Sports Flashcards
In a patient with swelling and ecchymosis over the chest wall after bench pressing what is the expected injury? What is the recommended treatment?
Mid-substance pectorals major tear. These injuries typically do not benefit from surgery. Period of immobilization followed by PT.
What is the most common complication after a lateral closing wedge high tibial osteotomy?
Anterior knee pain.
What does the dial test look for? How do you perform it?
posterolateral rotary instability of the knee . > 10 degrees of external rotation asymmetry at 30 and 90 degrees consistent with PLC and PCL injury. >10 degrees of external rotation asymmetry at 30 degrees only consistent with isolated PLC injury.
How do you test for anteromedial rotatory instability?
anterior drawer test with tibia in external rotation. Will expect greater laxity here with combined ACL and MCL injury than in neutral or internal rotation.
How do you measure Insall-Salvati Index? What is a normal value?
Ratio of patellar tendon length to patellar height. Normal values range from .8 to 1.2
What nerve plasy is most common with traction during hip arthroscopy?
pudendal nerve palsy.
What nerve is at risk with placement of the anterolateral portal for hip arthroscopy?
superior gluteal nerve.
What is the interval for an inside out medial meniscus repair?
Between the joint capsule and the medial head of the gastrocnemius.
Saphenous nerve is at risk.
Capsule is exposed by incising the sartorius fascia and retracting the pes tendons/semimembranosus posteriorly.
What is the interval for a inside out repair of the lateral meniscus?
between the lateral head of the gastrocnemius and the joint capsule.
What does a double PCL sign signify?
Medial mensicus bucket handle tear.
What is the leading cause of death in college football?
Exertional sickling collaps
Treat with rest, oxygen, and hydration.
good prognostic indicators for successful meniscus repair are:
Vertical and longitudinal tears
Peripheral tears
Tears in the red-red zone
Smaller rim width (rim width is the distance from the meniscocapsular junction and the tear). Smaller rim widths = better blood supply.
Describe the consequences of a malpositioned femoral tunnel that is too anterior, posterior, and centra/vertical.
Tibia tunnel malpositioned too anterior, posterior, medial, and lateral.
What is demonstrated in the radiograph and what injury is it associated with?
Segond fracture. Avulsion fracture of the anterolateral ligament.
Associated with ACL tear 75% of the time.
It is caused by internal rotation and varus load unlike the more common cause of ACL tears which is valgus stress.
What is demonstrated on the radiograph?
avulsion fracture of the arcuate complex where it inserts on the proximal fibula.
Fracture fragment is attached to the LCL or biceps femoris tendon.
Associated with curciate ligament injuries 90% of cases.
What are the three forms of snapping hip?
- External snapping hip, which is caused by the iliotibial band sliding over the greater trochanter.
- Internal snapping hip.
- Intraarticular snapping hip which is caused by loose bodies.
What condition is most likley if this image is from an otherwise healthy 20 football player?
Osteitis pubis. Will show bony erosion and irregularity and widening of the pubic symphysis.
From exissive physicla strain and is msot common in young football players.
Symptoms include loss of flexibility in the groin with dull aching pain. Can occassionally hav emore severe sharp pain when running, kicking, or chaning directions.
NSAIDs, physical therapy, an rest from sports.
What is Athletica pubalgia?
Sports hernia.
Overuse syndrome typically seen in high level athletes.
Extension-abduction of the leg with eccentric contraction of the adductors leads to high shear stress on the rectus and may lead to tears of the transverslais fascia, rectus muscle, and/or adductor magnus origin.
Describe the two bundles of the ACL and PCL with regards to which one is tight in flexion and extension?
What is the size of the ACL?
33mmx11mm
Describe the two bundles of the ACL?
Anteromedial: tight in flexion and loose in extension. fibers are parallel in extension and are externally rotated in flexion.
Posterolateral: prevents pivot shift. prevents internal tibial rotation with knee near extension. tight in extension and loose in flexion.
What is the most sensitive exam test for an ACL injury?
How is it graded?
Lachman’s test
A= firm endpint B= no endpoint
Grade 1: <5mm translation
Grade 2 A/B: 5-10mm translation
Grade 3 A/B: >10mm translation
In a normal knee at 90 degrees where is the medial tibial plateau relative to the femur?
1cm anterior to the medial femoral condyle.
If it is not should suspect a PCL injury.
May reduce with a quadriceps active test.
What are the grades of MCL injuries?
Grade I: 0-5mm opening
Grade II: 6-10mm opening
Grade III: 11-15mm opening
Medial opening at 30 degrees only -> isolated MCL injury
Medial opening at 0 and 30 degrees -> combined MCL and ACL and/or PCL. Same thought process for LCL.
What is a J sign about the knee?
Excessive lateral translation in extension which pops into groove as the patella engages the trochlea early in flexion.
Associated with patella alta.
What is a normal amount of passive patellar translation?
Normal motion is < 2 quadrants of patellar translation.
Midline of patella is considered 0
Lateral translation of medial border of patella to lateral edge of trochlear groove is considered 2 quadransts and is an abnormal amount of translation.
What kind of gait will you see in a patient with a PLC injury?
Varus thrust or hyperextension thrust.
What tests other than dial test are there to diagnose PLC injury?
Posterolateral drawer test- Performed with the hip flexed 45 deg, knee flexed 80 deg, and foor ER 15 deg. A combined posterior drawer and ER force is paplied to the knee to assess for an increase in posterolateral translation (lateral tibia externally rotates relative to later femoral condyle).
Reverse pivot shift test- With the knee positioned at 90 deg, ER and valgus forces are applied to tibia. Tibia reduces from a posterior subluxed position at 20 deg of flexion to a reduced position in full extension. Reduction force is from IT band transitioning from a flexor to an extensor of the knee.
External rotation recurvatum test- Positive when the leg falls into ER and recurvatum when the lower extremity is suspended by the toes in a supine patient.
How much force is transmited by the meniscus?
transmits 50% weight bearing load in extension and 85% in flexion.
The meniscus is more elastic than articular cartilage.
90% Type I collagen
67-75% water
What is the shape of the medial and lateral meniscus?
Medial: C-shaped with triangular cross section. Average width of 9-10mm. Average thickness of 3-5mm.
Lateral: Is more circular (the horns are closer together and approximate the ACL). Covers a large portion of the articular surface. AVerage width is 10-12mm. AVerage thickness is 4-5mm.
What are the attachments of the menisci?
transverses (intermeniscal) ligament- connects the medial and lateral meniscus anteriorly
coronary ligaments- connects the meniscus periperhally. Medial meniscus has less mobility with more rigid peripheral dixation than the lateral meniscus
Meniscofemoral ligament- connects the meniscus into the substance of the PCL. Originate from the posterior horn of the lateral meniscus and has two components:
Humphrey ligament (anterior)
Ligament of Wrisberg (posterior)
What is the blood supply of the menisci?
Middle genicular artery- supply to posterior horns
Medial inferior genicular artery- supplies peripheral 20-30% of medial meniscus
Lateral inferior genicular artery- supplies peripheral 10-25% of lateral meniscus
Central 75% receive nutrition through diffusion.
What are more common medial or lateral meniscal tears?
Medial are more common.
The exception is in the setting of an acute ACL tear where lateral tears are more common.
What is the most sensitive physical exam finding of a meniscal tear?
Joint line tenderness
What is a Thessaly test?
Provocative test for a meniscal tear.
Standing at 20 degrees of knee flexion on the affected limb the patient twists the knee with external and internal rotation. A positive test is discomfort and clicking.
What is another sign other than double PCL that indicates a meniscal tear?
Double anterior horn sing
What is the success rates after a partial meniscectomy?
What are predictors for success?
How many patients will have radiographic degenerative changes at final follow-up?
>80% satisfactory function at minimum follow-up.
Age<40 years, normal alignment, minimal or no arthritis, and a single tear.
50% will have osteophytes, flattening, joint space narrowing.
The best candidate for a meniscal repair has what characteristics?
red-red zone
low rim width
vertical or longitudinal tear
1-4mm in length
root tear
Acute repair combined with ACL reconstruction.
What are the indications for a meniscal transplantation?
What are the contraindications?
Outcomes?
Young patient with near total meniscectomy, especially lateral.
Inflammatory arthritis, instability, marked obesity, grade IV chondrosis (if not concurrently addressed), malaignment (if not concurrently addressed), and diffuse arthritis.
Requires 8-12 month s for graft to fully heal. Return to sports by 6-9 months.
10 year follow-up showed persistent improvement in subjective pain and function scores.
Most had radiographic progression of degenerative changes.
Re-tears or extrusion are common
What technique is considered the gold standard for meniscal repairs?
Inside-out technique
Medial Approach: Expose capsule by incising the sartorius fascia, retract pes tendons/semimembranosus posteriorly, develop plane between the medial gastrocnemius and capsule.
Lateral Approach: Develop plane between IT band and biceps tendon, then retract lateral head of gastrocnemius posteriorly.
When might an outside in repair technique be used for a meniscal tear?
Anterior horn tears.
Which suture technique provides the strongest fixation?
vertical mattress sutures
Which meniscus is usally involved in a discoid meniscus?
How often is the condition bilateral?
Lateral meniscus
25% bilateral
What are the radiographic findings that indicate a possible disocid meniscus?
Widening joint space up to 11mm.
Squaring of lateral condyle with cupping of lateral tibial plateau.
Hypoplastic lateral intercondylar spine.
Diagnosis with MRI can be made with 3 or more 5mm sagittal images with meniscal continuity. “Bow-Tie Sign”
What are the sex related differences in ACL injuries?
More common in female athletes 4.5:1 ratio
Younger age than males
Females get ACL injuries on the supporting leg while males get more ACL injuries on the kicking leg.
Landing biomechanics and neuromuscular activatin patterns (quadriceps dominant) play the biggest role.
What is the innervation to the ACL?
posterior articular nerve (a branch of tibial nerve)
What is depcited in the radiograph?
Deep sulcus (terminalis) sign
Depression on the lateral femoral condyle at the terminal sulcus, a junction between the weight bearing tibial articular surface and the patellar articular surface of the femoral condyle.
What bone bruising on MRI is consistent with an ACL tear?
Middle 1/3 of LFC (sulcus terninalis)
Posterior 1/3 of the lateral tibial plateau
Describe proper Femoral and Tibial tunnel placement for an ACL reconstruction.
Femoral Tunnel Placement: Sagittal plane 1-2mm rim of bone between the tunnel and posterior cortex of the femur. Coronal plane the tunnel should be placed on the lateral wall at 2 for a left knee and at 10 for a right knee. This creates a more horizontal graft.
Tibial tunnel placement: Sagittal plane the center of the tunnel entrance into the joint should be 10-11mm in front of the anterior border of the PCL insertion. 6mm anterior ro the median eminence and 9mm posterior to the inter-meniscal ligament. Coronal plane tunnel trajetory of <75 defrees from the horizontal Can be obtained by moving tibial starting point halfway between tibial tubercle and posterior medial edge of the tibia.
What does graft preconditioning due for ACL reconstructioning?
Can reduce stress relaxation up to 50%.
Graft tensioning in 20-30 degrees of flexion.
What are complications associated with bone-patellar-bone autograft?
Patella fractures, these usually occur post-op during rehab.
Patellar tendon rupture.
Re-rupture. This is associated <20 years and graft size < 8mm
Which graft has better peak flexion strength at 3 years? BTB or Quadruple hamstring?
Bone-PT-Bone
What are the different ways allograft is processed before use for ACL grafts?
What are the effects on pathogen transmission?
What are the effects on the grafts mechanical properties?
Supercritical CO2: decreases the structural and mechanical properties.
Radiation: > 3 is required to kill HIV however this decreased the structural and mechanical properties. 2-2.8 Mrad decreases stiffness by 30%. 1-1.2 Mrad decreases stiffness by 20%
Deep freeing: destroys cells but does not affect the strength of the graft.
4% chlorhexidine gluconate: destroys cells but does not affect the strength of the graft.
What immediate rehab is recommended after ACL reconstruction?
aggressive cryotherapy.
immediate weight bearing shown to reduce to patellofemoral pain.
emphasize early full passive extension. Especially if associated with MCL injury of patella dislocation.
What early rehab is recommended after an ACL reconstruction?
What rehab exercises should be avoided?
eccentric strengthening at 3 weeks has been shown to result in increased quadriceps volume and strength.
Isometric hamstring contractions at any angle
isometric quadriceps or simultaneous quadriceps and hamstrings contraction
Active knee motion between 35 degrees and 90 degrees of flexion.
Emphasize closed chain (planted foot) exercises.
Avoid: isokinetic quadriceps strengthening (15-30 deg ) during early rehab. Open chain quadriceps strengthening.
What is the most common infection after ACL reconstruction?
Staph epidermidis
Staph Aureus is 2nd most common
Can treat with arthroscopic I&D and retention of graft with staph epi. Less likely to be successful with S. aureus.
What treatment should be recommended for arthrofibrosis and loss of motion after an ACL reconstruction?
< 12 weeks, then treat with appressive PT and serial splinting.
> 12 weeks, then treat with lysis of adhesions/manipulation under anesthesia
Patella infera is another name for what?
Patella baja.
How will a cyclops lesion present after ACL reconstruction?
block to extension
Click heard at terminal extension
What three mechanisms most commmonly lead to PCL injury?
Direct blow to proximal tibia with a flexed knee. (dashboard injury)
Noncontact hyperflexion with a plantar-flexed foot
Hyperextension injury
Chronic PCL injuries are most likely to have degenerative changes in what knee compartments?
Patellofemoral and medial compartments.
This is due to increased contact pressures and varus alignment.
What radiograph can be obtained to diagnose and quantify a PCL injury?
Lateral stress view
Apply stress to anterior tibia with the knee flexed to 70 degrees.
10-12 mm more likely isolated PCL
>12 mm suggests a combined injury
What treatment is recommended for a Grade II PCL injury?
Grade I partial (1-5mm posterior tanslation posterior drawer), Grade II complete (6-10mm), Grade III (>10mm) combined.
PWB and rehab.
Quadriceps rehabilitation with a focus on knee extensor strengthening.
Return to sport in 2-4 weeks
When may non-operative treatment be an option for Grade III PCL injuries?
Older lower demand patient and must be isolated.
Less likely for bony avulsions or a young athlete.
4 weeks Extension bracing with limited daily ROM excercises.
Period of immobilization is followed by quadriceps strengthening.
What are the results of PCL reconstruction?
Typically are less successful than ACL reconstruction.
Often have residual posterior laxity.
Reconstruction options include tibal inlay vs transtibial methods. Single bundle bs double bundle.
No studies have clearly supported one reconstruction technique over another.
What are the indication sfor PCL repair or reconstruction?
Repairs are unsuccesful unless ORIF of bony avulsions.
Combined ligamentous injuries.
Isolated chronic PCL injuries with a functionally unstable knee.
The image is from an 18 year old with a remote history of a PCL injury. He has medial knee pain that has failed conservative measures. What treatment whould you recommend.
High tibial osteotomy.
Medial opening wedge osteotomy is a better choice than a lateral closing wedge osteotomy as the opening wedge more effectively increases posterior tibial slope which is helpful in PCL deficient knees.
Increasing tibial slope reduces the posterior sag of the tibia.
What is the theoretic advantage of a double bundle PCL reconstruction?
Biomechanically show to improve function in both flexion and extension.
Anterolateral bundle tensioned in 90 degrees of flexion
Posteromedial bundle tensioned in extension
Clinical advantage has yet to be determined.
Briefly describe the arthroscopic transtibial technique for PCL reconstruction?
Standard arthroscopic portals with an accessory posteromedial portal. This portal is placed 1 cm proximal to the joint line posterio to the MCL. Avoid injury to branches of the saphenous nerve during placement.
Posteromedial corner of the knee is best visualized with a 70 degrees arthroscope either through the notch (modified Gillquist view) or using a posteromedial portal.
Transtibial drilling anterior to posterior
Fix graft in 90 degrees of flexion with an anterior drawer.
Briefly describe an Open tibial inlay technique for PCL reconstruction.
Uses a posteromedial incision between medial head of gastrocnemius and semimembranosus.
Also used for ORIF of bony avulsion
Biomechanical advantage with a decrease in the killer turn with less fraft attenuation and failure.
screw fixation of the graft bone block is within 20mm of the popliteal artery
Rehabilitation after PCL reconstruction?
Immobilize in extension early and protect against gravity.
Early motion should be in prone position
Focus on quadriceps rehabilitation
Avoid resisted hamstring strengthening exercises (ex. hamstring curls) in early rehab. They create a posterior pull on the tibia which increases stress on the graft.
What is the most common ligamentous injury in the knee?
MCL injury
Males > females
valgus stress is the most common mechanism
usually with the knee held in slight flexion and external rotation
Where does MCL rupture more commonly occur?
Rupture usually occurs at the femoral insertion of the MCL
Proximal MCL tears have greater healing rates.
Distal MCL tears have inferior healing and residual valgus laxity.
What is the most common multiligamentous knee injury?
ACL-MCL
95% of associated MCL injuries are with an ACL injury
Often associated with high grade MCL injuries.
What mensicus tear is most common with MCL injury?
Medial > Lateral
Only about 5% of isolated MCL injuries are associated with meniscus tears.
What is Pellegrini-Stieda Syndrome?
Calcification at the medial femoral insertion site.
Results from chronic MCL deficiency.
Describe the different grades of PLC injury?
What bone bruising may be seen on MRI with PLC injuries to the knee?
Bruising of medial femoral condyle and medial tibial plateau
What is the best way to assess for trochlear dysplasia?
Lateral Radiograph
May see:
Crossing sign- trochlear groove lies in same plane as anterior border of lateral condyle. Represents flattened trochlear groove.
Double contour sing- Anterior border of lateral condyle lies naterior to anterior border of medial condyle. Represents convex trochlear groove/hypoplastic medial condyle.
Supratrochlear spur- arises in proximal aspect of trochlea.
What is the insall-Salvati method?
What is a normal value?
Normal between .8 and 1.2
How do you measure the Blackburn-Peel Index?
What is a normal value?
Normal .5 to 1.
What radiographic measurement is used to determine if a lateral retinacular release may be helpful?
Lateral Patello-femoral angle.
Angle formed by lateral patellar facet and a line drawn across most prominent aspects of anterior portion of the trochlea on a CT scan or Sunrise view radiograph.
If there is a negative patellar tilt on this measurement the patient may benefit from a lateral release for pain relief.
How do you measure the TT-TG distance?
What is considered an abnormal valued?
Measures the distance between 2 perpendicular lines from the posterior cortex to the tibial tubercle and the trochlear groove.
>20mm usually considered abnormal
Describe the Outerbridge classification of Chondromalacia?
Describe a basic algorithm for dealing with cartilage defects?
How do you measure the head-neck offset ratio to evaluate for femoroacetabular impingement?
What is a normal value?
See photo for method of obtaining.
Use a lateral radiograph.
If value is <.17 then a cam deformity is likely present.
What provides a landmark for the iliopsoas tendon during hip arthroscopy?
Zona orbicularis
Need to use the distal anterolateral portal in order to visualize the peripheral compartment of the femoral neck.
3-5cm distal to the anterolateral portal.
What are the three phases of a bone scan?
What will it show tibial stress syndrome vs a stress fracture?
Phase 1 flow phase. Phase 2 blood pool phase Phase 3 delayed phase
Tibial stess syndrome will show normal phase 1 and 2. Phase 3 will show increased uptake.
Stress fracture has focal intense hyperperfusion and hyperemia in phase 1 and 2. Fusiform uptake in phase 3.
Stress syndrome pain is from periosteum where stress fracture is pain from the bone.
Describe the graduated return to play protocol for concussions?
Each step should take 24 hours so an athlete should take one week to proceed through the full protocol and return to play.
