Gross Anatomy: Bones

intercondylar eminence

patellar surface
Gross Anatomy: Skeletal Structure

22
Gross Anatomy: Articular Surfaces
Gross Anatomy: Menisci
 Fibrocartilaginous structures
Attach to tibia in intercondylarregion
Transverse ligament connects the
anterior horns of each menisci
Vascular periphery (2-3 mm)
Medial meniscus
 Oval-shaped
 Attached to MCL
 Thinner , less mobile
Lateral meniscus
 Circular
 Thicker, more mobile
Gross Anatomy: Synovial Membrane
PCL
Bursae:
•Suprapatellar MM
LM
•Subpopliteal
ACL
•Prepatellar
• Subcutaneous
infrapatellar Does not invest cruciateligaments!
•Deep infrapatellar
Gross Anatomy: Ligaments
 Medial Collateral (MCL)
 Lateral Collateral (LCL)
 Anterior Cruciate (ACL)
 Posterior Cruciate (PCL)
 Meniscofemoral (MFL) Meniscofemoral
ligament
Gross Anatomy: Muscles
 Thigh
 Quadriceps femoris – VL, VM, VI,RF
 Sartorius
(Pes anserinus)
 Gracilis
 Hamstrings – BF, SM, ST
 IT band – GM, TFL
 Leg
 Gastrocnemius
 Plantaris
 Popliteus
Gross Anatomy: Popliteal Fossa
1. Semitendinosus
2. Biceps femoris
3. Semimembranosus

4. Sciatic nerve
5. Popliteal vein
6. Popliteal artery

Tibial n. Common
peroneal n.
 Gross Anatomy: Vasculature
 Popliteal Artery
 Med./Lat. Superior Genicular
 Middle Genicular – enters capsule post.
to supply ligaments andsynovium
 Med./Lat. Inferior Genicular
 Circumflex Fibular
 Patellar Plexus
 Anastomoses of descending
branch of lateral circumflex
femoral a., anterior tibial
recurrent a., and genicular
branches
Gross Anatomy: Nerve Supply
 Sciatic nerve
 Tibial n.
 Common
peroneal n.
 Wraps around
head of fibula
 Saphenous
branches
 Run deep topes
anserinus
Anterior Cruciate Ligament
 Most common knee injury
among athletes
 AM fibers taut in flexion
 Check anteriordisplacement
 PL fibers taut inextension
 Check rotation
 Hyperextension, internal
rotation – rarely isolated
injury from contactforce (LEFT KNEE)
 “unhappy triad”
 May tear from tibia(3-10%),
from femur (7-20%), or in
midportion (70%)
 Proximal end receives branch
from middle geniculara.
Internal rotation of right knee
ACL: Diagnosis: Examination
 History, large hemarthrosis
 Autonomic symptoms
 Anterior drawertest
 Tibia neutral, pull ant.
 NOT RELIABLE BY ITSELF
 Lachman test
 Knee only flexed 15-20
 Pivot shift/jerk test
 Start in extension, tibia
internally rotated, valgus
 Slowly flex, lateral tibial
condyle temporarily
subluxates anteriorly~30
 Reduces with furtherext.
 Jerk test opposite (90o)
ACL: Diagnosis: Imaging
 X-ray
 Segond fracture of
lateral tibial condyle
 ACL tear with it 75-
100%
 Tibial spineavulsion
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
PRICES, rehab, bracing
of slightly flexed knee
 Most tears, athleteswill
require reconstruction
Posterior Cruciate Ligament
 Broader, longer, stronger
 PM and AL fiber bundles
 Receives better vasc. from
MGA, synovial membrane
 Checks post. displacement
 Tears much less frequently Posteriorview
 Only in isolation when
Medial
“dashboard knee” injury femoral
condyle
 Hyperextension in sports,
especially with sideforce
 Falling to ground with
foot plantarflexed
Anteriorview
PCL: Diagnosis
 Posterior drawertest
 Neutral startvital!
 Gravity or sagtest
 Hips at 45 or 90,
compare tibial
tuberosities forsag
 Abduction/adduction stress
test at fullextension negative positive
 X-ray to confirm sagtest
 MRI shows lower-signal
intensity for intact PCL
compared to ACL dueto its
fiber organization
 Take on all 3 axes, butbest
is sagittal oblique
PCL: Treatment
 Controversial
 PRICES , rehab, bracing for most isolated tears
 Rehab focused on quadriceps musclesfor
compensatory anteriordrawer
 Surgery avoided when possible because PCL not
easy to access without additional risk factors
 Prognosis good because better blood supply=
revascularization
Cruciate Ligament Reconstruction
 Complete excision followed
by graft insertion
 Allograft
 Autograft
 Patellar, quadriceps,
hamstrings, calcaneus
tendons used
 Undergoes biological
modifications:
inf lamed, necrotic 
revascularization 
extrinsic fibroblasts
repopulate
ACL Reconstruction
 Autografts
 B-PT-B
 Quadruple hamstrings
 Semitendinosus, gracilis
 Only replace AM
 Double-Bundle
 Provides rotational
stability
 BTB as AM bundle
 Fixed at 20
 ST as PL bundle
 Fixed at 90
PCL Reconstruction
 Usually allograft –
calcaneus tendon
 Incorporates well
with long-term
stability
 BTB and ST oftentoo
short A B

 Can achieve full

function with
reconstruction of just
AL bundle
A. Low-power view cross section of PCL 11 years after
calcaneus tendon graft. B. High-power
 Future of Reconstruction
 Goals:
 Improve recovery time
 Improve remodeling of insertion sites
 Improve nervous and vascularrestoration
 With biological manufacture of:
 Growth factors, cytokines
 Antibiotics
 Techniques:
 Gene therapy – viral/non-viral vector delivers specific gene
 Tissue engineering – mesenchymal stemcells
Patellar Dislocation
 Predisposition
 Genu valgum
 Overweight
 Patellar hypermobility
 Weak quadriceps
 Mechanisms
 Direct contact to
medial side
 External tibial rotation
with forceful
quadriceps contraction
Patellar Dislocation
 Vastus medialis
strain
 Tearing of medial
patellar
retinaculum
 Hemarthrosis
 Reduces with
extension
Patellar Dislocation: Diagnosis
 Obvious if notyet
reduced
 Patellar hypermobility/
apprehension test
 X-ray/MRI only
necessary to ruleout
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 or complete
rupture of MPFL
 Crutches, PRICES
 Rehabilitation focusing
on vastus medialis
Meniscal Tears
 Shear force from femur
 Acute ordegenerative
 Athletes, elderly,
overweight
 Vascular zone?
 Horizontal
 Within substance
 Longitudinal
 Bucket handle – ACLrisk
 Radial orvertical
 Parrots beak
Medial Meniscus Tear
 Tears easier than lateral
due to certain traits
 Squatting
 Internal rotation of tibia
with knee flexed
 Member of “unhappytriad”
 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
 PRICES for isolated and minimal tear
 Partial arthroscopic meniscectomy mostcommon
Lateral Meniscus Tear
 Lower incidence
 Often more painful
 More likely to incur femur
radial or parrotsbeak
 Not rare foranterior Discoid
meniscus
horn
 Discoid meniscus
 Wrisberg variety
 Congenital (1.5-3%)
 MM only 0.1 – 0.3%
Lateral Meniscus: Diagnosis/Treatment
 Same techniques asfor
medial meniscus
 McMurray’s test and
Apley’s testperformed
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 abductionforce
(football)
 Pain localized to medial
joint line, but cansubside
following Grade III tear
 Leads to furtherinjury
MCL: Diagnosis: Examination
 Abduction stress test
 First at 30
 Again at fullextension
 Rule out PCLtear
 Anterior drawer testwith
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
 Grade I: indistinct MCL
(edema)
 Grade II: thicker, looser
 Grade III: severe edema
MCL: Treatment
 Surgery necessary for  Surgery
compound injury  Open incision
 Crutches + PRICES +  Midsubstance ruptures
rehab for Grade I, II sutured
only if isolated  Tear from bone repaired
 Grade III tears may with sutureanchors
require surgical repair,
but immobilization can
be effective if isolated
(rare)
 3-4 months recovery
Lateral Collateral Ligament
 Courses slightly posterior
 Sprained least frequently
 Adduction force rare
 BF, popliteus, IT tract
 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 full extension
 Ext. rotation recurvatum
 Lift legs by greattoes
 Recurvatum + ext rotation+
varus = PL cornerinjury
 Posterolateral drawertest
 Tibia externallyrotated,
posterior forceapplied
 Reverse pivot shifttest
 Knee 90, tibia ext. rotated
 With valgus, slowly extended
 Temporary posterior
subluxation of lateral tibial
condyle around 30
 Forcibly reduces withextension
LCL: Imaging and Treatment
 MRI
 Coronal oblique scan
 Sagittal scan to rule
out fibular fracture,
avulsion
 Tear looks less tautor
discontinuous – no
thickening
 Treatment
 Similar to MCL
 Grade III usually
requires surgery
 Knee Dislocations
 High association of injuries
 Ligamentous Injury
 ACL, PCL, Posterolateral Corner
 LCL, MCL
 Vascular Injury
 Intimal tear vs. Disruption
 ObtainABI’s  (+)  Arteriogram
 Vascular surgery consult with repair
within 8hrs
 Peroneal >> Tibial N. injury
 Patella Fractures
 History
 MVA, fall onto knee, eccentric
loading
 Physical Exam
 Ability to perform straight leg
raise against gravity (ie, extensor
mechanism still intact?)
 Pain, swelling, contusions,
lacerations and/or abrasions at the
site of injury
 Palpable defect
 Patella Fractures
 Radiographs
 AP/Lateral/Sunrise views
 Treatment
 ORIF if ext mechanism is
incompetent
 Non-operative treatment with
brace if ext mechanism remains
intact
 Tibia Fractures
 Proximal Tibia Fractures
(Tibial Plateau)
 Tibial Shaft Fractures
 Distal Tibia Fractures
(Tibial Pilon/Plafond)
Tibial Plateau Fractures

 MVA, fall from height, sporting injuries

 Mechanism and energy of injury plays a
major role in determining orthopedic care
 Examine soft tissues, neurologic exam
(peroneal N.), vascular exam (esp with medial
plateau injuries)
 Be aware for compartment syndrome
 Check for knee ligamentous instability
 Tibial Plateau Fractures
 Xrays: AP/Lateral +/- traction films
 CT scan (after ex-fix if appropriate)
 Schatzker Classification of Plateau Fxs

Lower Energy

Higher Energy
 Tibial Plateau Fractures
 Treatment
 Spanning External
Fixator may be Insert blister
Pics of ex-fix here
appropriate for
temporary stabilization
and to allow for
resolution of soft tissue
injuries
 Tibial Plateau Fractures
 Treatment
 Definitive ORIF for patients
with varus/valgus instability,
>5mm articular stepoff
 Non-operative in non-
displaced stable fractures or
patients with poor surgical
risks
 Tibial Shaft Fractures

 Mechanism of Injury
 Can occur in lower energy, torsion type injury (e.g.,
skiing)
 More common with higher energy direct force (e.g.,
car bumper)
 Open fractures of the tibia are more common than
in any other long bone
Tibial Shaft Fractures

 Open Tibia Fx
 Priorities
– ABC’S
– Associated Injuries
– Tetanus
– Antibiotics
– Fixation
Tibial Shaft Fractures
 Management of Open Fx
SoftTissues
 ER: initial evaluation 
wound covered with sterile
dressing and leg splinted,
tetanus prophylaxis and
appropriate antibiotics
 OR: Thorough I&D
undertaken within 6 hours
with serial debridements as
warranted followed by
definitive soft tissue cover
Tibial Shaft Fractures
 Definitive Soft Tissue Coverage
– Proximal third tibia fractures can be covered with
gastrocnemius rotation flap
– Middle third tibia fractures can be covered with
soleus rotation flap
– Distal third fractures usually require free flap for
coverage
Tibial Shaft Fractures
 TreatmentOptions
 IM Nail
 ORIF with Plates
 External Fixation
 Cast
 Tibial Shaft Fractures
 Advantages of IM nailing
 Lower non-union rate
 Smaller incisions
 Earlier weightbearing and function
 Single surgery
 Tibial Shaft Fractures
 IM nailing of distal
and proximal fx
 Can be done but
requires additional
planning, special nails,
and advanced
techniques