Ligament and Tendon Injuries Flashcards
What are ligaments?
Dense bands of collagenous tissue
Span a joint and anchored to bone at either end
Joint stability
Multiple and different tensions at different positions
Describe the ligament structure
Collagen, fibroblasts, sensory fibres (proprioception, stretch and sensory), vessels on surface and crimping to allow stretch
Describe ligaments vs tendons in structure
Ligaments have lower percentage of collagen, higher percentage of proteoglycans and water, less organised collagen fibres, and rounder fibroblasts
Describe ligament rupture
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
Describe the haemorrhage stage of healing in ligaments
Blood clot
Resorbed
Replaced with heavy cellular infiltrate
Hypertrophic vascular response
Describe the proliferative phase in ligament healing
Production of scar tissue
Disorganised collagenous connective tissue
Describe the remodelling stage in healing of ligaments
Matrix becomes more ligament like
Major differences in composition, architecture and function persist
When is the conservative treatment used for ligament rupture?
Used in partial rupture and in complete when no instability
Poor candidates for surgery
What is used in conservative treatment for ligament rupture?
Soft tissue brace
Walker
Cast
Active mobilisation
When is operative treatment for ligament injury?
Instability - ACL ruptures and lateral ligament injuries of ankle
Expectation - sports
Compulsory - multiple ligaments
What is used for operative treatment of ligament injury?
Direct repair
Augmentation - tapes added
Replacement - sometimes taken from tendons of hamstrings
What is included in muscle unit?
Muscle origin, belly, musculotendinous junction, tendon, sheath, and insertion
Describe the composition of tendons
Longitudinal arrangement of cells and fibres
Mostly tenocytes and collagen type 1 - triple helix
Describe the structure of tendons
Fascicles of long narrow spiralling collagen bundles
Collagen bundles covered by endotenon
Fascicles covered by paratenon
Tendon covered by epitenon
What is the blood supply for tendons?
Come through Vinculum
And paratenon has fine network of blood vessels
Describe tendon sheath
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)
What is the function of a tendon?
Flexible and very strong in tension
Movement is life - immobility reduces water content + glycosaminoglycans conc. and strength
What are some types of injuries to tendons?
Degeneration, inflammation, enthesopathy, traction apophysitis, avulsion, tear of intrasubstance or musculotendinous junction, and laceration
What is a type of degeneration to tendon?
Achilles tendon
Describe Achilles tendon degeneration
Intrasubstance mucoid degeneration
May be swollen, painful, tender or asymptomatic
Can sometimes be a precursor to rupture
What is an example of inflammation?
De Quervain’s stenosing tenovaginitis
Describe de Quervain’s stenosing tenovaginitis
Tendons of EPB and APL passing through common tendon sheath at radial aspect of wrist
Swollen, tender, hot and red
Positive Finklestein’s test
What is Enthesiopathy?
Inflammation at insertion to bone
Muscle/ tendon - usually at muscle origin rather than tendon insertion
Is caused from repeated actions
Ligaments - plantar fasciitis
What is traction apophysitis?
Insertion of patellar tendon into anterior tibial tuberosity
Adolescent active boys
Recurrent load
Inflammation component
Describe avulsion and bone fragment
Failure at insertion
Load exceeding failure strength while muscle contracting
What is Mallet finger?
Type of avulsion
Insertion of extensor tendon into dorsum of base of distal phalanx of finger
Forced flexion of extended finger
What is the treatment of avulsion?
Conservative - limited application. Used for retracted tendon
Operative - reattachment of tendon and fixation bone fragment
How does a intrasubstance rupture occur?
Tear - ex. Achilles tendon
Load exceeds failure strength
What is the mechanism for rupture of tendon?
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
What is the clinical sign of Achilles tendon rupture?
Positive Simmond’s (squeeze) test - lie prone and calve muscle squeezed and foot will move if no damage
Palpable tender gap
What is a common example of musculotendinous junction tear?
Medial head of gastrocnemius at musculotendinous junction with Achilles tendon
What is the treatment for ruptures?
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
What is an example of laceration of tendon?
Finger flexors (FDS and FDP)
Common in males
Young adults
Always repair surgically
