PANTOMATH

 

MECHANICALLY WEAK BECAUSE…

• Tibial condyles are too small to hold the larger femoral condyles.
• complicated & incongruent shape of joint surfaces.
• Femur slants medially;
• Tibia is almost vertical.

STABILITY OF THE JOINT

• Functional stability of the joint is derived from the passive restraint of the ligaments, the active support of muscles, the joint geometry, and the compressive forces pushing the bones together.
• Cruciate ligaments maintain Anteroposterior stability.
• Collateral ligaments maintain side to side stability.
• Iliotibial tract supports on lateral side in slightly flexed knee

ARTICULAR SURFACES

• Femoral surface.
• Proximal tibial surface (plateau).
• Patellar surface.

MENISCI

• Crescentic.
• Made of fibro-cartilage.
• Attached and free border.
• Peripheral portion is vascular.
• Function – improve congruence, stability, helps distribute weight.
• Horns, Coronary ligament.

Menisci or Semilunar Cartilages :

• are two fibrocartilaginous discs.
• crescent shaped.
• deepen articular surfaces of the condyles of the tibia,
• partially divide the joint cavity into upper and lower compartments.
• Flexion and extension of the knee take place in the upper compartment,
• rotation takes place, in the lower compartment

STRUCTURES IN INTERCONDYLAR EMINENCEMedial meniscus

• Semi-circle
• Broader posteriorly
• Attached to the medial collateral ligament and the semimembranous muscle through the capsule.

Lateral Meniscus

• Forms 4/5 of a circle
• Attached to the popliteus muscle, posterior cruciate ligament
• Menisco-femoral ligaments (anterior menisco-femoral ligament or ligament of Humphrey and posterior menisco-femoral ligament or ligament of Wrisberg)

LIGAMENTS SUPPORTING

• Extra-capsular.
• Intra-capsular.

FIBROUS CAPSULE

• Deficient…
• Upper attachment.
• Lower attachment.

SYNOVIAL MEMBRANE

• Lines the internal aspect of the capsule, attaches to the periphery of the patella and edges of the menisci.
• Infra-patellar synovial fold.
• Intercondylar septum.
• Intercondylar foramen.

EXTRA-CAPSULAR

• Tibial collateral lig. (medial coll.lig.).
• Fibular collateral lig. (lateral coll.lig.).
• Oblique popliteal lig.
• Arcuate popliteal lig.
• Patellar lig. (Ligamentum patella).

INTRA-CAPSULAR

• Cruciate ligaments
• Coronary lig.
• Transverse lig. of knee.
• Menisco - femoral ligaments.

EXTRA-CAPSULAR LIGAMENTS

TIBIAL COLLATERAL LIGAMENT

• Superficial and deep parts.
• Proximal attachment :
  • both parts to medial epicondyle
• Distal attachment :
  • Superficial : medial condyle &upper part of medial border of shaft of tibia.
  • Deep : to medial condyle of tibia along the upper margin of groove for semi-membranous.

CONTINUED..

TCL :

• - is weaker than fibular coll.lig.
• - is more often damaged and commonly injured during sports.
• Tibial collateral ligament is morphologically considered to be the degenerated part of Ischial part of Adductor Magnus and Fibular collateral ligament is the degenerated part of peroneus longus muscle.

FIBULAR COLLATERAL LIGAMENT

• Proximal: lateral epicondyle.
• Distal: Head of fibula, close to its styloid process.
• Deep surface of the lig. is not adherent to the fibrous capsule.

OBLIQUE POPLITEAL AND ARCUATE LIGAMENTS OBLIQUE POPLITEAL LIGAMENT

An expansion from insertion of semi-membranosus.

• extends from the posterior surface of the medial condyle of tibia to the lateral part of the intercondylar line of femur.

ARCUATE LIGAMENT

• Y shaped
• Stem: Attached to the styloid process of head of fibula.
• Posterior band : Attached to lateral condyle of tibia.
• Anterior band : Attached to lateral condyle of femur.

PATELLAR LIGAMENT

• Derived from the tendon of Quadriceps Femoris.
• Extends from the apex of patella to upper part of tibial tuberosity.

Intra-capsular

ANTERIOR CRUCIATE LIGAMENT

• Arises from : Anterior inter-condylar area of tibia
• Attached to : Posterior part of medial side of lateral condyle of femur.

TAUT WHEN KNEE IS FULLY EXTENDED.

• Has a relatively poor blood supply.

FUNCTIONS:

• binds bones together.
• prevents hyper extension.
• prevents forward displacement of tibial condyles.

Posterior cruciate ligament

• Stronger
• Below: from posterior intercondylar area of tibia
• Above: anterior part of lateral surface of medial condyle of femur.

TAUT IN FLEXION.

FUNCTIONS:

• binds the bones.
• prevents backward displacement of tibial condyles.
• Is the main stabilizing factor for the femur in weight bearing flexed knee.   

Transverse ligament

• Connects anterior horn of medial meniscus to the anterior margin of lateral meniscus.

Menisco - femoral ligament

• Posterior horn of lateral meniscus to the medial condyle of femur by the anterior & posterior menisco - femoral ligament.

Coronary ligament

• Are parts of fibrous capsule, which provide attachment to the peripheral margins of the medial & lateral menisci.

Movements

• Active movements
  • Flexion
  • Extension
  • Medial rotation
  • Lateral rotation

FLEXION

• HAMSTRINGS(PRIME MOVER)
• initiated by : Popliteus                
• assisted by :
  • Sartorius.                                      
  • Gracilis.                                      
  • Both heads of Gastrocnemius.                                      
  • Plantaris.

EXTENSION

QUADRICEPS FEMORIS(PRIME MOVER)

• Movement limited by cruciate & collateral ligaments.
• Assisted by : Tensor Fascia Lata.

ROTATION

• Medial rotation : Semi-membranosus,
  • Semi - tendinosus, Popliteus,
  • Sartorius, Gracilis.
  • Movement checked by cruciate ligaments.
• Lateral rotation  : Biceps Femoris.
  • Movements checked by collateral igaments.

RELATIONS

• In front
  • Quadriceps.
• Antero-medially
  • Medial patellar retinaculum.
• Antero-laterally
  • Lateral patellar retinaculum, ilio-tibial tract.
• Postero-medially
  • Sartorius, gracilis, semitendinosus, semimembranosus.
• Postero-laterally
  • Tendon of biceps, common peroneal nerve.
• Behind
  • Popliteal vessels, tibial nerve, both heads of gastrocnemius, plantaris.

POPLITEUS-UNLOCKING MUSCLEQUADRICEPS FEMORIS- LOCKING MUSCLEBURSAE

• In front
  • 4 bursae namely Suprapatellar, prepatellar, Subcutaneous infrapatellar and deep infrapatellar
• Laterally - 3 bursae behind biceps tendon, between popliteus and fibular collateral ligament, behind popliteus.
• Medially - Behind tibial collateral, between tibial collateral and semimembranosus

BLOOD SUPPLY

• Descending genicular branch of femoral artery.
• Descending branch of lateral circumflex femoral artery.
• Genicular branches of popliteal artery.
• Anterior & posterior recurrent branches of anterior tibial artery.
• Circumflex fibular artery.

       ALL FORM GENICULAR  ANASTOMOSIS.NERVE SUPPLY

• Femoral N through N. to Vastii. (3)
• Tibial nerve. (3)
• Common peroneal nerve. (3)
• Posterior division of obturator nerve. (1)
• L3 – S1.

APPLIED ANATOMY

• Fracture of patella.
• Knee Joint Injuries:
  • Injury to Collateral Ligaments.
  • Injury to menisci.
  • Injury to Cruciate Ligaments.
• Aspiration of Knee Joint.
• Arthroscopy of Knee Joint.
• Osteoarthritis & Knee Replacement.

FRACTURE PATELLA & K WIRE FIXATIONTERRIBLE TRIAD

• Anterior cruciate ligament.
• Tibial collateral ligament.
• Medial meniscus.
• Mnemonic- ATM.

CLINICAL CASE SCENARIO-1

• 24 yr old Mr.Ravi presented to orthopaedic OPD with C/O Pain and swelling of Right knee and inability to extend knee for past 2 days. On probing patient gave history of being a food ball player went to a tournament and sustained minor injury and blow to the lateral side of knee, during the play followed by which he developed symptoms. On examination, drawer sign was negative. X ray knee joint revealed no fractures.

QUESTIONS

1. What is your probable diagnosis?
2. Name the ligaments commonly injured following sports injury?
3. What is “Terrible triad” or “Unhappy triad of O donogue”
4. Treatment advised?
5. Advice to be followed in future…

ANSWERS

1. Terrible triad injury.
2. ATM- Anterior cruciate ligament, tibial collateral ligament and Medial Meniscus injury.
3. A strong blow to lateral side of a flexed knee, can easily rupture tibial collateral ligament. As Tibial collateral is firmly attached to Medial meniscus, there is concominant tear of Medial meniscus than lateral meniscus.
4. Surgical Repair of torned ligaments.
5. Bed rest for atleast 6 weeks.

MENISCUS REPAIR SURFACE MARKING BEFORE MENISCECTOMY SURGERY ARTHROSCOPIC MENISCECTOMY JOINT ASPIRATION ARTHROSCOPYKNEE OSTEOARTHRITIS ROBOTIC KNEE REPLACEMENT SURGERY