Ligament and Tendon Injuries

Question 1

What are ligaments?

Answer 1

Dense bands of collagenous tissue
Span a joint and anchored to bone at either end
Joint stability
Multiple and different tensions at different positions

Question 2

Describe the ligament structure

Answer 2

Collagen, fibroblasts, sensory fibres (proprioception, stretch and sensory), vessels on surface and crimping to allow stretch

Question 3

Describe ligaments vs tendons in structure

Answer 3

Ligaments have lower percentage of collagen, higher percentage of proteoglycans and water, less organised collagen fibres, and rounder fibroblasts

Question 4

Describe ligament rupture

Answer 4

Forces exceed strength of the ligament
Can be expected or unexpected
Also rate of load - more resistant the faster it occurs
Can be complete or incomplete

Question 5

Describe the haemorrhage stage of healing in ligaments

Answer 5

Blood clot
Resorbed
Replaced with heavy cellular infiltrate
Hypertrophic vascular response

Question 6

Describe the proliferative phase in ligament healing

Answer 6

Production of scar tissue
Disorganised collagenous connective tissue

Question 7

Describe the remodelling stage in healing of ligaments

Answer 7

Matrix becomes more ligament like
Major differences in composition, architecture and function persist

Question 8

When is the conservative treatment used for ligament rupture?

Answer 8

Used in partial rupture and in complete when no instability
Poor candidates for surgery

Question 9

What is used in conservative treatment for ligament rupture?

Answer 9

Soft tissue brace
Walker
Cast
Active mobilisation

Question 10

When is operative treatment for ligament injury?

Answer 10

Instability - ACL ruptures and lateral ligament injuries of ankle
Expectation - sports
Compulsory - multiple ligaments

Question 11

What is used for operative treatment of ligament injury?

Answer 11

Direct repair
Augmentation - tapes added
Replacement - sometimes taken from tendons of hamstrings

Question 12

What is included in muscle unit?

Answer 12

Muscle origin, belly, musculotendinous junction, tendon, sheath, and insertion

Question 13

Describe the composition of tendons

Answer 13

Longitudinal arrangement of cells and fibres
Mostly tenocytes and collagen type 1 - triple helix

Question 14

Describe the structure of tendons

Answer 14

Fascicles of long narrow spiralling collagen bundles
Collagen bundles covered by endotenon
Fascicles covered by paratenon
Tendon covered by epitenon

Question 15

What is the blood supply for tendons?

Answer 15

Come through Vinculum
And paratenon has fine network of blood vessels

Question 16

Describe tendon sheath

Answer 16

Tendons connected to sheath by vincula
Synovial lining and fluid - gliding lubrication and nutrients
Ex. flexor tendons in distal palm and fingers (strong annular pulleys)

Question 17

What is the function of a tendon?

Answer 17

Flexible and very strong in tension
Movement is life - immobility reduces water content + glycosaminoglycans conc. and strength

Question 18

What are some types of injuries to tendons?

Answer 18

Degeneration, inflammation, enthesopathy, traction apophysitis, avulsion, tear of intrasubstance or musculotendinous junction, and laceration

Question 19

What is a type of degeneration to tendon?

Answer 19

Achilles tendon

Question 20

Describe Achilles tendon degeneration

Answer 20

Intrasubstance mucoid degeneration
May be swollen, painful, tender or asymptomatic
Can sometimes be a precursor to rupture

Question 21

What is an example of inflammation?

Answer 21

De Quervain’s stenosing tenovaginitis

Question 22

Describe de Quervain’s stenosing tenovaginitis

Answer 22

Tendons of EPB and APL passing through common tendon sheath at radial aspect of wrist
Swollen, tender, hot and red
Positive Finklestein’s test

Question 23

What is Enthesiopathy?

Answer 23

Inflammation at insertion to bone
Muscle/ tendon - usually at muscle origin rather than tendon insertion
Is caused from repeated actions
Ligaments - plantar fasciitis

Question 24

What is traction apophysitis?

Answer 24

Insertion of patellar tendon into anterior tibial tuberosity
Adolescent active boys
Recurrent load
Inflammation component

Question 25

Describe avulsion and bone fragment

Answer 25

Failure at insertion Load exceeding failure strength while muscle contracting

Question 26

What is Mallet finger?

Answer 26

Type of avulsion Insertion of extensor tendon into dorsum of base of distal phalanx of finger Forced flexion of extended finger

Question 27

What is the treatment of avulsion?

Answer 27

Conservative - limited application. Used for retracted tendon Operative - reattachment of tendon and fixation bone fragment

Question 28

How does a intrasubstance rupture occur?

Answer 28

Tear - ex. Achilles tendon Load exceeds failure strength

Question 29

What is the mechanism for rupture of tendon?

Answer 29

Pushing off with weight bearing forefoot whilst extending knee joint Unexpected dorsiflexion of ankle - slipping into hole Violent dorsiflexion of plantar flexed foot - fall from height

Question 30

What is the clinical sign of Achilles tendon rupture?

Answer 30

Positive Simmond's (squeeze) test - lie prone and calve muscle squeezed and foot will move if no damage Palpable tender gap

Question 31

What is a common example of musculotendinous junction tear?

Answer 31

Medial head of gastrocnemius at musculotendinous junction with Achilles tendon

Question 32

What is the treatment for ruptures?

Answer 32

Conservative - mobilise, splint/ cast, and if healing will occur + if ends can be opposed Operative - high risk re-rupture, high activity and ends cannot be opposed

Question 33

What is an example of laceration of tendon?

Answer 33

Finger flexors (FDS and FDP) Common in males Young adults Always repair surgically