KNEE

PATHOLOGY
Basic Anatomy of the Knee
• Large Hinge Joint
• Femur
• Tibia
• Fibula
• Patella

2
Cruciate ligaments
• Control anterior and
posterior movements
• Fit inside the
intercondylar fossa
Collateral ligaments
• Control lateral movement
• Exposed to valgus (MCL) and varus (LCL) forces
Menisci
• Weight distribution
• Without menisci the weight of
the femur would be
concentrated to one point on
the tibia
• Converts the tibial surface into
a shallow socket
Patello-femoral Joint
• articulation of the
patella and femur

• the patella is a true

sesamoid bone

• posterior surface of the

patella is covered with
thick hyaline cartilage

• the patella slides

within the trochlear
groove
Ligaments
• Provide most of the support
to the knees
• Little structure or support
from the bones
Gross Anatomy: Muscles
Thigh
Quadriceps femoris
Sartorius
Gracilis
Hamstrings
IT band
Leg
Gastrocnemius
Plantaris
Popliteus
Patellar Dislocation
Predisposition
Genu valgum
Overweight
Weak quadriceps
Mechanism
Direct contact to
medial side
External tibial rotation
with forceful
quadriceps contraction
Patellar Dislocation: Diagnosis
Obvious if not yet
reduced
Patellar hypermobility/
apprehension test
X-ray/MRI only
necessary to rule out
osteochondral
fractures, other
associated injuries
Patellar Dislocation:
Treatment
Knee extension
Aspiration to relieve
discomfort and check for
fat in blood
Surgery unnecessary
unless osteochondral
fracture
Crutches, PRICE
Rehabilitation focusing
on vastus medialis
Meniscal Tears
Shear force from femur
Acute or degenerative
Athletes, elderly,
overweight
Horizontal
Within substance
Longitudinal
Bucket handle –ACL risk
Radial or vertical
Parrots beak
Medial Meniscus Tear
Tears easier than lateral
due to certain traits
Squatting
Internal rotation of tibia
with knee flexed
Member of “unhappy triad”
Medial meniscus
MCL
ACL
Medial Meniscus: Diagnosis
Examination
McMurray’s test
Apley’s compression test
MRI
Low-signal intensity
(black triangle ) =
normal
White interruption =
lesion
Arthroscopy as last
resort
Medial Meniscus: Treatment
PRICE for isolated and minimal tear
Partial arthroscopic meniscectomy most common
Lateral Meniscus Tear
Lower incidence
Often more
painful
More likely to incur
radial or parrots beak
Not rare for anterior
horn
Discoid meniscus
Lateral Meniscus: Diagnosis/Treatment
Same techniques as for
medial meniscus
McMurray’s test and
Apley’s test performed
with internal tibial
rotation
MRI slightly less
accurate than with MM
Treatment similar
Medial Collateral Ligament
Attached to fibrous
capsule and MM
Injury rarely isolated –
“unhappy triad”
Can tear with external
rotation (skiing), but
more commonly from
valgus or abduction force
(football)
Pain localized to medial
joint line, but can subside
following Grade III tear
MCL: Diagnosis: Examination
Abduction stress test
First at 30
Again at full extension
Rule out PCL tear
Anterior drawer test
with external rotation of
tibia
Hip flexed 45
Knee flexed 90
Tibia rotated 30ext.
Anterior rotation of
medial tibial condyle
MCL: Diagnosis: Imaging
X-ray
Only useful for young
patients to differentiate
from epiphyseal fracture
Taken at 20-30flexion
Enlarged joint space = tear

MRI
Coronal scan
Normal MCL looks thin,
taut, low-signal
MCL: Treatment
Surgery
Surgery necessary for Open incision
compound injury Midsubstance ruptures
Crutches + PRICES + rehab sutured
for Grade I, II only if isolated
Tear from bone repaired
Grade III tears may require
surgical repair, but with suture anchors
immobilization can be
effective if isolated (rare)
• 3-4 months recovery
Lateral Collateral Ligament
Courses slightly posterior
Sprained least frequently
Flexed knee = isolated tear
Anteromedial blow 
hyperextension/ postero-
lateral corner injury
Risk to common peroneal
nerve
Foot drop, sensation loss
LCL: Diagnosis:Examination
Adduction stress test
At 30, then fullextension

Posterolateral drawer test

Tibia externally rotated,
posterior forceapplied

Reverse pivot shift test

Knee 90, tibia ext. rotated
With valgus, slowlyextended
Temporary posterior
subluxation of lateral tibial
condyle around 30
Forcibly reduces with extension
LCL: Imaging andTreatment
MRI
Coronal oblique scan
Sagittal scan to rule
out fibular fracture,
avulsion
Tear looks less taut or
discontinuous – no
thickening
Treatment
Similar to MCL
Grade III usually
requires surgery
Anterior Cruciate Ligament
Most common knee injury
among athletes

Hyperextension, internal
rotation – rarely isolated
injury from contact force

“unhappy triad”

May tear from tibia (3-10%),

from femur (7-20%), or in
midportion (70%)
Proximal end receivesbranch
from middle genicular a.
ACL: Diagnosis: Examination
History, large hemarthrosis
Autonomic symptoms
Anterior drawer test
Tibia neutral, pull ant.
NOT RELIABLE BYITSELF
Lachman test
Knee only flexed 15-20
Pivot shift
Start in extension, tibia
internally rotated, valgus
Slowly flex, lateral tibial
condyle temporarily
subluxates anteriorly ~30
ACL: Diagnosis: Imaging
X-ray
Segond fracture of
lateral tibial condyle
ACL tear with it 75-
100%
Tibial spine avulsion
in young patients
MRI – 95% accuracy
All 3 planes in full
extension
Edema/hemorrhage
often obscuresACL
Normal ACL Torn ACL
ACL: Treatment
Extrasynovial, heals
poorly
Partial, isolated tears
may be treated with
PRICE, rehab, bracing
of slightly flexed knee
Most tears, athletes
will require
reconstruction
Posterior Cruciate Ligament
Broader, longer, stronger
The PCL, is not injured as frequently as the ACL

Tears much less frequently

Only in isolation when
“dashboard knee” injury
Hyperextension in sports,
especially with side force
Falling to ground with
foot plantar flexed
PCL: Diagnosis
Posterior Drawer Test
Gravity or sag test
Hips at 45 or 90,
compare tibial
tuberosities forsag
Abduction/adduction stress
test at full extension
X-ray to confirm sag test negative positive
MRI shows lower-signal
intensity for intact PCL
compared to ACL due to its
fiber organization
Take on all 3 axes, but best
is sagittal oblique
PCL:Treatment
Controversial
PRICE, rehab, bracing for most isolated tears
Rehab focused on quadriceps muscles for
compensatory anterior drawer
Surgery avoided when possible because PCLnot
easy to access without additional risk factors
Prognosis good because better blood supply =
revascularization
Future of Reconstruction
Goals:
Improve recovery time
Improve remodeling of insertion sites
Improve nervous and vascular restoration
With biological manufacture of:
Growth factors, cytokines
Antibiotics
Techniques:
Gene therapy – viral/non-viral vector delivers specific gene
Tissue engineering – mesenchymal stem cells