SOFT TISSUE INJURIES OF THE KNEE (MENISCI & LIGAMENTS)

femoral condyle is covex n tibia straight

Meniscus injuries
Anatomy:
Crescentric, triangular in cross section, wedge shaped
Anterior and posterior horns: Intercondylar area
Peripheral 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 tibial cover
LM smaller in dia, smaller, wider, thicker and more mobile due to
attachment of popliteus and ant and post menisco femoral lig.2/3rd cover
Blood 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, wrestling
MM > LM 5:1
Predisposing factors: 1. Degenerated meniscus
2. Cyst of meniscus
3. Congenital anomalies e.g. discoid meniscus
4. Congenital relaxed joints
5. Ligaments injuries abnormal kinetics
6. 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 rupture
Flexed knee weight bearing rotational movement Extension like foot ball, rotate
latetal lm... rotate medial lm.
Other injuries Ligaments, capsule, cartilaginous injuries
Classification:
Complete / Incomplete
otientation:
1. Longitudinal tears Bucket handle tears
2. Radial and transverse tears
3. Oblique Parrot beak tears
4. 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. effusion
4. Catching, snapping, click, jerks degenerated tears
5. 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 late
1. Wasted quads esp. VM
2. Effusion
3. Local tenderness in the joint line
4. Click in the joint line
5. McMurrys test: trapping m btw condules. hold ankle flex knee flex
thm rotate.
6. Appleys grinding test prone position
7. Squat test
8. Pain in opposite compartment
Investigations
1. X-rays to exclude other injuries

2. Arthrography- Double contrast

3. MRI 90% accuracy first choice.
4. Arthroscopy 2nd choice for diagnosis confirmation.
Management: Treatment of torn meniscus is surgery
Conservative: POP Cylinder for 6 weeks
Indications:
1. Incomplete, small (< 5mm) peripheral tear, no other injury
2. 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 menisectomy
Open vs. arthroscopic surgery Skill, equipment, post. horn, additional injuries
requiring surgery
Timing: Elective
Tourniquet, EUA, position, equipment
Open menisectomy:
2 incisions in the capsule: anterior horn; posterior horn by additional incision
Post 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; Exercises
Meniscal repairs
Within vascular zone.
Open technique Debride; vertical mattress; delayed absorbable sutures
Arthroscopic 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 Injuries
Ligaments: 17 ligaments
MCL Medial femoral epicondyles to medial tibial condyle; Superficial & deep part
LCL - Lateral femoral epicondyles to head of fibula
ACL Anterior part of I/C area to medial aspect of lateral femoral condyle
PCL Posterior aspect of the proximal tibia & lateral surface of medial femoral condyle
Primary & secondary constraints of the knee
Mechanism of injury
Extreme force to a stretched ligament with or without rotation:
Valgus stress MCL towards mid line tibia goes outward
Varus stress LCL away tibia goes inward.
Hyperextension, external rotation, abduction - ACL
Posterior displacement of the flexed knee (dashboard) - PCL
Concomitant / Combined injuries to other ligaments and meniscal injuries
Triad of O`Donhaugh
majority 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 torn
on mri we can see. very wide.
Symptoms
Immediate 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 knee
Stability of the knee & stress tests for the ligament:
MCL Valgus stress in extension & 20 flexion
LCL Varus stress in extension & 20 flexion
ACL - Anterior drawer sign; Lachmanns sign; Pivot shift and jerk test
PCL Posterior drawer; posterior sag
Investigations
Stress radiography
Arthrography
Arthroscopy
MRI
Treatment
Grade 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 treatment
Primary 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; Augmentation
Reconstruction (Later than 2-3 months) Instability despite adequate rehab
MCL:
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 exercises
extensor apparatus last soft tissue.