Injuries of Knee and Leg

Functional Anatomy:
The knee is a hinge joint made up of the articulations between the femoral and tibial
condyles and between the patella and the patellar surface of the femur. The capsule is
attached to the margins of these articular surfaces but communicates above with the
suprapatellar bursa (between the lower femoral shaft and the quadriceps), posteriorly
with the bursa under the medial head of gastrocnemius and often, through it, with the
bursa under Semimembranosus. It may also communicate with the bursa under the
lateral head of gastrocnemius. The capsule is also perforated posteriorly by popliteus,
which emerges from it in much the same way that the long head of biceps bursts out of
the shoulder joint. The capsule of the knee joint is reinforced on each side by the
medial and lateral collateral ligaments, the latter passing to the head of the fibula and
lying free from the capsule. Anteriorly, the capsule is considerably strengthened by the
Ligamentum patellae, and, on each side of the patella, by the medial and lateral patellar
retinacula, which are expansions from vastus medialis and lateralis. Posteriorly, the
tough oblique ligament arises as an expansion from the insertion of semimembranosus
and blends with the joint capsule. In the joint are a number of important structures
(figure 10-1).
The cruciate ligaments: are extremely strong connections between the tibia and femur.
They arise from the anterior and posterior intercondylar areas of the superior aspect of
the tibia, taking their names from their tibial origins, and pass obliquely upward to
attach to the intercondylar notch of the femur. The anterior ligament resists forward
displacement of the tibia on the femur and becomes taut in hyperextension of the knee,
it also resists rotation, and the posterior resists backward displacement of the tibia and
becomes taut in hyperflexion.
The semilunar cartilages (menisci): are crescent-shaped and are triangular in crosssection, the medial being larger and less curved than the lateral. They are attached by
their extremities to the tibial intercondylar area and by their periphery to the capsule of
the joint, although the lateral cartilage is only loosely adhering and the popliteus
tendon intervenes between it and the lateral collateral ligament. They deepen, although
to only a negligible extent, the articulations between the tibial and femoral condyles
and probably act as shock absorbers. If both menisci are removed, the knee can regain
complete functional efficiency, although it is interesting that, following surgery, a rim
of fibrocartilage regenerates from the connective tissue margin of the excised menisci.

Figure 10-1: Anatomy of the knee joint.

Acute Ligamentous Injury of the Knee:

Mechanism of injury:
1. Direct thrust with the tibia forced anteriorly on femur leading to ACL injury; or
the tibia forced posteriorly on the femur leading to PCL injury; varus or valgus
stress of the femur leads to lateral or medial collateral ligament tear respectively.
2. The commonest injury is an external rotation of the tibia on the femur (twisting
force) with the knee flexed and loaded; this injury leads to group of soft tissue
injuries starts with tear of the medial capsule, then with further rotation there
will be medial collateral ligament tear, and lastly the ACL will get torn.
These forces mentioned above can cause an associated meniscus tear especially the
medial meniscus (figure 10-2).

Figure 10-2: Mechanism of acute ligamentous injury of the knee joint.

Clinical features:
History of trauma, localized or diffuse knee pain & tenderness, knee swelling due to
haemarthrosis which occurs immediately after injury (to be differentiated from
synovial effusion of meniscus tear which appears after several hours to 24 hours).
Medial collateral ligament tear usually occurs at its femoral attachment while lateral
collateral tear usually occurs at its fibular attachment; this leads to localized pain at
the site of injury.
A partial tear gives severe pain without instability, while complete tear gives little
pain with great instability.
Knee stability is examined by different stress tests (figure 10-3):
1. Anterior Drawer Tests to examine the ACL.
2. Posterior Drawer Test to examine the PCL.
3. Valgus & Varus stress tests to examine the medial & lateral collateral ligaments
respectively.
N/B: Sometimes those stress tests are painful and needs local or general anesthesia to
be done.

Figure 10-3: Clinical evaluation of acute ligamentous injury of the knee joint.

X-Ray:
It may show associated avulsion fracture of medial femoral condyle, the tibial spine or
the head of the fibula. Stress tests with X-ray may be useful & sometimes done under
anesthesia.
Arthroscopy:
Indications in acute injury are:
1- Suspected isolated ACL injury.
2- Suspected associated meniscal tear.
Contra-indication: in case of complete collateral ligament tears where there will be
extravasation of the fluid used during arthroscopy into the calf region which may lead
to compartment syndrome.
Treatment:
Partial Tears:
Aspiration of tender haemarthrosis.
Ice packing and sometimes local steroid injection.
Removable back splint that allow physiotherapy and exercises for 3-4 weeks.
After removal of the splint continue with physiotherapy and exercises.
Complete Tears:
A. Ideally it needs surgical repair, but this is not always applicable.
B. We do arthroscopy of the joint, we inspect the medial & lateral meniscus &
remove any torn meniscus when indicated, repair any torn capsule or other
repairable structures as follows:
Medial & lateral collateral ligaments: we do direct repair with sutures;
sometimes we add reinforcement by using surrounding structures like
tendons or fascia lata.
ACL If there is avulsion of tibial spine we do fixation. If the ligament is
torn; direct suture is neither useful nor enough it usually needs
reconstruction by using nearby structures like tendons (semitendinosus) or
fascia lata to be inserted in a direction where they can act like ACL to take
some of its function. Postoperatively we do full length POP leg cast for
3-4 weeks, followed by functional brace for anther 3-4 weeks with
physiotherapy & graduation of weight bearing.
C. In those cases of complete tears sometimes we treat patients non-operatively like
in older patients or in young non-athletic patients; we do long POP cast for 6-8
followed by physiotherapy & exercises with graduation of weight bearing.
Complications:
1- Adhesions: especially in cases of incomplete tears, patient having increasing
pain, giving way and localized tenderness while the knee is still stable.
Treatment is by examinations & manipulation under anesthesia with local
steroid injection physiotherapy.
2- Chronic instability: after complete tears, patient have chronic pain & instability
with possible later osteoarthritis, it needs special treatment.

Dislocation of the Knee Joint:

It is a serious injury of young adults associated with severe trauma. It is usually
associated with ACL and one or both collateral ligaments tear, sometimes there is
neurovascular injury.

Figure 10-4: Clinical and radiology of dislocation of the Knee Joint.

Clinical features: Swollen, deformed & bruised knee neurovascular examination is

essential (figure 10-4).
X-ray: It can show the dislocation and the possible associated fracture sometimes
arteriogram to cheek vascular injury (figure 10-5).

Figure 10-5: X-ray of dislocation of the Knee Joint.

Treatment: MUA is urgent to relocate the knee and prevent circulatory injury followed
by back-splint in 15degrees of flexion, then check the circulation. If this fail goes to
open reduction & suturing & repair of the torn ligaments and soft tissues with back
splint. After 2-4 weeks change it to full POP cylinder for 12-16 weeks Q-exercises and
graduation of weight bearing is done as soon as the patient is comfortable.
Complications: Early: neurovascular injury.
Late: 1. Knee stiffness. 2. Knee instability.

Fracture of Tibial Plateau (condyle):

The plateau fractures when the leg is subjected to varus or valgus stress with axial
compression such as in:
1. Fall from a height.
2. Car striking a pedestrian by its bumper (Bumper injury). It is fracture of adult at
any age.
Clinical features: Knee is swollen deformed with extensive bruising; it feels doughy
because of haemarthrosis. Always check distal neurovascular function and under
anesthesia we may need to assess knee ligament injury.
X-ray:
1. Plane films AP, Lat, and Oblique.
2. Stress views under anesthesia to show associated ligament injury
3. CT scan is the best to show the fracture extension & degree of displacement.
Classification: called Schatzker Classification (Figure 10-6):
Type I: lateral condylar fracture, which is vertical split injury.
Type II: lateral condylar fracture, which is crushing comminuted depressed.
Type III: lateral condyle fracture like type two with intact lateral cortex.
Type IV: medial condylar fracture.
Type V: bicondylar fracture.
Type VI: bicondylar fracture with proximal shift comminution.

Figure 10-6: Schatzker Classification.

Treatment: Conservative treatment can be used & gives good range of motion but
angular deformity is common. Surgical treatment (figure 10-7) gives good and rapid
results but associated with high incidence of stiffness. So the choice sometimes is
difficult. The fracture is said to be displaced or unstable if the fracture gap is more than
5mm or if there is associated knee ligament injury. This is important to decide the
treatment.
Undisplaced fractures: Treated with bed rest & skeletal traction with early
physiotherapy & movements for 10-15 days until patient is pain-free and comfortable,
we can use cast-bracing & partial wt. bearing for the next 4-6 weeks until healing.
Displaced fractures: Treatment is can conservative, as above if there is
contraindication for surgery, which is the treatment of choice here. It is by ORIF
followed by early mobilization & physiotherapy.

Figure 10-7: Treatment according to Schatzker Classification.

Complications:
Early: 1. Nerve injury. 2. Vessel injury. 3. Knee ligament. 4. Compartment syndrome.
Late: 1. Joint stiffness.
2. Varus or valgus deformity. 3. Osteoarthritis.
Fracture of Tibial Spine:
It is can be a type of avulsion injury of ACL when the knee subjected to forces that
stress the ACL. Also when the knee subjected to varus or valgus stress with twisting.
Clinical features: Knee swollen, tender, and doughy by haemarthrosis EUA may show
associated ligament injury or ACL dysfunction.
X-ray: May not obvious and there is only partial or undisplaced fracture (figure 10-8).
Treatment: Under anesthesia examination of the knee ligaments is done & aspiration
of haemarthrosis. MUA of the knee in full extension & check x-ray, if reduction is
good we do POP cylinder. If not good do Arthrotomy and ORIF with screw in adults or
with sutures in children followed by 4-6 weeks of POP cylinder & physiotherapy.

Figure 10-8: X-ray of fracture of Tibial Spine.

Fractures of the Patella

Morphology
The patella is the largest sesamoid bone in the body and lies within the fascia and
fibers of the quadriceps tendon. The upper is covered with articular cartilage. The
articular surface of the patella is divided into medial and lateral facets, which articulate
with the anterior trochlea. As you can see from the diagram, the lateral facet is the
largest. A vertical ridge near the medial facet defines the odd facet. Transverse ridges
are present which further define the facets. The infero-medial odd facet does not
articulate with the femoral condyle until 135 degrees of knee flexion (Figure 10-9).

Figure 10-9: Functional anatomy of Patella.

Patellar Retinaculum:
The patella in invested in a strong soft tissue envelope formed by the joining of the
quadriceps tendon, the iliotibial band and distal quadriceps muscles and the patella
tendon. The patellar retinaculum originates from the deep fascia along with fibers of
the vastus medialis and vastus lateralis. There are also contributions from the iliotibial
tract and patellofemoral ligaments of the joint capsule.
Blood Supply
The blood supply consists of an extraossoeus and intraosseous vascular system. The
primary blood supply is from branches of the geniculate arteries. The intraosseous
blood supply enters the bone through the mid-portion of the patella and through distal
pole vessels (Figure 10-10). The primary blood supply is derived from a dorsal ring
formed by geniculate arteries. The secondary blood supply enters posterior surface of
distal pole.
Origins & Insertions
The quadriceps tendon inserts into the superior pole. Vessels enter the patellar midsection and the patellar ligament originates from the inferior pole.
Articular surface
The proximal posterior patellar surface is approximately 75% is articular. One tends to
forget the inferior pole is non-articular and it constitutes 25% of patellar height.
Function
1. Changing the direction of the pull of the extensor mechanism.
2. Provide a mechanical advantage to the knee extensor mechanism by increasing
its moment arm from the axis of knee rotation.
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3. In full flexion, the patella increases the lever arm of quadriceps by only 10 %. At
45 degrees of flexion patella increases the quadriceps lever arm by 30 %.
4. At terminal extension the patellar moment arm is critical, as the last fifteen
degrees (15 - 0) require twice the amount of torque from full flexion to 15
degrees. Post patellectomy patients will therefore have extensor lag and
weakness (Figure 10-11).

Figure 10-10: Blood supply of Patella.

Figure 10-11: Bio-mechanic of Patella.

Mechanism of injury:
1. Direct trauma: this usually causes either crack undisclosed fracture within an
intact extensor expansion or comminuted minimally displaced fracture also with
intact expansion.
2. Indirect trauma: avulsion fracture by powerful quadriceps contraction against
resistance, which causes transverse displaced fracture associated with rupture of
the extensor expansion.
Clinical Evaluation:
One must complete a thorough history and physical examination of the patient. There
may be pain, swelling and hemarthrosis. The defect may be palpable. The skin should
be examined closely in those injuries sustained from direct trauma to evaluate for the
presence of an open injury. The extensor mechanism is evaluated by the ability to
extend the knee against gravity or to maintain the knee in full extension versus gravity
(with or without knee joint aspiration and intra-articular lidocaine injection).

Figure 10-12: Palpable gap of fractured Patella.

X-Ray:
It can show the fracture type & its displacement by AP, lateral & sunrise views that are
taken with the knee flexed to check the integrity of the extensor expansion by
measuring the gap between the fragments.
Comparison views of the unaffected limb may be of value to further define the bony
anatomy. On the lateral view, one should evaluate the position of the patella. A low
riding patella (patella baja) may indicate a quadriceps tendon rupture, while a high
riding patella (patella alta) may indicate a patella tendon rupture. The Insall method is
used for assessment of patella position. In this method, the patella length is measured
and compared in a ratio to length of the patella tendon. Normally, the ratio is 1:1 a ratio
of 0.8 or less suggests a patella tendon rupture. The sunrise view may be helpful to
further delineate fracture displacement. This view is helpful in the diagnosis of
patellofemoral disorders and osteochondral defects.
CT scans may be useful in peri-articular injuries, evaluation of alignment, detection of
occult fractures, and analysis of fracture healing.

Figure 10-13: X-ray of fractured Patella.

Figure 10-14: Bipartite Patella.

Differential diagnosis:
An important one is the congenital bipartite patella (figure 10-14) it occurs due to
failure of fusion of the two epiphyses of the patella leaving a radiological gap at the
supero-lateral angle other x-ray features to differentiate bipartite patella are:
It is bilateral.
The margins are flat & smooth.
It is always at the supero-lateral angle.
The edges are thick & sclerotic.
Classification:
Classification systems are ideally designed to allow communication between
physicians, guide treatment and predict outcomes. For the patella, there are no
universally accepted classification systems. Descriptive terms may be used to classify
patella fractures and an example is demonstrated on the picture. Vertical fractures may
not result in disruption of extensor mechanism.

Figure 10-15: Classification of fractured Patella.

Treatment:
The key for the management is the integrity of extensor expansion mechanism.
Treatment of patella fractures is based on the fracture type and physical examination.
The ultimate goals are to preserve and/or restore extensor mechanism function and
reduce complications of this articular fracture.
1. Crack undisplaced fracture: conservative treatment by aspiration of the
haemarthrosis with POP cylinder cast (figure 10-16) and weight bearing as
tolerated, for 4-6wk + Quadriceps exercise & physiotherapy.
2. Minimal displaced fractures (less than 2mm of articular step off and less than
3mm of diastasis) with an intact extensor mechanism, non-operative treatment is
indicated. Non-operative treatment also may be indicated for elderly patients or
those patients with underlying medical co morbidities, which preclude surgery.

Figure 10-16: POP cylinder cast for treatment of fractured Patella.

3. Transverse displaced fracture: ~~~~ ORIF (Figure 10-17).

4. Comminuted fracture:
Patient below 40yr treatment is by POP cylinder for 4-6 weeks until
healing then Physiotherapy & Quadriceps exercise.
Patient above 40yr we do patellectomy & suturing of the extensor
expansion followed by early movements & exercise.

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Figure 10-17: Surgical treatment of fractured Patella.

Traumatic dislocation of the patella

It occurs due to direct lateral violence with the knee flexed & relaxed, this leads to
either subluxation with the patella over-riding the lateral femoral condyle, or it is
completely dislocated laterally. This injury usually associated with damage to the
medial side of the extensor mechanism & haemarthrosis.

Figure 10-18: Traumatic dislocation of the Patella.

Clinical features:
1. Patient collapsed & unable to straighten his leg stands or walks.
2. Swelling of the Knee (haemarthrosis).
3. Deformity is evidence but sometime misleading because the medial condyle may
be prominent and mistaken for the patella (Figure 10-19).

Figure 10-19: Clinical feature of traumatic dislocation of the Patella.

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X-Ray:
It shows the displaced patella and the possible associated osteochondral fracture that
occur in 15% (Figure 10-20).

Figure 10-20: X-ray of traumatic dislocation of the Patella.

Treatment:
Urgent reduction with or without anesthesia by pushing the patella medially
while straightening the leg, sometime we need aspirate a tender haemarthrosis
(figure 10-21).
When there is severe medial joint bruise it means that there is serious underlying
soft tissue damage needs surgical suturing and repair to avoid future recurrence
of dislocation.
Immobilization by back-slab for 3-4 weeks followed by quadriceps exercises.
Operative treatment is indicated when there is associated fracture.

Figure 10-21: Relocation of dislocated Patella.

Figure 10-22: POP cast used in lower limb.

Fractures of Tibia & Fibula

The tibia is a subcutaneous bone; it is commonly fractures & can be associated with
skin damage or loss leading to open (compound) fracture.
Mechanism of injury:
Twisting force leads to spiral fracture of both bones at different levels; angulatory force
or direct trauma causes transverse or short oblique fracture of the bones at the same
level, sometimes the fracture is comminuted or associated with butterfly fragment. The
fracture can be compound open from the primary injury or the sharp bony fragments
may puncture from the skin within. Sometimes the fracture is closed but there is severe
soft tissue damage & necrosis, which makes the skin in danger of sloughing, and there
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are associated problems of bone healing. There is always associated risk of

compartment syndrome in cases of closed fracture also there is possibility of vascular
injury.
Clinical features:
Skin condition is important sometimes it get damaged or lost; sometimes its severely
bruised and ischemic & can sloughs later on. The limb is swollen and deformed.
Always assess the distal neurovascular function and look for sings of compartment
syndrome.
X-ray:
Show the fracture its type & its displacement.
Treatment:
Principles:
1. Preserve skin and limit soft tissue injury.
2. Recognize and prevent compartment syndrome.
3. Obtain good fracture alignment.
4. Early wt. bearing to enhance fracture healing.
5. Early joint movement to avoid stiffness.
Priorities:
1. Open fracture: debridement, antibiotics & anti-tetanus, external fixation,
delayed wound healing with rehabilitation.
2. Suspected skin damage: external fixation & antibiotics with follow up.
3. Compartment syndrome: treated by fasciotomy +/- external fixation.
4. For closed fracture good alignment we do full POP cast from metatarsal
necks up to upper thigh, if alignment is poor we improve it by MUA under
screen then we do POP as above (figure 10-22). Limb must always elevated
to avoid swelling, if the swelling is severe we split the POP and properly
cheek the circulation in the first 2-3 days, after 2 weeks we do check x-ray
and 12 weeks in adults all with graduation of weight bearing, exercises and
elevation.
5. ORIF: this is by intramedullary nail (locked or unlocked), or plate and screw.
Postoperatively physiotherapy and muscle exercises with graduation of
weight bearing are important.
Complications:
Early:
1. Infection.
2. Vascular injury.
3. Compartment syndrome.
4. Nerve injury.
Late:
1. Malunion may lead to ankle & knee osteoarthritis; it's treated by corrective
osteotomy.
2. Delayed union & nonunion (9 months +), treated by osteotomy, bone graft &
internal fixation with early mobilization & joint movement.
3. Joint stiffness.
4. Algodystrophy treated by physiotherapy & NSAID.
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Single leg bone fracture:

Tibia fracture alone follows the same principles of both bone fracture but when nonunion occurs we need to do fibular osteotomy to allow tibia to heal (remove the intact
fellow bone).
Fibula fracture specially neck or upper third spiral fracture must always raise the
possibility of POTTS fracture dislocation around the ankle joint. If single fracture
occurs its treated by pressure bandage, analgesia & allows the patient to walk as soon
as possible.

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