SOFT TISSUE INJURIES OF THE KNEE (MENISCI & LIGAMENTS)femoral condyle is covex n tibia straight

Meniscus injuriesAnatomy:

Crescentric, triangular in cross section, wedge shapedAnterior and posterior horns: Intercondylar areaPeripheral attachment to synovium and coronary ligament. Inner edge free.Inferior surface flat and superior surface concave to fit tibia and femur.MM – larger in dia., longer, narrow, thinner and fixed – ½ tibial coverLM – smaller in dia, smaller, wider, thicker and more mobile due to attachment of popliteus and ant and post menisco femoral lig.–2/3rd coverBlood supply – Peripheral 1/3rd called red zone– 5 mm. rest is wdout blood

supply n gets from synovium.white one. n middle is red white zone.Functions:Weight transmission, Lubrication, Stability during rotation, Filler of joint, Shock Absorber, Prevents impingement of synovium and capsule.Movements: Moves with tibia in flexion / extension and with femur in rotation.Incidence: Male > Female

Young > Old Sports –Football, Kabadi, wrestlingMM > LM 5:1

Predisposing factors: 1. Degenerated meniscus2. Cyst of meniscus3. Congenital anomalies e.g. discoid meniscus 4. Congenital relaxed joints5. Ligaments injuries – abnormal kinetics6. Less mobile meniscus due to injury / surgery

Mechanism of injury: sports, male and young. medial is more exposed and old age more liable.

grinding btw 2 structures causes ruptureFlexed knee – weight bearing – rotational movement – Extension like foot ball, rotate

latetal lm... rotate medial lm. Other injuries – Ligaments, capsule, cartilaginous injuries

Classification: Complete / Incompleteotientation:

1. Longitudinal tears – Bucket handle tears2. Radial and transverse tears3. Oblique – Parrot beak tears4. Horizontal cleavage tears 5. Complex tears

Symptoms: 1. History of injury – mechanism with a sound followed by effusion; In degenerative tears less reliable – squatting, prayers.2. Pain 3. Swelling – Haemarthrosis vs. effusion4. Catching, snapping, click, jerks – degenerated tears5. Locking - D/D – LB, Intra articular injuries; Pseudo locking last 20

degree is not extended. n if obs go he has a jerk so ppl say thy r unstable.

6. Giving way – Subluxation on rotary motion; D/D LB, CMP, Lig injuries

Signs: Immediate after injury or late1. Wasted quads esp. VM2. Effusion3. Local tenderness in the joint line4. Click in the joint line5. McMurry’s test: trapping m btw condules. hold ankle flex knee flex

thm rotate.6. Appley’s grinding test prone position7. Squat test8. Pain in opposite compartment

Investigations1. X-rays to exclude other injuries

2. Arthrography- Double contrast3. MRI – 90% accuracy first choice.4. Arthroscopy 2nd choice for diagnosis confirmation.

Management: Treatment of torn meniscus is surgeryConservative: POP Cylinder for 6 weeks

Indications:1. Incomplete, small (< 5mm) peripheral tear, no other injury2. Tears with Lig. Injury that is not being treated

Menisectomy:resect n repair

white has to b resection and red is repaired.Total vs. partial menisectomyOpen vs. arthroscopic surgery – Skill, equipment, post. horn, additional injuries requiring surgeryTiming: ElectiveTourniquet, EUA, position, equipment

Open menisectomy:2 incisions in the capsule: anterior horn; posterior horn by additional incisionPost op Robert Jones bandage, immobilize for ten days; elevation; exercises; crutches for 6 weeks; sports after 3 months

Arthroscopic menisectomy – noe a days we do this. 2 or 3 ports; anterior or posterior horn first

Early mobilization; ExercisesMeniscal repairs

Within vascular zone.Open technique – Debride; vertical mattress; delayed absorbable suturesArthroscopic – Inside out or outside in

Complications after menisectomy:Haemarthrosis, Chronic Synovitis, Infection, Synovial fistula, Retained fragments, Popliteal vessels, Neuroma – infra patellar branch of saphenous nerve, Unmasking of instabilities, DVT, RSD, Late arthritis.

Ligament InjuriesLigaments: 17 ligamentsMCL – Medial femoral epicondyles to medial tibial condyle; Superficial & deep partLCL - Lateral femoral epicondyles to head of fibulaACL – Anterior part of I/C area to medial aspect of lateral femoral condylePCL – Posterior aspect of the proximal tibia & lateral surface of medial femoral condylePrimary & secondary constraints of the knee

Mechanism of injuryExtreme force to a stretched ligament with or without rotation:Valgus stress – MCL towards mid line tibia goes outwardVarus stress – LCL away tibia goes inward.Hyperextension, external rotation, abduction - ACLPosterior displacement of the flexed knee (dashboard) - PCLConcomitant / Combined injuries to other ligaments and meniscal injuriesTriad of O`Donhaughmajority occur with combination. mcl acl n lcl

Classification:Grade 1: <25% fibers torn; Grade 2: 25-50% torn 2-3 cm opening; Grade 3: >50%

fibers tornon mri we can see. very wide.SymptomsImmediate after injury:

Popping sound, inability to walk, immediate swelling and pain.Late:

Weakness & feeling of giving way.Signs

At the time of injury: Swelling, bruising and local tenderness over the point of rupture.Stress testing – local/ general anesthesia

Late:Wasted quadriceps, effusion in the kneeStability of the knee & stress tests for the ligament:MCL – Valgus stress in extension & 20° flexionLCL – Varus stress in extension & 20° flexion ACL - Anterior drawer sign; Lachmann’s sign; Pivot shift and jerk testPCL – Posterior drawer; posterior sag

InvestigationsStress radiographyArthrographyArthroscopyMRI

TreatmentGrade 1 tears: Conservatively with ice packs, crepe bandage, analgesics.Grade 2 tears: POP cylinder for 4-6 weeks, followed by exercises.Grade 3 tears: Operative treatmentPrimary repair (within 2 weeks) – Proximal or distal attachment, mid substance tears with in 10 days.Exposure, finding the tear, repair: re attachment of the avulsed bony attachment, repair of the mid-substance tears; AugmentationReconstruction (Later than 2-3 months) Instability despite adequate rehabMCL: Advancement of proximal attachment (Slocum operation); double

breasting of MCL, Pes plasty.ACL: Substitute (BTB, semitendinosus, allograft, artificial ligament), isometric

points, fixation – Modified Clancy operation.LCL: Iliotibial band (McIntosh repair)graft ftom patella, lagmentum patella.... hamstring.Post operative:

Immobilization 3-4 weeks exercisesextensor apparatus last soft tissue.