The Knee: Core Lecture

Class Physician Associate Studies 2017-2019

Lecturer
Dr. Daniel Creegan MB, BCH, BAO
Original slides for IC3 MSK teaching

Lecturers Iain Feeley

Richard Downey
Martin Kelly
Lauren Tiedt
Learning
Objectives
• After this lecture you should be able to:
• Obtain a structured musculoskeletal history from a patient presenting with knee
pain
• Demonstrate a structured comprehensive examination of the knee joint
• Be able to explain aetiology; prognosis; treatment and possible complications of
treatment for common knee pathologies
• Demonstrate a structured approach to the assessment of radiographs of the
knee
 Basic
s• Largest and most complicated joint in the body
• Complex pivotal synovial hinge joint
• Knee – Genu
• Most commonly replaced joint in the USA
• Knee OA most common joint disease
• Most common arthroscopic procedure
Anatom
y• Connects the femur to the tibia
• Made up of medial and lateral condyles of femur attaching to
tibia condyles

• Gliding joint b/t the patella and patellar surface of the femur

• Hinge joint b/t the femur and tibia

• Covered with a layer of hyaline cartilage

• Fibula is NOT part of the knee joint

Anatomy -
Capsule
• Joint capsule attaches to the
margins of the articular surfaces
and surrounds the sides and
posterior aspect of the joint

• The front the capsule is absent

which permits the synovial
membrane to pouch upward
beneath the quadriceps tendon
creating the suprapatellar bursa
Anatomy -
Ligaments
• Patellar Ligament (Tendon)
• Continuation of central portion of the quadriceps tendon
• From inferior patellar border to tibial tuberosity
Anatomy -
Ligaments
• Medial Collateral Ligament
• Broad, flat band

• From medial femoral condyle to medial tibial shaft

• Provides stability against valgus stress

• It is firmly attached to medial meniscus

• NB MCL tears may also injure medial meniscus

Anatomy -
Ligaments
• Lateral Collateral Ligament
• Cordlike

• From lateral condyle of the femur to fibular head

• Provides stability against varus stress

Anatomy -
Ligaments
• Anterior Cruciate Ligament
• From anterior intercondylar area of the tibia to the postero-medial surface of lateral femoral
condyle

• Slack when knee is flexed, taut when knee is extended

• Prevents posterior displacement of the femur on the tibia

Anatomy -
Ligaments
• Posterior Cruciate Ligament
• Attaches to the posterior intercondylar area of the tibia and the lateral surface of the medial femoral condyle

• Slack when the knee is extended, taut when the knee is flexed

• Prevents anterior displacement of the femur on the tibia

Anatomy -
Menisci
• Crescent shaped fibro cartilage

• Upper surfaces are concave and in contact with the

femoral condyles

• Lower surfaces are flat and in contact with the tibial

condyles

• Function: stability, lubrication, nutrition, shock/energy

absorption

• Medial meniscus is semicircular, attached to the MCL,

more commonly torn

• Lateral meniscus is more O shaped, NOT attached to

LCL
Anatomy -
Muscles
• Quads
Anatomy -
Muscles
• Quads- flexion • Hamstring group- extension
Anatomy -
Neurovascular
• Nerve Supply
• Femoral, obturator, common
peroneal, and tibial nerves
(terminal branches of the sciatic
nerve)
• Blood Supply
• The popliteal artery and its
geniculate branches form a rich
anastomosis around the knee joint
Histor
y
•Pain
• SOCRATES model

• What does it feels like?

• Sharp: muscle strain/tear, fracture
• Dull: OA, RA
• Achy: OA, RA
 Histor
y
• What were they doing when th e
pain came on?
• Did they fall?
• fractures,
muscle tears,
haematomas, ect
• Playing sports?
• Muscle sprain, ligament
sprain/tear
• Prolonged exercise?
• OA
• Gradual vs sudden?
• RA,OA vs. Trauma, gout
• Did they hear a pop?
• Ligament injury
 Histor
y
• How bad is it and is it always there?
• Always ask the patient to score their pain based
on their pain threshold

• OA is worse as the day goes on- wear and tear

• RA present with morning stiffness- systemic

• Ligament injuries are worse when you walk/bend

the knee

• Tendonitis is worse when jumping, climbing

stairs,ect

• Bursitis becomes achy while walking, worse with

stairs
 Histor
y
• How does the pain affect their daily
life?
• How far can they walk?

• Difficulty walking up/down stairs?

• Can they still play sports?

• Are they still able to do their favourite

hobbies?

• Has their partner noticed their pain

limiting
them?

• Are they taking regular analgesia?

 Histor
y
PMHx:
Have they had any childhood knee
disease?
Osgood Shlatter’s disease
Have they previously injured their knee
or had problems with their knee?
Previous knee fractures may lead to OA
Previous bursitis may become aggravated
Previous ligament damage is at risk of
being damaged again
Any other illnesses?
Is the patient fit for surgery if they need
it?
Do they need to be reviewed by
respiratory, cardiology
Will they be at risk of infection? DM,
PVD
Social
History
• Who will take care of them when
they go home post operatively?
• Will they need to go to a step down
facility?
• Does OT need to asses their home?
• Stairs, bathroom access
• Are they liable to fall at home???
• Do they smoke?
• If so they are at a higher risk of
infection, wound breakdown
• Do they play sports
professionally?
• If so they may need earlier surgery,
more aggressive physio
 Examinatio
n
Watch the patient walk into the
room and sit down
- walking aid, limp,
uncomfortable gait
Inspect knee for scars, swelling,
obvious deformity
• Previous scars: ligament repair,
TKR
• Swelling: gout, OA, bursitis
 Palpatio
n
• Feel for quadriceps wasting

• Feel for a warmth and synovial swelling

• Patellar Tap (joint effusion):

-rest one hand over quads muscle and milk down any fluid into the knee, rest hand over lower
part of quads and compress the suprapatellar bursa with the other hand gently push the patella down
- the sign is positive if the patella is felt to sink and taps the underlying femur

• Bulge sign: detects small effusion

- compress the suprapatellar pouch
- run your fingers on one side of the patella and then the other
- notice any bulge on the side not being compressed
 Movement
• Test flexion (135 deg)

• Test Extension (5 deg)

 Check
stability
• MCL: Valgus stress

• LCL: Varus stress

• ACL: Check for excess anterior translation of tibia in
relation to femur
• Anterior drawer test
• Lachmann’s test
• Pivot shift test (under GA)

• PCL: Posterior translation of tibia in relation to femur

• Posterior lag sign
• Posterior drawer test
 Menisci
i line tenderness most
• Joint
sensitive for meniscal injury

• McMurray test- don’t do-

risk for injury

• Apley test
• Compression
• Distraction
 To
Finish
• Neurovascular exam

• Offer to examine the joint above

and joint below

• Thank the patient

• Any specific imaging or

investigations required?
Adult Pathology -
Osteoarthritis
• OA knee most common joint disease

• Revise pathogenesis:
• initial changes in articular cartilage  fibrillation
of cartilage vertical clefts  exposure of
subchondral bone  eburnation

• REM Primary and Secondary OA

Adult Pathology -
Osteoarthritis
• REM 4 cardinal XR signs?
• Joint space narrowing
• Subchondral sclerosis
• Osteophytes
• Subchondral cyst
formation
Adult Pathology -
Osteoarthritis
• Joint space narrowing

• Subchondral sclerosis

• Subchondral pseudocyst formation

• Osteophytosis
Adult Pathology -
Osteoarthritis
Conservative Treatment
Weight loss
Modify daily activities, walking aids
Exercising within the limits of pain should be encouraged
Physiotherapy
Analgesia: aspirin, paracetamol NSAIDS
Surgical Treatment
Arthroplasty
When patients have severe pain, nocturnal pain, pain at rest, and severely restricted mobility
Arthrodesis
Rarely used in OA, sometimes used in pt too young for hip replacement
Osteotomy
Utilised to realign deformities and spread the transmitted loads more evenly in younger pts
Adult Pathology – Rheumatoid
Arthritis
• Chronic systemic disease of unknown aetiology

• Characterized by chronic symmetric inflammation of the joints

• Variable extra articular manifestations – eyes, skin, lungs etc

• F>M 4:1

• Genetic predisposition with HLA

• a/w low grade fever, loss of appetite, malaise, fatigue

Adult Pathology – Rheumatoid
Arthritis
• Soft tissue swelling

• Juxta-articular osteopaenia

• Marginal erosions

• Joint space narrowing

• Deformity
• Hands are often affected
earliest
Adult Pathology – Rheumatoid
Arthritis
• Medical Treatment:
• First Line Tx - NSAIDs
• Reduce stiffness and synovitis, improve mobility
• Second Line Tx - DMARDS
• Gold salts, penicillamine, immunosuppressants (methotrexate), infliximab (anti tnf-α)
• Third Line Tx - Corticosteroids
• Systemic or Intra-articular in accessible joints

Surgical Treatment
• Early in disease process before significant radiographic changes – synovectomy
• Can be perfomed arthroscopically
• Advanced disease
• Joint replacement (Arthroplasty)
• Restores pain free function
• Joint fusion (arthrodesis)
Osteoarthritis and Rheumatoid
Arthritis
Trauma/Pathology – Meniscal
Injuries
• Three common meniscal problems
• Congenital discoid meniscus
• Generally presents in childhood
• Longitudinal meniscus tears
• Occur in young adults, rarely in females
• Horizontal cleavage tears
• Occur in both sexes in middle age

• The periphery of each meniscus has a tenuous blood supply

• The central part of the meniscus is nourished by diffusion only

• It is thus incapable of repair
Adult/Paed Pathology – Discoid
Meniscus
• In the early stages of development the menisci are disc shaped
• Later, the central portion of the disc is resorbed, producing the normal semilunar
configuration
• In some people this process fails to occur
• The resulting solid meniscus tends to detach at its periphery

• If the meniscus is relatively stable

• Arthroscopic resection of the central portion
• Partial meniscectomy

• If meniscus is too unstable

• Arthroscopic total meniscectomy is often required
Trauma/Pathology– Meniscal
Tears
O/E:
• Effusion

• Muscle wasting from long term meniscal injury (pt

won’t fully extend so VMO becomes wasted)

• Localised palpable tenderness

• May have decreased extension, pain on full flexion

• Positive McMurray/Apley grind test

Trauma/Pathology– Meniscal
Tears
• Longitudinal tear is by far the most common types of meniscal injury
• Occurs in the young adult – traumatic
• Normally degenerative in elderly

• 3 factors are generally found to have been present

• The knee was weight bearing
• It was flexed
• It was twisted (i.e., subject to rotational stress)
• Most commonly the tear involves the mid-portion of the meniscus
• If the tear is extensive, the inner limb of the torn meniscus may become
displaced – Bucket Handle tear
• In others, further transverse tearing - Parrot Beak tear
Trauma/Pathology– Meniscal
Tears
Arthroscopic resection of the torn portion of the
meniscus
Most popular method of treatment
Resect back to a stable rim

Open arthrotomy
Mainly reserved for failed
arthroscopic resections

Meniscal repair
Reserved for peripheral tears in
younger patients

Physio post op is essential

Trauma/Pathology– Ligament
Injuries
• ACL Injury
• Most common ligament to be injured
• Most frequent cause of acute haemarthrosis
• It can be torn in isolation
• Often, other structures injured simultaneously
• Mechanism of Injury
• External rotation of the tibia on the femur combined with an abduction force
• Pt gives a history of significant injury
• Often with the sensation of something giving within the knee or an audible “pop”
• Invariably followed by a rapidly forming haemarthrosis
• Some patients present late
• Complain of feelings of instability
• Incidents of giving way followed by effusion
• Can be difficult to differentiate from a meniscal tear
Trauma/Pathology– ACL
Injury
• Anterior Drawer Test • Lachmanns
Test
Trauma/Pathology – ACL
Injury
• Conservative Tx • Surgical Tx
• Knee Supports • Surgery is reserved for patients who during
normal activities have symptoms of instability
• Basic
• Common reconstructive procedures use
• Hinged either part of the patellar ligament or woven
• Stabilised synthetic implants

• Intensive PT
Trauma/Pathology – PCL
Injury
• Much less common than ACL injury
• Often found combined with other ligamentous injuries

• Mechanism of Injury
• Fall on the flexed knee
• Dashboard impaction during an RTA

• May be overlooked unless the possibility of its occurrence is kept in mind and a
careful examination is performed
• When the knee is flexed, the tibia usually sags backwards under the femur
• Comparison with the opposite side is essential
Trauma/Pathology – PCL
Injury
• In acute cases, conservative treatment is often advocated
• Intensive quadriceps exercises can produce good results

• Persisting instability can lead to severe and rapidly progressive OA

• If conservative measures fail, surgical ligament reconstruction may reduce the risk of serious
complication

• Positive sign on the Posterior draw test

• Instability of the joint
• Associated with the feeling of the knee giving way
Trauma/Pathology – Collateral Ligament Injury
• Commonly injured

• MCL is more frequently affected

• Requires significant force

• Sporting tackle
• Blow to the side of the leg from a motor vehicle

• In a number of cases there are associated fractures of the tibial

plateau
Trauma/Pathology – Collateral Ligament y
Injur
RICE
Rest from training
Wear a hinged knee brace to support the joint in severe injuries
Wear a heat retainer after the acute phase
Apply a support bandage or plaster cast.
Aspirate the joint if effusion present
Apply sports massage techniques
Physio
US/ laser therapy
Surgery
Pathology – Retropatellar Pain
Syndrome
• Characterised by ill-localised patellar pain
• No specific features apart from being made worse by prolonged sitting or by walking on
slopes or stairs
• Pain is usually not severe but may sometimes limit activities
• Sometimes a small joint effusion – knee may give way
• Common in adolescent and young females
• Generally self limiting

• No clear cut pathological lesion

• Deep layers of the articular cartilage of the patella may degenerate (Chondromalacia
patellae)
Pathology – Retropatellar Pain
Syndrome
• Investigation
• X-Rays which should include a skyline (tangental) view
• May reveal maltracking of the patella

• Treatment
• General advice is given to avoid activities which are known to aggravate the
condition

• Quadriceps building exercises

Pathology – Osgood-Schlatter’s
Disease
• Common problem in the young adolescent

• It is a traction apophysitis
• Can be bilateral

• Causes mild pain which is worse after exercise

• Typically, the tibial tubercle is tender and prominent

• Knee movements are unaffected
Pathology – Osgood-Schlatter’s
Disease
• A lateral radiograph shows displacement or fragmentation
of the apophysis

• Treatment is generally symptomatic as the condition is

self-limiting

• Restriction of activity may be sufficient

• In refractory cases, 6 weeks immobilisation in a plaster cast
may be required
Pathology – Osteochondritis
Dessicans
• Condition in which a small fragment of bone just deep to the articular
surface is rendered avascular
• Along with the healthy cartilage capping it, it becomes detached from the
healthy structures
• Can form a loose body

• Aetiology uncertain
• Contact between the
femoral condyles and tibial
spines or ACL may be
significant
Pathology – Osteochondritis
Dessicans
• 70% of defects involve the lateral aspect of the medial femoral condyle
• May be bilateral

• Initially it is symptom free

• Later it may cause mild pain in the joint and an effusion

• Loose body may cause locking of the joint

Pathology – Osteochondritis
Dessicans
• Diagnosis
• Often confirmed by routine x-rays of the knee
• Specialised tunnel projections – show intercondylar area

• Arthroscopic assessment
• Helpful in deciding whether the fragment is becoming detached and likely to form a loose body

• Treatment
• Fragment remains in situ
• Observation with serial x-rays
• Mobile fragment
• Area may be drilled – promotes healing
• Defect may be pinned back / loose bodies removed
Orthopaedic Interventions
• Total Knee Replacement

• Femoral and Tibial components

• Polyethylene liner
Orthopaedic Interventions
• Unicondylar Knee Replacement
• Knee is divided into medial, lateral, and
patellofemoral
• 10-30% of patient have wear only in one
compartment
• Pros: smaller incision, easier rehab, shorter
hospital stay, less blood loss, lower
infection risk
• Cons: less reliable long term
• Patellofemoral Replacement
Complication
s
• Immediate; early; late
• General; specific
Specific
Complications
• Femoral notching/peri-prostetic fracture
• Peroneal nerve palsy (tourniquet/retractor)
• Vascular complication
• Extensor mechanism rupture
• Stiffness/limited ROM post op
• Infection
• Unhappy patient