Kin191 A.Ch.6.Knee.Patellofemoral.Anatomy

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  • Kin191 A.Ch.6.Knee.Patellofemoral.Anatomy

    1. 1. KIN 191A Advanced Assessment of Lower Extremity Injuries KNEE /PATELLOFEMORAL ARTICULATION ANATOMY
    2. 2. INTRODUCTION <ul><li>ANATOMY </li></ul><ul><ul><li>BONY STRUCTURES </li></ul></ul><ul><ul><li>ARTICULATIONS </li></ul></ul><ul><ul><li>LIGAMENTS </li></ul></ul><ul><ul><li>MENISCI </li></ul></ul><ul><ul><li>MUSCLES </li></ul></ul><ul><ul><li>BURSAE </li></ul></ul><ul><ul><li>NEUROANATOMY </li></ul></ul><ul><ul><li>VASCULAR ANATOMY </li></ul></ul>
    3. 3. BONY STRUCTURES <ul><li>Femur </li></ul><ul><li>Tibia </li></ul><ul><li>Patellar </li></ul><ul><li>Fibular (Head) </li></ul>
    4. 4. Femur <ul><li>Distal end of the femur </li></ul><ul><ul><li>Medial and lateral condyles  articulate with the tibia </li></ul></ul><ul><ul><li>Articular surface of medial condyle is longer than lateral condyle </li></ul></ul><ul><ul><li>Condyles share a common anterior surface, then diverge posteriorly, Intercondylar notch </li></ul></ul>
    5. 5. <ul><li>Distal end of the femur </li></ul><ul><ul><li>Anterior depression, femoral trochlea </li></ul></ul><ul><ul><ul><li>Patellar glides it with the knee flexion/extension </li></ul></ul></ul>
    6. 6. Video
    7. 7. <ul><ul><li>Lateral epicondyle is wider and emanates from the femoral shaft at a less angle then the medial epicondyle </li></ul></ul><ul><li>Linea aspera </li></ul><ul><ul><li>Posterior ridge along medial and lateral lips </li></ul></ul>
    8. 8. <ul><li>Adductor tubercle </li></ul><ul><ul><li>Arises off the superior crest of the medial epicondyle </li></ul></ul>
    9. 9. Tibia <ul><li>Medial and lateral tibial plateaus </li></ul><ul><ul><li>Medial plateau: concave in both the frontal and sagittal planes </li></ul></ul><ul><ul><ul><li>50% larger than L. </li></ul></ul></ul><ul><ul><li>Lateral plateau: concave in the frontal plane and convex in the sagittal plane </li></ul></ul>Medial Lateral Anterior Posterior
    10. 10. <ul><li>Intercondylar eminence </li></ul><ul><ul><li>Raised area between the tibial plateaus </li></ul></ul><ul><ul><li>Match the femur ’ s intercondylar notch </li></ul></ul>
    11. 11. <ul><li>Tibial tuberosity </li></ul><ul><ul><li>Infrapatellar tendon attachment site </li></ul></ul>
    12. 12. Patellar <ul><li>Superior pole (Base), quadriceps femoris tendon attachment </li></ul><ul><li>Inferior pole (Apex), infrapatellar tendon attachment </li></ul>L M
    13. 13. <ul><li>Anteriorly protected/covered by prepatellar bursa </li></ul>
    14. 14. Patellar <ul><li>Lateral facet </li></ul><ul><ul><li>Broader & </li></ul></ul><ul><ul><li>More concave than medial facet </li></ul></ul><ul><li>Medial facet </li></ul><ul><ul><li>Shallower </li></ul></ul><ul><li>3 rd facet </li></ul><ul><ul><li>Contact with the medial femoral condyle in extreme flexion of the knee </li></ul></ul>Lateral Medial
    15. 15. Fibula <ul><li>Head </li></ul><ul><ul><li>Muscular and ligamentous attachment site </li></ul></ul><ul><ul><li>Biceps femoris, soleus, peroneus longus </li></ul></ul><ul><ul><li>LCL, Arcuate ligament, popliteofibular ligament, meniscofibular ligament </li></ul></ul>
    16. 16. Arcuate Ligament Popliteus Popliteal Artery
    17. 17. ARTICULATIONS <ul><li>Tibiofemoral joint </li></ul><ul><li>Petellofemoral joint </li></ul><ul><li>Proximal tibiofibular joint </li></ul><ul><li>Joint capsule </li></ul>
    18. 18. Tibiofemoral Joint <ul><li>Double condyloid articulation </li></ul><ul><li>2 degrees of freedom </li></ul><ul><ul><li>Flexion and Extension </li></ul></ul><ul><ul><li>Internal and External rotation </li></ul></ul><ul><ul><li>Other movements: valgus and varus bending & anterior and posterior glide (accessory motions) </li></ul></ul>
    19. 19. Joint Capsule <ul><li>Anteriorly, </li></ul><ul><ul><li>Arises superior to the femoral condyles and attaches distal to the tibial plateau </li></ul></ul><ul><li>Posteriorly </li></ul><ul><ul><li>Inserts on the posterior margins of the femoral condyles above the joint line and </li></ul></ul><ul><ul><li>Inferiorly, to the posterior tibial condyle </li></ul></ul>
    20. 20. <ul><li>The strength of the capsule is reinforced by </li></ul><ul><ul><li>Medial collateral ligament (MCL) </li></ul></ul><ul><ul><li>Patellofemoral ligament </li></ul></ul><ul><ul><li>Medial and lateral retinaculum </li></ul></ul><ul><ul><li>Posterioly, </li></ul></ul><ul><ul><ul><li>Oblique popliteal ligament and arcuate ligament </li></ul></ul></ul><ul><ul><li>Anteriorly, </li></ul></ul><ul><ul><ul><li>Patellar tendon </li></ul></ul></ul><ul><ul><li>Muscles that cross the knee joint </li></ul></ul>
    21. 21. Arcuate (Popliteal) Ligament Popliteus Oblique Popliteal Ligament Popliteus Fascia
    22. 22. <ul><li>Synovial capsule </li></ul><ul><ul><li>Lines the articular portions of the fibrous joint capsule </li></ul></ul><ul><ul><li>Synovium surrounds the articular condyles of the femur and tibia medially, anteriorly and laterally </li></ul></ul><ul><ul><li>Invaginates anteriorly along the femur ’ s intercondylar notch and tibia ’ s intercondylar eminences </li></ul></ul><ul><ul><ul><li>Excluding the cruciate ligaments from the synovial membrane </li></ul></ul></ul>
    23. 23. LIGAMENTS <ul><li>Anterior Cruciate Ligament </li></ul><ul><li>Posterior Cruciate Ligament </li></ul><ul><li>Medial (Tibial) Collateral Ligament </li></ul><ul><li>Lateral (Fibular) Collateral Ligament </li></ul><ul><li>Arcuate Ligament Complex </li></ul><ul><li>Proximal Tibiofibular Ligaments </li></ul>
    24. 24. A nterior C ruciate L igament <ul><li>Arises from the anteromedial intercondylar eminance of the tibia, travels posterioly, and </li></ul><ul><li>Passes lateral to the posterior cruciate ligament to insert on the medial wall of the lateral femoral condyle </li></ul>
    25. 25.
    26. 26. <ul><li>1. MCL </li></ul><ul><li>2. Medial condyle of </li></ul><ul><li>femur </li></ul><ul><li>3. PCL </li></ul><ul><li>4. Anterior </li></ul><ul><li>meniscofemoral L. </li></ul><ul><li>5. ACL </li></ul><ul><li>6. Lateral condyle of </li></ul><ul><li>femur </li></ul><ul><li>7. Popliteus </li></ul><ul><li>8. LCL </li></ul><ul><li>9. Biceps tendon </li></ul><ul><li>10. Lateral condyle </li></ul><ul><li>of tibia </li></ul><ul><li>11. Lateral meniscus </li></ul><ul><li>12. Medial meniscus </li></ul><ul><li>13. Medial condyle of </li></ul><ul><li>tibia </li></ul><ul><li>14. Posterior </li></ul><ul><li>meniscofemoral L. </li></ul><ul><li>15. Capsule of </li></ul><ul><li>superior tibiofibular </li></ul><ul><li>joint </li></ul><ul><li>16. Apex of head of fibula </li></ul>
    27. 27. <ul><li>ACL serves as a static stabilizer against </li></ul><ul><ul><li>Femur from moving posteriorly during weight bearing (anterior translation of the tibia on the femur) </li></ul></ul><ul><ul><li>Internal rotation of the tibia on the femur </li></ul></ul><ul><ul><li>External rotation of the tibia on the femur </li></ul></ul><ul><ul><li>Hyperextension of the tibiofemoral joint </li></ul></ul><ul><ul><li>Secondary restraint for valgus and varus stress with collateral ligaments </li></ul></ul><ul><ul><li>Anteromedial bundle </li></ul></ul><ul><ul><ul><li>Taut when the knee is fully flexed </li></ul></ul></ul><ul><ul><li>Postolateral bundle </li></ul></ul><ul><ul><ul><li>Taut when the knee is fully extended </li></ul></ul></ul>
    28. 28. Video Lateral View
    29. 29. P osterior C ruciate L igament <ul><li>Arises from the posterior aspect of the tibia and takes a superior and anterior course, and </li></ul><ul><li>Passing medially to the ACL, to attach on the lateral portion of the femur ’ s medial condyle </li></ul><ul><li>The primary stabilizer of the knee </li></ul><ul><ul><li>Stronger and wider than the ACL </li></ul></ul>
    30. 30.
    31. 31. <ul><li>Posterior cruciate ligament (PCL) serves as a static stabilizer against </li></ul><ul><ul><li>Femur from moving anteriorly during weight bearing (posterior translation of the tibia on the femur) </li></ul></ul><ul><ul><li>External rotation of the tibia on the femur </li></ul></ul><ul><ul><li>Hyperextension of the tibiofemoral joint </li></ul></ul><ul><ul><li>Anterolateral bundle </li></ul></ul><ul><ul><ul><li>Taut when the knee is between 40-120 degrees of flexion </li></ul></ul></ul><ul><ul><li>Postomedial bundle </li></ul></ul><ul><ul><ul><li>Taut when the knee is beyond 120 degrees of flexion </li></ul></ul></ul>
    32. 32. Video Medial View
    33. 33. Video Posterior View
    34. 34. Medial Collateral Ligament <ul><li>Primarily medial stabilizer of the knee </li></ul><ul><li>Protect the knee against valgus forces </li></ul><ul><ul><li>Also providing a secondary restraint against external rotation </li></ul></ul>
    35. 35. <ul><li>Formed by two layers </li></ul><ul><ul><li>Deep layer is a thickening of the joint capsule </li></ul></ul><ul><ul><li>Attached to the medial meniscus </li></ul></ul><ul><ul><li>Separated from the deep layer by a bursa </li></ul></ul><ul><ul><li>Superficial layer arises from a broad band just below the adductor tubercle to insert on a relatively narrow site 7 to 10 cm below the joint line </li></ul></ul>
    36. 36. <ul><ul><li>As a unit, the two layers of the MCL are tight in complete extension </li></ul></ul><ul><ul><li>As the knee flexed to the mid range </li></ul></ul><ul><ul><ul><li>Anterior fibers are taut </li></ul></ul></ul><ul><ul><li>In complete flexion </li></ul></ul><ul><ul><ul><li>The posterior fibers are tight </li></ul></ul></ul>
    37. 37. Video
    38. 38. Lateral Collateral Ligament <ul><li>Primarily restraint against varus forces when the knee is between full extension and 30 degrees of flexion </li></ul><ul><ul><li>Provides secondary restraint against internal and external rotation of the tibia and the femur </li></ul></ul>
    39. 39. <ul><li>No attachment to the joint capsule or meniscus </li></ul><ul><li>A cordlike structure arises from the lateral femoral epicondyle, sharing a common site of origin with the lateral joint capsule, and inserts on the proximal aspect of the fibular head </li></ul><ul><li>Taut during knee extension but relaxed during flexion </li></ul>
    40. 40. Video
    41. 41. Arcuate Ligament Complex <ul><li>Supports to the posterlateral joint capsule </li></ul><ul><li>Arcuate ligament </li></ul><ul><li>Lateral collateral ligament </li></ul><ul><li>Oblique popliteal ligament </li></ul><ul><li>Popliteus tendon </li></ul><ul><li>Lateral head of gastrocnemius </li></ul>
    42. 42. Arcuate Ligament Popliteus Popliteal Artery LCL
    43. 43. Arcuate (Popliteal) Ligament Popliteus Oblique Popliteal Ligament Popliteus Fascia LCL
    44. 44. Proximal Tibiofibular Ligaments <ul><li>Proximal anterior and posterior tibiofibular ligaments (proximal syndesmosis joint) </li></ul>
    45. 45. MENISCI <ul><li>Deepen the articular facets of the tibia </li></ul><ul><ul><li>Increase the stability of the joint </li></ul></ul><ul><li>Improve lubrication for the articular surfaces </li></ul><ul><li>Cushion any stress placed on the knee joint </li></ul><ul><li>Maintain spacing between the femoral condyles and tibial plateau </li></ul>
    46. 46. <ul><li>Medial meniscus </li></ul><ul><ul><li>“ C” shaped fibrocartilage, larger </li></ul></ul><ul><li>Lateral meniscus </li></ul><ul><ul><li>“ O” shaped fibrocartilage, smaller </li></ul></ul>
    47. 47. Meniscal Blood Supply
    48. 48. <ul><li>Coronary ligament </li></ul><ul><li>Transverse ligament </li></ul><ul><li>Meniscofemoral ligaments </li></ul><ul><ul><li>Anterior: ligament of Humphrey </li></ul></ul><ul><ul><li>Posterior: ligament of Wrisberg </li></ul></ul>
    49. 50. MUSCLES <ul><li>Anterior – Quadriceps </li></ul><ul><li>Posterior – Hamstrings </li></ul><ul><li>Medially – Pes anserine group </li></ul><ul><li>Laterally – Il l iotibial band </li></ul>
    50. 51. Anterior Musculature <ul><li>Rectus femoris </li></ul><ul><li>Vastus lateralis </li></ul><ul><li>Vastus intermedius </li></ul><ul><li>Vastus medialis </li></ul>
    51. 52. Rectus Femoris <ul><li>O: AIIS </li></ul><ul><li>I: Tibial tuberosity via infrapatellar tendon </li></ul><ul><li>N: Femoral </li></ul><ul><li>A: Knee extension, hip flexion </li></ul>
    52. 53. Vasti Muscles <ul><li>O: VL – Greater trochanter, upper ½ of linea aspera; VI – Anterolateral upper 2/3 of femur, lower ½ of linea aspera VM – Distal intertrochanteric line, medial linea aspera </li></ul><ul><li>I: Tibial tuberosity via infrapatellar tendon </li></ul><ul><li>N: Femoral </li></ul><ul><li>A: Knee extension </li></ul>
    53. 54. Posterior Musculature <ul><li>Biceps femoris </li></ul><ul><li>Semimembranosus </li></ul><ul><li>Semitendinosus </li></ul><ul><li>Popliteus </li></ul><ul><li>(Gastrocnemius) </li></ul>
    54. 55. Biceps Femoris <ul><li>O: Long – ischial </li></ul><ul><li>tuberosity; Short – lateral linea aspera, upper 2/3 of supracondylar line </li></ul><ul><li>I: Fibular head, lateral tibial plateau </li></ul><ul><li>N: Long – tibial Short – common peroneal </li></ul><ul><li>A: Knee flexion, Hip extension (long H.), Knee external rotation </li></ul>
    55. 56. Semimembranosus <ul><li>O: Ischial tuberosity </li></ul><ul><li>I: Posteromedial of medial tibial plateau </li></ul><ul><li>N: Tibial </li></ul><ul><li>A: Knee flexion, Hip extension, Knee internal rotation </li></ul>
    56. 57. Semitendinosus <ul><li>O: Ischial tuberosity </li></ul><ul><li>I: Medial tibial flare (pes anserine) </li></ul><ul><li>N: Tibial </li></ul><ul><li>A: Knee flexion, </li></ul><ul><li>Hip extension, Knee internal rotation </li></ul>
    57. 58. Popliteus <ul><li>O: Lateral femoral condyle </li></ul><ul><li>I: Posteromedial tibia </li></ul><ul><li>N: Tibial </li></ul><ul><li>A: Knee internal rotation, </li></ul><ul><li>Knee flexion </li></ul>
    58. 59. Pes Anserine Muscles <ul><li>Sartorius (most anterior) </li></ul><ul><li>Gracilis (middle) </li></ul><ul><li>Semitendinosus (most posterior) </li></ul>
    59. 60. Sartorius <ul><li>O: ASIS </li></ul><ul><li>I: Anteromedial tibial flare (pes anserine) </li></ul><ul><li>N: Femoral </li></ul><ul><li>A: Hip flexion, </li></ul><ul><li>Hip abduction, </li></ul><ul><li>Hip external rotation </li></ul><ul><li>Knee flexion </li></ul>
    60. 61. Gracilis <ul><li>O: Symphysis pubis, inferior ramus of pubic bone </li></ul><ul><li>I: Anteromedial tibial flare (pes anserine) </li></ul><ul><li>N: Obturator </li></ul><ul><li>A: Hip adduction, </li></ul><ul><li>Hip flexion, </li></ul><ul><li>Knee flexion </li></ul>
    61. 62. Iliotibial Band/TFL <ul><li>O: Anterior superior iliac crest </li></ul><ul><li>I: Anterolateral tibia at Gerdy’s tubercle </li></ul><ul><li>N: Superior gluteal </li></ul><ul><li>A: Hip flexion, </li></ul><ul><li>Hip abduction, </li></ul><ul><li>Hip internal rotation </li></ul>
    62. 63. Popliteal Fossa <ul><li>Borders </li></ul><ul><ul><li>Superomedial: semimembranosus </li></ul></ul><ul><ul><li>Superolateral: biceps femoris </li></ul></ul><ul><ul><li>Inferomedial: medial gastroc head </li></ul></ul><ul><ul><li>Inferolateral: lateral gastroc head </li></ul></ul><ul><li>Contents </li></ul><ul><ul><li>Popliteal artery and vein </li></ul></ul><ul><ul><li>Tibal and common peroneal nerves </li></ul></ul>
    63. 64. BURSAE
    64. 65. NEUROANATOMY <ul><li>Tibial nerve </li></ul><ul><li>Common peroneal nerve </li></ul><ul><li>Femoral nerve </li></ul>

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