Internal

Derangements of
Knee
Dr.SHANAVAS E.K
MS (Ortho), D.Ortho, DNB

Associate Professor,
MCH, Trivandrum

Internal derangements of the

knee (IDK)
It is a term used to cover a group of
disorders involving disruption of the
normal functioning of the ligaments
or cartilages (menisci) of the knee
joint.

Aetiology
Physical trauma is the cause of the vast majority of

IDKs.
The majority of acute knee injuries result from a
valgus and/or twisting strain. Most commonly, they
involve the medial joint structures and the anterior
cruciate ligament.
The type of physical trauma causing IDK may be a
sports injury, a road traffic accident or an
occupational stress; by far the most common at the
present time is a sports injury.

MOB
TCD

Anatomy of Knee Joint

The knee joint is the largest joint in

the body
One of the most frequently injured
Synovial condylar joint
Knee has six degrees of freedom,
three translations and three
rotations
Flexion and extension occur
between femur and menisci
Rolling occurs above the meniscus,
Rotation between menisci and tibia
Gliding below the meniscus

Gross Anatomy: Skeletal Structure

22

Ligamentous Anatomy
Anterior cruciate ligament

(ACL) prevents anterior

tibial translation

Posterior cruciate ligament

(PCL) prevents posterior

tibial translation

Medial collateral ligament

(MCL) protects against

valgus stress

Lateral collateral ligament

(LCL) protects against

varus stress

Gross Anatomy: Menisci

Fibrocartilaginous structures
Attach to tibia in intercondylar
region
Transverse ligament connects
the anterior horns of each menisci
Vascular periphery (2-3 mm)
Medial meniscus
Oval-shaped
Attached to MCL
Thinner , less mobile
Lateral meniscus
Circular
Thicker, more mobile

Mensci :

History
Mechanism of injury/etiology
Direct trauma (contusion, fracture, bursitis)
Hyperextension (ACL/joint capsule sprain)
Hyperflexion (PCL/joint capsule sprain)
Fall on flexed knee (PCL sprain)
Valgus stress (MCL sprain, meniscus injury)
Varus stress (LCL sprain, meniscus injury)
Rotational stress (ACL sprain, meniscus injury)

MOB
TCD

Knee Joint
The mechanism of the injury is an

important factor in determining

which structure is damaged
Injury to the anterior cruciate
ligament occurs in both contact
and non contact sports
Females are more at risk
particularly gymnastics, skiing,
soccer volleyball and basketball
A rapid effusion into a joint after an
injury is a haemarthrosis and, in
75% of cases, is due to rupture of
the anterior cruciate ligament

The most frequent cause of damage to the medial

collateral ligament is forced valgus injury to the

knee
Lateral collateral ligament injuries are much less
common, as varus stress to the knee occurs much
less frequently than valgus stress.
Anterior cruciate ligament injury occurs from forced
valgus stress to the fully extended knee.
Posterior cruciate ligament injury is liable to occur
in motor car accidents caused by high velocity
trauma, with posterior dislocation of the tibia on a
flexed knee, as in a dashboard impact

Meniscus tears occur when substantial

rotational stresses are applied to the flexed

knee. They are particularly common in
footballers, when the player is tackled from
the side; they are also liable to occur in other
sports such as hockey, tennis, badminton,
squash and skiing.

Ligamentous Injuries
ACL injuries
PCL injuries
MCL injuries
LCL injuries

MEDIAL COLLATERAL LIGAMENT

Anatomy:
MCL is composed of superficial & deep portions
superficial MCL
anatomically this is the middle layer of the Medial compartment
proximal attachment: posterior aspect of medial femoral
condyle.
distal attachment: metaphyseal region of the tibia, upto 4-5 cm
distal to the joint, lying beneath the pes anserinus

Medial Collateral
Ligament
Attached to fibrous

capsule and MM
Injury rarely isolated
unhappy triad
Can tear with external
rotation (skiing), but
more commonly from
valgus or abduction
force (football)
Pain localized to medial
joint line, but can
subside following
Grade III tear
Leads to further injury

MCL: Diagnosis:
Examination
Abduction stress test
First at 30
Again at full extension

Rule out PCL tear

Anterior drawer test

with external rotation of

tibia
Hip flexed 45
Knee flexed 90
Tibia rotated 30 ext.
Anterior rotation of

medial tibial condyle

Examination
Findings:
valgus stress test
clinical findings may be subtle even with complete injury;

it is helpful to anchor the thigh on the table with the knee

and leg off the edge of the table;

opening of 5-8 mm compared to opposite knee may

indicate complete tear;

determine the point of maximal tenderness to determine

whether the tear has occurred proximally, mid-substance,
or distally;

instability in slight flexion:

anterior portion of the medial capsule is primary
stabilizer at 30 deg of flexion;
hence at 30 flexion, testing is specific for just MCL;

instability in extension:
posterior portion of the MCL, posterior oblique
ligament, ACL, medial portion
of posterior capsule & possibly PCL;

MCL: Diagnosis: Imaging

X-ray
Only useful for young

patients to differentiate
from epiphyseal fracture
Taken at 20-30 flexion

Enlarged joint space = tear

MRI
Coronal scan
Normal MCL looks thin,

taut, low-signal
Grade I: indistinct MCL
(edema)
Grade II: thicker, looser
Grade III: severe edema

MCL: Treatment
Surgery necessary for

compound injury
Crutches + PRICES +
rehab for Grade I, II
only if isolated
Grade III tears may
require surgical repair,
but immobilization can
be effective if isolated
(rare)
3-4 months recovery

Surgery
Open incision
Midsubstance

ruptures sutured
Tear from bone
repaired with suture
anchors

TREATMENT
Non Operative Treatment:
optimum healing of the medial collateral ligament occurs when

the torn ends are in contact

healingpotential is directly related to size of the gap between the
torn ends
healing of extra-articular ligaments is analogous to healing of
other soft tissue structures,through production and remodeling
of scar tissue
maturation of scar occurs from 6 weeks to upto one year
although the maturing scar tissue has only about 60% of the

strengh of the normal MCL,ultimate load to failure is unchanged

(since the amount of scar tissue is larger thanoriginal
ligamentous tissue)

Lateral Collateral
Ligament
Courses slightly posterior
Sprained least frequently
Adduction force rare
BF, popliteus, IT tract

Flexed knee = isolated

tear
Anteromedial blow
hyperextension/ posterolateral corner injury
Risk to common peroneal
nerve
Foot drop, sensation loss

Lateral collateral
ligament
Discussion
lateral collateral ligament is primary restraint to varus
angulation
LCL also acts to resist internal rotation forces
cutting of LCL in combination with either anterior or
PCL results in large increase in varus opening

LCL: Diagnosis:
Examination
Adduction stress test
At 30, then full extension
Ext. rotation recurvatum
Lift legs by great toes
Recurvatum + ext rotation +
varus = PL corner injury
Posterolateral drawer test
Tibia externally rotated,
posterior force applied
Reverse pivot shift test
Knee 90, tibia ext. rotated
With valgus, slowly extended

Temporary posterior subluxation

of lateral tibial condyle around

30
Forcibly reduces with extension

LCL: Imaging and

Treatment
MRI
Coronal oblique scan
Sagittal scan to rule

out fibular fracture,

avulsion
Tear looks less taut
or discontinuous
no thickening

Treatment
Similar to MCL
Grade III usually

requires surgery

Anterior Cruciate Ligament (ACL) :

Attached to the anterior intercondylar area
of the tibia , passes upward , backward &
laterally to get attached to the lateral femoral
condyle .
Prevents posterior displacement of the
femur ( With the knee joint flexed , the ACL
prevents the tibia from being pulled
anteriorly)

FUNCTIONAL ANATOMY OF ACL

The ACL is a broad ligament joining the anterior

tibial plateau to the posterior intercondylor notch.

The tibial attachment is to a facet, in front of &
lateral to anterior tibial spine.
Femoral attachment is high on the posterior aspect
of the lateral wall of the intercondylar notch.
It is composed of multiple non-parellel fibres which
though not anatomically separate, act as two
distinct bundles i.e. anteromedial & posterolateral

FUNCTIONS
The biomechanical function of the ACL is
complex for it provides both mechanical
stability & proprioceptive feedback to the
knee.
In its stabilising role it has four main
functions;
1.Restrains anterior
translation of tibia.
2.Prevents
hyperextention of knee.
3.Acts
as a secondary stabiliser to valgus stress,
reinforcing medial collateral ligament.

MOB
TCD

ACL Bundles
The ACL consists of a smaller

anteromedial and a larger

posterolateral bundle, which twists
on itself from full flexion to extension
The posterolateral bundle is larger
and longest in extension and resists
hyperextension
The taut ACL is the axis for medial
rotation of the femur, during the
locking mechanism of the knee in
extension
Hunziker et al.,1992

ACL

Anterior Cruciate
Ligament
Most common knee injury

among athletes
AM fibers taut in flexion
Check anterior displacement

PL fibers taut in extension

Check rotation
Hyperextension, internal

rotation rarely isolated

injury from contact force
unhappy triad
May tear from tibia (3-10%),
from femur (7-20%), or in
midportion (70%)

(LEFT KNEE)

Proximal end receives branch

from middle genicular a.

Internal rotation of right knee

The four "classic" symptoms

when the ACL is torn
Hear a "pop" from inside the

knee
Feel the knee give away at
the time of injury
Swollen immediately, or
within a few hours
Severe pain can not continue
play

ACL: Diagnosis:
Examination
History, large hemarthrosis
Autonomic symptoms
Anterior drawer test
Tibia neutral, pull ant.
NOT RELIABLE BY ITSELF

Lachman test
Knee only flexed 15-20
Pivot shift/jerk test
Start in extension, tibia

internally rotated, valgus

Slowly flex, lateral tibial condyle
temporarily subluxates
anteriorly ~30
Reduces with further ext.
Jerk test opposite (90 o)

Examination
ANTERIOR DRAWER TEST
With the knee flexed to 90*, verification of relaxation of hamstrings is
confirmed. With foot stabilised & in neutral rotation, a firm but gentle grip
on the proximal tibia is achieved.

An anterior force is applied to the proximal tibia

with a gentle to & fro motion to assess for increased

translation compared to contralateral knee. 5mm is
the upper limit of anterior tibial displacement
normally.

LACHMANS TEST
One hand secures

and stabilises the

distal femur while
the other hand
grasps the proximal
tibia.

A gentle anterior

translation force is
applied to the proximal
tibia.

PIVOT SHIFT TEST

Patient rotated 20* from supine towards the

unaffected side. With slight distal traction on the

leg,a valgus & internal rotation force is applied
to the extended knee.

ACL: Diagnosis: Imaging

X-ray
Segond fracture of

lateral tibial condyle

ACL tear with it 75100%

Tibial spine avulsion

in young patients

MRI 95%

accuracy
All 3 planes in full

extension
Edema/hemorrhage
often obscures ACL
Normal ACL

Torn ACL

Roentgenographic studies:
Plain roen.often are normal, however,a tibial

eminence fracture indicates an avulsion of the tibial

attachment of ACL.MRI is the most helpful.

Anterior

translation of
tibia as a
secondary sign of
ACL tear.
Tangential line to
the posterior
margin of tibia
passes through
the posterior horn
of lateral
Meniscus
(uncovered
meniscal sign).
In normal knee,
this line passes

Rupture of ACL causes significant short term &

long term disability.

With each episode of instability there is

subluxation of tibia on the femur, causing

stretching of the enveloping ligaments &
abnormal shear stress on the menisci & on the
articular cartilage.
Delay in the diagnosis & treatment gives rise to

increased intrarticular damage as well as the

stretching of secondary capsular ligaments.

Severity
Grade I A mild injury that causes only

microscopic tears in the ACL. Although

these tiny tears may stretch the ligament
out of shape, they do not affect the
overall ability of the knee joint to support
your weight.
Grade II A moderate injury in which the
ACL is partially torn. The knee can be
somewhat unstable and can "give away"
periodically when you stand or walk.
Grade III A severe injury in which the ACL
is completely torn through and the knee
feels very unstable.

Most ACL injuries are severe Grade III

10% - 28% being either Grade I or Grade II.

TREATMENT OF RUPTURED ACL:

Conservative or non-operative Rx
Surgical Rx
Indications of non-operative Rx
isolated ACL tears ; likely to be succesfull in patients

with partial tears & no instability symptoms.

complete tears & no symptoms of knee instability
during low demand sports who are willing to give up
high demand sports
Who do light manual work or live sedentary habits
Whose growth plates are still open(children)

Non surgical
Precautions
Modification of active lifestyle to avoid

high demand activities

Muscle strengthening exercises for life
May require knee brace
Despite above precautions ,secondary
damage to knee cartilage & meniscus
leading to premature arthritis

ACL injuries usually

combined
With the menisci (50 %)
With articular cartilage (30

%),
With collateral ligaments
(30%),
In football players and skiers,
consists of injuries to the ACL,
the MCL and the medial
meniscus.
In cases of combined injuries, surgical treatment
may be warranted and generally produces better
outcomes

OPERATIVE RX
INDICATIONS
Patients with knee instability, pain, swelling or

giving way should consider surgical

reconstruction of the knee.
In some cases reconstruction is necessary

because of damage to menisci or articular

cartilage of the knee.
Progressive premature degenerative changes in

patients with unstable knee may also be an

indication.

Surgical Intervention and

Considerations
ACL tears are not repaired using suture
Replaced by a graft made of tendon
Long-term success rates of over 95 percent
The goal is
prevent instability
restore the function of the torn ligament
allows the patient to return to sports

Not performed until several weeks after the

injury

To allows the swelling decreases, inflammation

subsides, and range of motion improves

Patient Considerations
Active adult patients: consider surgical

treatment
Young children or adolescents: delay ACL
surgery until the child is closer to skeletal
maturity if necessary should modify the ACL
surgery technique

Cruciate Ligament Reconstruction

Complete excision

followed by graft insertion

Allograft
Autograft
Patellar, quadriceps,
hamstrings, calcaneus
tendons used
Undergoes biological
modifications: inflamed,
necrotic
revascularization
extrinsic fibroblasts
repopulate

The grafts commonly

used
Autograft
Patellar tendon
Hamstring tendon
Quadriceps tendon

Allograft (from a
cadaver)
Patellar tendon,
Achilles tendon,
Semitendinosus,
Gracilis, or posterior
tibialis tendon

Surgical technique

POSTERIOR CRUCIATE LIGAMENT:

ANATOMY
Intra-articular but extrasynovial, static stabiliser of

knee:
composed of two major parts:Large anterior part that

forms the bulk of the ligament & a smaller portion that

runs obliquely to the back of tibia.
PCL is attached proximally to the posterior part of the

latral surface of the medial condyle.The tibial

attachment is to a depression behind & below the
intra-articular portion of tibia with a slip usually
blending with the posterior horn of the latral meniscus.

Functions
provides restraint against hyperextension,
against posterior displacement of tibia in flexed

knee,
internal rotation of the tibia &
valgus/varus angulation-particularly in extended

knee.

Posterior Cruciate
Ligament
Broader, longer, stronger
PM and AL fiber bundles
Receives better vasc. from

MGA, synovial membrane

Checks post. displacement
Tears much less frequently
Only in isolation when

dashboard knee injury

Hyperextension in sports,
especially with side force
Falling to ground with foot
plantar flexed

Posterior view
Medial
femoral
condyle

Anterior view

Posterior Cruciate
PCL is the strongest ligament

of knee
It tends to be shorter
More vertical
Less oblique
Twice as strong as ACL
Closely applied to the centre of
rotation of knee
It is the principle stabiliser
Hunziker et al., 1992

MOB
TCD

PCL: Diagnosis
Posterior drawer test
Neutral start vital!

Gravity or sag test

Hips at 45 or 90,

compare tibial
tuberosities for sag
Abduction/adduction
stress test at full
extension
X-ray to confirm sag test
MRI shows lower-signal
intensity for intact PCL
compared to ACL due to
its fiber organization
Take on all 3 axes, but

best is sagittal oblique

negative

positive

POSTERIOR DRAWER TEST

With knee flexed to approx. 90*, verification of

complete relaxation of hamstrings is confirmed by

palpation .

QUADRICEPS ACTIVE
TEST:

It is performed with
the knee flexed to
80deg & in neutral
rotation.Its starting
point is in effect the
tibial drop back
test.

MRI studies are more reliable for diagnosis of

PCL tears than ACL tears.

TREATMENT OF PCL INJURIES:

NON-OPERATIVE TREATMENT:

The quoted criteria for non-operative RX include:

(1).A posterior drawer test of < 10mm with the

tibia in neutral rotation(posterior drawer excursion

decreases with internal rotation of tibia on femur).
(2). < 5* of abnormal rotatory laxity(specifically,

abnormal external rotation of the tibia with the

knee flexed 30*,indicating posterolateral
instability).
(3).No significant valgus-varus abnormal laxity.

OPERATIVE TREATMENT
Reconstruction is usually delayed for 1 to 2 weeks
after injury to allow painful intra-articular reaction
to subside & to allow the patient to regain full
motion and some strength.
Clinically, isolated acute PCL disruptions are

repaired if the ligament is avulsed with a fragment

of bone.
Knee is examined arthroscopically before any open

surgical procedure.

PCL Reconstruction
Usually allograft

calcaneus tendon
Incorporates well
with long-term
stability
BTB and ST often
too short
Can achieve full
function with
reconstruction of
just AL bundle

A. Low-power view cross section of PCL 11

years after calcaneus tendon graft. B. High-

MENISCUS
INJURY

Anatomy
The menisci are C-shaped or semicircular

fibrocartilaginous structures with bony attachment

at anterior and posterior tibial plateau. The medial
meniscus is C-shaped, with a posterior horn larger
than the anterior horn in the anteroposterior
dimension.
The capsular attachment of medial meniscus on the

tibial side is referred to as the coronary ligament. A

thickening of the capsular attachment in the
midportion spans from the tibia to femur and is
referred to as the deep medial collateral ligament.

The lateral meniscus is also anchored

anteriorly and posteriorly through bony

attachments and has an almost semicircular
configuration. It covers a larger portion of the
tibial articular surface than does medial
meniscus

Menisci
Medial meniscus
Larger, C-shaped

Lateral meniscus
Smaller, O-shaped

Medial menisci

Lateral menisci

Nearly semicircular

Nearly circular

Posterior fibers of anterior end Posterior end of meniscus is

continues with the transverse attached to the femur through
ligament
two meniscofemoral
ligaments

Peripheral part attach with

deep part of tibial collateral
ligament

Medial part of tendon of

politius attach to lateral
meniscus

Functions
Make articular surfaces more congruent
Act as shock absorbers
Lubricate joint cavity
Give rise to proprioceptive impulses due to their nerve
supply

Functions
joint stabilization

Tibio-femoral stress reduction

Joint nutrition
Wt transmission abt 40-70 % across the knee joint
As a shock absorber
Increase the tibiofemoral contact area by 40 %
Helps knee in locking mechanism
Prevents impingement of synovial

membrane,capsule etc
Assists and control gliding and rolling motion of
knee

Medial meniscus is more commonly

injured than lateral meniscus and is

usually associated with other ligament
injuries
Seen in abt 71 % of cases,and 5% its
bilateral
Lateral meiscus is less injured
because:
oSmaller in diameter
oThicker in periphery
oWide
oMore mobile

symptoms
Not all meniscal tears are symptomatic
Swelling
Pain along the joint line (tenderness)
Pain when squatting, kneeling or pivoting
Locking of the knee
Giving way snaps, clicks, catches in knee.
Atrophy of quadriceps
Instability of joint

History
Most meniscal injuries can be diagnosed by

obtaining a detailed history.

Mechanism of injury

Meniscus tears are sometimes related to trauma;but

significant trauma is not necessary.

A sudden twist or repeated squatting can tear the

meniscus.
Meniscus tears typically occur as a result of twisting

or change of position of the weight-bearing knee in

varying degrees of flexion or extension.

Meniscal Injuries
May be isolated from

flexion/hyperflexion with
rotation of the knee
pinched between tibia
and femur

Often injured in association

with cruciate ligament

injury

Classic symptoms include

joint line pain and clicking

or locking helpful but not
definitive evaluative tools

Limited reliability of special

tests

Physical findings
Joint line tenderness
Joint line tenderness is an accurate clinical sign.

This finding indicates injury in 77-86% of patients

with meniscus tears. Despite the high predictive
value, operative findings occasionally differ from
the preoperative assessment.
The examiner must differentiate collateral ligament

tenderness that may extend further toward the

ligament attachment sites above and below the
joint line.

Provocative maneuvers
These techniques cause impingement by creating

compression or shearing forces on the torn

meniscus between the femoral and tibial surfaces.

 Apleys compression test positive

Pt in prone position,fixing the thigh against

the table,the examiner presses the foot and leg
downward while rotating the tibia,pain implies
meniscal lesion.pain on lateral rotation
indicates a medial meniscal tear

The McMurray test:

This maneuver usually elicits pain or a reproducible
click in the presence of a meniscal tear.
The medial meniscus is evaluated by extending the
fully flexed knee with the foot/tibia internally
rotated while a varus stress is applied.
The lateral meniscus is evaluated by extending the
knee from the fully flexed position, with the
foot/tibia externally rotated while a valgus stress is
applied to the knee.
One of the examiner's hands should be palpating
the joint line during the maneuver.

The Steinmann test:

Tibial rotation is performed with the patient seated
and the knee flexed 90*.Asymmetric pain is created
with external (medial meniscus) or internal (lateral
meniscus) rotation.

The Apley test:

This maneuver is performed with the patient prone
and the knee flexed 90*. An axial load is applied
through the heel as the lower leg is internally and
externally rotated. This grinding maneuver is
suggestive of meniscal pathology if pain is elicited at
the medial or lateral joint.

Meniscal Tears
Shear force from femur
Acute or degenerative
Athletes, elderly,

overweight
Vascular zone?
Horizontal
Within substance

Longitudinal
Bucket handle ACL risk

Radial or vertical
Parrots beak

Medial Meniscus Tear

Tears easier than

lateral due to certain

traits
Squatting
Internal rotation of tibia
with knee flexed
Member of unhappy
triad
Medial meniscus
MCL
ACL

Medial Meniscus:
Diagnosis
Examination
McMurrays test
Apleys compression

test

MRI
Low-signal intensity

(black triangle ) =
normal
White interruption =
lesion

Arthroscopy as last

resort

Medial Meniscus:
Treatment
PRICES for isolated and minimal tear
Partial arthroscopic meniscectomy most

common

Lateral Meniscus Tear

Lower incidence
Often more painful
More likely to incur

radial or parrots
beak
Not rare for anterior
horn
Discoid meniscus
Wrisberg variety
Congenital (1.5-

3%)
MM only 0.1 0.3%

femur
Discoid
meniscus

Lateral Meniscus:
Diagnosis/Treatment
Same techniques as

for medial meniscus

McMurrays test and
Apleys test
performed with
internal tibial
rotation
MRI slightly less
accurate than with
MM
Treatment similar

Imaging Studies
Plain radiography: An AP weight-bearing view, PA

45* flexed view, lateral view and Merchant

patellar view should be obtained to rule out
degenerative joint changes (arthritis) or fractures
Arthrography: Historically, arthrography was the

standard imaging study for meniscal tears but it

has been replaced now by MRI.
MRI: This is the standard imaging study for

imaging meniscus pathology and all intra-articular

disorders.

Most meniscal tears do not heal without

intervention.
If conservative treatment does not allow the patient

to resume desired activities, his or her occupation,

or a sport, surgical treatment is considered.
Surgical treatment of symptomatic meniscal tears is

recommended because untreated tears may

increase in size and may abrade articular cartilage,
resulting in arthritis

 Partial meniscectomy is the treatment of choice

for tears in the avascular portion of the

meniscus or complex tears that are not
amenable to repair.

Meniscus repair is recommended for tears that

occur in the vascular region (red zone or redwhite zone), are longer than 1 cm, involve
greater than 50% of the meniscal thickness, and
are unstable to arthroscopic probing.

Total meniscectomy
Partial meniscectomy
Meniscal repair
Inside out
Outside in
All inside

THANK YOU