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minicus patella plica fat pad Flashcards

1
Q

What are the determinates of knee rotation?

A
  1. Bone
  2. muscular
  3. meniscial
  4. ligaemntous
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2
Q

How does the bones of the knee influence its rotation?

A
  1. greater lateral condyle articular area in the sagittal plane creating greater motion
  2. convex A/P or sagittal joint surface of the lateral tibial facet versus the biconcave medial facet
    - about 15 degree of flexion the medial condyle starts to glide forward impart due to the concave facet
    - the lateral condyle continues to roll posteriorly for about 5 more degrees of flexion until it starts to glide anteriorly due to the convex facet
  3. Medial condyle extends further distally creating an oblique orientation of the femur on the tibia facilitating tibial ER with quad pull
  4. patella
    - moves medially during extension as it follows the femoral trochlear groove tensioning the lateral menisopatellar fibers
    - Screw home- the patella is released from the trochlear groove allowing for a greater lateralization of the quads pull
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3
Q

What are the muscular influence of knee rotation?

A
  1. Q-angle of the quad facilitates ER of the tibia with extension
  2. VMO fiber orientation facilitates tibial internal rotation
  3. VLO fiber orientation facilitates tibial external rotation
  4. popliteus
    - unlocks the knee from terminal knee extension pulling the tibia into IR
    - pulls the lateral meniscus posterior allowing for greater mobility
  5. semimembranous ties into the medial meniscus
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4
Q

How does the medial menisci influence rotation of the knee?

A
  1. attachments of the medial meniscus promote stability (6 mm of motion)
    a. capsular ligament at the periphery
    b. transverse ligament with lateral anterior horn
    c. ACL to the anterior horn pulls anteriorly during knee flexion femoral ER
    d. meniscopatellar fibers to anterior aspect of meniscus limiting motion with flexion
    e. MCL to medial aspect limiting movement with extension
    f. Semimembranosus posteriorly
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5
Q

How does the lateral meniscus influence rotation of the knee?

A
  1. attachments of the lateral meniscus promote mobility (12 mm)
    a. meniscopatellar fibers increasing motion during extension and allow more motion during flexion
    b. Popliteus tendon posteriorly pulling posteriorly during flexion
    c. meniscofemoral fibers attaching to the posterior horm pull the lateral meniscus anteriorly with femoral IR and knee extension
    d. No capsular or collateral attachments
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6
Q

How does the meniscopatellar ligaments influence rotation of the knee?

A
  1. Tibial IR with knee flexion > femoral ER > decreased lateral MP fiber tension and increased Medial MP tension > increased lateral meniscus mobility and decreased medial meniscus mobility
  2. tibial ER with knee extension > femoral IR > increased lateral MP fiber tension and decreased medial MP fiber tension > lateral meniscus is pulled anterior and medial meniscus is not pulled forward
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7
Q

How do the ligaments of the knee influence rotation?

A
  1. colaterals
    a. obliquely oriented so they tighten with extension limiting tibial external rotation
    b. MCL attaches to the medial meniscus halting the motion of the meniscus as it tightens where as the lateral is not influenced by the LCL
  2. cruciates
    a. winding of the cruciates during flexion limit tibial internal rotation
    b. during knee flexion the ACL is tensioned pulling the anterior medial tibia towards posterior lateral femur (i.e. tibial internal rotation)
    c. during knee extension the PCL is tensioned pulling the posterior lateral tibial towards the anterior medial femur (i.e. tibial external rotation)
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8
Q

What are the six functional contributions of the tibiofemoral menisci?

A
  1. Deepen the tibial fossa
  2. improve congruency of the tibia and femur
  3. improve stability of the knee
  4. provide shock absorption and lubrication to the knee
  5. reduce friction
  6. improve weight distribution
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9
Q

What attachments do the medial and lateral meniscus share or have in common?

A
  1. anterior horns in the intracondylar fossa
  2. posterior horns in the intracondylar fossa
  3. meniscal tibial ligaments at the edges
  4. anterior transverse ligament
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10
Q

What is the shape of the medial meniscus?

A
  1. semiciruclar
  2. about 3.5 cm long
  3. posterior horn wider than anterior
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11
Q

What are the attachments of the medial menisus?

A

1.capsular ligament at the periphery
2.Intracondylar fossa at the anterior horn
3.transverse ligament with lateral anterior horn
4,ACL to the anterior horn
5.meniscopatellar fibers to anterior aspect of meniscus
6.MCL to medial aspect
7.Semimembranosus posteriorly
8.intracondylar fossa posterior horn

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12
Q

What is the shape of the lateral meniscus?

A
  1. smaller and more round compared to the medial meniscus

2. the two horns almost meet in the mid line

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13
Q

What are the attachments of the lateral meniscus?

A
  1. posterior horn
  2. PCL to the posterior horn
  3. arcuate ligament posteriorly
  4. Popliteus tendon posteriorly
  5. meniscofemoral ligaments to posterior horn
  6. Anterior horn
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14
Q

What vessels supply the blood to the meniscus?

A
  1. Medial and lateral geniculate give rise to
  2. perimeniscal capillary plexus within the capsule and synovium give rise to
  3. meniscal vessels that penetrate 10-25% of medial and 10-30% of lateral meniscus
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15
Q

How does the flexion meniscus quadrant test work?

A

during flexion the the meniscus are pulled posteriorly as the femur roles back tensioning the meniscus with an posteriorly directed force > adding internal rotation of the tibia (ie external rotation of the femur) you get an anteriorly directed force medially with a second posterior directed force lateral > consequent you compress the posterior medial horn creating a click and pull the anterior lateral horn creating pain

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16
Q

How does the extension meniscus quadrant test work?

A

during extension the meniscus are pulled forward as the femoral condyle roll forward creating and anteriorly directed force > applying tibial external rotation (femoral internal rotation) you create a second anteriorly directed force lateral and a posteriorly directed force medially > you will have pain at the posterior lateral horn and click at the anterior medial horn

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17
Q

What type of injuries typically occur with the meniscus?

A
  1. horizontal tears- cleft like tear
  2. radial tears- inside towards outside
  3. flap- oblique tears
  4. longitudinal- through the body
  5. degenerative
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18
Q

What is a meniscal cyst and how does it form?

A
  1. a snynovial fluid filled pocket within the meniscus

2. most common in lateral meniscus horizontal tears

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19
Q

What are the most common clinical findings with meniscus tears?

A
  1. popping
  2. tenderness over the joint line
  3. complaints of pain over the joint line
  4. swelling
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20
Q

What is shape of the patellar articular surface?

A
  1. The patellar surface is convex wider laterally and has three distinct parts
    - superior- widest
    - inferior- rounded
    - middle- contains vascular orifices
  2. There are three facets on the articular surface separated by a boney ridge
    - medial
    - lateral
    - odd
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21
Q

What attaches to the patella?

A
  1. synovial lining
  2. joint capsule
  3. patellofemoral ligament
  4. quadricpes expansion or retinaculum
  5. fibrous expansion from TFL
  6. patellar tendon
  7. meniscopatellar fibers
22
Q

What are the retinacular structures of the patella?

A
  1. fibrous expansions of the vastus muscles
  2. attach to the medial and lateral borders of the patella and blend with the capsule
  3. lateral is stronger medial due to the overlap with the ITB expansion
23
Q

What are the dimensions of the patellar tendon?

A

3 cm wide at patellar insersion
2.5 cm tibial tubercle
5-6 cm long
0.7 cm thick

24
Q

What and where are the patellar recess?

A
  1. extensions of the capsule that create pockets in the joint capsule
  2. suprapatellar
  3. two parapetellar
25
Q

What are the purposes of the patellar recess?

A

it allows the patella to travel more than twice its length along the femor

26
Q

How do the compressive forces of the patellofemoral joint change as knee is loaded?

A
  1. it increases with knee flexion
  2. it is 1.5x the force on the force on the quad tendon at 90 degrees
  3. equal or less than body weight when walking
  4. stair climbing is about 3x body weight
  5. full squats are about 8x body weight
27
Q

What are the contact points of the patella and how does that change with ROM?

A
  1. full extension no contact
  2. 10-20 degrees inferior patella
  3. 45 degrees central/lateral patella
  4. 90 degrees superior patella
  5. 135 degrees lateral and medial patellar facet
28
Q

How are patellar compression forces minimized?

A
  1. the compression site changes as the knee moves
  2. the patellar tendon falls into the groove of the femoral condyles shorten the compression lever arm
  3. retinaculums don’t have significant compressive force due to there line of force wrapping around the condyles
29
Q

What are the primary functions of the patella?

A
  1. centrilize the force vectors of the four parts of the quad
  2. transmit force from the patellar tendon
30
Q

How far does the patella glide?

A

twice its length

31
Q

How does the Q-angle relate to the patella?

A
  1. the patella is the central point between the quad tendon the the patellar tendon
  2. the Q-angle is the measure between the two tendons
32
Q

What creates patellar stability?

A
  1. greater A/P length of the lateral femoral condyle elevates the lateral side prevent displacement
  2. Stronger lateral retinaculum prevents medial glide
  3. opposing forces of the medial and lateral vasti
  4. the large oblique fiber orientation of the the VMO of 65 degrees
  5. extensor mechanism
33
Q

What factors interfere or damage patellar tracking?

A
  1. increased q-angle
  2. tightness in the musculature and lateral structures
  3. patellar displacement: alta, baja, hypermobility
  4. vmo weakness
  5. deficits in the extensor mechanism
  6. subtalar tightness > decreases talocural DF > force tibia into greater external rotation > increases lateral patellar displacement
34
Q

Tightness in what muscle can effect patellar tracking?

A
  1. rectus femoris prevents full movement
  2. ITB and everything that ties into it can pull the patella laterally
  3. hamstrings by increasing the demand for DF and once the talocural joint is maxed out you can more from the subtalar joint that then leads to tibial and femoral IR and increased Q angle
  4. Gastroc follows the same pattern as the hamstrings
35
Q

What are the causes and contributing factors to patellar dislocation?

A

increased Q angle and deficiency of the extensor mechanism are required for dislocation to occur

36
Q

How is patellar alta and baja diagnosed?

A
  1. Radiograph at 45 degree knee flexion
  2. alta patella rides high
  3. baja patella rides low
37
Q

How can the hamstrings contribute to patellar compression issues?

A

increases tone in the hamstrings will increase resistance to knee extension therefore will require greater quad force and compression of the patella

38
Q

What are the attachments of the menisco-patellar fibers?

A

connective tissue running from the medial and lateral patella to the medial or lateral meniscus

39
Q

How do the meniscopatellar fibers impact movement of the knee?

A

the laxity or tautness of the fibers directly influences the ability of the meniscus to follow the femoral condyles with movement

40
Q

How do the meniscopatellar fibers influence the movement of the meniscus?

A
  1. Tibial IR with knee flexion > femoral ER > decreased lateral MP fiber tension and increased Medial MP tension > increased lateral meniscus mobility and decreased medial meniscus mobility
  2. tibial ER with knee extension > femoral IR > initially both fibers are tight with the pull of the quad > screw home > increased lateral MP fiber tension and decreased medial MP fiber tension > lateral meniscus is pulled anterior and medial meniscus is not pulled forward
41
Q

In what ROM should you initially start treatment for chondramalacia?

A

20-45 degree because you maximize boney stability and prevent shearing of the posterior aspect of the patella across the lateral condyle

42
Q

What is the patellar plica?

A
  1. crecent sharped fold of synovial tissue developing during development of the capsule as the three separate cavitities joint together to form the synovial cavity of the knee
  2. Lateral- the most common forms within the vastus lateralis tendonis insersion in about 65% of the population
  3. Superior-
  4. medial- present in 24% of the population and can snap over the medial condyle
  5. infrapatellar- connects to fat pad and runs back and attaches in the intracondylar notch and can attach or blend with the ACL
43
Q

What are the borders of the infrapatellar fat pad?

A
  1. beneth the patellar tenon
  2. superiorly the inferior patella
  3. inferiorly to the tibial tubercle
  4. laterally to the patellomeniscal ligaments are formed by the transition to the capsular synovium
44
Q

What attachments does the infrapetallar fat pad have?

A
  1. the synovial lining on the posteior aspect can form the infrapetellar plica that runs into the intracondylar notch and can even blend with ACL
  2. proximal patellar tendon
  3. inferior pole of patella
  4. transverse meniscal ligament
  5. medial and lateral anterior horns
  6. periostium of tibia
  7. patellomeniscal ligmanets
45
Q

What are the borders of the infrapatellar fat pad?

A
  1. beneth the patellar tenon
  2. superiorly the inferior patella
  3. inferiorly to the tibial tubercle
  4. laterally to the patellomeniscal ligaments are formed by the transition to the capsular synovium
46
Q

What attachments does the infrapetallar fat pad have?

A
  1. the synovial lining on the posteior aspect can form the infrapetellar plica that runs into the intracondylar notch and can even blend with ACL
  2. proximal patellar tendon
  3. inferior pole of patella
  4. transverse meniscal ligament
  5. medial and lateral anterior horns
  6. periostium of tibia
  7. patellomeniscal ligmanets
47
Q

Is the fat pad intra- or extra- capsular?

A

it is extrasynovial (it is lined with synovium), but intracapsular

48
Q

How does the infrapatellar fat pad move?

A
  1. during flexion the fat pad fills the anterior portion of the intercondylar notch
  2. during extension it occupies the patellar groove and cover the trochlear surface of the femur
  3. as you move between flexion and extension the fat pad moves across the condyles
49
Q

How would you diagnose a fat pad entrapment?

A
  1. pain at end range extension
  2. reduction in pain with distraction and tibial rotation
  3. Hoffa’s test- palpation of the medial or lateral fat pad starting in 30 degree flexion is painful and the pain increases when the knee is brought into full extension
  4. referred pain in the area of the fat pad and medial thigh
  5. loss of coordination of the VMO
50
Q

What innervates the fat pad?

A
  1. posterior aricular of the posterior tibial nerve has been shown to pass through the menisci, cruciates and synovium to reach the fat pad
  2. Pretty much anything that passess near it including obturator, femoral, fibular recurrent, lateral aricular, saphenous
  3. high density of the type IVs
51
Q

What is the function of the fat pad?

A
  1. possible biomechanical influences
  2. reservoir for repair cells after injury
  3. removal the fat pad has shown to result in decrease patellar tendon length
52
Q

What types of injury occur with the fat pad?

A

Typically you have inflammation and or fibrosis due to its highly vascular state

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