Orthopedics

The Knee

Symptoms of Knee Injuries

Pain - this is the most common symptom with which patients will present. The pain may be
localised, which is more suggestive of a mechanical dysfunction or, generalised pain which
may suggest an inflammatory or degenerative condition.

Swelling - this symptom may also be localised or generalised. It may also be acute or
chronic. Acute sudden swelling may indicate a local synovitis, a haemarthrosis or pyogenic
arthritis amongst it’s causes. Chronic swelling may indicate inflammatory conditions such as
R.A. or degenerative conditions such as O.A.

Stiffness - Patient may present with a degree of stiffness in the knee. This should not be
mistaken for true locking of the knee joint even though the patient may describe it as such.
Stiffness may cause some limitation in the range of movement of the joint. Stiffness may be
due to local fluid accumulation, muscle hypertonicity or derangement of the joint as in O.A.

Locking - Careful attention should be given to a patient complaining of locking of the knee.
It must be distinguished from simple stiffness in the joint. True locking occurs when the knee
is fixed in semi-flexion and the patient is unable to extend the knee fully. True locking is
almost always due to a loose body becoming trapped between the joint surfaces.

Alteration of the Gait - Patients with knee injuries may exhibit some changes in their gait.
Often most noticeable is a limp. Patients may change their gait to avoid pain (antalgic gait),
or due to a reduced range of movement or mechanical derangement of the joint. Remember
that alteration of the gait may not necessarily be related to the knee itself but could be a result
of foot, hip or low back dysfunction.

Giving Way - Sudden and unexpected collapse of the knee is most commonly due to
mechanical abnormalities of the knee such as ligament ruptures, meniscal tears or an unstable
patella. In some cases, it may be due to local muscle weakness.

Deformity - Most commonly in acute injuries the knee will be held, usually by muscle
spasm, in a degree of flexion. This is often apparent in acute ligamentous or meniscal
injuries. Degenerative conditions such as O.A. may also produce a flexion deformity and this
may be accompanied by a varus deformity. A valgus deformity of the knee is more common
in R.A.

Bony Injuries
Fractures of the Patella

The Patella can be quite easily fractured by a direct blow to a flexed knee. One of the main
causes of Patella fractures is car accidents. In some cases, forced, passive flexion of the knee
whilst the Quadriceps are contracted may produce a transverse fracture across the Patella.
Those fractures caused by direct blows tend to be either transverse fractures with little
displacement or comminuted 'stellate' fractures.

The knee will be painful and is often swollen. In some cases, a gap may be palpable between
the fracture fragments. Blood will be present in the joint in the majority of Patella fractures.
Active extension ability should be assessed as this will often influence the management plan.

Confirmation of the patella fracture requires radiological investigation and the three type of
fracture will be easily distinguished.

Treatment is dependent upon the type of fracture and the integrity of the extensor mechanism.
If the fracture is undisplaced and the extensor mechanism is intact, then the treatment will be
quite conservative. The knee will be immobilised with a plaster of Paris cast for a period of
between 4-6 weeks whilst the patient is encouraged to isometric Quadriceps exercise daily.

For a comminuted 'stellate' fracture, there are two choices of treatment. They depend upon
the degree of displacement of the fragments. If there is only minimal displacement, then the
Patella may be preserved and treatment would depend upon the application of a backslab to
immobilise the knee joint. This would be removed on a daily basis to allow the patient to
exercise the knee. It is hoped that the daily exercise will allow the fragments to position
themselves in such a way as to restore as much normality to the patello-femoral joint surfaces
as possible, thereby limiting later osteoarthritic changes. Some schools of thought advocate
the complete removal of the patella if a comminuted fracture has occurred, no matter how
limited the displacement. This is to limit the disruption to the Patello-femoral joint and limit
any degenerative changes.

If a transverse fracture has resulted in displacement of the fragments and subsequent

disruption of the extensor mechanism, then surgical intervention is the only viable solution.
The fragments are fixed internally using Kirschner wires and the rupture to the extensor
muscles is repaired. A plaster of Paris backslab is used to immobilise the knee although this
is removed on a daily basis to allow the patient to flex and extend the knee.

Tibial Plateau Fractures

These fractures almost always occur in adults and are more common in those with
osteoporosis. Many of these fractures are the results of pedestrians being hit be cars at the
level of the bumper.
They may also result from falling onto the knee from a height with the knee being forced into
a varus or valgus strain. In the majority of cases, the lateral tibial plateau is affected, less so
the medial plateau and in very rare cases both may become fractured.
The patient will be in pain and the knee will often be swollen and hot due to haemarthrosis. It
will be painful on palpation of the fracture site and may also be painful on the opposite side if
there is ligament injury on that side.

Diagnosis is confirmed on X-ray and may reveal one of three types of fracture:
» Fragmentation of the lateral plateau.
» Compression of the part of the plateau.
» Fracture and displacement of a single large piece of tibial plateau.

The most important aspect to treatment of tibial plateau fractures is to restore as much
function to the affected knee as possible. It is not always necessary to try to achieve a perfect
X-ray. Treatment is dependent upon the type of fracture and the degree of displacement of the
fragments. The basis of treatment is to reduce displaced fragment where necessary either
externally or internally and then apply sustained traction to the Tibia for approximately 6
weeks. This will usually result in fairly good function in the knee although some deformity
may exist. It is often unwise to try to surgically correct minor deformity as this may produce a
good looking knee with reduced or minimal function.

Complications of Tibial plateau fractures may include:

» Compartment syndrome.
» Valgus deformity
» Joint stiffness

Femoral Condyle Fractures

Fractrures can occur that will separate the femoral condyles away from the main shaft of the
femur. If one condyle is fractured, it usually follows an oblique line. In some cases, both
condyles can become separated by a Y-shaped farcture. Any disruption to the femoral
condyles can have a dramatic affect upon the function of the patello-femoral joint and hence a
sunsequent affect upon the knee itself. Treatment therefore aims to reduce any displacement
as accurately as possible to try to ensure as near normal function of the knee as possible.

Undisplaced fractures can be treated simply by aspiration of th joint to remove the blood
folowed by immobilisation under sustained traction for approximately four weeks or until
union is sufficient to be safely immobilised in a cast.

Displaced fractures must be reduced which usually occurs via surgery and subsequent internal
fixation. Complications can occur as a result of condylar fractures. These may include
avascular necrosis of the fragments with subsequent collapse and gross deformity. Malunion
of the fragments will cause a varus or valgus deformity and will cause secondary
degeneration.

Fractures of the Fibula Shaft

The fibula can be fractured in one of three ways. Direct trauma to the outer side of the lower
leg, twisting injuries or repetitive stress . In some cases, twisting injuries may produce a
spiral fracture of the Fibula shaft with an associated fracture of the lower pole of the Tibia.
This combination is called a Maisonneuve fracture. This type of fracture responds poorly to
conservative treatment.

Examination may reveal local bruising together with tenderness over the fracture site.
Dorsiflexion of the ankle may also exacerbate the symptoms. If the fracture occurs in
isolation the patient should be able to weight bear but will avoid the heel strike phase of gait.

If the Tibia is intact and tha patient is able to weight bear then no immobilisation is required.
However, if movement is accompanied by pain that a POP cast which immobilises the ankle
may be necessary. Stress fractures require a period of immobilisation.

Fracture of the Tibial Shaft

In some cases, the Tibia can be fractured whilst leaving the Fibula intact. This can occur in
three ways:
i) direct trauma to the lower leg
ii) rarely through twisting injuries
iii) Repetitive stress.

Treatment can often be hindered by the intact Fibula as it may hold the two ends of the
fracture away from eachother thereby impairing union. In some cases, the Fibula may need to
be cut. Otherwise, treatment is exactly the same as for simultaneous fracture of both Tibia
and Fibula.

Fractures of both Tibia and Fibula

Simultaneous fractures of the Tibia and Fibula are common injuries. They are often sustained
as the result of RTA's or sports injuries. In some cases, these fractures become open fractures
as one or more of the fragment pierce the overlying skin. In these cases, the area should be
covered as rapidly as possible with the cleanest material available. The leg should be
immobilised for the journey to hospital. Diagnosis and the direction of any displacement is
achieved through X-ray.

The fractures should be reduced and immobilised for between 10 & 16 weeks. The area can
be immobilised with either a POP cast, internal fixation or external fixation. The choice of
immobilisation depends upon whether the area is stable, unstable or contaminated.

If the area is stable the fracture can be immobilised with a POP cast from groin to ankle. If
unstable then internal fixation is indicated. If unstable and contaminated then external
fixation is indicated.

Complications may occur as a result of these injuries and may include:

i) Non-union
ii) Delayed union
iii) Mal-union
iv) Vascular damage - possibly leading to gangrene
v) Soft tissue damage
vi) Skin loss
vii) Compartment Syndrome
 Joint Abnormalities

Dislocation of the Patella

Dislocations of the patella tend to occur when the knee is slightly flexed but the Quadriceps
are relaxed. It is dislocated by direct trauma, often a twisting trauma, that dislocates the
Patella laterally. It most commonly occurs in teenagers, particularly girls with a degree of
ligamentous laxity. The patella may rest on the ridge of the femoral condyle before either
reducing spontaneously into it's correct alignment or moving laterally to a position on the
lateral aspect of the leg. The anterior surface of the Patella will be facing laterally.

The patient will usually fall to the ground as the knee collapses. There is obvious deformity
as the medial femoral condyle becomes uncovered and unusually prominent. The Patella can
be felt on the lateral aspect of the leg. The joint may be swollen due to haemarthrosis and the
medial side of the patella will be painful due to rupture of the medial soft tissues. X-ray will
confirm the dislocation if necessary.

Treatment requires the reduction of the Patella, if this has not happened spontaneously, and
aspiration of the joint if haemarthrosis is present. If there is no evidence of a haemarthrosis
then the Patella may be reduced without anaesthetic. However, if the joint is swollen this is
best aspirated arthroscopically. If the knee is bruised, this may indicate rupture of the
Quadriceps and this should be surgically repaired in order to limit the possibility of future
dislocations.

If the joint requires surgical reduction and aspiration then the joint should be immobilised for
a period of about 4 weeks in order for the medial sift tissues to heal and stabilise the knee.
Physical therapy should be introduced as soon as possible to mobilise the knee and strengthen
the Quadriceps muscle which is essential for knee stability

Recurrent Dislocation of the Patella

This injury most commonly occurs as the result of a traumatic dislocation of the Patella. It
may be predisposed by other factors such as:
» Ligamentous laxity
» Abnormalities of the Patella or Lateral Femoral Condyle
» Valgus deformity of the knee.

Recurrent dislocations are more common in teenagers, particularly teenage girls rather than in
boys. This is because girls tend to have looser ligaments and smaller bones. The dislocation
may be bilateral in some cases. The knee tends to dislocate with minimal trauma. If it
usually associated with contraction of the Quadriceps with the knee flexed.
The Patella dislocated laterally and the patient experiences acute pain. The knee may collapse
and the patient may fall. Between dislocations, the patella may be positioned too high and
often the knees are hyperextended.
Treatment usually relies upon surgical stabilisation of the knee although this is only
considered if the knee has dislocated on three or more occasions and if the patient has stopped
growing. The Patella can be stabilised in several ways:
» Re-aligning the Quadriceps muscle by moving the Tibial tuberosity medially.
» Moving the Tibial tuberosity distally to pull the Patella lower down into the Patella groove.
» Detaching the lateral structures of the Patella.
» Tightening the medial structures of the Patella.

The choice of treatment is dependent upon the abnormality the surgeon is trying to correct. If
the knee is anatomically intact, a release of the lateral structures is often sufficient.

Dislocation of the Knee

In order to dislocate the knee, the cruciate ligaments and at least one of the collateral
ligaments has to be ruptured. This takes considerable force and such trauma will often
damage the local arteries and nerves. The patient will be in acute pain with severe swelling
and bruising and gross deformity will be apparent. Accurate assessment of the vascular and
neurological supply to the lower leg and foot should be carried out and monitored in order to
note any deterioration. X-ray may reveal fractures of the tibia and/or fibula. If arterial
damage is apparent then an arteriogram is indicated in order to assess the extent and nature of
the damage.

Treatment involves rapid reduction of the dislocation under anaesthetic. If this cannot be
achieved externally than open reduction is indicated. Damage of the nerves and /or vessels
requires immediate repair. Once reduced, then knee should be immobilised for a period of
between 6 and 12 weeks in a plaster of Paris cast. During this time, the patient is encouraged
to perform static Quadriceps exercises.

Ligament Injuries

The knee has very little intrinsic stability from the articular surfaces of the joint, it also has
little support from local muscle and tendons. It is therefore heavily reliant upon ligaments to
stabilise the joint and prevent excessive movement. Most ligament injuries are related to
trauma and often rotational or angulation trauma. Ligaments do not heal properly once they
have been injured unlike most other tissues and therefore they have potentially more serious
long-term effects than other injuries, even fractures. Knee ligaments tend to become injured
on a layered basis, dependent upon the degree of trauma.
Initially, the superficial capsular ligaments become injured, followed by the collateral
ligaments and then the cruciate ligaments. Most often, the medial ligaments are injured due
to a valgus and rotational injury.

Anterior Cruciate Rupture

These ligaments tend to be ruptured as a result of sporting injuries. They occur due to either a
forcible rotation injury or the upper part of the Tibia being pushed forcibly forwards. These
are relatively common injuries and are responsible for approximately 70% of all
haemarthroses. Often associated with this type of injury is rupture of the medial collateral
ligament or tearing of the medial meniscus. In the majority of cases, the patient believes that
they have fractured their leg as the rupture occurs with an audible snapping noise that can be
heard by both the patient and those nearby. In the initial minutes after the incident, it is easy
to assess the instability caused by the rupture. However, after approximately 15-30 minutes
the swelling and muscle spasm is too severe to accurately assess the knee.

The outcome of this injury is by no means predictable, patient tend to fall into one of three
categories:
» Some patients (approximately one third) will require very little treatment and the ligament
heals sufficiently without surgical intervention to allow the patient to return to normal life,
including playing sport.
» A further third of patients will continue to exhibit a degree of instability to a lesser or
greater degree. These patients are usually able to lead a fairly normal life although they do
usually have to give up sporting activities. Some patients in this category will elect for
reconstructive surgery to allow them to return to sports etc.
» In the most severe cases, a third of patient will exhibit persistent instability of the knee to
such an extent that the knee will give way even when the patient is walking over flat ground.
obviously, this makes the patient very hesitant of using the knee. These patients require
reconstructive surgery of the anterior cruciate ligament.

Conservative treatment of rupture of the anterior cruciate ligament involves arthroscopic

drainage of the knee to reduce the haemarthrosis. It also allows the surgeon to assess the
degree of damage to the anterior cruciate ligament. In most cases, where diagnosis is certain,
the knee does not have to be immobilised and physical therapy should be used to strengthen
the local muscle groups. It is most important to strengthen the Hamstring muscles as these
will prevent excessive anterior movement of the knee.

Surgical treatment involves the replacement of the anterior cruciate ligament. Repair of the
existing ligament is usually ineffective and has largely been abandoned as a form of
treatment. Reconstruction of the ligament is complex and requires a considerable amount of
rehabilitation. It involves reconstruction of the anterior ligament using the medial third of the
patella tendon and reconstruction of the extra-articular structures using the ilio-tibial tract.
The results are usually good in approximately 80% of patients.

Differences between anterior cruciate ligament injuries and meniscal injuries include:
» Cruciate injuries are caused by high speed twisting injuries with the knee almost
completely extended, whereas meniscal injuries are caused by low speed injuries with
the knee flexed.
» Ligament injuries usually follow a memorable injury whereas meniscal injuries often
do not.
» Anterior ligament injuries will cause the knee to collapse whereas meniscal injuries
cause it to lock in extension.

Posterior Cruciate Rupture

The posterior cruciate ligament is ruptured by either a direct blow to the upper end of the tibia
when the knee is flexed or by a hyperextension injury to the knee. The injury will cause an
observable posterior displacement of the tibia in relation to the femur and the knee will be
swollen due to a haemarthrosis.
Similar to anterior cruciate ruptures, the prognosis of each patient is almost impossible to
assess at the time of injury. However, in the majority of cases patient will respond very well
with only minimal treatment and can return to normal life, including sporting activities. In a
few cases, the knee will exhibit persistent instability that may require surgical intervention in
order to stabilise it.

Conservative treatment involves aspiration of the joint in order to remove the blood followed
by vigorous physical therapy to strengthen the Quadriceps muscle. This should be continued
until the Quadriceps on the affected side is larger than that of the un-affected side. The
Quadriceps is then used to prevent excessive posterior movement of the Tibia.

Surgical treatment should only be considered if the posterior cruciate ligament has become
avulsed from it's attachment with a piece of bone still attached to it. Surgical repair is not
usually beneficial if the ligament has ruptured along it's course. In these cases, the patient
should be treated conservatively as most patients can manage without a P.C.L

Lateral Collateral Ligament Rupture

As with most other ligament injuries, this is traumatically induced. In most cases, the
ligament is injured in association with other local structures. The lateral collateral ligament
attaches the femur to the fibula and is therefore not considered as important as other ligaments
when considering the stability of the knee.

The patient will tend to present with pain around the lateral aspect of the knee. The area may
exhibit local effusion. The injury is usually associated with a specific trauma, normally
causing a varus strain through the knee. The knee will exhibit varying degrees of instability.

Treatment involves immobilisation of the affected knee in a thigh to ankle plaster cast for up
to 6 weeks. After this time, the knee should be mobilised. In the majority of cases, patients
do well and the area becomes rapidly assymptomatic. In a few cases, a patient may exhibit
intermittent instability which is usually symptomatic. If this does occur, there is little
effective treatment.

Medial Collateral Ligament Rupture

More often than not, these injuries are associated with a rupture of the anterior cruciate
ligament. In rare cases, they occur isolation as the result of a forceful, pure valgus strain.
These isolated injuries usually require little treatment and can heal sufficiently without
surgical intervention.
With this type of injury, it is often wise to immobilise the knee with a plaster cast from thigh
to ankle and to limit weightbearing until healing has occurred (approximately 6 weeks). If the
injury is associated with an anterior cruciate rupture then the surgeon may elect to repair the
medial collateral ligament surgically if the A.C.L. is to be repaired in this way.

Sprained Ligaments

Ligament sprains are far more common injuries than complete ruptures. All ligaments can
become strained, usually as the result of a rotational or angulation injury. In these cases, only
a few of the ligament fibres become torn and although painful the joint remains stable. On
examination, the area overlying the injured ligament is painful and there may some local
effusion. In severe sprains, provocation tests may exacerbate the pain. In some cases, it is
useful to strap the area in order to give the ligament a degree of support whilst it is healing
and to help prevent any further injury to it. The application of local ice packs will also help in
the acute stage. Once the acute pain has eased, alternating hot and cold therapy may help to
accelerate the healing process. As soon as is possible, the patient should be encouraged to
exercise the area to strengthen the local muscles. Ligament sprains will often take a long time
to heal due to their poor direct blood supply and the fact that they are often re-injured during
the healing process.

Meniscal Injuries

The menisci act as shock and load absorbers in the knee. They convert the downward force of
the femoral condyles into lateral force, thereby limiting the impact upon the Tibia. They have
the ability to reduce the force through the tibia by up to 500%. Meniscal lesions are the most
common disorder to affect the intrinsic knee joint. It is often thought that the trauma required
to cause these injuries is severe, however, in reality the force can be so minimal that the
patient does not remember the exact incident. The menisci are similar in structure to
ligaments although their ground matrix is slightly stiffer. They are similar in shape to
horseshoes and wrap around the Tibial condyles.

Tears of the menisci are most common in young adults and are often the result of sporting
injuries. They are particularly associated with rotational injuries although as previously
mentioned in some many cases the patient is unaware of the exact causative factor. Menisci
can become torn in a variety of ways (see diagrams), but tend to give similar clinical features.
The meniscus is avascular and so spontaneous repair does not occur unless the periphery of
the meniscus is the part that becomes damaged. The fragmented part of the meniscus will
cause irritation of the synovium giving local inflammation and pain.

Initially the knee may become painful and in some cases the pain is severe. Occasionally the
knee will become 'locked' in semi-flexion and active extension is impossible. The knee will
swell although it may take up to 12-24 hours for the effusion to become apparent.
The symptoms will often improve with rest and a course of NSAID's but return after a minor
traumatic incident, particularly another twisting injury. The medial meniscus is injured more
commonly than the lateral one. The pain associated with a medial meniscal tear tends to be
localised to the joint margin whilst that associated with a lateral meniscal tear is more diffuse.
The exacerbations of the knee pain may be accompanied by the knee giving way or more
commonly becoming locked. Locking is most synonymous with a bucket handle tear.
Examination will often reveal a slightly limited range of extension and the knee is held in
slight flexion. There maybe tenderness around the medial joint margin or the lateral aspect of
the knee depending upon which meniscus has been damaged. A local effusion may also be
apparent. Between exacerbations there are few, if any, symptoms. The history of the injury
and any subsequent exacerbations maybe helpful in diagnosing the condition. Occasionally,
McMurray's test an the Apley grinding test will elicit pain. Confirmation of the diagnosis can
be achieved most easily with an MRI scan or arthroscopic investigation. Diagnosis using the
clinical features only is accurate in only 70% of cases.
It is important that the diagnosis is an accurate one due to the importance of the menisci and
the essential role they play in the distribution of weight through the Tibia. They should not be
disturbed until diagnosis has been confirmed.

If a tear of the meniscus is diagnosed, the torn fragment should be excised leaving as much of
the meniscus intact as possible. This should be performed arthroscopically. The patient
should then be able to return to light work after only one week and heavy work in two. Open
meniscectomy can be used to the same ends although the rehabilitation process is much
longer, up to 3 months. The only indication for this type of surgery is if the surgeon is unable
to perform arthroscopic meniscectomy. Meniscal injuries and the operative treatment
required to repair them predisposes the patient to early degeneration of the knee.

Muscle Injuries

Rupture of Rectus Femoris

This injury occurs as the result of a sudden and violent contraction of the Quadriceps muscle.
The patient is aware of sudeen pain and a defect can be felt in the muscle. There is no
effective treatment except the application of an ice pack, elevation and analgesics.
Mobilisation should be encouraged within the limits of comfort. The defect will remain but
the functional loss is minimal.

Ruptured Quadriceps Tendon

The same forces described for a rupture of the Rectus muscle causes rupture of the
Quadriceps tendon. The patient will feel sudden severe pain together with a defect in the
muscle. The rupture occurs above the patella and the tendon will displace proximally. The
patient will also notice a loss of extension of the knee. This injury must be repaired surgically
or the defect will widen and the power of the Quadriceps will be lost.

Bursitis of the Knee

Bursae are located where moving structures (i.e. skin, tendons) are in close approximation
with other structures, usually bone. They are particularly common where the course of a
tendon becomes tortuous i.e. around a bone or under retinaculae. Some bursae, particularly
those around the knee or elbow are said to be subcutaneous and occur where skin moves
freely over subcutaneous bone. In such cases, the bursae are little more than sacs of synovial
membrane with a thin film of fluid between them.
These sacs are surrounded by a dense layer of collagenous tissue, the whole structure being
supported by loose areolar tissue. Subcutaneous bursae are tethered internally to the
periosteum of the underlying bone and the dermis of the overlying skin. There function is to
provide total freedom of movement between the two tissues over a limited range of
movement. It is also thought that they exist to provide a means of limiting friction between
the two surfaces.

Other types of tendon lie between tendons and bones, tendon and ligaments or between two
tendons, these are said to be subtendinous bursae. Submuscular bursae are those that lie
between a muscle and a tendon, bone or ligament.
There are several different reason why bursae can become symptomatic, they can include:
» Acute Trauma
» Chronic Trauma
» Acute Infection
» Chronic Infection
» Arthritis (Osteo-, Rheumatoid and Crystal (Gout) Arthritis)
» Neoplasms
» Calcium Deposition.

When bursae become symptomatic for which ever reason, they tend to exhibit similar
symptoms although the site and severity varies in each case. The classic symptoms associated
with irritation of the bursae include swelling and pain. Some causes of irritation such as acute
infection or Gout may cause local heat, erythema and muscle spasm to occur simultaneously.

Pre-Patellar Bursitis

This condition tends to occur as the result of either repetitive friction or a local infection. Due
to it's site on the anterior surface of the patella, it is prone to infections following local
laceration. Bursitis due to repetitive frictional irritation (Housemaid's knee) is common in
carpet fitters, tilers, roofers and miners. It results from fluid accumulation within the
pre-patellar bursa and present with a characteristic swelling over the patella with or without
associated pain. In such cases, avoidance of the causative factor can be sufficient to reduce
the symptoms. If the symptoms persist, aspiration may be needed and a local injection of
cortisone. People with occupations likely to cause irritation should use protective knee pads.

Infective pre-patellar bursitis will present with local swelling, pain, erythema, heat and
possibly a dysfunctional joint (due to pain only). Treatment should include aspiration and
antibiotics.

Infra-Patellar Bursitis

This condition is almost always due to repetitive friction and may be referred to as
Clergyman's knee. This is possibly due to the fact that Clergymen tend to kneel more upright
when praying thereby applying more force to the infra-patellar bursa then perhaps a
housemaid or carpet fitter would. Symptoms tend to be very similar to those associated with
pre-patellar bursitis although the area of swelling tend to occur inferior to the patella.
Treatment is as for pre-patellar bursitis.

Semimembranosus Bursitis

This sub-muscular bursa separates the semimembranosus tendon and the medial head of
gastrocnemius. In some cases, it may become enlarged and present as a painless lump behind
the knee, in the medial aspect of the popliteal fossa. In most cases, it is assymptomatic and
requires no treatment. Rarely, the bursa may become painful and if not relieved with simple
analgesics or NSAID's then excision of the bursa is indicated.

Pes Anserine Bursa

A sub-tendinous bursa that separates Gracilis, Satorius and Semimembranosus from the
upper, medial border of the Tibia. It is occasionally the site of repetitive microtrauma
resulting in local swelling of the Pes anserine bursa and associated pain. The bursa can be
distinguished on palpation and is tender.

Treatment should be conservative initially with rest, ice and NSAID's. If the symptoms
persist then a local injection of cortisone should be administered. If symptoms continue to
persist than underlying pathology should be suspected.

Loose Bodies

Loose bodies are quite a common occurrence in the knee joint. They can result from
Osteochondritis dissecans, synovial chondromatosis or fragmentation of the articular
cartilage. They tend to 'float' around in the knee and can restrict joint mobility. X-rays may
be helpful in identifying loose bodies although approximately one quarter will be
radio-luscent.

Osteochondritis Dissecans

This condition involves the medial femoral condyle and causes a fragment of bone to dissect
out from the main condyle. It tends to occur in children between 8 and 12 years and is 6 times
more common in boys than in girls. The pathology underlying this condition is thought to be
similar to that associated with Osteochondritis dissecans of the elbow. The patient will
present with pain which is made worse when walking and on hyperextension of the knee.
Examination may elicit pain on palpation of the antero-medial joint margin and on
hyperextension of the knee. During the early stages of the condition, radiological
investigation will often reveal no abnormality. Later in it's course, a loose body may be
visible in the joint space.
Once the bony fragment has entered the joint space, the knee has a tendency to lock. Once
confirmed on X-ray, surgical removal of the fragment via an arthroscope is usually the
treatment of choice. The space left in the femoral condyle quickly becomes filled with fibrous
tissue. Once the fragment has been removed, the patient should be able to use the knee
normally, however the patient is predisposed to early osteoarthritic degeneration both due to
the condition and the trauma associated with the arthroscopic removal of the fragment.

Anterior Knee Pain in Teenagers

Anterior knee pain is a common complaint in teenagers, particularly teenage girls. Often
there is little physically wrong with the knee and clinical examination will reveal few signs.
In some instances, the patella and patello-femoral joint will be palpably tender. The pain can
often be quite severe and will limit the patients ability to do sport and in extreme cases will
limit their ability to walk. In many patients, no specific cause can be isolated. One
explanation is that the pain is associated with the adolescent growth spurt. Both the increase
weight bearing due to increased bone and muscle growth and the lengthening of the lower
limbs bones which increases the forces of leverage upon the knee could explain why the pain
occurs.
Investigation should be kept to a minimum and arthroscopic investigation actively avoided.
Treatment consists of supportive treatment, sympathy and reassurance that the symptoms will
ease spontaneously. In severe cases, the patient may be given a short course of analgesics or
NSAID's.

Chondromalacia Patellae

Chondromalacia patellae is a term that means softening of the cartilage of the patella. It is not
the only diagnosis to consider when a patient presents with anterior knee pain. The cause of
this condition is not clearly known, although it is thought to be associated with a degree of
incongruence between the patella and the femur, causing a degree of tracking abnormality. It
is also often associated with excessive strain of the knee and so may be more common in
patients who participate in a considerable amount of sport. Whatever the cause, it results in
inflammation and swelling of parts of the retro-patella cartilage.

The patient will classically present with anterior knee pain. The patient is often a teenage girl.
The patient is often increased by walking up and down stairs. In some cases, a local effusion
may be observable or palpable. The patella tap test may be positive. Examination of the knee
may reveal local tenderness around the patella. If the patella is pushed sideways and the
posterior aspect of the patella palpated it may elicit pain. Also, applying direct pressure to the
patella and then trying to move it may also cause pain. Arthroscopy may reveal areas of
cartilage softening.

Treatment involves conservative treatment such as avoidance of excessive exercise or other

activities that may strain the area. Analgesics may also be useful to help alleviate the
symptoms. In many cases, the pain will resolve although it may take up to 2 years to do so. If
the pain does not resolve than surgical intervention may be indicated. Several methods of
arthroscopic treatment can be used that includes:

» shaving the softened articular cartilage.

» arthroscopic wash-out
» realignment of the patella.
» patellectomy.

In most cases, there are few secondary complications although it may predispose the patient to
early degeneration of the patello-femoral joint.

Infrapatella Tendinitis - (Jumpers Knee)

This condition is a repetitive strain injury of the infra-patella tendon. The mechanism of
injury is very similar to that of tennis elbow. The site of injury tends to be the insertion of the
infra-patella tendon onto the inferior border of the patella. It's onset is characteristically
linked with sports people, especially those people who participate in athletics.

Treatment will usually consist of rest and a course of NSAID's. If this fails then up to three
injections of cortisone may be given. These are injected into the region of the tendon, not
directly into it. If this treatment also fails then surgical intervention may be indicated. If
surgery is undertaken then the person if often unable to do any sport for at least six months.
Bipartite Patella

This condition is often detected purely by accident should the patient have an X-ray of the
knee for another reason. X-ray will reveal that the patient has a separate fragment of bone at
the supero-lateral aspect of the patella. The condition is often bilateral and it is not clearly
understood as to whether the condition is congenital of the result of trauma. In the majority of
cases, the patient does not have any ill effects. However, should the patient become
symptomatic, excision of the fragment will usually alleviate the symptoms.

Osgood-Schlatter's Disease

This common condition affects the Tibial tuberosity and results in local inflammation and
pain. It is a condition that affects teenagers (mainly boys) and mostly those who participate in
a considerable amount of sport. It results from excessive traction on the tuberosity from the
Quadriceps muscle. It is a condition that occurs before the apophysis has fused to the shaft of
the Tibia. In some cases, the tuberosity may be enlarged and is often tender. In severe cases,
resisted extension of the knee will be painful.

Diagnosis is usually made on the clinical presentation although X-ray confirmation may
reveal an enlarged tibial tuberosity that may be fragmented.

Treatment is usually conservative and requires rest until the initial symptoms have healed.
Analgesics or NSAID's may be useful in the initial stages of severe cases. Ice packs may also
be helpful in the acute stage.
Once the acute symptoms have subsided, the patient should be encouraged to regularly stretch
the Quadriceps muscles to try to limit the degree of tension they exert upon the Tibial
tuberosity. They should also be encouraged to warm up and warm down before and after
sport.

In most cases, the symptoms will ease and as soon as fusion of the apophysis has occurred
they will not return. In a small percentage of patients, pain will persist due to a small
fragment of bone around the Tibial tuberosity and in some cases this needs to be excised.

Sinding Larson Johannson Syndrome

This is the name given to a traction apophysitis affecting the lower pole of the patella due to
prolonged or excessive traction of the infra-patellar tendon. Clinically, the symptoms are
similar to Osgood-Schlatters disease but the site of the pain differs. The onset of the problem
is usually a couple of years earlier in life than Osgood-Schlatters. Treatment is usually
conservative and involves the use of analgesics, NSAID's and rest.

Pyogenic Arthritis

Pyogenic arthritis can affect any joint but the knee is often a more common site of infection.
Pyogenic arthritis can occur as the result of:
i) spread of infection from a bone
ii) direct infection from a penetrating wound
iii) bacteraemia.

This is an acute condition as a result of which the knee will become rapidly painful, swollen,
hot, erythematous and dysfunctional. The patient will often be systemically ill and have a
fever. If untreated, pyogenic arthritis will cause rapid destruction of the knee and subsequent
ankylosis.

Treatment involves aspiration and drainage of the joint together with a flushing out of the
infected debris. Effective antibiotic treatment should be administered immediately. The knee
is then flushed out a regular hourly or two hourly intervals. Arthroscopic division of the
intra-articular adhesions may be required to restore normal function once the infection has
been eradicated.