Knee InjuriesKnee Injuries

University of Debrecen

Medical and Health Science Centre

Department of Traumatology and Hand Surgery

University of Debrecen

Medical and Health Science Centre

Department of Traumatology and Hand Surgery

Anatomy of the kneeAnatomy of the knee

Osseous structures: 3 componentsOsseous structures: 3 components

-patella-patella

-distal condyles of the femur-distal condyles of the femur

-proximal tibial plateaus (condyles)-proximal tibial plateaus (condyles)

The knee is a hinge joint: extension and The knee is a hinge joint: extension and flexion BUT…its motion also has a flexion BUT…its motion also has a rotary componentrotary component

Anatomy of the knee- Anatomy of the knee- extraarticularextraarticular

Lateral Collateral ligament Lateral Collateral ligament An independent An independent

ligament ligament originating from originating from the lateral the lateral epicondyle of epicondyle of the femur and the femur and inserting on the inserting on the head of the head of the fibulafibula

It is It is independant of independant of the joint capsule the joint capsule and meniscusand meniscus

Anatomy of the knee - Anatomy of the knee - extraarticularextraarticular

Medial collateral ligamentMedial collateral ligament Origin from the Origin from the

medial medial epicondyle of epicondyle of the femur, the femur, meshes with the meshes with the capsule and the capsule and the edge of the edge of the medial medial meniscus, and meniscus, and inserts on the inserts on the tibiatibia

Anatomy of the knee- Anatomy of the knee- intraarticular Anterior intraarticular Anterior

cruciate ligamentcruciate ligament Originates from Originates from

the posterior the posterior surface of the surface of the lateral femoral lateral femoral condyle, goes condyle, goes forward and forward and downwards to downwards to insert in front of insert in front of the intercondylar the intercondylar eminenceeminence

Anatomy of the knee- Anatomy of the knee- intraarticular Posterior intraarticular Posterior

cruciate ligamentcruciate ligament Originates from Originates from

the lateral the lateral surface of the surface of the medial femoral medial femoral condyle, and condyle, and goes backwards goes backwards to insert behind to insert behind the the intercondylar intercondylar eminenceeminence

Anatomy of the knee: Anatomy of the knee: intraarticular Menisciintraarticular Menisci

Lateral and medial Lateral and medial meniscusmeniscus

functions:functions:

-distribution of -distribution of joint joint fluidfluid

-nutrition-nutrition

-shock absorption-shock absorption

-deepening and -deepening and stabilization of the jointstabilization of the joint

-load or weight--load or weight-bearing bearing functionfunction

Medial stabilizers of the knee

1.Superficial portion of the medial collateral ligament

2.Posterior oblique ligament

3.Middle 1/3 of the medial capsular ligament

4.Pes anserinus semimembranous muscle

Lateral stabilizers of the knee

7.Lateral collateral ligament

9.Middle 1/3 of the capsular ligament

10.Popliteal tendon

11.Biceps tendon

Injuries of the kneeInjuries of the knee Stable injuriesStable injuries

Contusion:Contusion: caused by direct trauma, local caused by direct trauma, local pain and bruisingpain and bruising

Distorsion (sprain):Distorsion (sprain): caused primarily by caused primarily by indirect trauma, morphological changes indirect trauma, morphological changes without connective tissue instabilitywithout connective tissue instability

Unstable injuriesUnstable injuries Simple or one dimensional injuries: Simple or one dimensional injuries:

caused by frontal or sagital forcescaused by frontal or sagital forcesMedial, lateral, dorsalMedial, lateral, dorsal and and ventralventral

instabilityinstability

Injuries of the knee: Injuries of the knee: bony injuriesbony injuries

Fractures of the osseus componentsFractures of the osseus components

patellar fracturepatellar fracture

fracture of femoral condylesfracture of femoral condyles

fracture of tibial plateaufracture of tibial plateau

Ligamentous injuries of Ligamentous injuries of the kneethe knee

Complex or rotational instabilityComplex or rotational instabilityCaused by forces acting in more than one planeCaused by forces acting in more than one planeTypes:Types: anteromedial, anterolateral, anteromedial, anterolateral,

posterolaterális, posteromedial instabilityposterolaterális, posteromedial instability Combined complex instabilityCombined complex instability

Caused by forces acting in more than one plane, Caused by forces acting in more than one plane, one of which is stronger and lasts longer one of which is stronger and lasts longer

Possible combinations:Possible combinations: Anteromedial and posteromedialAnteromedial and posteromedial Anteromedial and anterolateralAnteromedial and anterolateral Anterolateral and posterolateralAnterolateral and posterolateral Knee dislocations are also placed in this Knee dislocations are also placed in this

categorycategory

Meniscus injuriesMeniscus injuries

Common knee injury. Usually caused by Common knee injury. Usually caused by indirect rotational forces. The menisci are indirect rotational forces. The menisci are bradytrop tissues, only the bradytrop tissues, only the outer ¼outer ¼ („red („red zone”)zone”) has a blood supplyhas a blood supply, the , the remaining ¾ remaining ¾ receives nutrients by diffusionreceives nutrients by diffusion. A . A „white zone”„white zone” injuries undergo rapid degeneration. The injuries undergo rapid degeneration. The medial meniscus is injured 20 times more medial meniscus is injured 20 times more often than the lateral due to its anatomical often than the lateral due to its anatomical characteristics. The partial or complete characteristics. The partial or complete rupture rupture („buckethandle”)(„buckethandle”) causes knee pain causes knee pain and may even cause knee immobility. Long-and may even cause knee immobility. Long-term injuries may cause loss of muscle mass as term injuries may cause loss of muscle mass as well as fluid collection in the joint.well as fluid collection in the joint.

Diagnosis of knee injuriesDiagnosis of knee injuries

Physical examinationPhysical examination X-ray (roentgenogram) in 2 views X-ray (roentgenogram) in 2 views

(A-P and side views) with tangential (A-P and side views) with tangential patellar view can give information patellar view can give information regarding possible bone injuriesregarding possible bone injuries

UltrasoundUltrasound CTCT MRIMRI ArthroscopyArthroscopy

Examination of the kneeExamination of the knee HistoryHistory

Direction of forceDirection of force When did pain startWhen did pain start Mobility following injuryMobility following injury When did swelling startWhen did swelling start Is there catching in the jointIs there catching in the joint

ObservationObservation Observable skin changes, deformities, Observable skin changes, deformities,

axis deformities, movement difficulties, axis deformities, movement difficulties, ability to walkability to walk

Palpation: paraarticular and Palpation: paraarticular and intraarticular fluid collectionintraarticular fluid collection

Localization of painLocalization of pain

Examination of stabilityExamination of stability

Patient supine and always Patient supine and always compare both sidescompare both sides

Active and passive movementsActive and passive movements Testing varus and valgus with Testing varus and valgus with

knee extended (abduction and knee extended (abduction and adduction stress test)adduction stress test)

Abduction and adduction tests Abduction and adduction tests with knee in 30 degree flexionwith knee in 30 degree flexion

Abnormal movement in sagital Abnormal movement in sagital planeplane

Examination of stabilityExamination of stability Anterior drawer signAnterior drawer sign Lachmann testLachmann test

In fresh injuries this is easier than In fresh injuries this is easier than anterior drawer as there is no need anterior drawer as there is no need to bend the knee 90 degreesto bend the knee 90 degrees

Posterior drawer signPosterior drawer sign Special testsSpecial tests

Pivot shift test for chronic injuriesPivot shift test for chronic injuries

Testing for stabilityTesting for stability

Treatment of knee Treatment of knee injuriesinjuries

Conservative treatment: rest, icing, Conservative treatment: rest, icing, bandaging, brace, castbandaging, brace, cast

Surgical treatment: open surgery, Surgical treatment: open surgery, arthroscopyarthroscopy

Bone tendon bone graft for LCA Bone tendon bone graft for LCA replacementreplacement

Replacement of lateral collateral Replacement of lateral collateral ligament using a graftligament using a graft

Replacement of medial Replacement of medial collateral ligament using a collateral ligament using a

graftgraft

Thank you for yourAttention!!