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Functional Anatomy and Mechanism of    Knee Injury  Dr. Hytham Nafady
Introduction          Types of jointsFibrous    Cartilaginous    Synovialjoints        joints         joints
Types of                 synovial jointsUniaxial           Biaxial •Hinge joint                    •Condyloid             ...
Hinge joint
Pivot joint
Gliding joint
Condyloid joint
Saddle joint
Ball & socket joint
Functional anatomy of the kneeThe articular bones of the knee have a little contribution to the stability of the joint.Sta...
Supporting structures of the knee
:Medial supporting structures          3 layers           Superficial layer:          Crural fascia (fascia continuous   ...
   Superficial layer unite with    middle layer anteriorly to form    the medial patellar retinaculum.   It separated fr...
Superficial Medial collateral                  ligament Anterior vertical  portion;Which is separated from  the deep MCL ...
Deep medial collateral ligament   Menisco-tibial attachment.   Menisco-femoral attachment.
Medial supporting structuressuccessive coronal PD W images
Medial supporting structures   Axial PD WI obtained      Axial PD WI obtained    above the level of         at the level...
Posteromedial supporting            structures Semimembranosis muscle & tendon. Medial head of gastrocnemius Posterior ...
Postero-medial supporting        structures          Sagittal T1 WI shows:           origin of medial          head of ga...
:Lateral supporting structures3 layers:Superficial layer:  iliotibial tract & its anterior expansion.  Biceps tendon & i...
Anterolateral supporting structures   Iliotibial tract. (inserted in Gerdy’s    tubercle).   Superior and inferior Later...
Posterolateral supporting structures   LCL.   Biceps femoris tendon.   Popliteus muscle and tendon.   Popliteo-menisca...
LCL:             Lateral femoral      Styloid process.      Lateral stabilizer &                 epicondyle.              ...
Lateral supporting structures
Anterolateral supporting structures
Anterolateral supporting strucures                    Coronal PD WIs                     showing the                     ...
Posterolateral supporting structures
Lateral collateral ligament
Biceps tendon
Popliteal tendon
   Sagittal PD WI:    showing the LCL,    popliteal & biceps    tendons.
Conjoined tendon
Fabello-fibular ligament
Arcuate ligament
Popliteo-meniscal & popliteo-fibular            ligaments
Posterior supporting structures   Gastrocnemius muscle and tendons.   Posterior joint capsule reinforced by    the obliq...
Posterior supporting structures
Types of injury   pure hyperextension;   hyperextension with varus;   hyperextension with valgus;   pure valgus;   pu...
Hyperextension injuryIncidence: Pure hyperextension. 2% Hyperextension with varus. 8% Hyperextension with valgus. 2%
Trauma of hyperextension injury   Forces applied to hyperextended    (locked) knee:              Types of trauma       Di...
Direct trauma:Indirect trauma
Restraints of hyperextension1ry restraints of hyperextension:  PCL.2ry restraints of hyperextension:  ACL.  Posterior s...
Effects of    hyperextension injury             Effects of       hyperextension injuryImpaction injury   Distraction injur...
Impaction injuryKissing (contiguous) Bone marrowcontusions of the anterior aspect ofthe femoral condyles & anterior tibial...
Impaction injury in pure   hyperextension         Kissing bone marrow           contusions of the           anterior surfa...
Impaction injury in hyperextension            with varus                 Kissing bone marrow                   contusions ...
Impaction injury in hyperextension           with valgus                 Kissing bone marrow                  contusions ...
Distraction injury                   Distraction                  bone injury     Pure        Hyperextension   Hyperextens...
Distraction bone injury       in pure hyperextension   Avulsion bone marrow contusion of    the posterior tibial plateau.
Distraction injury inhyperextension with varus             Arcuate fracture:             Avulsion fracture of            ...
Distraction injury in     hyperextension with valgus   Avulsion bone marrow contusion of    the posteromedial tibial plat...
Distraction                      soft                 tissue injury     Pure        Hyperextension   Hyperextensionhyperex...
Distraction soft tissue injury       ((pure hyperextensionACL tear.PCL tear.Injury of the posterior supporting  structures...
Distraction soft tissue injury      ((hyperextension with varus   ACL injury.   PCL injury.   Posterior capsule disrupt...
Posterolateral corner syndromeUnrecognized injuries to the  posterolateral corner is an important  factor in postsurgical...
Lateral collateral ligament tear                   Coronal PD WI with FS                    shows:                    com...
Injury of the popliteal muscle &             tendon                Injury of the popliteal                  myotendineous ...
Injury of the biceps tendon                 Coronal T1 W                  image shows                  thickening,       ...
Distraction soft tissue injury   ((hyperextension with valgusPosteromedial instability: Injury of semimembranosis tendon....
Axial PD WI with FS  shows intrasubstance  partial tear of the  semimembranosis  tendon.Sagittal T2 WI shows  partial tear...
Flexion with valgus & external              rotationIncidence: 46%Trauma:Pivot shift injury during skiing .
Effects of Pivot shift injury              Effects of          Pivot shift injuryImpaction injury     Distraction injury  ...
Impaction injury    Non kissing    contusions of   the lateral femoral    condyle &   posterolateral    tibial plateau.
Distraction injuryAvulsion bone marrow   contusions at the:  posteromedial   tibial plateau &  medial femoral   condyle(...
Distraction soft tissue injuryO’ Donoghue’s triad: ACL injury. MCL injury. Tear of the posterior horn medial  meniscus.
Flexion with varus and internal              rotationIncidence: 1%Trauma:pivoting during deceleration with  change directi...
Effects of deceleration injury                        Effects of                   deceleration injury   Impaction injuryN...
Impaction injury           Non contiguous            bone marrow            contusions of the            lateral femoral ...
Distraction injury            Coronal PD FS WI             shows avulsion             fracture of the             Gerdy’s...
Distraction soft tissue injury   Anterolateral instability                                   Midsubstance tear          ...
Hyperflexion injury with posterior            tibial dislocation Incidence: 8% Trauma:Dashboard injury
Hyperflexion injury with posterior            tibial dislocation                      Effects of                  Dash boa...
Impaction injury        Bone marrow         contusion of the         anterior tibia
Distraction injury            Avulsion fracture of             the posterior tibial             plateau
Distraction soft tissue injuryPCL tear Midsubstance tear. Avulsion of the tibial attachment. Avulsion of the femoral at...
PCL INJURY
Disruption of the posterior capsule                  Sagittal STIR WI                   showing complete                  ...
Injury of the gastrocnemius muscle Grade I sprain:Interstitial oedema (giving feathery  appearance on STIR & T2 images).I...
Injury of the medial head of       gastrocnemius
Injury of the lateral head of       gastrocnemius
Pure valgus stress Incidence:6% Trauma:Clip injury.
Effects of valgus stress                       Effects of                     Valgus stress    Impaction injuryBone marrow...
Impaction injury           Bone marrow            contusion of the            lateral femoral &            tibial condyles
Distraction injury         Avulsion bone          marrow contusion          or fracture at the          tibial attachment ...
Distraction soft tissue injuryinjury of the medial collateral  ligament:Grade I:Grade II:Grade III:
Grade I MCL tear   Oedema superficial to the MCL
Grade II MCL tear   ligamentous thickening,   intraligamentous abnormal signal, and   edema superficial and deep to the...
GradeIII MCL tear   avulsion of the distal tibial attachment of the MCL    with proximal ligament retraction and increase...
Pure varus stressIncidence: 1 %Trauma:It is a rare pattern of injury as valgus  stress is usually assoicated with  flexion...
Patellar dislocation  Incidence: 6% Trauma:flexion and internal rotation of femur on fixed tibiaOften associated with pr...
Impaction injury           Non kissing            contusions of the            medial patellar            facet and later...
   Osteochonral    fracture of the    medial patellar    margin (has a    concave surface)
Distraction injury            Osteochondral             injury of the medial             patellar margin
Distraction soft tissue injury                  Torn medial                   patellar                   retinaculum at i...
Direct trauma   Localized bone marrow contusion    without soft tissue injury
Mechanism of knee injury
Mechanism of knee injury
Mechanism of knee injury
Mechanism of knee injury
Mechanism of knee injury
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Mechanism of knee injury

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Transcript of "Mechanism of knee injury"

  1. 1. Functional Anatomy and Mechanism of Knee Injury Dr. Hytham Nafady
  2. 2. Introduction Types of jointsFibrous Cartilaginous Synovialjoints joints joints
  3. 3. Types of synovial jointsUniaxial Biaxial •Hinge joint •Condyloid Multiaxial •Pivot joint Ball and socket •Saddle•Gliding joint
  4. 4. Hinge joint
  5. 5. Pivot joint
  6. 6. Gliding joint
  7. 7. Condyloid joint
  8. 8. Saddle joint
  9. 9. Ball & socket joint
  10. 10. Functional anatomy of the kneeThe articular bones of the knee have a little contribution to the stability of the joint.Stability of the knee joint depends mainly on its supporting soft tissue structures.
  11. 11. Supporting structures of the knee
  12. 12. :Medial supporting structures 3 layers  Superficial layer: Crural fascia (fascia continuous anteriorly with fascia covering vastus medialis & posteriorly with fascia covering sartorius muscle).  Middle layer: Superficial MCL  Deep layer: Deep MCL (medial capsular ligament).
  13. 13.  Superficial layer unite with middle layer anteriorly to form the medial patellar retinaculum. It separated from the middle layer in the middle third by fatty tissue. The middle layer unite with the deep layer posteriorly to form the posterior oblique ligament. The middle layer is separated from the deep layer at the middle third by fatty tissue & medial collateral bursa.
  14. 14. Superficial Medial collateral ligament Anterior vertical portion;Which is separated from the deep MCL by fat and MCL bursa. Posterior oblique portionWhich blends with the posterior medial meniscus (forming what is called posterior oblique ligament).
  15. 15. Deep medial collateral ligament Menisco-tibial attachment. Menisco-femoral attachment.
  16. 16. Medial supporting structuressuccessive coronal PD W images
  17. 17. Medial supporting structures Axial PD WI obtained  Axial PD WI obtained above the level of at the level of joint joint space space
  18. 18. Posteromedial supporting structures Semimembranosis muscle & tendon. Medial head of gastrocnemius Posterior oblique ligament(obliquely oriented portion of MCL). Joint capsule
  19. 19. Postero-medial supporting structures Sagittal T1 WI shows:  origin of medial head of gastrocnemius from medial supracondylar ridge &  insertion of semimebranosis tendon in the posterior tibia.
  20. 20. :Lateral supporting structures3 layers:Superficial layer: iliotibial tract & its anterior expansion. Biceps tendon & its posterior expansion.Middle layer: Lateral patellar retinaculum which is complete anteriorly and represented posteriorly by 2 patellofemoral ligaments.Deep layer:Superficial lamina: LCL And terminates at the fabellofibular ligament.Deep lamina: The coronay ligament (with its meniscotibial & mensico- femoral attachment). And terminates at the arcuate ligament.
  21. 21. Anterolateral supporting structures Iliotibial tract. (inserted in Gerdy’s tubercle). Superior and inferior Lateral patellar retinacula. Vastus lateralis muscle. Joint capsule.
  22. 22. Posterolateral supporting structures LCL. Biceps femoris tendon. Popliteus muscle and tendon. Popliteo-meniscal and popliteo-fibular ligaments. Oblique popliteal ligament. Arcuate ligament. Fabellofibular ligament. Lateral gastrocnemius muscle
  23. 23. LCL: Lateral femoral Styloid process. Lateral stabilizer & epicondyle. external rotator of the tibia.Popliteal Posteromedial Popliteal sulcus in Lateral stabilizer & internalmuscle & surface of the the lateral rotator of the tibia.tendon tibia. femoral condyle (intra-articular).Popliteal Popliteal tednon Lateral meniscus. Prevent excessive forwardmeniscal displacement of the lateralligament: meniscus during extension of the knee.Popliteal Popliteal tendon. Styloid process of Acts as a pully fixing thefibular the fibula. muscle in position duringligament: contraction.Oblique Recurrent fascicle arcuate ligament. Reinforces the posteriorpopliteal of capsule.ligament: semimembranosi s tendon.Arcuate lateral limb; medial limb;ligament: blends with the curves over theV shaped capsule near the popliteal tendon &thickening of lateral head of joins the obliquethe posterior gastrocnemius. poplitealcapsule. ligament.fabellofibular fabella or lateral styloid process ofligament: femoral condyle. the fibula.
  24. 24. Lateral supporting structures
  25. 25. Anterolateral supporting structures
  26. 26. Anterolateral supporting strucures  Coronal PD WIs showing the iliotibial tract.
  27. 27. Posterolateral supporting structures
  28. 28. Lateral collateral ligament
  29. 29. Biceps tendon
  30. 30. Popliteal tendon
  31. 31.  Sagittal PD WI: showing the LCL, popliteal & biceps tendons.
  32. 32. Conjoined tendon
  33. 33. Fabello-fibular ligament
  34. 34. Arcuate ligament
  35. 35. Popliteo-meniscal & popliteo-fibular ligaments
  36. 36. Posterior supporting structures Gastrocnemius muscle and tendons. Posterior joint capsule reinforced by the oblique popliteal ligament. PCL.
  37. 37. Posterior supporting structures
  38. 38. Types of injury pure hyperextension; hyperextension with varus; hyperextension with valgus; pure valgus; pure varus; flexion with valgus, external rotation; flexion with varus, internal rotation; flexion with posterior tibial translation; patellar dislocation (flexion, valgus, internal rotation of femur on tibia); and direct trauma.
  39. 39. Hyperextension injuryIncidence: Pure hyperextension. 2% Hyperextension with varus. 8% Hyperextension with valgus. 2%
  40. 40. Trauma of hyperextension injury Forces applied to hyperextended (locked) knee: Types of trauma Direct trauma Indirect trauma
  41. 41. Direct trauma:Indirect trauma
  42. 42. Restraints of hyperextension1ry restraints of hyperextension: PCL.2ry restraints of hyperextension: ACL. Posterior supporting structures:
  43. 43. Effects of hyperextension injury Effects of hyperextension injuryImpaction injury Distraction injury Avulsion bone Distraction marrow contusion soft tissue injury
  44. 44. Impaction injuryKissing (contiguous) Bone marrowcontusions of the anterior aspect ofthe femoral condyles & anterior tibialplateau.If varus force applied duringhyperextension, the bone marrowcontusion will be located moremedially & vice versa.
  45. 45. Impaction injury in pure hyperextension Kissing bone marrow contusions of the anterior surfaces of the femum and tibia.
  46. 46. Impaction injury in hyperextension with varus Kissing bone marrow contusions of the medial femoral & tibial condyles
  47. 47. Impaction injury in hyperextension with valgus  Kissing bone marrow contusions of the anterior extents of lateral femoral and tibial condyles.
  48. 48. Distraction injury Distraction bone injury Pure Hyperextension Hyperextensionhyperextension with varus with valgus
  49. 49. Distraction bone injury in pure hyperextension Avulsion bone marrow contusion of the posterior tibial plateau.
  50. 50. Distraction injury inhyperextension with varus Arcuate fracture: Avulsion fracture of the styloid process of the fibula.
  51. 51. Distraction injury in hyperextension with valgus Avulsion bone marrow contusion of the posteromedial tibial plateau.
  52. 52. Distraction soft tissue injury Pure Hyperextension Hyperextensionhyperextension with valgus with varus
  53. 53. Distraction soft tissue injury ((pure hyperextensionACL tear.PCL tear.Injury of the posterior supporting structures: (posterior capsule disruption or injury to gastrocnemius muscle).Injury to the popliteal vessels
  54. 54. Distraction soft tissue injury ((hyperextension with varus ACL injury. PCL injury. Posterior capsule disruption. Injury of the posterolateral supporting structures (posterolateral corner syndrome).
  55. 55. Posterolateral corner syndromeUnrecognized injuries to the posterolateral corner is an important factor in postsurgical failure after cruciate ligament reconstruction and in chronic instability and degenerative changes after knee trauma
  56. 56. Lateral collateral ligament tear  Coronal PD WI with FS shows: complete tear of the LCL with soft tissue edema.  Coronal PD WI shows: diffuse thickening of the LCL suggestive of partial tear.
  57. 57. Injury of the popliteal muscle & tendon Injury of the popliteal myotendineous junction. Avulsion injury of the popliteal tendon.
  58. 58. Injury of the biceps tendon  Coronal T1 W image shows thickening, heterogeneity & retraction of the biceps tendon evidence of its complete tear.
  59. 59. Distraction soft tissue injury ((hyperextension with valgusPosteromedial instability: Injury of semimembranosis tendon. Injury of the medial head of gastrocnemius.
  60. 60. Axial PD WI with FS shows intrasubstance partial tear of the semimembranosis tendon.Sagittal T2 WI shows partial tear of the medial head of gastrocnemius and semimembranosis tendon.
  61. 61. Flexion with valgus & external rotationIncidence: 46%Trauma:Pivot shift injury during skiing .
  62. 62. Effects of Pivot shift injury Effects of Pivot shift injuryImpaction injury Distraction injury Avulsion bone Distraction marrow contusion soft tissue injury
  63. 63. Impaction injury Non kissing contusions of the lateral femoral condyle & posterolateral tibial plateau.
  64. 64. Distraction injuryAvulsion bone marrow contusions at the: posteromedial tibial plateau & medial femoral condyle(attachments of coronary ligaments).
  65. 65. Distraction soft tissue injuryO’ Donoghue’s triad: ACL injury. MCL injury. Tear of the posterior horn medial meniscus.
  66. 66. Flexion with varus and internal rotationIncidence: 1%Trauma:pivoting during deceleration with change direction.
  67. 67. Effects of deceleration injury Effects of deceleration injury Impaction injuryNon kissing contusions of Distraction injury& lateral femoral condyle posterior tibial plateau Avulsion fracture of Distraction Gerdy’s tubercle soft tissue injury (Segond fracture) Anterolateral instability
  68. 68. Impaction injury  Non contiguous bone marrow contusions of the lateral femoral condyle & the posterolateral tibial plateau.
  69. 69. Distraction injury  Coronal PD FS WI shows avulsion fracture of the Gerdy’s tubercle with subcortical oedema (Segond fracture).
  70. 70. Distraction soft tissue injury Anterolateral instability  Midsubstance tear of the ilitibial tract rather than avulsion of the Gerdy’s tubercle.
  71. 71. Hyperflexion injury with posterior tibial dislocation Incidence: 8% Trauma:Dashboard injury
  72. 72. Hyperflexion injury with posterior tibial dislocation Effects of Dash board injury Impaction injuryBone marrow contusion of Distraction injury The anterior tibia Distraction soft tissue injury Avulsion fracture of PCL The posterior tibial plateau Posterior joint capsule Gastrocnemius muscle
  73. 73. Impaction injury Bone marrow contusion of the anterior tibia
  74. 74. Distraction injury  Avulsion fracture of the posterior tibial plateau
  75. 75. Distraction soft tissue injuryPCL tear Midsubstance tear. Avulsion of the tibial attachment. Avulsion of the femoral attchment.Injury of the posterior joint capsule.Injury of the gastrocnemius muscle.
  76. 76. PCL INJURY
  77. 77. Disruption of the posterior capsule Sagittal STIR WI showing complete avulsion of the femoral attachment of the PCL with disruption of the posterior capsule & bone marrow oedema of the anterior tibia.
  78. 78. Injury of the gastrocnemius muscle Grade I sprain:Interstitial oedema (giving feathery appearance on STIR & T2 images).Intramuscular hematoma.Grade II:Partial tear without retraction.Grade III:Complete tear with retraction.
  79. 79. Injury of the medial head of gastrocnemius
  80. 80. Injury of the lateral head of gastrocnemius
  81. 81. Pure valgus stress Incidence:6% Trauma:Clip injury.
  82. 82. Effects of valgus stress Effects of Valgus stress Impaction injuryBone marrow contusions of Distraction injury & lateral femoral condyle lateral tibial plateau Avulsion fracture of Distraction Gerdy’s tubercle soft tissue injury (reverse Segond fracture) MCL injury
  83. 83. Impaction injury  Bone marrow contusion of the lateral femoral & tibial condyles
  84. 84. Distraction injury Avulsion bone marrow contusion or fracture at the tibial attachment of the MCL (reversed Segond fracture).
  85. 85. Distraction soft tissue injuryinjury of the medial collateral ligament:Grade I:Grade II:Grade III:
  86. 86. Grade I MCL tear Oedema superficial to the MCL
  87. 87. Grade II MCL tear ligamentous thickening, intraligamentous abnormal signal, and edema superficial and deep to the ligament. There is no loss of MCL continuity
  88. 88. GradeIII MCL tear avulsion of the distal tibial attachment of the MCL with proximal ligament retraction and increased ligamentous laxity.
  89. 89. Pure varus stressIncidence: 1 %Trauma:It is a rare pattern of injury as valgus stress is usually assoicated with flexion and internal rotation.
  90. 90. Patellar dislocation Incidence: 6% Trauma:flexion and internal rotation of femur on fixed tibiaOften associated with predisposing conditions such as patella alta or shallow trochlear groove.
  91. 91. Impaction injury  Non kissing contusions of the medial patellar facet and lateral femoral condyle
  92. 92.  Osteochonral fracture of the medial patellar margin (has a concave surface)
  93. 93. Distraction injury  Osteochondral injury of the medial patellar margin
  94. 94. Distraction soft tissue injury  Torn medial patellar retinaculum at its femoral or patellar origin
  95. 95. Direct trauma Localized bone marrow contusion without soft tissue injury
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