Medical Diagnosis for Michael s Knee

Medical Diagnosis for Michael s Knee Introduction The following report mainly concerns the diagnosis and treatment of the patient, Michael. Given that Michael s clinical problem surrounds an injury about his right knee during a football game, it was identified that his knee has been hyperextended, whilst his tibia was internally rotated. This in turn caused the patient pain after experiencing a popping sensation. His knee begun to swell and his knee locked during flexion and extension. Each time this occurred, pain increased in the lateral region of the knee. Analysis of the information resulted in two possible areas of injury, injury about the anterior cruciate ligament (ACL) or about the posterior cruciate ligament (PCL). Fig. 1 1 shows a diagram of the knee anatomy can be found to illustrate the positions of these ligaments. Confirmation of the injury was derived from two tests and a scan; the anterior drawer and Lachman s test, and an MRI (Magnetic Resonance Imaging) scan. The report provides details on their procedures and results. The results lead on to the treatment available for the patient. This section of the report dictates possible surgery, side-effects of surgery, cost, recovery and rehabilitation duration and general advice that the patient is recommended to follow. Explanation of Hypothesis The two tests conducted support the hypothesis that the injury did occur at the ACL because Michael s stability was reduced hence primary focus was emphasised on the four stabilising ligaments within the knee. After discussion it was thought to be the ACL as the swelling occurred within two hours whereas the medial and lateral ligaments did not swell at all. Since the cruciate ligaments hold the femur and tibia and control the rotation and extension of thebones, it can be presumed that the ACL was damaged. His knee was also hyper extended, with rotation of the tibia, the injury was more prone to the ACL. The symptoms of the patient s injury were used to initiate two diagnostic tests. A major indication from the scenario was the fact that he lost balance as well asthe popping sensation experienced. Tests Fig. 1: Diagram of knee anatomy The two tests used to determine the injured ligament were; anterior drawer and Lachman s tests as well as MRI scans. The Lachman s test and the anterior drawer test involve the same procedure, therefore only the anterior drawer test has been explained. The Anterior Drawer Test: Michael was positioned lying down with his hip being flexed to 45 o and his knee flexed to 90 o. The medical examiner was in front of the knee holding the tibia, which is just below the joint line of the knee (Fig. 3). The examiner placed their thumbs along the joint line on either side of the patella tendon. The index fingers were used to ensure that the hamstring tendons were relaxed to allowan accurate test. The tibia was pulled forward to observe extension was beyond the normal amount. If the tibia were to hyperextend beyond the normal angle, the test would be considered positive, indicating damage to the ACL. 2 Fig. 3: A schematic demonstration of the anterior drawer test 1 http://www.orthspec.com/knee_anatomy.htm 2 http://physicaltherapy.about.com/od/orthopedicsandpt/ss/specialtests_2.htm, http://www.ehow.com/how_2107926_perform-anteriordrawer-test-knee.html http://orthoassessment.blogspot.com/2007/05/knee-anterior-drawer-test.html

MRI: MRI uses powerful magnets and radio waves for imaging internal human anatomy. This process was used when scanning the knee in order to confirm the damaged knee component. 3 The process involved: Lying down on a narrow table, this moved into the tunnel shaped scanner (Fig. 4) 4.This lasted between 30 to 60 minutes. The Results The anterior drawer test The ACL has mechanical and proprioceptive functions when considering its biomechanical function. When considering it regarding stability it has the main roles of; Restraining anterior translation of the tibia Preventing knee hyperextension Reinforcing the medial collateral ligament Controlling rotation of tibia The anterior draw test of Michael s injured knee indicate that the degree of anterior translation of the tibia increased when compared to his uninjured knee therefore this was a positive result. This indicated that the ACL was no longer restraining the anterior translation of the tibia and so must be ruptured. Since the knee underwent hyperextension, this supported the idea that the ACL was most likely to be ruptured. MRI Scans Fig. 4: Above, we can see what happens when the MRI of the knee is taken. In Fig 5 it is clearly visible that the ACL(C) is attached from anterior tibial plateau to the posterior intercondylar notch, forming a diagonal. This illustrated that the knee is not injured and so is healthy. However in the right knee (Fig 6) the said structure is no longer connected the two bones at these specific anatomical regions hence the MRI scans indicated ACL rupture. Additionally, no damage at the medial and lateral aspects eliminated the possibility of collateral ligament damage. 5 Fig 7: Saggital plane MRI scan of patient s healthy knee (right half) and injured knee (left half) From Fig 7 6 it is clear that injury has also Fig 5: Michael s left knee 4 Fig 6: Michael s right knee 4 3 http://www.nlm.nih.gov/medlineplus/ency/article/007361.htm 4 http://blog.remakehealth.com/blog_healthcare_consumers-0/bid/7423/open-mri-scanner-pictures 5 http://www.sportsci.org/encyc/aclinj/aclinj.html 6 http://www.sportsci.org/encyc/aclinj/aclinj.html

occurred to the posterior horn of the lateral meniscus, where the arrow points to, since the defect bears is not seen on the healthy knee. Injuries to the meniscus are caused normally by rotational twisting movements of the knee and are commonly associated with ACL rupture. The patient s symptoms of knee swelling, pain, popping and lock are synonymous with those of menisci injury. Additionally, no damage at the medial and lateral aspects eliminates the possibility of collateral ligament damage. Treatment for ACL Non-surgical treatment Physical therapy and rehabilitation can restore the knee to a condition close to its pre-injury state and educate the patient on how to prevent instability. This may be supplemented with the use of a hinged knee brace. However, many people who choose not to have surgery may experience secondary injury to the knee due to repetitive instability episodes. A hinged knee brace is likely to provide the best support and contains metal reinforcements in the sides which are connected by a hinge in the middle, also providing support to protect the medial and lateral ligaments. No support can guarantee protection to the ACL as it only requires just a few degrees of twisting to damage it. Therefore this may not be suitable for Michael if he wants to continue with his profession. Surgical Treatment Before any surgical treatment, the patient is usually sent to physical therapy.it is also recommended that some ligament injuries be braced and allowed to heal prior to ACL surgery. Surgery involves the reconstruction or the repairing of the torn ACL. Patients may benefit from an anaesthetic block of the nerves of the leg to decrease postoperative pain. Repairing the ACL: The damaged ligament is stitched if the tear is in the middle; conversely if the ligament has detached from the bone, then the bony fragment is reattached. Reconstructing the ACL An extra-articular technique is used, (taking a structure that lies outside the joint capsule such as a portion of the hamstring tendon) or an intra-articular technique (using a structure from within the knee such as part of the patellar tendon) which will replace the ACL. The goal of this reconstruction is to prevent instability and restore stability of the damaged knee, allowing patient to return to sport. Active adult patients, such as Michael involved in sports or jobs that require pivoting, turning as well as heavy manual work are encouraged to consider surgical treatment. Secondary knee damage can also develop if the torn ACL is not treated, therefore reconstruction should be considered. Common Surgical Choices Treatment Procedure Advantages Disadvantages

Patellar tendon autograft Hamstring tendon autograft Allografts. The middle third of the patellar tendon of the patient, along with a bone plug from the shin and the kneecap is used in the patellar tendon autograft The hamstring tendon on the inner side of the knee is used, with some surgeons using an additional tendon, the gracilis, which is attached below the knee in the same area. Allografts are grafts taken from cadavers and are becoming increasingly popular. These grafts are also used for patients who have failed ACL reconstruction. Recommended for highdemand athletes and patients whose jobs do not require a significant amount of kneeling -Fewer problems with anterior knee pain or kneecap pain after surgery -Less postoperative stiffness problems -Smaller incision -Faster recovery -Elimination of pain -Decreased surgery time -Smaller incisions -Recent improvements in allograft tissue testing and processing techniques -Postoperative pain behind the kneecap -Pain with kneeling -Slightly increased risk of postoperative stiffness -Low risk of patella fracture -Risk of blood clotting -The graft may stretch or rupture due to revascularization -Loss of muscle strength and mass can occur at donor site (hamstring muscle) -Risk of infection (HIV and Hepatitis C) -Death linked with bacterial infection due to improper sterilisation Treatment for Menisci Tears Once torn the meniscus does not heal well because of limited blood supply. The outer portion contains few vessels and over a prolonged period may heal if the tear is small, however the inner area is avascular hence any tear within this region will fail to heal. The functions of the menisci are to increase the area across which body weight is distributed, helping prevent arthritis, so preservation of the meniscus is vital. Probing the meniscus to locate the exact area of damage is important in choosing the treatment procedure. The main treatments 7 for meniscus injury are: Partial meniscectomy; tears in avascular region, or those that are not reparable are cut out to even the surface Meniscus repair; considered for tears in the middle third, peripheral third and longitudinal tears (including bucket handle tears). There are four main techniques for repair chosen depending upon the surgeon s preference. Meniscus transplantation; missing meniscus cartilage replaced with donor tissue Meniscus implants; collagen meniscal implants, made from natural substances, are inserted. These allow cells to penetrate and grow missing meniscus tissue. Since Michael is young and physically active, invasive methods of surgical treatment are advised to be at the forefront of his treatment list. Once the exact area of meniscus damage has been located any of these methods will help to restore the patient to his prior health. Surgical costs 7 http://www.dcmsonline.org/jax-medicine/2001journals/augsept2001/meniscal.htm http://orthopedics.about.com/cs/meniscusinjuries1/a/meniscus.htm http://www.patient.co.uk/health/knee-injury-meniscus-cartilage-tear.htm

The surgical costs involved for Michael s treatment will vary from hospital to hospital. The main reason for this is because these surgeries come under private treatment. However the cost of this treatment ranges from approximately 3700 to 6400, these may include costs for both or either the operations and physical therapy 8. Recovery and Rehabilitation Duration After surgery first two weeks of surgery the patient is likely to have a stiff and swollen knee and will be recommended to take pain killers. The wound is kept clean and dry, and emphasis is placed on straightening the knee and restore quadriceps control. The knee is iced regularly to reduce swelling and pain. Weight-bearing status (use of crutches to keep some or all of the patient's weight off of the surgical leg) is also determined by physician preference, as well as other injuries addressed at the time of surgery. During the second to sixth week after surgery, the pain and swelling should subside. At this point physical therapy commences. Much of the success of ACL reconstructive surgery depends on the patient's dedication to physical therapy. Physical therapy aims to fully extend and bend the damaged knee, strengthen surrounding muscle, improve balance and to walk properly. Between sixth weeks to six months after surgery the patient should return to their normal level activity and take part in swimming and cycling but not vigorous sports, that include sufficient twisting, turning and jumping. In this case Michael would be advised to wait up to nine months for recovery in order to regain his previous level of performance. 9 Conclusion Overall, a conclusion can be made that the injury to Michael s knee did occur at the ACL. Having evaluated the symptoms and the knee anatomy, two stabilising ligaments were highlighted, the posterior and anterior cruciate ligaments. With the use of the anterior drawer test and an MRI scan for diagnostic testing, the results confirmed the hypothesis, yet provided information on how to treat the injury. The MRI scan also revealed that the lateral menisci had also been damaged, which is understandable as this particular injury often accompanies an ACL injury. This showed that two bones were not connected at certain anatomical regions, which gave further evidence to show that the ACL was ruptured. Michael s results indicated a positive test in the anterior drawer test as his injured knee had an extension that was beyond the normal amount. This helped to confirm that the ACL was no longer restraining the anterior translation of the tibia and so must be ruptured. The first treatment to be considered for Michael is physiotherapy, which will enable him to learn to strengthen the other ligaments which with increase the stability of the knee which is important, especially if he is to eventually resume to an active lifestyle. However, like every treatment a negative of the therapy is that the weaker knee is more prone to damage from movements. Hence, surgery combined with physiotherapy would be extremely beneficial in terms of Michael wanting to return to playing football. Once his options have been considered, Michael can chose whether or not to undergo surgery, knowing that complete recovery can take up to 9 months. In addition, strength (muscle, stamina, speed) may be lost therefore clearly, returning to original athletic excellence may not occur, highlighting that such injury to the knee can have a long term effect. However attention must be drawn to the fact that if surgery does take place, it is highly likely that Michael will be able to return to playing football in the future, if he wishes to do so. Without surgery, this concept is very unlikely as he will never be able to regain a fully functional knee able to twist and turn which is necessary in a career concerning sport. 8 http://www.privatehealth.co.uk/hospitaltreatment/whatdoesitcost/cruciate-ligament-repair/ 9 http://www.nhs.uk/conditions/repairtotendon/pages/recovery.aspx