Acknowledgment

First and foremost, I would like to express my heartfelt

gratitude to God for guiding me and granting me the
strength to successfully complete this project.

I am deeply thankful to my Rachana Sharir teacher, Dr.

Mukesh Rani, whose valuable guidance and support
have been instrumental throughout the project. Her
expert suggestions and instructions played a crucial
role in ensuring the successful and effective completion
of this work.

I would also like to extend my sincere thanks to our

respected Principal, Dr. Shailendra Bhardwaj, for
providing all the necessary facilities and a supportive
environment.

My gratitude also goes to the library department for

offering access to sufficient and relevant resources that
greatly aided my research.

I am equally grateful to my friends for their help and

encouragement during the final stages of this project,
especially under time constraints.

Last but certainly not least, I would like to thank my

parents for their unwavering support, valuable
suggestions, and constant motivation, which have been
a great help throughout every phase of this project.

Name:..............................................
 KNEE JOINT

●​ Features
dislocation of the tibia. The posterior ligament
is injured in posterior dislocation of the tibia.
The injury may vary from simple sprain to complete
tear. Tear of the ligaments leads to abnormal
anteroposterior mobility (Figs 12.15a and b). In
the tear of anterior cruciate ligament, tibia is
pushed anteriorly, while in the tear of posterior
cruciate ligament, it is pushed posteriorly.

c. Injuries to collateral ligaments are less

common, and may be produced by severe abduction
and adduction strains (Figs 12.16a and b).

Malalignment of patella: Ideally, the patella is

resting in the centre of the width of the femur in
a relaxed standing position. However, the patellar
position may be altered congenitally or due to
tightness of surrounding structures which may lead
to painful conditions of the patellofemoral joint.

Semimembranosus bursitis is quite common. It

causes a swelling in the popliteal fossa region on
the posteromedial aspect (see Fig. 7.5).Baker's
cyst is a central swelling, occurring due to
osteoarthritis of the knee joint. The synovial
membrane protrudes through a hole in the posterior
part of the capsule of the knee joint.

Hip joint and knee joint may need to be replaced,

if beyond repair.
In knee joint disease, vastus medialis is first to
atrophy and last to recover.
The knee is the largest and most complex joint
of the body. The complexity is the result of
fusion of three joints in one. It is formed by
fusion of the lateral femorotibial, medial
femorotibial, and femoropatellar joints.

●​ Type

It is a condylar synovial joint, incorporating two

condylar joints between the condyles of the femur
and tibia, and one saddle joint between the femur
and the patella. It is also a complex joint as the
cavity is divided by the menisci.

●​ Articular Surfaces

The knee joint is formed by:

1 The condyles of the femur

2 The patella (Figs 12.10a-c and 12.12)

3 The condyles of the tibia.

The femoral condyles articulate with the tibial

condyles below and behind, and with the patella in
front.

●​ Ligaments

The knee joint is supported by the following

ligaments.
1 Fibrous capsule

2 Ligamentum patellae

3 Tibial collateral or medial ligament

4 Fibular collateral or lateral ligament

5 Oblique popliteal ligament

6 Arcuate popliteal ligament

7 Anterior cruciate ligament

8 Posterior cruciate ligament

9 Medial meniscus

10 Lateral meniscus

11 Transverse ligament

●​ Fibrous (Articular) Capsule

The fibrous capsule is very thin, and is deficient

anteriorly, where it is replaced by the
quadriceps. femoris, the patella and the
ligamentum patellae.

Femoral attachment: It is attached about half to

one centimetre beyond the articular margins. The
attachment has three special features.
1 Anteriorly, it is deficient.
2 Posteriorly, it is attached to the intercondylar
line.
3 Laterally, it encloses the origin of the
popliteus.

Tibial attachment: It is attached about half to

one centimetre beyond the articular margins. The
attachment has three special features.

1 Anteriorly, it descends along the margins of the

condyles to the tibial tuberosity, where it is
deficient.

2 Posteriorly, it is attached to the intercondylar

ridge which limits the attachment of the posterior
cruciate ligament (ser Figs 2.26 and 2.27).

3 Posterolaterally, there is a gap behind the

lateral condyle for passage of the tendon of the
popliteus. Some terms applied to parts of the
capsule are as

follows.

Coronary ligament: The fibrous capsule is attached

to the periphery of the menisci. The part of the
capsule between the menisci and the tibia is
sometimes called the coronary ligament.

Short lateral ligament: This is a cord-like

thickening of the capsule deep to the fibular
collateral ligament. It extends from the lateral
epicondyle of femur, where it blends with the
tendon of popliteus, to the medial border of the
apex of the fibula.
The capsular ligament is weak. It is
strengthened anteriorly by the medial and lateral
patellar retinacula, which are extensions from the
vastus medialis and lateralis; laterally by the
iliotibial tract; medially by expansions from the
tendons of the sartorius and semimembranosus; and
posteriorly, by the oblique popliteal ligament.

Openings:

The capsule has two constant gaps.

1 One leading into the suprapatellar bursa.

2 Another for the exit of the tendon of the

popliteus.
Sometimes there are gaps that communicate
with the bursae deep to the medial head of the
gastrocnemius, and deep to the semimembranosus.

●​ Ligamentum Patellae

This is the central portion of the common tendon

of insertion of the quadriceps femoris; the
remaining portions of the tendon form the medial
and lateral patellar retinacula. The ligamentum
patellae is about 7.5 cm long and 2.5 cm broad. It
is attached above to the margins and rough
posterior surface of the apex of the patella, and
below to the smooth, upper part of the tibial
tuberosity. The superficial fibres pass in front
of the patella. The ligamentum patellae is related
to the superficial and deep infrapatellar bursae,
and to the infrapatellar pad of fat.

●​ Tibial Collateral or Medial Ligament

This is a long band of great strength. Superiorly,
it is attached to the medial epicondyle of the
femur just below the adductor tubercle.
Inferiorly, it divides into anterior and posterior
parts.
The anterior or superficial part is about
10 cm long and 1.25 cm broad, and is separated
from the capsule by one or two bursae. It is
attached below to the medial border and posterior
part of the medial surface of the shaft of the
tibia. It covers the inferior medial genicular
vessels and nerve, and the anterior part of the
tendon of the semimembranosus, and is crossed
below by the tendons of the sartorius, gracilis
and the semitendinosus.

The posterior (deep) part of the ligament is short

and blends with the capsule and with the medial
meniscus. It is attached to the medial condyle of
the tibia above the groove for the
semimembranosus.

Morphologically, the tibial collateral ligament

represents the degenerated tendon of the adductor
magnus muscle.

●​ Fibular Collateral or Lateral Ligament

This ligament is strong and cord-like. It is about

5 cm long. Superiorly, it is attached to the
lateral epicondyle of the femur just above the
popliteal groove. Inferiorly, it is embraced by
the tendon of the biceps femoris, and is attached
to the head of the fibula in front of its apex .
It is separated from the lateral meniscus by the
tendon of the popliteus. It is free from the
capsule. The inferior lateral genicular vessels
and nerve

separate it from the capsule . Morphologically, it

represents the femoral attachment of the peroneus
longus,

●​ Oblique Popliteal Ligament

This is an expansion from the tendon of the

semi-membranosus. It runs upwards and laterally,
blends with the posterior surface of the capsule,
and is attached to the intercondylar line and
lateral condyle of the femur. It is closely
related to the popliteal artery, and is pierced by
the middle genicular vessels and nerve, and the
terminal part of the posterior division of the
obturator nerve.

●​ Arcuate Popliteal Ligament

This is a posterior expansion from the short

lateral ligament. It extends backwards from the
head of the fibula, arches over the tendon of the
popliteus, and is attached to the posterior border
of the intercondylar area of the tibia.

●​ Cruciate Ligaments

These are very thick and strong fibrous bands,

which act as direct bonds of union between tibia
and femur, to maintain anteroposterior stability
of the knee joint. They are named according to the
attachment on the tibia.

Anterior cruciate ligament begins from the

anterior part of the intercondylar area of tibia,
runs upwards, backwards and laterally and is
attached to the posterior part of medial surface
of lateral condyle of femur. It is taut during
extension of the knee.

Posterior cruciate ligament begins from the

posterior part of the intercondylar area of tibia,
runs upwards, forwards and medially and is
attached to the anterior part of the lateral
surface of medial condyle of femur. It is taut
during flexion of the knee.
These are supplied by middle genicular
vessels and nerves.

●​ Menisci or Semilunar Cartilages

The menisci are two fibrocartilaginous discs. They

are shaped like crescents. They deepen the
articular surfaces of the condyles of the tibia,
and partially divide the joint cavity into upper
and lower compartments. Flexion and extension of
the knee take place in the upper compartment,
whereas rotation takes place in the lower
compartment.

Each meniscus has the following.

a. Two ends: The anterior and posterior ends of
menisci are attached to the tibia and are referred
to as anterior and posterior horns.

b. Two borders: The 'outer' border is thick,

convex and close to the fibrous capsule; while the
'inner' border is thin, concave and free.

c. Two surfaces: The upper surface is concave for

arti-culation with the femur. The lower surface is
flat and rests on the peripheral two-thirds of the
tibial condyle. The peripheral thick part is
vascular. The inner part is avascular and is
nourished by synovial fluid.

The medial meniscus is nearly semicircular, being

wider behind than in front. The posterior fibres
of the anterior end are continuous with the
transverse ligament. Its peripheral margin is
adherent to the deep part of the tibial collateral
ligament.

The lateral meniscus is nearly circular. The

posterior end of the meniscus is attached to the
medial condyle of femur through two meniscofemoral
ligaments. The tendon of the popliteus and the
capsule separate this meniscus from the fibular
collateral ligament. The more medial part of the
tendon of the popliteus is attached to the lateral
meniscus. The mobility of the posterior end of
this meniscus is controlled by the popliteus and
by the two meniscofemoral ligaments.

Because of the attachments of the menisci to

multiple structures, the motion of the menisci is
limited to a great extent. Out of the two menisci,
the medial meniscus has more firm attachments to
the tibia.

In a young person, the peripheral 25-33% of the

meniscus is vascularised and is innervated. The
remaining part of the meniscus receives its
nutrition from the synovial fluid. Therefore,
movement is important for cartilage nutrition
since movement causes diffusion of nutrients from
synovial fluid to the cartilage.

Functions of menisci

1 They help in making the articular surfaces more

congruent. Because of their flexibility, they can
adapt their contour to the varying curvature of
the different parts of the femoral condyles, as
the latter glide over the tibia.

2 The menisci serve as shock absorbers.

3 They help in lubricating the joint cavity.

4 Because of their nerve supply, they also have a

sensory function. They give rise to proprioceptive
impulses.

●​ Transverse Ligament

It connects the anterior ends of the medial and

lateral menisci.
 ●​ SYNOVIAL MEMBRANE

●​ Features

The synovial membrane of the knee joint lines the

capsule, except posteriorly where it is reflected
forwards by the cruciate ligaments, forming a
common covering for both the ligaments.

In front, it is absent from the patella. Above the

patella, it is prolonged upwards for 5 cm or more
as the suprapatellar bursa. Below the patella, it
covers the deep surface of the infrapatellar pad
of fat, which separates it from the ligamentum
patellae. A median fold, the infrapatellar
synovial fold, extends backwards from the pad of
fat to the intercondylar fossa of the femur. An
alar fold diverges on each side from the median
fold to reach the lateral edges of the patella.

●​ Bursae Around the Knee

As many as 12 bursae have been described around

the knee-four anterior, four lateral, and four
medial. These bursae are as follows.

●​ Anterior

1 Subcutaneous prepatellar bursa

2 Subcutaneous infrapatellar bursa
3 Deep infrapatellar bursa
4 Suprapatellar bursa

●​ Lateral
1 A bursa deep to the lateral head of the
gastrocnemius.

2 A bursa between the fibular collateral ligament

and the biceps femoris.

3 A bursa between the fibular collateral ligament

and the tendon of the popliteus.

4 A bursa between the tendon of the popliteus and

the lateral condyle of the tibia.

●​ Medial

1 A bursa deep to the medial head of the

gastroc-nemius.

2 The anserine bursa is a complicated bursa which

separates the tendons of the sartorius, the
gracilis and the semitendinosus from one another,
from the tibia, and from the tibial collateral
ligament.

3 A bursa deep to the tibial collateral ligament.

4 A bursa deep to the semimembranosus.

●​ Relations of Knee Joint

●​ Anteriorly

Anterior bursae, ligamentum patellae, and patellar

plexus of nerves.

●​ Posteriorly
1 At the middle: Popliteal vessels, tibial nerve.

2 Posterolaterally: Lateral head of gastrocnemius,

plantaris, and common peroneal nerve.

3 Posteromedially: Medial head of gastrocnemius,

semitendinosus, semimembranosus, gracilis, and
popliteus at its insertion.

●​ Medially

1 Sartorius, gracilis and semitendinosus.

2 Great saphenous vein with saphenous nerve.

3 Semimembranosus.

●​ Laterally

Biceps femoris, and tendon of origin of popliteus.

●​ Blood Supply

The knee joint is supplied by the anastomoses

around it. The chief sources of blood supply are:

1 Five genicular branches of the popliteal artery.

2 The descending genicular branch of the femoral

artery.
3 The descending branch of the lateral circumflex
femoral artery.
4 Two recurrent branches of the anterior tibial
artery. 5 The circumflex fibular branch of the
posterior tibial artery.

●​ Nerve Supply

1 Femoral nerve, through its branches to the

vasti, especially the vastus medialis.

2 Sciatic nerve, through the genicular branches of

the tibial and common peroneal nerves.

3 Obturator nerve, through its posterior division.

●​ MOVEMENTS AT THE KNEE JOINT

●​ Features

Active movements at the knee are flexion,

extension, medial rotation and lateral rotation.

Flexion and extension are the chief movements.

These take place in the upper compartment of the
joint, above the menisci. They differ from the
ordinary hinge movements in two ways.

1 The transverse axis around which these

move-ments take place is not fixed. During
extension, the axis moves forwards and upwards,
and in the reverse direction during flexion.

2 These movements are invariably accompanied by

rotations or conjunct rotation. When the foot is
on the ground, while standing erect, medial
rotation of the femur occurs during the last 30°
of extension as in position of 'attention' by the
vastus medialis. It is called conjunct rotation.
During the position of 'stand at ease', there is
lateral rotation of the femur, during initial
stages of flexion, by the popliteus muscle.
Medial rotation of the femur occurs during
the last 30 of extension, and lateral rotation of
the femur occurs during the initial stages of
flexion. When the foot is off the ground as while
sitting on a chair the tibia rotates instead of
the femur, in the opposite direction.
Rotatory movements at the knee are of a small
range. Rotations take place around a vertical
axis, and are permitted in the lower compartment
of the joint, below the menisci. Rotatory
movements may be combined with flexion and
extension or conjunct rotations, or may occur
independently in a partially flexed knee or
adjunct rotations. The conjunct rotations are of
value in locking and unlocking of the knee.
During different phases of movements of
the knee, different portions of the patella
articulate with the femur. The lower pair of
articular facets articulates during extension;
middle pair during beginning of flexion; upper
pair during midflexion; and the medial strip
during full flexion of the knee.

●​ Locking and Unlocking of the Knee Joint

Locking is a mechanism that allows the knee to

remain in the position of full extension as in
standing without much muscular effort.
Locking occurs as a result of medial rotation of
the femur during the last stage of extension. The
antero-posterior diameter of the lateral femoral
condyle is less than that of the medial condyle.
As a result, when the lateral condylar articular
surface is fully 'used up' by extension, part of
the medial condylar surface remains unused. At
this stage, the lateral condyle serves as an axis
around which the medial condyle rotates backwards,
i.e. medial rotation of the femur occurs, so that
the remaining part of the medial condylar surface
is also 'taken up'. This movement locks the knee
joint. Locking is aided by the oblique pull of
ligaments during the last stages of extension.
When the knee is locked, it is completely rigid
and all ligaments of the joint are taut. Locking
is produced by continued action of the same
muscles that produce extension, i.e. the
quadriceps femoris, especially the vastus medialis
part.

The locked knee joint can be flexed only after it

is unlocked by a reversal of the medial rotation,
i.e. by lateral rotation of the femur. Unlocking
is brought about by the action of the popliteus
muscle.
Accessory or passive movements can be
performed in a partially flexed knee. These
movements include:

a. A wider range of rotation

b. Anteroposterior gliding of the tibia on the

femur
c. Some adduction and abduction

d. Some separation of the tibia from the femur.

Morphology of Knee Joint

1 The tibial collateral ligament is the

degenerated tendon of the adductor magnus.

2 The fibular collateral ligament is the

degenerated tendon of the peroneus longus.

3 Cruciate ligaments represent the collateral

ligaments of the originally separate femorotibial
joints.

4 Infrapatellar synovial fold indicates the lower

limit of the femoropatellar joint.

●​ CLINICAL ANATOMY

Osteoarthritis is an age-related cartilage

degene-ration of the articular surfaces. It is
characterized by growth of osteophytes at the
articular ends, which make movements limited and
painful. However, osteoarthritis may set in at an
early age also due to underlying congenital
deformities or fractures around the knee joint.

Structurally, the knee is a weak joint because the

articular surfaces are not congruent. The tibial
condyles are too small and shallow to hold the
large, convex, femoral condyles in place. The
femoropatellar articulation is also quite insecure
because of the shallow articular surfaces, and
because of the outward angulation between the long
axis of the thigh and of the leg.

The stability of the joint is maintained by a

number of factors:

a. The cruciate ligaments maintain anteroposterior

stability.

b. The collateral ligaments maintain side-to-side

stability.

c. Various ligaments strengthening the capsule

have been enumerated earlier.

d. The iliotibial tract plays an important role in

stabilising the knee.

●​ Deformities of the knee: The angle between the

long axis of the thigh and that of the leg may
be abnormal and the leg may be abnormally
abducted (genu valgum or knock knee) or
abnormally adducted (genu varum or bow knee).
This may occur due to rickets, and posture, or
as a congenital abnormality.

●​ Diseases of the knee: The knee joint may be

affected by various diseases. These include
osteoarthritis and various infections.
Infections may be associated with collections
of the fluid in the joint cavity. This gives
rise to swelling above, and at the sides of
the patella. The patella appears to float in
 the fluid. Aspiration of fluid can be done by
passing a needle into the joint on either side
of the patella. Bursae around the joint may
get filled with fluid resulting in swellings.

●​ Injuries to the knee:

a. Injuries to menisci: Strains in a slightly

flexed knee, as in kicking a football, the
meniscus may get separated from the capsule, or
may be torn longitudinally (bucket-handle tear) or
trans-versely (see Fig. 2.18). The medial meniscus
is more vulnerable to injury than the lateral
because of its fixity to the tibial collateral
ligament, and because of greater excursion during
rotatory movements. The lateral meniscus is
protected by the popliteus which pulls it
backwards so that it is not crushed between the
articular surfaces.

b. Injuries to cruciate ligaments are also common.

The anterior cruciate ligament is more commonly
damaged than the posterior. It may be injured in
violent hyperextension of the knee or in anterior
dislocation of the tibia. The posterior ligament
is injured in posterior dislocation of the tibia.
The injury may vary from simple sprain to complete
tear. Tear of the ligaments leads to abnormal
anteroposterior mobility. In the tear of anterior
cruciate ligament, tibia is pushed anteriorly,
while in the tear of the posterior cruciate
ligament, it is pushed posteriorly.
c. Injuries to collateral ligaments are less
common, and may be produced by severe abduction
and adduction strains.

●​ Malalignment of patella: Ideally, the patella

is resting in the centre of the width of the
femur in a relaxed standing position. However,
the patellar position may be altered
congenitally or due to tightness of
surrounding structures which may lead to
painful conditions of the patellofemoral
joint.

Semimembranosus bursitis is quite common. It

causes a swelling in the popliteal fossa region on
the posteromedial [Link]'s cyst is a central
swelling, occurring due to osteoarthritis of the
knee joint. The synovial membrane protrudes
through a hole in the posterior part of the
capsule of the knee joint.

Hip joint and knee joint may need to be replaced,

if beyond repair.

In knee joint disease, vastus medialis is first to

atrophy and last to recover.