This lecture explains knee and ankle injuries, along with types, mechanisms involved and management.
Overview of Lecture
Knee and ankle injuries
Knee is the lower extremity joint connecting the femur and the tibia.
The knee is a complex, compound, condyloid variety of a synovial joint.
The human knee joint
Since in humans the knee supports nearly the entire weight of the body, it is the joint most vulnerable both to acute injury and to the development of osteoarthritis.
The knee accepts and transfer biomechanical loads between the femur, tibia, patella, and fibula.
The movements at the knee are:
flexion, extension.
Slight medial and lateral rotation.
Special locking and unlocking mechanisms, related to movement by the femoral condyles on the tibial plateau.
The ligaments and menisci, along with the muscles which traverse the joint, prevent movement beyond the knee’s intended range of motion.
It is also classified as a hinge joint.
Assessment And Management Of The Knee Injury
Knee injuries
Overuse knee injuries
Acute knee injuries
Overuse knee injuries
iliotibial band friction syndrome
popliteus tendinitis
patellofemoral joint pain syndrome
patellofemoral synovial plica
infrapatellar fat pad syndrome
patellar tendinitis(jumper’s knee)
pes anserinus bursitis
And in addition
Knee problems not to be missed
Baker’s Cyst
Osteoarthritis
Septic Arthritis
Osteomyelitis
Referred pain
House maids knee
Clergyman’s knee
ACUTE KNEE INJURIES
Fractures
Anterior cruciate ligament rupture (acl)
Posterior cruciate ligament rupture (pcl)
Medial collateral ligament tear (mcl)
lateral collateral ligament tear (lcl)
injuries to the menisci
osteochondral problems
patellofemoral instability
History
Mechanism of injury is vitally important.
Flexed/Twisting
Forced flexion/Hyperextension
Falls/Direct Blow
Knee Examination
Look
Wasting, swelling, deformity
redness, scars
Feel
Temp, Effusion, crepitus
Move
Passive, Active
Resting position, SLR, Extension, flexion, collateral ligaments, cruciates menisci
X-RAYS
When to X-ray?
X-rays are required if any of the following is present.
Isolated bony tenderness of the patella.
Bony tenderness of the fibula head.
Patient cannot flex knee to 90°
Patient cannot bear weight (4 steps) after injury.
Fractures of lower femur/ upper tibia ?
Fractures
Tibia Plateau Fracture
Tibia Plateau fracture
Proximal tibia examination reveals tenderness.
Swelling, haemarthrosis, ligament damage.
X-ray
Patella Facture
Patella Fracture
Direct blow,
Fall, Violent flexion, Quadriceps contraction.
Pain/Swelling, Crepitus, Pain on extension
Straight leg raise.
Haemarthrosis
X-ray
Patella
Dislocation
Dislocation of the Knee
Dislocation
Serious ligamentous and soft tissue damage.
Vascular and Nerve damage.
Haemarthrosis
Acute haemarthrosis
Onset of swelling following injury
Warm, tense, painful
Causes
Cruciate ligament damage
tibial avulsions
fractures
Cruciate Ligament Rupture
Examination
ACL Rupture
PCL Rupture
(tibial sag)
Meniscal Injury
Usually ‘twisting” injury
History crucial
McMurray’s Test
Collateral Ligament Injury
Examination
Grade I
Local tenderness+ slight or no laxity
Grade II
Local tenderness+ laxity
Complete rupture
Soft Tissue Injuries
Ruptured Quadriceps
Unable to straight leg raise
Possible palpable defect.
Surgical repair
Ruptured Patellar Tendon
Unable to straight leg raise
Possible palpable defect. Displaced patella
Avulsion of tibial tuberosity
Surgical repair.
Ankle Injuries
Ankle
Anatomical Structures
Tibia
Fibula
Talus
Ankle Ligaments
There are three lateral ligaments predominantly responsible for the support and maintenance of bone apposition (best possible fit). These ligaments prevent inversion of the foot.
These ligaments are:
Anterior talofibular ligament
Calcaneofibular ligament
Posterior talofibular ligament
The deltoid ligament
This is located on the medial aspect of the foot. It is the largest ligament but is actually comprised of several sections all fused together. This ligament prevents (eversion) of the ankle. The deltoid ligament is triangular in shape and has superficial and deep layers. It is the most difficult ligament in the foot to sprain.
Specific Injuries
Ankle Injuries: Sprains
Single most common injury in athletics caused by sudden inversion or eversion moments
GRADE 1 ( Mild ) SPRAINS (Ligament is affected)
GRADE 2 (Moderate) SPRAINS (Ligament is torn)
GRADE 3 ( Severe ) SPRAINS (Uncommon severe injuries, associated with fractures)
Inversion Sprains
Most common and result in injury to the lateral ligaments
Anterior talofibular ligament is injured with inversion, plantar flexion and internal rotation
Occasionally the force is great enough for an avulsion fracture to occur w/ the lateral malleolus
Inversion
Inversion ankle sprains
Inversion ankle sprain injures the lateral ligaments of the ankle.
About 90% of all ankle sprains are inversion sprains.
Eversion sprain
Ankle dislocation
An injury to the ankle so that the bones are displaced and are no longer in the correct alignment.
Ankle dislocations are almost always associated with sprains and fractures.
Ankle dislocation
Fracture/Dislocation
Ankle dislocation
Patient Evaluation
History
Mechanism
Time since injury
Associated injuries
Comorbidities
Diabetes
Neuropathy
Obesity
Alcoholism / drug abuse
Physical Exam
Note obvious deformities
Neurovascular exam
Pain to palpation of malleoli and ligaments
Palpate along the entire fibula
Pain at the ankle with compression
syndesmotic injury
Examine the hindfoot and forefoot for associated injuries
X-ray Evaluation
AP, Lateral and Mortise views of the ankle
AP and lateral of tibia
Foot series if tender
Fifth metatarsal
Calcaneus fracture
Mortise View
AP view of ankle with foot internally rotated
Abnormal findings:
medial joint space widening
tibia/fibula overlap <1mm
Types of fractures
Managment
Conservative if stability present
Closed reduction
Compression dressing, splint, and elevation
Pain control
Surgery if stability compromised
