Escolar Documentos
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Cultura Documentos
Chetan Kaushik
M.P.T 2nd year(Ortho)
CONTENTS
MENISCI
Fibrocartilagenous disks.
Improves
congruency of d joint by
inc. concavity.
Med.& lat. Menisci.
Distributes wt. bearing
forces.
Shock absorber
Reduces friction b/t tibia &
femur.
Located on the top of the
plateau.
MED. MENISCUS
C- shaped
Has more lig. & capsular
restrains.
Limited translation so more
inj. They r: Transverse lig.
Patellomeniscal lig.
Coronary lig.
Antero medial meniscus
From med. Capsule, MCL &
reinforced by med.
Retinaculum.
This thickened
capsule is deep
portion of MCL.
Ant. Horn ACL
Post. Horn- PCL
Semimemb.- to
post. Horn, just
ant. To PCL via
capsule.
LAT. MENISCUS
Oval- of a circle.
Post. Attach to PCL & med.
Condyle by
meniscofemoral lig.
If attach ant. To PCL then
called as lig. Of
HUMPHREY.
If post. Then lig of
WRISBERG.
Popliteus tendon via
poplitial hiatus.
No attachment to the LCL
& less to the capsule.
MENISCAL INNERVATION
Nociceptors-innervates
horns & peripheral part
3 mechanoreceptorsA. Ruffini corpuscles
B. Pacinian corpuscles
C. Golgi tendon organs
. Responsible for. Pain
. Propioception
MECHANISM OF INJURY.
Mechanism of injury is a rotational
force when a flexed knee extends.
In young,it can occur only when weight
is being taken,knee is flexed and there
is twisting strain.
Young active athletes are more prone.
In middle life fibrosis has decreased the
mobility of meniscus and hence tear
occurs with less force.
Meniscal instability
Torn meniscus is the most common causes of
mechanical symptoms in the knee.
Pathomechanics
Turning or twisting on a loaded joint (weight bearing)
may trap the meniscus between the joint surface and
tear the meniscus.
This may occurs in combination with other injuries such
as tear of the ACL that produce excessive tibial
displacement on the loaded joint, causing the meniscus
to displace and tear from its peripheral attachment.
With age the meniscus become less compliant and
stiffer subjecting it injury with less force
Clinical Presentation
History
Pain
Catching
Buckling / Giving Way
Joint Stiffness
Antalgic Gait
Joint Line Pain
Shelbourne et al
1995
Medial joint line pain
is 34.5% predictor of
meniscal injury
Lateral joint line pain
is 49.1 % predictor of
meniscal injury
Effusion
Clicking during ROM
Increased Pain in full
flexion
Pain with Squatting
Duck Walk
Radiograph
ODonohues Test
Tests for meniscal tear or capsular
irritation
(+) test is increased pain, clicking, or
popping in the joint line in either one
or both flexion or extension during
internal or external rotation
McMurrays Test
Tests for meniscal injuries
Tibia IR
Indicates lateral
meniscus injury
Tibia ER
Indicates medial
meniscus injury
Diagnostic Tools
Aspiration
Radiologic Exam
MRI
90% accurate in
diagnosing meniscal
injury (Bernstein
2000)
Meniscal Injuries
Arthroscopic View
LIGAMENTS
Provides stability to
the joint by restricting Exec. Knee ext.
Varus & valgus stress
Ant& post
Displacement of tibia.
Med& lat. Rotation of
tibia.
Rotatory stability(A-P
P-A & rotation.)
MCL
On med. Side.
2 portions SUPERFICIAL:- fan
shaped
From med condyle to
proximal tibia(distal to
pes anserinus)
DEEP:From med condyle to
tibial plateau.
attaches With joint
capsule.
&to med. Meniscus
FUNCTION OF MCL
Restricts valgus & lat.
Rotation stresses.
Mainly in extended knee.
In absence of ACLrestricts ant. Translation
of tibia.
Post. Oblique lig.oblique fibers to
semimemb, stops antmed rotation of tibia.
Heals faster- rich blood
supply.
LCL
On lat. Side.
From lat condyle
(proximal to poplitial
tendon) to fibula
head(joins biceps
femoris tendon)
Extra capsular lig.
Restricts varus & lat.
Rotation stresses.
ACL
From- ant. Tibial
spine(med,broad
attachment) to the med
surface of lat condyle.
(semicircle- curved at
post side)
GoesPosterosuperolaterally.
(obliquely.)
Average length-38mm
Width-10mm
Thickness- 5mm
Macroscopically- 2
bundles
Anteromedially(AMB)
Posterolaterally(PLB)
(depends on the
origin 4m tibia)
Increase tension: Knee full ext.-PLB
Knee full flex.- AMB
PCL
From- post tibial spine to lat
aspect of med condyle.
Goessuperomedioanteriorly
(less oblique than ACL)
Average length-31mm
Width-13mm
Macroscopically-2 bands
AMB
PLB
More tension: Full ext- PLB
Full flex.-AMB
Restricts post.
Displacement of
tibia.
Some varus&
valgus stresses.
Short ,thick & less
oblique than ACL.
More tension:- int.
rotation(wraps
around ACL)
Occurrence
75% of ACL rupture occurs in
midstance.
20% are injuries involving the
femoral attachment
5% involve tibial attachment
Pathomechanics
Common mechanism
A valgus force applied to a flexed, externally
rotated knee with the foot planted (or
hyperextension), often combined with
internal rotation.
Less common mechanism
This include hyper flexion or direct valgus
force.
A direct valgus force may produce a tear of
the MCL,ACLand medial meniscus which is
known as the ODonoghue triad.
Grades
Grade 1(sprain): It involves a microscopic partial tear of
the ligament, which over all remains
intact.
Ligament fibers stretched causing
haemorrhage and microscopic disruption
of the structure within the ligament.
No increased laxity compate to
contralateral knee and end points are
firm.
Special Tests
Lachmans Test
Best acute ACL
test
Best on field test
(+) test is a
mushy or
empty end-feel
False (-) if tibia is
IR or femur is not
properly
stabilized
Slocums Test
Tests for multi-planar
instability
ALRI- Anterior lateral
rotary instability
(+) test indicates:
ACL, posterior lateral
capsule, arcuate
complex, LCL & PCL
Diagnostic Imaging
Pathomechanics
Common mechanism
Mechanism of most athletic PCL injuries is the
fall on the flexed knee with foot and ankle
plantar flexed.
eg. In motor vehicle accident, knee is flexed and
the tibia is forced posteriorly on impact with the
dashboard.
Less common mechanism
Injury by the downwardly directed force
appliedto the thigh while the knee is hyperflexed
eg. When landing from a jump
Occurrence
70% PCL disruption occurs on the
tibial side
15% occurs at femoral side.
15% midsubstance tear
Associated injuries with PCL:12% of the chondral
27% of meniscal tear commonly
lateral compartment
Conditions
There is audible crack or pop at the
time of the time of initial injury.
There is mild moderate swelling
within the first 2 to 6 hours
But uplike ACL injuries these
indivdual may return to activity.
Grades
Grade 1(sprain): It involve microscopic tear of the
ligament which overall remains intact.
The ligament fibers are streched,
causing haemorrhage and microscopic
disruption of the structure within the
ligament.
There is no increased laxity compared
with the contralateral knee and the
end point is firm
Godfreys Test
Tests for
posterior cruciate
ligament damage
(+) test is a
posterior
displacement of
the tibial
tuberosity
Diagnostic Testing
Radiographs
MRI
96-100% accurate in
detecting PCL injury
Diagnostic Testing
Normal MRI
Torn PCL
Pathomechanics
Common mechanism
The MCL is injured by a valgus stress to the
knee that exceeds the strength of the MCL
This most commonly occurs froma blow to
lateral aspect of knee during sporting
event
Uncommon mechanism
Non contact valgus injury the knee
Such as which occurs in skiing can produce
isolated tear to MCL
Occurrence
65% of MCL injury involve the femoral insertion site
25% involves tibial insertion
10% involve deep portion of the MCL at the level of
jointline
Conditions : The patient complain hit by another person on
lateral aspect and there is pain on the medial acpect
Swelling occurs quickly. There is ecchymosis in 1to3
days.
The walking of patient is with a limp and with the
knee partial flexed because extension streach the
ligament and cause pain.
Grades
Grade 1(sprain): It involves microscopic tear of the
ligament which overall remains intact
The ligamentous fibres are streched
causing hamorrage and microscopic
disruption
On examination no increase in laxity
compared with the contralateral knee
and the end point are firm
(+) Test in 30
MCL (superficial)
Posterior oblique ligament
PCL
Posterior medial capsule
Grading Sprains
Pathomechanics
Common mechanism
The injury occurs as a result of direct varus stress
to the knee, generally with the foot planted and
the knee in extension
The injury to LCL tends to occur as a result of non
sports high energy activities, because a direct blow
to the medial aspect of the knee is unusual
occurrence in sports.
Varus stress to the knee may also occur during the
stance phase of gait, with sudden imbalance and
shift of the center of gravity away from the side of
injury resulting in tension on the lateral structure.
Occurrence
Condition
There is pop sound in the knee and
lateral knee pain
LCL lesions do not commonly result
in an effusion of the knee.
Grades
Grade 1(sprain): Microscopic partial tearing of the
ligament but ligament overall remains
intact
The ligament fibers are streatched
causing haemorrhage and microscopic
disruption within the ligament
No increase laxity as compare to
contralateral knee, the end point is firm
There is tenderness along the ligament
LCL
Posterior Lateral Capsule
Arcuate Complex
PCL/ACL
(+) Test in 30
LCL
Posterior lateral capsule
Arcuate complex
Grading Sprains
Unhappy Triad
MCL, ACL, Medial
Meniscus
ODonahue
Typically due to a
valgus force with the
foot planted
PFJ Biomechanics
During extension,
patella glides
cranially
During flexion,
patella glides
caudally
Patellar
compression
OKC greatest at end
range (final 30
degrees)
increases in CKC
after 30 degrees of
flexion
Patellofemoral Pain
Syndrome(CHONDROMALACIA
OF THE PATELLA; PATELLOFEMORAL
OVERLOAD SYNDROME))
General term to describe anterior
knee pain
Caused by a variety of factors:
Signs & Symptoms:
Poorly localized P!
Theater sign
Little to no swelling
Pt. Tenderness under lateral patella
Insidious onset
Apprehension Test
Tests for patellar
subluxation or
dislocation
(+) test is verbal
or facial
apprehension
from the athlete,
OR an attempt to
contract the
quadriceps to
avoid dislocation
Arthroscopy
Cartilage softening is common in asymptomatic knees, and painful
knees may show no abnormality.
However, arthroscopy is useful in excluding other causes of
anterior knee pain; it can also serve to gaugepatello-femoral
congruence, alignment and tracking
Differential diagnosis
Other causes of anterior knee pain must be excludedbefore finally
accepting the diagnosis of patellofemoral pain syndrome (see Table
20.1). Even then,the exact cause of the syndrome must be
establishedbefore treatment: e.g. is it abnormal posture,
overuse,patellar malalignment, subluxation or some abnormality in the
shape of the bones?
Treatment
CONSERVATIVE MANAGEMENT
In the vast majority of cases the patient will be
helpedby adjustment of stressful activities and
physiotherapy,combined with reassurance that
most patients eventuallyrecover without
physiotherapy.
Exercises aredirected specifically at
strengthening the medialquadriceps so as to
counterbalance the tendency tolateral tilting or
subluxation of the patella.
Somepatients respond to simple measures
such as providingsupport for a valgus foot.
Aspirin does no more thanreduce pain, and
corticosteroid injections should beavoided.
OPERATIVE TREATMENT
Surgery should be considered only if (1)
there is ademonstrable abnormality that is
correctable by operation,or (2)
conservative treatment has been tried for
at least 6 months and (3) the patient is
genuinely incapacitated.
Lateral release.
Proximal realignment.
Distal realignment.
Distal elevation of the patellar ligament.
Chondroplasty.
Patellectomy.
Plica Syndrome
An anomaly or fold in the
synovial membrane
Usually found along the
anterior, superior medial
border of the patella
Only becomes
symptomatic if inflamed
or taut
Signs & Symptoms:
Snapping, Clicking, or
jumping of the patella
during flexion
p! along medial border of
the patella
Swelling
Pathology
The plica in itself is not pathological.
But if acute trauma, repetitive strain
or some underlying disorder(e.g. a
meniscal tear) causes inflammation,
the plica may become oedematous,
thickened and eventually fibrosed; it
then acts as a tight bowstring
impinging on other structures in the
joint and causing further synovial
irritation.
Diagnosis
There is still controversy as to whether plica
syndrome constitutes a real and distinct clinical
entity. In some quarters, however, it is regarded
as a significant cause of anterior knee pain. It
may closely resemble other conditions such as
patellar overload or subluxation; indeed, the
plica may become troublesome only when those
other conditions are present.
The diagnosis is often not made until arthroscopy
is undertaken. The presence of a chondral lesion
on the femoral condyle secondary to plica
impingement confirms the diagnosis.
TREATMENT
The first line of treatment is rest,
anti-inflammatory drugs and
adjustment of activities.
If symptoms persist, the plica can be
divided or excised by arthroscopy.
Loose bodies,knee
Clinical features
knee pain and swelling, with intermittent
locking or catching of the joint.
The locking disappears spontaneously, only
to recur.
Individuals may report hearing a grating
sound (crepitus) with joint movement.
They may also report that the joint
intermittently "gives way" or "goes out,"
causing them to fall.
Any history of osteoarthritis or injury should
be taken into consideration while making a
diagnosis.
Loose bodies (a) This loose body slipped away from the
fingers when touched; the term joint mouse seems
appropriate. (b) Which is the loose body here? Not the large
one (which is a normal fabella), but the small lower one
opposite the joint line. (c) Multiple loose bodies are seen in
synovial chondromatosis, a rare disorder of cartilage
metaplasia
in the synovium.
Tests
Larger loose bodies are typically calcified and
thus easily visible on a plain film x-ray of the
affected joint.
Loose bodies that are small or contain little or
no bone may not be visible with an x-ray and
are typically diagnosed using either CT or
arthrography.
MRI may be useful in determining whether
associated bone changes have occurred.
Ultrasound scans may be performed to
determine the presence and location of loose
bodies.
Treatment
To encourage the best possible
management, whenever possible the
underlying cause of loose bodies should
be identified.
For small loose bodies, treatment may be
directed at relief of symptoms.
If pain and swelling are present,
analgesics or nonsteroidal antiinflammatory medications (NSAIDs) may
be prescribed.
In general, any loose body that is causing
symptoms should be removed.
Rehabilitation
Evaluation
Diagnosis begins with a proper
physical examination followed by XRays.
a bone scan or MRI to aid in the
diagnosis and to pinpoint the extent
of damage of the area affected.
Medical Management
By minor cases rest can prescribed.
The patient has to stop activities for
three to six months.
Stages three and four are always
treated surgically, and also when the
conservative treatment in stages one
and two was inadequate.
Surgical techniques
In stages one and two the articular cartilage is
still intact, through retrograde operation trying
to tap into to the affected bone from behind
and clear it. The advantage of this surgical
technique is that the articular cartilage stays
intact .
Not yet dissected fragment will be fixed by
means of an operation .
Repair of blood supply by drilling arthroscopic
through the cartilage and the hearth of
osteochondrosis into the healthy bones ,
Stabilization of the fragment through pinning or
through screw fixation
Osteochondral autograft
transplantation (OATS).
Osteochondral allograft
transplantation.
Autologous chondrocyte implantation
(ACI)
Blounts disease
This is a progressive bow-leg deformity associated
with abnormal growth of the postero -medial part
of the proximal tibia.
The children are usually overweight and start
walking early; the condition is bilateral in 80 per
cent of cases.
Children of negroid descent appear to be affected
more frequently than others.
Deformity is noticeably worse than in
physiological bow legs and may include internal
rotation of the tibia.
The child walks with an outward thrust of the
knee; in the worst cases there may be lateral
subluxation of the tibia.
INVESTIGATION(X-ray)
The proximal tibial epiphysis is flattened medially
and the adjacent metaphysis is beak-shaped.
The medial cortex of the proximal tibia appears
thickened; this is an illusory effect produced by
internal rotation of the tibia.
The tibial epiphysis sometimes looks
fragmented; occasionally the femoral epiphysis
also is affected.
In the late stages a bony bar forms across the
medial half of the tibial physis, preventing further
growth on that side. The degree of proximal tibia
vara can be quantified by measuring the
metaphyseo-diaphyseal angle
Treatment
Spontaneous resolution is rare and, once itis clear that the
deformity is progressing, a corrective osteotomy should be
performed, addressing both the varus and the rotational
components.
A preoperative(or peroperative) arthrogram, to outline the
misshapen epiphysis, will help in planning the operation.
Slight over-correction should be aimed for as some recurrence
is inevitable.
In severe cases it may be necessary also to elevate the
depressed medial tibial plateau using a wedge of bone taken
from the femur.
If a bony bar has formed, it can be excised and replaced by a
free fat graft. In older children it may be easier to perform a
surgical correction and then (if necessary) lengthen the tibia
by the Ilizarov method.
All these procedures should be accompanied by fasciotomy to
reduce the risk of a postoperative compartment syndrome.
SYNOVIAL
CHONDROMATOSIS
This is a rare disorder in which the joint comes to
Treatment
The loose bodies should be removed
arthroscopically. At the same time an
attempt shouldbe made to remove
all abnormal synovium.
DISLOCATION OF PATELLA
if the intercondylar groove is unusually shallow, or the
patella seated higher than usual, or the ligaments are
abnormally lax, dislocation is not that difficult.
Mechanism of injury:
While the knee is flexed and the quadriceps muscle
relaxed, the patella may be forced laterally by direct
violence; this is rare. More often traumatic dislocation
is due to indirect force: sudden, severe contraction of
the quadriceps muscle while the knee is stretched in
valgus and external rotation.
Typically this occurs in field sports when a runner
dodges to one side.
The patella dislocates laterally and the medial
patellofemoral ligamentand retinacular fibres may be
torn.
DIAGNOSIS
Anteroposterior, lateral and tangential
(skyline)x-ray views are needed.
In an unreduced dislocation,the patella is
seen to be laterally displaced and tilted or
rotated. In 5 per cent of cases there is an
associated osteochondral fracture
MRI may reveal a soft-tissue lesion (e.g.
disruptionof the medial patellofemoral
ligament) as well as articularcartilage
and/or bone damage.
TREATMENT
In most cases the patella can be pushed back into place
without much difficulty and anaesthesia is not always
necessary; the exception is an intra-articular
(intercondylar) dislocation, which may need open
reduction.
If there are no signs of soft tissue rupture i.e.
there is minimal swelling, no bruising and little tenderness
cast splintage alone will usually suffice.
The knee is aspirated and then immobilized in almost full
extension; a small pad along the lateral edge of the patella
may help to keep the medial soft tissues relaxed.
The cast is retained for 2 or 3 weeks and the patient then
undergoes a long period (23 months) of quadriceps
strengthening exercises.
OPERATIVE TREATMENT
The area is approached through a medial incision. If
the patellofemoral ligament is avulsed from the
femur,it is reattached with suitable anchors.
Mid-substance tears of the ligaments are sutured
directly. At the same time, if the lateral retinaculum is
tight it is released.
Osteochondral fragments are removed unless they
are single, large and amenable to reattachment.
Postoperatively a padded cylinder cast is applied with
the knee in extension; this can be renewed when the
swelling has subsided.
A hinged brace is substituted,which provides control
for weight bearing and allows knee movement.
Quadriceps exercises are encouraged
Osgood-Schlatter
Disease
Osgood-Schlatter disease used to be considered a
TREATMENT
The mechanical inefficiencies of the extensor
mechanism should be treated by appropriate
rehabilitative exercises.
Inflexibility should be addressed throughstretching
and ankle dorsiflexion .
strengthening if weakness is found .
This condition usually resolves without any
significant additional treatment.
Complete immobilization is neither necessary nor
practical.
A simple patellar support, such as a Neoprene
rubber, knee sleeve, may help.
THANX..
THANX