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Knee Injury Seminar

Group members
1. Nor Hidayah binti Borhan A131887
2. Nur Khairunnisa binti Raja Mohammad A139354
3. Nurul Aqilah binti Ab Rahman GA02491
4. Muhd Fahimi bin Mustapa A136380
5. Noor Nelza Nadia binti Abd Wahad A139959
6. Kavireshna a/l kanabari GA02454
7. Komathi a/p chow kwai ying A131833
8. Ezzah Bazillah binti Zaharin A139525
9. Luqman Hakim bin Ahmad Zaini A136146
10. Nur Hanisah binti Hishamudin A136215
KNEE ANATOMY
3 3
joints compartme
: nts:

Lateral Median
Femorotib Femorotib
ial ial

Femoropat
ellar
: extracapsular
:intracapsular
Smaller
More moveable:
only attachment to
medial femoral
condyle via
posterior
meniscofemoral
ligament

C-shaped, broader
Less moveable:
attached to
intercondylar are +
deep surface of LCL
Descen. Femoral a.
Branch of
lateral Descen. Popliteal a.
femoral Genicular
circumflex a.
a.
Superior Superior
lateral medial Middle
genicular a. genicular a. genicular a.
GENICULAR Cruciate
ANASTOMOSES
Inferior Inferior ligament
lateral medial Synovial
genicular a. genicular a. memb.
Menisci
margins
Anterior Circumflex
tibial fibular a.
recurrent a.
Anterior Posterior
tibial a. tibial a.
Femoral
nerve

Articular Cutaneous
branches branches

Common
Tibial peroneal Obturator
nerve nerve nerve
Saphenous
Anterior nerve
Posterior
Lateral
ACL runs between the tibial plateau
anteriorly and the lateral femoral condyle
posteriorly
Dual-bundle
Anteromedial (AM) bundle

Posterolateral (PL) bundle

Functions:
Prevent anterior tibial displacement
Prevent hyperextension of knee
Provide rotational stability
PCL runs between the tibial plateau posteriorly and the
medial femoral condyle anteriorly
Dual-bundle
Anterolateral (AL) bundle
Posteromedial (PM) bundle
Functions
Prevent posterior tibial displacement
Prevent hyperextension of knee joint
Secondary action includes resistance to varus, valgus, and
external rotation
ANTERIOR CRUCIATE LIGAMENT
+ve anterior Drawing test
+ve Lachmans test

POSTERIOR CRUCIATE LIGAMENT


+ve posterior Drawing test
+ve posterior saging

**Positive drawer sign is a diagnostic of tear,


but negative does not exlude one!
CRUCIATE LIGAMENT TEAR
ACL is more common
PCL is stronger and broader

PCL ACL
Mech. Of Anterior force, hyperextension No contact: sudden twist,
injury with foot in dorsiflexion (exp: in (exp: landing from jump)
football tackle)
Contact: Blow to the lateral side of the
extended knee.
Anterior force on flexed knee
(exp: dashboard injury)
PCL ACL
Symptoms Knee swelling, stiffness Knee swelling (haemathrosis- rapid and
Painful knee doughly feeling)
Instability sensation esp when Pain, esp when trying to put wt on
descends stairs injured leg
Popping sound knee gives way
Popping sound

Signs Usually full/ functional ROM Gross effusion


Positive post sag sign Limited ROM: lack of complete
Positive posterior drawer test * extension
Positive Lachman test *
Positive anterior drawer sign
Anterior Cruciate Ligament Posterior Cruciate Ligament:
Mechanism Twisting injury often noncontact Anterior force on tibia (eg: dashboard
pivoting injury) or sports (hyperextension)
Commonly presented with : terrible associated with collateral and/or PL
triad (ACL + meniscal tear + collateral corner injuries
ligament)
Common in female athlete
History Twisting injury Pain in the posterior aspect of knee

Pop sound No popping sound

Swelling of the knee joint Swelling at knee joint


Sensation of knee giving away Instability
(instability)
Inability to continue playing
Physical examination Effusion (hemarthrosis) +/- effusion
Lachman test quadriceps active test
Anterior drawer test + posterior drawer
Pivot shift posterior sag
Investigations X-ray : X-ray:
Segond fracture (avulsion fracture of Knee series (look for avulsion
lateral tibial condyle) meniscus)
MRI: MRI:
Absent/detached ACL Confirm diagnosis, Evaluates meniscus
Arthrocentesis : and articular cartilage
Hemarthrosis
TREATMENT
Sprains and partial tears Complete tears Combined injuries

Fibres splint, ACL-early operative ACL and collateral


followed by active reconstruction ligament injury
exercise PCL treated start with joint
bracing and
Aspirating conservatively
physiotherapy in
hemathrosis and order to restore a
applying ice-packs good ROM
relieves pain Followed with
Bandage- knee reconstruction
must be protected
from rotation and PCL and collateral
angulation by injury
bandage or similar approach
functional brace. -but all damaged
structures will need to
be repaired
COLLATERAL LIGAMENT INJURY
-MEDIAL
-LATERAL
DEEP MEDIAL
COLLATERAL
LIGAMENT

LATERAL
COLLATERAL
LIGAMENT
SUPERFICIAL
MEDIAL
COLLATERAL
LIGAMENT
MEDIAL LATERAL
COLLATERAL COLLATERAL
LIGAMENT LIGAMENT

ORIGIN Medial femoral epicondyle Lateral femoral epicondyle

INSERTION SUPERFICIAL:Proximal tibia Anterolateral of fibula head


DEEP:Medial meniscus

FUNCTION Provide restraint to valgus Provide support to varus


angulation angulation
MECHANISM OF INJURY

Valgus force
from lateral
knee

Varus force
from medial
knee
PRESENTATION
LCL MCL

SYMPTOMS -Difficulty in ascending or -H/O pop at time of injury


descending stairs -medial joint pain and
-lateral joint pain and swelling
swelling. -instability
-instability
PHYSICAL EXAMINATION -ecchymosis,tender or knee -ecchymosis,tender or knee
effusion at lateral aspect of effusion at medial aspect of
knee knee
-Varus stress test Valgus stress test
at 30 flexion-isolated LCL At 30 flexion-isolated
injury superficial MCL
At 0 and 30-combined LCL and At 0-ass with
ACL/PCL. posteromedial capsule or
cruciate ligament injury.

Common peroneal nerve Saphenous nerve


INVESTIGATION
Knee X-Ray-MCL-Pellegrini-Steida sign( post-
traumatic calcification
within the medial collateral
ligament ( chronic).
-LCL- Fibula head avulsion fracture.
MRI-imaging modality of choice that provide
severity and location.
MANAGEMENT
Conservative treatment( for mild MCL and LCL
tear)
Analgesia
Cryotherapy
Hinged brace 4-6weeks
Physiotherapy- strengthening exercise
Surgical treatment (for severe LCL or MCL tear)
Surgical reconstruction

Rehabilitation
Bracing
Physiotherapy- strengthening exercise
MENISCUS INJURY
Anatomy
Semilunar shaped fibrocartilage
3 parts:- ant,post horn,lateral OR
-red zone(outer 1/3), redwhite zone, white zone
Branches of geniculate arteries
medial meniscus
-the anterior horn attach to ACL in the
intercondylar area
-lateral aspect attach to MCL(not mobile)
-posterior horn is attach to the posterior
intercondylar area
lateral meniscus
-the anterior horn attaches immediately lateral
to ACL insertion.
-posterior horn attaches to the posterior
intercondylar area anterior to the medial
meniscus and posterior to ACL insertion
-lateral not attach to LCL
Fx of menisci:
1. increase stability of knee
2.Shock absorption
3.Distribute load during movement
Mechanism of injury
fall in flexed knee with twisting strain
(eg: football,rugby)
-torn of medial meniscus >>>> lateral
meniscus d/t *attach to MCL
*larger
Type of tear
Bucket handle tear
-split is vertical and rus along circumference of
meniscus : loose body may displace toward into
joint and cause locking

horizontal tear
-usually degenerative or repeated trauma
-some a/w meniscus cyst
Symptoms
1. Severe pain at joint line post trauma
2. Locking in partial flexion (bucket
handle)
3. Swelling but late(hours or next days)
Loose tag
Complication
Articular damage
inflammation
Synovial effusion
Secondary OA
Examination
1. Swelling, bruises, bleeding, scar, quad wastg
2. Temp, tenderness jt line, menicus, effusion
3. Rom, locking
4. Mcmurray test, grinding test
1. MRI Investigation
-absent bow tie sign
Double PCL sign
Management

Arthroscopic surgery-based on the zone


Outer 1/3-menisectomy
Inner2/3- repair,trim
-removed loose body
after surgery, physiotherapy
*after menisectomy, high risk to get OA so
advice pt
Fracture of patella
Patella fracture is a condition
characterized by a break in the knee cap
bone (patella)
The knee comprises of the union of 3
bones:
- femur (long bone of thigh)
- tibia (shin bone)
- patella (knee cap)
Type of fracture
1. Undisplaced crack across patella; which is
probably due to a direct blow
2. Comminuted or stellate fracture; due to a fall
or direct blow on the front of the knee
3. Transverse fracture with a gap between the
fragment; this is indirect traction injury due to
forced, passive flexion of knee while quadriceps
muscles contracted entire extensor
mechanism is torn impossible to extend the
knee
Clinical features
Symptoms:-
Pain
Swelling
Haemarthrosis (Blood in the joint)/effusion
Inability to extend knee (esp in transverse
fracture, affects the treatment)
Signs:-
Bruising of knee joint with or without
abrasions
Patellar deformity; gap may be felt
Tenderness over patella
Proximal displacement of patella (esp in
transverse fracture)
Investigations
X-ray (AP, lateral, skyline)
- three types of fractures clearly
indistinguishable

* A crack fracture sometimes confuse with congenital bipartite


patella (present of smooth line that extends obliquely across
superolateral angle of bone)
Non-displaced patellar fracture

AP view Lateral view


Displaced patellar fracture

AP view Lateral view


Bipartite Patella
Treatments
Depend on type of fracture:-
o General indications for surgery:
Significant articular step-off > 2mm
Loss of extensor mechanism with displacement >3mm
Open fracture
o Undisplaced or minimally displaced crack:
Aspirate haemarthrosis (if present)
Protection with plaster cylinder holding knee straight
(4-6 weeks) if extensor mechanism is intact
Physiotherapy : early ROM to preserve mobility
o Comminuted (stellate) fracture
Acceptable displacement : backslab and early
ROM
Severe displacement : complete or partial
patellectomy (depend on severity of
dicplacement) to avoid damage to patellofemoral
joint predisposed by irregular undersurface of
patella
o Displaced transverse fracture
Internal fixation (tension band wiring + 2 K-wires)
Extensor expansion repair if torn
Plaster backslab worn until active extension of
knee is regained
Complications
PFOA (patellofemoral osteoarthritis)
Dislocation: Joint surfaces Dislocation
are completely displaced
and are no longer in of Knee
contact.

Requires high-energy
trauma to produce
dislocation (eg. road
accident)

Tearing of at least 3
stabilizing ligaments
cruciate ligaments (A/P)
one or both collateral
ligaments (lateral/medial)
Causes: Trauma (MVA, sport injuries, severe
fall)

EMERGENCY!
- limb threatening injury popliteal artery
disruption/thrombosis
CLASSIFICATION
(POSITIONAL)
Describes position of the tibia relative to the femur
Anterior (severe knee hyperextension)
Posterior (dashboard injury)
Lateral
Medial
Rotatory

anterior posterior lateral medial


1) Anterior dislocation
- Forceful hyperextension (>300 )
- Risk of popliteal a. injury inc. with increasing extension
- a/w PCL, ACL tear A P A P

2) Posterior dislocation
-force on flexed knee
-risk of popliteal a. injury inc. with increasing displacement
-a/w PCL, ACL tear A P A P

B A
3)Lateral dislocation
-valgus force
-a/w MCL, ACL, PCL tear Dimple sign

4) Medial dislocation
-varus force

5)Rotatory dislocation
-rotatory force
*All type of dislocation will a/w rupture of cruciate
ligament(ACL/PCL) +/- collateral ligament
Symptom Sign

Intense Pain 1. Valgus/varus instability


Severe Bruising 2. Special test to assess
Swelling (haemarthrosis) ligamentous injury
]
Gross Deformity (knee)
Popliteal artery may be torn or ** must check
obstructed -pulse (DPA,PTA, popliteal a.)
- Absence of pulse -sensation (*1st webspace)
Damage to common peroneal -dorsiflexion
nerve
- Reduced sensation at the
first webspace
- Impaired dorsiflexion of
foot - Foot Drop
Associated fracture of tibia &
Investigation

II. Vascular injury assessment


I. Imaging
X-Ray (AP and Lateral)
Separation of tibia with Doppler Ultrasound
respect to femur To measure the ankle brachial
arterial pressure index. (ABI/API)
fracture of tibial spine due to
(ABI/API) < 0.90
ligament avulsion
Proximal fibular fracture
MRI
Soft tissue injury (ligaments Arteriography and seek
and meniscus)
vascular surgical consultation
Surgical planning

59
Treatment Reduction under anaesthesia is urgent
-if it is achieved, the limb is rested on a
backslab with the kneein 15 degrees of flexion

Postreduction assessment
-Repeat AP and lateral radiographs
-Vascular and neurological status examination

If the joint is unstable, an anterior external


fixator can be applied.
When swelling has subsided, cast is applied and
is worn for 12 weeks ( if ligaments are not torn)

Quadriceps muscle exercise

60
Complication
Acute Chronic

popliteal artery injury knee instability


(10-65%) stiffness
Peroneal nerve injury post-traumatic OA
(20-40%)
Open knee injury (20-
30%)
Patellar dislocation/instability

Patella may dislocate or sublux laterally


Young, active patients at highest risk (~ages
13-20)
Common in football & basketball
Female common than male
Recurrence is common, especially if first
dislocation < 15 yo

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Patellar dislocation/instability

Indirect trauma most


common mechanism
Strong quad
contraction while leg
is in valgus and foot
planted
Other knee ligament
injuries can occur

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Patellar dislocation/instability

Risk factors:
Trauma
Pes planus
Genu valgum
Weak VMO

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Patellar dislocation/instability
Hx:
Feel a pop and immediate pain
Obvious knee deformity
Painful, difficult to bend knee
May spontaneously relocate, left with feelings of
instability

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Patellar dislocation/instability

PE:
Laterally shifted
patella
Patellar
apprehension
Swelling

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Patellar dislocation/instability

Imaging:
Standard knee x-rays
a good start

Likely need an MRI if


injury seems
significant or
associated injuries
seem possible

MRI

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Treatment
Reduction
Plaster backslab with knee in
extension ( 3 weeks)
Quadriceps strengthening exercise
(2-3 months)

If there is much bruising / swelling / tenderness medially ->


patellofemoral ligament and retinacular tissues are torn ->
immediate operative repair (prevent later recurrent dislocation)

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Complication
Recurrent dislocation
Predisposing factors:
Non-operative tx for the first-time dislocation.
Ligamentous laxity
High-riding patella
Valgus deformity
Shallow patellofemoral groove

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Patellar dislocation/instability
Prognosis
Recurrent instability is common, but rehab is
mainstay and very useful
When to refer
Associated fracture
Poor response to rehab
Multiple dislocations (#?) & skill level

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Quadriceps and Patellar Tendon
Rupture
Anatomy
The quadriceps tendon
and the patellar tendon
are parts of the
extensor mechanism of
the knee
Types
a) Partial : The soft tissue
is not completely
disrupted
b) Complete : The soft
tissue split into 2
Mechanism of Injury
Occurs during a rapid, eccentric contraction of
the quadriceps muscle, with the foot planted
and the knee partially flexed
History of presenting illness
Painful and swollen knee
Tearing and popping sensation
Unable to straighten the knee
Difficulty walking due to the knee buckling or
giving way
Physical Examination
Tenderness at site of rupture
Suprapatellar swelling and ecchymosis
Unable to extend knee against resistance
Unable to perform straight leg raise test with
complete rupture
Investigations
X-ray showing normal location of The kneecap has moved out of place
knee cap due to a torn of quadriceps tendon
In an x-ray, if the patella is located:
Too high : Patellar tendon rupture (patella alta)
Too low : Quadriceps tendon rupture

MRI To differentiate between complete and


partial tear
Treatment
a) Nonoperative
Knee immobilization
Partial tear with intact knee extensor mechanism
Patients who cannot tolerate surgery
3-6 weeks
Physiotherapy
Restore stregth and ROM
b) Operative
Primary repair with reattachment to patella
Complete rupture with loss of extensor mechanism
Complications
Strength deficit (33-50% of patients)
Stiffness
Functional impairment
50% patients unable to return to prior level of
activity/sports
Osteochondritis Dissecan
Definition: disorder of one or more ossification centres, characterize by
1. Sequential degeneration/aseptic necrosis
2. recalcification
OCD lesions involve both bone and cartilage
In skeletally immature
individuals, the
vascularity to
The most common location of OCD is in the knee at the end of the femur (thighbone).
epiphyseal bone is very
good

supporting both
osteogenesis and
chondrogenesis.

With disruption of the


epiphyseal vessels,
varying degrees and
depth of necrosis occur

resulting in a cessation leads to nonspecific resulting in


of growth to both changes that subchondral
osteocytes and produce disordered avascular necrosis
chondrocytes enchondral or OCD.
ossification
4 stages of OCD have been identified

revascularization and formation of granulation tissue

delay in the revascularization stage osteoclasis of necrotic fragments

remodeling of new bone


osteochondritis dissecans lesion develops
intertrabecular osteoid deposition
OCD lesions may lead to articular-surface
irregularities

cause degenerative arthritic changes.


History of the patient??
Depending on the joint that's affected, signs and symptoms of osteochondritis
dissecans might include:
1. Pain. This most common symptom of osteochondritis dissecans might be
triggered by physical activity walking up stairs, climbing a hill or playing
sports.
2. Swelling and tenderness. The skin around your joint might be swollen and
tender.
3. Joint popping or locking. Your joint might pop or stick in one position if a loose
fragment gets caught between bones during movement.
4. Joint weakness. You might feel as though your joint is "giving way" or
weakening.
5. Decreased range of motion. You might be unable to straighten the affected
limb completely.
Finding on physical examination??
1. Effusion may be present.
2. Quadriceps atrophy and weakness may be evident.
3. Occasionally, a loose body may be palpable.
4. The patient may lack full knee extension compared with
the contralateral knee.
5. Tenderness is noted over the lesion.
6. Evaluate gait for external rotation of the tibia.
7. Perform the Wilson test to check for OCD. The examiner
flexes the knee to 90 while internally rotating the tibia. A
positive Wilson sign occurs when pain is elicited at 30 of
flexion and is relieved with external rotation.
How to investigate??

1. Plain radiography
(anteroposterior, lateral, and tunnel views) shows:
OCD lesions as well-circumscribed crescent-shaped
areas of radiolucency above an area of subchondral
bone, separated from the femoral condyle. In 75% of
cases, the lesion is located on the posterolateral aspect
of the MFC. MRI can obtain similar data.

2. MRI
can obtain similar data.
How to manage this patient??
Observation and Activity Changes
In most cases, OCD lesions in children and young teens will
heal on their own, especially when the body still has a great
deal of growing to do. Resting and avoiding vigorous sports
until symptoms resolve will often relieve pain and swelling.

Nonsurgical Treatment
If symptoms do not subside after a reasonable amount of time,
your doctor may recommend the use of crutches, or splinting
or casting the affected arm, leg or other joint for a short
period of time.In general, most children start to feel better
over a 2- to 4-month course of rest and nonsurgical
treatment. They usually return to all activities as symptoms
improve.
Surgical Treatment
Your doctor may recommend surgery if:

1. Nonsurgical treatment fails to relieve pain and swelling


2. The lesion is separated or detached from the surrounding
bone and cartilage, moving around within the joint
3. The lesion is very large (greater than 1 centimeter in
diameter), especially in older teens

There are different surgical techniques for treating OCD, depending


upon the individual case:

1.Drilling into the lesion to create Replacing the damaged area with a
pathways for new blood vessels new piece of bone and cartilage
to nourish the affected area. This Holding the lesion in (called a graft). This can help
will encourage healing of the place with internal regenerate healthy bone and
surrounding bone. fixation (such as pins cartilage in the area damaged by
and screws). OCD.
Complication??
A nonunion of the OCD fragment may occur
and progress to dissociation, leading to intra-
articular loose body symptoms. This, in turn,
may lead to a type of reconstructive procedure
such as OATS or ACI (see Surgical Intervention
in Acute Phase). Regardless of treatment,
degenerative articular changes may develop
over time
STAGES I II III IV V VI

DEFINATION Lateral split of Lat split Depression Medial Bicondylar Bicondylar


lat condyle with of lat condyle fracture fracture
depression condyle fracture with
with intact involvemnt
rim metaphyses
/diaphyses
ETIOLOGY d/t valgus d/t Older pt d/t varus Axial High-
stress & valgus/axial with stress stress energy
bumper injury stress osteo- Often severe with trauma
in younger pt In older pt porosis injuries severe
w stronger w osteo- Often d/t trauma
bones porosis fall
ASSOCIATED Lat meniscal Lat&med Ass/w joint Ass/w Neuro- Neuro-
INJURIES
tear meniscal,m instability avulsion of vascular, vascular
ed inter-condylar ACL, injry
collateral eminence meniscal ACS,ACL
ligament (indicate ACL) injury injury
Lat colatrl,
peroneal
nerve,
popliteal injry
TYPES OF INJURIES TREATMENT & MANAGEMENT
Undisplaced & minimal Tx conservatively
displaced # of lateral Haemarthrosis aspirated if skin is threatened + compressn bandage
condyles Start knee movement (as soon as pain and swelling subside)
No weigh bearing for 3weeks + hinged cast-brace

Markedly displaced Treadted by open reduction and int fixation (w lag screws and
and/or communited # buttress)
of lateral condyles Bone graft done at area of depression

# of medial condyles Best treated by open reduction and fixation with buttress plate and
screws
Repairing lateral ligament (may ass/w lat ligament)

Bicondylar # Reduced and stabilize surgically is the best


IF with plates and screws
screw fixation + circular external fixator
(< risk of wound complication)

Osteoporotic condylar Can be treated same as above


# But if # pattern permits can undergo with total knee replacement.