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0. Anatomy (During Ortho Residency) > Knee/Leg > Flashcards

Knee/Leg Flashcards

1
Q

Label the Diagram Below

A
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2
Q

Which femoral condyle is larger?

A

Medial

  • Creates “rollback” and ER on lateral condyle in flexion
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3
Q

What are the shapes of the medial and lateral tibial plateau? Which plateau is more distal?

A
  • Medial - golf tee
    • Lies more distal because proximal tibia is in 2-3 degrees varus
  • Lateral - more proximal, shaped like hockey stick
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4
Q

What is the posterior tibial slope?

A

8-10 degrees

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5
Q

Types of trochlear grooves (4)

A
  1. Shallow Trochlea (>145 degrees)
  2. Flat Trochlea
  3. Medial Condyle Hypoplasia
  4. “Cliff”

*clinical relevance in risk factors for patellar instability

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6
Q

What are the deforming forces in the proximal tibia?

A
  • Deformity is procurvatum & valgus
  • Procurvatum
    • Extensor Mechanism
    • Gastrocs
  • Valgus
    • Pes
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7
Q

What is the average patellar thickness? What is the thinnest you can cut it in a patellar resurfacing?

A
  • Average 23-25mm
  • Do not cut to <12mm - associated with increased risk of fracture
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8
Q

How many facets does the patella have?

A

Seven (3 medial, 3 lateral, 1 odd facet)

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9
Q

Where do you normally see a bipartate patella?

A

Superolateral pole

Seen in 2% of population

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10
Q

What is the TT-TG and what is its clinical relevance?

A
  • Distance between tibial tuberosity and deepest part of trochlear groove.
    • <15mm = normal
    • 15-20 = at risk
    • >20mm = abnormal
  • Increased risk of patellar instability with higher TT-TG value
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11
Q

What is the mechanical axis?

A
  • Line from the centre of the femoral head ot the center of the distal tibial plafond
    • Femur 3 degrees valgus from vertical axis
    • Tibia 3 degrees varus from vertical axis
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12
Q

What is the anatomic axis of the lower limbs?

A
  • Line down the center of the long axis of the femur and tibia
    • Femur - anatomic axis 6 degrees valgus from mechanical axis, 9 degrees valgus from vertical
    • Tibia - mechancial axis = anatomic axis = 3 degrees varus from vertical
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13
Q

What is the Lateral Distal Femoral Angle?

A

81 Degrees

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14
Q

What is the Lateral Proximal Tibial Angle?

A

93 degrees

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15
Q

What do you have to do, to ensure even flexion and extension gaps when performing your femoral cuts?

A
  • Need to rotate your femoral cutting guide 3 degrees to account for the 3 degrees of external rotation of the posterior condyles
    • This makes it paralell to the tibial cut at 0 degrees.
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16
Q

How do you draw the Q Angle? What is normal for males and females?

A
  • Angle between:
    • Line from ASIS to centre of patella
    • Line from centre of patella to tibial tuberosity.
  • Normal:
    • Males - 14 degrees
    • Female - 17 degrees
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17
Q

What are the ligaments of the proximal tibiofibular joint?

A
  1. Anterior ligament of the fibular head
  2. Posterior ligament of the fibular head
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18
Q

What kind of joint is the proximal tib/fib joint?

A

Plane/Slinding Joint

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19
Q

What are the ligaments of the Anterior Knee?

A

Retinacular Ligaments:

  1. Medial and Lateral Transverse Patellar Ligaments
  2. Medial and Latearl Longitudinal Patellar Ligments
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20
Q

List the Layers of the Lateral Knee

A
  • Superficial Layer
    • Anterior ITB
    • Posterior Biceps Femoris
  • Middle Layer
    • Patellar Retinaculum
  • Deep Layer
    • Superficial Deep Layer
      • LCL
      • Patellofibular Ligament
      • ALL
    • Deep Deep Layer
      • Lateral joint capsule
      • Popliteofibular Ligament
      • Popliteus Tendon
      • Arcuate Ligament
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21
Q

Components of the Posteriolateral Corner

A

PAPP Loves Immature Litle Blondes

Popliteus

Arcuate Ligament

Posterolateral Capsule

Popliteofibular Ligament

LCL

ITB

Lateral Head of Gastrocs

Biceps Femoris

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22
Q

Describe the Dial Test

A
  • Have patient with knees together.
  • Test ER at 30 degrees and 90 degrees
    • If >10 degrees difference at 30 degrees alone = PLC injury
    • If >10 degrees difference at 30 & 90 degrees = PLC & PCL injury
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23
Q

In the Laprade technique for PLC reconstruction, which structures are reconstructed?

A
  1. LCL
  2. Popliteofibular Ligament
  3. Popliteus Tendon
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24
Q

In which % of PLC injuries is there a concomittant peroneal nerve injury?

A

13%

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25
Q

What is the most anterior structure on the fibular head?

A
  • The LCL. Biceps Femoris attaches posteriorly.
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26
Q

What is the origin and insertion of the LCL?

A
  • Origin- Lateral Epicondyle
  • Insertion- Fibular Head
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27
Q

Describe the Layers of the Medial Knee

A
  • Superficial:
    • Anterior: medial patellar retinaculum from vastus medialis
    • Middle: deep fascia of the thigh around sartorius
    • Deep: Deep fascia of the thigh around gastrocs and roof of popliteal fascia
  • Middle:
    • Anterior: MPFL
    • Middle: Superficial MCL
    • Deep: Semimembranosus
  • Deep:
    • Joint Capsule
    • Deep MCL - attached to medial meniscus
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28
Q

Between which layers of the medial knee does the pes lie?

A

Between Layers 1 &2

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29
Q

Where does the saphenous nerve and short saphenous vein lay in relation to the pes?

A

Just posterior to the pes insertion.

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30
Q

List the pes anserinus tendons from superficial to deep.

A
  1. Sartorius
  2. Gracilis
  3. Semimembranosis
  4. Semitendonosis
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31
Q

What is the course of the Medial Patellofemoral Ligament (MPFL)?

A
  • Upper 1/3 of the patella to Schottle’s Point (between adductor tubercle and medial epicondyle
32
Q

Describe the location of Schottle’s Point

A
  • 1mm anteiror to the posterior cortex line
  • 2.5mm distal to posterior orign of the medial femoral condyle
    • proximal to Blumensaat’s line
33
Q

List the course of the MCL and it’s components.

A
  • Medial Epicondyle to anteromedial tibia 4.5 cm distal to joint line and deep to Pes
  • Layers
    • Superficial - importantn to protect in TKA (important to stability)
    • Deep - attached to medial meniscus
34
Q

Compontents of the Posterior Knee.

A
  1. Oblique Popliteal Ligament
  2. Arcuate Ligament
  3. Popliteus
35
Q

Components of the Posteromedial Corner (5)

A
  1. Posterior Oblique Ligament (POL)
  2. Semimembranosus Tendon and it’s Expansions
  3. Oblique Popliteal Ligament
  4. Posterior Horn of Medial Meniscus
  5. Posteriomedial Joint Capsule
36
Q

Describe the course, bundles, innervation, function and blood supply of the Anterior Cruciate Ligament (ACL).

A
  • Origin: Medial aspect of lateral femoral condyle (behind lateral intracondylar ridge). To
    • Bifurcate Ridge separates AM and PL bundles
  • Insertion: Posterior to anterior horn of medial mensicus
  • Bundles: AM (tight in flexion), PL
  • Innervation: Tibial N.
  • Function: Primary restriaint to anterior movement of the tibia. Secondary restraint to rotation
  • Blood Supply: Middle Geniculate Artery
37
Q

What is the Function of the Anterolateral Ligament (ALL)?

A

Thought to control rotation (pivot).

38
Q

Describe the course, bundles, function and blood supply of the Posterior Cruciate Ligament (PCL)

A
  • Origin: medial aspect of lateral femoral condyle
  • Insertion: posterior tibia 1cm from joint line
  • Bundles: AL, PM. (PAL- PCL has AL bundle).
    • AL tight in flexion
  • Function: prevents posterior translation of the tibia.
    • Secondary restraint to varus/valgus
  • Blood Supply: Middle geniculate a.
39
Q

Which bundle of the ACL is tight in flexion? PCL?

A
  • ACL - AM
  • PL - AL

*Always the ANTERIOR BUNDLE that is tight in flexion

40
Q

List the meniscal ligaments (4).

A
  1. Cornary Ligament - connec the periphery of the menisci with the joint capsule and tibia.
  2. Transverse Meniscal Ligament - connects the anterior horns of the menisci
  3. Wrisberg Ligament - Connects posterior aspect of the lateral meniscus to the medial femoral condyle. Runs posterior to PCL
  4. Humphries Ligament- Connects posterior aspect of the lateral meniscus to the medial femoral condyle. Runs anterior to PCL
41
Q

What is the function of the menisci? (4)

A
  1. Shock absorption (Lateral meniscus absorbs 70% of lateral compartment, medial meniscus absorbs 50% of medial compartment)
  2. Seconadry restraint in knee stability
  3. Increase joint congruity and contact area
  4. Proprioception
42
Q

Describe the anatomic zones according to blood flow, within the meniscus from superifical to deep. Comment on the healing potential of each zone.

A
  1. Red-Red : High healing
  2. Red- White- middling healing
  3. White-White - low healing potential; gets nutrients from synovial fluid
43
Q

What is the blood supply to the menisci?

A

Medial and lateral geniculate arteries through the perimeniscal plexus

44
Q

What are the boarders and contents of the popliteal fossa?

A
  • Boarders:
    • Superior
      • Lateral: Semimembranosis & Semitendinosis
      • Medial: Biceps Femoris
    • Inferior
      • Lateral: lateral head of gastrocs
      • Medial: medial head of gastrocs
  • Contents (med to lat)
    • Popliteal A. & V.
    • Tibial Nerve
    • Common Peroneal N.
    • Short Saphenous V.
45
Q

List the contents of the anterior compartment of the leg from medial to lateral.

A
  1. Tibialis Anterior
  2. EDL
  3. EHL
  4. Anterior Tibial A. & V.
  5. Deep Peroneal N.
  6. Peroneus Tertius
46
Q

List the contents of the lateral compartment of the leg.

A
  1. Peroneus Longus
  2. Peroneus Brevis - deep
  3. Superficial Peroneal N.
47
Q

List the conents fo the superficial posterior compartment of the leg.

A
  1. Gastrocs
  2. Soleus
  3. Plantaris (medial)
48
Q

List the contents of the deep posterior compartment of the leg.

A
  1. Posterior Tibial A. & V.
  2. Tibial N.
  3. FDL
  4. FHL
  5. Tibialis Posterior
  6. Popliteus
  7. Peroneal A. & V.
49
Q

Which muscle of the deep posterior compartment of the leg has its musculotendinous junction the most distal in the leg?

A

FHL - fleshy at the ankle,

50
Q

Describe the course of the Tibial N.

A
  1. Popliteal Fossa gives off medial sural cutaneous nerve
  2. Crossess ontoop of plantaris and popliteaus
  3. Dives deep to soleus in the deep posterior compartment
  4. Travels down leg deep to transverse intramuscular septum between FDL and FHL
  • Travels with posterior tibial artery and vein
51
Q

Describe the course of the Common Peroneal N.

A
  1. Starts in popliteal fossa, runs medial to biceps femoris
  2. Crosses over top the lateral head of gastrocs and gives of lateral sural cutaneous nerve (lateral to soleus)
  3. Winds around fibular neck, deep to peroneus longus
  4. Penetrates posterior intramuscular septum and splits to deep and superficial peroneal nerves.
52
Q

Describe the course of the Deep Peroneal N.

A
  1. Sharp turn, enters the ateiror compartment through anterior intramuscular septum
  2. Travels along the anterior surface of the OM with the anterior tibial artery.
  3. Passess deep to extensor retinaculum
  4. Supplies EDB
53
Q

Describe the Course of the Superficial Peroneal N.

A
  1. Runs in lateral compartment
  2. Proximal 1/3 runs on lateral surface of tibia
  3. Passes under longus and ontop of brevis (between brevis and EDL)
  4. Heads anterior 8-10 cm proximal to tip of fibula to pierce facia and run along dorsum of foot
54
Q

Describe the course of the Sural N.

A
  1. Combined medial (tibial) and lateral (common peroneal), sural cutaneous nerves
  2. Crosses over lateral head of gastrocs
  3. Runs down posteriolateral calf with short saphenous vein (runs lateral to vein)
  4. Runs lateral to the Achilles tendon
55
Q

Describe the Course of the Saphenous N,

A
  1. Starts in adductor canal (VAN), lateral to vessel
  2. Runs ontop of artery on the underside of sartorius and ends medial to vessels at end of the adductor canal
  3. Peirces fascia at medial knee, between gracilis and sartorius (runs posterior to pes)
  4. Becomes subcutaneous and runs with great saphenous vien
  5. Divides at ankle
    • Larger branceh passess anterior to medial malleolus
    • Smaller branch follow smedial tibial boarder to level of ankle
56
Q

Describe the course of the Popliteal Artery

A
  1. Enters popliteal fossa between biceps and semimembranosis
  2. Lies behind posterior horn of the lateral meniscus (9mm posterior with knee bent to 90 degrees)
  3. Passess superior to popliteus
  4. Runs deep to gastrocss and solus with tibial nerve under fibrous arch of the soleus
  5. Bifurcates at the distal aspect of the popliteus
    • Anterior Tibial A.
    • Tibioperoneal Trunk
57
Q

What are the divisions of the Tibioperoneal Trunk? Where does it split?

A
  1. Posterior Tibial A.
  2. Peroneal A.

*Splits 2.5 cm below popliteal bifurcation.

58
Q

Describe the course of the Anterior Tibial Artery.

A
  1. Passess between 2 heads of tib post
  2. Runs through IOM into anterior compartment
  3. Runs with deep peroneal N. (runs medial to nerve). on the IOM between EHL and TA
  4. Passess deep to superior and inferior extensor retinaculum
  5. Crosses underneath EHL at ankle, runs lateral to EHL into the Foot
  6. Ends as Dorsalis Pedis
59
Q

Describe the course of the Posterior Tibial Artery.

A
  1. Continues in deep posterior compartment
  2. Runs with Tibial N., Superficial to Tib post.
  3. Runs between TP and FDL
  4. Runs behind angle (Tom, Dick & Very Nervous Harry)
  5. Terminates as Medial Plantar A. and Lateral Plantar A.
60
Q

Describe the course of the Peroneal Artery.

A
  1. Largest Branch of Posterior Tibial A
  2. Runs in deep posterior compartment deep to FHL
  3. Terminates as
    • Anterior Perforating Artery
    • Lateral Calcaneal Branch
61
Q

Describe the course of the Saphenous Vein

A
  1. Runs down medial thigh and leg
  2. Passess anterior to medial malleolus
  3. Passes through Fossa Ovalis (aka saphenous opening); defect in fascia lata
  4. Drains into femoral vein
62
Q

Describe 3 ways to measure patellar height.

A
  1. Insall- Salveti Ratio
    • Length of Patellar Tendon / Length of Patella
    • Alta >1.2, Baja <0.8
  2. Blackburn Peel
    • Draw a Horizontal Line at the level of the tibial plateau
    • Line along the patellar articular surface/line perpendicular to horizontal to base of patellar articular surface.
    • Normal =0.8, Alta >1.0
  3. Caton Deschamps
    • Length from anterior tibial crest to inferior edge of articular surface of patella/ Length of articular surface of patella
    • >1 = Alta
63
Q

Describe two techniques for compartment release of the leg.

A
  • Two- Incision Technique
    • Anterolateral Incision
      • Halfway between tibial crest and fibula
      • Find intermuscular septum
      • Open anterior and lateral compartments
      • Beware of SPN
    • Posteromedial Incision
      • 2 cm posterior to the posterior aspect of the tibia
      • Find septum
      • Repelase superficial posterior compartment and deep posterior compartment by elevating soleus from soleal ridge
  • One Incision Technique
    • Longintudinal line just posterior to the fibula.
    • Develop anterior and posterior flaps
    • Find anterior IM septum, release anterior and lateral compartments
    • Find posterior IM septum, release superficial and deep posterior compartments by working between FHL and soleus
      • Beware of the NV Bundle
64
Q

Name the 15 ligaments of the Knee

A
  1. ACL
  2. PCL
  3. LCL
  4. MCL
  5. ALL
  6. Transverse Meniscal Ligament
  7. Ligament of Humphries
  8. LIgament of Wrisberg
  9. Posterior Oblique Ligament
  10. Popliteofibular Ligament
  11. Arcuate Ligament
  12. MPFL
  13. Oblique Popliteal Ligament
  14. Retinacular Ligament
  15. Coronary Ligament
65
Q

What are 4 ways to increase Q angle in TKA

A
  1. Internally Rotate Femoral Component
  2. Inernally Rotate Tibial Component
  3. Medialize the Femoral Component
  4. Lateralize the Patellar Component
66
Q

Which ligament of the knee have attachment to the menisci?

A
  1. Ligament of Wrisberg
  2. Ligament of Humphries
  3. Transverse Meniscal Ligament
  4. MCL
  5. Coronary Ligament
67
Q

What attaches to the fibular head?

A
  1. LCL (anterior)
  2. Biceps Femoris
68
Q

What are the compartment of the leg?

A
  1. Anterior
  2. Lateral
  3. Superficial Posterior
  4. Deep Posterior
69
Q

Describe the position of the peroneus longus and brevis:

a) above the ankle
b) behind hte peroneal groove
c) in the foot

A
  • a) longus superficial to brevis
  • b) longus posterior to brevis
  • c) longus passes under brevis and dives deep into midfoot
70
Q

Describe the peroneal tendon sheaths.

A
  • Run in common sheath and divides into individual sheaths past the distal end of the fibula
71
Q

What is the arrangement of muscles of the deep posterior compartment of the leg above and behind the ankle?

A
  • Medial to Lateral
    • Proximal to Ankle: FDL, Tib Post, FHL
    • Behind Ankle: Tib Post, FDL, FHL
72
Q

What is the notch sign, and what does it represent?

A

Notch Sign: Depression in the lateral femroal condle at the terminal surface

  • Junction between weightbaring tibial articular surface and patellaartcular surface of the femoral condyle
  • Abnormaly large notch or asymmetric/irregular notch can be an indirect sign fo an ACL injury with positive pivot shift
73
Q

Where would you put blocking screws to help combat deformity in proximal 1/3 tibia fracture?

A

Posterior and lateral in the proximal segment

* put in the concave side of deformity in proximal fragment

74
Q

Describe 7 reduction techniques for proximal 1/3 tibia fractures.

A
  1. Blocking Screws
  2. Percutaneous Clamping
  3. Open Reduction and Unicortical Plate
  4. External Fixator
  5. Femoral Distractor
  6. Manual Traction
  7. “F” Tool
75
Q

Where does the peroneal nerve exit into the popliteal fossa compared to the fibular head?

A
  • Exits under biceps femoris 6cm proximal to fibular head
    • This distance decreases with knee flexion
  • Common peroneal n. wraps around fibular head 3-4 cm distal to tip of fibular head.

0. Anatomy (During Ortho Residency) (10 decks)

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