DisordersDisorders ofof thethe KneeKnee PainPain Swelling,Swelling, effusioneffusion oror hemarthrosishemarthrosis LimitedLimited jointjoint motionmotion Screw home mechanism – pain, stiffness, fluid, muscular weakness, locking InstabilityInstability – giving way, laxity DeformityDeformity References: 1. Canale ST. Campbell’s operative orthopaedics. 10th edition 2003 Mosby, Inc. 2. Netter FH. The Netter collection of Medical illustrations – musculoskeletal system, Part I & II. 1997 Novartis Pharmaceuticals Corporation. 3. Magee DJ. Orthopedic Physical assessment. 2nd edition 1992 W. B. Saunders Company. 4. Hoppenfeld S. Physical examination of the spine and extremities. 1976 Appleton-century-crofts. AnteriorAnterior CruciateCruciate LigamentLigament Tibial insertion – broad, irregular, diamond-shaped area located directly in front of the intercondylar eminence Femoral attachment Femoral attachment Figure 43-24 In addition to their – semicircular area on the posteromedial synergistic functions, cruciate aspect of the lateral condyle and collateral ligaments exercise 33 mm in length basic antagonistic function 11 mm in diameter during rotation. A, In external Anteromedial bundle — tight in flexion rotation it is collateral ligaments that tighten and inhibit excessive Posterolateral bundle — tight in extension rotation by becoming crossed in 90% type I collagen space. B, In neutral rotation none 10% type III collagen of the four ligaments is under unusual tension. C, In internal Middle geniculate artery rotation collateral ligaments Fat pad (inferior medial & lateral become more vertical and are geniculate arteries) more lax, while cruciate Primary restraint (85%) to anterior ligaments become coiled around translation each other and come under strong tension. PosteriorPosterior CruciateCruciate LigamentLigament Tibial insertion – a sulcus posteriorly, below the articular surface of the tibia Femoral attachment – broad half-moon or crescent shape anterolaterally on the medial femoral condyle 38 mm in length 13 mm in diameter Figure 28-A-2 The four-bar Anterolateral bundle — tight in flexion cruciate linkage model. The model includes two crossed Posteromedial bundle — tight in extension bars, which represent the Anterior meniscofemoral ligament anterior and posterior cruciate (Humphry) ligaments (ACL; PCL). The remaining two bars represent posterior meniscofemoral ligament the tibial and femoral (Wrisberg) attachments of the ligaments. Middle geniculate artery IC, instantaneous center of joint rotation. Primary restraint (95%) against posterior tibial displacement MedialMedial CollateralCollateral LigamentLigament Superficial (tibial collateral ligament) – anterior — tighten during the first 90° of motion – posterior — tighten in extension Deep (middle capsular ligament) – meniscofemoral ligament – meniscotibial (conorary) ligament Primary restraint to valgus angulation Figure 43-11 Fibers of tibial collateral ligament. Points A and B are at anterior border of long fibers. C is 5 mm LCLLCL (Fibular(Fibular CollateralCollateral Ligament)Ligament) posterior to B. Tightest in extension, relax in flexion Primary restraint to varus angulation PosteolateralPosteolateral ComplexComplex (PLC)(PLC) Popliteus tendon Arcuate complex LCL FunctionsFunctions ofof MenisciMenisci AidAid inin loadload transmissiontransmission ReduceReduce stressstress onon articulararticular surfacesurface ContributeContribute toto jointjoint stabilitystability AidAid inin lubricationlubrication SupplySupply chondralchondral nutritionnutrition MedialMedial MeniscusMeniscus Peripheral 20 – 30% vascularized (medial genicular artery) More “C” shaped LateralLateral MeniscusMeniscus Peripheral 10 – 25% vascularized (lateral genicular artery), also less vascular in the area of popliteal hiatus Incomplete “O” shaped TransverseTransverse ((IntermeniscalIntermeniscal)) LigamentLigament MeniscalMeniscal HealingHealing andand RepairRepair Figure 43-34 Superior aspect of medial (A) and lateral (B) Figure 43-35 Frontal section of menisci after vascular perfusion with India ink and medial compartment of knee. tissue clearing using modified Spaltheholz technique. Branching radial vessels from Note vascularity at periphery of meniscus, as well as at perimeniscal capillary plexus anterior and posterior horn attachments. Absence of (PCP) can be seen penetrating peripheral vasculature at posterolateral corner of lateral peripheral border of medial meniscus (arrow) represents area of passage of meniscus. F, Femur; T, tibia. popliteal tendon. HistoryHistory TakingTaking Figure 43-25 Movement of femur relative to tibia during flexion, showing contact points generated by combination of rolling and PhysicalPhysical ExaminationExamination gliding. This represents true physiological action of tibiofemoral joint. Inspection Palpation Range of motion (active & passive) Neurologic examination Tests (signs) Figure 28-A-1 Coordinate system for knee joint rotations Referred pain and translations. Flexion-extension rotation is about the fixed femoral axis. Internal-external rotation is about a fixed tibial axis. Abduction-adduction is about an axis that is perpendicular to the femoral and tibial axes. The joint translations occur along each of the three coordinate axes. The mechanical axis of the leg is measured in the standing position with InspectionInspection an imaginary “plumb line” dropped from the femoral head to the ground. Malalignment – genu valgum (knock-knee), genu varum (bowleg), genu recuvatum (back knee) Swelling, effusion, skin integrity, ecchymosis, erythema Patella position The anatomic axis is measured by drawing lines parallel to the long axis of the femur and the tibia and measuring the intercepting angle. – patella alta, patella baja, small patella, camel sign, squinting patella, grasshopper or frog eyes appearance Leg length discrepancy, deformity (eg, pigeon- toed foot deformity), gait PalpationPalpation TendernessTenderness (location(location && degree)degree) SwellingSwelling EffusionEffusion DeformityDeformity (contour,(contour, mobilitymobility ofof patella)patella) ThighThigh circumferencecircumference TestsTests (Signs)(Signs) EffusionEffusion – ballottement (patellar tap), fluctuation, balloon, brush or stroke MeniscusMeniscus – McMurray, Apley compression & distraction, O’Donoghue, bounce home, Steinman, modified Helfet, Payr, Bohler sign, Bragard sign, Kromer sign, Childress sign, Anderson med-lateral grind, Passler rotational grinding, Cabot popliteal sign TestsTests (Signs)(Signs) CollateralCollateral ligamentsligaments – valgus (abduction) stress, varus (adduction) stress AnteriorAnterior instabilityinstability – Lachman, anterior drawer Figure 43-44 Abduction stress test. (Finodrietto jumping sign) PosteriorPosterior instabilityinstability – posterior “sag” sign (gravity drawer), quadriceps contraction, reverse Lachman, posterior drawer, Godfrey, deceleration, disco (Merke sign), leaning hop, one-leg hop Figure 43-47 Anterior drawer test. A, In resting Figure 43-49 Lachman test for anterior position tibial plateau is held in normal position by cruciate instability. intact posterior cruciate ligament. B and C, With anterior cruciate insufficiency tibia can be pulled forward against force of gravity and tone of flexors. Figure 43-51 With posterior drawer testing, loss of normal step-off of medial tibial plateau with respect to medial femoral condyle indicates posterior cruciate ligament tear. Figure 43-53 “Posterior drawer” often is mistaken for “anterior Figure 43-54 Quadriceps drawer” because tibia sags posteriorly and appears to move active test for posterior abnormal distance forward when examiner tests for anterior cruciate ligament deficiency. drawer phenomenon. A, “Posterior sag” of right tibia is obvious when compared with normal silhouette of healthy knee joint. B, Tibial sag in resting position. If patient starts to raise his foot from this position, pull of quadriceps first displaces tibia anteriorly into neutral position until anterior cruciate ligament is tight (C). Only then is foot raised from table (D). E, Same knee joint as in A now manually restored to its normal position. Both silhouettes are now equal. F, “Drop back” or sagging of tibia in foreground in relation to femur in presence of posterior cruciate disruption. TestsTests (Signs)(Signs) Anteromedial rotary instability – Slocum Anterolateral rotary instability – Slocum, lateral pivot-shift (MacIntosh or Lemaire), active pivot-shift, Losee, jerk (Hughston), crossover (Arnold), Noyes (flexion-rotation drawer), flexion- extension-valgus, Nakajima (“N”), Martens Posteromedial rotary instability – Hughston posteromedial and posterolateral drawer sign Posterolateral rotary instability – Hughston posteromedial and Figure 43-62 Demonstration – Hughston posteromedial and of shift in vertical axis away posterolateral drawer sign, Jakob from center of tibia as tibia (reverse pivot-shift), external rotation shifts excessively and recurvatum, dynamic posterior shift, abnormally in relation to active posterolateral drawer sign, femur. Position of femur is Loomer posterolateral rotatory instabilitydesignated by shaded area. TestsTests (Signs)(Signs) PlicaPlica – mediopatellar plica, plica “stutter”, Hughston plica PatellaPatella – (Noble) compression & grinding (inhibition), (Fairbank) apprehension, J sign, passive patellar tilt, Clarke sign, Waldron, McConnell, lateral pull, Zohler sign, Frund sign, Dreyer, Q angle (P-F angle), Daniel quadriceps neutral angle, Wilson TinelTinel sign,sign, NobleNoble