Acute Knee Injuries: Meniscal Tears and Ligament Injuries

 
 
 
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a
r
t
h
r
o
s
c
o
p
i
c
a
l
l
y
;
a
n
y
 
m
e
n
i
s
c
a
l
 
l
e
s
i
o
n
 
c
a
n
 
b
e
d
e
a
l
t
 
w
i
t
h
 
s
a
m
e
 
t
i
m
e
.
 
 
 
 
Knee deformity :-Bow legs(Genu varum)and Knock
knees(Genu valgum)
BY the end of growth, the knees are normally in 5-7
degrees of valgus,so any thing more or less than that would
be classified as deformity.
In general,deformity is usually can be noticed by simple
observation,this is best done with the 
Bilateral genu
varum(bow leg)
 
can be recorded by measuring the
distance between the knees with the legs straight and the
medial malleoli just touching;it should be less than 6 cm.
Genu valgum(knock knee)
 
can be recorded by measuring
the distance between the medial malleoli when the knees
are held touching with patellae facing forwards;it is usually
less than 8 cm.
patient standing and bearing weight.
 
 
G
e
n
u
 
v
a
r
u
m
 
a
n
d
 
v
a
l
g
u
m
 
 
 
 
I
n
 
c
h
i
l
d
r
e
n
 
 
t
h
e
s
e
 
d
e
f
o
r
m
i
t
i
e
s
 
a
r
e
 
s
o
 
c
o
m
m
o
n
 
t
h
a
t
a
r
e
 
c
o
n
s
a
r
s
i
d
e
r
e
d
 
n
o
r
m
a
l
 
s
t
a
g
e
s
 
o
f
d
e
v
e
l
o
p
m
e
n
t
,
m
o
s
t
 
c
o
r
r
e
c
t
 
s
p
o
n
t
a
n
e
o
u
s
l
y
 
b
y
t
h
e
 
a
g
e
 
o
f
 
1
0
-
1
2
.
T
r
e
a
t
m
e
n
t
 
 
i
s
 
u
n
n
e
c
e
s
s
a
r
y
 
b
u
t
 
r
e
a
s
s
u
r
e
d
 
t
h
e
p
a
r
e
n
t
s
 
a
n
d
 
t
h
e
 
c
h
i
l
d
 
s
h
o
u
l
d
 
b
e
 
s
e
e
n
 
a
t
i
n
t
e
r
v
a
l
s
 
o
f
 
6
m
o
n
t
h
s
 
t
o
 
r
e
c
o
r
d
 
p
r
o
g
r
e
s
s
.
I
f
 
t
h
e
d
e
f
o
r
m
i
t
y
 
i
s
 
s
t
i
l
l
 
m
a
r
k
e
d
,
b
y
 
t
h
e
 
a
g
e
o
f
 
1
0
 
y
e
a
r
s
s
o
 
o
p
e
r
a
t
i
v
e
 
c
o
r
r
e
c
t
i
o
n
 
i
s
 
n
e
e
d
e
d
 
b
y
:
-
1
-
s
t
a
p
l
i
n
g
 
o
n
e
 
s
i
d
e
 
o
f
 
t
h
e
 
p
h
y
s
i
s
 
t
o
 
s
l
o
w
 
g
r
o
w
t
h
o
n
 
t
h
a
t
 
s
i
d
e
(
e
p
i
p
h
e
s
e
o
d
e
s
i
s
)
.
 
2
-
o
s
t
e
o
t
o
m
y
 
,
a
t
 
a
l
a
t
e
r
 
s
t
a
g
e
.
 
 
 
 
B
o
n
e
 
d
y
s
p
l
a
s
i
a
s
 
a
n
d
 
r
i
c
k
e
t
s
 
a
r
e
 
a
s
s
o
c
i
a
t
e
d
 
w
i
t
h
 
m
o
r
e
 
i
n
t
r
a
c
t
a
b
l
e
d
e
f
o
r
m
i
t
i
e
s
 
w
h
i
c
h
 
n
e
e
d
e
d
 
o
p
e
r
a
t
i
v
e
 
c
o
r
r
e
c
t
i
o
n
.
B
l
o
u
n
t
'
s
 
d
i
s
e
a
s
e
 
i
s
 
a
p
r
o
g
r
e
s
s
i
v
e
 
b
o
w
 
l
e
g
 
d
e
f
o
r
m
i
t
y
 
a
s
s
o
c
i
a
t
e
d
 
w
i
t
h
a
b
n
o
r
m
a
l
 
g
r
o
w
t
h
 
o
f
 
t
h
e
 
p
o
s
t
e
r
o
m
e
d
i
a
l
 
p
a
r
t
 
o
f
 
t
h
e
 
p
r
o
x
i
m
a
l
 
t
i
b
i
a
,
c
h
i
l
d
r
e
n
 
a
r
e
 
o
f
t
e
n
 
o
v
e
r
w
e
i
g
h
t
 
a
n
d
 
s
t
a
r
t
 
w
a
l
k
i
n
g
 
e
a
r
l
y
;
d
e
f
o
r
m
i
t
y
 
i
s
u
s
u
a
l
l
y
 
b
i
l
a
t
e
r
a
l
 
a
n
d
 
r
o
t
a
t
i
o
n
a
l
 
e
l
e
m
e
n
t
.
e
t
h
e
 
e
p
i
p
h
y
s
i
s
.
s
p
o
n
t
a
n
e
o
u
s
 
r
e
s
o
l
u
t
i
o
n
 
i
s
 
r
a
r
e
 
a
n
d
 
o
p
e
r
a
t
i
v
e
c
o
r
r
e
c
t
i
o
n
 
i
s
 
u
s
u
a
l
l
y
 
n
e
e
d
e
d
.
V
a
l
g
u
s
 
a
n
d
 
v
a
r
u
s
 
d
e
f
o
r
m
i
t
i
e
s
 
i
n
 
a
d
u
l
t
s
 
e
s
p
e
c
i
a
l
l
y
 
i
f
 
t
h
e
y
 
a
r
e
u
n
i
l
a
t
e
r
a
l
 
a
r
e
 
l
i
k
e
l
y
 
d
u
e
 
t
o
 
r
h
e
u
m
a
t
o
i
e
d
 
a
r
t
h
r
i
t
i
s
(
v
a
l
g
u
s
)
 
o
r
o
s
t
e
o
a
r
t
h
r
i
t
i
s
(
v
a
r
u
s
)
.
T
r
e
a
t
m
e
n
t
 
:
s
l
i
g
h
t
 
d
e
f
o
r
m
i
t
y
 
c
a
n
 
b
e
 
w
e
l
l
 
t
o
l
e
r
a
t
e
d
 
b
u
t
 
i
f
 
t
h
e
 
d
e
f
o
r
m
i
t
y
i
s
 
m
a
r
k
e
d
 
o
r
 
a
s
s
o
c
i
a
t
e
d
 
w
i
t
h
 
i
n
s
t
a
b
i
l
i
t
y
,
i
t
 
c
a
n
 
b
e
 
c
o
r
r
e
c
t
e
d
 
b
y
 
j
o
i
n
t
r
e
c
o
n
s
t
r
u
c
t
i
o
n
 
o
r
 
s
u
p
r
a
c
o
n
d
y
l
a
r
 
f
e
m
o
r
a
l
 
o
s
t
e
o
t
o
m
y
 
 
f
o
r
 
v
a
l
g
u
s
 
a
n
d
h
i
g
h
 
t
i
b
i
a
l
 
o
s
t
e
o
t
o
m
y
 
f
o
r
 
v
a
r
u
s
 
.
 
 
 
 
 
 
 
O
s
t
e
o
c
h
o
n
d
r
i
t
i
s
 
(
O
s
t
e
o
c
h
o
n
d
r
o
s
i
s
)
 
 
 
 
I
t
s
 
a
g
r
o
u
p
 
o
f
 
c
o
n
d
i
t
i
o
n
s
 
i
n
 
w
h
i
c
h
 
t
h
e
r
e
 
i
s
 
c
o
m
p
r
e
s
s
i
o
n
,
f
r
a
g
m
e
n
t
a
t
i
o
n
o
r
 
s
e
p
a
r
a
t
i
o
n
 
o
f
 
s
m
a
l
l
 
s
e
g
m
e
n
t
 
o
f
 
a
r
t
i
c
u
l
a
r
 
c
a
r
t
i
l
a
g
e
 
a
n
d
 
b
o
n
e
,
t
h
e
r
e
'
s
 
a
f
e
a
t
u
r
e
s
 
o
f
 
i
s
c
h
e
m
i
c
 
n
e
c
r
o
s
i
s
 
w
i
t
h
 
d
e
a
t
h
 
o
f
 
b
o
n
e
 
c
e
l
l
s
 
a
n
d
r
e
a
c
t
i
v
e
 
v
a
s
c
u
l
a
r
i
t
y
 
a
n
d
 
o
s
t
e
o
g
e
n
e
s
i
s
 
i
n
 
t
h
e
 
s
u
r
r
o
u
n
d
i
n
g
b
o
n
e
;
d
e
s
p
i
t
e
 
t
h
e
 
n
a
m
e
,
t
h
e
r
e
 
a
r
e
 
n
o
 
s
i
g
n
s
 
o
f
 
i
n
f
l
a
m
m
a
t
i
o
n
.
I
t
 
o
c
c
u
r
s
 
m
a
i
n
l
y
 
i
n
 
a
d
o
l
e
s
c
e
n
t
s
 
a
n
d
 
y
o
u
n
g
 
a
d
u
l
t
s
C
a
u
s
e
s
:
-
I
t
 
o
c
c
u
r
s
 
d
u
r
i
n
g
 
p
h
a
s
e
s
 
o
f
 
i
n
c
r
e
a
s
e
d
 
p
h
y
s
i
c
a
l
 
a
c
t
i
v
i
t
y
 
a
n
d
 
m
a
y
 
b
e
i
n
i
t
i
a
t
e
d
 
b
y
 
t
r
a
u
m
a
 
o
r
 
r
e
p
e
t
i
t
i
v
e
 
s
t
r
e
s
s
 
,
h
o
w
e
v
e
r
 
t
h
e
r
e
'
s
 
o
t
h
e
r
p
r
e
d
i
s
p
o
s
i
n
g
 
f
a
c
t
o
r
s
(
m
u
l
t
i
f
o
c
a
l
 
o
r
 
f
a
m
i
l
i
a
l
)
T
h
e
r
 
a
r
e
 
t
h
r
e
e
 
t
y
p
e
s
 
o
f
 
O
s
t
e
o
c
h
o
n
d
r
i
t
i
s
 
:
-
1
-
c
r
u
s
h
i
n
g
 
O
s
t
e
o
c
h
o
n
d
r
i
t
i
s
.
2
-
s
p
l
i
t
t
i
n
g
 
O
s
t
e
o
c
h
o
n
d
r
i
t
i
s
(
O
s
t
e
o
c
h
o
n
d
r
i
t
i
s
 
d
i
s
s
e
c
a
n
s
)
.
3
-
p
u
l
l
i
n
g
 
o
s
t
e
o
c
h
o
n
d
r
i
t
i
s
(
t
r
a
c
t
i
o
n
 
O
s
t
e
o
c
h
o
n
d
r
i
t
i
s
)
.
 
 
 
 
C
r
u
s
h
i
n
g
 
O
s
t
e
o
c
h
o
n
d
r
i
t
i
s
 
 
 
 
 
 
 
 
 
 
 
 
 
 
i
t
'
s
 
c
h
a
r
a
c
t
e
r
i
z
e
d
 
 
b
y
 
s
p
o
n
t
a
n
e
o
u
s
 
n
e
c
r
o
s
i
s
 
o
f
 
 
t
h
e
 
o
s
s
i
f
i
c
n
u
c
l
e
u
s
 
i
n
 
l
o
n
g
 
b
o
n
e
 
e
p
i
p
h
e
s
i
s
 
o
r
 
o
n
e
 
o
f
 
t
h
e
 
c
u
b
o
i
d
a
l
 
b
o
n
e
s
 
o
f
 
t
h
e
w
r
i
s
t
 
o
r
 
f
o
o
t
.
T
h
e
 
 
p
a
t
h
o
l
o
g
i
c
a
l
 
c
h
a
n
g
e
s
 
a
r
e
 
t
h
e
 
s
a
m
e
 
a
s
 
 
t
h
o
s
e
 
i
n
 
o
t
h
e
r
 
f
o
r
m
s
 
o
f
o
s
t
e
o
n
e
c
r
o
s
i
s
 
:
 
b
o
n
e
 
d
e
a
t
h
,
f
r
a
g
m
e
n
t
a
t
i
o
n
 
o
r
 
d
i
s
t
o
r
t
i
o
n
 
o
f
 
t
h
e
 
n
e
c
r
o
t
i
c
s
e
g
m
e
n
t
 
a
n
d
 
r
e
a
c
t
i
v
e
 
n
e
w
 
 
b
o
n
e
 
f
o
r
m
a
t
i
o
n
 
a
r
o
u
n
d
 
t
h
e
 
i
s
c
h
e
m
i
c
t
r
a
b
e
c
u
l
a
e
.
C
l
i
n
i
c
a
l
 
f
e
a
t
u
r
e
s
 
:
P
a
i
n
 
a
n
d
 
l
i
m
i
t
a
t
i
o
n
 
o
f
 
j
o
i
n
t
 
m
o
v
e
m
e
n
t
 
a
r
e
 
t
h
e
 
u
s
u
a
l
 
c
o
m
p
l
a
i
n
t
s
.
T
e
n
d
e
r
n
e
s
s
 
i
s
 
s
h
a
r
p
l
y
 
l
o
c
a
l
i
z
e
d
 
t
o
 
t
h
e
 
a
f
f
e
c
t
e
d
 
b
o
n
e
.
X
-
r
a
y
s
 
 
s
h
o
w
 
t
h
e
c
h
a
r
a
c
t
e
r
i
s
t
i
c
 
i
n
c
r
e
a
s
e
d
 
d
e
n
s
i
t
y
,
a
c
c
o
m
p
a
n
i
e
d
 
i
n
 
t
h
e
 
l
a
t
e
r
 
s
t
a
g
e
s
 
b
y
d
i
s
t
o
r
t
i
o
n
 
a
n
d
 
c
o
l
l
a
p
s
e
 
o
f
 
t
h
e
 
n
e
c
r
o
t
i
c
 
s
e
g
m
e
n
t
.
E
x
a
m
p
l
e
s
 
o
f
 
 
c
r
u
s
h
i
n
g
 
O
s
t
e
o
c
h
o
n
d
r
i
t
i
s
 
a
r
e
 
F
r
e
i
b
e
r
g
'
s
 
d
i
s
e
a
s
e
s
 
o
f
 
t
h
e
m
e
t
a
t
a
r
s
a
l
 
;
 
K
o
h
l
e
r
'
s
 
d
i
s
e
a
s
e
 
o
f
 
t
h
e
 
n
a
v
i
c
u
l
a
r
 
;
 
K
i
e
n
b
o
c
k
'
s
 
d
i
s
e
a
s
e
 
o
f
t
h
e
 
c
a
r
p
a
l
 
l
u
n
a
t
e
 
;
 
P
a
n
n
e
r
'
s
 
d
i
s
e
a
s
e
 
o
f
 
t
h
e
 
c
a
p
i
t
u
l
u
m
 
a
n
d
S
c
h
e
u
e
r
m
a
n
n
'
s
 
 
d
i
s
e
a
s
e
 
(
v
e
r
t
e
b
r
a
l
 
 
O
s
t
e
o
c
h
o
n
d
r
i
t
i
s
 
)
.
T
r
e
a
t
m
e
n
t
 
i
s
 
c
o
n
s
e
r
v
a
t
i
v
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In adult,it is doubtful,however it is generally
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p
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o
r
r
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n
i
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g
 
a
r
e
 
a
 
c
o
m
m
o
n
 
c
a
u
s
e
.
 
 
Physical findings
 
are limited to the area of the tibial
tubercle and patellar tendon. Generally, there is a
prominence and soft tissue swelling over the tibial
tubercle
. 
Tenderness
 of the patellar tendon may be
present. The remainder of the knee examination
usually is normal. Attempted flexion against
resistance may produce pain. Patients may resist
knee flexion because of inflammation and pain
from pull on the patellar tendon. Tight hamstrings
and/or quadriceps may also be noted when
compared to the uninvolved side.
I
m
a
g
i
n
g
 
S
t
u
d
i
e
s
:
W
h
i
l
e
 
r
a
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a
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d
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s
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s
,
 
a
 
s
e
p
a
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a
t
e
o
s
s
i
c
l
e
.
 
 
 
 
T
R
E
A
T
M
E
N
T
:
 
 
 
 
M
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d
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c
a
l
 
t
h
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r
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w
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m
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i
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d
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d
 
i
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c
h
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d
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.
 
 
 
O
U
T
C
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A
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D
 
P
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N
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:
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c
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K
r
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y
 
(
1
9
9
0
)
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9
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p
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m
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c
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m
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c
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.
 
 
 
C
h
o
n
d
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o
m
a
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a
c
i
a
 
p
a
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l
l
a
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(
p
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s
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s
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k
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p
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y
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P
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(
a
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p
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)
.
 
 
C
l
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f
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:
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,
 
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p
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o
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d
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o
c
a
t
i
o
n
.
 
 
I
m
a
g
i
n
g
 
 
:
x
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y
 
e
x
a
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Acute knee ligament injuries
 
     Injuries of knee ligaments are common,specially
in 
sport medicine and road traffic accidents,
where they may be associated with fractures and
dislocation.They vary in  severity from simple
sprain to  complete rupture,its rarely isolated or
unidirectional,it may  involve more than one
stracture e.g 
anteromedial instability due to torn
of medial collateral and anterior cruciate
ligaments.
 
 
    
Clinical features:
The patient gives ahistory of a twisting and the knee is 
painful
and 
in contrast to meniscal injury 
the 
swelling
 appears almost
immediately due to 
haemoarthrosis
,there’s also 
tenderness
 over
torn ligament and stressing one or other side of the joint may
produce severe pain .
Tests can be performed for 
ligamental stability,
partial tears 
has
no abnormal movement but with pain while 
complete tears 
has
abnormal movement with little pain.
Sideways tilting(varus test for lateral coll.ligaments and valgus
test for medial coll.ligament)  
is examined,first with knee at 30
degrees flexion and then with the knee straight.
Anteroposterior stability
 
is assessed first by placing the knee at
90 degrees with feet on couch and look from the side for
posterior sag
 of the proximal tibia which is areliable sign for
posterior cruciate ligamental  instability.also on the same
position we can do 
anterior drawer test  
for anterior cruciate
lig.and 
posterior drawer test 
forposterior cruciate lig.
 
 
Imaging  investigations:
     
Stress x-rays 
of the knee may be provide visual
evidence of instability.plain films and 
CT scan
may show that the ligament has avulsed asmall
piece of bone.
MRI
 is  a reliable method for
diagnosis of both ligamental and meniscal
injuries.
Arthroscopy :
    Its mainly indicated for isolated cruciate lig.
Tears and to exclude meniscal injuries but not
used for severe tears of collateral lig. And
capsule.
 
 
Treatment :
    
Sprains and parial tears:-
       The intact fibres splint the torn ones and eventual
healing.
Aspiration
  of the haemoarthrosis and apply 
ice-
packs 
to relieve pain.weight bearing is allowed but the
knee is protected  from rotation and angulation strains by
heavily padded 
bandage or a functional brace.
   
Complete tears:-
      Isolated tears of the medial or lateral collateral lig. Can
be treated as above.
     isolated  tears of the anterior cruciate may be treated by
early  
operative reconstruction 
specially for the
professional sportman other wise  it can be treated by
conservative method 
above,the cast brace is worn only
until symptoms subside and thereafter movement and
muscle-strengthening exercises are encouraged.
 
 
    
Combined injuries:
    With combined anterior cruciate and collateral lig.
Injury,it wiser to start with joint bracing and
physiotherapy in order to restore a good range of
movement before anterior cruciate reconstruction
while the collateral lig. Does not need
reconstruction.,the same approach for combined
injuries involving the posterior cruciate lig.
 
 
Complications:
    1-Adhesions
:if the knee with partial ligament
tear is not actively exercised,torn fibres stick
to intact fibres  and to the bone,the patient
present with  giving way and localized
tendernesson torned ligament.
    
2-Instability
: the knee may continue to give
way and lead to osteoarthritis ,reconstruction
before the onset of degeneration is wise.
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Acute knee injuries, such as meniscal tears and ligament injuries, are commonly caused by trauma or twisting motions. Meniscal tears can lead to pain, swelling, and locking of the knee joint, especially in young active individuals. Understanding the anatomy of the knee joint and meniscus, along with the different types of tears and clinical features, is crucial for proper diagnosis and treatment of these injuries.


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  1. ACUTE KNEE INJURIES A- Lesions of the menisci . B-Ligaments injuries .

  2. Anatomy of knee joint

  3. Lesions of the menisci Meniscal tears The menisci have arole in(1)increase the stability of the knee,(2)controlling the complex rolling and gliding actions of the joint and(3)distribution load during movement. Tears are common in young adults,it split in its length by aforce grinding it between the femur and the tibia,this occur when weight is being taken on the flexed knee and there is twisting strain in young (footballers). Medial meniscus is affected more than lateral because its attachments to the capsule make it less mobile.

  4. Acute tears are often related to trauma, most frequently as a result of a twisting motion. Most common in active people aged 10 45.

  5. Anatomy of meniscus

  6. Types of tears :- 1-Vertical tears like (a)bucket-handle tears when split vertical but still attached anterioly and posteriorly;(b)anterior or posterior horn tears when afree fragment remains attached anteriorly or posteriorly. 2-Horizontal tears are usually degenerative or due to repetitive minor trauma ,may be associated with meniscal cysts. Most of meniscus is avascular and spontaneous repair does not occur unless the tear is in outer third which is vascularized from the capsule. The loose tags act as amechanical irritant,which give rise to recurrent synovitis ,effusion and secondary osteoarthritis .

  7. Meniscal tears

  8. Clinical features:- The patient is young age with history of twisting injury to the knee on sport field. Pain is severe and occasionally the knee is locked in partial flexion; swelling some hours later. With rest the initial symptoms subside and recur after trivial strains or twists;sometimes the knee gives way and again followed by pain and swelling. If the patient is over 40 with no history of trauma,the main complaint is of recurrent giving way or locking. Locking is a sudden inability to extend the knee fully suggests abucket-handle tear. On examination ; the joint may be held slightly flexed and effusion,tenderness localized to the joint line on medial side;later on there's wasting of the quadriceps ;Apley's grinding test may be positive.

  9. Imaging :- Plain x-ray are normal but MRI are reliable method for diagnosis that are missed by arthroscopy . Arthroscopy :- It has advantage that if a lesion is identified ,it can be treated as the same time . Treatment :- In the past, meniscal tears were treated by open operation;nowadays arthroscopic surgery is preferable. For the peripheral tears,operative repair is feasible otherwise displaced portion should be excised(partial or complete meniscectomy).postoerative physiotherapy is an important part of the treatment.

  10. Investigation

  11. Meniscal cysts A meniscal cyst can be likened to ganglion because it contain gelateneous fluid and surrounded by fibrous tissue.Its probably traumatic in origin, arising from either asmall horizontal tear or repeated squashing of the peripheral part of the meniscus. The patient presents with pain, and a small lump can be seen and felt,usually on the lateral side of the joint;it may feel firm or tense particularly when the knee is extended. If it's symptomatic,the cyst can be decompressed or removed arthroscopically;any meniscal lesion can be dealt with same time.

  12. Knee deformity :-Bow legs(Genu varum)and Knock knees(Genu valgum) BY the end of growth, the knees are normally in 5-7 degrees of valgus,so any thing more or less than that would be classified as deformity. In general,deformity is usually can be noticed by simple observation,this is best done with the Bilateral genu varum(bow leg) can be recorded by measuring the distance between the knees with the legs straight and the medial malleoli just touching;it should be less than 6 cm. Genu valgum(knock knee) can be recorded by measuring the distance between the medial malleoli when the knees are held touching with patellae facing forwards;it is usually less than 8 cm. patient standing and bearing weight.

  13. Genu varum and valgum

  14. In children these deformities are so common that are consarsidered normal stages of development,most correct spontaneously by the age of 10-12. Treatment is unnecessary but reassured the parents and the child should be seen at intervals of 6months to record progress.If the deformity is still marked,by the ageof 10 years so operative correction is needed by:- 1-stapling one side of the physis to slow growth on that side(epipheseodesis). 2-osteotomy ,at a later stage.

  15. Bone dysplasias and rickets are associated with more intractable deformities which needed operative correction. Blount's disease is aprogressive bow leg deformity associated with abnormal growth of the posteromedial part of the proximal tibia, children are often overweight and start walking early;deformity is usually bilateral and rotational element. ethe epiphysis.spontaneous resolution is rare and operative correction is usually needed. Valgus and varus deformities in adults especially if they are unilateral are likely due to rheumatoied arthritis(valgus) or osteoarthritis(varus). Treatment :slight deformity can be well tolerated but if the deformity is marked or associated with instability,it can be corrected by joint reconstruction or supracondylar femoral osteotomy for valgus and high tibial osteotomy for varus .

  16. Osteochondritis (Osteochondrosis) Its agroup of conditions in which there is compression,fragmentation or separation of small segment of articular cartilage and bone ,there's afeatures of ischemic necrosis with death of bone cells and reactive vascularity and osteogenesis in the surrounding bone;despite the name,there are no signs of inflammation. It occurs mainly in adolescents and young adults Causes:- It occurs during phases of increased physical activity and may be initiated by trauma or repetitive stress ,however there's other predisposing factors(multifocal or familial) Ther are three types of Osteochondritis :- 1-crushing Osteochondritis. 2-splitting Osteochondritis(Osteochondritis dissecans). 3-pulling osteochondritis(traction Osteochondritis).

  17. Crushing Osteochondritis it's characterized by spontaneous necrosis of the ossific nucleus in long bone epiphesis or one of the cuboidal bones of the wrist or foot. The pathological changes are the same as those in other forms of osteonecrosis : bone death,fragmentation or distortion of the necrotic segment and reactive new bone formation around the ischemic trabeculae. Clinical features : Pain and limitation of joint movement are the usual complaints. Tenderness is sharply localized to the affected bone.X-rays show the characteristic increased density,accompanied in the later stages by distortion and collapse of the necrotic segment. Examples of crushing Osteochondritis are Freiberg's diseases of the metatarsal ; Kohler's disease of the navicular ; Kienbock's disease of the carpal lunate ; Panner's disease of the capitulum and Scheuermann's disease (vertebral Osteochondritis ). Treatment is conservative(analgesia and splintage) rarely need operation .

  18. Click to see larger picture

  19. splitting Osteochondritis(Osteochondritis dissecans) a small segment of articular cartilage and the subjacent bone may separate(dissect) as an avascular fragment.it occur typically in young adults usually men and affects particular sites: the lateral surface of the medial femoral condyle in the knee , the anteromedial corner of the talus , the superomedial part of the femoral head , the humeral capitulum and the first metatarsal head. The cause is almost certainly repeated minor trauma resulting in osteochondral fracture of a convex surface;the fragment loses its blood supply. The knee is the commonest joint to be affected with intermittent pain,swelling,joint effusion,locking of the joint and giving way. X-rays show the dissecting fragment is defined by the radiolucent line of the demarcation,when it separates,the resulting (crater). The early changes are better shown by MRI;there's decreased signal intensity in the area of the affected osteochondral segment. Radionuclide scanning with 99mTc-HDP show markedly increased activity in the same area.

  20. Treatment in the early stage consist of load reduction and restriction of the activity. In children,complete healing may occur(up to 2 years). In adult,it is doubtful,however it is generally recommended that partially detached fragments are pinned back in position(by arthroscopy in the knee joint), if the fragment becomes detached and causes symptoms ,it should be fixed back in position or else completely removed .

  21. pulling osteochondritis(traction Osteochondritis) there's localized pain and increased radiographic density in an unfused apophysis may result from tensile stress on the physeal junction. Ther are two sites: tibial tuberosity(Osgood- Schlatter's disease)and the calcaneal apophysis(Sever's disease); both are subject to unusual traction forces from powerful tendons which insert into the apophysis junction .

  22. Osgood-Schlatter Disease Osgood-Schlatter (OS) disease is more appropriately described as a disorder or a condition. Osgood, in the English literature, and Schlatter, in the German literature. OS condition is a traction phenomenon resulting from repetitive quadriceps contraction through the patellar tendon at its insertion upon the skeletally immature tibial tubercle. This occurs in preadolescence during a time when the tibial tubercle is susceptible to strain. OS condition should be distinguished from overuse of the patella- patellar tendon junction, which is referred to as Sinding-Larsen-Johansson syndrome (the adolescent equivalent of jumper's knee).

  23. Etiology: The etiology of OS condition is controversial. Several causes have been hypothesized. The most likely cause is that the apophysis is subject to traction during the adolescent years, which can result in microfractures. The tibial tubercle apophysis appears in children aged 7-9 years. Usually, an apophysis develops proximally toward the epiphysis as the epiphysis grows distally toward the apophysis. Repeated traction from the patellar tendon can cause microfractures in the apophysis.

  24. Clinical features: Obtaining the individual's history and performing a physical examination are usually sufficient for the physician to make a diagnosis of OS condition.OS condition is the most frequent cause of knee pain in children aged 10-15 years. Patients present with a history of pain inferior to the patella at the insertion of the patellar tendon. Typically, individuals report a sport or other activity that aggravates the pain, which generally is improved with rest and worsened with activity. While any activity may be involved, sports involving jumping or running are a common cause.

  25. Physical findings are limited to the area of the tibial tubercle and patellar tendon. Generally, there is a prominence and soft tissue swelling over the tibial tubercle. Tenderness of the patellar tendon may be present. The remainder of the knee examination usually is normal. Attempted flexion against resistance may produce pain. Patients may resist knee flexion because of inflammation and pain from pull on the patellar tendon. Tight hamstrings and/or quadriceps may also be noted when compared to the uninvolved side. Imaging Studies: While radiographs are not essential, they usually are obtained. Radiographs show fragmentation of the tibial tubercle apophysis and, at times, a separate ossicle.

  26. TREATMENT: Medical therapy:- Most patients respond to conservative care that consists of rest and avoidance of the offending activity. Stretching of the quadriceps and hamstrings before engaging in athletics may be helpful. Applying ice after physical activity may decrease swelling and pain. Immobilization by casting or bracing usually is unnecessary except in severe cases. Nonsteroidal anti- inflammatory drugs may be used but have not been shown to decrease the course of the disease. Steroidal injections should not be used. Other than the presence of an ossicle that causes pain with kneeling, there are no long-term disabilities or problems associated with this condition. Surgical therapy:- Surgery to treat OS condition is rarely indicated. Occasionally, adults have a large ossicle and an overlying bursa, which may cause pain with kneeling. If so, treatment consists of excision of the bursa, ossicle, and any prominence. Surgical treatment is rarely, if ever, indicated in children.

  27. OUTCOME AND PROGNOSIS : OS condition has a natural history that is self- limiting. In the Krause study (1990), 90% of patients were relieved of all their symptoms approximately 1 year following onset of symptoms with conservative care. Occasionally, patients may have continued problems kneeling into adulthood or have a tender ossicle and/or bursa that may require resection.

  28. Chondromalacia patellae(patellofemoral overload syndrome) The syndrome of anterior knee pain and patellofemoral tenderness is common among active adolescents and young adults. Parthenogenesis:- The basic disorder is due to mechanical overload of the patellofemoral joint which due to : 1-malcongruence of patellofemoral surfaces(abnormal shape of patella or intercondylar groove). 2-malalignment of the extensor mechanism or relative weakness of the vastus medialis which causesthe patella to tilt or subluxate during flexion and extension. Pathology: Patellofemoral overload leads to both changes in articular cartilage and the subchondral bone. Articular cartilage :-there's softing and fibrillation of articular surface of patella. Subchondral bone:- there's reactive vascular congenstion(apotent cause of pain).

  29. Clinical features : The patient is usually a teenage girl or an athletic young adult ,complains of pain over the front of the knee or underneath the knee-cap. Symptom are aggravated by activity or climbing stairs, or when standing up after prolonged sitting. The quadriceps may be wasted and there may be asmall effusion. Patellofemoral pain is elicited by pressing the patella against the femur and asking the patient to contract the quadriceps-first with central pressure, then compressing the medial facet then the lateral. If in addition, the apprehension test is positive, this suggest previous subluxation or dislocation.

  30. Imaging : x-ray examination should include skyline views of patella, which may show abnormal tilting or subluxation, and a lateral view with knee partly flexed to see if the patella is high or small. The most accurate way of showing and measuring patellofemoral malposition is by CT or MRI with the knees in full extension and varying degrees of flexion.

  31. Arthroscopy: Cartilage softening is common in asymptomatic knees and painful knees may show no abnormality. However, arthroscopy is useful in excluding other causes of anterior knee pain. Differential diagnosis of anterior knee pain : 1-Referred from hip. 2- Patellofemoral disorders (patellar instability, patellofemoral overload, patellofemoral osteoarthritis, osteochondral injury). 3-Joint disorders (osteochondritis dissecans, loose body in the joint, synovial chondromatosis ). 4-Periarticular disorders(patellar tendinitis, patellar ligament strain, bursitis, Osgood-Schlatter's disease

  32. Treatment: In the vast majority of cases the patient will be helped by adjustment of stressful activities and physiotherapy and reassurance that most patints recover. Exercises are directed at strengthening the medial quadriceps so as to counterbalance the tendency to lateral tilting or subluxation of the patella. If the symptoms persist, surgery can be considered-lateral release, or lateral release combined with one of the realignment procedures: 1-proximal realignment with vastus medialis reefing. 2-distal realignment with transposition of the lateral half of the patellar ligament towards medial side or through transposition of patellar ligment insertion(tibial tubercle).other procedures like chondroplasty(shaving of patellar articular surface by arthroscopy or lastly patellectomy.

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