1. Anuchit NawatthakulSixth year medical studentPhramongkutklao college of medicine

2. HN : 11593/56Case : A young Thai man 22 yrs , an officerCC : 1 yr PTAPI : 1 yr PTA Pop 3. PH : - no underlying disease- no history of previoussurgery - no history of drugallergy - no current medication 4. Physical examnination GA : good conscious , not pale , nojaundice HEENT : normal Heart : normal s1s2 , no murmur Lung : clear , no adventitioussound Abdomen : soft , not tender 5. Affected part ( Right knee)Swelling , pain on motionFull ROM , normal lengthvalrus / valgus : nrgative ballotment : negativeLachman test : negativeAnterior drawer test : positive 2+Pivot shift test : negativeMc Murray test : negativeApley s test : negativeNeurovascular : ok 6. 90 7. 30 proximal tibiadistal femur proximal tibia distal femur 8. Pertinent finding Rt knee in jury in football match Swelling Anterior drawer test positive No deformities Normal Neurovascular status 9. Problem list Rt knee injury in football match with anterior drawer test positive 10. Differential Diagnosis Knee ligamentous injury Fracture 11. Ligamentous Injuries ACL injuries PCL injuries MCL injuries LCL injuries 12. ACL Injuries Most MOI are non-contactrotational forces Tibia displaced anteriorly onfemur (or vice versa), rotationalstress (cutting) orhyperextension May be isolated, but typicallydue to MOI, other structures(joint capsule, menisci) alsoinjured Positive anterior drawer and/orLachmans tests 13. PCL Injuries Most common MOI is fall on flexed knee driving tibiaposterior on femur May also occur with rotational and/or hyperextension MOI Often treated non-operatively as quadriceps muscles areable to minimize posterior displacement of tibia on femur Positive posterior drawer and/or posterior sag tests 14. MCL Injuries Most common MOI isblow to lateral knee withresulting valgus tensionforces May also be injured bynon-contact and/orrotational stresses Positive valgus stress test 15. LCL Injuries Most common MOI isblow to medial kneewith resulting varustension forces Internal rotation of tibiamay be secondarycontributor to LCL injury Positive varus stress test 16. Meniscal Injuries May be isolated fromflexion/hyperflexion withrotation of the knee pinchedbetween tibia and femur Often injured in associationwith cruciate ligament injury Classic symptoms includejoint line pain and clicking orlocking helpful but notdefinitive evaluative tools Limited reliability of specialtests 17. Investigation X-ray MRI 18. X-ray 19. MRITorn of Anterior Cruciate Lingament (complete tear)Torn medial miniscus ( Basket handle) 20. DiagnosisComplete torn Anterior Cruciate Lingament with torn medial meniscus 21. ACL hyperextension tibia.3.valgus varusinternal rotation external rotat4. screw home 22. ACL Injuries Most MOI are non-contactrotational forces Tibia displaced anteriorly onfemur (or vice versa), rotationalstress (cutting) orhyperextension May be isolated, but typicallydue to MOI, other structures(joint capsule, menisci) alsoinjured Positive anterior drawer and/orLachmans tests 23. Grading ligamentous injury Grade 1 :Ligament Swelling, localized tenderness Grade 2 : Ligamentstretchingpartial tearSwelling Grade 3 : Ligament complete tearMay 12,2009 24 24. Management 25. knee bracejone s bandageNSAID 26. CommercialHinge-Knee Brace 27. Anterior Cruciate Ligament Injury International Knee Documentation Committeeactivity level 4 level 1 jumping, pivoting football ,soccer ) level 2 heavy manual work or side-to- side sports (skiing, tennis) level 3 light manual work or noncutting sports (jogging, running)May 12,2009 28 28. Non operative treatment ACL injurylevel 3level 4level 1level 2sport activityreconstructionphysical therapy Functional bracerehabilitation swellingeffusion ,hamstrings muscleatrophyMay 12,2009 29 29. Non operative treatment Rehabilitation ROM swelling , effusion strengthening of hamstring musclefor balance power of quadricepsinstability 30. Non operative treatment ACL injury brace bracephysical therapycontrol stability conservative minimal surgery debridement of articular cartilage defect, trimming or repairing meniscus excising ligament stumpprocedures ligament reconstructionMay 12,2009 31 31. Surgical treatment ACL injury intraarticular reconstruction ACL reconstruction arthroscopic assisted endoscopic techniques transfixation technique hamstring graft fixationfemoral tunnelMay 12,200932 32. Surgical treatment ACL injury fixation graft interference screwtitanium bioabsorbable screw stable fixation transfix pin screwMay 12,200933 33. Operation : Arthroscopic ACL reconstruction with medial meniscus repair Indicationcomplete tear(grade 3)Medial meniscus tear instability 34. Patient Education , , , 35. Progress notev/spain controlMorphine , Dynastaton continuous passivemotion , Axillary Crutch 36. ReflectionApproch Knee ligament injury-- knee ligament injury-