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Knee Ligament Injuries
Overview Ligament Anatomy Biomechanics Ligament Specific Epidemiology Classification Clinical exam Imaging Tx
Ligament Anatomy Type 1 collagen (70%) Elastin Extracellular matrix Hierarchical structure Fibrils > fibres >subfascicular unit >fasciculus Longitudinal fasciculi (MCL, LCL) Helical fasciculi (ACL, PCL)
Anatomic Features Bonding Crimping Random collagen alignment Complex blood supply Diffusion from synovium Proprioception and nociception
Biomechanics Laxity Stiffness Strength Viscoelastic behavior (creep, stress relaxation, hysteresis) Dynamic properties
Ligament healing Immobilization Loading dramatically affects recovery of normal mechanical properties Decrease strength Insertion site vs. midsubstance Exercise Favourable effect
Epidemiology Increasing incidence Combined injuries common Females > males Conditioned vs. unconditioned
ACL Anatomy Intracapsular Extrasynovial Varied blood supply FAMPLE Origin / Insertion
ACL Function Limit anterior displacement 2 0 restraint rotation 2 0 restraint varus / valgus in extension
Mechanism / Hx Usually noncontact Change direction Stop / jump Audible “pop” Instability Swelling
General Ligament Exam Difficult acutely Early exam beneficial Pt. relaxed Displacement Endpoint quality Compare
ACL Exam Lachman – best Pivot Shift – diagnostic Anterior drawer – chronic tear Associated injuries
ACL Imaging XRAY R/O # ACL avulsion Segond # Arthrography - poor Arthroscopy - gold standard
ACL MRI 95% accurate Low signal intensity Saggital view Acute injury high signal intensity on T 2 image Bone bruising
ACL Tx Pt selection Operative vs. Non-operative Demand level Modify lifestyle ACL dependent Other lesions
Non-operative Acutely – splint & crutches Early active ROM Closed chain WB to strengthen Avoid high risk Functional bracing controversial
Operative Pt selection High demand Young Good ROM Open vs. endosopic Learning curve
Graft Auto vs. allo Collagen lattice Resorption – revascularization – restructuring Bone-patellar tendon-bone Semitendinosus/gracilis tensioning
Rehab Closed kinetic chain strengthening Acutely fixation weak Graft weakest 6-12 wks Outcome >90% stable 3-5 yrs
MCL Anatomy Origin – femoral condyle Insertion – 4cm below joint line + posterior obl. Lig. + middle capsular ligament Parallel collagen
MCL Most common isolated ligament injury Valgus force Post. Obl. Lig. damage with rotn. injury Associated ACL common
MCL exam Valgus force Flex – isolated Extension Assoc. POL,ACL,PCL 5-8 mm difference significant Swelling Hemarthrosis vs. soft tissue
MCL Tx Non-surgical RICE Bracing Strengthening Functional brace
MCL Classification / Tx Grade 1 : 1-5 mm Symptomatic Tx Grade 2 : 6–10 mm Hinge brace 2-3 wks Grade 3 : mm Hinge brace 3-4 wks Physio
PCL Injury 1.5 x ACL strength 5% all knee lig. inj. 1 0 restraint post. translation tibia Forced flexion Dashboard Associated injuries
PCL Pain Usually stable Posterior subluxation Medial & patellofemoral OA
PCL exam Posterior drawer test –best Grade I - III Quadriceps active test Post sag sign
Non-operative Aggressive rehab Focus quadriceps No support for bracing closed kinetic chain Open kinetic chain extension avoided 90% quads strength prior to normal athletics
PCL Tx Repair : Associated posterolateral corner Associated ACL / MCL Grade 3 Drawer test Bony avulsion 20% athletes with isolated injury require repair
Operative Repair Require good ROM pre-op Graft > 40mm No good rehab protocol
Posterolateral Complex Combination of Structures ITB biceps femoris fibular collateral Popliteus complex Capsule etc
Posterolateral corner Usually assoc with: PCL Knee dislocation Rarely ACL Instability esp descending inclines Peroneal N. inj. 10% pain
Biomechanical Increased: External tibial rotation Varus rotation Posterior tibial translation
Exam Swelling / bruising Gait : Varus thrust AP translation > 30 0 than 90 0 Best tests: Varus stress opening > 30 0 than 0 0 Prone external rotation test Other tests
Operative 1 0 Repair Acute injury Bony avulsion Reconstruction Biceps tenodesis / arcuate lig advancement : mixed results Graft - results pending Varus malalignment - HTO
Conclusion Common injuries Easily missed Large area Ongoing research
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