Knee Joint

Introduction

• It is a biaxial, complex, modified hinge joint .

• Formed by articulation between the distal femur , proximal tibia and the
patella.
• The knee joint has 2 sub joints-
• Tibio-femoral joint
• Patello-femoral joint
Tibiofemoral joint: Patellofemoral joint:

• Formed by the articulation between the distal femur with • Patella is a sesamoid bone in the quadriceps tendon.
the 2 femoral condyles and the proximal tibia with 2
tibial plateau. • Articulation with the inter-condylar groove of the anterior
aspect of the knee.
• The femoral condyles are convex while the tibial
plateaus are concave. • The articular surface of the patella is covered with hyaline
cartilage. Ti is connected to the tibia via the ligamentum
• The medial femoral condyle is longer than the lateral patellae.
and results in the locking of the knee and also the medial
tibial plateau is longer compared to the lateral.
• Meniscus are present on the tibial condyles, medial and
lateral, connected by the coronary ligament and to each
other by transverse ligament and to the patella via
patellominisceal ligament. They help improve the
congruency of the joint.
 Q-Angle: Patellar Alignment:
• It is defined as the angle formed by the intersection of • The pull of the quadriceps muscle and the attachment to tibial
the 2 lines, one drawn from the ASIS to mid-patella and tubercle via patellar tendon define the alignment of the
one drawn from the tibial tubercle to the mid-patella. patella in the frontal plane.
• Normal Q angle is greater in women than men, is 10 o- • When the pull increases it causes the patella to track laterally.
15o. ( Bowstring effect)
• Increased Q-angle: it occurs due to a wide pelvis,
femoral anta-version, coxa-vera, genuvalgum, laterally
displaced tibial tuberosity.
• Due to this increased Q-angle, there may be an increased
pressure exerted by the lateral tibial facet over the lateral
femoral condyle during weight bearing and flexing the
knee.
 Muscle Function:
1. Knee flexors:
2. Knee extensors:
Knee flexors • The extensors of the knee are collectively called the quadriceps
Semimembranosus femoris muscle namely-
Produce varus a) Vastus-medialis
Semitendinosus
movements
Gastrocnemius (medial head) b) Vastus-lateralis
Bicep femoris (long and short c) Vastus-intermedius
head) Produce valgus d) Rectus femoris
Popliteus movements
• The 3 vastus muscles originate from the femur and merge with the
Gastrocnemius (lateral head) rectus femoris muscle into a common tendon called the quadriceps
Sartorius tendon which inserts into the proximal aspect of the patella and
then continues as the patellar tendon.
Gracilis
• The rectus femoris a 2 joint muscle, crossing the hip and knee to
attach on the ASIS.
• Except the short head of the bicep femoris and the
popliteus muscle, all the other 5 muscles are two joint
muscles.
• The bicep femoris , semimembranosus and
semitendinosus muscle together are called the
hamstrings and originate from ischial tuberosity and
insert onto the tibia and fibula and supplied by the
sciatic nerve.
Screw-home mechanism:
• The rotation that occurs between the femoral condyles and the tibia during the
terminal degrees of extension is called the locking, or screw-home mechanism.
• When the tibia is fixed in the weight bearing position, terminal extension causes the
femur to rotate internally, which in turn causes the hip to move into extension, due
to which the iliofemoral ligament becomes taut and reinforces the medial rotation of
the femur.
• As the knee is unlocked, the femur rotates laterally. The unlocking of the knee is
caused due to hip flexion indirectly, and directly due to action of the popliteus
muscle action.
Stabilizers of the knee:

Direction Structures Function

ACL
Iliotibial band
Hamstring muscle Limit anterior Tibial translation
Soleus(in weight bearing)
Gluteus maximus(weight bearing)
A-P/Hyperextension
stabilizers PCL
Meniscofemoral ligament
Quadricep muscle Limit posterior Tibial translation
Popliteus muscle
Medial and lateral head of gastrocnemius

MCL, ACL, PCL, Arcuate ligament, Sartorius,

Gracilis, semitendinosus, semimembranosus, medial Limit valgus of Tibia
head of gastrocnemius ms
valgus/varus
stabilization LCL, Iliotibial band, ACL, PCL, Arcuate ligament,
Posterior oblique ligament, Biceps femoris muscle,
Lateral head of gastrocnemius muscle Limit varus of Tibia
 ACL, PCL, Posteromedial
capsule, Miniscofemoral Limit medial rotation of Tibia
ligament, Bicep femoris
Internal/External rotational Postero-lateral capsule,
stabilizers MCL, LCL, Popliteus
muscle, Sartorius muscle,
Limit lateral rotation of Tibia
Gracilis muscle,
Semimembranosus muscle,
Semitendinosus muscle
Ligaments -
• The ligaments function to maintain the joint stability.
• They help with resisting –
a) Excessive knee extension
b) Valgus and varus stress
c) Anterior and posterior displacement of tibia
d) Medial and lateral rotation of tibia

• The knee joint has the following ligaments-

1. Medial collateral
2. Lateral collateral
3. Anterior cruciate
4. Posterior cruciate
5. Menisco-femoral
Medial Collateral :
• It has 2 portions – superficial and deep, which are separated by a bursa
• The superficial portion arises from the medial femoral condyle and travels distally to inserts
into the medial aspect of the proximal tibia.
• the deep portion of the MCL arises from the inferior aspect of the medial femoral condyle and
inserts on the proximal aspect of the medial tibial plateau.
• The deep portion of the MCL is strongly fixed to the medial border of the medial meniscus.
• The superficial portion is the primary restraint to excessive abduction(valgus) and lateral
rotation stresses at the knee.
• The MCL is taught in full extension and tends to become more lax leading to greater joint space
opening with flexion.
Lateral collateral:
• It is located on the lateral side of the tibiofemoral joint. It originates
from the lateral femoral condyle, traveling distally to the fibular head
where it joins with the tendon of bicep femoris muscle to form the
conjoined tendon.
• It is primarily responsible for checking varus stresses, and limits
varus motion most effectively in full extension.
Anterior Cruciate Ligament:
• It is attached to the anterior tibial spine, where it extends superiorly and posteriorly to reach the lateral femoral
condyle.
• In addition the ACL twists inwardly as it travels proximally.
• It has 2 bands- antero-medial and postero-lateral band.
• The major blood supply is by the genicular artery.
• The main function of the ACL is to limit the anterior translation of the tibia on the femur.
• In extension, the PLB is taut and as the knee flexion range increases it loosens and the AMB becomes tight.
• The ACL is also responsible for resisting the hyper extension of the knee. It also acts as a secondary restrain
against either varus or valgus motions at the knee.
Posterior Cruciate ligament
• The PCL attaches distally to the posterior tibial spine and travels superiorly and somewhat
anteriorly to attach to the lateral aspect of the medial femoral condyle.
• Even PCL has 2 bands – AMB and PLB in accordance to their tibial origin.
• It mainly limits posterior translation of the tibia on the femur and also acts to resist the
valgus and varus stress at the knee joint.
• PCL plays a role in producing and limiting rotation of the tibia.
Arthrokinematics

Physiological motion Roll Slide

Tibial motion- open chain (non-weight bearing)
Flexion Posterior and medial Posterior
rotation
Extension Anterior and lateral Anterior
rotation
Femoral motion- closed chain (weight bearing)
Flexion Posterior and lateral Anterior
rotation
Extension Anterior and medial Posterior
rotation
Common fractures of the knee joint
 Mechanism of knee injuries:
• The knee is subjected to various degrees of force in day to day activities.
• The nature of the force maybe direct or indirect . An indirect force on the knee maybe:
1. Valgus or varus
2. Hyperextension
3. Twisting
• Mostly there is always a combination of the above mentioned forces.
A) CONDYLAR FRACTURE OF THE FEMUR
• Are mainly 3 types :
1) Supracondylar –
- fracture line is just proximal to the femoral condyle.
- The distal fragment is pulled backwards by the pull of the gastrocnemius
muscle.
- The sharp edge of the fracture may injury the popliteal artery.
- Patient complains of pain , swelling and bruising around the knee is
seen.
- Diagnosis is made on an X- ray.
Treatment
• CONSERVATIVE:
- The fracture is reduced under GA
and the limb is immobilized in a
Thomas splint.
- A skeletal traction is applied
through the upper end of the tibia
and the knee is maintained in 30o of
flexion using a Pearson knee
attachment.
- The limb is immobilized for 8-12
weeks.
Complications:
1. Malunion and Non-union – can be treated by corrective osteotomy. The bone is
fixed internally with nail or plate.
• OPERARTIVE:
- Indicate if conservative treatment
fails or there is need for popliteal
artery repair.
- ORIF is done using a condylar blade
plate, Dynamic compression screw
(DCS), or an intramedullary
supracondylar nail.
- Post operatively, mobilization can be
started after 2 weeks but weight
bearing is started about 3 months.
2. Knee stiffness – due to dense intra and peri-articular adhesions. Can be
treated by intense knee mobilization programmes. In sever cases,
quadricepsplasty is done where lengthening of the quadriceps is carried
out.
3. Osteoarthritis- fracture with intra- articular extension gives rise to
osteoarthritis a few years later.
2) Inter-condylar fracture:
- Occurs usually due to direct trauma. Either single or both condyles may be
fractured.
- When both the condyles are involved, the fracture line may pass through the
condyles causing a T or Y shaped fracture.
- Since it is intra-articular, it is usually associated with haemarthrosis.
Treatment: Aims to restore congruity of the articular surfaces.

• Conservative: • Operative:
- Skeletal traction is applied through - It the fracture is not comminuted
the upper tibia and is maintained ORIF is done using multiple screws,
for 6-8 weeks. K-wires, blade plates, DCS or LCP
- Knee mobilization is started after 6- implant.
8 weeks. - Knee mobilization is started early, i.e.
after 2 weeks.
Complications:
1. Injury to the popliteal neurovascular bundle, especially, the popliteal artery
needs immediate repair.
2. Risk of infection to the superficial implants. Needs careful monitoring.
3. Knee stiffness, OA and mal-union are some possible late complications.
3) Uni-condylar fracture:
- If undisplaced, a long leg cast is given for 3-6 weeks, followed by protected
weight bearing.
- If displaced, ORIF is done with multiple cancellous screws. A buttress plate
may be required in some cases.
Management:

Maximum protection phase Moderate protection phase Minimum protection phase

Partial weight bearing or toe
Limb elevation, compression Self-assisted relaxed, knee
touch is started with
bandage , ATMs. swinging in bed side sitting.
crutches/walker
Non-weight bearing with 2 Progressive Resistive
Isometrics to the quadriceps
point gait using a Exercise with increasing
and glutei.
walker/crutches. weights.
Gradual knee mobilization
Improve quadriceps and
(PROM) followed by
hamstrings strength.
thermotherapy or cryotherapy.
Isotonic exercises can be
CPM may be very helpful.
prescribed.
Comfortable ROM of knee
flexion beyond 90o should be
attained with minimal effusion
and full extension at the knee.
B) Patellar fracture:
• It is a common fracture and can occur due to-
a. Direct injury, like blow on anterior aspect of the flexed knee.
b. Indirect injury.
• Direct injuries usually cause an undisplaced fracture , which is usually comminuted. Also called
‘Stellate’ fracture.
• Indirect injury results in a transverse fracture with displacement of the fragments.
• The displacement is caused by forced passive flexion of the knee , when the quadriceps muscle is in
a state of contraction , which pulls the fragments apart and results in a separated fracture of the
patella with some comminution.
• Clinical features:-
- Patient complains of pain and swelling in the knee.
- In an undisplaced fracture, the swelling and tenderness are localized over the patella.
- Crepitus is felt in a comminuted fracture.
- In case of displaced fracture, a gap can be felt btwn the pragments.
- The pt is unable to lift his leg with the knee in full extension due to damage to the extensor
mechanism.
• Diagnosis:-
- AP and Lateral views are usually enough.
- Sometimes a skyline view is required in certain cases of undisplaced fractures.
Treatment:
• Conservative:
- A plaster cast extending from groin
to just above the malleoli, with the
knee in full extension (cylinder
cast) is given for 3 weeks.
- Extensor mechanism should be
intact.
• Operative:
- Mostly performed for comminuted and
displaced fractures.
a) Internal fixation: transverse fracture is
fixed internally by using a screw or by
TBW. The extensor mechanism is
repaired. An above knee POP cast is
applied for 4-6 weeks.
b) Excision of the patella: in severely
comminuted fractures where the fracture
cannot be fixed properly or in elderly
with OA, the patella is excised partially
or completely and the quadriceps
mechanism is repaired.
Management:

• Basic goals-
1. To reduce effusion, pain and inflammation.
2. To provide effective quadriceps mechanism.
3. To regain maximum possible ROM of flexion-extension.

Undisplaced:
- Usually done conservatively in plaster cast for 3-4 weeks.
1. Static quads, assisted SLR with out pain with 10 sec hold.
2. Weight bearing and ambulation is started the next day and the pt returns to function by 3-4 days.
3. Cast removed after 4-6 weeks and flexion is initiated passively.
4. Knee flexion may be preceded by thermotherapy or cold therapy.
5. Correct gait and balance training to avoid limp. Full function should be regained by 8-12 weeks.
• Displaced:
Maximum protection Moderate protection Minimum protection
Progressive Resisted
Immobilization in posterior plaster cast
Stitches are removed by 10-14 day.
th
Exercises with prone
or pressure bandage.
kneeling
Limb elevation, ATMs and passive PROM or CPM with in the beginning
Isotonic exercises.
movements of hip. ranges.

Isometrics to quads after 3-4 days by

pressing the whole leg against the plinth
Strong isometrics to the quadriceps. Progression of gait training.
with a small soft pillow under the knee or
with sustained dorsiflexion.

The pt must regain adequate

Self-assisted stretching to the knee in knee ROM and M/S power
Assisted SLR to be started after 3-4 days
flexion as well as terminal extension by 6-8 weeks. However,
but with out pain.
ranges in bed side sitting. mild extension lag may
continue fro about 6 months

Gradual weight bearing from 6

Non-weight bearing gait with
weeks, first in parallel bars. Proper
crutches/walker started as soon as pain
gait and balance training, first with
free.
walker then crutches/ cane.
Comminuted fracture treated with patellectomy:
Maximum protection
Strong ATMs and leg elevated.
Mild indirect isometrics to the
quadriceps, to avoid pain.
ES can be used to re-educate
the quadriceps contraction.
Assisted SLR, enough
assistance to initiate the lift
should be started at the
earliest, without much
discomfort.
Moderate protection
Partial weight bearing, gait
training are added and the
exercises are contd more
vigorously.
Self-assisted small arc passive
movements.
Controlled CPM or passive
movement.
Minimum protection
Assisted active movement
with graduated weigh bearing,
gait training.
Hydrotherapy can be used for
strength and mobility.
Intense PRE to strengthen the
Quadriceps , hamstrings and
ligaments.
Progression of gait training
and functional training.

After patellectomy, there is urgency to begin quadriceps strengthening and initiating

isometrics as early as possible and regularly monitoring the strength is essential.
C)Patellar dislocation:
• Usually dislocates laterally.
• It can be of 3 types :
1. Acute
2. Recurrent
3. Habitual

1) Acute:-
- Occurs in a semi-flexed knee, sudden contraction of the quadriceps muscle.
- The patella dislocates laterally and lies on the outside of the knee.
- The patient is unable to straighten the knee.
- The medial condyle of the femur appears more prominent.
- At times the dislocation reduces spontaneously but tenderness is markedly present antero-medially
due to the rupture of the capsule at that site.
- Treatment- Reduction under GA and immobilization in cast for 3-4 weeks, after which the knee
is mobilized.
2. Re-current:-
- It is the repeated episode of dislocation of the patella. The patient is usually asymptomatic between the episodes.
- The reason for recurrence can be due to the laxity of the medial capsule or an underlying defect in the anatomy
of the knee, which could be-
a) Excessive joint laxity
b) Small patella
c) Patella alta
d) Genu valgum
- The dislocation occurs with severe pain and with a positive apprehension test.
• Treatment –
-surgical intervention is the best choice.
- Realignment of the quadriceps mechanism to prevent dislocation of the patella laterally when the knee is flexed.
- Insertion of the patellar tendon is shifted medially and downwards to make the quads line of pull shift medially.
- Transfer of pes-anserinus to lower pole of the patella to provide a ‘checkrein’ effect.
- Knees with OA, patella is removed and quadriceps mechanism is repaired.
• Post oppratively, an above knee POP cast is given for 4-6 weeks.
3. Habitual:-
- Dislocation of the patella every time the knee is flexed but reduces spontaneously as soon as extended.
- The patient presents very early in childhood.
- Causes are similar to those of recurrent dislocation. In addition , shortened quadriceps may result in an
abnormal lateral pull on the patella when the knee is flexed.
• Treatment :-
- Treated by release of the tight structures on the lateral side and repair of the lax structure on the medial side.
- An additional ‘checkrein’ mechanism is created to prevent re-dislocation.
- Management:-
- Full knee ROM, adequate control of knee mechanism should be regained by 6-8 weeks
Maximum protection Moderate protection Minimum protection
Isokinetic exercises for
Ankle toe movements. Whirlpool is very useful.
improving endurance.
PROM or self assisted AROM is
Supported SLR, to improve hip Strengthening using theraband
initiated in pain free ranges
control and strength. and free weights.
using knee swinging.
Isometrics to the quadriceps Progressive resisted exercises.
Assisted SLR.
muscle.
By 10-12 weeks, body resistive
On 2nd post operative day, non-
squats may be begun with brief
weight bearing, 2 point gait with Self assisted hamstring
periods of jogging, running and
crutches. exercises.
light sport.

Knee orthosis for protection for

8-10 weeks while walking, till
patient regains full active
extension and 70-90 degrees of
flexion.
D) Tibial plateau fracture:

• Occurs as a result of valgus or varus strain.

• Most commonly occurs due to 2 wheeler accidents. Also called ‘bumper’ fracture.
• Patient presents with a painful, swollen knee with haemarthrosis of the knee joint.
Unable to bear weight.
• Crepitus is heard or felt.
• Diagnosis is on X-ray and CT scan.
• Classification –
 Schatzker classified tibial plateau fractures into 6 types, of which type 1- 4 involve only one
condyle either lateral or medial and types 5 - 6 are more complex intercondylar fractures.

Type 1- Wedge or split fracture of the lateral tibial plateau.

Type 2 – Split or depression fracture of the lateral plateau and involves an articular injury.
Type 3- A pure depression fracture of the lateral plateau that also involves an articular injury.
Type 4 – Split depression fracture of the medial tibial plateau, often involving the intercondylar
eminence and associated cruciate ligament. Also associated with an articular injury.
Type 5 – Bicondylar fracture involving both plateaus. Also known as an inverted Y fracture and
is usually associated with an articular injury.
Type 6 – fracture at the proximal tibial diaphyseal-metaphyseal junction.
Treatment:
• Conservative: • Operative:
1. Plaster immobilization – used only for
undisplaced fractures. - ORIF is indicated in displace
- An above knee plaster cast is applied for 3-4 fractures or when tibial plateau is
weeks. depressed due to impact.
- Knee mobilization is started after removal of - Undisplaced fracture can be
cast and weight bearing is allowed after 3
months. treated by a long screw .
2. Traction – simple and commonly used for - Post operatively, knee movements
displaced fractures. can be started after 1 week but
- Below knee skin traction or skeletal traction weight bearing is allowed after 3-
through the tibia is given for 3 weeks. 4 months.
- After 3 weeks, knee is mobilized.
- Weight bearing after 3 months.
 Disadvantage is that , the immobilization
period is longer, but the results are better
considering the knee movements/ mobility.
Management:
• Immobilization –
- Early initiation of isometrics to quadriceps and hamstring muscles.
- ATMs, assisted SLR, non-weight bearing gait with axillary crutches from ¾ post opp
day.
• Mobilization –
- CPM, PROM, Electrotherapy.
- Regain early knee extension ranges.
- Strengthening exercises, PRE.
- Weight bearing from 10th week (partial) if union is proved.
Progress from 2 crutches to 1 crutch to no support by 12 weeks.
- Proper gait and balance training.
E) Intercondylar fracture of tibial plateau:

-Fracture through both the condyles due to a force that pushes the femoral condyles on the
tibial plateaus. Example – fall from a height.
-Either T or Y shaped fracture through the tibial condyles. It a rare injury.

Treatment :

• Conservative:
- Fracture fragments reduced under GA and limb
immobilized by skeletal traction applied through the lower
end of the tibia.
- Traction maintained for 4-6 weeks .
- Full weight bearing after 3 months.
• Operative:
- ORIF with screws and special plates.
- Post operatively, mobilization started after 1 week or 10 days.
- Weight bearing after 3 months.