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Bones Of The Leg Popliteal Fossa The Knee Dr. Fadel Naim Orthopedic Surgeon IUG DR FADEL NAIM IUG PATELLA The largest sesamoid bone Triangular Its apex lies inferiorly The posterior surface articulates with the condyles of the femur DR FADEL NAIM IUG PATELLA Connected to the tuberosity of the tibia by the ligamentum patellae. It is prevented from being displaced laterally during the action of the quadriceps muscle by: The lower horizontal fibers of vastus medialis The large size of the lateral condyle of the femur DR FADEL NAIM IUG Patella Supported by muscle bone and ligamentous structures Muscle- through quad tendon Bone Medially- vastus medialis Laterally- vastus lateralis Superiorly- rectus femoris and vastus intermedius Trochlear groove Ligamentous Patellar ligament Patellar retinacula Lateral Medial DR FADEL NAIM IUG Function Increased efficiency of quadriceps Changes line of pull Protection of anterior knee joint DR FADEL NAIM IUG Functions of Patello-femoral Joint with patella (1) increases angle of pull of quads on tibia, improves the ratio of motive:resistive torque by 50% (2) centralizes divergent tension of quads into a single line of action (3) some protection of anterior aspect of knee DR FADEL NAIM IUG without patella DR FADEL NAIM IUG Patella Exposed position in front of the knee joint and can easily be palpated through the skin. It is separated from the skin by an important subcutaneous bursa DR FADEL NAIM IUG Tibia The large weight-bearing medial bone of the leg It articulates with: The The The The condyles of the femur head of the fibula talus distal end of the fibula It has an expanded upper end, a smaller lower end, and a shaft. DR FADEL NAIM IUG Tibia At the upper end: The lateral and medial condyles (sometimes called lateral and medial tibial plateaus), Articulate with the lateral and medial condyles of the femur Anterior and posterior intercondylar areas separate the upper articular surfaces of the tibial condyles Intercondylar eminence lies between these areas DR FADEL NAIM IUG DR FADEL NAIM IUG The lateral condyle possesses on its lateral aspect a small circular articular facet for the head of the fibula. The medial condyle has on its posterior aspect the insertion of the semimembranosus muscle DR FADEL NAIM IUG Proximal Tibia Anatomy 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Lateral tibial Plateau: convex, smaller than medial plateau Lateral intercondylar eminence Medial intercondylar eminence ------------------------------------Medial tibial plateau: concave, larger than lateral plateau Tibial tubercle: insertion of patellar tendon Tibial shaft Fibular shaft Fibular head: Styloid process of fibular head is the incertions of the lateral collateral ligament. Gerdy's tubercle: insertion site of iliotibial band DR FADEL NAIM IUG The Shaft Of The Tibia Triangular in cross section Three borders and three surfaces Anterior, medial borders and the medial surface are subcutaneous. The anterior border is prominent and forms the the shin. At the junction of the anterior border with the upper end of the tibia is the tuberosity, Receives attachment of the ligamentum patellae. The anterior border becomes rounded below, where it becomes continuous with the medial malleolus DR FADEL NAIM IUG The Shaft Of The Tibia The lateral or interosseous border gives attachment to the interosseous membrane The posterior surface of the shaft shows an oblique line, the soleal line for the attachment of the soleus muscle DR FADEL NAIM IUG The lower end of the tibia is slightly expanded and on its inferior aspect shows a saddleshaped articular surface for the talus. The lower end is prolonged downward medially to form the medial malleolus. The lateral surface of the medial malleolus articulates with the talus. The lower end of the tibia shows a wide, rough depression on its lateral surface for articulation with the fibula. DR FADEL NAIM IUG FIBULA The slender lateral bone of the leg No part in the articulation at the knee joint Below it forms the lateral malleolus of the ankle joint. No part in the transmission of body weight Provides attachment for muscles. An expanded upper end, a shaft, and a lower end. DR FADEL NAIM IUG The upper end, or head A styloid process. Articular surface for articulation with the lateral condyle of the tibia The shaft of the fibula Long and slender. Four borders and four surfaces The medial or interosseous border gives attachment to the interosseous membrane. DR FADEL NAIM IUG The lower end of the fibula Forms the triangular lateral malleolus, which is subcutaneous. On the medial surface of the lateral malleolus is a triangular articular facet for articulation with the lateral aspect of the talus. Below and behind the articular facet is a depression called the malleolar fossa. DR FADEL NAIM IUG DR FADEL NAIM IUG DR FADEL NAIM IUG DR FADEL NAIM IUG PATELLAR DISLOCATIONS Congenital recurrent dislocations caused by underdevelopment of the lateral femoral condyle. Traumatic dislocation of the patella results from direct trauma to the quadriceps attachments of the patella (especially the vastus medialis), with or without fracture of the patella. DR FADEL NAIM IUG DR FADEL NAIM IUG PATELLAR FRACTURES A result of direct violence Broken into several small fragments Because the bone lies within the quadriceps femoris tendon, little separation of the fragments takes place. The close relationship of the patella to the overlying skin may result in the fracture being open. A result of indirect violence Caused by the sudden contraction of the quadriceps Snapping the patella across the front of the femoral condyles. The knee is in the semiflexed position The fracture line is transverse Separation of the fragments usually occurs. DR FADEL NAIM IUG DR FADEL NAIM IUG FRACTURES OF THE TIBIA Fractures of the tibia and fibula are common. If only one bone is fractured, the other acts as a splint and displacement is minimal. Fractures of the shaft of the tibia are often open because the entire length of the medial surface is covered only by skin and superficial fascia. DR FADEL NAIM IUG FRACTURES OF THE TIBIA Fractures of the distal third of the shaft of the tibia are prone to delayed union or nonunion. This can be because the nutrient artery is torn at the fracture line, with a consequent reduction in blood flow to the distal fragment; The splint like action of the intact fibula prevents the proximal and distal fragments from coming into apposition. DR FADEL NAIM IUG Fractures of the proximal end of the tibia (tibial plateau) Common in the middle aged and elderly Usually result from direct violence to the lateral side of the knee joint The tibial condyle may show: A split fracture Be broken up The fracture line may pass between both condyles in the region of the intercondylar eminence. As a result of forced abduction of the knee joint, the medial collateral ligament can also be torn or ruptured. DR FADEL NAIM IUG DR FADEL NAIM IUG INTRAOSSEOUS INFUSION OF THE TIBIA IN THE INFANT For the infusion of fluids and blood when it has been found impossible to obtain an intravenous line. The bone marrow needle is directed at right angles through the skin, superficial fascia, deep fascia, and tibial periosteum and the cortex of the tibia. Once the needle tip reaches the medulla and bone marrow, the operator senses a feeling of "give." The position of the needle in the marrow can be confirmed by aspiration. The transfusion may then commence. DR FADEL NAIM IUG Popliteal Fossa a diamond-shaped intermuscular space situated at the back of the knee most prominent when the knee joint is flexed. DR FADEL NAIM IUG BOUNDARIES DR FADEL NAIM IUG Popliteal Fossa It contains: 1. 2. 3. 4. 5. 6. 7. 8. The popliteal vessels The small saphenous vein The common peroneal nerve Tibial nerve The posterior cutaneous nerve of the thigh The genicular branch of the obturator nerve Connective tissue Lymph nodes DR FADEL NAIM IUG DR FADEL NAIM IUG Popliteus A thin, triangular muscle Forms the inferior part of the floor of the popliteal fossa The apex of its fleshy belly emerges from the joint capsule of the knee joint. Origin: Insertion: posterior lateral condyle of femur upper posterior medial surface of tibia Action flex knee, internally rotate knee DR FADEL NAIM IUG POPLITEAL ARTERY deeply placed and enters the popliteal fossa through the opening in the adductor magnus ends at the level of the lower border of the popliteus muscle by dividing into anterior and posterior tibial arteries. DR FADEL NAIM IUG POPLITEAL ARTERY Relations Anteriorly: The popliteal surface of the femur the knee joint the popliteus muscle Posteriorly: The popliteal vein the tibial nerve Fascia skin Branches muscular branches articular branches to the knee. DR FADEL NAIM IUG DR FADEL NAIM IUG DR FADEL NAIM IUG POPLITEAL ANEURYSM The pulsations of the wall of the femoral artery against the tendon of adductor magnus at the opening of the adductor magnus is thought to contribute to the cause of popliteal aneurysms. DR FADEL NAIM IUG SEMIMEMBRANOSUS BURSA SWELLING The most common swelling found in the popliteal space. It is made tense by extending the knee joint and becomes flaccid when the joint is flexed. A baker's cyst Centrally located Arises as a pathologic (osteoarthritis) diverticulum of the synovial membrane through a hole in the back of the capsule of the knee DR FADEL NAIM IUG joint. DR FADEL NAIM IUG POPLITEAL VEIN Formed by the junction of the venae comitantes of the anterior and posterior tibial arteries at the lower border of the popliteus muscle It begins on the medial side of the popliteal artery. As it ascends through the fossa, it crosses behind the popliteal artery so that it comes to lie on its lateral side It passes through the opening in the adductor magnus to become the femoral vein. Tributaries Veins that correspond to branches given off by the popliteal artery. Small saphenous vein, which perforates the deep fascia and passes between the two heads of the gastrocnemius muscle to end in the popliteal vein. DR FADEL NAIM IUG Popliteal fossa 1. Semitendinosus 2. Biceps femori 3. Semimembranosus 4. Sciatic nerve 5. Popliteal vein 6. Popliteal artery DR FADEL NAIM IUG ARTERIAL ANASTOMOSIS AROUND THE KNEE JOINT Genicular anastomosis To compensate for the narrowing of the popliteal artery, which occurs during extreme flexion of the knee around the knee joint is a profuse anastomosis of small branches of: The femoral artery Muscular and articular branches of the popliteal artery Branches of the anterior and posterior tibial arteries . DR FADEL NAIM IUG TIBIAL NERVE The larger terminal branch of the sciatic nerve The tibial nerve arises in the lower third of the thigh. It runs downward through the popliteal fossa, lying first on the lateral side of the popliteal artery, then posterior to it, and finally medial to it The popliteal vein lies between the nerve and the artery throughout its course. The nerve enters the posterior compartment of the leg by passing beneath the soleus muscle. DR FADEL NAIM IUG COMMON PERONEAL NERVE The smaller terminal branch of the sciatic nerve arises in the lower third of the thigh It runs downward through the popliteal fossa closely following the medial border of the biceps muscle It leaves the fossa by crossing superficially the lateral head of the gastrocnemius muscle. It then passes behind the head of the fibula, winds laterally around the neck of the bone it is subcutaneous and can easily be rolled against the bone DR FADEL NAIM IUG Knee Dr. Fadel Naim Orthopedic Surgeon Faculty of medicine IUG DR FADEL NAIM IUG Surface Anatomy DR FADEL NAIM IUG KNEE JOINT The largest and most complicated joint in the body. Basically, it consists of (2+1): Two condylar joints between: The medial and lateral condyles of the femur The corresponding condyles of the tibia A gliding joint, between the patella and the patellar surface of the femur. The fibula is not directly involved in the joint. DR FADEL NAIM IUG DR FADEL NAIM IUG Articulation of Knee Joint Above are the rounded condyles of the femur Below are the condyles of the tibia and their cartilaginous menisci In front is the articulation between the lower end of the femur and the patella. hinge variety some degree of rotatory movement is possible.. a synovial joint of the plane gliding variety The articular surfaces are covered with hyaline cartilage. Medial and lateral tibial plateaus: The articular surfaces of the medial and lateral condyles of the tibia DR FADEL NAIM IUG Capsule Attached to the margins of the articular surfaces Surrounds the sides and posterior aspect of the Joint On the front of the joint, the capsule is absent Permitting the synovial membrane to pouch upward beneath the quadriceps tendon, forming the suprapatellar bursa DR FADEL NAIM IUG Capsule Behind the joint, the capsule is strengthened by the oblique popliteal ligament an expansion of the semimembranous muscle An opening in the capsule behind the lateral tibial condyle permits the tendon of the popliteus to emerge DR FADEL NAIM IUG Capsule On each side of the patella, the capsule is strengthened by expansions from the tendons of vastus lateralis and medialis DR FADEL NAIM IUG Ligaments Extracapsular 1. The ligamentum patellae 2. Attached above to the lower border of the patella and below to the tuberosity of the tibia A continuation of the central portion of the common tendon of the quadriceps femoris muscle. The oblique popliteal ligament A tendinous expansion derived from the semimembranosus muscle. It strengthens the posterior aspect of the capsule DR FADEL NAIM IUG Ligaments Extracapsular 3. The lateral collateral ligament 4. Cordlike attached above to the lateral condyle of the femur and below to the head of the fibula The tendon of the popliteus muscle intervenes between the ligament and the lateral meniscus The medial collateral ligament A flat band and is attached above to the medial condyle of the femur and below to the medial surface of the shaft of the tibia It is firmly attached to the edge of the medial meniscus DR FADEL NAIM IUG DR FADEL NAIM IUG DR FADEL NAIM IUG Intracapsular Ligaments The cruciate ligaments Two strong intracapsular ligaments Cross each other within the joint cavity Named anterior and posterior, according to their tibial attachments These important ligaments are the main bond between the femur and the tibia through out the joint's range of movement. DR FADEL NAIM IUG Green :ACL Yellow: PCL Red: Med men Blue: Lat Men Anterior Cruciate Ligament Attached to the anterior intercondylar area of the tibia Passes upward, backward, and laterally Attached to the posterior part of the medial surface of the lateral femoral condyle Prevents posterior displacement of the femur on the tibia. With the knee joint flexed Prevents the tibia from being pulled anterioriy. DR FADEL NAIM IUG Posterior Cruciate Ligament Attached to the posterior intercondylar area of the tibia Passes upward, forward, and medially Attached to the anterior part of the lateral surface of the medial femoral condyle Prevents anterior displacement of the femur on the tibia. With the knee joint flexed, prevents the tibia from being pulled posteriorly. DR FADEL NAIM IUG The ACL prevents the femur from sliding posteriorly on the tibia or the tibia from sliding anteriorly on the femur. F E M U R PATELLA The PCL prevents the femur from sliding anteriorly on the tibia or the tibia from sliding posteriorly on the femur. DR FADEL NAIM IUG T I B I A Tests for ACL Lachman’s DR FADEL NAIM IUG Anterior Draw DR FADEL NAIM IUG Menisci C-shaped sheets of fibrocartilage. The peripheral border is thick and attached to the capsule The inner border is thin and concave and forms a free edge The upper surfaces are in contact with the femoral condyles. The lower surfaces are in contact with the tibial condyles. DR FADEL NAIM IUG Menisci Each meniscus is attached to the upper surface of the tibia by anterior and posterior horns. Because the medial meniscus is also attached to the medial collateral ligament, it is relatively immobile Their function is to: DR FADEL NAIM IUG Deepen the articular surfaces of the tibial condyles to receive the convex femoral condyles Serve as cushions between the two bones. DR FADEL NAIM IUG DR FADEL NAIM IUG DR FADEL NAIM IUG Synovial Membrane lines the capsule attached to the margins of the articular surfaces On the front and above the joint, it forms a pouch, which extends up beneath the quadriceps femoris muscle for three fingerbreadths above the patella, forming the suprapatellar bursa This is held in position by the attachment of a small portion of the vastus intermedius muscle, called the articularis genus muscle DR FADEL NAIM IUG The synovial membrane is reflected forward from the posterior part of the capsule around the front of the cruciate ligaments As a result, the cruciate ligaments lie behind the synovial cavity and are not bathed in synovial fluid. In the anterior part of the joint, the synovial membrane is reflected backward from the posterior surface of the ligamentum patellae to form the infrapatellar fold The free borders of the fold are termed the alar folds DR FADEL NAIM IUG DR FADEL NAIM IUG Bursae Related to the Knee Joint Numerous bursae are related to the knee joint. They are found wherever skin, muscle, or tendon rubs against bone Four are situated in front of the joint Six are found behind the joint The suprapatellar bursa and the popliteal bursa always communicate with the joint, and the semimembranosus bursa may communicate with the joint. DR FADEL NAIM IUG Bursae Related to the Knee Joint Anterior Bursae 1. 2. 3. 4. The The The The DR FADEL NAIM IUG suprapatellar bursa prepatellar bursa superficial infrapatellar bursa deep infrapatellar bursa Posterior Bursae The popliteal bursa The semimembranosus bursa The remaining four bursae are found related to the tendon of insertion of: The biceps femoris The sartorius Gracilis Semitendinosus DR FADEL NAIM IUG DR FADEL NAIM IUG DR FADEL NAIM IUG DR FADEL NAIM IUG Nerve Supply The The The The DR FADEL NAIM IUG femoral nerve obturator nerve common peroneal nerve tibial nerve Movements The knee joint can flex, extend, and rotate DR FADEL NAIM IUG Screw Home Mechanism The extended knee is in locked position medial rotation of the femur results in a twisting and tightening of all the major ligaments of the joint The knee becomes a mechanically rigid structure The cartilaginous menisci are compressed like rubber cushions between the femoral and tibial condyles DR FADEL NAIM IUG When the foot is firmly planted on the ground when a person is standing, the femur is medially rotated on the tibia to lock and stabilize the knee joint. The foot is raised off the ground, the tibia may be laterally rotated on the femur to lock the knee joint. DR FADEL NAIM IUG Unlocking Or Untwisting Process Before flexion of the knee joint can occur, it is essential that the major ligaments be untwisted and slackened to permit movements between the joint surfaces This process is accomplished by the popliteus muscle, which laterally rotates the femur on the tibia. DR FADEL NAIM IUG Unlocking Or Untwisting Process The menisci have to adapt their shape to the changing contour of the femoral condyles. The attachment of the popliteus to the lateral meniscus results in that structure being pulled backward. DR FADEL NAIM IUG Locking and unlocking at the knee joint. Shaded area = femur Solid line = tibia in extension Broken line = tibia in flexion DR FADEL NAIM IUG When the knee joint is flexed to a right angle, a considerable range of rotation is possible. In the flexed position, the tibia can also be moved passively forward and backward on the femur. This is possible because the major ligaments, especially the cruciate ligaments, are slack in this position DR FADEL NAIM IUG Important Relations Anteriorly: Posteriorly: The popliteal vessels Tibial and common peroneal nerves Lymph nodes The muscles that form the boundaries of the popliteal fossa, The semimembranosus The semitendinosus The biceps femoris The two heads of the gastrocnemius The plantaris Medially: The prepatellar bursa Sartorius Gracilis Semitendinosus Laterally: Biceps femoris Common peroneal nerve DR FADEL NAIM IUG STRENGTH OF THE KNEE JOINT The strength of the knee joint depends on The strength of the ligaments that bind the femur to the tibia On the tone of the muscles acting on the joint. The most important muscle group is the quadriceps femoris It is capable of stabilizing the knee in the presence of torn DR FADEL NAIM ligaments. IUG KNEE INJURY AND THE SYNOVIAL MEMBRANE If the articular surfaces, menisci, or ligaments of the joint are damaged, the large synovial cavity becomes distended with fluid. The wide communication between the suprapatellar bursa and the joint cavity results in this structure becoming distended The swelling of the knee extends three or four fingerbreadths above the patella and laterally and medially beneath the aponeuroses of insertion of the vastus lateralis and medialis, DR FADELrespectively. NAIM IUG ARTHROSCOPY Arthroscopy involves the introduction of a lighted instrument into the synovial cavity of the knee joint through a small incision This technique permits the direct visualization of structures, such as the cruciate ligaments and the menisci, for diagnostic purposes. DR FADEL NAIM IUG DR FADEL NAIM IUG LIGAMENTOUS INJURY OF THE KNEE JOINT Four ligaments ligament are commonly injured The The The The medial collateral ligament lateral collateral ligament anterior cruciate ligament posterior cruciate ligament Sprains or tears occur depending on the degree of force applied. DR FADEL NAIM IUG Medial Collateral Ligament Injury Forced abduction of the tibia on the femur can result in partial tearing of the MCL At its femoral or tibial attachments. Tears of the menisci result in localized tenderness on the joint line Sprains of the MCL result in tenderness over the femoral or tibial attachments of the ligament. DR FADEL NAIM IUG Lateral Collateral Ligament Injury Forced adduction of the tibia on the femur can result in injury to the lateral collateral ligament (less common than MCL). DR FADEL NAIM IUG DR FADEL NAIM IUG Injury To The Cruciate Ligaments When excessive force is applied to the knee joint. Tears of the anterior cruciate ligament are common The injury is always accompanied by damage to other knee structures; the collateral ligaments are commonly torn or the capsule may be damaged. The joint cavity quickly fills with blood (hemarthrosis) so that the joint is swollen. Examination of patients with a ruptured anterior cruciate ligament shows that the tibia can be pulled excessively forward on the femur With rupture of the posterior cruciate ligament, the tibia can be made to move excessively backward on the femur DR FADEL NAIM IUG Injury To The Cruciate Ligaments The stability of the knee joint depends largely on the tone of the quadriceps femoris muscle and the integrity of the collateral ligaments Operative repair of isolated torn cruciate ligaments is not always attempted. The knee is immobilized in slight flexion in a cast, Active physiotherapy on the quadriceps femoris muscle is begun at once. If the capsule of the joint and the collateral ligaments is torn, early DR FADEL NAIM operative repair is essential. IUG Arthroscopy Intact ACL DR FADEL NAIM IUG Torn ACL DR FADEL NAIM IUG MENISCAL INJURY OF THE KNEE JOINT Injuries of the menisci are common. The medial meniscus is damaged much more because of its strong attachment to the medial collateral ligament of the knee joint, which restricts its mobility. when the femur is rotated on the tibia, or the tibia is rotated on the femur with the knee joint partially flexed taking the weight of the body The tibia is usually abducted on the femur, and the medial meniscus is pulled into an abnormal position between the femoral and tibial condyles A sudden movement between the condyles results in the meniscus being subjected to a severe grinding force, and it splits along its length "locked Knee” When the torn part of the meniscus becomes wedged between the articular surfaces, further movement is impossible DR FADEL NAIM IUG MENISCAL INJURY OF THE KNEE JOINT Injury to the lateral meniscus is less common probably because it is not attached to the lateral collateral ligament of the knee joint consequently more mobile. The popliteus muscle sends a few of its fibers into the lateral meniscus DR FADEL NAIM IUG these can pull the meniscus into a more favorable position during sudden movements of the knee joint. Types of Mensicus Tear? a) Normal meniscus b) Longitudinal Tear c) Bucket Handle Tear d) Radial Tear e) Degenerative changes DR FADEL NAIM IUG Treatment of Meniscal Tears Suture/ Repair DR FADEL NAIM IUG Debridement
