Unit 5 Case 1: ACL tear Flashcards
anatomy in this case
anatomy of the knee joint
which movements does the knee joint allow
extension
flexion
lateral rotation
medial rotation
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what is a bursa
synovial fluid filled sac found between moving structures in a joint
aim is to reduce wear and tear on those structures
4 bursae located in the knee
supra patellar
prepatellar
infra patellar
semimemmbranosus
suprapatellar bursa
extension of the synovial cavity of the knee
located between the quadriceps femurs and the femur
prepatellar bursa
found between apex of the patella and the skin
infra patellar bursa
split into deep and superficial
deep bursa lies between tibia and patellar ligament
superficial lies between patellar ligament and skin
semimembranosus bursa
located posteriorly in the knee joint
between semimembranosus muscle and medial head of the gastrocnemius
what does NSAID stand for
non steroidal anti-inflammatory drugs
examples of NSAID’s
aspirin
naproxen
ibruprofen
moa of NSAID’s
inhibit COX-1 and COX-2 enzymes which convert arachidonic acid into prostanoids
to produce prostaglandins, thromboxane and prostacyclin
COX-1 of NSAID’s
GIT effects
preserves integrity of gastric mucosa
COX-2 of NSAID’s
inducible form
predominates at sites of inflammation
stimulates prostaglandin formation
what are adverse effects of NSAID’s caused by
COX-1 pathways
how are NSAID’s administered
orally
topical gel
parenterally
suppositories
when are NSAID’s given
for mild-moderate pain as they have analgesic effects
inflammation
and pyretic
when should you avoid NSAID’s
if severe Renal impairment
heart or liver failure
NSAID’s side effects
GI toxicity
renal impairment
increased risk of cardiovascular events
hypersensitivity reactions
fluid retention
how can you gastroprotect when giving NSAID’s
low dose NSAID
standard dose of PPI
types of prostaglandin
E2, PGE2
D2, PGD2
F2 alpha, PGF2 alpha
prostacyclin, PGI2
prostaglandin function
inhibits gastric acid secretion, E2
maintains renal blood flow, E2
inflammation, E2 and D2
pain, E2
inhibits platelet aggregation, E2
thromboxane function
stimulates activation of platelet aggregation
thromboxane function
stimulates activation of platelet aggregation
blood clotting
vasoconstriction
prostacyclin funciton
inhibits platelet aggregation
vasodilation
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function of osteoprogenitor cells
stem cells to osteoblasts
function of osteoclasts
erode mineralised bone
function of osteoblasts
synthesis of osteoid
function of osteocytes
inactive osteoblasts trapped in mineralised bone
function of osteoid
organic component of bone matrix
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features of hyaline cartilage
perichondrium
type 2 collagen fibres
chondrocytes arranged in groups
articular ends of bones, nose, trachea, ventral end of ribs
features of fibrocartilage
perichondrium
contains elastin and type 2 collagen
pinna of the ear, epiglottis
features of elastic cartilage
no perichondrium
chondrocytes are arranged in parallel rows
dense, coarse, type 1 collagen in the matrix
for withstanding tensile strength
intervertebral discs, pubic symphysis
inflammatory response to knee injurt
immediate response is an increase in synovial fluid
releases IL-1 alpha, IL-1 beta, IL-6, IL-8, TNF- alpha, matrix metalloproteinases, cartilage oligomeric matrix protein
function of IL-1 alpha
DAMP
released to the extracellular space after apoptosis
stimulated chemokine production
results in infiltration of neutrophils first followed by monocytes
function of IL-1 beta
pro-inflammatory cytokine
crucial for host defence responses to infection and injury
function of IL-6
induces synthesis of acute phase proteins (CRP)
serum amyloid A
fibrinogen
hepcidin in hepatocytes
inhibits albumin production
function of IL-8
chemoattractant produced by tissue and blood cells
targets neutrophils
activates neutrophils in inflammatory regions
function of TNF-alpha
vasodilation
edema formato
leukocyte adhesion to epithelium through the expression of adhesion molecules
regulates coagulation
contributes to oxidative stress in inflammation sites
induces fever indirectly
function of MMP’s
activity of inflammatory cytokines and chemokine
collagen breakdown
function of cartilage oligomeric matrix protein
non-collagenous extracellular matrix protein expressed in cartilage
ligaments and tendons
binds to other ECM proteins
catalyse polymerisation of type 2 collagen fibrils
regulate chondrocyte proliferation
where are similar inflammatory responses found to those in the knee
elbow
inter pharyngeal joints (hand, foot, tibiotalar of ankle)
bundles of the anterior cruciate ligament
anteriomedial
posterolateral
function of the ACL
restraint to limit anterior movement of the tibia
knee rotational stability
location of the ACL
normally will parallel blumensaats line
clinical presentation of an ACL tear
popping sensation
significant pain
hemarthrosis (delayed)
loss of full range of motion
tenderness along the joint one
discomfort/ inability to walk
rapid joint swelling
hemarthrosis
bleeding into the joint
differential diagnosis for an ACL tear
proximal tibial fracture
distal femur fracture
meniscal tear
collateral ligament tear
quadriceps tendon tear
patellar ligament tear
examinations done in order to test ACL tear
Lachman test
anterior draw test
x ray
MRI
ultrasound
lachman test
30 degrees flexion
stabilise femur
pull tibia forward
assess anterior movement of tibia vs the femur
compare knees
anterior draw test
90 degrees flexion
place thumbs on joint line
index fingers on hamstring tendons
apply forces anteriorly to see tibial excursion
compare knees
x ray in this case
rule out fractures
doesn’t confirm any soft tissue injury
MRI in this case
hard and soft tissues
radio waves
ultrasound in this case
sound waves
check injuries in ligaments, tendons and muscles
treatment options for ACL tear
elevate and stay off leg (immediate)
apply ice and take NSAID’s (immediate)
leg brace
ACL reconstructive surgery
when is ACL reconstructive surgery completed
not straight away, when the swelling has reduced
assessed to see if it is severe enough for surgery
ACL reconstructive surgery
phase one of the rehabilitation program
weeks 0-2
eliminate the swelling
receive full range of motion
regain strength in hamstrings and quads
exercises: calf raises, lateral band walks, balance, static cycling
phase 2 of the rehabilitation program
weeks 3-6
regain balance
recover majority of muscle strength
single leg exercises
low impact exercise: walking, swimming and cycling
phase 3 of the rehabilitation program
weeks 7-12
hopping performance
complete agility exercises
regain strength and balance
light jogging, outdoor cycling and swimming
phase 4 of the rehabilitation program
3-6 months
knee feels normal but no strenuous sport
polymetrics
sports drills
phase 5 of the rehabilitation program
months 6+
continue with strength, balance, landing and agility
return to pre-injury exercise
MDT involved in an ACL tear
physio
trauma team
theatre nurse
social teams
ward nurse
discharge coordinator
clinical support worker
ward clerk
porter
GP
osteopaths
occupational therapist
pharmacist
radiologist
anaesthetist
orthopaedic surgeon
psychological implications of an ACL tear
very painful
depression
pain after surgery
decreased athletic identity
