Knee Ligament Injuries PDF
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Pharos University in Alexandria
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This document provides comprehensive information on knee ligament injuries, covering their anatomy, biomechanics, mechanisms of injury, diagnosis, treatment, and rehabilitation strategies, potentially useful for diagnosing and managing injuries.
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Knee ligament injuries َم ْل ِع اَل َكَن ا ُس ْبَح َّل َنا ِإ َما َع ْمَتَناۖ اَّل َل ْل َأ َك ِإَّن ْنَت ا َعِليُم ي ْل ا Anatomy Originates from the distal part of the medial aspec...
Knee ligament injuries َم ْل ِع اَل َكَن ا ُس ْبَح َّل َنا ِإ َما َع ْمَتَناۖ اَّل َل ْل َأ َك ِإَّن ْنَت ا َعِليُم ي ْل ا Anatomy Originates from the distal part of the medial aspect of the lateral condyle of the femur. Anatomy It courses anteriorly, distally and medially to be inserted into the intercondylar area of the tibial plateau, at the medial tibial spine and anterior to it. Anatomy Average length 38 mm Average width10 mm Tendency to external rotation of its fibers as it courses distally Well marked slip to the anterior horn of Anatomy Many authors suggests the existence of 2main bundles, the anteromedial and the posterolateral ones. The ant med bundle becomes tighter in flexion and the post lat one slackens, and vice versa. Some other authors suggested the presence of 3 bundles!!! biomechanics Controls anterior displacement in the unloaded knee. Resist rotatory instability. Resist varus valgus instability together with the medial and the lateral ligaments of the knee. Proprioception biomechanics Amis and Dawkins found that the fiber bundles were not isometric, the anteromedial bundle lengthens, and the posterolateral bundle shortens during flexion, Fiber recruitment concept. biomechanics The cruciate ligaments are first “strain gauges” used as input for control of the limb. the cruciate ligaments are first displacement transducers that provide input to the neuromuscular control system. Only in the extremes of motion are they “checkreins” that directly constrain motion. Mechanism of injury The reverse of its stabilising effect Twisting and stress valgus injuries are the most 2 common mechanisms management Diagnosis, very common story History of extreme importance, usually pop sound after a twisting knee injury, followed by swelling and inability to keep on playing Look for the initial injury Repetitive giving way if left untreated (very common), may be catching and /or locking if got complicated by meniscal or chondral damage Diagnosis C/E knee haemarthrosis in the acute settings (most common cause ) or variable degrees of effusion if chronic no ecchymosis (intracapsular injury) Anterior instability detected best by Lachmann’s test on the examination couch, pivot shift under anasthesia and anterior drawer test Medio-lateral instability mildly increased Look for other associated injuries Diagnosis Anterior instability detected best by Lachmann’s test on the examination couch Diagnosis Anterior instability detected best by pivot shift under anesthesia and anterior drawer test Diagnosis Medio-lateral instability mildly increased Look for other associated injuries Diagnosis Radiology, MRI diagnostic in most of the cases, most obvious in the vertical cuts though not necessary for diagnosis, shows discontinuity of the ligament MRI detects other injuries as well , less accurate for chondral damage Diagnosis Lateral condyle contusion and occasionally avulsion of posterolateral capsule (segond’s fracture) Treatment Operative treatment of choice Postpone the athlete for the 1st 3weeks, then for surgery in most of young athletes Rehabilitation from the 1st day with POLICE Aspiration of haemarthrosis if necessary, by the 2-3 days post injury Early surgery for recent injuries to avoid further damage Graft Choice Types Of Grafts: Autografts Allografts synthetic grafts LARS Graft Choice Types Of Grafts: Autografts extensor tendon grafts (anteriorly harvested) 1. patellar tendon 2. quadriceps tendon grafts Graft Choice Types Of Grafts: Autografts Flexor tendon grafts (hamstrings graft) semi T gracillis Operative treatment Pros and cons: BTB and quadriceps grafts are stiffer, but has higher incidence of anterior knee pains post op. best for revision and probably professional soccer players and hypermobile pts Semi T and gracillis less harvest site morbidity but may be less stiff, for regular ACL recon Allografts, incidence of sp infection(AIDS) expensive, not available Synthetic grafts high incidence of failure infection, expensive, not always available Tunnel placement The concept of anatomic reconstruction Femoral tunnel is to be located at the distal end of the medial wall of the lateral condyle of the femur, distal to the lateral inter condylar ridge(resident ridge) Femoral tunnel Femoral tunnel Tunnel placement The tibial tunnel is to be located in the middle of the insertion area, more medially than laterally, roughly at the level of the post border of the ant horn of the lat meniscus Fixation devices Developing and changing, nothing ideal, matter of surgeon’s preference Characters of ideal fixation tool: 1. Stable fixation 2. biologic 3. no reaction 4. joint line fixation 5. easy revision 6. fast and technically feasible 7. cheap Operative treatment The idea is to keep the graft in place in the desired tension until healing occurs. Rehab should consider healing issues, and be aware of it as of the fixation tool and the circumstances of surgery, be in contact with your surgeon Non-operative treatment Think conservatively in older recreational athletes, with modification of life style and type of sport Coppers and non coppers for older athletes ACL surgery and prevention of OA The aim is always regaining stability and proprioception Rehabilitation Post op rehabilitation should start the day of surgery, at least by keeping up the muscles alert Maintaining full extension is the earliest mission of both the surgeon and therapist Progress towards having back the range, proprioception and strength before having the decision of being back to sports Long process (9-12 months), should be all done in strict adherence to instructions and be well supervised. The medial collateral ligament Anatomy: a broad sheet on the medial side of the knee with Principal 2 parts, the superficial and the deep ligaments The superficial lig is the largest medial structure, 10- 12cm long and 1.5cm wide. It attaches just proximal and posterior to the medial epicondyle of the femur and inserts at the medial proximal tibia The deep ligament is shorter and stronger, it is a thickened part of the middle part of the capsule. Subdivided into the medial capsular, the posterior oblique, the meniscofemoral and the meniscotibial parts Anatomy The pes anserine is found superficial to the superficial part of the MCL and deep to the Sartorius fascia, and they may act as dynamic stabilisers. The semi M is found more posteriorly at the same plane and inserts with different slips to the tibia and the capsule to add more dynamic stability biomechanics The MCL is the primary restraint to valgus stress in 5-25 deg. of flexion. The less the flexion angle, the more responsible are the posteromedial capsular structures. Mechanism of injury Stress valgus injuries especially with minimal degrees of flexion(up to 25deg of flexion) More in contact sports like ice hockey, soccer and handball Classification Generally 3 grades: grade I suggestive history and pain and tenderness on the medial side with minimal opening of the joint line on valgus stress test grade II = grade I + opening of the medial joint line with an end point grade III non stop opening on valgus stress Management A- Diagnosis clinical presentation: The most commonly injuried knee ligament History of a valgus stress injury Pain and tenderness on the medial side of the knee, maximally on the medial epicondyle or the medial proximal tibia according to the part of the ligament injuried Valgus stress test should be performed in full extension and 30 deg of flexion (cruciate lig are secondary restraints to med lat stability) in comparison to the other knee Minimal or no swelling at the knee, especially if occurred in isolation Minimal instability symptoms especially for grades I and II (more commonly occurring than grade III) Management A- Diagnosis Radiology: MRI is diagnostic in most of the cases, shows irregularity and oedema at the medial side of the knee with or without discontinuity of the ligament Extent, location of the injury and other associated injuries like cruciate or meniscal injuries. X rays are to be done in case of doubt of bony injury or in ch. instability cases. Management Treatment - The medial ligament has high potential for healing being broad, thus R is essentially conservative. - for grade I and II, Hinged knee braces are one of the best modalities as it allows motion in the normal arc and protect the knee from varus valgus stress until healing occurs, which is expected to be in 6-8 weeks. - Local measures and PT are to start early putting into consideration the side-to-side limitation. Management Operative R is kept for grade III tears where there is no endpoint on doing stress valgus testing or if there is an avulsed bone fragment with the ligament which is usually found on the femoral side In these cases, open repair with sutures or fixation of the avulsed fragment is indicated. Rehabilitation following surgery is much more prolonged, be ware of the commonly occurring stiffness of the knee after any surgical intervention on the medial side. The posterolateral corner Anatomy: Used to be considered the dark side of the knee for its anatomical complexity Consists of static structures, mainly the lateral collateral ligament and the dynamic structures, mainly the iliotibial band, the biceps tendon, the popliteus tendon complex, the popliteofibular ligament and the arcuate ligament complex Anatomy the LCL extends from the lateral epicondyle of the femur and inserts at the head of the fibula. The popliteus tendon complex consists of the muscle bulk and the musculotendinous junction, as it originates from the medial proximal tibia and extends proximally, medially and anteriorly through its tendon that pierces the capsule of the knee just behind the lateral meniscus, to be inserted on the lateral aspect of the lateral condyle of the femur. Anatomy The popliteus tendon has definite attachments to each of following structures: The femur, the lateral meniscus and the head of the fibula. The later is called the popliteofibular ligament. The biceps tendon is inserted at the head of the fibula where the common peroneal nerve passes just distal to it. The ileotibial band inserts at the prximal medial tibia, in gerdey’s tubercle. Biomechanics: Resists varus and external rotation of the knee. The LCL resists external rotation in lower knee flexion angles while popliteus and popliteofibular ligament resist external rotation at higher knee flexion angles The cruciate ligaments are 2ry restraints against varus stresses Mechanism of injury: stress varus injury especially if associated with external rotation force of the knee in varying degrees of flexion would injure one or more of those structures. management clinical assessment: history would suggest posterolateral force to the anteromedial tibia happening commonly in contact sports like soccer Non contact hyperextension injury with external tibial rotation. Pt. c/o pains and tenderness along the lateral or the posterolateral aspects of the knee with varying degrees of ecchymosis. management PLC injuries usually occurs in conjunction with other ligament or meniscal injuries, commonly the PCL. Overall limb assessment for nerve or vessel injury should be carried out. Gentle varus stress test in 0 and 30 deg of flexion, dial test, assessment of external rotation of the knee and posterior drawing should be all carefully done among other knee clinical examination assessments. Always compare the findings with the normal side. management Radiology should include x rays and MRI to rule out fractures and confirm the diagnosis and for diagnosing associated injuries, like the PCL or meniscal or chondral damage. management Treatment: - Surgery as early as possible , exploration and primary repair +/- augmentation would reveal best results. - Associated injuries should ideally be dealt with the same surgical session to avoid extra-loading the repaired structures that result in stretching and failure Posterior cruciate ligament Anatomy: The thickest ligament of the knee, commonly occurring with other injuries, as it is the main knee stabiliser. It originates from the proximal part of the lateral wall of the medial condyle of the femur and courses obliquely distally, laterally and posteriorly to be inserted into the proximal part of the back of the middle area of the tibia 1-2 cm distal to the joint line. Biomechanics: Controls the posterior displacement and the varus valgus stresses secondarily. Has a role in posterolateral and posteromedial stability and found to be tense almost at the whole arc of motion, though most of its fibers are more tense with increasing flexion. Mechanism of injury: Direct blow to the proximal tibia while in flexion like the dashboard injury is the most common mechanism. In sports, it usually happens in contact and collision sports like in ice hockey, rugby and motor cycling. management Clinical assessment: History taking usually uncover a more violent incident, with a direct blow anteriorly to the knee most commonly happening. Physical exam entails posterior drawer test, (tibia drawn posteriorly) Radiology: x rays to rule out avulsions or other bone injuries. MRI is diagnostic in most of the cases and excluding other injuries. Treatment: - Post cruciate ligament has high potential for healing, conservative R is of choice for partial and isolated cases in PCL brace Combined injuries or failed conservatively treated cases are treated surgically through the scopic reconstruction tech. using semi T and gracillis grafts or the open in-lay technique using the BTB graft. Knee dislocation injury Defined as more than 2 ligaments ruptured Acutely presenting knee dislocations are the worst injuries of the lower limb which may injure the neurovascular bundle. Occurs in high-speed vehicle sports and necessitate prompt surgical management with special attention to the circulation. Commonly complicated postoperatively by stiffness Patellar dislocation Usually to the lateral side, occurs due to a direct hit to the medial side of the patella The medial patellofemoral ligament ruptures almost in all cases Treatment depends on the extent of injury, usually would be conservative if only having soft tissue elements and for the 1st time Bony injuries are treated surgically as well as recurrent cases.. MPFL reconstruction should be part of R of recurrent cases. Sports ankle injuries Acute ankle injuries are the most common injury of sports, constituting about 20% of all sports’ injuries. Very common in team ball sports like basketball , handball, soccer and volleyball Sports ankle injuries Anatomy: The lateral aspect of the ankle is stabilised by the anterior talofibular, the posterior talofibular and the middle calceneofibular ligaments Sports ankle injuries Biomechanics: The lateral ligament complex guards against supination and internal rotation injury of the foot. Thus, excessive force at this direction would injure them with varying degrees of ligament disruption according to the amplitude of the causing traumatic incident Sports ankle injuries Classification: Grade I is partial rupture of the ATFL Grade II is total rupture of the ATFL Grade III total rupture of the ATFL and calceneofibular ligaments Complete ruptures (grades I and II) are commoner. Sports ankle injuries Management: Diagnosis : Suggestive history, ball team player who sustained a supination internal rotation injury to the foot. Pain and swelling on the lateral, aspect of the ankle and tenderness just in front of, just distal to and behind the lateral malleolus. Sometimes it presents with oedema and even ecchymosis of the lateral aspect of the ankle that might raise the possibility of having a fracture. Sports ankle injuries Ottawa rules: Palpation is the most important finding and should be done carefully and thoroughly, to the following 4 structures especially: The lateral malleolus The medial malleolus The base of 5th metatarsal bone The navicular bone If no tenderness and the pt. is able to walk well, then no need to do an Xray. Sports ankle injuries If suspicious, x ray must be done to exclude bony injuries U/S is of little clinical significance and operator dependent, though it is evolving rapidly nowadays MRI will show the ligaments with high sensitivity but it is not essential in the acute setting. It will also delineate any osteochondral lesions or bone marrow contusions which are common findings with ankle injuries Sports ankle injuries Treatment: Functional R is the R of choice, especially for grades I and II and in many cases grade III as well Surgical R may be indicated for top level athletes grade III injuries in the well experienced hands Cast immobilisaton has been the classic way of R for many years, however, it is not the best R modality especially for athletes Sports ankle injuries In the 1st few days (max one week)the goal is to limit bleeding (swelling )and reduces pain which is best achieved by PRICE, non wt bearing using crutches, bracing or tapping with or without NSAIDs After the acute symptoms have subsided, PT protocols should start straight ahead and continue until full function is regained Use of electrotherapy, laser and U/S have no effect in R and exercises constitute the main bulk of R. Sports ankle injuries Mobility, strength, functional and sports’ specific exercises are all part of the rehabilitation program which consistms of 3 phases, the acute, rehabilitation and training phases. Neuromuscular function is by far the most important function to regain and to be focused at before getting back to sports to avoid recurrence of instability. Sports ankle injuries Chronic ankle instability is not uncommon in our country because of lack of neuromuscular function as well as other functional aspects of the ankle. It is common after prolonged cast immobilization Intense rehab protocol should be attempted for 10 weeks before re- evaluation, where surgery could be indicated. Sports ankle injuries Surgery: Rarely necessary in cases of ankle instability if conservative R is competent May take the form of acute primary repair for top level athletes in case experienced surgeon is available In the chronic settings, ligament repair should be 1 st tried, if failed, surgical reconstruction using a tendon graft should be done. Autografts as well as allograft are used, most commonly used graft is the peroneal tendon auto graft passed in tunnels in the distal fibula and in the talus