Knee 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 knee Osseous structures: 3 components Osseous structures: 3 components-patella -distal condyles of the femur -proximal tibial plateaus (condyles) The knee is a hinge joint: extension and flexion BUT…its motion also has a rotary component

Anatomy of the knee- extraarticular Lateral Collateral ligament An independent ligament originating from the lateral epicondyle of the femur and inserting on the head of the fibula An independent ligament originating from the lateral epicondyle of the femur and inserting on the head of the fibula It is independant of the joint capsule and meniscus It is independant of the joint capsule and meniscus

Anatomy of the knee - extraarticular Medial collateral ligament Origin from the medial epicondyle of the femur, meshes with the capsule and the edge of the medial meniscus, and inserts on the tibia Origin from the medial epicondyle of the femur, meshes with the capsule and the edge of the medial meniscus, and inserts on the tibia

Anatomy of the knee- intraarticular Anterior cruciate ligament Originates from the posterior surface of the lateral femoral condyle, goes forward and downwards to insert in front of the intercondylar eminence Originates from the posterior surface of the lateral femoral condyle, goes forward and downwards to insert in front of the intercondylar eminence

Anatomy of the knee- intraarticular Posterior cruciate ligament Originates from the lateral surface of the medial femoral condyle, and goes backwards to insert behind the intercondylar eminence Originates from the lateral surface of the medial femoral condyle, and goes backwards to insert behind the intercondylar eminence

Anatomy of the knee: intraarticular Menisci Lateral and medial meniscus Lateral and medial meniscusfunctions: -distribution of joint fluid -nutrition -shock absorption -deepening and stabilization of the joint -load or weight-bearing function

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 knee Stable injuries Stable injuries Contusion: caused by direct trauma, local pain and bruising Contusion: caused by direct trauma, local pain and bruising Distorsion (sprain): caused primarily by indirect trauma, morphological changes without connective tissue instability Distorsion (sprain): caused primarily by indirect trauma, morphological changes without connective tissue instability Unstable injuries Unstable injuries Simple or one dimensional injuries: caused by frontal or sagital forces Simple or one dimensional injuries: caused by frontal or sagital forces Medial, lateral, dorsal and ventral instability

Injuries of the knee: bony injuries Fractures of the osseus components Fractures of the osseus components patellar fracture fracture of femoral condyles fracture of tibial plateau

Ligamentous injuries of the knee Complex or rotational instability Complex or rotational instability Caused by forces acting in more than one plane Types: anteromedial, anterolateral, posterolaterális, posteromedial instability Combined complex instability Combined complex instability Caused by forces acting in more than one plane, one of which is stronger and lasts longer Possible combinations: Anteromedial and posteromedial Anteromedial and posteromedial Anteromedial and anterolateral Anteromedial and anterolateral Anterolateral and posterolateral Anterolateral and posterolateral Knee dislocations are also placed in this category Knee dislocations are also placed in this category

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

Diagnosis of knee injuries Physical examination Physical examination X-ray (roentgenogram) in 2 views (A-P and side views) with tangential patellar view can give information regarding possible bone injuries X-ray (roentgenogram) in 2 views (A-P and side views) with tangential patellar view can give information regarding possible bone injuries Ultrasound Ultrasound CT CT MRI MRI Arthroscopy Arthroscopy

Examination of the knee History History Direction of force Direction of force When did pain start When did pain start Mobility following injury Mobility following injury When did swelling start When did swelling start Is there catching in the joint Is there catching in the joint Observation Observation Observable skin changes, deformities, axis deformities, movement difficulties, ability to walk Observable skin changes, deformities, axis deformities, movement difficulties, ability to walk Palpation: paraarticular and intraarticular fluid collection Palpation: paraarticular and intraarticular fluid collection Localization of pain Localization of pain

Examination of stability Patient supine and always compare both sides Patient supine and always compare both sides Active and passive movements Active and passive movements Testing varus and valgus with knee extended (abduction and adduction stress test) Testing varus and valgus with knee extended (abduction and adduction stress test) Abduction and adduction tests with knee in 30 degree flexion Abduction and adduction tests with knee in 30 degree flexion Abnormal movement in sagital plane Abnormal movement in sagital plane

Examination of stability Anterior drawer sign Anterior drawer sign Lachmann test Lachmann test In fresh injuries this is easier than anterior drawer as there is no need to bend the knee 90 degrees Posterior drawer sign Posterior drawer sign Special tests Special tests Pivot shift test for chronic injuries

Testing for stability

Treatment of knee injuries Conservative treatment: rest, icing, bandaging, brace, cast Conservative treatment: rest, icing, bandaging, brace, cast Surgical treatment: open surgery, arthroscopy Surgical treatment: open surgery, arthroscopy

Bone tendon bone graft for LCA replacement

Replacement of lateral collateral ligament using a graft

Replacement of medial collateral ligament using a graft

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