Posteromedial corner injury of the knee

Changed by Zishan Sheikh, 24 Mar 2018

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Posteromedial corner injury of the knee is a ~~poorly reco~~readily identifiable but frequently underappreciated on imaging. Importantly, it can result in increased stress on the cruciate ligaments and can result in anteromedial rotatory instability of the knee.

Clinical presentation

These injuries are frequently seen in athletes and are usually sustained with the knee in valgus. On examination may reveal tenderness along the medial joint line. The anterior draw test is used with the tibia held in external rotation to evaluate for anteromedial rotatory instability.

Pathology

The structures that comprise the posteromedial corner (PMC) are:

posterior oblique ligament:
- injury in virtually all cases with associated instability
- made of three parts
  - superficial arm
  - tibial arm
  - capsular arm
oblique popliteal ligament
meniscotibial ligament
semimembranosus tendon
medial meniscus: posterior third

Up to 88% of injuries can be associated with a cruciate ligament injury, overwhelmingly the ACL ¹.

Radiographic features

Plain radiographs

May non-specific features such as a lipohaemarthrosis. A fracture of the medial tibial corner may be seen. Weight bearing views can reveal a valgus deformity.

MRI

Is the investigation of choice as it can readily demonstrate all the components of the PMC.

posterior oblique ligament
- can be thickened with adjacent fluid if sprained
- marrow oedema may be seen with rupture
meniscocapsular
- easiest seen on coronal
- reverse Segond fracture if meniscotibial ligament insertion is pulled off
semitendonosus tendon
- may be an avulsion fracture at the posteromedial tibial plateau at its insertion
oblique popliteal ligament
- best seen on axials
medial meniscus

Treatment and prognosis

Whether or not surgical intervention is offered depends on the presence of knee instability and concurrent cruciate or other ligamentous injuries. Surgical approaches vary with either surgical repair or reconstruction.

~~-<p><strong>Posteromedial corner injury of the knee</strong> is a poorly reco</p>~~
+<p><strong>Posteromedial corner injury of the knee</strong> is a readily identifiable but frequently underappreciated on imaging. Importantly, it can result in increased stress on the cruciate ligaments and can result in <a href="/articles/anteromedial-rotatory-instability">anteromedial rotatory instability</a> of the knee.</p><h4><strong>Clinical presentation</strong></h4><p>These injuries are frequently seen in athletes and are usually sustained with the knee in valgus. On examination may reveal tenderness along the medial joint line. The anterior draw test is used with the tibia held in external rotation to evaluate for anteromedial rotatory instability. </p><h4>Pathology</h4><p>The structures that comprise the posteromedial corner (PMC) are:</p><ul>
+<li>
+<a href="/articles/posterior-oblique-ligament">posterior oblique ligament</a>:<ul>
+<li>injury in virtually all cases with associated instability</li>
+<li>made of three parts<ul>
+<li>superficial arm</li>
+<li>tibial arm</li>
+<li>capsular arm</li>
+</ul>
+</li>
+</ul>
+</li>
+<li>oblique popliteal ligament</li>
+<li>meniscotibial ligament</li>
+<li>semimembranosus tendon</li>
+<li>medial meniscus: posterior third</li>
+</ul><p>Up to 88% of injuries can be associated with a cruciate ligament injury, overwhelmingly the ACL <sup>1</sup>.</p><h4>Radiographic features</h4><h5>Plain radiographs</h5><p>May non-specific features such as a lipohaemarthrosis. A fracture of the medial tibial corner may be seen. Weight bearing views can reveal a valgus deformity.</p><h5>MRI</h5><p>Is the investigation of choice as it can readily demonstrate all the components of the PMC. </p><ul>
+<li>posterior oblique ligament<ul>
+<li>can be thickened with adjacent fluid if sprained</li>
+<li>marrow oedema may be seen with rupture</li>
+</ul>
+</li>
+<li>meniscocapsular<ul>
+<li>easiest seen on coronal</li>
+<li>reverse Segond fracture if meniscotibial ligament insertion is pulled off</li>
+</ul>
+</li>
+<li>semitendonosus tendon<ul><li>may be an avulsion fracture at the posteromedial tibial plateau at its insertion</li></ul>
+</li>
+<li>oblique popliteal ligament<ul><li>best seen on axials</li></ul>
+</li>
+<li>medial meniscus</li>
+</ul><h4>Treatment and prognosis</h4><p>Whether or not surgical intervention is offered depends on the presence of knee instability and concurrent cruciate or other ligamentous injuries. Surgical approaches vary with either surgical repair or reconstruction.</p>

References changed:

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3. Geiger D, Chang EY, Pathria MN, Chung CB. Posterolateral and posteromedial corner injuries of the knee. (2014) Magnetic resonance imaging clinics of North America. 22 (4): 581-99. <a href="https://doi.org/10.1016/j.mric.2014.08.001">doi:10.1016/j.mric.2014.08.001</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/25442024">Pubmed</a> <span class="ref_v4"></span>
4. Pedersen RR. The Medial and Posteromedial Ligamentous and Capsular Structures of the Knee: Review of Anatomy and Relevant Imaging Findings. (2016) Seminars in musculoskeletal radiology. 20 (1): 12-25. <a href="https://doi.org/10.1055/s-0036-1579710">doi:10.1055/s-0036-1579710</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/27077583">Pubmed</a> <span class="ref_v4"></span>
4. Pedersen RR. The Medial and Posteromedial Ligamentous and Capsular Structures of the Knee: Review of Anatomy and Relevant Imaging Findings. (2016) Seminars in musculoskeletal radiology. 20 (1): 12-25. <a href="https://doi.org/10.1055/s-0036-1579710">doi:10.1055/s-0036-1579710</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/27077583">Pubmed</a> <span class="ref_v4"></span>
4. Pedersen RR. The Medial and Posteromedial Ligamentous and Capsular Structures of the Knee: Review of Anatomy and Relevant Imaging Findings. (2016) Seminars in musculoskeletal radiology. 20 (1): 12-25. <a href="https://doi.org/10.1055/s-0036-1579710">doi:10.1055/s-0036-1579710</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/27077583">Pubmed</a> <span class="ref_v4"></span>
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5. Tibor LM, Marchant MH, Taylor DC, Hardaker WT, Garrett WE, Sekiya JK. Management of medial-sided knee injuries, part 2: posteromedial corner. (2011) The American journal of sports medicine. 39 (6): 1332-40. <a href="https://doi.org/10.1177/0363546510387765">doi:10.1177/0363546510387765</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/21173192">Pubmed</a> <span class="ref_v4"></span>
6. Mark E. Cinque, Jorge Chahla, Bradley M. Kruckeberg, Nicholas N. Dephillipo, Gilbert Moatshe, Robert F. Laprade. Posteromedial Corner Knee Injuries: Diagnosis, Management, and Outcomes. (2017) Jbjs Reviews. 5 (11): e4. <a href="https://doi.org/10.2106/JBJS.RVW.17.00004">doi:10.2106/JBJS.RVW.17.00004</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/01874474-201711000-00002">Pubmed</a> <span class="ref_v4"></span>
3. Tibor LM, Marchant MH, Taylor DC, Hardaker WT, Garrett WE, Sekiya JK. Management of medial-sided knee injuries, part 2: posteromedial corner. (2011) The American journal of sports medicine. 39 (6): 1332-40. <a href="https://doi.org/10.1177/0363546510387765">doi:10.1177/0363546510387765</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/21173192">Pubmed</a> <span class="ref_v4"></span>
4.
4. Mark E. Cinque, Jorge Chahla, Bradley M. Kruckeberg, Nicholas N. Dephillipo, Gilbert Moatshe, Robert F. Laprade. Posteromedial Corner Knee Injuries: Diagnosis, Management, and Outcomes. (2017) Jbjs Reviews. 5 (11): e4. <a href="https://doi.org/10.2106/JBJS.RVW.17.00004">doi:10.2106/JBJS.RVW.17.00004</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/01874474-201711000-00002">Pubmed</a> <span class="ref_v4"></span>
5.