Knee joint and popliteal fossa

By Professor Nzarubara
Knee joint
 Summary
It will be considered under the following subtopics:
• Type of joint
• Articular surfaces
• Ligaments: Extra (5)
Intra articular: Cruciate (2) and menisci(2)
• Bursae 4 anterior
6 posterior
4 Communicating
• Nerve, blood , movements and relations
• Clinical relevance
 Knee joint
• It is the largest joint in the body.
• It is basically a compound synovial joint of the
hinge type.
• It has two main movements and that is flexion
and extension.
 Articular surfaces
• Interposed between the medial and lateral
condyles of the femur and tibia is a pair of
semilunar cartilages or menisci that prevent
direct contact between the circumferences of
tibial and femoral articular facets.
• Viewed from behind, the two femoral condyles
are seen to be separated from one another by
a depression, the intercondylar fossa.
Skeleton of the Proximal Lower Limb, Posterior View
 Articular surfaces
• On the tibia, the intercondylar eminence is interposed
between the two condylar articular facets.
• Articular surfaces of the femur, tibia and patella are
covered with hyaline cartilage like any articular
surfaces.
• Knee joint therefore consists of three articulations:
• Two femoro-tibial articulations are between the
lateral and the medial femoral and tibial condyles.
• One intermediate femoro-patellar articulation is
between the patella and the femur.
 Stability
Stability of the knee joint like any other joint
depends on:
• articular surfaces, ligaments, capsule and tone
of the muscles around the joint.
But here the most important are:
• strength and actions of surrounding muscles
and their tendons
• ligaments connecting the femur and tibia.
 Capsule
• Capsule is attached to the margins of the
articular surfaces and surrounds the sides and
posterior aspect of the joint.
• Anteriorly, capsular attachment is deficient,
there being a gap on the front of both femur
and tibia which is closed by the quadriceps
tendon, patella and ligamentum patellae.
 Capsule
• This deficiency permits the synovial membrane
to pouch upward beneath the quadriceps
tendon, forming the suprapatellar bursa.
• Tendinous fibers from the quadriceps reinforcing
the capsule on each side are known as patellar
retinacula.
• Posteriorly, the back is reinforced by tendinous
expansions of semimembranosus and is known
as oblique popliteal ligament.
 Capsule
• On each side of the patella, the capsule is
reinforced by expansions from the tendons of
vastus lateralis and medialis.
• An opening in the capsule behind the lateral
tibial condyle permits the tendon of the
popliteus to emerge.
 Synovial membrane
• Synovial membrane lines the capsule and covers all
intra-articular structures.
• It is attached to the margins of the articular surfaces.
• In front and above the joint, synovial membrane forms
a pouch which extends up beneath quadriceps femoris
muscle forming the suprapatellar bursa.
• At the back of the joint, synovial membrane is
prolonged downward on the deep surface of the
tendon of the popliteus forming popliteal bursa.
 Ligaments
• Ligaments of the knee joint may be divided
into those that lie outside the capsule (extra
capsular) and those that lie within the capsule
(intra capsular).
 Extracapsular ligaments
• There are five; they strengthen the joint
capsule:
• ligamentum patellae, fibular (lateral) collateral
ligament, tibial (medial) collateral ligament,
oblique popliteal ligament and arcuate
popliteal ligament.
Collateral ligaments of the knee joint. A. Lateral view. B. Medial
view.
Fibrous membrane of the knee joint capsule. A. Anterior view. B.
Posterior view.
 Ligamentum patellae
• It is attached above to the border of patella
and below to the tuberosity of the tibia.
• It is a continuation of the central portion of
the quadriceps femoris tendon.
 Tibial (medial) collateral
• Tibial (medial) collateral ligament is a flat
broad band extending from medial epicondyle
of the femur to the medial condyle and
superior part of the medial surface of the
tibia.
• It is firmly attached to the edge of the medial
meniscus.
 Fibular (lateral) collateral
• Fibular (lateral) collateral ligament is strong,
rounded and cord-like.
• It extends inferiorly from the lateral
epicondyle of femur to the lateral surface of
the head of the fibula.
• The tendon of the popliteus passes deep it,
separating it from the lateral meniscus.
 Tibial and fibular
• Both tibial and fibular ligaments become taut
in full extension
• Chief function is to provide side to side
stability to the knee joint.
 Oblique popliteal
• It is a reflected expansion of the tendon of the
semimembranosus that strengthens the joint
capsule posteriorly.
• It arises posterior to the medial tibial condyle
and passes superolaterally to attach to the
central part of the posterior aspect of the joint
capsule.
 Arcuate popliteal
• Arcuate popliteal ligament strengthens the
fibrous capsule posterolaterally.
• It arises from the posterior aspect of the
fibular head, passes superomedially over the
tendon of the popliteus, and spreads over the
posterior surface of the knee joint.
 Intracapsular ligaments
• The intra-articular ligaments within the knee joint consist
of the cruciate ligaments and menisci. The popliteus
tendon is also intra-articular during part of its course
• Cruciate ligaments are named anterior and posterior
according to their tibial attachments.
• These are two strong intracapsular ligaments that cross
each other within the joint cavity.
• On crossing each other, they resemble St. Andrew’s cross.
• These ligaments are the main bond between the femur
and the tibia throughout the joint’s movements.
Articular surfaces of the knee joint C. Anterior view (flexed
 Cruciate ligaments
• Their main function is to prevent
anteroposterior displacement of the two
bones upon one another.
• In full extension, both cruciate ligaments are
tight and they also impart side to side stability
to the knee.
 Anterior cruciate ligament
• It is attached to the anterior part of the
intercondylar area of tibia and passes
backwards, upward and laterally to be
attached to the posterior part of the medial
surface of the lateral femoral condyle.
• It prevents posterior displacement of the
femur on the tibia. With the knee joint flexed,
the anterior cruciate ligament prevents the
tibia from being pulled anteriorly.
Cruciate ligaments of knee joint.
 Posterior cruciate ligament
• It is attached to the posterior intercondylar
area of the tibia and passes upward, forward
and medially to be attached to the anterior
part of the lateral surface of the medial
femoral condyle.
• It prevents anterior displacement of the femur
on the tibia. With the knee joint flexed, the
posterior cruciate ligament prevents the tibia
from being pulled posteriorly.
Cruciate ligaments of the knee joint. Superolateral view
 Menisci
• Menisci are two semilunar or C-shaped sheets
of fibrocartilage.
• peripheral border is thick and attached to the
capsule, and the inner border is thin and
concave and forms a free border.
• The upper surfaces are in contact with the
femoral condyles.
 Menisci
• The lower surfaces are in contact with the tibial
condyles and both surfaces are moistened by
synovial fluid.
• Both menisci are anchored by their anterior and
posterior horns to the intercondylar eminence.
• The medial meniscus is more fixed by tibial
collateral ligament attached to it and is more
widely open than the lateral meniscus.
Menisci of the knee joint.
 Menisci
• Their function is:
• to deepen the shallow articular surfaces of the
tibial condyles
• to receive the convex femoral condyles
• to serve as cushion between the two bones
and partially divide the joint cavity.
 Bursae around the knee joint
• There are several bursae around the joint.
• Four are situated anterior and six are behind
the joint.
• Four bursae communicate with the articular
cavity of the knee joint: suprapatellar,
popliteal, semimembranosus and
gastrocnemius bursae.
 Anterior bursae
• Suprapatellar lies beneath quadriceps muscle
• Prepatellar lies in the subcutaneous tissue
between the skin and lower half of patella
• Superficial infrapatellar lies in the
subcutaneous tissue between skin and lower
part of the ligamentum patellae
• Deep infrapatellar lies between the
ligamentum patellae and the tibia
 Posterior bursae
• Popliteal is found in association with popliteus
• Semimembranosus is related to the insertion
of the membranosus muscle
• The other four bursae are found related to the
tendon of insertion of biceps femoris,
sartorius, gracilis, and semitendinosus
Synovial membrane of the knee joint and associated bursae
The right knee joint as seen from the lateral aspect.
 Nerve supply
• Nerves of the knee joint are articular branches
from the femoral, tibial, common fibular,
obturator and saphenous nerves
 Blood supply
• Arteries supplying the knee joint form the
periarticular genicular anastomosis around the
knee:
• genicular branches of the femoral, popliteal
and anterior and posterior tibial arteries.
Anastomoses of arteries around the knee. Anterior view.
 Movements
• Knee joint can flex, extend and rotate.
• Flexion of the knee is normally limited by
contact between the calf and thigh.
• In full extension, the angle between the tibia
and femur is slightly greater than 1800 in
women and slightly less in men.
 Movements
• During full extension, medial rotation of the
femur results in twisting and tightening of all
the major ligaments of the joint and the knee
becomes a mechanically rigid structure;
• menisci are compressed between the femoral
and tibial condyles.
• The extended knee is said to be in the locked
position.
 Movements
• Maximum stability of the knee joint is attained in full
extension because there is close packing of the joint.
• Before flexion can occur, knee has to be unlocked.
• The major ligaments have to be untwisted and slackened
to permit movements between the joint surfaces.
• Unlocking is done by popliteus muscle which medially
rotates the tibia or laterally rotates the femur on the
tibia. When the knee joint is flexed to a right angle, a
considerable range of rotation is possible.
 Movements
• The following muscles produce movements at
the knee joint.
• Flexion by hamstrings assisted by gracilis,
sartorius, popliteus and gastrocnemius.
• Extension by quadriceps
• Medial rotation by sartorius, gracilis and
semitendinosus.
• Lateral rotation by biceps femoris
 Important relations.
• Anteriorly are prepatellar bursa
• Posteriorly are popliteal vessels, tibial and
common peroneal nerves, lymph nodes, and
muscles that form the boundaries of the
popliteal fossa
• Medially are sartorius, gracilis, and
semimembranosus muscles
• Laterally are biceps femoris and common
peroneal nerve.
Relations of the right knee joint
Popliteal fossa.
 Summary
It will be considered under the following
subtopics:
• Boundaries
• Contents
 Popliteal fossa.
• It is a rhomboid or diamond shaped
intermuscular space located behind the knee
joint.
• Largely filled by fat, the fossa transmits major
nerves and blood vessels between the thigh
and the leg.
 Boundaries
• Proximally:
• lateral boundary is formed by biceps femoris
• medial boundary by the semitendinosus and
semimembranosus.
• Distally:
• lower borders are formed by the large superficial muscle
of the calf, gastrocnemius
• medially by the medial head of the gastrocnemius muscle
• laterally by the plantaris muscle and the lateral head of
the gastrocnemius muscle.
 Popliteal fossa.
• Roof is formed by the skin, superficial fascia,
deep fascia of the thigh and popliteal fascia.
• Floor of the fossa is formed by the popliteal
surface of the femur, the knee joint capsule,
posterior ligament of knee joint, popliteus
muscle, which covers the back of the upper
end of the tibia.
popliteal fossa
 Contents
• popliteal vessels
• small saphenous vein
• common peroneal and tibial nerves,
• posterior cutaneous nerve of the thigh
• genicular branch of obturator nerve
• connective tissue and lymph nodes and
lymphatics.
 Popliteus muscle
• Popliteus muscle arises from the lateral condyle of
the femur by a rounded tendon and by a few fibers
from the lateral semilunar cartilage.
• It is inserted on the posterior surface of tibia above
soleal line.
• Nerve supply is tibial nerve and action medial
rotation of the tibia on the femur and lateral rotation
of the femur on the tibia if the foot is on the ground.
• The latter action is called unlocking the knee joint.
 Popliteal artery
• Popliteal artery commences at the adductor
canal and terminates by dividing into anterior
and posterior tibial arteries after it has left
the fossa at the lower border of popliteus
muscle.
• It descends through the middle of the fossa
anterior to the vein and gives off genicular
arteries to the knee joint.
 Branches

• Superior genicular arteries (a pair) run around

the lower end of femur.
• Inferior genicular arteies (a pair) encircle the
upper end of tibia.
• Middle geniculate artery is distributed to the
structures within the joint.
• Sural arteries which are paired arteries and
supply the gastrocnemius and soleus muscle
before it terminates.
 Popliteal vein
• Popliteal vein is formed by the union of venae
comitantes of anterior and posterior tibial
arteries at the lower border of popliteus
muscle.
• After adductor hiatus, it becomes femoral
vein.
 Nerves
• Sciatic nerve reaches the popliteal fossa
where it divides into the tibial and common
fibular nerves in the upper part of the fossa
lying posterolateral to popliteal vessels.
• Common fibular nerve diverges laterally to
pass around the lateral side of the leg,
whereas the larger tibial nerve descends
almost straight down through the fossa.
 Tibial nerve
• It is the larger terminal of sciatic nerve.
• Where it starts varies.
• Popliteal vein lies between the nerve and
artery throughout its course.
• The nerve enters the posterior compartment
of the leg by passing beneath the soleus
muscle.
 Tibial nerve
• Its branches are sural nerve which descends
between the two heads of gastrocnemius
muscle and is usually joined by sural
communicating branch of the common
peroneal nerve.
• It accompanies small saphenous vein behind
lateral malleous others are medial calcaneal
nerve, muscular and articular branches.
 Common fibular (peroneal) nerve
• Common fibular (peroneal) nerve runs down
the fossa closely following the medial border
of the biceps muscle.
• It leaves the fossa by crossing superficially the
lateral head of gastrocnemius muscle.
 Common fibular (peroneal) nerve
• It then passes behind head of fibula, winds
laterally around the neck of the bone, pierces
the peroneus longus muscle, and divides into
two terminal branches: the superficial and
deep peroneal nerves.
• It is subcutaneous at the lateral aspect of the
neck of the fibula. Its branches are sural
communicating, lateral cutaneous nerve of
the calf, muscular and articular.
 Obturator nerve
• Obturator nerve leaves the adductor canal
with the femoral artery and terminates by
supplying the knee joint.
 Popliteal lymph nodes
• Popliteal lymph nodes receive both superficial
lymph vessels accompanying small saphenous
vein and deep lymphatics accompanying the
deep veins.
Clinical relevance
 Patella
• A fall or a direct blow may smash the patella.
Two types are possible; patella fractured into
two pieces or multiple fractures.
• Patella is part of the extensor mechanism of
the knee joint. Therefore its injury interferes
with extension.
 Knee joint injuries
• Tibial/fibular for medial/lateral displacement
• Cruciate for antero-posterior displacement
• Meniscal injuries are also very common. The
medial meniscus is damaged much more
frequently than the lateral and this is probably
because of its strong attachment to the medial
collateral ligament of the knee joint, which
restricts its mobility.
 Bursitis in the knee region
• Prepatellar bursitis (housemaid's knee) is
usually a friction bursitis caused by friction
between the skin and the patella.
• The suprapatellar (clergyman’s knee} bursa
communicates with the articular cavity of the
knee joint. The infection may spread to the
knee joint.
 Genu valgum and genu varum
• A medial angulation of the leg in relation to
the thigh, in which the femur is abnormally
vertical is a deformity called genu varum
(bowleg) that causes unequal weight
distribution.
• A lateral angulation of the leg in relation to
the thigh (exaggeration of knee angle) is genu
valgum (knock-knee).
 Compartment Syndromes
• Trauma to muscles and/or vessels in the compartments
may produce hemorrhage, edema and inflammation of
the muscles.
• Because the septa and deep fascia of the leg forming
the boundaries of the leg compartments are strong,
the increased volume as a consequence of any of these
processes increases intra-compartmental pressure.
• This results in compartment syndromes, in which
structures within or distal to the compressed area may
become ischemic and permanently injured.