On each side of patella, the capsule is strengthen by tendons of vastus medialis & vastus lateralis Inside this capsule is synovial membrane which provides nourishment to all surrounding structures Extracapsular Ligaments Ligamentum patella Continuation of quadriceps femoris muscle
Oblique popliteal ligament Derived from semimembranosus muscle
Anterior cruciate ligament (ACL) Posterior cruciate ligament (PCL) Origin Lateral femoral condyle Medial femoral condyle Insertion Anterior intercondylar of tibia Posterior intercondylar of tibia Action Prevent posterior displacement of femur Knee flex: Prevent anterior displacement of tibia Prevent anterior displacement of femur (Main stabilizer for femur in weight bearing esp during walking down hill) Knee flex: Prevent posterior displacement of tibia Prevent hyperextension of knee Provide rotatory stability Resist excessive valgus and varus angulation Posterior view PCL Anterior view ACL double bundles - Anteromedial (AM) bundle prevent anterior displacement of tibia when knee flex - Posterolateral (PL) bundle tightens when knee extend
PCL double bundles - Anterolateral (AL) bundle prevent posterior displacement of tibia when knee near 90 flexion - Posteromedial (PM) bundle when knee extend
Meniscus
Fibrocartilage disc interposed in between femoral condyles and tibial plateaus. Have a triangular cross section thickest at the periphery tapering to a thin central edge
Functions - Load transmission - Shock absorption - Joint stability & lubrication - Control rolling & gliding actions of knee joint Zones 1. Red zone Meniscus base; in immediate contact with joint capsule
2. Red-white zone Intermediate meniscus region
3. White zone White fringes
-Vessels penetrate through red zone until central third of the meniscus (red-white)
-The white fringe indicates no vessels- nourished via joint fluid LATERAL MENISCUS MEDIAL MENISCUS
Circular C-shaped
More mobile - More likely to move dt loose peripheral attachment Less mobile - Less likely to move dt firm attachment to tibia and capsule via deep MCL
Less likely to tear More likely to tear Left knee Blood Supply of the Knee Femoral artery popliteal artery help to form arterial network surrounding the knee joint. 6 main branches:- 1. Descending genicular artery 2. Superior medial genicular artery 3. Inferior medial genicular artery 4. Superior lateral genicular artery 5. Inferior lateral genicular artery 6. Anterior recurrent tibial artery
The medial genicular arteries penetrate the knee joint.
Nerves of the Knee Femoral nerve Saphenous nerve
Sciatic nerve Tibial nerve Common peroneal nerve Superficial peroneal nerve Deep peroneal nerve Lateral view Patella Flat, triangular bone In front of the knee joint Sesamoid bone within tendon of quadriceps femoris Dense cancellous tissue, covered by a thin compact lamina Function : Protect the front of the joint Increase leverage of Quadriceps femoris by making it act at a greater angle Base Apex Articular surface Anterior surface Convex Numerous rough and longitudinal striae Covered by : an expansion from the tendon of quadriceps femoris which it continous below with the superficial fibers of ligamentum patellae Separated from integument by a bursa Posterior surface Smooth, oval, articular area divided into two facets by a vertical ridge : lateral and medial. the lateral facet is the broader and deeper. Below the articular surface is a rough, convex, non-articular area lower half : attachment to the ligamentum patellae upper half : separated from the head of the tibia by adipose tissue. Borders Superior border (base) : thick, and sloped from behind, downward, and forward attachment of the portion of the Quadriceps femoris which is derived from the Rectus femoris and Vastus intermedius. The medial and lateral borders are thinner and converge attachment of those portions of the Quadriceps femoris which are derived from the Vasti lateralis and medialis. Apex Pointed attachment of the ligamentum patellae KNEE INJURIES KNEE INJURIES PATELLA
PATELLA FRACTURE Patellar fracture I : Undisplaced crack fracture II : Displaced transverse fracture III : Comminuted (stellate) fracture Mechanism of Injury DIRECT FORCE (Fall onto knee / blow) Against dashboard of car : undisplaced crack or else a comminuted (stellate) fracture without severe damage to the extensor expansions.
INDIRECT FORCE (Traction force that pulls the bone apart and tears the extensor expansions) Someone catches the foot against solid obstacle & to avoid falling, contract the quadriceps muscle forcefully. transverse fracture with a gap between the fragments.
Clinical Features Knee becomes swollen and painful. May be an abrasion or bruising over the front of the joint. The patella is tender and sometimes a gap can be felt. Active knee extension should be tested. If there is an effusion, aspiration may reveal the presence of blood and fat droplets. If the patient can lift the straight leg, the quadriceps mechanism is still intact. If this maneuver is too painful, active extension can be tested with the patient lying on his side. X-ray Fracture with little or no displacement Severe comminutions Treatment I . Undisplaced or minimally displaced fractures Haemarthrosis should be aspirated. The extensor mechanism is intact and treatment is mainly protective. A plaster cylinder holding the knee straight for 34 weeks Quadriceps exercises are to be practiced every day.
II. Comminuted (stellate) fracture
Patella undersurface is irregular serious risk of damage patellofemoral joint Patellectomy Preserve the patella if the fragments are not severely displaced by applying backslab.
III. Displaced transverse fracture The lateral expansions are torn and the entire extensor mechanism is disrupted. Operation is essential. Patella repaired by the tension-band principle. The fragments are reduced and transfixed with two stiff K- wires; flexible wire is then looped tightly around the protruding K-wires and over the front of the patella. The tears in the extensor expansions are then repaired. A plaster backslab or hinged brace (until active extension of the knee is regained), removed every day to permit active knee-flexion exercises. Transfixed by K-wires Malleable wire is then looped around the protruding ends of the K-wires and tightened over the front of the patella. PATELLA TENDON INJURY Mainly occur in patient younger than 40 years old- athlete or non-athlete
Pain and tenderness in the middle of patellar ligament may occur in athletes- running and jumping sports
Previous history of local injection of cortocosteroid
History of: forceful contraction on a flexed knee (jump landing, weight lifting, stumbling)
Complain of: sudden pain on forced extension of the knee
Physical examination revealed hemarthrosis, proximally displaced patella, incomplete extensor function. Mechanism : Sudden resisted extension of the knee
Diagnosis by history, physical examination and radiological investigation. Lateral X-ray of the knee Normal lateral x-ray of knee with intact patella Lateral x-ray of knee with rupture of patellar tendon - high riding patella MRI : help to distinguish a partial from a complete tear Treatment Partial tears Apply plaster cylinder Complete tears Operative repair/ reattachment to the bone. Limits amount of flexion by using hinged brace for 6 weeks
PATELLA DISLOCATION Patella slips out of its normal position in the patellofemoral groove Knee is normally angled in slight valgus natural tendency for the patella to pull towards the lateral side when the quadriceps muscle contracts. Traumatic dislocation : severe contraction of the quadriceps muscle while the knee is stretched in valgus and external rotation Patella dislocates laterally and the medial retinacular fibres may be torn
Clinical features First-time dislocation : tearing sensation, feeling the knee has gone out of joint When running, collapse and fall to the ground Swelling in the knee joint Pain around the patella Impaired mobility in the knee Obvious displacement of the knee cap lateral side of the knee The top of the patella attaches to the quadriceps muscle via the quadriceps tendon,
the middle to the vastus medialis obliquus (VMO) and vastus lateralis muscles The bottom to the head of the tibia (tibial tuberosity) via the patellar tendon The medial patellofemoral ligament attaches horizontally in the inner knee to the adductor magnus tendon and is the structure most often damaged during a patellar dislocation. Finally, the lateral collateral and medial collateral ligaments stabilize the patella on either side. Predisposing Factors Young, female Athletic Population Patellar dislocation occurs in sports that involve rotating the knee. Direct trauma to the knee can knock the patella out of joint. Anatomical Factors Insufficient VMO strength - The VMO functions in maintaining the patella in its desired position within the patellofemoral groove during knee movements by pulling it towards the middle of the knee joint - an action known as 'tracking'. Q-angle - Larger than normal femoral angle (known as the Q-angle) and may have a 'knock-kneed' appearance (genu valgum). When the person straightens their leg, the patella will be forced to the outside of the knee. Thus any extra force applied to the inside of the knee may result in patellar dislocation. due to the central line of pull found in the quadriceps muscles that run from the anterior superior iliac spine to the center of the patella. Male < 15 Female < 20 > 25 high risk for patellar dislocation Treatment Conservative Pushed back patella into place. With knee straight, plaster backslab is applied for 3 weeks.
Operative When recurrent dislocations occur. To limit the amount of lost time in competition and to reduce the chances for cartilage lesions on the undersurface of the patella, which often are non-reparable, patellar stabilization procedures are appropriate. These procedures can be either soft tissue or bone procedures, or a combination thereof. First-time traumatic patellar dislocations can also be treated with procedures such as this, and in chosen situations doing so may be appropriate. Surgically treating those dislocations by lessening lateral tension and tightening medial restraint could reduce this recurrence rate Recurrent Dislocation 15-20 % patient treated conservatively will developed recurrent dislocation. Predisposing factors : Generalized joint laxity Marked genu valgum Unduly high patella DISLOCATION OF KNEE
Femur-tibia joint disrupted Cruciate ligaments & one/ both lateral ligaments are torn
Causes: Trauma distinguish between high velocity injuries & low velocity injuries (as this reflects incidence of vascular and nerve injuries); low-velocity: occurrence of vascular injury is about 5% and nerve injury is about 20% Class Anterior 31% Posterior 25% Lateral 13% Medial 3% Rotatory 4% 1. Positional classification (Kennedy) -based on position of displaced proximal tibia Anterior dislocation > 30 of hyperextension to produce this injury often PCL & ACL will both be torn either MCL or LCL or both will be injured
Posterior dislocation Anterior-to-posterior force on prox tibia (force on flexed knee, dashboard injury) possible extensor mechanism disruption A P P A A A P P Lateral dislocation Varus force
Medial dislocation Valgus force
Rotatory dislocation Rotatory force Usually posterolateral dislocation + dimple sign Often irreducible! Medial L L M M Lateral L L M M Dimple sign 2. Anatomical classification (Schenck; modified by Wascher) - Based on ligamentous injury involvement KD I Multiligamentous rupture with either cruciate intact KD II Bicruciate rupture with both collaterals intact (rare) KD IIIM Bicruciate and MCL rupture KD IIIL Bicruciate and LCL rupture KD IV Panligament rupture KD V Knee dislocation with periarticular fracture C (+ to above) Arterial injury included N (+ to above) Nerve injury included 1. Severe bruising 2. Gross deformity 3. Swelling 4. Pain 5. Immobility 6. Knee instability
Special test -to assess ligamentous injury *Pulse (DPA, PTA) -exclude popliteal artery involvement *Distal sensation & dorsiflexion exclude nerve injury Examine! 1. X-ray (AP & lateral view) - Dislocation - may show periarticular # - # of tibial spine (dt ligament avulsion)
2. Ankle-brachial pressure index (ABPI).. 3. Duplex US 4. CT angiography 5. Arteriogram
6. MRI assessment of which ligaments are intact determine whether ligament tears are midsubstance or are avulsions (off the femur or tibia)..
if doubt about circulation From A&E to ward mx
1) Reduction under anaesthesia (URGENT!) No pulse reduce immediately Has good peripheral pulse pre-reduction x-ray
2) Rest limb on backslab with knee flex in 15 To avoid re-dislocation
*No POP apply d/t swelling
3) If joint is unstable apply external fixator 4) Apply ice & elevate knee (to reduce oedema) 5) Post-reduction x-ray before assess for ligament injury 6) Admit ward & check circulation during 48 hours Operation if:
Open wound Vascular damage *Opportunity is taken to repair the ligaments and capsule; otherwise left undisturbed
Popliteal artery injury Peroneal nerve injury Open knee injury Compartment syndrome Acute Knee instability Joint stiffness Post-traumatic osteoarthritis Chronic ACUTE KNEE LIGAMENTS INJURY Anterior Cruciate Ligament Injury One of the most common knee injuries is an ACL sprain or tear Common in sports such as soccer, basketball and rugby About half of all injuries to the ACL occur along with damage to other structures in the knee, such as articular cartilage, meniscus or other ligaments
Non-contact Traumatic force during twisting motion in weight-bearing knee usually occurs when the athlete lands on the leg and quickly pivots in the opposite direction (landing from jump)
ACL: Mechanism of Injury Contact Blow to the lateral side of the extended knee esp at 0-30
Usually a/w unhappy triad of injuries: 1) MCL tear 2) Meniscus tear 3) ACL tear
Segond fracture - avulsion # of lateral aspect proximal tibial plateau PCL is approximately twice as strong and twice as thick as the normal ACL Therefore PCL is less commonly injured & an injury to PCL requires a powerful force Usually associated with ACL and collateral ligament injury (knee dislocation)
Posterior Cruciate Ligament Injury PCL: Mechanism of Injury Direct blow (anterior force) onto the lower leg when knee flexed
e.g. a bent knee hitting a dashboard in a car accident or a football player falling on a knee that is bent
Symptoms ACL injury PCL injury Has popping sound No popping sound Knee swelling (haemathrosis) will occur between 2-12 hours of injury Knee swelling (haemathrosis) within 3 hours of injury May/ may not has immediate pain at knee joint Pain at knee joint (common)
Instability sensation knee giving way Instability sensation knee giving way Discomfort when trying to put weight on injured leg Difficulty walking
Signs Examine ACL injured PCL injured LOOK Gross effusion (diffuse knee swelling) Knee swelling (mild) Skin changes (contussion) Positive posterior tibial sag sign FEEL Tenderness Tenderness MOVE Limited ROM (lack of complete extension) Usually full range of motion
SPECIAL TEST +ve anterior drawer test (AM bundle tear) +ve Lachman test (PL bundle tear) +ve posterior drawer test
Grading of injuries Grading of ACL tear (based on physical examination) Grade 1- 1-5 mm difference Grade 2- 6-10 mm difference Grade 3- 11-15 mm difference
Posterior sag sign Grade I -side-to-side asymmetry exists but tibial plateau is anterior to femoral condyles Grade II -tibial plateau is even with femoral condyles Grade III- tibial plateau falls behind the femoral condyles.
Investigation i. Plain x-ray of the knee to look for avulsion fracture
ii. Stress x-ray show whether the hinges open on one side (instability)
iii. MRI (90-98% sensitivity for ACL tear) differentiate partial & complete tears
iv. Arthroscopy for reconstruction of cruciate ligament tears Medial Collateral Ligament Injury Function of MCL resists widening of inside of the knee joint prevents the knee joint from medial instability (prevents valgus angulation of knee) MCL: Mechanism of Injury results of direct blow to lateral side of knee This pushes the knee inwards (toward the other knee) excessive valgus force applied to a partially flexed knee E.g. when a rugby player gets clipped on the outside of the leg, this opens the angle between the femur and tibia, stretching the MCL & leads to tear or complete rupture.
May be an isolated injury, or it may be part of a complex injury to the knee.
Lateral Collateral Ligament Injury Function of LCL prevents the knee joint from lateral instability (prevents varus angulation of knee)
LCL: Mechanism of Injury results of direct blow to medial side of knee.. occurs in sports that require a lot of quick stops & turns (e.g. soccer, basketball, skiing) or ones where there are violent collisions (e.g. football or hockey) greater force is required to rupture LCL than MCL often accompanied by other injuries; common peroneal nerve injury: it is near LCL- can be stretched during the injury or is pressed by swelling in the surrounding tissues rupture of the biceps femoris (hamstring) tendon Symptoms
MCL LCL SYMPTOMS Pain ranging from mild to severe (depending on how serious the injury) -Pain that can be mild or acute -Numbness or weakness in the foot if involve peroneal nerve -Stiffness -knee may give way under stress or may lock
SIGNS Swelling
Tenderness along inside of knee
Positive valgus stress test Swelling
Tenderness along outside of knee
Positive varus stress test
Investigation MCL LCL Plain knee x-ray -Calcified deposit seen on medial site of knee (Pellegrini-Steida syndrome)
Plain knee x-ray - Fibular head avulsion #
Stress knee x-ray -Complete tear of medial ligament Stress knee x-ray -Complete tear of lateral ligament
MRI MRI RICE method Used for acute soft tissue (sport) injury
Rest: vital to protect the injured muscle, tendon, ligament or other tissue from further injury and to promote effective healing.
Ice: Cold provides short-term pain relief & limits swelling by reducing blood flow to the injured area. (apply cold compresses for 15 min and then leave them off for the skin to re-warm)
Compression: helps limit & reduce swelling. Some people also experience pain relief from it.
Elevation: help to control swelling. It's most effective when the injured area is raised above the level of the heart. (if injury to ankle, pt lying on bed with foot propped on one or two pillows)
Management of Acute Ligament Injury Sprains and partial tears i. RICE method - Weight bearing is allowed with knee is protected from rotation or angulation strains by a heavily padded bandage or functional brace
ii. +/- aspirate haemarthrosis, NSAID
iii. Active exercise - to prevent adhesion during spontaneous healing (intact fibres splint the torn ones) Physiotherapy early ROM & strengthening of muscle that stabilizes knee jt Complete tears Isolated tears of PCL/ MCL/ LCL treated as above Isolated tears of ACL may be treated by early operative reconstruction if patient is professional sportsman
Avulsion # of tibial intercondylar eminence Reducible fragment & can fully extend knee immobilize in plaster cylinder for 6 weeks Irreducible or block to full extension open reduction & fixation (strong sutures/ small screws if physis has closed) + immobilize in plaster cylinder for 6 weeks
Joint bracing & physiotherapy to restore good ROM If involve ACL ACL reconstruction If involve PCL PCL reconstruction + repair all damage structures
MENISCAL INJURY Mechanism of Injury Meniscus been split in its length by a force grinding in between femur and tibia In young adults, usually due to rotational grinding force Weight is taken on flexed knee & theres twisting strain e.g. footballers flex and twist the knee + direct contact (tackle) leading to tear Middle-aged/ elderly often caused by stiffening and menisci fibrosis that has restricted mobility of the meniscus tear (even with little force) Medial meniscus is commonly affected than lateral meniscus. Medial meniscus attached to the capsule. This make it less mobile compared to lateral meniscus, thus it cannot easily accommodate to normal stresses.
TYPES OF TEAR Longitudinal or vertical (bucket- handle) Flap or oblique Radial or transverse Horizontal Complex degenerati on most common OA-changes associated Confined to centre; usually degenerative or due to repetitive minor trauma & some a/w meniscal cyst
Bucket-handle tear Split is vertical and runs along part of the circumference of the meniscus create loose slivers which is still attached anteriorly and posteriorly.
posterior anterior Longitudinal/ vertical tear Bucket-handle tear Handle displaced into intercondylar fossa (centre of the knee joint) jammed btwn femur-tibia block to extension (locked knee) A longitudinal tear is a vertical tear in the meniscus with a longitudinal direction, usually located in the periphery of the meniscus.
The longer the tear, the more unstable it is; leading to dislocation of the central part of the meniscus buckethandle tear.
Flap/ radial/ horizontal tears * A flap tear may also be caused by a horizontal tear A flap tear is an oblique vertical cleavage producing a flap (parrot beak) A radial tear is a vertical tear starting from inner free margin toward periphery Symptoms Young person twisting injury to knee on the sports field Pain severe & further activity is avoided Swelling (appears some hours later/ the next day) Knee is locked in partial flexion With rest, initial symptoms subside, only to recur periodically after trivial twists or strains Sometimes knee gives way spontaneously & again followed by pain & swelling locking -sudden inability to extend the knee fully but able to fully flex the knee suggest a bucket-handle tear -Patient sometimes learn to unlock the knee by bending fully or twisting it from side to side Patient > 40 yo initial injury maybe unremarkable chief complaint mainly recurrent giving way or locking Signs Joint held in flexed position Joint effusion Quadriceps muscle wasting (late presentations) Tenderness around joint line Flexion is full but extension is often slightly limited Positive McMurrays or Apleys Grinding Test.. Investigation X ray (usually normal) Arthroscopy Advantage in identifying & treating lesion at the same time MRI Most reliable to confirm dx Absent bow-tie sign May reveals tear that is missed by arthroscopy
Management Conservative management
If knee is not lock tear maybe at peripheral may heal spontaneously
Joint held straight in backslab for 3 to 4 weeks Physiotherapy Analgesics Activity modification
Operative management Surgery indicated if: a) the joint cannot be unlocked b) symptoms are recurrent
Tear close to periphery sutured (have capacity to heal) Tear other than peripheral third excise the torn portion
FRACTURE OF TIBIAL PLATEAU Tibial plateau is the top of the tibia that makes up part of the knee joint There are two bulges at the end of the tibia called lateral and medial condyles Anatomy of tibial plateau Causes of tibial plateau # Strong bending force combined with axial loads e.g. a car striking on a pedestrian (from knee side) aka bumper fracture; fall from a height in which the knee is forced into valgus or varus
One or both tibial condyles are crushed or split by opposing femoral condyle
Most commonly affect lateral tibial plateau due to: valgus alignment of lower extremity most injuring forces are directed laterally to medially
Clinical features Joint swollen & has doughy feel of heamarthrosis Diffuse tenderness on side of fracture site Diffuse tenderness on opposite site (if associated with ligament injury) Restricted movement or unable to bear weight
Investigation X-ray : multiple views to show true extent of the # Schatzker V tibial plateau fracture Schatzkers classification based on fracture pattern and fragment anatomy Treatment Principle: function is more important than pretty x-ray
Traction alone often produces a well-functioning knee
Undisplaced & minimally displaced lateral condyle # Aspirate haemarthrosis Apply compression bandage Knee movements as soon as pain & swelling subsided Hinge cast-brace * weight-bearing is not allowed for another 3 weeks Marked displaced &/or comminuted lateral condyle # Open reduction and internal fixation (lag screw & buttress plate) Elevate depressed area Bone grafting to support the reduction
Bicondylar # ORIF (combination of screw fixation and circular external fixation offers satisfactory stabilization)
Osteoporotic condylar fractures As above, sometimes need total knee replacement Complication Early Late Compartment syndrome -esp type 5 & 6: tendency to bleed and swelling
examine leg and foot repeatedly for sx of compartment syndrome Joint stiffness -failure to regain full knee bend minimised by early movement
Deformity -residual valgus or varus deformity is quite common -compatible with good function
Secondary osteoarthritis -caused by plateau depression, knee deformity or ligamentous instability