Week 2 Flashcards
What percentage of knee fractures occur at the patella?
40%
What percentage of knee fractures occur at the tibial plateau?
32%
What percentage of knee injuries actually have fractures?
6%
What are the imaging options for fracture?
Radiographs
CT scans (better bone detail)
MRI (ST injuries)
According to the Salter-Harris Classification, what type of fracture occurs through the physis causing a widening?
type I
According to the Salter-Harris Classification, what type of fracture occurs partway through the physis extending up into metaphysis?
type II
According to the Salter-Harris Classification, what type of fracture occurs, partway through the physis extending down into the epiphysis?
type III
According to the Salter-Harris Classification, what type of fracture occurs through the metaphysis, physis, and epiphysis which can lead to angulation deformities when healing?
Type IV
According to the Salter-Harris Classification, what type of fracture occurs when a crush injury occurs to the physis?
Type V
What are the goals of fracture management?
restore to optimal functional state
prevent Fx and ST complications
get the Fx to heal and in a position which will produce optimal functional recovery
rehabilitate as early as possible
What are the ways to minimize the effects of immobilization from fracture?
patient education, maintain CVS fitness, upper body ergometer, maintain uninvolved joints and extremities, provide means of safe mobility, prevent respiratory complications and decubiti
What are some interventions during mobilization stage of fractures?
education, manual therapy, therapeutic exercise, aerobic, strengthening, stretching, NM reeducation/proprioception, function
What type of radiograph is best for patellar fracture?
sunrise view to see Fx
What is a common structural defect that could be confused for a patellar fracture?
bipartite patella
What are the complications to be aware of for knee dislocations?
quads atrophy, joint stiffness, arthritis, other injuries, shock, fat emboli, avascular necrosis, quad tendon ruptures, patellar instability, damage to popliteal fossa structures
What are medical screening questions to rule in/out red flags?
recent fever? recent abx or medicine for an infection? recent surgery? recent injection? recent cut or open wound? dx w immunosuppressive disorder? hx of heart trouble? dx w poor circulation in legs? hx of cancer? recent long car or plane or bus ride? recent bed ridden? hip, thigh, groin, or calf pain that increases with exercise or training? recently begun a vigorous physical exercise or training program? recent blow to your shin or other trauma to your legs?
What type of collagen are ligaments?
type I arranged near parallel
What are some responses to immobilization of ligaments?
atrophy of ligament, get reduction in intracellular matrix and inferior ligament material production, can have resorption of boney insertion sites, reduced tensile strength, shortening (can loose 50% of mech strength by 6-9 weeks of immobilization)
Describe ligamentous recovery after immobilization.
physical activity and motion gradually, bone insertion sites recover first,
Which of the following is not true for the effects of aging?
a. peak energy absorption performance occurs at skeletal maturity (18-20 yrs) then gradually declines after
b. collagen content decreases with ago and loses tensile strenght
c. bony insertion sites are stronger in children so occur less often
c - they are weaker and less developed
= failure of ligaments in children usually occur here
Which of the following is not true regarding the MCL?
a. primary restraint to varus stress
b. deep layer has fibers that blend with medial meniscus (so can involve that in higher grade injuries)
c. superficial layer more vascular and first to be injured
d. a blow to the lateral side or planted foot and twist from medial load on inside knee tears it
e. taut in flexion
a - valgus stress
Which of the following is true for the LCL?
a. primary restraint to valgus stress
b. blow to medial knee that loads lateral knee can tear
c. attached to capsule or meniscus
d. weaker than MCL
e. ligament is taut in full extension
b is true.
a - varus stress
c - not attached
d - stronger than LCL
e. ligament is taut from 0-30 degrees of flexion (test in this range)
What separates the LCL from the meniscus?
popliteus
Which is not true for the ACL?
a. restrains anterior translation of tibia on femur
b. has attachments with anteromedial horn of meniscus
c. most likely injured in extension
d. anterior-medial bundle is most taut in flexion
e. posterior-lateral bundle is most taut in extension (greater role in rotational control)
c - most likely injured in flexion
Which is true for the PCL?
a. anterior-lateral bundle is most taut in extension
b. posterior-lateral bundle is most taut in flexion
c. main restraint of posterior femoral translation
d. secondary role in limiting femoral ER and tibial IR
d is true
a - AL taut in flexion
b. PL taut in extension
c. main restraint of posterior tibial translation or anterior femoral translation
When the knee extends, the PCL slides femoral condyles _ as femur rolls anteriorly.
posteriorly
When the knee flexes, the ACL slides the femoral condyles _ as femur rolls posteriorly.
anteriorly
What other things should be considered along with an ACL injury?
meniscal injury, multiple ligament injury, fracture/dislocation, chondral defects, neurovascular compromise
True/False: There is clear evidence that ACL reconstruction reduces rate of OA development or improves the long-term symptomatic outcome.
false - there is no clear evidence to support
_% back to pre-injury level of participation.
_% return to competitive sports.
63%, 44%
What are ACL copers?
people that can dynamically stabilize ACLD knee
to qualify: must resume previous activity for > 1 yr, no episodes of giving way, do not require surgery
What are ACL noncopers?
people that cannot dynamically stabilize an ACLD knee
giving way, unable to resume previous level of activity, require surgery
What are the some characteristics of copers?
(kinematic) joint stability, fewer episodes of giving way, “normal” knee ROM and forces during functional activities
(EMG) reduced quad control, preferential activation of VL and medial hamstring
What are the some characteristics of noncopers?
(kinematic) increased joint laxity, reduced knee ROM during hop testing, reduced knee compression and shear forces during gait
(EMG) poor quad activation, increased quad activity during knee flexion
True/False: Activity differences between copers and non-copers is the same.
true!
both return to activity = 82%, reduced activity scores = 21% and reports = “good function”
According to the US Study for classifying non-copers, describe the suspected copers list.
Hop tests - >=80% involved/uninvolved leg;
knee outcome survery = >=80% grade for survery; global rating of knee function - >=60%; <= 1 episode of giving way
True/False: Testing of ACL is better non-acutely.
true - should test after ~ 10 PT sessions, >60days, < 6 mos
What are the Pre-Op considerations for ACL surgery?
pain, effusion, ROM, muscle function, extension lag, gait, “anger” of it
What are the post-op considerations for ACL surgery?
initial graft strength, graft type, healing and maturation of graft
Rank the following grafts in strength to failure/stiffness order:
Quadrupled hamstring, quadricepts tendon, native ACL, patellar tendon
quadrupled hamstring > patellar tendon > quadriceps tendon > native ACL
Describe the pros/cons of autografts.
is own tissue so faster incorporation and healing; has better outcomes in young, active pts; donor site morbidity; risk of Fx using patellar tendon graft
Describe the pros/cons of allografts.
less acute pain, greater decrease in structural properties, slow rate of incorporation, better for revisions
For a BPTB autograft, which of the following is not true?
a. higher incidence of PFP
b. persistent quad weakness
c. injury to extensor mechanism
d. safe for eccentrics
e. modify squats to minimize PF compression forces
d - avoid early heavy eccentrics
For hamstring autografts, which of the following is true?
a. more aggressive early on
b. no isolated hamstring strengthening until p/o 8 weeks
c. hamstrings control the knee uniquely in the frontal plane
d. will likely not lose any HS strength
b is true
a - less aggressive early on
c - transverse plane
d - lose 10% of HS strength
True/False: Rehab following may need to be less aggressive compared to autograft.
true
What is ligamentizaton?
replacing ligament with tendon and it slowly converting to ligament: tendons weaken after surgery and comes back to life very similar to ligament (full function of it will not be complete until 1-2 yr post-op)
What are the initial post-op goals of ACL repair/reconstruction?
safely restore full passive extension as soon as possible, restore patellar mobility, control post op inflammation, gently and slowly increase Flexion ROM, est and increase volitional quad strength, restore normal gait pattern
Match the post-op timeframe to the ROM supposed to regain.
1-2 weeks, 2-3 weeks, 3-4 weeks, 4-6 weeks
a. full passive EXT
b. Full active EXT
c. 100deg Flexion
d. full flexion
1-2 weeks = a
2-3 weeks = c
3-4 weeks = b
4-6 weeks = d
What can lack of extension regain in post op ACL reconstruction indicate?
cyclops lesion, poor graft placement, restricted scar mobility
Name the best interventions for restoring ROM after ACL surgery.
wall slides (sup to assisted heel slides); LLLD heel drop (sup to prone hangs); frequent extension mobes; functional carryover!; address effusion
What needs to be the focus of rehab after ACL surgery?
restore NM control
Do ACL rehab programs need to be timeline based or criterion based?
both!
respect timeline but emphasize criterion (ultimately is up to pt response)
List the return to sport testing in order for ACL.
YBT, FMS Hop testing Tuck jump assessment Landing error scoring system Agility drills Fatigue protocol Kinesiophobia measures
