Bluebox: Joints of lower limb up to knee only

FRACTURES OF FEMORAL NECK Commonly referred to as fractured hips

Risk groups
People <40 years due to contact sports
o Usually result from high-energy impacts, when lower limb is
extended and the force of the impact is transmitted to hip joint,
even if applied at some distance from the joint
o Foot firmly braced against car floor with knee locked
o Knee is braced against dashboard during head-on collision
o Force is transmitted superiorly; femoral fracture results
People >60, especially in women due to brittle bones as a result of
osteoporosis
Characteristics of femoral neck fractures
Often intracapsular
Realignment of neck fragments requires internal skeletal fixation
Problems
o Lower limb laterally rotates
o Blood to head & neck of femur disrupted
Blood to these areas supplied by medial circumflex femoral
artery (retinacular branch)
Torn during dislocation/femoral neck fracture
Vascularisation via artery to the ligament of the femoral head
is left, inadequate for maintaining femoral head
o Lack of blood supply = aseptic vascular necrosis
NECROSIS OF FEMORAL HEAD IN CHILDREN

Traumatic dislocations of hip jointsdisrupts artery to head of femur

Fractures separate superior femoral epiphysisBlood supply to femoral
head disrupted/inadequatepost-traumatic avascular necrosis of
head of femur
Result
o Incongruity of joint surface occurs
o Growth at epiphysis is retarded
Risk groups & symptoms
o Children 3-9 years of age
o Hip pain that radiates to the knee

DISLOCATION OF HIP JOINT

Congenital dislocation of hip joint
Occurs in 1.5 per 1000 neonates, bilateral in ~50% of cases
Girls 8x more affected than boys
25% of arthritis of hip are direct result of residual effects from congenital
dislocation of hip
Cause: Dislocation occurs when femoral head is not properly located in
acetabulum

Symptoms
o Inability to abduct thigh
o Affected limb appears and functions as a shorter than normal limb,
resulting in positive Trendelenburg sign, where hip appears to
drop on one side when walking

Acquired dislocation of hip joint

Uncommon: Articulation is strong and stable
Cause: Occurs during automobile accident when hip is flexed, adducted
and medially rotated
Posterior dislocation of hip joint
Most common
Cause: Head-on collision that causes knee to strike dashboardHip
dislocates when femoral head is forced out of the acetabulum
Result: Joint capsule ruptures inferiorly and posteriorly, allowing femoral
head to pass through the tear in the capsule, and over the posterior
margin of the acetabulum onto the lateral surface of the ilium
Symptom: Limb is shortened and medially rotated
Injury to sciatic nerve
Sciatic nerve is closely related to hip joint
Sciatic nerve injury is common during posterior dislocations or fracturedislocations of the hip joint
Result:
o Paralysis of hamstrings & muscles distal to knee supplied by sciatic
nerve
o Sensory changes in skin over posterolateral aspects of leg & much
over the foot due to injury of sensory branches of sciatic nerve
Anterior dislocation of hip joint
Cause: Violent injury that forces hip into extension, abduction and lateral
rotation (catching ski tip during skiing)
Result: Femoral head is inferior to acetabulum
Complication: Acetabular margin fractures, producing fracturedislocation of hip joint
When femoral head dislocates, acetabular bone fragment and acetabular
labarum follows it
These injuries also occur with posterior dislocations
PATELLAR DISLOCATIONS
Nearly always dislocates laterally
More common in women because of their greater Q-angle
Q-angle + oblique placement of femur relative to tibia represents the pull
of quadriceps relative to the axis of the patella and tibia
Tendency toward lateral dislocation is normally counterbalanced by the
medial, more horizontal pull of the vastus medialis
Anterior project of the lateral femoral condyle and deeper slope for the
larger lateral patellar facet provide a mechanical deterrent to lateral
dislocation

Imbalance of the lateral pull and mechanisms resisting it result in

abnormal tracking of patella within patellar groove and chronic patellar
pain, even if actual dislocation doesnt occur

PATELLOFEMORAL SYNDROME Pain deep to patella

Cause:
o Excessive running, especially downhill (runners knee)
o Direct blow to patella
o Osteoarthritis of patellofemoral compartment (degenerative wear
and tear of articular cartilages)
Physiology: repetitive microtrauma cased by abnormal tracking of
patella relative to patellar surface of the femur
Cure: Strengthening of vastus medialis to correct patellofemoral
dysfunction
o V.medialis prevents lateral dislocation of the patella resulting from
Q-angle this muscle attaches to and pulls on the medial border of
patella
o Weakness of vastus medialis predisposes individual to
patellofemoral dysfunction and patellar dislocation
KNEE JOINT INJURIES Bloody long section
Introduction
Common as knee is low-placed, mobile and weight-bearing
Stability depends only on associated ligaments & surrounding muscles
Essential for everyday activities and sports: Mobility = chance of injury
Ligament sprain (Unhappy triad TCL, ACL, medial meniscus)
Common sports injury
Occurs when foot is fixed in the ground & force is applied against the
knee
TCL and FCL, which are tightly stretched when leg is extended prevents
disruption of the sides of the knee joint
Firm attachment of TCL to medial meniscus can result in tearing of medial
meniscus when TCL is torn
o Caused by blow to lateral side of external knee disrupts TCL and
concomitantly tears/detaches medial meniscus from joint capsule
Common in athletes who twist their flexed knees while running
ACL, which serves as a pivot for rotatory movements of knee, are taut
during flexion, may tear subsequent to the rupture of TCLUnhappy
triad
ACL Rupture
Cause: Hyperextension and severe force directed anteriorly against the
femur with knee semi-flexed football, skiing accidents
Result: ACL injury causes free tibia to slide anteriorly under the fixed
femur (Anterior drawer design) tested clinically via Lachman test
ACL tears away from femur or tibia; however tears commonly occur in the
midportion of the ligament

PCL rupture
Occurs when a player lands on the tibial tuberosity with the knee flexed
o Knocked to floor with basketball
o Head-on collisions when seat belts are not worn and proximal end
of tibia strikes dashboard
PCL ruptures usually occur in conjunction with tibial or fibular ligament
tears
PCL ruptures allow free tibia to slide posteriorly under fixed femur
posterior drawer sign
Meniscal tears
Usually involve medial meniscus
Lateral meniscus rarely tears due to its mobility
Symptom: Pain on lateral rotation of the tibia on the femur
**Occurs in conjunction with TCL and/or ACL tears
Healing
o Peripheral meniscal tears: Can be repaired/healed on their own due
to generous blood supply to the area
Meniscus removal (Arthroscopic surgery)
o Done if meniscal tear cannot be repaired/heal on its own
o Knee joints where a meniscus has been removed suffer no loss of
mobility. However, knee will be less stable and tibial plateaus often
undergo inflammatory reactions
BURSITIS IN KNEE REGION
Prepatellar bursitis & housemaids knee
Cause: Friction between skin and patella
Bursa can also be injured by compressive forces resulting from direct
blow, or from falling on flexed knee
Housemaids knee
o If inflammation is chronic, the bursa becomes distended with fluid,
forming a swelling anterior to the knee
o At risk: People who work on knees without knee pads Hardwood
floor/rug installers at risk of prepatellar bursitis
Subcutaneous infrapatellar bursitis/clergymans knee
Cause: Excessive friction between skin and tibial tuberosity
Symptom: Swelling (oedema) [frequent genuflecting]
Occurs in roofers and floor tilers if they do not wear knee pads
Deep infrapatellar bursitis
Result: Oedema between patellar ligament and tibia, superior to tibial
tuberosity
Cause: Overuse and subsequent friction between the patellar tendon
and the structures posterior to it (infrapatellar fat bad and tibia)
Enlargement of deep infrapatellar bursa obliterates the dimples normally
occurring on each side of the patellar ligament when leg is extended
Supra-patellar bursitis

Cause: Infection caused by bacteria entering the suprapatellar bursa

from torn skin
Complication: Infection my spread to cavity of knee joint, causing
localised redness and enlarged popliteal and inguinal lymph nodes
BIPEDALISM AND CONGRUITY OF ARTICULAR SURFACES OF HIP JOINT
Acetabulum is directed inferiorly, laterally and anteriorly in humans
Weight-bearing iliac portion of acetabular rip overlies femoral head
transfers weight to femur in erect position
Hip joint
o Mechanically most stable when a person is bearing weight
o Decreases in degree to which ilium overlies the femoral head may
indicate joint instability

Because of anterior direction the axis of acetabulum and posterior

direction of axis of femoral head and neck as it extends laterally, there is
an angle of 30-40 degrees between their axes
Consequently, articular surfaces of head and acetabulum are not fully
congruent in erect position
o Anterior part of femoral head is exposed, articulating mostly with
the joint capsule.
o Rarely is >40% of available articular surface of the femoral head in
contact with surface of acetabulum in any position
Relative to other joints and in view of large size of hip joint, extensive
contact contributes considerably to joints stability

SURGICAL HIP REPLACEMENT

Hip joint is subjected to severe traumatic injury & degenerative disease
o Osteoarthritis of hip joint
Pain, oedema, limitation of motion & erosion of articular
cartilage are common causes of disability
Procedure
o Metal prosthesis anchored to the persons femur by bone cement
replaces femoral head & neck.
o Plastic socket cemented to hip bone replaces acetabulum
GENU VALGUM AND GENU VARUM
Q-angle
o Tibia is vertical while femur is diagonal
o Angle between femur and tibia = Q-angle
o Greater in females than males due to wider pelves
Medial angulation Genu varum: Bowleg
o Femur is abnormally vertical, Q-angle is small
o Causes unequal weight bearing
o Line of weight bearing falls medial to center of knee
o Excess pressure placed on medial aspect of knee joint results in
destruction of knee cartilages known as arthrosis
o Fibular collateral ligament is also overstressed
Lateral angulation Genu valgum: Knock-knee
o Exaggerated knee angle Weight bearing line falls lateral to the
center of the knee

o As a result, tibial collateral ligament is overstretched and excess

stress is placed on lateral meniscus and cartilages of the lateral
femoral and tibial condyles
o Patella, normally pulled laterally by vastus lateralis, is pulled even
farther laterally when leg is extended in presence of genu valgum
Consequently, articulation of femur becomes abnormal
Epidemiology
o Genu varum appear in kids 1-2 years after starting to walk
o Genu valgum appears in kids 2-4 years of age
o Persistence in abnormal knee angles in late childhood means
congenital deformities exist that may require correction
o Irregularity of joint leads to wear and tear (arthrosis) of articular
cartilages and degenerative joint changes (osteoarthritis)

ARTHROSCOPY OF KNEE JOINT

Definition: Endoscopic examination that allows visualisation of interior of knee
joint cavity with minimal tissue disruption
Arthroscope and one or more additional cannulae are inserted through
tiny incisions (portals)
Second cannula is for passage of specialised tools or equipment for
trimming, shaving or removing damaged tissue
Used for:
o Removal of torn menisci
o Loos bodies in joint (bone chips)
o Debridement (excision of devitalised articular cartilaginous
material) in advanced cases of arthritis
o Ligament repair/replacement
Additional
o General anaesthesia is usually used, though local/regional
anaesthesia can also be used for knee arthroscopy
o During arthroscopy, articular cavity of knee must be treated as two
separate femorotibial articulations, owing to the imposition of
synovial fold around cruciate ligaments
ASPIRATION OF KNEE JOINT
Fractures of distal end of femur/lacerations of anterior thigh may involve
suprapatellar bursa, resulting in infection of the knee joint
During inflammation/infection, synovial fluid volume increases
Joint effusions
o Definition: Escape of fluid from blood/lymphatic vessels, resulting in
increased amounts of fluid in joint cavity
o Because suprapatellar bursa communicates freely with synovial
cavity of knee joint, fullness of thigh in region of suprapatellar
bursa may indicate increased synovial fluid
Solution
o Aspiration of bursa, approaching laterally, using 3 bony points to
insert needles.
o Area is also used for drug injections for treating pathology of the
knee joint
POPLITEAL CYST/baker cyst

Definition: Abnormal fluid-filled sacs of synovial membrane in region of

popliteal fossa
Cause of cyst
o Herniation of gastrocnemius or semimembranosus bursa through
the fibrous layer of the joint capsule into popliteal fossa,
communicating with the synovial cavity of the knee joint by a
narrow stalk
o Complication of chronic knee joint effusion
o Synovial fluid escape from knee joint/bursa around knee, collecting
in popliteal fossa, forming a new synovial-lined sac, a popliteal cyst.
Epidemiology
o Common in children but seldom cause symptoms
o Adult: Popliteal cysts can be large, extending as far as mid-calf and
interfering with knee movements
KNEE REPLACEMENT
Use of artificial knee joint to replace diseased knee resulting from
osteoarthritis
Joint consists of plastic and metal components that are cemented to
femoral and tibial bone ends after removal of defective areas
Combination of metal+plastic to mimic smoothness of cartilage
Problem: can break down in high sports activity, components may loosen.