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Knee Joint

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Abdessalam Ewais

on 11 December 2013

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Transcript of Knee Joint

Abdessalam Ewais
Knee Joint
Medial meniscus:
Nearly semicircular.
The peripheral border is attached to the capsule and Medial Collateral Ligament; it’s relatively fixed.
It doesn’t slide much in any direction.
So it’s more likely to tear.
Lateral meniscus:
Nearly circular (more rounded).
The peripheral border is separated from the Lateral Collateral Ligament.
More likely to move rather than tear.
Menisci
Their function is to deepen the articular surfaces of the tibial condyles to receive the convex fomoral condyles.

They also serve as cushions between the two bones.

They are connected to each other by the transverse ligament & to the margins of the head of tibia by the coronary ligaments.
Menisci
Anterior Cruciate Ligament:
Attached to the anterior intercondylar area of the tibia.
Passes upward, backward, and laterally.
Attached to the lateral femoral condyle.
Prevents posterior displacement of the femur.
With the knee joint flexed the ACL prevents the TIBIA from being pulled anteriorly.
Intracapsular Ligaments
Bones.
Capsule.
Ligaments.
Anatomical Components
It’s the largest & the most complicated joint of the body.
It consists of 3 joints:

Patellofemoral joint.
Lateral condylar (tibiofemoral) joint; lateral condyles of both femur & tibia, and lateral meniscus.
Medial condylar (tibiofemoral) joint; medial condyle of both femur & tibia, and medial meniscus.
Introduction & Anatomy
Posterior Cruciate Ligament:
Attached to the posterior intercondylar area of the tibia.
Passes upward, forward, and medially.
Attached to the medial femoral condyle.
Prevents anterior displacement of the femur.
With the knee joint flexed the PCL prevents the TIBIA from being pulled posteriorly.
Ligamentum patellae;
between the lower border of the patella & tibial tuberosity. It’s a continuation of the common tendon of the quadriceps femoris.

Lateral collateral ligament.

Medial collateral ligament.

Oblique popliteal ligament (from the semimembranous).
Extracapsular Ligaments
Surround the joint from the sides and posteriorly.
Attached to the margins of the articular surface.
On each side of the patella, it’s strengthened by extensions of the tendons of vastus lateralis & vastus medialis.
Behind the joint it’s strengthened by an expansion of the semimembranos muscle (oblique popliteal ligament).
Capsule
The largest sesamoid bone.
Anteriorly:
It can be divided into:
Upper third; coarse, flattened, rough, and serves as the attachment site for the tendon of the quadriceps femoris.
Middle third; has many vascular canaliculi.
Lower third; includes the apex, which serves as the origin of the patellar ligament.
Posteriorly:
Upper ¾ articulate with the femur, and is divided into medial and lateral facets by a vertical edge.
Patella
Objectives
Anatomy.
Knee Movements.
Clinical Assessment.
ACL injury
Meniscal tear
Patellar dislocation
Valgus & Varum.
Osteoarthritis.
Knee Joint
Synovial joint:
Hinge variety; between the femur & the tibia.
Plane gliding variety; between the femur & the patella.
Type
Femoral.
Obturator.
Common peroneal.
Tibial.
Innervation
Saclike structures that are filled with fluid, strategically situated to alleviate friction.
They are present wherever skin, muscle, or tendon rubs against bone.
Bursa
aka semilunar cartilages.
C-shaped lamellae of fibrocartilage.
Between the condyles of both the femur & the tibia.
Their peripheral border is thick, convex & attached to the capsule.
The inner border is thin and forms a free edge.
Menisci

Cruciate ligaments
They are named according to their tibial attachment.
Anterior cruciate ligament (ACL).
Posterior Cruciate ligament (PCL).
Intracapsular Ligaments
Bones
Intracapsular
Extracapsular
Menisci
Knee Movements
Medial rotation:
Sartorius.
Gracilis.
Semitendinosus.

Lateral rotaion:
Biceps femoris.

Performed by the quadriceps femoris.
Limited by the tension of the ligaments (especially ACL).
Extension:
Performed by the biceps femoris, the semitendinosus, and the semimembranosus.
Assisted by the gracilis, the sartorius, and the popliteus.
It’s limited by the contact of the back of the leg with the thigh.
Flexion:
Radiography
Diagnosis
History
Physical
Arthroscopy
Pain.
Swelling.
Stiffness.
Locking.
Deformity.
Giving way.
Loss of function.
Signs with the patient upright:
Normally the knees are in slight valgus.
Valgus & varus deformities.
Gait abnormalities.
Signs with the patient lying supine:
Look:
Position; valgus, varus, partially flexed, or hyperextended.
Swelling.
Scars.
Wasting.
Feel:
Temperature.
Tenderness.
Soft tissue and bony outlines.
Move:
Range of movement.
Signs with the patient lying prone:
S
cars or lumps
in the popliteal fossa.
S
welling:
Bulging capsule.
Bursa.
Baker’s cyst.

A
pley’s test.
Imaging:
X-Ray; AP & lateral views.
MRI.
They are likely to be secondary to disorders especially if they are unilateral or asymmetrical.
Joint injury.
RA (usually valgus).
Osteoarthritis (usually varus).
Slight degrees are usually tolerated, but if the deformity is marked or associated with instability it can be corrected by:
Joint reconstruction.
Osteotomy.
Supracondylar femoral for valgus.
Proximal tibial for varus.
Valgus & Varus In Adults
Progressive bow-leg deformity associated with abnormal growth of the posteromedial part of proximal tibia.
Children are often overweight and start walking early.
Blount’s disease (tibia vara)
Bilateral Genu Valgum (knock knees):
Measuring the distance between the medial malleoli when the knees are held touching & the patellae facing forward.
Usually less than 8 cm.
Bilateral Genu Varum (bow-legs):
Measuring the distance between the knees with the legs straight & the medial malleoli just touching.
Normally less than 6 cm.
Very common in children & correct spontaneously by the age of 10-12 years, if it didn’t resolve operative correction should be advised.
Bone dysplasia & rickets are likely to need operative correction.
Bow-legs (genu varum).
Knock-knees (genu valgum).
By the end of growth the knees are normally 5-7 degrees of valgus.
More or less than that usually doesn’t bother anyone unless it’s unilateral, of recent onset or progressive.
Best seen in upright position.
Varum & Valgum
The diagnosis is confirmed by X-ray that shows characteristic features such as abnormal flattening or sloping of the medial half of the epiphysis.
Spontaneous resolution is rare and operative correction is usually needed.
Varum & Valgum
Osteoarthritis
Pathology
Clinical Features
Treatment
Osteoarthritis
It’s a chronic inflammatory joint disorder in which there is progressive softening & disintegration of the articular cartilage, accompanied by new growth of cartilage & bone at the joint margins (osteophyte) and capsular fibrosis.

The knee is one of the commonest sites.
Primary;
when no cause is obvious.
Secondary;
when it follows a demonstrable abnormality.

Secondary causes include:
trauma, congenital or developmental diseases, metabolic diseases … etc
OA results from a disparity between the stress applied to articular cartilage & the ability of the cartilage to withstand that stress.

So it could be due to one or a combination of two processes:
Weakening
of the articular cartilage.
Increased mechanical stress
in some parts of the articular surface.
The cardinal features are:
Progressive loss of cartilage thickness.
Subarticular cyst formation & sclerosis.
Remodelling of the bone ends and osteophyte formation.
Synovial irritation.
Capsular fibrosis.
Age.
Gender; it’s equally common among men & women aged 45-55. After the age of 55 the disease becomes more common in women.
Secondary cause. For example trauma.
Obesity.
Family history.
Preexisting deformity (bow-leg).
Risk factors:
History:

Pain
The leading symptom.
Pain starts insidiously and increases slowly over time (months to years).
Aggravated by exertion and relieved by rest.
With time relief is less & less complete.
Stiffness; mainly after rest.
Swelling is common.
Giving way & locking may occur.
Deformity, muscle wasting & loss of mobility in advanced cases.
No systemic manifestations in contrast to inflammatory diseases.
On examination:
There may be an obvious deformity (usually varus).
Scar of a previous surgery.
The quadriceps muscle is usually wasted.
Movement is somewhat limited.

X-ray findings:
Narrowing of joint space.
Subarticular cyst formation & subchondral sclerosis.
Osteophyte formation.
Soft tissue calcification.
Evidence of secondary cause.
Clincal Features
Conservative;
if symptoms are not severe:
Analgesics.
Joint mobility; by physiotherapy.
Reduce the load; by using walking sticks, weight reduction, medical shoes & avoiding stressful activities.

Surgery;
for persistent pain unresponsive to conservative treatment, progressive deformity and instability.
For example replacement arthroplasty.
The End
E.Z
ACL injury
Anatomy & Function
origination Primary
insertion secondary
two bundles
blood supply
innervation
RISK FACTORS
Gender-related
Quadriceps-dominant deceleration
Increased valgus knee angulation with pivoting or deceleration
Effects of estrogen
Discrepancies in Q angle and bone length
Decreased intercondylar notch width
Extrinsic

Intrinsic
MECHANISM
Noncontact mechanism

Contact mechanism
Presentation
Acute phase

After the Acute phase
Diagnosis
TREATMENT
Acute management

Operative or nonoperative
Full transcript