Académique Documents
Professionnel Documents
Culture Documents
Group members
1. Nor Hidayah binti Borhan A131887
2. Nur Khairunnisa binti Raja Mohammad A139354
3. Nurul Aqilah binti Ab Rahman GA02491
4. Muhd Fahimi bin Mustapa A136380
5. Noor Nelza Nadia binti Abd Wahad A139959
6. Kavireshna a/l kanabari GA02454
7. Komathi a/p chow kwai ying A131833
8. Ezzah Bazillah binti Zaharin A139525
9. Luqman Hakim bin Ahmad Zaini A136146
10. Nur Hanisah binti Hishamudin A136215
KNEE ANATOMY
3 3
joints compartme
: nts:
Lateral Median
Femorotib Femorotib
ial ial
Femoropat
ellar
: extracapsular
:intracapsular
Smaller
More moveable:
only attachment to
medial femoral
condyle via
posterior
meniscofemoral
ligament
C-shaped, broader
Less moveable:
attached to
intercondylar are +
deep surface of LCL
Descen. Femoral a.
Branch of
lateral Descen. Popliteal a.
femoral Genicular
circumflex a.
a.
Superior Superior
lateral medial Middle
genicular a. genicular a. genicular a.
GENICULAR Cruciate
ANASTOMOSES
Inferior Inferior ligament
lateral medial Synovial
genicular a. genicular a. memb.
Menisci
margins
Anterior Circumflex
tibial fibular a.
recurrent a.
Anterior Posterior
tibial a. tibial a.
Femoral
nerve
Articular Cutaneous
branches branches
Common
Tibial peroneal Obturator
nerve nerve nerve
Saphenous
Anterior nerve
Posterior
Lateral
ACL runs between the tibial plateau
anteriorly and the lateral femoral condyle
posteriorly
Dual-bundle
Anteromedial (AM) bundle
Functions:
Prevent anterior tibial displacement
Prevent hyperextension of knee
Provide rotational stability
PCL runs between the tibial plateau posteriorly and the
medial femoral condyle anteriorly
Dual-bundle
Anterolateral (AL) bundle
Posteromedial (PM) bundle
Functions
Prevent posterior tibial displacement
Prevent hyperextension of knee joint
Secondary action includes resistance to varus, valgus, and
external rotation
ANTERIOR CRUCIATE LIGAMENT
+ve anterior Drawing test
+ve Lachmans test
PCL ACL
Mech. Of Anterior force, hyperextension No contact: sudden twist,
injury with foot in dorsiflexion (exp: in (exp: landing from jump)
football tackle)
Contact: Blow to the lateral side of the
extended knee.
Anterior force on flexed knee
(exp: dashboard injury)
PCL ACL
Symptoms Knee swelling, stiffness Knee swelling (haemathrosis- rapid and
Painful knee doughly feeling)
Instability sensation esp when Pain, esp when trying to put wt on
descends stairs injured leg
Popping sound knee gives way
Popping sound
LATERAL
COLLATERAL
LIGAMENT
SUPERFICIAL
MEDIAL
COLLATERAL
LIGAMENT
MEDIAL LATERAL
COLLATERAL COLLATERAL
LIGAMENT LIGAMENT
Valgus force
from lateral
knee
Varus force
from medial
knee
PRESENTATION
LCL MCL
Rehabilitation
Bracing
Physiotherapy- strengthening exercise
MENISCUS INJURY
Anatomy
Semilunar shaped fibrocartilage
3 parts:- ant,post horn,lateral OR
-red zone(outer 1/3), redwhite zone, white zone
Branches of geniculate arteries
medial meniscus
-the anterior horn attach to ACL in the
intercondylar area
-lateral aspect attach to MCL(not mobile)
-posterior horn is attach to the posterior
intercondylar area
lateral meniscus
-the anterior horn attaches immediately lateral
to ACL insertion.
-posterior horn attaches to the posterior
intercondylar area anterior to the medial
meniscus and posterior to ACL insertion
-lateral not attach to LCL
Fx of menisci:
1. increase stability of knee
2.Shock absorption
3.Distribute load during movement
Mechanism of injury
fall in flexed knee with twisting strain
(eg: football,rugby)
-torn of medial meniscus >>>> lateral
meniscus d/t *attach to MCL
*larger
Type of tear
Bucket handle tear
-split is vertical and rus along circumference of
meniscus : loose body may displace toward into
joint and cause locking
horizontal tear
-usually degenerative or repeated trauma
-some a/w meniscus cyst
Symptoms
1. Severe pain at joint line post trauma
2. Locking in partial flexion (bucket
handle)
3. Swelling but late(hours or next days)
Loose tag
Complication
Articular damage
inflammation
Synovial effusion
Secondary OA
Examination
1. Swelling, bruises, bleeding, scar, quad wastg
2. Temp, tenderness jt line, menicus, effusion
3. Rom, locking
4. Mcmurray test, grinding test
1. MRI Investigation
-absent bow tie sign
Double PCL sign
Management
Requires high-energy
trauma to produce
dislocation (eg. road
accident)
Tearing of at least 3
stabilizing ligaments
cruciate ligaments (A/P)
one or both collateral
ligaments (lateral/medial)
Causes: Trauma (MVA, sport injuries, severe
fall)
EMERGENCY!
- limb threatening injury popliteal artery
disruption/thrombosis
CLASSIFICATION
(POSITIONAL)
Describes position of the tibia relative to the femur
Anterior (severe knee hyperextension)
Posterior (dashboard injury)
Lateral
Medial
Rotatory
2) Posterior dislocation
-force on flexed knee
-risk of popliteal a. injury inc. with increasing displacement
-a/w PCL, ACL tear A P A P
B A
3)Lateral dislocation
-valgus force
-a/w MCL, ACL, PCL tear Dimple sign
4) Medial dislocation
-varus force
5)Rotatory dislocation
-rotatory force
*All type of dislocation will a/w rupture of cruciate
ligament(ACL/PCL) +/- collateral ligament
Symptom Sign
59
Treatment Reduction under anaesthesia is urgent
-if it is achieved, the limb is rested on a
backslab with the kneein 15 degrees of flexion
Postreduction assessment
-Repeat AP and lateral radiographs
-Vascular and neurological status examination
60
Complication
Acute Chronic
12/2/2017 62
Patellar dislocation/instability
12/2/2017 63
Patellar dislocation/instability
Risk factors:
Trauma
Pes planus
Genu valgum
Weak VMO
12/2/2017 64
Patellar dislocation/instability
Hx:
Feel a pop and immediate pain
Obvious knee deformity
Painful, difficult to bend knee
May spontaneously relocate, left with feelings of
instability
12/2/2017 65
Patellar dislocation/instability
PE:
Laterally shifted
patella
Patellar
apprehension
Swelling
12/2/2017 66
Patellar dislocation/instability
Imaging:
Standard knee x-rays
a good start
MRI
12/2/2017 67
Treatment
Reduction
Plaster backslab with knee in
extension ( 3 weeks)
Quadriceps strengthening exercise
(2-3 months)
12/2/2017 68
Complication
Recurrent dislocation
Predisposing factors:
Non-operative tx for the first-time dislocation.
Ligamentous laxity
High-riding patella
Valgus deformity
Shallow patellofemoral groove
12/2/2017 69
Patellar dislocation/instability
Prognosis
Recurrent instability is common, but rehab is
mainstay and very useful
When to refer
Associated fracture
Poor response to rehab
Multiple dislocations (#?) & skill level
12/2/2017 70
Quadriceps and Patellar Tendon
Rupture
Anatomy
The quadriceps tendon
and the patellar tendon
are parts of the
extensor mechanism of
the knee
Types
a) Partial : The soft tissue
is not completely
disrupted
b) Complete : The soft
tissue split into 2
Mechanism of Injury
Occurs during a rapid, eccentric contraction of
the quadriceps muscle, with the foot planted
and the knee partially flexed
History of presenting illness
Painful and swollen knee
Tearing and popping sensation
Unable to straighten the knee
Difficulty walking due to the knee buckling or
giving way
Physical Examination
Tenderness at site of rupture
Suprapatellar swelling and ecchymosis
Unable to extend knee against resistance
Unable to perform straight leg raise test with
complete rupture
Investigations
X-ray showing normal location of The kneecap has moved out of place
knee cap due to a torn of quadriceps tendon
In an x-ray, if the patella is located:
Too high : Patellar tendon rupture (patella alta)
Too low : Quadriceps tendon rupture
supporting both
osteogenesis and
chondrogenesis.
1. Plain radiography
(anteroposterior, lateral, and tunnel views) shows:
OCD lesions as well-circumscribed crescent-shaped
areas of radiolucency above an area of subchondral
bone, separated from the femoral condyle. In 75% of
cases, the lesion is located on the posterolateral aspect
of the MFC. MRI can obtain similar data.
2. MRI
can obtain similar data.
How to manage this patient??
Observation and Activity Changes
In most cases, OCD lesions in children and young teens will
heal on their own, especially when the body still has a great
deal of growing to do. Resting and avoiding vigorous sports
until symptoms resolve will often relieve pain and swelling.
Nonsurgical Treatment
If symptoms do not subside after a reasonable amount of time,
your doctor may recommend the use of crutches, or splinting
or casting the affected arm, leg or other joint for a short
period of time.In general, most children start to feel better
over a 2- to 4-month course of rest and nonsurgical
treatment. They usually return to all activities as symptoms
improve.
Surgical Treatment
Your doctor may recommend surgery if:
1.Drilling into the lesion to create Replacing the damaged area with a
pathways for new blood vessels new piece of bone and cartilage
to nourish the affected area. This Holding the lesion in (called a graft). This can help
will encourage healing of the place with internal regenerate healthy bone and
surrounding bone. fixation (such as pins cartilage in the area damaged by
and screws). OCD.
Complication??
A nonunion of the OCD fragment may occur
and progress to dissociation, leading to intra-
articular loose body symptoms. This, in turn,
may lead to a type of reconstructive procedure
such as OATS or ACI (see Surgical Intervention
in Acute Phase). Regardless of treatment,
degenerative articular changes may develop
over time
STAGES I II III IV V VI
Markedly displaced Treadted by open reduction and int fixation (w lag screws and
and/or communited # buttress)
of lateral condyles Bone graft done at area of depression
# of medial condyles Best treated by open reduction and fixation with buttress plate and
screws
Repairing lateral ligament (may ass/w lat ligament)