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just thank you, Megan. Um, okay, so today we're going to cover, uh, the today we're gonna cover the knee joint. So what this would do is just talking a bit about the anatomy of the knee, naming some of the ligaments, the neurovascular structures, the movements and muscle groups as well, and then go into the common pathological conditions that we can expect in the knee as well. Um, so, firstly, the knee joint is a synovial hinge joint. So what this means is that it is, um, joint that moves in only one plane. So if you take the example of a door hinge how it just moves in one particular plane, the knee is very similar to that. There are only two movements that we can expect with the knee. That is going to be a reflection and extension. Now, I'm looking at the anatomy of the knee in a little more detail, Uh, looking at this x ray that we have in front of us over here. So the knee joint is made up of, um, three particular bones, which is going to be your femur, your tibia and your patella. Um, so the distal aspect of the femur, Um, interacts with the proximal aspect of, uh, the tibia to make your primary knee joint. And this is reinforced by the patella is, But so as we can see the anatomy of the female in this x ray. So in your distal aspect, you have your lateral epicondyle, your medial epicondyle and your lateral condyle and medial condyle, which then interact with the lateral condyle and medial condon of the tibia, but through the articular surface as well. Your patella is a sesamoid bone, which is which means that it is not, um, attached to any bone. It is a free floating bone, and it's not connected to any, uh, bone per se. But then it is, uh, kept in place through the various ligaments that we will talk in the, uh, in the upcoming slides. Your fibula is present as well, just in the lateral aspect of the tibia. Uh, but it is not involved in the knee joint, so we will not be talking about that in much detail in this lecture. Some of the common MSK a pathology that we can expect in the knee, are going to be septic arthritis, osteoarthritis, Osgood Schlatter, disease, tendonitis, ligamentous injuries and fractures as well. And then we're going to talk about all of this in the upcoming, um, section of the of the lecture as well. So let's start off with the ligaments in the knee. So we have four main ligaments that we need to know. So these are going to be your MCL, which is medial collateral ligament your LCL, which is gonna be your lateral collateral ligament, your ACL, which is going to be your anterior cruciate ligament, and then your PCL, which is going to be a posterior cruciate ligament. So now you're let's start off for the MCL first. So MCL is your medial collateral ligament, which is, uh, present on the medial aspect of the knee joint. It runs from the, uh, distal aspect of the femur, the femoral epicondyle to your, uh, your tibial condyles as well. And, uh, reinforces the medial aspect of the knee joint and provides valgus stability. We'll talk a bit about valgus and virus in the upcoming slides as well, but just know that the medial collateral ligament is involved in providing valgus stability. The lateral collateral ligament provides the very similar Axion just on the lateral aspect of your knee. It again runs from the lateral epicondyle to your fibular head. In this case because the fibular head is present in that particular position and therefore provides, um, stability along that plane as well in your lateral aspect or virus stability, your ACL or anterior cruciate ligament. It is, uh, it runs again from the articular surface of the distal, uh, FEMA to your, uh, articular surface of the, uh, the proximal tibia. And, uh, it prevents the anterior displacement of the tibia relative to the femur. And we shall look at that in more detail as well as we go through the next sides. The PCL is again very similar to your ACL. It's just that it prevents the posterior displacement of tibia relative to FEMA and again runs in a very similar fashion. Uh, and we should have a look at that as well. So if, uh, so to understand, um, which one is which? Just by looking at the diagram. Uh, this demonic is really is really good. So if we take, uh, Pam and apple, Um, So Pam is going to be your posterior cruciate ligament runs anteriorly and immediately. So what this means is that it is going to run from the lateral last from the medial aspect of the femur to the lateral aspect, and it will move anteriorly if that makes sense. Um, on the other hand, your apple is going to be your anterior cruciate ligament, which runs from the, um Latt from the lateral aspect of the femoral from from the femoral, uh, from the from the femoral articular surface to the medial aspect of the tibia. And it moves posteriorly. If that makes sense now, as we spoke before regarding valgus and virus. So what this means is that, uh, the movement of the distal bone compared to that of the proximal bone. So this is not exclusive to the knee. But if we were to take the knee, for example, in this particular case, your normal alignment is going to be depicted in this first picture on the left hand side, over here. But in a virus position, your distal bone, which is going to be your tibia, is going to be more medial, uh, to your proximal bone, which is going to be your, um, uh, fema about. We're in the Validus position. It's going to be the other way around a simple way, Uh, to remember, this is that in a valgus position, your leg becomes in an L position compared to a virus position as well. Or now the way that we can remember is that a valgus position. You get pressure from the lateral aspect, so l n l whereas in the various position you get pressure from the medial aspect and it goes outwards. If that makes sense now, as we said earlier, your medial and lateral collateral ligaments are going to provide stability to prevent this move movement from occurring and, uh, prevent any deformities as well and increase the overall stability of the knee joint as well. Another important structure that is present in your knee is are going to be your minusca. I so these are not ligaments, but our cartilage is that are present on the superior articular surface of the tibia tibia tibia. You have two in each knee, which is the medial and lateral. They're both C shaped structures, and their main function is just to deepen the knee joint wee bit just to make it more stable and also act as shock absorbers and prevent any, um uh, prevent any injuries that we can get with twisting, Um uh, in high impact and twisting sports that we can expect. However, the that, uh, although this does not completely prevent any injuries, it does prevent any bony injuries from, um, occurring and is, um, devil very is very essential. Now, your medial meniscus is attached to the medial collateral ligament and the anterior cruciate ligament and therefore, um, injuries, uh, to the MCL will often cause meniscal tears as well and therefore cause problems. But we should have a look at that in detail, literal. Now, how do we examine these injuries? Clinically, um, is one question, Sonia, when you when you when you see a patient with suspected ligament as injuries Uh, there are certain tests that allow you to test um, each of these ligaments in particular and allows you to make a judgment as to which of these ligaments are injured. So if you talk about municipal tests first, meniscal tears often occur in younger patient's and usually through sport injuries and older patient's. It can, uh, occur above with more with less severe mechanisms. So for example of fall or just, um, twisting on their leg as well the common symptoms that we can get our pain. You feel that your knees are giving away some stiffness, some locking as well when you flex the knee, some swelling around the knee as well and decreased range of motion. The main tests that we do is, uh, please grind, grind test or McMurray's test. So if you look at a please grind test, what this involves is that the patient is lying in the prone position with their knees flex to 90 degrees. You apply downward pressure. Uh, you apply downward, uh, force whilst rotating their leg relative to the knee joint, so as depicted by the picture so you keep their femur in position by placing pressure over that with your hands, you push down the foot perpendicular to the FEMA and while providing a rotatory more movement as well. If you hear popping or clicking, then you, um, this is suggestive of a municipal damage moving on to other tests. So for the collateral ligament test so you can apply valgus and virus um, stress tests, which will show whether there is a tear or whether there is laxity in the joint and allows you to assess the stability of these ligaments adequately as well. So if you so for to test the medial collateral ligament, you are going to apply valgus, uh, valgus stress. So from the lateral aspect. So this can get a bit tricky as to which one you're assessing. So if you look over here in these pictures so if you look at the valgus stress as then you're applying stress from the outer aspect of from the lateral aspect this widens the joint space and the medial aspect. But what your medial collateral ligament does is prevents this widening of the joint space in ensures that there is stability in, um, the knee joint. So you're applying valgus valgus stress from the lateral aspect to test your medial collateral ligament. Similarly, in the other, um, similarly FOIA lateral collateral ligament, it's going to be exactly the opposite. We're applying medial stress and and forcing the need to a virus position to test the lateral collateral ligament. If there is an injury present, then there would be exaggerated response on these stress tests. However, if there is no injury present, then uh, there would be minimal axity when you apply. Uh, these, uh, stress is if that makes sense. Next, when you're assessing the anterior cruciate ligament, you do the anterior draw test. So what this involves is having the patient lie down, uh, in the supine position, flexing their knees up to 45 between 45 to 90 degrees and keep their foot flat on the table? Um, next thing you're going to do is have a seat on the patient's foot and always want the patient before you do this, because this can be very surprising to them. He use both hands as grip. So place your thumbs on the to bility velocity and your and your fingers just in the cough and apply. Forced to pull the leg, uh, towards yourself or anteriorly or forward, uh, in relation to the FEMA. If you're able to do this, then this is suggestive of an ACL injury. Um, but if you're not, this is going to be a normal finding. Similarly, another test that we can do, which is less painful. Uh, in the acute setting, especially, is going to be your Lachman's test. So which is very similar to the to the anterior draw test. Just that the knees are reflect up to 20 to 30 degrees. But you're using the same hand motions just to displace the tibia anteriorly or pull it forward towards yourself. Um, and if you're able to do that, then that depicts an anterior cruciate ligament injury. This is considered to be more sensitive than an anterior draw test and is also better picking up patient's with an E Z l injury, and therefore, this is often used more commonly. But it is good practice to, uh, do both tests together as well. Just to confirm the diagnosis. The next thing is going to be a posterior cruciate ligament, Um, test. So since we had an anterior draw test for your ACL, you're going to have a posterior draw test for your PCL as well. So you place the patient exactly the same position as your anterior draw test. But instead of pulling the tibia towards yourself, you're pushing the tibia away from yourself, uh, or posterior displacing it posterior in relation to the FEMA. If you're able to do this, um, then, uh, this is suggestive of, um of a posterior cruciate ligament injury. Um, so if you look at this picture over here, the tibia and the fibula are significantly displaced in relation to the femur. And therefore, there is definite, uh, PCL injury present in this, uh, particular, uh, picture. Generally speaking, the posterior cruciate ligament is usually harder to damage than the ACL. And therefore, you would expect a patient to be in a very high energy trauma. Uh, incident. Uh, so, for example, being in a car accident with the dashboard injury, your, uh, your knee hitting the the flexed knee hitting the dashboard can cause, uh, significant energy, Um, a significant pulse of energy through the knee and thus causing a tear in the posterior cruciate ligament as well. And generally speaking, knee ligament injuries can happen through various mechanisms, and the main one is going to be a twisting forces or hyper extension. Um, and we shall talk a bit more about this in our, uh, injury section as well and moving on to the neuro vasculature. So starting off with the blood supply of the knee, Uh, your main, um, blood supply is going to come from the genicular arteries, which is anastomosis arising from the femoral popliteal and lateral, uh, circumflex arteries. And, um, this is the blood supply is depicted in the diagram. Over here, you have your lateral superior genicular artery, medial spirit genicular artery and national inferior genicular artery and medial inferior, uh, genicular artery, which is just an osmosis from the, um from the from the, uh, arteries that I had mentioned earlier talking about versa. Versa is a fluid filled compartment that is present in various joint aspects, uh, in various joints, uh, and is present in the knee as well. The act of shock absorbers and prevent any, um, um, uh, prevent any contact. Damn. Damn, uh, prevent any damage that arises due to contact with bone to skin. And it also is reducing friction of movement and therefore, prevents any, uh, damage due to that as well. It is. Uh, it is a It is a synovial membrane that is filled with synovial fluid. And again, as I said, it's in lubrication of, uh, the joint. Uh, there are various. Um um, So in the knee, you have three main, um, three main. Um, birthday present. So you have your super patellar birthday, which is just present over the patella, and you have your pre patellar bursa, which is present just in front of your patella, and then your infrapatellar bursa, which is present just below the level of the patella. Now, this clinical significance of a bursa is that it can get inflamed. Uh, and the pre patellar one is often the most common, uh, one occurring in the knee. There are various mechanisms. Um, uh, as to why this happens, uh, but most of the time it is not due to infection. It is just an inflammation. And the treatment, uh, would just be an sets rest, ice compression, elevation. Uh, and if it gets too severe, then you can go for birth, birth aspiration or, uh, steroid injections as well. However, if the patient is clinically unwell, there are signs of infection. Then, um, an antibiotic would be helpful in these particular patient's as well. However, however, this is very rare. Uh, and it most often requires just kind of a conservative treatment. Clinical presentation of this particular of bursitis is going to be pain on toucher movement. Uh, there's gonna be swelling some redness associated with his, uh, I'm moving on to the movements of the knee. As I said earlier, you have two main movements of the knee flexion and extension. So flexion is where the, uh, the distal aspect of your, uh, of that limp. If we take this if we take the lower limb in this particular case, um comes proximal to the body, whereas extension is where it goes distal, uh, from the body. So if your foot is coming towards you, it's going to be a flexion. If your foot is going away from you, it's gonna be extension. Similarly, if you look at the hand as well, if your hand is going to come towards you, it's flexion. If it goes away from you, it's going to be extension Now, looking at knee flexion, um, so knee flexion you can go for up to 1 40 degrees of flexion. Your main muscles that are involved in this is going to be your hamstrings. That is just present in the back of your, uh, your three muscles that are involved in the hamstrings, which are going to be your biceps feminist, your semimembranosus and semi tendinosis. Um, so if you look at this over here, all of them have a common origin. They come from the ischial tuberosity, which is just present on your on your pelvis. Um, but it's just that you're short head of the biceps Feminist is going to come from the linear aspira of the femoral shaft, but the rest have a common origin, which is going to be your issue, Uh, curiosity in terms of the insertions. Um, So there's two insertion one is on the on the tibia and one is on the fibula. And this gives rise to the, uh this forms to borders of the popliteal fossa as well, just behind the knee. So your biceps families attaches onto the fibular head. But whereas your semi tender semi tendinosis and semimembranosus attaches onto the medial surface of the tibia and the medial tibial condyles, respectively, um, they're both, uh, innovated by the sciatic nerve. However, the semitendinosus semimembranosus and long head of biceps families is going to be innovated by the tibial aspect of the tibia, part of the sciatic nerve. Whereas the short head of biceps is going to be innovated by the, um, common fibula, part of the sciatic nerve. So if you look at the sciatic nerve over here. Um, so this is going to be the sciatic nerve coming in the back. Um, just, uh, on the posterior aspect of the thigh. And you have your tibial part, Which, which innovates the semimembranosus semi tendinosis long head of biceps. Uh, and other muscles as well, Such as your doctor Magnus. And then your common perennial part of the sciatic nerve is gonna be innovating. You're short head of biceps, uh, memories. And then this. Then bifurcates at the level of the knee to form the tibial nerve and the common perennial, uh, nerve as well. Okay. And then moving on to knee extension, then. So knee extension is, um you have so knee extension is just the muscles. The muscles is caused you to the muscles present in the anterior aspect of your thigh. And these are your quadriceps. Uh, so you have four muscles that form the quadriceps, so quad means four. So you have four muscles, so you have erectus families and then your three vast eye muscles. So which is going to be a vastus lateralis, vastus, medialis and vastus intermedius. So if you look at the muscles over here as well, so you have your on the lateral aspect. You have your vastus lateralis on your medial aspect. You have your vastus medialis, which makes it very easy to remember. And then you have your rectus femoris right in the middle. And then you have your vastus intermedius right in the middle as well. And that just makes it, um, easy to remember. In terms of the innovation, you have your femoral nerve. Uh, that is innovating all of these muscles. Um, so it's easy to remember that it's present on the FEMA. So it's going to be your femoral nerve, and your blood supply is going to be your femoral artery again. In terms of the insertion and origins, the insertion for this is all is very easy. All four attached to the patella distally via the quadriceps tendon. So they all merged to form one particular tendon, which is the quadriceps tendon, which then attaches to the patella. The patellar then, um, has attended, arising from the other end of it called the the Not a tendon ligament of the arising from the end of it called patellar ligament, which then attaches to the tibial tuberosity. This then forms one whole mechanism in in achieving appropriate flexion and extension of the Ortho knee in terms of the origins, uh, of the of these muscles. So your rectus femoris arises from the anterior inferior, uh, spine or of your ileum bone. Uh, vastus medialis comes from the intertrochanteric line of the femur or the medial lip of the, uh, linear aspira. And your vastus lateralis comes from the greater trochanteric clip. Uh, greater trochanter of the lip of lateral lip of the linear aspira and your vastus intermedius comes from the shaft of the femur. I hope that was okay. If you have any questions, please let me know before we move on to the next, uh, section. Yeah. Okay, so then moving on to the next section, we're going to talk about some of the common knee injuries that we can expect, um, to know as medical students and that we can expect in the clinical setting as well. Um so firstly, we're going to talk about ligament injuries, So these are one of the most common types of sports and injuries that we can get in one of the most common types of injuries that we will see, See in the E. D. Or in the orthopedic department as well in terms of your, uh, knee joint per se. Um, and the common ligament injuries include your ACL injury and your PCL injury that we had mentioned earlier as well. So in terms of it is the l injury. It is the most common form of ligament injury in the knee. Uh, it occurs predominantly due to sports related injuries, but there are other, um, mechanisms of actions as well that can lead to any cl injury. Uh, and as I said earlier, it leads to anterior and lateral rotary rotatory instability of the knee, which means that your tibia is going to be pushed, uh, anteriorly compared to the FEMA. And there can be lateral, uh, rotatory instability as well. So in terms of the history, uh, mechanism of action is very important in a patient that comes in with, uh, an injured knee, as this allows you to figure out what exactly is going on. So we have a very, very, very classic presentation of an ACL injury, which is when, uh so when, uh, the when there's a twist when there's twisting around the flexed knee and this is often what you here. Uh, when, um uh, this is often what you hear patient's complain of, and this is reported as turning suddenly. So what this involves is that the tibia translates anteriorly while the knee is slightly flexed and in a valgus position as well. So as we can see in this particular picture over here, the tibia is translated anteriorly, as we can see with over here, and the knee is slightly flexed as well. And it is a valgus position because there is, uh, forced from the lateral aspect. So this is a very, very, very common or classic presentation of, uh, an ACL injury. And this is also reported as a twisting around a fixed, uh, knee or flexed knee on or also know or or also can be reported as, uh, sudden or turning suddenly, as we can see in this particular picture, you can also get this from a direct impact to the lateral aspect of the, uh, knee. So in a very similar very similar fashion, if this patient was just standing and you have a lateral direct lateral blue on the on the knee, um, it could cause a very similar, um, injury as well and common activities that you can, uh, see. This is in football and basketball, uh, skiing rugby as well. But you can get other sports as well. Or other, um, other sports as well. That can. Then this can be, uh, senior. You often hear patient's complaining that they've heard a pop. When this happens and you have pain deep in your knee, there's immediate swelling associated with this as well. In terms of the examination, uh, you're gonna you're so when you're seeing the when you're observing the new when you're inspecting the knee, you can. You can often see this massive effusion present which, of course, uh, immediately after the injury as well. And the the knee is often going to be in your flexed position because you're avoiding that extension, uh, and stretching of the ligament and your quad, Uh, and the stretching of the ligament, which would cause more pain. Uh, when they're walking as well, they're going to be avoiding their quadriceps, and you can see that that's not being activated when they're walking, and they're often have a flexed position present as well. In terms of movements So when you're testing the movements, you would see a reflection might be okay, but be limited due to pain. But there would definitely be lack of full extension. Uh, the need in terms of the neurovascular status, it's always important to check the neurovascular status of, uh, any joint injury, any muscular, skeletal problem. So it's important to check the perennial, uh, nerve function as this can often get damaged in multi ligament, uh, injuries. As we said earlier, your anterior draw test and your Lachman's tests are going to be your most sensitive diagnostic tests. When you're going to, um, confirm any CL injury in terms of imaging, we can start off by doing, uh, an AP and lateral X ray of the knee, and this allows us to see if there's any fractures present. Any, uh, other pathology going on is, but it does not allow us to see the ligament directly, but it allows us to see any concurrent damage that has often been done with an A C. L. With an ACL injury, you can often observe Siegen Fracture, which is a which is an avulsion of the proximal lateral tibia. As we can see in this particular radiograph as well, Where in the lateral aspect of the tibia, the proximal lateral aspect of the tibia is just pulled off. And that is often, um, due to, uh and is often due to an ACL injury as well. In terms of your confirmatory diagnostic, uh, or imaging, um, modality. You're going to use an MRI. So this you're clearly able to see that the ACL has been damaged and you can also see if other, um, injuries have occurred, such as your medial collateral ligament or your meniscus. I as well. Okay, In terms of the treatment, this is again individualized, a different patient factors and patient preferences as well. Firstly, in terms of your non operative management, this was off. This is often indicated in low demand patient's with decreased laxity. So if you're if the if the injury is not, uh is not, uh, limiting, they're, um, day to day activities. Uh, then this would, uh, Then you would often employ the non operative approach, and and in this you'd use physiotherapy and lifestyle modifications, modifications and just strengthening the muscles around, um uh, the knee as well. Just to improve the stability of the knee is very essential in these patient's. An operative approach is going to be, um, uh, done in the in your other patient's so we'll have a look at the different operative approaches as well. So, firstly, ACL Reconstruction, where you completely reconstruct the ligament and this is often preferred in a younger, active patient's that have to have their full range of motion restored for So, for example, your athletes who need to get back on, uh, on the playing field, uh, neat will get an ACL reconstruction done as soon as possible. Uh, as soon as possible. Knee seal repair. This is where you're just joining back the ligaments together. And this occurred. This is often preferred in pediatric populations within a bulge in type, um, pattern as, uh, there is an increased, um, chance that because they are skeletally immature and they're still growing, the ligaments would heal themselves. And you just need to just reinforce, um, just need to even force, uh, the ligament. And it would restore itself eventually, an ACL revision. Reconstruction? Uh, so this is when you have failure of priory construction and there exists, uh, there exists instability there still exists in instability during desired activities. So you would go back again and do a revision surgery. All of these surgeries are not performed. Arthroscopically as we can see from this diagram, so too, Um so, uh, very minimal. Um, so you're you're very minimally invasive, so you have only two small incisions and your two ports are inserted with one being the camera and one being your instruments as well. Moving on to posterior cruciate cruciate ligament injuries. So these again are traumatic, um, traumatic injuries that often occur in combination with other injuries as well. The mechanism of injury is going to be a direct low to the proximal tibia with a flexed knee, as I mentioned earlier, like a dashboard injury. Or it can be a hyper extension injury or a hype hyperflexion of the knee with a plantarflexed foot as well. So as I said, this is going to be a dashboard injury. Um, or you can get a hyperflexion of the knee as we can see in this particular in figure. See over here with a plantarflexed. Um, but And it can lead to, uh, the posterior cruciate ligament injury. On examination, you're gonna see a posterior side sign and the posterior drawer test is going to be the most accurate. Uh, in terms of diagnosing P C LNG, the posterior side sign is when the knees are flexed at 90 90 degrees, the tibia automatically um, shifts, Um, posteriorly without you applying any force as well in terms of your, uh, imaging again a pa and lateral X rays of the knee here, you can see in a bulge in fracture present as well. And it's going to be, uh, most likely going to be on the posterior aspect of the tibia, as we can see in this diagram as well. The MRI, uh, the MRI is going to be your best imaging modality in this particular case as well as it it allows. It allows you to adequately view the PCL and confirm the diagnosis, identify any other pathologies as well treatment again individualized to patient factors and patient preferences. Again done, if again, can be divided in non operative and operative. Non operative is going to be protected. Feet bearing in rehab indicated in very minor injuries. Uh, there's relative, uh, immobilization in extension, uh, positions here, any is made straight for four weeks. Uh, and this can be indicated in grade three injuries as well, in terms of your operative approach, Um, so you have PCL repair of Boniva ulgen fractures or reconstruction in combination with other ligament is, uh, injuries as well. Um, and this is again done arthroscopically. So for medical students for medical school level, we don't need to know the different, uh, operative modalities that are being used at the minute. But we just need to know that how we just need to know how to identify a PCL injury, uh, through adequate history and examination and what is going to be our imaging modality as well. The next thing is going to be your municipal injuries. These are again very common in, uh, sports very common sports related injuries and is often seen in young athletes. It can be seen in combination with the ACL tears as well, but it can also present as degenerative condition in older patients as well. In terms of your history, the mechanism of injury is going to be very, very similar to that of the ECL. So twisting around a flexed knee, um, and you can get pain localizing to the medial and lateral side. And this tells you that whether it's the medial meniscus are that is torn or the lateral minister that is torn, you can get certain mechanical symptoms as well. So when when when you're flexing or extending the knee, you can hear locking and clicking, which is again, uh, suggestive of meniscal tear. But in this case, instead of an immediate swelling as we as we have seen with the ACL injury, you may get delayed. Er, intermittent swelling, um, present as well. In terms of your examination, you're gonna see tenderness along the joint line, some infusion. And as we said earlier, we're going to perform the A please in McMurray's test, which is gonna be confirmatory of, um, I'm in a school trip imaging again. So you're radiographs. It's always good to do one just to prevent just to rule out any bony abnormalities. It's an A P m last luxury, but in this case is going to be very normal. You wouldn't see any. You wouldn't expect to see any, um, any damage if it is an isolated meniscal tear. But, um, but if there's other concomitant pathologies, you you would be able to see that, Um, in terms of your definite of imaging modality, you're gonna get MRI again. This is the most sensitive, and it identifies the terror and allows grading of the terror as well. So we can see over here that is going to be your minusca. Uh, and there is a tear present as indicated, uh, with three. I'd arrows again. In terms of treatment, it can be divided into non operative and operative or non operative as first line in your degenerative terrorists, an older patient. So this would involve rest, um, use of analgesia through, uh, NSAID and rehabilitation as well, just to strengthen the muscles around the joint in terms of your operative approach, uh, you can either get partial meniscectomy, um or meniscal repair. Meniscectomy is reserved for those tests that are not amenable to repair. So these can be very complex or, um, large testing degenerative disease as well. Uh, meniscal repair is going to be your mainstay treatment and is often done in combination with an e c l. Because you often get these two, uh, injuries side by side. Uh, and it's characterized by, um, vertical and lodge students. Course moving on to some of the fractures that we can, uh, that we can see around the knee. So starting off with the patella. Um, so the patella is, as I said, is a sesamoid bone that just sits interiorly between your tibia and your FEMA, Um, the main in terms of your history. Uh, patellar factors are often caused due to direct trauma to the knee, but it can also occur due to rapid contraction of the quarter steps with the flex knee leading to loss of the extensive mechanism as well. So what this means is that when your knees flex the rapidly, uh, contract the quarter SEPs Um, your your your patella kind of splits like that, and that's what causes the fracture. So in terms of the examination findings, you will see a palpable patellar defect. As we can see in this particular picture. Over here, you will notice some significant hemarthrosis. What this means is that there's going to be blood in the joint, um, so this will present itself as it has an infusion, uh, and which can be confirmed by aspiration or just on on the X ray as well. These patient's will not be able to perform the straight leg straight leg raise. So what this means is they won't be able to extend their legs at all, and they won't be able to raise it up. Keep it straight in terms of your imaging again. Radiographs ap and large Luxury. Uh, and as we can see over here, we can see an obvious fracture present, uh, along the, uh in the in the middle of the patella. And we can assess the degree of the fracture displacement as well. And does, um, influencing our treatment treatment choices If there is a distal pole comminuted fracture or a patella stress stress fracture, then a CT scan as often, uh, indicated for those particular patient's as this allows you to adequately visualize the fracture and plan your treatment accordingly as well. Treatment can further be divided to non operative and operative. Non operative is where the needs just immobilized in an extension, uh, in the extended position with full be weight bearing, Uh, and it's indicated only if it is non displaced. Um, uh, if it's a non displaced fracture, if it's a vertical fracture or if the extent mechanism is still, uh, intact where in they're able to extend their leg adequately. So if you look at this particular X area over here, this will not be suitable for a non operative approach because it is a transfers fracture. Uh, it is completely displaced as well. And, uh, the extensive mechanism in this particular patient is not going to be intact as well. Moving on to the operative approach is, uh so there's two, uh to to so you have your r f and then your other, um techniques as well. So in terms of your r f, this is indicated if it is an open fracture, there's failure of extensive mechanism this loose bodies present, and it's a displaced fracture as well. So this would probably require an r f, um to be treated adequately, and R f just stands for open reduction in in, uh, fixation. So what this involves is opening it up, uh, compressing it together to keep in the reducing it together to keeping keeping it in the, uh, anatomical position and then fixing it accordingly. Now there's different techniques for fixing it, so you can use attention banding, uh, plates and screws or the surface wiring as well. So this is an example of the of tension bending and one of the most common, um, forms of fixing a patella fracture as well. So you have a wire that is essentially drawn as an eight. Um, and it's just pulled together just to keep the two fragments of the patella together, and then then stabilize using K virus as well, moving on to the femoral shaft fractures. So your femoral shaft again is gonna you're gonna get, um So your history is going to be very similar to your other fractures as well. It's very going to be very high energy fractures. Uh, this often is gonna be. So your femur is your strongest bone in the body is the longest bone in the body as well. Therefore, to break this, you need to have high energy, um, injury, and therefore, most often than not, you see these, um, in, uh, multi trauma cases because of the high energy aspect of, uh, the accident, you can get this in the elderly as well. However, uh, they would have more low energy. Um, low energy. Um, they would. The trauma would be low energy as well. This is because they have osteoporotic. Bone and bone is just more easy, uh, to break in. All patient's with the suspected femoral shaft fracture. Uh, you're you have to follow the a TLS guidelines and follow the ABCDE approach because they're often involved in multi trauma or polytrauma accident. And they have other life threatening issues as well. That needs to be managed first before you actually manage the fracture. So, for example, they may be in shock, and you need to be able to manage that first before you come to manage the family shaft fracture. But in terms of your examination, then when you actually come to it, uh, you're gonna see a tense, swollen tie. The leg is going to be shortened as well. You won't be, uh, the patient won't be moving their legs at all as, uh, they're extremely in pain. And your distal neurovascular status needs to be recorded recorded as well. So this involves your, um, pulse is such as your dorsalis pedis, your prosperity Bulus pulse and your they're still, uh, motor in your sensory function as well. In terms of your imaging, you start off with radiographs again a pa and lateral views of FEMA, plus the joint above and joint below. So that's going to be your hip and knee. So as we can see over here, we can see an obvious, uh, fracture present over here, which is displaced as well. And it's a spiral. Uh, it's a spiral pattern that is observed as well, indicating that this is going to be a high energy impact, uh, fracture. You can do, uh, CT as well, and this is indicated in mid shaft fractures to rule out any femoral neck fractures as well. In terms of your treatment again, to approach is non operative and operative, non operative is going to be just casting them. And this is indicated in patient's with non displaced fractures, patient's that are not suitable for surgery and paediatric patient's as well. Your operative approach is going to be your most common form of treatment, and it can be done using an anti graded, intramedullary nail retrograde intramedullary nail or 1/5 place in groups. So your antegrade inter intramedullary nail is going to be our gold standard. So as we can see in this picture, this is what it is. So what this means is that? Uh so the difference between anti grade and director grade is the approach in which, uh, the approach you take to insert the nail into the FEMA and this is, uh so anti grid is when you come from the proximal to distal. So that is from the head of the greater trochanter of the femur, down to the distal aspect of FEMA, whereas retrograde, you come down from the distal aspect of the femur into the top. If that makes sense, you retrograde intramedullary nail is indicated if you have a concurrent femoral neck fracture, so then you won't be able to come down from the top because it's a fracture present over there as well. If there's a tibial shaft fracture present as well, because it just makes it difficult. If you have multi system trauma, there's bilateral femoral fractures. If there's morbid obesity as well, because then it would be difficult to access the greater trochanter and pregnancy as well and in pregnancy, especially because you want to reduce the radiation to the pelvic region and therefore you start, um uh from the more distal aspect, or if with plates and screws, this is indicated if there is an absolute lateral femoral neck fracture as well that requires, uh or if the next thing is tibial plateau fractures. So these are periarticular fractures of the proximal tibia with associated soft tissue injury. So your mechanism is going to be either a valgus load or a virus load or axial load as well. So valgus load is going to cause injury to your lash will plateau because it's a national, uh, force, that is, Um, uh, because there is a lateral force that is applied, your virus load is going to affect your medial project because there's a medial force applied. Your axial load is going to cause by Candler fracture because there is a, um the the load is applied just from the top and therefore crushes the plateau and causes breaking of both, uh, the condyles terms of your history. They just won't be able to, uh, weight bear as we can see with all all fractures. But your your examination is gonna point you towards, uh, tibial plateau fracture because on valgus and virus stress testing, uh, you will observe laxity. And, uh, this will not be, uh this can be suggestive of medial lateral collateral ligament injury. But because they're unable to weight bear as well, this will point you towards point you more towards the tibial plateau fracture. Uh, in this particular setting, you always assess the neuro vascular status, as with any fracture pattern. And your tibia and perennial know function is very important in this particular case in terms of your imaging again a PN lateral x rays, which shows a depressed articular surface. So as we can see over here is your, uh your lateral lateral epicondyle condyle is affected of your tibia, and this is depressed as well. And, um, this is this can be observed on your X rays. Uh, CT can be done if your X ray is negative and you're still, uh, suspicious of it toble plateau fracture. And, uh, it will be able to, uh, pick that up sufficiently treatment. Uh, so we have a common theme running over here. Non operative and operative Non operative is going to be a close reduction in, uh, immobilization. This is indicated in minimally displaced depressed fractures in low energy fracture, uh, which has stable alignment and in non ambulatory patient's as well. Your operative operative treatment is going to be, uh, or if, uh, and this is indicated in a displaced fracture. If there's candle a widening, there's valgus or virus instability. If there's medium, uh, plateau fractures and if there's by candle A fractures as well. And in this particular case, uh, this shows how an R F is done. So there's multiple plates and screws that is applied across the tibial plateau just to keep it in, uh, place. The next thing is gonna be to Bill shaft fracture. Uh, and this is going to be the most common type of long bone fracture that we can, uh, see. And your lower limb? Uh, so the mechanism of injury is going to be low energy fall. Um, it can be either be low energy or high energy, so low energy would be fall from standing or twisting. Uh, so indirect indirect arsenal, uh, injury. So just the twisting, uh, twisting motion. But your high energy can be direct force onto your tibia or fall from a height or an athletics as well, um, athletes as well, and they're playing different kinds of sports. In terms of examination, you can often see a visible deformity, you can see some contusions. Blisters can observe open wounds as well. Um, around the around the Shin Region. And this should make you highly suspicious, Suspicious of particular shop fracture. It is important to check the firmness of each compartment, especially tibial shaft fractures, as there's a high likelihood of compartment syndrome. And you don't want that happening. Neurovascular assessment of distal pulses. Uh, and your, um uh, on the different nerves are important, as with any, uh, fracture. And these are the nerves that you test as well. In terms of your imaging, you start off with a pa and lateral X rays of the full length of the tibia, and you can often see of obvious fracture and the tibial fractures. You often don't get isolated tibial fractures, uh, as there's a closed system over here formed with your fibula as well. Therefore, if there is a fracture of the tibia, you often get fractured the fibula as well, and both needs to be fixed as soon as possible. A CT can be indicated in in if there's intra-articular involvement, or there is suspicion of a plateau fracture platform fracture, so plateau is going to be in the superior aspect. Uh, and the platform is going to be in your, uh, inferior aspect of the distal aspect if there is digital One third, uh, fracture or a spiral fracture. Or there's a risk of posterior Manulis fracture as well. And therefore you do a CT in that particular case as well, in terms of your treatment. So you're non operative approach, uh, is going to be close reduction and immobilization. And this is indicated if the if it is low energy fracture, there's acceptable alignment. And, uh, if it's if it's not an open fracture as well. Operative approach. Uh, so you start off by surgically draining and debriding. Uh, so if it is an open fracture, you start off by surgically draining and deep riding and give them antibiotics as soon as possible. Uh, you would then keep put an external fixator. So this is And this is often indicated in damage control for Polytrauma patient's, as they have other problems that need to be fixed first, and you don't want to be focusing on the on fixing the tibia as soon as possible. Therefore, an external fixator is often applied, uh, initially so that the bone is kept in place. Uh, and this is often done, and this is often seen like this, uh, the bonus keep kept in place, and then they come. They are taken back to theater at later stage when they're more stable and a proper definite of management is often, uh, formed. It is also indicated open fractures because you don't want, um to, uh, to go to to start with any definite of management support, such as inter mentally nailing or or if, if you have an open fracture is there's a high risk of osteomyelitis as well, um, as well. So then you're definite of management either intramedullary nailing or or if so, intramedullary. Nailing I am nailing is indicated. If there's an unacceptable, uh, alignment with closed reduction in casting, or there's soft tissue damage that will not tolerate costing or there's a comminuted fracture as well. Or, if it's done with plates and screws, is indicated of proximate or distal tibia fractures with, uh, the I am nailing is not adequate. Uh, and then there's presence of an implant or hardware, uh, as well. So, for example, a previous total need replacement would be indicated uh, would indicate, uh, or of as well. And we look at some of the other diseases that we can expect with the knee. Sophia. So you have the Oscar Oscar, uh, flatters disease. So what this means is that osteochondrosis or traction apophysitis of the tibial tubercle? So what? This What this means is that there is a problem with the growth plate. Uh, and there's a stress from the extensive mechanism causing, um damage to the growth plate, uh, and is often seen in Children. It presents this anterior knee pain in the pediatric population. And on examination, you may notice that there's an enlarged, typical typical and this tenderness over the tibial typical as well as indicated in this picture over here, your imaging on your lateral X So you do any PN lateral X ray on lateral X ray often observe an irregularity. Fragmentation of the typical typical has indicated over here in terms of treatment again, non operative and operative, your non operative is going to be your most, uh, common motive managing these patient's or your NSAID rest ice activity modification strapping to decrease tension on the growth plate and contraceptive stretching as well and you can either do You can also do cost and mobilization for six weeks if the symptoms are most severe and did not respond, uh, to the previous mention, uh, management options as well Operative approach such as our surgical excision very into Remove. Uh, some of that, uh, some of the bone, uh, and is indicated only in patients with refractory, uh, disease. And, um so, for example, these treatment modalities don't work at all. The non operative treatment treatment modalities don't work at all. Or if they keep presenting, uh, in a similar fashion on multiple times, then you would consider this It is also, uh it can also be considered in skeletally mature patient's with persistent symptoms as well. So, uh, once they've started to go into adulthood Uh, and they have, uh, similar similar presentation. Then operation would be more, um, ideal as well. Lastly, um, we have osteo contractors. Desiccants. This is a pathological lesion affecting the articular cartilage and subchondral bone, and it has very various clinical patterns as well. In terms of your history, this is gonna be activity related. Um uh, so pain on activity, and that is weak and poorly localized as well. You just often here have some knee pain. Uh, during activity on in terms of examination, you have localized tenderness around the knee. You have stiffness of the knees, swelling of the knee as well. In terms of your imaging, you get weight bearing, um, a P and large leks Aries. And this shows subcontract, crescent sign or loose bodies as we can see over here, Highlighted by the blue arrow. There is some There is a crescent, uh, sign, uh, present to be here, which is indicated all of of this disease. An MRI can also be done to evaluate the cartilage around the area to visualize any loose bodies and is also used to stage and assess the stability of the lesion. In terms of your management, the patient's need to be referred to orthopedics as soon as possible. This can be operative or non operative, but this is out of the scope of this particular lecture, and that's all for today. So, uh, if you have any questions, please let me know. You can put it in the chat box and sorry for going over time as well. Um, but yes, that's it. Virtually If you have any questions, just let me know. 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