Ligament Injuries (Exam 4) Flashcards
Role of Ligaments
Provide stability to joints
Keep the bones of the joint in close approximation in both static and moving situations
Overstretched ligament - loose, can lead to arthritis and
dislocation
Following an injury: (sprain or stretch) the ligaments do not return to their previous resting length - more likely to
re-injure
sprain = lig injury
strain = muscle injury
Post injury conservative action - immobilization through splinting and casting for 6 weeks, if this fails then surgery via pinning or lig reconstruction
ex: Tommy Johns - use palmaris longus lig
Ligamentous Structures
Lateral or collateral ligaments - prevents joints from moving side to side (keep translation from occurring)
Cruciate ligaments - prevent forward and backward motion
Volar plate - prevent volar motion (fingers/wrist)
wrist - complex ligamentous system that consists of volar, dorsal intrinsic, extrinsic and inter-carpal ligaments
glenohumeral labrum in the shoulder ligamentous structure - there are not as many lig, they do not provide stability in the shoulder Mm provide stability (rotator cuff Mm)
elbow - stability is bone olecranon and olecranon fossa
ulnar collateral ligament gets stretched and torn with pitchers when throwing balls on full ext rotation
Ligament Sprain
An injury caused by overstretching of a ligament and in some cases mild tearing of the fibers of ligamentous tissue
Tx = immobilization for 6-8 weeks
anti-inflammatory meds
modalities as needed (ice, heat, ultrasound, kinesi
ligaments can be totally torn as well
don’t provide cortisone injection b/c of soft tissue breakdown
Ligament Tear
Usually occurs from trauma
May include a bone fx known as an avulsion - bone pulled away from insertion, insertion sight of the ligament torn away
Avulsion fractures can heal if bone fragment is in place as long as everything is approximated
Surgical management can include pinning, screws and suturing the ligamentous tissue
Autograft - from yourself your own body
Allografts - from someone else, cadaver or bovine
Ulnar Collateral ligament sprain - called skiers thumb b/c of falling on outstretched lig or game keepers thumb
Dislocation of a Joint
A complete separation of the bone ends that normally articulate to form a joint
Fx and dislocations often go hand and hand
With dislocations you will have ligament damage
Described according to : direction of movement of the
distal dislocation bone
Glenohumeral joint most commonly dilocated joint, the hip is a little more stable b/c acetabulum comes in contact with more of the femur
Fingers are 2nd most frequent site especially PIP joints
Medical Diagnosis and Tx for Dislocation
Dx: x-ray, MRI or CT scan, arthrogram and physical exam
Tx: re-align and/or reduce separation by closed reduction ASAP, often done in doctors office or ER
Must put joint back into place, the sooner the better
If closed reduction (through skin) is not effective must do open reduction under general anesthesia in operating room.
Dislocation Recovery
When treated early, most dislocations do not cause permanent injury
Injuries to the surrounding tissues generally take 6-12 weeks to heal (12 weeks tolerate cutting, weight bearing)
Sometimes surgery to repair a lig that tears when the joint is dislocated is needed
Injury to Nn and blood vessels may result in more long-term or permanent problems
Once a joint has been dislocated. It is more likely to happen again
Dislocation of the Elbow
“The Unforgivable Elbow” so many things can go wrong - gets stiff easily
3 peripheral Nn of UE pass very close to joint capsule of the elbow - nerve traction injury is high or other things that cross the joint (blood vessels, tendons, Nn)
Dislocation of the Radius
Common UE injury to infants and children (2-5 yrs)
Seen more frequently in girls as compared to boys
Sudden onset
Radial Head Dislocation = causes the radial head to displace, with injury to the annular ligament (pops out of annular lig)
the annular lig is the only thing holding the radius in place
other dx (not lig) but shoulder subluxation, brachial plexus injury and fx can coincide
Mechanism = while swinging a child by their hands
after a fall
when an infant rolls over in an unusual way
UE is pulled/jerked up too hard by the hand
or wrist while forearm is pronated
once the elbow dislocates it is likely to do so
again, especially in 3-4 wks after injury
it is often seen after someone lifts a child up
by one arm (when trying to lift over a curb)
commonly occurs when child is falling and
person holding hand does not let go
Interventions = physical exam
closed reduction (supinated hand and arm
slightly flexed at elbow
sling - use following re-setting if site is
tender
elbow splint - if tx is delayed more than
12 hrs
cast - if more than 3 recurrent episodes and
if it has been dislocated for a while
(splint or cast at 80-90 degrees flex
typically neutral forearm
2-3 wks
then progress to
long arm elbow splint or brace under
protective motion protocols can start
as early as wk 1, then gradually increase
in extension (4wks in splint)
full ext 6wks
Education = kids: avoid movmt at radial head to allow time
for healing
avoid weight based activity with injured
arm, sudden changes in joint angle and
movmt should also be avoided
adults: you can't immobilize for a sign period
of time - get too stiff
wear sling 1st wk and then a brace with
gradual motion, can do a little sup/pro
with elbow flexed, forearm has to be in
neutral
full extension is the least stable for the
elbow and not allowed until 4 wks
post-op
elbow likes to develop HO
heterotopic ossification especially in
the brachialis which runs deep right
next to the joint capsule, it tends to
develop tone tension to protect
good tech = deep pressure but not
too aggressive and biofeedback
get them to relax brachialis
(too aggressive could increase tone)
Out of brace but deficit in extension:
heat with arm resting on towel roll
gently extend with gravity
soft tissue work around brachialis and
collateral lig around fingers
splint at night on volar surface
(static long arm splint)
tight lig = joint mobs
Review Stability
Wrist = ligaments Shoulder = Mm Elbow = bones
The Wrist
LOTS OF LIGAMENTS
Carpal Instabilities = motion btwn the carpal bones from
lax or torn ligaments
leads to arthritis and pain with weight
bearing and grip
Wrist should have an 11-12 degree palmar tilt of the lunate
if no palmar tilt you might have a lig problem
Carpal Kinematics = scaphoid likes to live in slight flex
triquetrium likes to live in slight ext
lunate will hang out with which ever
one its connected to - b/c it is
connected to both it stays in a
neutral position with a little flex
if there is a disruption in the
connection, the lunate will go with
the carpal it is still connected to
DISI: Dorsal Intercalated Segment Instability
TEST!!!!
Very common
Lunate is also known as an intercalated segment
Scapholunate ligament tears and results in a DISI
b/c lunate is hanging out with the triquetrium =
lunate tilts upward
If x-ray shows a gap - this is a sign of a BAD lig disruption
VISI: Volar Intercalated segment instability
TEST!!!
Lunate hangs with the scaphoid in flexion secondary to a luno-triquetral ligament tear or sprain -
lunate facing downward
TFC and TFCC
Triangular Fibrocartilage Complex
TFC = The disc, like a meniscus in the knee
TFCC = The ligamentous borders
ECU and its sheath
the disc
TFCC Injuries = common structure to get abutment with
gymnastics or cross fit
gloves and wrist supports provided before
damage - wrist straps give compression
and stabilizes the distal radial ulnar lig
use scale and weight bear and try again
with wrist tapped
Ligament Injuries to the Fingers
DISLOCATION OF DIGITS = Jammed Finger
more common in males
sprained lig in finger
usually PIP
painful, swollen, stiff
collateral ligs thicken
sometimes jts don’t go back to size
displacement of bones of finger from
normal position
can occur in any finger joint
most common in PIP of digits 2-5
CAUSES = accidents causing “jamming” force applied to end of finger or finger may be forcefully overextended or bent beyond the limit of motion, can also happen with metacarpal
EX: small finger ulnarlly deviated - both collateral ligaments injured but radial is worse
Incidence = more than 80% of all traumatic hand injuries
VOLAR PLATE = is like an accordion
digits ext it is stretched
digits flex it folds onto itself
VOLAR PLATE TORN =
volar plate stretched - subluxation and swan neck
volar plate tight - 1st PIP flex contracture and then
may get boutonnieres
S/S:
finger appears crooked and swollen
very painful
may be bent upward or at strange angel
inability to bend or straighten fingers
may have numbness/tingling with severe dislocations
(b/c of digital Nn)
may cause skin to break
TX: Volar plate injuries are placed in a dorsal blocking splint that blocks full extension to -30, no motion
SURGICAL REDUCTION AND REPAIR:
finger can be realigned with or without anesthesia by closed reduction (applying traction and repositioning bone)
after joint reduction the individual wears a protective splint or has finger taped to another finger for 3-6 wks (buddy taped)
PROGNOSIS:
usually good but may take 4-6 months for finger pain to disappear
in some cases a small amount of swelling around the injured joint, especially the PIP
in athletes a finger that has been dislocated often is injured again
