Knee and Leg Fractures

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25 Knee and Leg Fractures

Anatomy of Knee and Leg

image

Bones of the Leg (Right)

Patella

• Largest sesamoid bone, attached between quadriceps and patellar tendons
• Patellar tendon attaches to tibial tuberosity.
• Inferior (deep) surface is hyaline cartilage that articulates with femoral condyles as part of complex knee joint.

Tibia

• Parts and landmarks: intercondylar eminence (plateau), lateral and medial intercondylar tubercles, lateral and medial condyles, Gerdy’s tubercle (iliotibial tract insertion), tibial tuberosity, anterior border; lateral, medial, and posterior surfaces; interosseus border, soleal line, fibular notch, medial malleolus, inferior articular surface (for talus)

Fibula

• Parts and landmarks: apex, head, neck, interosseus border, medial crest, posterior border, lateral malleolus, malleolar fossa
image

Knee Joint

Knee Joint(s)

• Fibrous capsule provides relatively little support to complex knee joint.
• Patellofemoral joint: synovial articulation between patella and femoral condyles
• Medial meniscus

image Articular fibrocartilage between medial femoral and tibial condyles
image More crescent-shaped, attached to tibial collateral ligament

• Lateral meniscus

image Articular fibrocartilage between lateral femoral and tibial condyles
image More circular

• Transverse meniscal ligament: between anterior aspects of menisci; stabilizing
• Posterior meniscofemoral ligament (of Humphrey): from posterior lateral meniscus to medial femoral condyle; stabilizing
• Anterior cruciate ligament (ACL): from posteromedial aspect of lateral femoral condyle to anteromedial tibial eminence
• Posterior cruciate ligament (PCL): from lateral aspect of medial femoral condyle to posteromedial tibial eminence
• Tibial (medial) collateral ligament

image Medial femoral epicondyle to medial tibia and medial meniscus
image Resists valgus angulation

• Coronary ligament: stabilizes medial meniscus
• Pes anserinus

image Distal tendons of sartorius, gracilis, and semitendinosus inserting on medial subcondylar tibia, superficial to collateral ligaments
image Resists valgus angulation

• Lateral (fibular) collateral ligament

image Lateral supracondylar femur to fibular head
image Resists varus angulation

image

Leg: Cross Section and Compartments

Compartments of the Leg

• Crural fascia

image Tough, nonexpansible, deep fascial sheath surrounds leg compartments, attached to the tibia anteriorly
image Continuous with fascia lata above knee
image Fuses with deep intermuscular septa surrounding compartments

• Anterior compartment

image Ankle/foot (plantar) extensor muscles: tibialis anterior, extensor digitorum longus, extensor hallucis longus, peroneus (fibularis) tertius (when it exists)
image Vessels: anterior tibial artery and vein
image Nerve: deep fibular (peroneal)

• Superficial posterior compartment

image Knee and ankle/foot (plantar) flexor muscles: gastrocnemius and soleus (triceps surae), plantaris, tibialis posterior, flexor digitorum longus (fibular) branches
image Vessels: posterior tibial and fibular (peroneal) arteries and veins
image Nerve: tibial

• Deep posterior compartment

image Knee and ankle/foot (plantar) flexor muscles: popliteus, tibialis posterior, flexor digitorum longus, flexor hallucis longus
image Vessels: posterior tibial and fibular (peroneal) arteries and veins
image Nerve: tibial

• Lateral compartment

image Evertors of ankle and foot: peroneus (fibularis) longus and brevis
image Vessels: anterior tibial and fibular (peroneal) arteries and veins (perforating branches)
image Nerve: superficial fibular (peroneal)

Vessels and Nerves

image

Arteries and Nerves of Leg: Deep Dissection (Posterior View)

Arterial Supply

• Popliteal artery (from femoral) gives rise to medial and lateral genicular branches above and below knee joint (superior and inferior).
• Tibial artery continues from popliteal and branches into the

image Posterior tibial artery

image Fibular (peroneal) artery branch runs laterally along fibula, between flexor hallucis longus and tibialis posterior.
image Anterior tibial artery emerges through uppermost interosseus membrane, providing an anterior tibial recurrent branch to genicular anastomosis.

• Anastomoses around knee include

image Descending genicular artery, medial branch of distal femoral artery
image Superior lateral genicular and superior medial genicular arteries, branches of popliteal artery
image Inferior lateral genicular and inferior medial genicular arteries, branches of popliteal artery
image Posterior and anterior recurrent branches of tibial artery

• Dorsalis pedis artery typically arises from terminal portion of anterior tibial.
• Terminal, perforating branch of the (peroneal) artery typically anastomoses with dorsalis pedis.

Veins of the Knee and Leg

• Main deep veins run parallel to popliteal and to anterior and posterior tibial arteries and their branches.
• Popliteal vein (tributary of the femoral) includes anterior and posterior tibial branches draining plantar and dorsalis pedis.
• Surface drainage along greater and lesser saphenous veins, into the proximal femoral vein
image

Arteries and Nerves of Leg: Deep Dissection (Anterior View)

Nerves

• Hilton’s law: nerves supplying a joint also innervate muscles acting across it, as well as skin over distal insertions of those muscles

Sciatic Nerve (L4-S1)

• Dominant nerve supply for lower extremity
• Tibial divisions (anterior): posterior compartment of leg (and plantar foot), flexors
• Fibular (peroneal) divisions (posterior)

image Deep fibular (peroneal) nerve: anterior compartment extensors of ankle and foot
image Superficial fibular (peroneal nerve): lateral compartment extensor and evertors

image

Veins, Lymph Vessels, and Nodes of Lower Limb

Clinical Correlates

Compartment Syndrome

• Can occur with open tibial fracture or intramedullary nailing
• Chronic: relatively common without accompanying fracture in runners and other training athletes
• Dependent position of limbs promotes high compartment pressures
• Common findings

image Isolated pressure increase in deep posterior compartment most common
image Anterior compartment pressure increase second most common

image

Tibial Fractures

image

Rupture of the Anterior Cruciate Ligament

image

Sprains of Knee Ligaments

Fractures of Knee Region and Leg

Patellar Fractures

• Typically result from direct blow
• Displaced or nondisplaced
• Classifications: comminuted, transverse, vertical, osteochondral, apical, or inferior pole fractures
• Surgical treatment for open, comminuted, or >2 mm displacement or incongruity

Tibial Plateau Fractures

• Common result of falls and vehicle accidents
• Lateral more common, often occur in low-energy trauma of fall in elderly person with osteoporosis
• Medial fractures more commonly associated with ligament, peroneal nerve, meniscal, and popliteal vessel injuries; high-force injury
• Schatzker classification

image Type I: lateral plateau split
image Type II: lateral plateau split depression
image Type III: lateral plateau depression
image Type IV: medial plateau and tibial spine fracture
image Type V: bicondylar
image Type VI: bicondylar with diaphyseal extension

Tibial Shaft Fractures

• Tibia relatively poorly supplied by posterior tibial artery nutrient branches
• Periosteal supply from anterior tibial artery
• Most common long bone fractures, resulting from direct or indirect trauma
• Simple: transverse, spiral, or oblique
• Comminuted

image May be segmental
image Result from high-energy torsion, bending, or crush injuries

• Butterfly: result from twisting, bending
• Stress: repetitive overuse (e.g., in dancers, sports, or military training)

Fibular Fractures

• Although non–weight bearing, fibula is often fractured with tibia.
• Interosseus membrane transmits forces from tibia.
• Shaft fracture types comparable to those of tibia
• Pilon fracture

image Fibular shaft fracture with tibial articular surface compression fracture
image From vertical loading of ankle joint, fall from height, landing on heel

Malleolar Fractures

• See Chapter 26, Fractures of the Ankle and Foot

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