anatomy and sports injuries of the knee · anatomy • not a hinge joint • 6 degrees of freedom...
TRANSCRIPT
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Anatomy and Sports Injuries of the Knee
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I. Anatomy II. Assessment III. Treatment IV. Case Study V. Dissection
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Anatomy
• Not a hinge joint • 6 degrees of
freedom • Flexion/Extension • Rotation • Translation
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Anatomy
• Three Compartments
• Proximal Tib/Fib Joint
• Has not fully adapted
• Patella a sesamoid?
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Muscles
• Quadriceps • Hamstrings • IT Band/Tract • Popliteus
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Neurovascular Structures
• Posterior Tibial Artery • Tibial Nerve • Peroneal Nerve • Saphenous Nerve
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Menisci Anatomy
• Zones • Ultrastructure • Intermeniscal
ligament • Coronary ligament • Mensicofemoral
ligaments
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Role of Menisci
• Biomechanics “Shock Absorbers” • Load Transmission
– 50% in extension, 85% in 90 flexion
• Partial Meniscectomy (15-34%) increases contact pressure 350% !
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Meniscal Functions
• Increase congruity = Stability
• Proprioception
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Medial Meniscus
• C-shaped • Wider posteriorly • More commonly
torn • Restraint to anterior
translation
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Medial Compartment
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Lateral Meniscus
• More Discoid • Popliteal Hiatus • More difficult to
repair • Worse prognosis
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Lateral Compartment
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ACL
• Anteromedial Tibia to Posterolateral Notch
• Primary Restraint to Anterior Translation
• Bundles/Fiber Regions AM, PL
• Reciprocal tightening • Isometry, Physiometry
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PCL • Anterolateral Femur to posterior tibia
• Primary restraint to posterior translation
• Intimate with ACL • Better blood supply
and synovial sheath • Bundles AL, PM • Much broader origin
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Normal PCL and ACL
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Posterolateral Corner
• Popliteus • Arcuate Complex • LCL/fibular collateral • Lateral Head of Gastrocnemius • Restraint to ER at 30 degrees
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Collaterals
• MCL 2 components • Deep portion intimate with MM • LCL • Varus/Valgus at 30 degrees
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Anatomy
• Patellofemoral joint • Medial Patellofemoral Ligament • Retinaculum
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Assessment
• History not MRI most important • Mechanism • Locking, Catching, Giving Way • Swelling? • Plain Films
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Assessment
• Inspection – Effusion – Ecchymosis – Attitude
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Assessment
• ROM • NV Check • Joint Line Tenderness • Stability
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ACL
• Lachman “Gold Standard” watch medial tibia
• Anterior Drawer • Pivot Shift (lateral tibia) • Pivot Glide
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PCL
• Posterior Drawer (Knee at 90) • Quads Active • Godfrey Test (Sag Sign) • Reverse Pivot Shift • Pivot Jerk • Grades
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Posterior Drawer
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Posterolateral Corner
• Posterolateral Drawer • External Rotation Recurvatum • External Rotation at 30 and 90 • Prone ER at 90 and 30
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Collaterals
• Test at 30 • Palpate LCL in figure 4
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Menisci
• Joint Line Tenderness • MacMurray’s • Duck Walk • Squat
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Patellofemoral Joint
• Patellar Glide • Patellar Inhibition • Patellar Tracking
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Don’t Miss Obvious
• Extensor Rupture • Fracture • Knee Dislocation • Physeal Fracture
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Arthroscopy
• Systematic • Standard Portals • Pump
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Meniscus
• Zones • Tear Types • Biomechanics • Meniscectomy, Repair, Replacement
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Bucket Handle Tear
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Horizontal Tear
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Radial Tear
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Discoid Meniscus
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ACL
• Non contact • Gives way • Immediate swelling • Bloody effusion
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ACL
• Why fix it? (meniscus and djd, lifestyle) • Endoscopic one incision • Tension at 30 or full extension • Allo or autograft • Hamstrings, Achilles, BTB, Fascia Lata • Fixation • Return to sports 6 months
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ACL Basic Science
• Native ACL 2700 newtons • ACL graft completely replaced • 30-50% strength of native ACL after
incorporation
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ACL Complications
• Tunnel Placement • Loss of fixation • Loss of motion • Patellofemoral pain • Surgeon Dependent
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PCL
• Dashboard Injury • Blow to anteromedial tibia • Hyperflexion • Usually combined with PL corner
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PCL
• Many techniques (2 bundle femur) • Indications - symptoms of functional
instability • Tension at 90 degrees
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Posterolateral
• Primary Repair (early) • Split Biceps (Clancy) • Semitendinosus figure 8 • Hughston Imbrication
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Chondral Defects
• Chondroplasty • Microfracture (Steadman) • Osteochondral Transplant (Hair plugs) • Carticel
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Meniscus Repair
• Inside-out, Outside-in, All-inside • Fibrin Clot • Arrows, Darts, Screws • Heal faster with ACL
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Meniscal Allograft
• Patients with early disease (Grade I-II) • Technically challenging • Expensive • Patients must undergo change in lifestyle
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Meniscus Rehab
• Meniscectomy: none • Repair: WBAT in full extension 6 weeks
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ACL Rehab
• Hinged Knee Brace • WBAT in full extension • Crutches
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ACL Rehab
• Decrease swelling • Full extension • Quad Control • Patellar Mobilization
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ACL Rehab
• Closed chain • Co-Contraction
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ACL
• Cycling • Stairmaster • Straight ahead Jogging • Return to cutting sports 6-9 months • (Jerry Rice 3 months = Patella Fracture)
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Braces
• No evidence of increased proprioception • Can’t protect ligament • Patients expect them
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Braces
• Cti • Donjoy Defiance • Playmaker • Townsend • Richards • Breg
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Extensor Realignment • Very Controversial • Lateral Release • Proximal Imbrication (Insall) • Maquet • Elmslie-Trillat • Hauser • Roux-Goldthwait • Fulkerson
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Fulkerson
• Anteromedialization • Complications
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Case Study
• 23 y.o. male playing basketball
• Varus injury • Fibular head
fracture • Peroneal nerve
palsy
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MCL PLC
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Normal PCL and ACL
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Thank You