Table Of ContentSpringer-Verlag
Geschaftsbibliothek - Heidelberg
Michael Strobel
Hans-Werner Stedtfeld
Diagnostic Evaluation
of the Knee
With a Foreword by John A. Feagin
Translation by Terry C. Telger
With 369 Figures (Mostly in Color)
Containing 541 Separate Illustrations
and 109 Tables
Springer-Verlag Berlin Heidelberg New York
London Paris Tokyo Hong Kong
Dr. Michael Strobel
Klinik und Poliklinik fUr Unfall- und Handchirurgie
WestHilische Wilhelms-Universitat, lungeblodtplatz 1
0-4400 Munster
PO Dr. Hans-Werner Stedtfeld
Stadtisches Klinikum, Zentrum Chirurgie
Fachabteilung Unfallchirurgie, FlurstraBe 17
0-8500 Nurnberg
Translator
Terry C. Telger
6112 Waco Way, Ft. Worth, TX 76133, USA
ISBN -13: 978-3-642-74399-3 e-ISBN- 13: 978-3-642-74397-9
001: 10.1007/978-3-642-74397-9
Library of Congress Cataloging-in-Publication Data
Strobel, Michael. [Diagnostik des Kniegelenkes. English]
Diagnostic evaluation of the knee 1 Michael Strobel, Hans-Werner Stedtfeld :
with a foreword by John A. Feagin : translation by Terry C. Telger. p. ern.
Translation of: Diagnostik des Kniegelenkes.
Includes bibliographical references. Includes index.
ISBN -13 :978-3-642-74399-3
1. Knee-Wounds and injuries-Diagnosis. 2. Knee-Mechanical properties. 3. Arthroscopy. I. Stedtfeld,
Hans-Werner, 1944-11. Title. [DNLM: 1. Arthroscopy. 2. Knee Injuries-diagnosis. 3. Knee Joint.
WE 870 S919d] RD561.S7713 1990 617S8207545-dc20 DNLM/DNLC
for Library of Congress 90-10232 CIP
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under the prosecution act of the German Copyright Law.
©Springer-Verlag Berlin Heidelberg 1990
Softcover reprint of the hardcover 1st edition 1990
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2124/3145-543210 - Printed on acid-free paper
To our wives
Foreword
Knee surgeons world wide have been aware that a beautifully illustrated
book on diagnostic evaluation of the knee existed. What we in the English
speaking world did not appreciate was the superb quality of the text that ac
companied these splendid illustrations. Now, Dr. Michael Strobel and Dr.
Hans-Werner Stedtfeld's work, Diagnostic Evaluation of the Knee, has been
translated by Mr. Terry Telger into an English text that is clear and cogent.
The authors' message is comprehensive and straight forward. They show how
diagnosis of knee disorders lends itself to a disciplined, orderly thought pro
cess based on a substantial body of scientific knowledge. This book, through
effective illustrations, clarity of text and thought, and subject organization,
leads the reader through the diagnostic evaluation of the knee in an enjoy
able and unforgettable way.
Some may think the diagnostic process is dead with the advent of magnetic
resonance imaging. They are wrong: the diagnostic process has never been
more alive, and M. Strobel and H.-W. Stedtfeld capture the excitement of
modern day diagnosis through the integration of many disciplines - anato
my, pathophysiology, general examination, special examinations, and special
studies. This is the unique character of this book and why it will be a text ap
preciated by all who care for the knee-injured patient.
Diagnostic Evaluation of the Knee is a timely work: it fills a needed void,
and yet is also an in-depth reference companion. This scientific text is truly
deserving of the broad dissemination that will be gained through translation.
We appreciate having Diagnostic Evaluation of the Knee available in English.
August 1990 JOHN A. FEAGIN, M. D.
Durham, North Carolina
Preface
The knee joint, like no other joint in the human body, forms a focal point for
diagnostic evaluations by the traumatologist and orthopaedist as well as by
the sports physician and general practitioner. This is because of the excep
tional vulnerability of the knee joint and its extremely complex anatomic and
biomechanical structure.
New scientific discoveries in anatomy, biomechanics, pathophysiology,
and diagnostics have led to a significant evolution and reframing of tradition
al views. This accounts both for the vast body of literature and for the fre
quent contradictory reports on the diagnosis, classifications, and treatment of
knee injuries and their sequelae. Our knowledge of anatomy, too, has been
greatly expanded, leading to new functional descriptions for a number of an
atomic structures.
While many different tests and procedures are available for examinations
of the knee, there is much diversity of opinion as to their appropriate use and
value.
Injuries and diseases of the knee deserve special attention because, though
very common, they are complex in terms of their detection and differential
diagnosis. Examiners must cope with a frustrating lack of consensus in the
classification of these lesions and in the evaluation of diagnostic test proce
dures. This diagnostic "tentativeness" leads to errors that can result in chron
ic, refractory, and at times irreversible damage to the entire joint. What is true
in the diagnostic realm is even more true in treatment, as evidenced by the
fact that, to date, more than 300 different surgical procedures have been de
scribed for repairs and reconstructions of the ACL, yet there is still no gener
ally accepted "procedure of choice."
Similar problems exist with regard to evaluations of the menisci and patel
la. By contrast, fractures about the knee joint (femoral condyles, proximal
tibia, patella) pose few diagnostic problems because they are so accessible to
visualization and evaluation by a variety of radiologic techniques.
This book is intended as a reference work and "diagnostic companion"
that will guide the examiner in the conduct of clinical examination proce
dures, both general and specialized, as well as in the various radiologic
studies, machine evaluations, and diagnostic arthroscopy.
We express particular thanks to Dr. A. Menschik of Vienna for his generous
help, his many useful comments, and for proofreading the chapter on bio
mechanics and biometry.
We thank Prof. Dr. M. Reiser (Institute of Clinical Radiology, Westphalian
Wilhelm University, Munster) for his kind and energetic support in compil
ing the chapters on X-ray examinations and magnetic resonance imaging.
Prof. Dr. P. E. Peters, Director of the Department of Clinical Radiology of
)( Preface
the Westphalian Wilhelm University of Munster, furnished the many )(-ray
films that are reproduced in this text, and his assistance is gratefully acknowl
edged.
We thank Prof. Dr. E. Brug (Director, Clinic of Traumatology and Hand
Surgery, Westphalian Wilhelm University of Munster) and Prof. Dr. H. Bunte
(Director, Clinic of General Surgery, Westphalian Wilhelm University of
Munster) for the generous help, which proved to be essential in the planning
of this book.
We are also indebted to Dr. Sciuk for proofreading the chapter on scintig
raphy. We thank our friend Dr. Hans PassIer (Bopfingen) for his support and
for supplying several of the illustrations.
We thank Dr. H. Neumann, Dr. U. Sulkowski, and Mrs. U. Strobel for their
extensive help with proofreading, Mrs. C. Werfs and Mrs. M. Wiewer for typ
ing the manuscript, and Mr. Eschkotter for his outstanding photographic
documentation of the clinical examination and numerous findings.
It was a pleasure working with the publishing staff at Springer Verlag,
whom we thank for their excellent work in the production of this book.
Finally, we give special recognition and our sincere thanks to Mr. Terry
C. Telger CFt. Worth, TI) for undertaking the English translation.
Munster, July 1990 MICHAEL STROBEL
HANS-WERNER STEDTFELD
Contents
Anatomy, Proprioception, and Biomechanics
1 Anatomy, Proprioreception, and Biomechanics . 2
1.1 Introduction .. . . . . . . . . . 2
1.2 Bony Structures . . . . . . . . . 2
1.2.1 Femur . 2
1.2.2 Patella ..... . 4
1.2.3 Tibia ...... . 4
1.3 Anterior Complex 5
1.3.1 Quadriceps Femoris Muscle. 5
1.3.2 Medial and Lateral Retinacula 7
1.3.3 Infrapatellar Fad Pad . . . . 7
1.4 Central Complex . . . . . . . 7
1.4.1 Anterior Cruciate Ligament . 8
1.4.2 Posterior Cruciate Ligament. 12
1.4.3 Anterior and Posterior Meniscofemoral Ligaments 14
1.4.4 Menisci ..... . 14
1.4.4.1 Medial Meniscus . 16
1.4.4.2 Lateral Meniscus. 16
1.5 Medial Complex . 17
1.5.1 Medial Collateral Ligament . 17
1.5.2 Medial Capsular Ligament . 19
1.5.3 Posterior Oblique Ligament . 21
1.5.4 Semimembranosus Muscle 22
1.5.5 Pes Anserinus. . . 23
1.6 Posterior Complex . . . . . 25
1.6.1 Posterior Capsule ..... 25
1.6.2 Oblique Popliteal Ligament 25
1.6.3 Arcuate Popliteal Ligament 25
1.6.4 Popliteus Muscle . . . . 27
1.6.5 Gastrocnemius Muscle. . . 29
1.7 Lateral Complex . . . . . . 29
1.7.1 L~teral Capsule, Lateral Capsular Ligament . 29
1.7.2 Lateral Collateral Ligament . . 30
1.7.3 Iliotibial Tract ..... 30
1.7.4 Biceps Femoris Muscle 32
1.8 Proprioception . . . . . 32
1.8.1 Classification . . . . . . 33
1.8.2 Distribution of Proprioceptors in the Knee Joint 33
1.8.2.1 Anterior Cruciate Ligament . 34
1.8.2.2 Medial Collateral Ligament . . . . . . . . . . . . 35
XII Contents
1.8.2.3 Meniscus .......... . 35
1.8.3 Therapeutic Implications .. 35
1.9 Biomechanics and Biometry . 38
1.9.1 Basic Considerations. . . . . 38
1.9.2 Analysis of an Unknown Biologic Motion System 40
1.10 Radiographic Anatomy . . 43
1.10.1 Anteroposterior Projection .... . 43
1.10.2 Lateral Projection ......... . 43
1.10.3 Tangential Projection (Sunrise View) 46
1.11 Congenital Anomalies and Malformations of Ligamentous
Structures . 46
1.12 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
General Clinical Diagnosis
2 General Oinical Diagnosis 50
2.1 History ....... . 50
2.1.1 Time of Injury . . . . 52
2.1.2 Mechanism of Injury . 53
2.1.3 Locking. 54
2.1.4 Snapping ...... . 56
2.1.5 Pain ......... . 57
2.1.5.1 Reflex Sympathetic Dystrophy 57
2.1.5.2 Pain Orginating Outside the Knee 58
2.1.5.3 Knee Pain in Children . 59
2.1.5.4 Chronic Knee Pain . 60
2.1.6 Giving Way .. 61
2.2 Inspection ..... . 61
2.2.1 Open Injuries . . . . 61
2.2.2 Effusion and Other Swelling 64
2.2.3 Muscular Atrophy 64
2.2.4 Skin Changes . . . . . . . . . 67
2.2.5 Loss of Extension ..... . 69
2.2.6 Spontaneous Posterior Drawer 73
2.2.7 Limb Axis .... 73
2.3 Function Testing 73
2.3.1 Mobility ..... 73
2.3.2 Rigidity Tests . . 76
2.3.3 Muscular Function . 77
2.3.4 Sensation 78
2.3.5 Circulation . . . . . 78
2.4 Palpation ..... . 79
2.4.1 Intraarticular Effusion . 79
2.4.2 Extraarticular Swelling 80
2.4.3 Intraarticular Phenomena 81
2.4.4 Local Pain and Tenderness 81
2.4.4.1 Anterior Pain and Tenderness . 81
2.4.4.2 Lateral Pain and Tenderness 86
2.4.4.3 Medial Pain and Tenderness 89
