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Knee joint

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Title: Knee joint


1
Knee joint
  • Dr.Rebar M.noori

2
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

3
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

6
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

9
  • 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

12
imaginng
  • X-ray showed the pattern of the fracture
    transverse comminuted vrtical displaced or
    undisplaced

13
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

16
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

19
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

20
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

23
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.

24
  • 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

28
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

29
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

32
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

33
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

34
  • 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

37
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

38
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

39
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

40
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

41
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

45
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

46
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

47
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

51
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

54
  • 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.

57
  • 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.

58
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.

59
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.

62
  • 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

66
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

67
  • 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

68
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

69
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

70
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

73
Patellar dislocation
  • Types
  • 1.traumatic
  • 2.habitual whenever the knee flexed the patella
    dislocates
  • 3. congenital dislocation the patella is
    permanently dislocated
  • 4.

74
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

75
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.

76
  • 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

79
  • 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.

80
  • (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

83
  • 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

84
  • 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,

87
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).

88
treatment
  • A loose body causing symptoms should be removed
    unless the joint is severely osteo arthritic.
    This can usuallybe done through the arthroscope.

89
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

90
  • Osteoarthritis is often bilateral and in these
    cases there is a strong association with
    Heberdens nodes and generalized osteo arthritis

91
  • 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

92
  • 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

95
  • 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).
  • .

96
  • 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,

97
  • 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.

98
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.

99
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

100
  • Clinical features
  • The patient chiefly complains of instability
    pain (other than tabetic lightning pains) is
    unusual. The joint is swollen and often grossly
    deformed

101
SWELLINGS OF THE KNEE
  • 1.swelling of the entire joint
  • 2. swellings in front ofthe joint
  • 3. swellings behind the joint
  • 4. bony swellings.

102
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

103
  • 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

104
  • 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

105
Swelling infront of the knee
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