5.4 - Injury and Healing 2 Flashcards
What is soft tissue made up of?
Type I collagen
What are ligaments?
- connect bone to bone
- restricts joint motion
- stability and proprioception
What are tendons?
- connect muscle to bone
- transmits forces
What can cause ligament and tendon injuries?
- pivoting forces
- eccentric contraction
- trauma
- laceration
- avulsion injury - when small piece of bone attached to a tendon/ligament gets pulled away from the main part of the bone
- injuries are often sports related
What is a grade I tear?
- slight incomplete tear
- no notable joint instability
- integrity intact
What is a grade II tear?
- moderate/severe incomplete tear
- some joint instability
- one ligament may be completely torn
What is a grade III tear?
- complete tearing of one or more ligaments
- obvious instability
- surgery may be required
How do ligaments and tendons heal?
- bleeding - over the first few hours, inflamed
- inflammation - hours to months
- proliferation - days to months
- remodelling - weeks to months
- maximum strength recovery at >6 months
- may never fully recover full tensile strength
What are the components of the knee?
- bones - patella, tibia, fibula, femur
- muscles - quadriceps, hamstring
- ligaments - anterior cruciate ligament (ACL), lateral collateral ligament (LCL), medial collateral ligament (MCL), posterior cruciate ligament (PCL), patellar ligament
- cartilage - articular cartilage, meniscus
What is the role of the ACL?
- gives knee joint stability
- rotational stability - back to forth movement of lower leg
- proprioception
- ACL is an oblique ligament running from front to back of knee
What symptoms can arise due to an ACL tear?
- difficulty running
- instability (with twisting/pivot movement)
What different examinations can you do to test for an ACL tear?
- Lachmann’s test - bring tibia forward, high level of movement is pathological
- anterior drawer - knee bent at 90 degrees, move tibia anteriorly, moves a lot if torn ACL
- pivot shift - ‘locked’ knee on bending if torn ACL, might hear a click, can damage meniscus/cartilage
What is the acronym for short term management of a torn ACL?
- P - protect
- R - rest
- I - ice
- C - compress
- E - elevate
What are the factors affecting tissue healing?
Mechanical environment:
- movement
- forces
Biological environment:
- blood supply
- immune function
- infection
- nutrition
What do we need to consider when thinking about management of tendon/ligament tears?
Need to consider the patient:
- functional demands
- patient factors
- compliance - how likely they are to listen
Things to think about specifically when it comes to management of an ACL tear?
- how old?
- symptoms - pain or giving way? instability? locking?
- activity level
- has physio been tried?
- other structures involved? meniscus
- indications for ACL reconstruction
- graft choice - autograft (from hamstring/patellar tendon), allograft, synthetic
What are different methods for long term management of an ACL tear?
- non operative: brace - ACL does not heal well but some muscles can compensate in some cases
- operative - repair and replace
Which tendon is likely to be injured if a squash player did not warm up before a match, felt severe pain in ankle when reaching back, loud snap sound and feeling of being shot in back of the ankle?
Achilles tendon
What are the risk factors for a ruptured Achilles tendon?
- male, 30-50 years (in this case 35)
- anabolic steroid use
- fluroquinolone - antibiotic that increases risk
- ‘weekend warrior’ - participates in activity only in their spare time
What muscles insert into the Achilles tendon?
- M. gastrocnemius (biventer muscle of the calf)
- M. soleus
What is the function of the Achilles tendon?
Plantarflexion
What would you find when examining a patient with a ruptured Achilles tendon?
- difficulty walking / limp
- unable to perform heel raises (standing on tiptoes)
- thickening, tenderness and swelling on the affected side
- when prone with feet off the end of couch, the affected side is held in dorsiflexion
- Simmonds Calf Squeeze Test - patient lies face down with feet hanging off edge of bed, positive result = no movement of foot (normally plantarflexion) on squeezing the corresponding calf = ruptured Achilles tendon
What are management options for a ruptured Achilles tendon?
Operative:
- open vs percutaneous
- primary repair
- augmentation of repair
Non-operative:
- functional bracing
- gradual removal of wedges to plantigrade
- casting
Rehabilitation:
- range of motion
- strength
- proprioception
What must be considered when thinking about management of a ruptured Achilles tendon?
- functional demands
- patient factors
- injury factors - based on USS/MRI, acute/chronic
What are complications that can occur due to an operation?
General (early/late):
- DVT (deep vein thrombosis)
- infection
- prolonged immobility (UTI, chest infections, sores)
Specific:
- neurovascular injury - sural nerve
- tendon re-rupture
- local infection
- ankle stiffness
- pressure sores from plaster/boot
- reduced strength
