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The Knee

University College Hospital London

The Knee

Anatomy
complex joint 4 bones 3 joints cartilage 2 menisci

ligaments
muscles

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Anatomy
femur
medial condyle > trochlea: more proximal lateral

tibia
medial plateau > medial concave

patella
sesamoid bone lateral facet >
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Anatomy
menisci
+/- avascular

PCL

cartilage
ACL

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Anatomy
cruciate ligaments collateral ligaments
lateral MCL condyle LCL
posterior LM ACL

anterior

ACL MM

medial condyle

PCL
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Anatomy
muscles

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Anatomy
muscles

Bursae and plica


suprapatellar medial mucosum

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Anatomy
muscles

bursae and plicae


suprapatellar medial mucosum

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History
pain other symptoms: locking, giving way, effusion function
med condyle

past history

plateau
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Clinical examination
look: scars, swelling, alignment, redness, muscle atrophy, limping

feel: effusion, cfr. anatomy


move: flexion-extension, active-passive, hip!! special tests

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Technical examination
radiographs: 4 views ultrasound CT (+/-arthrography)

MRI
bonescan

arthroscopy
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Patello-femoral joint

chondropathy

dyplasia

malalignement

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Patello-femoral joint
history: movie sign, stairs, grinding, giving way

examination

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Patello-femoral joint
XR CT + arthrography bone scan

MRI?

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Patello-femoral joint
conservative: physiotherapy (quads+++), NSAID, glucosamine?

arthroscopy: when in doubt dont operate, lateral release open: medial reefing, tuberosity transfer

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Extensor mechanism
tendonitis: patellar tendon, ITB apophysitis: Osgood Schlatter, SindingLarsen-Johanson rupture

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Extensor mechanism
history examination: palpation, active straight leg raise technical: XR, ultrasound, MRI treatment: stretching, immobilization?, NSAID, rest, brace, infiltration, surgery

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Anterior cruciate ligament


history: torsion, valgus, hyperextension examination: effusion, haemarthrosis, anterior drawer, Lachman, pivot shift diagnosis: MRI (XR segond) treatment: ACL physio/surgery

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Anterior cruciate ligament

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Posterior cruciate ligament


history: varus, hyperflexion, dashboard examination: effusion, haemarthrosis, posterior drawer, reverse pivot shift, sagging, quadriceps active test

diagnosis: MRI
treatment: PCL carefully neglect

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Collateral ligaments
history: MCL valgus, LCL varus examination: stress test (+/-30 of flexion) I = pain, II = opening at 30, III = opening at 0 diagnosis: ultrasound, MRI treatment: rest, physio, nsaid, infiltration, brace, surgery?

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Meniscal injuries
history: flexionrotation, effusion, locking examination: effusion, pain with hyperflexion, pain at joint line, McMurray, Apley, cysts diagnosis: MRI treatment: conservative, surgery (partial meniscectomy, suture, transplant)

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Meniscal injuries

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Cysts
Lo:

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Cartilage

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Cartilage

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Cartilage
conservative: glucosamine, quads, unloading brace, NSAID, steroids

debridement and lavage


abrasion arthroplasty and microfracturing osteochondral allografts
Brittberg M et al. NEJM 1994; 331: 889-95

autologous chondrocyte implantation


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Conclusion
effusion

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Conclusion
immediately
ACL/PCL
cartilage fracture meniscus

delayed
meniscus
cartilage inflammatory

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Conclusion
effusion pain locking or giving way

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Conclusion
locking
meniscus

giving way
ACL

cartilage

PF

ACL

meniscus

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Conclusion
effusion pain locking or giving way

always plain XR (exclude tumor, fracture)


orthopaedics = anatomy

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Thank you

The Knee