Knee joint

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Knee joint

• Dr.Rebar M.noori

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Anatomy

• Composed of articulation between the distal
  femoral condyle and tibial plateau and bet.the
  femoral condyle and patella (sesamoid bone)
• It is a hinge joint
• Synovial joint
• Because of the shape of the bone it depend on the
  ligaments as a major stabilizing element

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What are important ligaments

• ACL
• PCL
• LCL
• MCL

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Knee problems

• History of trauma ,previous Hx of trauma
• ,pain,catching ,clicking, locking
• Examination
• Investigation
• Blood investigation CBCESR
• FBS
• S.uric acid

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Imaging

• Pain X-ray
• CT scan
• MRI
• Bone scan techniscium
• Arthrography

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Patellar fracture

• Patella is a sesamoid bone in continuity of the
  quadricps mechanism and receive insertion of the
  vastus medialius and lateralis and intermedius
• Mechanism of injury
• 1.Direct force that break the bone like tile
  under blow of hammer like fall on the knee or
  blow against dashboard

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• Indirect force by the forecfull contraction of
  the quadriceps muscle while the knee goes into
  flexion as in case of stumbling this wil give a
  tranverse fracture with gap between the fragments

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Clinical features

• The knee is swollen ,tense ,painfull ,skin is
  bruised some time gap can be felt
• Active extension should be tested if the Pt can
  extend the knee it means that the extensor
  mechanism is intact

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imaginng

• X-ray showed the pattern of the fracture
  transverse comminuted vrtical displaced or
  undisplaced

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Calssification

• Transverse
• Vertical
• Comminuted or stellate
• polar

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treatment

• Undisplaced fracture Aspiration of
  hemarthrosis with cylinder in full extension for
  3-4 weeks
• Some times for comminuted fracture because of
  disruption of the articular suface patellectomy
  is advisable and sometimes if the fracture is
  undisplaced to treat them by casting and to
  remove the displaced pieces and start early
  physiotherapy

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Displaced fracture

• Treatment is surgical fixation of the fracture
  by tension band wiring or screw fixation with
  repair of extensor mechanism

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Patellar dislocation

• Because of the normal valgus aliengment of the
  knee there is a tendency of the patella to
  dislocate laterallywhen thequaricps muscle
  contract
• Mechanism of injury
• 1. indirect While the knee is flexed and quads
• are contracted dislocation will occur
• 2.Direct direct force applied to the lateral
  part while the knee forced to valgus and external
  rotation

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Clinical feature

• There is tearing sensation and falling on the
  ground most of the times the patella rturns back
  to its position and sometimes remains dislocated
  on the lateral side of the knee as prominent lump
  
• Rarely there may be intraarticular dislocation to
  the intercondylat notch

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imaging

• Xray shows the classical dislocation and
  sometimes there may be osteochondral fracture

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Treatment

• Most of the cases can be treated conservatively
  by replacing the patella to its position with or
  without anesthesia for 2-3 weeks S.T surgery
  required ror ruptured medial patellofemoral
  liamgamrnt

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Knee dislocation

• Knee dislocation happen after considerable force
  by RTA or FFH it is associated with rupture of
  the ACL,PCL,LCL,MCL with or without
• Clinical features
• There is hemarthrosis with bruising and soft
  tisssue laceration loss of the normal shape of
  the knee there is 40 chances of injury to the
  popliteal vessel.

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• And there is 20 injury to the common peroneal
  nerve
• X-ray shows classical dislocation ST there may be
  avulsion of the tibial spine or collateral
  ligaments or of the head of the fibula
• ST artiography my be needed in cses of vascula
  injry
• MRI shows the pattern of ligament injury

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Treatment

• Immediate reduction under anesthesia avoiding
  hyperextension in order not to tension the
  poplitael vessel the splint is applied and
  checking of the circulation done repeatedly for
  48 hr
• Vascular injury need urgent intervension with
  application of Ex.fixation
• Early reconstruction of all the ligament is done
  when the patient become stable by arthroscopic
  technique

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Tibial plateau fractures

• These fractures are common and are due to
  combined axial force with valgus or varus load
  like when pedestrian striked by car (bumper ) or
  FFH
• The tibial condyle is crushed by opposing femoral
  condyle

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types

• 11. or vertical split lateral tibial condyle
• 2.Vertical split with depression of the adjacent
• articular surface.
• 3.Depression of the lateral articular surface
  with intact rim
• 4.Vertical split of the medial tibial condyl
• 5.Bicondylar fracture
• 6.Bicondylar with subcondylar extension
• 4.

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Clinical features

• Knee swelling bruising is extensive and doughy
  feeling because of haemarthrosis there may be
  ischaemia to the foot because of vascular injury
  of the popliteal vessels ,there may be damage to
  the tibial or peroneal nerve
• Imaging
• X-ray shows the fracture pattern
• CT scan shows thethree dimensional picture

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trearment

• Undisplaced fracture can be treated
  conservatively by applying back slab the after 2
  weeks can be changed to cast brace non wt bearing
  contiued for 6-8 and in complex fracture it may
  need 12 weeks during this period PT of the knee
  under taken to restore knee flexion
• Operative treatment indicated if there gross
  displacement of the ORIF of the displaced
  fragement

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treatment

• Treatment by skeletal traction but often leave
  residual angulation on the other hand obsessional
  surgery will give a nice x-ray but with poor
  function

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• And applying plate and screw s in severly
  comminuted fractures illizarov technique is
  applied

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Complication

• 1.early
• A.compartment syndrome
• Late
• A.joint stiffness esp from comminuted it can be
  avoided by early PT
• B.deformityeither varus or valgus deformity may
  results from conservative treatment or from
  displacement after reduction
• C.Osteoarthritis from damage to the articular
  surface

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Fracture seperation of the proximal tibial
epiphysis

• Caused by sver hyperextension injuryand valgus
  strain ,the epiphysis displaced anteriorly and
  laterally often with small ????? fragment of
  tibial metaphysis (SH type ) there may be damage
  to the popliteal artery
• Clinical feature knee is swollen with deformity
  of hyperextension and valgus there may be
  ischaemia
• X-ray shows SH type 1 or 2

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Treatment

• Under anesthesia closed manipulation usually
• successes with fixation with smooth K-wire
• Some time open reduction is needed when closed
  manipulation failed
• After sugery knee is held in 30 degree flexion in
  back slab for 6-8 weeks

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Acute injury to the extensor apparatus

• Disruption of the extensor apparatus occurs at
  the following sites
• 1.avulsion of the tibial tubercle at adolescent
• 2.young adult ..rupture of the patellar tendon
• 3. middle aged .. patella
• 4.older people and those with chronic
  illness.rupture of the quariceps tendon

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Fracture of the tibial tubercle

• Usually occur in adolescent during sport activity
  when the knee suddenly forced to flexion while
  quads is contracting ,afragment or whole of the
  tubercle avulsed
• C.F knee is swollen and tender
• X-ray shows the and the patella is abnormally
  high

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treatment

• Undisplaced R by long leg cast in full
  extension for 6 weeks
• Complete seperation require open reduction and
  fixation with screw with application of casting
  postoperatively
• Osgoog schlatter disease repititive strain on
  the patellar ligament give rise to paifull tender
  swelling over the tibial tubercle ,this condition
  is common among adolescent and treated by
  restriction of sport till symptoms improves

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ruputure of the patellar tendon

• This uncommon injuey happen in young athletes
  ,the tear may in the proximal or distal
  attachment of the ligaments there may be previous
  Hx of local steroid injection to the ligament
• C.F Hx of sudden sever pain and swelling on
  forced extension
• X-ray showed high riding patella or klake of bone
  from the proximal or distal part of tye ligament

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treatment

• Acute tear R by application of plaster cylinder
  in full extension for 6 weeks
• Complete one R by operative repair or attachment
  to the bone and protection of then repair by
  extension cast or better by cast brace to avoid
  stiffness
• Late cases is difficult to treat due to proximal
  retraction of the patella so two staged surgery
  needed first to release the contracred soft
  tissue and later to reconstruct the patellar
  ligament

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Fracture of the tibial spine

• Sever twisting injury with valgus or varus force
  may damage the knee ligaments or facture the
  tibial spine it is indeed a variant if cruciate
  ligament happen in adolescent
• The fragement may remain undisplaced or be
  partially displaced i.e hinged or completely
  displaced
• the piece in fact much bigger than it appear on
  x-ray

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Clinical feature

• Knee swollen and immobile tense and tender
  because of haemarthrosis
• Examination under anesthesia reveal extension
  block there may be ligament injury MCL or LCL
• X-ray shows the fracture

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Imaging of the knee

• X-ray we need AP,Lateral ,axial
  view,intercondylar notch or tunnel view
• Ap view should be in standing position
• CT scan used to detect
• MRI for ligamentous injuey
• Radioscitigraphydetect secondaries occult
  infection in joint replacement

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Diagnostic calendar

• Congenital disorder present either at birth or
  in the 20th or 30 year
• Adolescentanterior knee pain due to patellar
  instability,plica syndrome,or osteochondritis
• Young adult with sport activities meniscal
  injury or ligamentous injury
• Above midddle agemostly degenerative changes OA
  either primary or secondary

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Deformities of the knee

• By the end of the growth the knee will be in 5-7
  degree of valgus anything from this regarded as
  abnormal
• Bow legs and knock knees in children

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• distance between the knees with the child
  standing
• and the heels touching it should be less than 6
  cm.
• Similarly, knock knee can be estimated by
  measuring
• the distance between the medial malleoli when the
• knees are touching with the patellae facing
  forwards
• it is usually less than 8 cm.

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Physiological bow legs and knock knees

• Bow legs in babies and knock knees in 4-year-olds
  are so common that they are considered
• to be normal stages of development
• Other postural abnormalities
• such as pigeon toes and flat feet may coexist
• the parents should be reassured and the child
  should be seen at intervals of 6 months to record
  progress.

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• In the occasional case where, by the age of 10,
  the deformity is still marked (i.e. the
  intercondylar distance is more than 6 cm or the
  intermalleolar distance more than 8 cm),
  operative correction should be advised.

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Pathological bow leg and knock knee

• Disorders which cause distorted epiphyseal and/or
  physeal growth may give rise to bow leg or knock
  knee these include some of the skeletal
  dysplasias and the various types of rickets, as
  well as injuries of the epiphyseal and physeal
  growth cartilage.

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GENU RECURVATUM (HYPEREXTENSIONOF THE KNEE)

• Congenital recurvatum This may be due to abnormal
  intra-uterine posture it usually recovers
  spontaneously.
• Hereditory like generalized joint laxity
• Inflammatory like RA
• Paralytic condition like poliomyelitis
• Trauma like growth plate injuries

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LESIONS OF THE MENISCI

• The menisci have an important role in
• (1) improving articular congruency and
  increasing the stability of the knee,
• (2) controlling the complex rolling and gliding
• actions of the joint and
• (3) distributing load duringmovement.

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• If the menisci are removed, articular stresses
  are markedly increases.
• The medial meniscus is much less mobile than the
  lateral, and it cannot as easily to accommodate
  to abnormal stresses.
• This may be why meniscal lesions are
• more common on the medial side than on the lateral

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• Even in the absence of injury, there is gradual
  stiffening and degeneration of the menisci with
  age, so
• splits and tears are more likely in later life
  particularly if there is any associated arthritis

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TEARS OF THE MENISCUS

• The split is usually initiated by a rotational
  grinding force, which occurs (for example) when
  the knee is flexed and twisted while taking
  weight
• hence the frequency in footballers.
• In middle life, when fibrosis has restricted
  mobility of the meniscus, tears occur with
• relatively little force

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• Most of the meniscus is avascular and spontaneous
  repair does not occur unless the tear is in the
  outer third, which is vascularized from the
  attached synovium and capsule.
• The loose tag acts as a mechanical irritant,
  giving rise to recurrent synovial effusion and,
• in some cases, secondary osteoarthritis

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Clinical features

• Pain (usually on the medial side) is often severe
  and further activity is avoided occasionally the
  knee is locked in partial flexion.
• Almost invariably, swelling appear s some hours
  later, or perhaps the following day.
• Sometimes the knee gives way spontaneously and
  this again followed by pain and swelling.
• Locking that is, the sudden inability to
  extendthe knee fully suggests a bucket-handle
  tear

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investigation

• Plain x-ray
• MRI
• Arthroscopy
• Treatment acute phace rest in knee splint in
  extension ,daily physiotherapy ,ice packs
  application for 3-4 weeks in hope that thee tear
  will heal
• Opeative if the knee is locked and can not be
  reduced ,frequent giving way , then arthroscopic
  menisectomy or repair done

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MENISCAL CYSTS

• Cysts of the menisci are probably traumatic
  in origin, arising from either a small horizontal
  cleavage tear or repeated squashing of the
  peripheral part of the meniscus.
• It is also suggested that synovial cells
  infiltrate into the vascular area between
  meniscus and capsule and there multiply.

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Clinical feature

• Lump on the sides of the joints slightly below
  joint line
• Intermittent pain esp.after activity
• Treatment if the cyst is symptomatic
  arthroscopic decompression with partial
  menisectomy done

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Patellar dislocation

• Types
• 1.traumatic
• 2.habitual whenever the knee flexed the patella
  dislocates
• 3. congenital dislocation the patella is
  permanently dislocated
• 4.

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Causes of anterior knee pain

• 1. Referred from hip
• 2. Patellofemoral disorders
• Patellar instability
• Patello-femoral overload
• Osteochondral injury
• Patello-femoral osteoarthritis
• 3. Knee joint disorders
• Osteochondritis dissecans
• Loose body in the joint
• Synovial chondromatosis
• Plica syndrome
• 4. Peri-articular disorders
• Patellar tendinitis
• Patellar ligament strain
• Bursitis
• OsgoodSchlatter disease

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OSTEOCHONDRITIS DISSECANS

• An increase in the OCD has been observed in
  recent years, probably due to the growing
  participation of young children of both genders
  in competitive sports.
• A small, well-demarcated, avascular fragment of
  bone and overlying cartilage sometimes separates
  from one of the femoral condyles and appears as a
  loose body in the joint.

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• The most common cause is trauma
• In 80 of the cases the site is the medial
  aspect of the lateral femoral condyle condyle
• Pathology
• An area of subchondral bone becomes avascular and
  within this area an ovoid osteocartilaginous
  segment is demarcated from the surrounding bone.
• At first the overlying cartilage is intact and
  the fragment is stable

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• over a period of months the frag ment
  separates but remains in position
• finally the fragment breaks free to become a
• loose body in the joint. The small crater is
  slowly filled with fibrocartilage, leaving a
  depression on the articular surface

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• Clinical features
• The patient, usually a male aged 1520 years,
  presents with intermittent ache or swelling.
  Later, there are attacks of giving way such that
  the knee feels unreliablelocking sometimes
  occurs
• The quadriceps muscle is wasted and there may be
  a small effusion. Soon after an attack there are
  two
• signs that are almost diagnostic.

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• (1) tenderness localized to one femoral
  condyle and
• (2) Wilsons sign if the knee is flexed to 90
  degrees, rotated medially and then gradually
  straightened, pain is felt repeating the
• test with the knee rotated laterally is painless

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Treatment

• Those lesions with an intact articular surface
  have the greatest potential to heal with
  non-operative treatment if repetitive impact
  loading is avoided.
• In the earliest stage, when the cartilage is
  intact and the lesion is stable, no treatment
  is needed but activities are curtailed for 612
  months. Small lesions often heal spontaneously

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• If the fragment is unstable, i.e. surrounded by
  a clear boundary with radiographic sclerosis of
  the underlying bone, or showing MRI features of
  separation,
• treatment will depend on the size of the lesion.
• A small fragment should be removed by arthroscopy
  and the base drilled the bed will eventually be
  covered by fibrocartilage, leaving only a small
  defect.
• large fragment (say more than 1 cm in diameter)
  should be fixed in situ with pins

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• If the fragment is completely detached but in one
  piece the crater is cleaned and the floor drilled
  before replacing the loose fragment
• and fixing it with special screws
• In recent years attempts have been made to fill
  the residual defects by articular cartilage
  transplantation either the insertion of
  osteochondral plugs harvested from another part
  of the knee or the application of
• sheets of cultured chondrocytes.

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LOOSE BODIES

• may be produced by
• (1) injury (a chip of bone orcartilage)
• (2) osteochondritis dissecans (which may
• produce one or two fragments)
• (3) osteoarthritis(pieces of cartilage or
  osteophyte)
• (4) Charcots disease(large osteocartilaginous
  bodies).
• (5) synovialchondromatosis (cartilage metaplasia
  in the
• synovium,

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Clinical features

• Loose bodies may be symptomless. The usual
  complaint is attacks of sudden locking without
  injuryThe joint gets stuck in a position which
  v aries from one attack to another
• A pedunculated loose body may be felt one that
  is truly loose tends to slip away during
• palpation (the well-named joint mouse).

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treatment

• A loose body causing symptoms should be removed
  unless the joint is severely osteo arthritic.
  This can usuallybe done through the arthroscope.

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OSTEOARTHRITIS

• The knee is the commonest of the large joints to
  be affected by osteoarthritis .
• Often there is a predisposing factor
• injury to the articular surface,
• torn meniscus,
• ligamentous instability
• preexisting deformity of the hip or knee.
• in many cases no obvious cause can be found

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• Osteoarthritis is often bilateral and in these
  cases there is a strong association with
  Heberdens nodes and generalized osteo arthritis

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• changes are most marked in the medial
  compartment.
• The characteristic features of cartilage
  fibrillation,sclerosis of the subchondral bone
  and peripheral osteophyte formation are usually
  present
• in advanced cases the articular surface may be
  denuded of cartilage and underlying bone may
  eventually crumble

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• Clinical features
• Patients are usually over 50 years old they tend
  to be overweight and may have long standing
  bow-leg deformity.
• Pain is the leading symptom, worse after use, or
  (if the patello-femoral joint is affected) on
  stairs.
• Afterrest, the joint feels stiff and it hurts to
  get going after sitting for any length of time.
  Swelling is common,
• giving way or locking may occur.

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• On examination there may be an obvious deformity
  (usually varus) or the scar of a previous
  operation.
• The quadriceps muscle is usually wasted
• Movement is somewhat limited and is often
• accompanied by patello-femoral crepitus
• The natural history of osteoarthritis is one of
  alternating bad spells and good spells

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• X-ray
• The anteroposterior x-ray must be obtained with
  the patient standing and bearing weight only in
  this way can small degrees of articular cartilage
  thinning be revealed. The tibio-femoral joint
  space is diminished
• (often only in one compartment) and there is
  subchondral sclerosis. Osteophytes and
  subchondral cysts are usually present and
  sometimes there is soft-tissue calcification in
  the suprapatellar region or in the joint itself
  (chondrocalcinosis).
• .

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• Treatment
• If symptoms are not severe, treatment is
  conservative.
• Joint loading is lessened by using a walking
  stick. Quadriceps exercises are important.
  Analgesics are prescribed for pain, and warmth
  (e.g. radiant heat or shortwave diathermy) is
  soothing.
• Intra-articular corticosteroid injections will
  often relieve pain,

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• New forms of medication have been introduced
• in recent years, particularly the oral
  administration of glucosamine and intra-articular
  injection of hyalourans.
• There is, as yet, no agreement about the
• long-term efficacy of these products.

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OPERATIVE TREATMENT

• Arthroscopic washouts, with trimming of
  degenerate meniscal tissue and osteophytes
• Realignment osteotomy is often successful in
  relieving symptoms and staving off the need for
  end-stage surgery.
• Replacement arthroplasty is indicated in older
• patients with progressive joint destruction.

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CHARCOTS DISEASE

• Charcots disease (neuropathic arthritis) is
  a rare cause of joint destruction. Because of
  loss of pain sensibility and proprioception, the
  articular surface breaks down and the underlying
  bone crumbles. Fragments of
• bone and cartilage are deposited in the
  hypertrophic synovium and may grow into large
  masses

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• Clinical features
• The patient chiefly complains of instability
  pain (other than tabetic lightning pains) is
  unusual. The joint is swollen and often grossly
  deformed

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SWELLINGS OF THE KNEE

• 1.swelling of the entire joint
• 2. swellings in front ofthe joint
• 3. swellings behind the joint
• 4. bony swellings.

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Acute swelling

• 1.acute swelling
• A.traumatic haemarthrosis
• Swelling immediately after injury means blood
  in the joint. The knee is very painful and it
  feels warm, tense and tender. Later there may be
  a doughy feel. Movements are restricted. X-rays
  are essential to see if there is a fracture if
  there is not, then suspect a tear of the anterior
  cruciate ligament

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• 2.bleeding disorder like haemophilia ,christmas
  disease
• 3.septic arthritis the joint is hot tender and
  painfull and tense ,the infecting organism
  usually is staphylococcus and in adult gonococcal
  infection should be excluded
• Joint aspiration reveal purulent discharge
• ESR and WBC are highly elevated
• Treatment is urgent if the pus is thin repeated
  aspiration with appropriate antibiotics given by
  i.v route if the pus is thick or if there is no
  response after 36 hr surgical drianage should be
  done

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• Traumatic synovitis
• Chronic swelling
• 1.arthritis like osteoarthritis and rheumatoid
  arthritis
• 2. synovial disorder like synovial chondromatosis
  and pugmented villonodular synovitis and T.B
  arthritis

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Swelling infront of the knee