Overview Ligament Injuries. Anatomy. Epidemiology Very commonly injured joint. ACL Injury 20/06/2016. Meniscus Tears. Patellofemoral Problems

Transcription

1 Overview Ligament Injuries Meniscus Tears Pankaj Sharma MBBS, FRCS (Tr & Orth) Consultant Orthopaedic Surgeon Manchester Royal Infirmary Patellofemoral Problems Knee Examination Anatomy Epidemiology Very commonly injured joint Reported incidence of 1: % soft tissue injuries In USA 11 million knee injuries/year Largest joint in body vulnerable during sport Dynamic function reliant on ligaments for stability ACL Injury Increasing frequency Predominantly non contact situations Netball/Football/Basketball/Skiing Women > Men 1

2 ACL Injury History ACL Injury Symptoms Usually non-contact Pivot or hyperextension Audible pop in knee Unable to play on Haemarthrosis soon > 50% have associated meniscal injury Lateral > Medial Instability gives way Patient does not trust knee Recurrent episodes of effusion & pain Unable to return to sport ACL Rupture Management Operative vs Non-operative Depends on individual patient need Functional demand level Ability to modify lifestyle Other lesions Indications for Surgery ACL Grafts Most active people will require surgery to restore adequate function and decrease instability Recurrent instability risk of secondary injury Inability to modify activity Associated injuries: meniscus Age? Wait three weeks due to arthrofibrosis risk 2

3 Results of Surgery MCL Injury 88-95% knees stable at 3-5 years 80-92% return to sports at 3-5 years 10-40% anterior knee pain with BTB 10% hamstring deficits with HT 6% anterior knee pain with HT Most Common isolated knee ligament injury Mechanism = valgus stress Medial joint line pain Lack of large effusion Often associated with ACL injury Difficulty weight-bearing MCL Examination Tender to palpation along MCL Pain + instability with valgus stress 30 o flexion = MCL 90 o flexion = associated ACL COMPARE SIDES Grading Ligament Injuries GRADE 1 No instability Good endpoint GRADE 2 Some instability Fair endpoint GRADE 3 Opens wide Poor endpoint Managing MCL Injuries PCL Injury Grade I symptomatic Rx Grade II/III ROM Brace 4-6 weeks, then physio Grade III combined with ACL consider repair 1.5 x ACL strength 5% all knee lig. inj. 1 0 restraint post. translation tibia Forced flexion Dashboard Associated injuries 3

4 Physical Examination + Effusion + Posterior drawer test + Posterior sag sign Management Usually non-operative with rehabilitation Surgery for select cases particularly multilig injury False positive Lachman test Medial & patellofemoral OA in chronic cases Meniscal Tears Common Usually age Increasingly seen in years Different presentations Different anatomy Bucket handle can be minimally symptomatic Types of Meniscus Tears Longitudinal Horizontal Oblique Radial Pathology bucket handle tear Meniscal Repair 4

5 Extensor tendinopathy Pain with: Jumping Stairs Prolonged sitting Mechanism = overuse Tendon degeneration predisposing to rupture Physical Examination Tender superior/inferior pole of patella Tender tibial tubercle Tight hams, Achilles, quads Pain with resisted action of muscle Management Load reduction relative rest Physio eccentric exercises Ultrasound, laser, massage PRP Injection Surgery tendon decompression Patellar Instability Patellar tracking dysfunction Acute patellar subluxation Acute patellar dislocation Q Angle MPFL rupture Two lines; ASIS to MPP; the other from TT to MPP. Angle of intersection called Q angle 5

6 Patellar dislocation Assessment Tender peripatellar structures Medial retinaculum Lateral femoral condyle Effusion? Patella dislocated laterally Xrays- osteochondral fracture, effusion Management Knee extension immobilizer x 4-6 wks Early quad setting exercises Return to sport Full, painless ROM Normal strength Adequate aerobic fitness Surgery for recurrent instability Physical Exam of the Knee Inspection Palpation Range of Motion Special tests Neurovascular assessment Important points Inspection Examine normal side first Always check for intact straight leg raise If knee too swollen/painful defer examination 1-2 weeks Effusion Erythema Ecchymosis Edema Q angle Angular deformities Muscular asymmetry 6

7 Palpation ANTERIOR Tibial tubercle Infrapatellar tendon Quad insertion Patellar facets Crepitus? MEDIAL MCL Meniscus Pes anserine insertion Tibial plateau Femoral condyle Palpation LATERAL Head of the fibula LCL Meniscus Tibial plateau Femoral condyle Gerdy s tubercle POSTERIOR Menisci (posterior horns) Popliteal fossa Hamstring tendons Assessment of Collateral ligaments Special Knee Tests Anterior Draw Test Tests for ACL laxity Anterior drawer sign Lachman s test Pivot shift Treatment of Knee Injuries Rest Ice Compression Elevation Anti-inflammatories NSAIDs COX-2 Ref: Snider, R. The Essentials of Musculoskeletal Care. AAOS: 1997 Lachman s Test 7

8 Treatment of Knee Injuries If improves with RICE continue to monitor If concern regarding significant injury refer for Orthopaedic opinion +/- MRI scan Thank You 8