Knee disorders

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Knee disorders
Salsabeel Matalqah
Medical ppt
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Menisci Tears
Common among young active adults. Common in
Football players flexion of knee joint in
addition to twisting. Little force is needed in
middle aged, because fibrosis restricts mobility
of meniscus. After age 50, tears are more
commonly due to arthritis than trauma. Medial
Menisci more prone to injury because of its
restricted anatomy due to attachment to the joint
capsule and to the tibial collateral ligament
make it less mobile.
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Meniscus Tears

• Classification according to
• Mechanism ( traumatic Vs degenerative)
• Pattern of tear ( bucket handle Vs horizontal.
  ).

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Menisci Tears
Patterns of tears Bucket-Handle Tears The
split is vertical, along the circumference of the
meniscus leaving anterior and posterior segments
attached loosely. Sometimes the torn part
displaces towards the center, causing locking
(extension block).
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Menisci Tears
Horizontal tears Usually degenerative in origin
or due to repetitive minor trauma, or with
association with meniscal cysts. Generally
speaking, most of the meniscus is avascular,
except the outer third-from capsule-, due to this
spontaneous repair doesnt occur. The loose part
act as a mechanical irritant causing recurrent
synovial effusion, and in severe cases secondary
osteoarthritis.
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Menisci Tears

• Clinical Features
• Patients may complain of pain at the joint line
  area, locking, clicking, giving way, and swelling
  with activity.
• In ptn gt40yrs the main complaint is recurrent
  giving way or locking.
• Physical exam
• Joint line tenderness (Mostly medial).
• Joint held slightly flexed.
• Joint effusion may be present.
• In late cases quadriceps are wasted.
• Flexion is full , extension limited.

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• _ Joint line tenderness
• the most imp and specific test
• _ Apleys grind test
• Isolates meniscii
• Prone with knee flexed,axial load
• and rotation.
• - McMurrays test
• Flex/ext with varus/valgus and
• int/ext rotation.
• Goal is to get torn piece to pop
• in and out of place.
• Positive if pop or reproduction of pain.

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Menisci Tears
Imaging X-ray Normal MRI most useful may
reveal tears missed by arthroscopy Arthroscopy
Diagnostic and therapeutic. You have to be
certain that the lesion you can see is the one
causing the patients symptoms. Treatment Most
meniscal tears do not heal without intervention.
If conservative treatment does not allow the
patient to resume desired activities, occupation,
or 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.
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Menisci Tears

• Treatment
• Conservative treatment of meniscal injuries
  begins with RICE (Rest, Ice, Compression, and
  Elevation).
• Arthroscopy is the preferred method.
• peripheral tears surgery.
• The displaced portion should be excised.
• Postoperative physiotherapy.

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Recurrent patellar dislocation

• Anatomy of patella Soft tissue elements affecting
  the patella are the stabilizing capsular and
  ligamentous structures within which the patella
  lies. Some ligaments of the knee are continuous
  with the fibrous capsule surrounding the patella.
• When injuries occur, all structures are
  simultaneously affected. These ligaments hold the
  patella in place during static and dynamic
  phases.

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Recurrent patellar dislocation

• The knee is normally in slight valgus so there is
  a natural tendency for the patella to pulled to
  the lateral side when the quadriceps muscle is
  contracted
• Traumatic dislocation is due to sudden sever
  contraction of the quadriceps muscle while the
  knee is stretched in valgus and external
  rotation.
• The patella dislocates laterally and the medial
  retinacular fibers may be torn
• 15-20. of patient with patellar dislocation
  will have recurrent episodes.
• It may develop without initial trauma

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Recurrent patellar dislocation

• The predisposing factors are
• 1- generalized ligamentous laxity .
• 2- under development of lateral femoral condyle
  and flattening of the intercondyler groove.
• 3- maldevelopment of the patellatoo high or to
  small .
• 4- valgus deformity of the knee.
• 5- primary muscle defect.

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Clinical features

• Females gt males .
• Often bilateral
• c/o
• -acute pain tearing sensation
• - knee is stuck in flexion and the patient may
  fall. Often the patella is repositioned
  spontaneouslly
• if the patella remain unreduced
• Medial mass because the uncovered medial
  femoral condoyle stand out prominently- NOT THE
  PATELLA-.
• no active or passive movement is
  possible
• On exam
• - Tenderness on the medial side of the joint.
• Swelling .
• Aspiration may reveled a blood stained effusion .
• positive Apprehension test.

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Clinical features CONT.
Apprehension sign. The knee is placed at 30
flexion, and lateral pressure is applied. Medial
instability results in apprehension by the
patient.
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Imaging

• X-ray (includes anteroposterior, true lateral,
  and axial or sunrise views (
• CT scan
• MRI

lateral patellar dislocation (arrows)
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Sunrise (skyline) view
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Recurrent patellar dislocation

• Complications
• -Repeated dislocation damage the contiguous
  surface of patella and femoral condyle which lead
  to further dislocation
• -later Secondary OA.
• Rx
• If still dislocated
• PUSH IT BACK ( gently) cylinder plaster or
  splint is applied for 2-3 weeks
• quadriceps strengthening exercise for 3 months.
• In children
• The patellar mechanism tends to stabilize as the
  child grows but 15 of these children will suffer
  from repeated attacks which will be an indication
  for surgery .
• Role of surgery in recurrent patellar dislocation
  
• 1- to repair or strengthen the medial
  patellofemoral ligament .
• 2- to realign the extensor mechanism.

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Ligament injury

• Anterior Cruciate Ligament
• The Anterior Cruciate Ligament (ACL) is the main
  support structure of the knee that prevents
  rotation of the Femur on the Tibia .The ACL also
  prevents the Tibia from translating forward on
  the Femur. This ligament is injured in sports
  more.

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• The knee is a hinge joint, comprised of three
  bones and four main ligaments. The joint has one
  plane of motion, flexion and extension. Due to
  this construction, a slight amount of rotation
  does occur, but the ligaments limit this motion.
  The three bones are the Femur, Tibia and Patella
  .The four ligaments in the knee are the ACL,
  Posterior Cruciate (PCL), Medial Collateral
  (MCL), and Lateral Collateral (LCL). These
  ligaments connect the Tibia and Femur and provide
  the structural integrity to the knee.

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• The ACL and PCL were named for their location.
  The two ligaments are located in the middle of
  the knee and cross one another (cruciate is Latin
  for cross). The ACL has its origin on the front,
  or anterior, aspect of the Tibia, while the PCL
  originates on the back, or posterior, aspect of
  the Tibia. The MCL is located on the inside, or
  medial, aspect of the knee and the LCL is located
  on the outside, or lateral, aspect of the knee.

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Which ligament is affected?
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History

• History of hyper-extension and twisting injury,
  claim to have heard a pop as the tissue snapped
  (at the time of injury).
• Immediate swelling
• Knee is painful
• Tenderness is most acute over the torn ligament.
  Stressing one or other side of the joint may
  produce excruciating pain

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• P/E
• Physical exam shows a positive anterior drawer
  sign at 30 degrees (Lachman test) and at 90
  degrees.
• drawer test
  Lachman test
• the pivot shift test is also positive.

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Investigation

• Stress x-rays may provide evidence of instability
• Plain x-rays may show that the ligament has
  avulsed a small piece of bone-
• -The MCL usually from the femur
• -LCL from the fibula
• -ACL from the tibial spine
• -PCL from the back of the upper tibia

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treatment
Conservative management is indicated in
patients who can accept modification of
activities that produce instability instability
is thought to put the menisci at risk of damage
Surgical repair is not successful reconstruction
is an individual decision based on the patients
desires and requirements Patients engaging in
competitive athletics generally require
reconstruction the methods vary but generally
use autograft to replace the ACL
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Sprains and partial tears

• Intact fibers splint the torn ones and so
  spontaneous healing will occur
• Adhesions may result, so active exercise is
  prescribed
• Aspirating the haemarthrosis and applying ice
  packs intermittently relieves pain
• Weight-bearing is allowed
• Knee is protected from rotation or angulation
  strains by a heavily padded bandage or a
  functional brace

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Complete tears

• Isolated MCL or LCL treated as above
• Isolated tears of ACL may be treated by early
  operative reconstruction if the individual is a
  professional sportsman
• Cast-brace is worn until symptoms subside,
  thereafter movement and muscle-strengthening
  exercise. This is sufficient in about half of the
  patients as they regain good function and need no
  further treatment.
• Remainder will have varying instability, late
  assessment will identify those who will benefit
  from ligament reconstruction.
• Isolated tears of the PCL are usually treated
  conservatively

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Combined injuries

• In ACL and collateral ligament injury treatment
  starts with joint bracing and physiotherapy to
  restore a good range of movements before ACL
  reconstruction
• Combined injuries involving the PCL the same
  approach is used however all damaged structures
  need to be repaired

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Complications

• Adhesions
• If the knee with a partial ligament tear is not
  actively exercised, torn fibers will stick to
  intact fibers and bone.
• The knee gives way with catches of pain,
  localized tenderness and pain on lateral or
  medial rotation occur
• Confusion with a torn meniscus can be resolved by
  the grinding test or arthroscopy
• Instability
• The knee continues to give way and tends to get
  worse predisposing to osteoarthritis.
  Reconstruction before degeneration is wise.

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