LOWER EXTREMITY I

CAPSULAR LIGAMENT STABILITY, DISLOCATION

AND LIGAMENT INJURY OF THE HIP AND KNEE JOINT

Dr. M. Wibowo Ariyanto, SpOT (K)

Orthopedic and Traumatology Department
Sub Adult Reconstruction Hip and Knee Ansari Saleh Hospital Banjarmasin
South Borneo
BONY ANATOMY OF THE HIP JOINT

Largest weight bearing joint, ball and socket joint type

and it was surrounded by capsular ligament, tendons
and muscles.
The cup-shaped acetabulum is formed by the
innominate bone and composed by ilium (40%),
ischium (40%) and the pubis (20%). It’s oriented 45°
caudally and 15° anteriorly
Labrum has a sensory function owing to existence
of free nerve endings with proprioceptors and
nociceptors and sealing function to keep the
femoral head within the acetabulum with a vacuum
force
The central part of the acetabulum or acetabular
fossa is non-articular and is filled with a fatty layer
(pulvinar)
Intra-capsular : teres and angular ligament (zona
orbicularis)
Fibrocartilaginous tissue surrounding the acetabulum, the acetabular labrum,
has several functions:
1. Load transmission
2. Negative pressure maintenance (vacuum seal)
3. Regulation of synovial fluid hydrodynamic properties
4. Increases the depth of the socket (acetabulum)
 Acetabular orientation influences the joint stability, retroverted
acetabulum tends to posterior instability, and anteverted
acetabulum tends to anterior instability
Femoral anteversion and femoral neck-shaft angle influence
hip stability
 CAPSULAR LIGAMENT OF THE HIP
JOINT

 Hip capsule is composed of several

ligamentous structures
 Anterior part, iliofemoral (strongest)
and pubofemoral (weakest) ligament
 restriction of external rotation
 Posterior part, ischiofemoral
ligament  restriction of internal
rotation

Hip joint movement is restricted by the 3 fundamental ligaments : iliofemoral

ligament splitting into transverse & descending parts, pubofemoral ligament, and
ischiofemoral ligament (extracapsular)
The ligamentum teres has 3 function :
1. Additional support of stabilizing joint
2. Distribution of synovial fluid and force in the acetabulum
3. Somatosensory functions
 HIP JOINT STABILITY

The hip is an inherently stable joint as a result of the femoral head to sit
deeply within the highly congruent acetabular fossa.
Hip joint capsuloligamentous (iliofemoral, ischiofemoral, and pubofemoral)
play role in functional mobility and joint stability
Maintenance joint stability is collaboration from passive, active and neural
systems
Joint instability result from a deficit of one or more of these systems and the
other systems cannot compensate.
 Hip joint stabilizer was differentiated by passive and dynamic stabilizer mechanisms
 If the passive stability mechanism of the hip was inadequate, due to local pathology
or insufficiency, the muscular system will be needed to augment stability or dynamic
stability mechanism
 Dynamic stabilizer consists of the rectus femoris, gluteal muscles, and short external
rotators
 The deep external rotators (piriformis, quadratus femoris, obturator internus and
externus and the gemelli) are key dynamic stabilizers of the hip
In vitro cadaveric studies saw on individual capsular ligament
contributions to hip joint stability in passive stabilizer mechanism
 DISLOCATION OF THE HIP JOINT

Etiology and Mechanism of Injury

Dislocations of the hip can be classified as congenital or acquired
Mostly acquired hip dislocation results from high energy trauma
Hip dislocation occurs when the internal forces of the hip (labrum, capsule,
ligamentum teres, muscles, bones, and mechanical anatomy) are
overpowered by high energy transmission through the joint.
Because the anterior ligaments are stronger, trauma to the hip commonly
presents as a posterior dislocation
Dislocation & subluxation is the most common etiology of hip instability
 Clinical Assessment

Chief complaint
History of significant "clunk" or "popping" followed
immediately pain after injury

Physical examination
ATLS procedure, local wound or deformity and
neurovascular examination of injured hip or limb
Radiograph examination
1. Plain X ray (pelvis AP, obturator, iliac, outlet and inlet view)

NORMAL DISRUPTION SHENTON

LINE

2. Ct scan (2D and 3D)

3. Angiography (vascular injury case)
 Management and Treatment

Conservative or non operative treatment

Closed reduction using several maneuver

Operative treatment
Open reduction and internal fixation

Treatment of patients with hip dislocation is performed in two stages. Initially, the
goal is to perform rapid reduction of the hip. The second stage is focused on
definitive management.
 Long-term Complications of Hip Dislocation

Most common long-term complication of hip dislocation is posttraumatic

osteoarthritis (20%)
Avascular necrosis or AVN (2-10%) due to disruption of the blood supply,
arterial vasospasm, and compromised venous outflow
Sciatic nerve palsy (10%-15%)
Heterotopic ossification (2,8-9%)
 POSTERIOR DISLOCATION OF THE HIP
JOINT

Mechanism of Injury

Mostly acute traumatic hip dislocation occur

when a sudden, excessive axial load is
applied to the femur with the hip in a flexed
position.
This type of injury can produces posterior
wall fracture of the acetabulum
Clinical Appearance
Limb adducted, flexed, internally rotated and shortening
Radiograph Study

Simple case Fracture & Dislocation

 Management and Treatment

Conservative or Non-surgical treatment

Closed reduction using Bigelow, Allis, Captain Morgan and Stimson Manoeuvre
Surgical treatment
Indication :
1. Failed closed reduction
2. Proximal femoral fracture or associated acetabular fracture
3. Noncongruent reduction due to incarcerated bony fragment or soft tissue
obstruction
4. Open dislocation
 Simple Posterior hip dislocation

8 y.o old boy with left hip pain after ground level fall on his knee. Left lower limb looks shorthening
in flexion, abduction and external rotation appearance. Pelvis x ray reveals posterior dislocation
of left hip, concentric reduction after closed reduction.

Trauma Case Reports. https://doi.org/10.1016/j.tcr.2021.100418

 Posterior hip dislocation with acetabulum fracture

26 y.o male had a car accident shortening with internal rotation, adduction and shortening of the
left limb. Pelvic x ray saw left femoral head came out of the acetabulum and visible fractures on
the posterior wall of the acetabulum. After closed reduction, is proceeded to internal fixation
posterior wall fracture due to instability.

International Journal of Surgery Case Reports. https://doi.org/10.1016/j.ijscr.2020.04.009

 ANTERIOR DISLOCATION OF THE HIP
JOINT

Anterior dislocation of the hip is an uncommon injury, occurring in only 5-10%

of all traumatic dislocations of the hip
Subtype :
1. Superior (iliac or pubic) type
2. Inferior (obturator) type
Inferior dislocation is the most common type of anterior dislocation, comprising
more than 70% of anterior dislocations.
The lower incidence of anterior dislocation may be due in part to the strong
anterior capsule and Y-shaped ligament of Bigelow
Mechanism of Injury
An anterior superior dislocation results when, along with abduction and
external rotation, the hip is in extension, and anterior inferior dislocation occurs
when the hip is in flexion. With more abduction, the head is displaced
superomedially (pubic) and less abduction superolaterally (iliac)
Clinical Appearance
Pain in the groin, swelling, shortening,
deformity, tenderness, crepitation and
neurology deficit of affected limb
In superior dislocation (pubic and iliac type) the limb appears shortened, but in
inferior dislocation, the is lengthened.
In superolateral (iliac) type, the dislocated femoral head could be palpated as
a mass just below the ASIS, whereas in superomedial type in the inguinal
region and in inferior type in the groin.
The anteriorly dislocated limb has an abducted and externally rotated attitude
Radiograph Study
Pelvis AP (anteroposterior)
The superolateral anterior dislocation is easily
mistaken for posterior dislocation
Prominent lesser trochanter due to the external
rotation and an abducted attitude of the femoral
shaft help in differentiating from posterior
dislocation where the lesser trochanter is less
prominent and shaft is adducted

posterior dislocation
 Management and Treatment

Conservative or Non-surgical treatment

Closed reduction

Surgical treatment
It’s same indication with surgical treatment to posterior dislocation
 Obturator type of anterior hip dislocation

45 y.o male athlete, swollen and left groin pain after collision, hip flexion, abduction and external rotation and
with a bent knee. Pelvis X-ray revealed an obtutor type of anterior right hip dislocation. CT scan of the pelvis
showed vacuity of the acetabulum with the head of the femur facing the obturator foramen, no bone lesion. A
control X-ray of the pelvis after closed reduction 2 hour later

International Journal of Surgery Case Reports https://doi.org/10.1016/j.ijscr.2022.106983

 Superolateral type of anterior hip dislocation

46 y.o male with exposing of left femoral head in the groin after collision, hip in extension,
abduction and external rotation. Radiographs revealed high superior dislocation type of anterior hip
dislocation of the left hip, with prominence of the lesser trochanter, and after reduction
Rev Bras Ortophttp://dx.doi.org/10.1016/j.rboe.2014.01.003
 CENTRAL DISLOCATION OF HIP JOINT

Mechanism of Injury
Direct lateral impact over the greater trochanteric region caused the femoral
head to be pushed anteriorly and medially causing displaced anterior column
fracture radiating to the iliac wing and the quadrilateral surface to fracture.
The initial anterior displacement of the anterior column at the moment of the
impact caused an enlargement of the anteroposterior diameter of the
acetabulum allowing the femoral head to migrate medially fracturing the
quadrilateral surface to the inner pelvis.
Clinical appearance
Lower limb was locked in adduction, internal rotation and shortened due to
medial displacement of the femoral head caused by displaced acetabular
fracture.
Radiograph Study

Displaced right acetabular fracture dislocation with anterior column fracture

associated with a central migration of the right femoral head through the
quadrilateral surface.
 Management and Treatment

Conservative or Non-surgical treatment

Closed reduction

Surgical treatment
ORIF (open reduction and internal fixation)

The goal : good long-term function & the avoidance of 2nd OA hip
 Central dislocation of hip

13 y.o boy fall dawn when riding bike and his right lower limb was locked in internal rotation.
Concentric reduction was achieved after ORIF

Case Reports in Orthopedics https://doi.org/10.1155/2017/6873484

 BONY ANATOMY OF THE KNEE JOINT

2 bony articulations : the articulation between the

femur and tibia or femorotibial joint (bears of the
body weight) and the articulation between the patella
and femur or patellofemoral joint

Range of motion : flexion, extension (sagittal planes), internal, external rotation

(transverse plane), varus, and valgus stress (frontal plane).
Capsular Ligament of The Knee Joint

The capsule connects the distal end of the femur

with the proximal border of the tibia
The capsular ligaments, functionally: component
of the extensor mechanism (patellofemoral
articulation) & tibiofemoral articulation
The posterior capsule is strengthened by two
irregular ligamentous structures : the oblique
popliteal and the arcuate popliteal ligaments
 Knee Joint Stability

The knee is stabilized by both primary stabilizers and secondary stabilizers.

Primary knee stabilization is achieved through knee ligaments, while muscles
around the knee play a secondary role.
Ligaments are fibrous bands of tissue that connect bone to bone and provide
support to joints. The knee is reinforced by 2 collateral ligaments (MCL and
LCL) and 2 cruciate ligaments (ACL and PCL) that prevent excessive anterior,
posterior, varus, and valgus displacement of the tibia in relation to the femur.
The medial ligamentous complex
2 layers: the deep and superficial of
medial collateral ligament (MCL)
The MCL is the primary stabilizer of the
medial side of the knee and against
excessive valgus forces and external
rotation
The lateral collateral ligament
The lateral collateral ligament (LCL) is part of the so-called lateral quadruple
complex (biceps tendon, iliotibial tract, popliteus and LCL), responsible for the
lateral stability of the knee and against excessive varus movement

The cruciate ligaments

Consist of : anterior cruciate ligament (ACL) dan posterior cruciate ligament
(PCL)
The cruciate ligaments lie in the center of the joint, but extra synovial because
of the posterior invagination of the synovial membrane.
The cruciate ligaments ensure the anteroposterior stability of the knee and,
together with the collateral ligaments, prevent rotational movements during
extension

The anterior cruciate ligament (ACL)

ACL attaches to the anterior intercondylar area of the tibia, go to laterally &
posteriorly to internal aspect of lateral condyle of the femur
The ACL primarily resists anterior and rotational displacement of the tibia
relative to the femur
 The ACL is the main stabilizer of the knee, contributing to about 85% of the knee
stabilization.
 The ACL is innervated by branches of the tibial nerve, and has three
mechanoreceptors and nerve endings with a specific function

The posterior cruciate ligament (PCL)

 PCL attaches at the posterior border of the tibial plateau, and insert at the lateral
surface of the medial condyle, deeply in the intercondylar fossa.
 The PCL primarily resists posterior and rotational displacement of the tibia relative to
the femur
 DISLOCATION OF THE KNEE JOINT

Dislocation of the knee is defined as gross instability of two or more ligaments

after a traumatic event (collision and sport injury)
Limb threatening injury (extensive soft-tissue & neurovascular damage)
Base on displacement of the tibia relative to the femur, it’s divided into 5 types :
anterior, posterior, medial, lateral and rotatory
Rotatory sub types are divided into anterolateral, anteromedial, posterolateral
and posteromedial types (the most difficult to reduce)
Another classification based on patterns of ligamentous damage (Schenck) or
injury of arterial and neurological (Wascher)
Anterior Dislocations of The Knee Joint

The most common type, 40% of knee dislocations

Anterior dislocations are caused by hyperextension
injuries. The posterior capsule was first torn at 30°
hyperextension, followed by injury to the ACL and then
the PCL as the hyperextension continued.
Higher likelihood of an intimal tear to the popliteal artery
and arterial thrombus
Posterior Dislocations of The Knee Joint

The second most common injury, about 33% of all

dislocations
Posterior dislocations are caused by a posterior force, most
commonly the dashboard mechanism (33%).
The PCL acts as key to posterior stability, is always ruptured.
The ACL is frequently ruptured.
Case : acute posterior dislocation of knee joint

A 38 y.o male after a motorcycle crash, unable to

walk due to left knee pain. Clinically multiple
abrasion and left deformity and have no
neurovascular disturbances.
Knee radiograph reveals posterior dislocation
MRI : tears of the anterior and posterior cruciate
ligament (ACL, PCL) and lateral collateral ligament
(LCL).
Management : external fixator to stabilize reduction
J Bone Joint Surg Am. 2004;86-A:910-915
Medial or lateral Dislocations of The Knee Joint

Medial (4%) and lateral (18%) dislocations are usually

associated with fractures.
Lateral dislocation may be irreducible due to the medial
femoral condyle ‘button-holing’ through the capsule, and
clinically will look a medial skin dimple
Medial dislocations are associated with the highest risk
of posterior-lateral corner (PLC) damage and thus the
highest risk of irreducible dislocation
 Rotatory Dislocations of The Knee Joint

A combination of varus/valgus stress with hyperextension/blow to proximal tibia

will likely produce one of the rotatory dislocations
Early management
Advanced Trauma Life Support (ATLS) procedure for all case
Aim : patient stabilization, dislocation reduction and to avoid neurovascular
disturbance

Closed reduction Knee brace External fixator

Limb immobilization using :
1. external support (brace, splint or above knee plaster) to patient comfort, limb
stability and the unloading of soft tissue injuries. The knee is positioned in 200
of flexion to prevent posterior subluxation of the tibia and does not disturbance
neurovascular bundle
2. External fixator is indicated for gross instability, associated fractures or the
presence of vascular injuries
 Management and treatment

Operative management
 Aim : to create a stable, mobile, functional knee and free from complications
 Absolute indications : open fracture or dislocation, compartment syndrome and
arterial injury
 Timing : after 3 weeks, delayed surgical treatment is recommended to reduced
anterior instability and decreased rates of flexion loss > 100
 If surgery is performed within 2-3 weeks following injury will high risk of severe
arthrofibrosis.
 Reconstruction surgery (arthroscopy) is pointed to significant knee instability due to
ligamentous injury
Rehabilitation program post operative
Start 3 weeks after injury (acute inflammation has been subsided) to prevent
quadriceps muscle wasting and after post operative to protect the operative
repair or reconstruction
Complications of Knee Dislocation
1. Vascular compromise
2. Ischaemic limb
3. Permanent nerve damage
4. Popliteal vessel thrombosis
5. Acute compartment syndrome
 Multiple ligament injury of Knee The Joint

Knee dislocations frequently result in the disruption of the ACL, PCL, joint
capsule and collateral ligaments (multiple-ligament).
Disruption of at least 2 of the 4 primary knee ligaments is called multiple-
ligament injury of knee
Mechanism of Injury
High and low energy mechanisms can both lead to knee dislocation and its
associated ligamentous disruption
Clinical evaluation
Evaluation of knee stability, deformity, malalignment and soft tissue damage
Symptoms
Patients with multi-ligament knee injuries may
experience pain, swelling, limited range of
motion, injuries to nerves and arteries of the
leg, and knee instability
Physical Examination (PE)
The examination of knee ligaments is performed after limb-threatening
pathologies.
1. Lachman test 3. pivot shift test
2. Anterior and posterior drawer test 4. valgus and varus stress test
Neurovascular examination
Imaging
Plain x-ray : rule out the associated fracture
MRI : assessment ligament & meniscal injury
Management and Treatment
Surgical : repair or reconstruction (arthroscopy)
Rehabilitation post operation
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