mohsen mardani-kivi, m.d. orthopedic department, guilan university of medical sciences
TRANSCRIPT
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Mohsen Mardani-Kivi, M.D.Orthopedic Department, Guilan University Of Medical Sciences
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Anatomy
Bones:FemurTibiapatella
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ligaments MCL LCL ACL PCL
Anatomy
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Extensor muscles :
Muscles:Quadriceps:
Vastus medialis Vastus lateralis Rectus femoris Vastus
intermedius
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Flexor muscles:
Semimembranosus
Semitendinosus Biceps femoris gastrocnemius
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Biomechanics:
Tibiofemoral Joint
Patello-femoral joint
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Patella :
largest sesamoid bone
The primary functional role: knee Extension
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Femoral condyles
The medial condyle is larger and lower than the lateral condyle.
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Valgus and Varus Genu
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Flexion : 120-150°
Extension : 5-10°
Internal rotation : 10°
External rotation : 30-40°
Major Movements
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Inspection :
Baker's cyst genu recurvatum Valgus deformity (knock-kneed) Varus deformity (bowlegged)
Physical Examination
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Palpation :
Temperature change Joint line tenderness
Physical Examination
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Motion :
The patient should be asked to move their knee
Full ROM is 0-135 degrees Examination of crepitus : clicking of
the joint with motion
Physical Examination
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Physical Examination
• Valgus or varus stress test:• One hand at the lateral aspect of the
knee joint and the other hand at the medial aspect of the distal tibia.
•Valgus or varus stress is applied to the knee at both zero degrees (full extension) and 30 degrees of flexion.
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1-Anterior Drawer Test
Anterior force applied at 90 degrees of flexion
Examination
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2-Posterior Drawer Test
Most accurate test for PCL tear. Patient in supine position with knee flexed 90°. Apply a posteriorly directed force to proximal tibia.
Examination
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3-Lachman Test: best test for ACL laxity.
Knee placed in 20-30 degrees of flexion, the femur is stabilized, and an anteriorly directed force applied to proximal calf.
Examination
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4-Pivot-Shift TestConfirms complete ACL tear. Based on very early flexion causing anterior subluxation of the tibia that is reduced with further flexion (20-40 degrees) due to the posterior pull of the iliotibial tract.
Examination
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Mc. Murray’s Test
Examination
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ACL
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• Etiogenesis: • Sports-related injurySports-related injury (80%
non-contact!)• Motor-vehicle collisions• Falls• Work-related injuries.
• occur when pivoting or landing from a jump. The knee gives-out from under the athlete when the ACL is torn.
ACL injury
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How is the ACL injured
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• ACL injuries in Female athletes:• higher risk while
participating in competitive sportscompetitive sports.
ACL injury
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NoncontactAudible pop (usually a hyper-Ext.+ pivot combinationHemarthrosisUnable to return to play.
Contact and high-energy traumaOften associated with other ligamentous and meniscal injuries.A valgus stress to the knee The classic "terrible triadterrible triad": ACL, MCL, and medial meniscus tears
Clinical feature
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Signs and Symptoms
AcuteMarked pain and popSwellingDifficulty at bearing weight on the affected knee
ChronicThe knee feels looseloose“buckling”, “giving waygiving way” or instabilityPain and swelling
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Radiography
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Diagnosis
HistoryPhysical examX-rays normal (only to R/O fracture)MRI (Gold Standard) (Gold Standard) excellent for evaluating not only the ACL but also the meniscus, articular cartilage and other knee ligaments
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In adult with bone fractureWith other lesion Just ligament tearing :
General Population
Athlete Chronic tearing
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Treatment
What is the treatment for an acuteacute ACL tear?
Rest Ice ElevationCompressionProtected Weight BearingBrace
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Treatment
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SurgerySurgery
Reconstruction of the ACL by drilling tunnels in your femur and tibia
Tunnel in thigh bone for graft passage
↑
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Meniscal Tear
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Functions of the menisci
Lubrication and nutrition of the jointShock absorbersEvenly distribute weight throughout the kneeAllows for smoother motions between the femur and tibia
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The inner 2/3 of the menisci are avascularOnly! outer 1/3 is vascular (with blood supply)
Anatomy
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Mechanisms of injury
Sport injury:Usually the foot stays fixed on the ground and the rest of body rotatesGetting up from a squatting or crouching positionLoading the knee from a fixed position
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Types of Meniscal Tear
Types:Vertical Radial HorizontalDegenerateComplex Horn
A loss of any part of the meniscus causes uneven weight distribution and can lead to early wear of the knee
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Torn meniscus Suture repair of meniscus
Treatment
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MCL SPRAIN
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MCL SprainMCL Sprain
• Usual cause: • Contact sports Contact sports • Force applied to
the outside of the knee, which pushes the knee inwards and beyond its normal range of motion.
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• Inside knee Pain • Swelling • Instability• Perhaps a popping sound heard at the
moment of injury
Sprained MCL SymptomsSprained MCL Symptoms
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Medical history Ph/Ex. X-ray imaging R/O fractures MRI
MCL Sprain Diagnosis
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• Usually respond to conservative treatment, • Ice pack• Resting the knee joint• Bandage and Bracing• NSAIDs
• Surgery is rarely required.
MCL Sprain Treatment
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MCL Tear
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MCL Tear
May occur: isolated or complex injury (most commonly: ACL and/or Meniscal tear).
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Pain Swelling Limitated ROM positive valgus stress test
Symptoms
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Simple Radiography Stress Film Ant. Graphy in Abd
Diagnosis
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Cast Brace Surgery
Treatment
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LCL Tear
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LCL Tear
Etiogenesis:• direct blow to
the inside of the knee
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Pain Swelling Limited ROM positive varus stress test Drop foot: Weakness in the foot, if the
peroneal nerve is stretched during the injury or is pressed by swelling in surrounding tissues
Symptoms
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Rest NSAIDs Ice Knee Exercises
Treatment
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Rehab
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physical therapy
The first few sessions of PT more modalities / fewer manual techniques:
Heat/iceUltrasoundElectrical stimulationManual stretchingPassive ROM for full knee flexion and extension
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Once pain and swelling are reduced mainly focus on increasing the strength and flexibilityVary depending on the individual
physical therapy
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StretchingHamstrings
Quadriceps
Calf muscles
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Stretching continuedHip flexors
Hip adductors
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StrengtheningFocusing on strengthening the muscles around the knee is essential in rehabilitation Quad sets Straight leg raises (in all planes)
Heel raises Leg Curl
Leg extension
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Balance
Balance can sometimes be compromised after an injury or surgery
Here are some balance exercises that can help
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Dynamic exercises
Progression to more dynamic sports specific exercises helps with the transition back into sports
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