Internal derangement of the Knee

Joint

Govind Gopakumar
What is Internal derangement of the Knee?

The internal derangement of knee means an internal damage to the knee caused due to
trauma. This damage can be due to injury or due to an overuse of the knee.
This damage results in certain disorders of joint which includes torn meniscus, loose
bodies in the knee and damaged ligaments.
Internal derangement of knee does not include chronic disorders such as osteoarthritis
of the knee, chondromalacia patellae, discoid meniscus and meniscal cysts. Internal
derangement of knee is also called as knee instability.
Causes
Strenuous physical activities involved during sports, work-related activities and accidents can
cause internal derangement of knee.
A sudden stop while running
A direct injury on the knee joint can also cause internal derangement of knee
Ligament injuries occur while playing rugby and football
Anterior cruciate ligament injuries occur in a gymnast
Landing heavily on the flexed knee joints
Elderly people (>60 years) are more prone to internal derangement of knee than young people
Injuries to ligaments and menisci most often occur in middle aged adults.
Females are more prone to patellar and lateral meniscus problems.
Children experience more damage to the bones than to the ligaments of the knee joint.
Symptoms and Diagnosis

Symptoms
A snapping or tearing sensation at the time of the injury can be a symptom of internal derangement of knee.
The development of marked swelling within two hours which indicates bleeding of the joint
An immediate sensation of instability can be a symptom of internal derangement of knee
Diagnosis
MRI-scan is performed to view the ligaments, menisci and tendons; while CT scan is used to view bone
fractures.
Ultrasound is used to distinguish cysts, aneurysm and blood clots.
An invasive surgical procedure such as arthroscopy is used. In this case a tiny camera is inserted into the
knee joint for viewing the problem.
Examination of the Knee Joint
History
Nature of Violence- When a twist in the knee joint occurs with flexed knee and weight
bearing, as seen in football players and coal miners, it results in tears of meniscus (medial is
more common than lateral).
Pain- Duration,Site,nature of pain(continuous/intermittent),association with activities are
asked
Swelling- In an around the knee joint may be due to effusion,hemarthosis,dislocation of
patelle
Locking of knee- due to meniscal tear or loose bodies in the joint cavity
Instability-Expecially in climbing. Intermittent instability of knee joint with sudden severe
pain is seen in meniscal tear
Disability-Inability to walk/stand due to partial sprain/tear,complete in supracondyle
fracture.
Local Examination
Inspection

Attitude- Knee commonly assumes an attitude of 30 degree flexion

Deformity- Normally the midinguinal point,midpoint of patella,midpoint of ankle all
fall in a straight line which prolonged passes through 2nd web space.
Knee is examined from front back and sides for contour,position,size,shape of patella
Swelling- Patellar dislocation can cause swelling on lateral aspects over femoral
condyles.
Palpations
Temperature over the knee joint
Muscles and tenderness are palpated for tenderness and wasting.
Tenderness anterior to the medial collateral ligament (it is elicited on flexed knee using thumb pressing at this
point and knee is gradually extended) suggests a bucket-handle tear. Tenderness over the medial collateral
ligament at the level of joint line indicates injury to medial meniscus. Tenderness posterior to medial collateral
ligament indicates tear of the posterior horn of medial meniscus.
Bones are palpated for irregularity and tenderness.The supported knee is extended and the quadriceps is relaxed,
the patella is pushed to the other side and with the other hand the articular surfaces are palpated, which is
repeated in the other action.
The femoral condyles are palpated by gradually flexing the knee to the fullest extent. The articular aces of the
tibial condyles are palpated in 90 degrees flexed sition of the knee.
In supracondylar fracture, lower end of femur will be directed backward and upper end will be directed forward.
Lateral tibial condyle is commonly fractured than medial.
Squeezing the lower part of tibia and fibula will cause tenderness in fibular fracture side (upper end of fibula -
springing of fibula-indirect method eliciting tenderness)
Depending on which bone has fracture can lead to spring of tibia(on lateral side) springing of fibula (on medial
Measurements and Movements
Measurement
Both thigh and leg length are taken and compared with normal side to assess the
shortening. Circumference of thigh and leg are taken from fixed bony points and
compared for any muscle wasting. Breadth of lower end of femur and upper end of
tibia is measured with callipers
Movements
Active and passive movements at the knee joint are checked. In fracture of tibial
spine, there is limitation of last few degrees of extension. There is 0-135 degrees of
flexion, extension from 135 degrees to 0 degree; at 90 degrees flexion there is some
amount of abduction, adduction, medial rotation and lateral rotation. Any abnormal
mobility at the injured site is checked.
Specific Test
Mc Murray’s Test
It is used to detect the integrity of posterior half of medial and lateral meniscus.
With the patient lying in supine position, the examiner stands by the side of injured
limb. Knee joint is flexed till the foot touches the buttocks. With one hand, knee is
steadied and with other hand, foot is grasped.
While the foot is laterally rotated, leg is slowly extended and abducted. Patient
develops pain and click due to injury to medial meniscus.
Pain and click, if develops in the beginning, means injury to posterior part of medial
meniscus, in the middle of extension means injury to middle of meniscus; at the end
of extension means injury to anterior end of meniscus.
Lateral meniscus is checked similarly by medial rotation of foot and adduction of leg
Apley’s grinding test
Result
Compression is applied over the femoral condyles by pressing with the body weight
over the tibial plateau. With compression, the leg is laterally rotated. If patient
complains of pain, it indicates tear of medial meniscus.
Similarly, if pain appears on compression and medial rotation of leg, it indicates tear
of lateral meniscus
Apley’s Distraction test
Similar to the above, with the patient lying on his face on a couch with knee flexed to
90 degrees patient's ham steadied by examiner's knee, if patient develops pain on
pulling the leg upwards and rotated laterally indicates injury to medial collateral
ligament.
Likewise pain develops on upwards pull and medial rotation of leg indicates injury to
lateral collateral ligament
Pivot shift test
The pivot shift is a dynamic but passive test of knee stability, carried out by the
examiner without any activity of the patient. It shows a dysregulation between rolling
and gliding in the knee joint.
The patient lies supine with legs relaxed. The examiner grasps the heel of the involved
leg with examiners opposite hand placed laterally on the proximal tibia just distal to
the knee.
The examiner then applies a valgus stress and an axial load while internally rotating
the tibia as the knee is moved into flexion from a fully extended position.
A positive test is indicated by subluxation of the tibia while the femur rotates
externally followed by a reduction of the tibia at 30-40 degrees of flexion.
Dial test
The purpose of the Dial Test is to diagnose Posterolateral Knee Instability, as well as to differentiate
between isolated Postero-lateral corner (PLC) injury and combination of PLC and Posterior Cruciate
Ligament injury(PLC)
Procedures
1. The knees are held together and bent to 30°, the clinician turns the lower legs and feet outwards and
compares the amount of external rotation using the tibial tubercle as point of reference. Repeat the test
with the knees at 90°.
2. The knee is flexed over the side of the bed. The clinician stabilized the thigh and apply an external
rotation force through the foot and ankle. Then, the clinician looks for the amount of external rotation of
the tibial tubercle, and compare it with the other knee
Evaluation
An isolated injury to the PLC - more than 10° of external rotation in the injured knee is present at 30° of
flexion, but not at 90° of flexion.
Instability of the PCL: more than 10° of external rotation in the injured knee is present at 90° of flexion,
but not at 30° of flexion.
• A combined injury: more than 10° of external rotation in the injured knee is present at 30° and 90° of
flexion. This is an injury of the PCL and the PLC.
Test for Abnormal Motility (Stability)
Abduction and adduction tests for lateral mobility: With patient seated and knee
fully extended, foot is held up with one hand, other hand is kept behind the knee in the
upper part of popliteal space. Leg is abducted to feel any abnormal opening of the
joint on the medial side in case of medial collateral ligament injury. When adducted,
joint opens laterally in lateral collateral ligament injury. This movement is compared
with the other joint.
Drawer sign: Patient sleeps on his couch with knee flexed of midleg against the right
angle) and foot resting on the bed. Foot is fixed by the examiner with one hand f or by
sitting on foot. Upper end of tibia is moved with the other hand antero-posteriorly to
check increased mobility. Increased anterior mobility of tibial condyles over the femur
means it is anterior cruciate ligament injury; increased posterior movement of tibial
condyles over femur means it is injury of posterior cruciate ligament
Other Examination
Palpate the dorsalis pedis and posterior tibial artery pulsation as the popliteal artery is
often involved with supracondylar fracture.
Checking for complications: Popliteal artery injury, venous edema, hematoma of calf,
compartment syndrome, nerve injuries (lateral peroneal nerve in fibular injury) can
occur. Lateral popliteal nerve may get involved in the fracture of neck of fibula.