INTERNAL

DERANGEMENTS OF
THE KNEE
• The Knee is one of the joints most commonly affected
by trauma

• Definition of internal derangement of the knee:

It is a variety of intra-articular and extra-articular
disturbances, usually of traumatic origin, that interfere
with the function of the joint.
Efforts to determine what is deranged
should be made and require good
history, accurate clinical examination,
radiological investigations and
sometimes arthroscopic examination.
These include:
- Traumatic effusion or haemoarthrosis
- Meniscal injury
- Ligamentous injury
- Loose bodies
INJURIES OF SEMILUNAR CARTILAGE
(INJURY OF THE MENISCI)
• Menisci are made of
fibrocartilage, the medial
meniscus is C-shaped, whereas
the lateral meniscus is O-shaped.
• The outer surface of the medial
meniscus is adherent to the deep
fibers of the medial ligament,
While the lateral meniscus is
separated from the lateral
ligament by the popliteus tendon.
INJURIES OF SEMILUNAR CARTILAGE
(INJURY OF THE MENISCI)
Functions of the menisci:
• 1. Weight bearing: carry load in weight
bearing.
• 2. Shock absorption: As the articular
cartilage is unable to absorb sudden
compression forces without damage.
• 3. Stabilization: Menisci increase the
stability of the joint by deepening the
articular surfaces of the tibial plateau.
• 4. Facilitates rotation movements
• 5. Joint lubrication function
 INJURIES OF SEMILUNAR CARTILAGE
(INJURY OF THE MENISCI)

Mechanism of injury:
• Meniscal tear is the result of
rotational force of the body to one
side while standing on a fixed foot,
with the knee slightly flexed.
• The resulting force causes grinding of
the meniscus between the femur and
the tibia splitting the meniscus. Injury
of the menisci is common in football
players.
INJURIES OF SEMILUNAR CARTILAGE
(INJURY OF THE MENISCI)
Common Types of meniscal tears:
• 1. Longitudinal tears (Bucket handle
tear)
• 2. Transverse tears
• 3. Separation of the peripheral
attachment
Symptoms
• History of trauma (study the mechanism of injury)
• pain localizing to medial or lateral side
• mechanical symptoms (locking and clicking), especially with
squatting
• delayed or intermittent swelling
Physical exam
• joint line tenderness is the most
sensitive physical examination
finding
• Swelling and effusion
• Wasting of the quadriceps
muscle
provocative tests
• Apley compression test = prone-
flexion compression
Thessaly test
• standing 20 degrees of knee flexion on the
affected limb, the patient twists with knee
external and internal rotation with positive test
being discomfort or clicking.
McMurray's test
• flex the knee and place a hand on medial side of
knee, externally rotate the leg and bring the
knee into extension.
• a palpable pop / click + pain is a positive test
and can correlate with a medial meniscus tear.
B. Radiological Investigations:
• a. Plain x-ray: to exclude other
lesionsShould be normal in
young patients with an acute
meniscal injury
• b. MRI: very useful and highly
specific

• C. Arthroscopy:
• May be used to establish an
accurate diagnosis and for
treatment as well.
Nonoperative
• rest, NSAIDS, rehabilitation
• Indications first line treatment for degenerative tears
• outcomes
• improvement in knee function following physical therapy
• "noninferior" when compared to arthroscopic partial
meniscectomy
Treatment:
• 1. Partial
arthroscopic
menisectomy.
• 2. Meniscal suture
by arthroscopy in
case of peripheral
detachment
• 3. Total
menisectomy.
LIGAMENTOUS INJURIES OF
THE KNEE
These are
• 1. The anterior cruciate ligament (ACL)
• 2. Posterior cruciate ligaments (PCL)
• 3. The medial collateral ligaments (MCL)
• 4. Lateral collateral ligaments (LCL)
Mechanism of injury:
• Abduction force on the knee
may injure the medial collateral
ligament, while adduction force
may cause injury to the lateral
ligament.
• Antero-posterior force
applied to the tibia or
femur (dashboard injury)
or hyperextension force
may produce injury to
either the ACL or PCL
depending on the
direction of the tibial
displacement.
• Combined rotation and
impact to the bent
knee may result in a
wide variety of
complex injury as
injury of the medial
ligament + medial
meniscus + ACL
(unhappy triad)
Pathology:
• Degree of ligament injury varies
from mild degree sprain with a
tear of minimum number of fibers
to complete tear with obvious
instability.
• The ligament injury may be at the
femoral or at the distal
attachments, less common at the
middle.
Diagnosis:
A. History & Clinical Picture:
• 1. History of trauma & mechanism of injury
• 2. Pain and tenderness at the injured ligament (MCL & LCL)
• 3. Hemarthrosis& Doughy feel in tear of ACL
• 4. Special tests
 ACL

• Lachman's test Pivot shift

knee brought from extension (anteriorly subluxated) to
most sensitive exam test flexion (reduced) with valgus and internal rotation of tibia
PCL

• posterior sag sign

patient lies supine posterior drawer test (at 90° flexion) most accurate
with hips and knees maneuver for diagnosing PCL injury
flexed to 90°,
examiner observes for with the knee at 90° of flexion, a posteriorly-directed
a posterior shift of the force is applied to the proximal tibia and posterior tibial
tibia as compared to
the uninvolved knee translation is quantified
MCL
valgus stress testing at 30° knee
flexion
• isolates the superficial MCL
• medial gapping as compared to
opposite knee indicates grade of
injury
• 1- 4 mm = grade I
• 5-9 mm = grade II
• > or equal to 10 mm = grade III
valgus stressing at 0° knee
extension
• medial laxity with valgus stress
indicates posteromedial capsule
or cruciate ligament injury
LCL
varus stress test
• varus instability at
30° flexion only -
isolated LCL injury
• varus instability at
0° and 30° flexion -
combined LCL +/-
ACL/PCL injuries
B. Radiological Investigations:
• Plain x-ray: to exclude other lesions or ligamentous injury with
bone avulsion
• MRI: to detect the site of ligamentous injury

C. Arthroscopy: May be used to establish an accurate diagnosis

and for treatment
ACL
• Often normal
• Segond fracture (avulsion fracture
of the proximal lateral tibia) is
pathognomonic for an ACL tear
associated with ACL tear 75-100% of
the time
• Deep sulcus (terminalis) sign
depression on the lateral femoral
condyle at the terminal sulcus, a
junction between the weight bearing
tibial articular surface and the patellar
articular surface of the femoral condyle
MCL
• Radiographs AP and lateral
• stress radiographs
• may indicate gapping
findings
• usually normal
• calcification at the medial
femoral insertion site
(Pellegrini-Stieda Syndrome)
MCL
LCL
Radiographs
• weightbearing AP, lateral, and varus
stress radiographs
• may show asymmetric lateral joint line
widening
MRI
• imaging modality of choice to grade
severity and location of LCL injury
• most tears are noted off of fibular
insertion
Treatment:
• Minor injuries (the knee joint is stable) are treated with a splint for
rest and pain killers
• Severe injuries:
• Repair in acute cases,
• Reconstruction in neglected cases.