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Musculoskeletal Physiotherapy 3 > Week 9: Post Surgical > Flashcards

Week 9: Post Surgical Flashcards

1
Q

what is the most commonly injured ligament

A

MCL

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2
Q

what is the most commonly ruptured ligament

A

ACL

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3
Q

what is the most commonly injured part of the meniscus

A

medial

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4
Q

what is involved in a knee triad

A

MCL, Medial meniscus, ACL

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5
Q

how do acute meniscal tears occur

A

shear stress in knee flexion + compression with femoral rotation

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6
Q

Degenerative meniscus tears

A

older population >35
often without MOI & also without symptoms
horizontal cleavage injury common
75-95% incidence in OA
Rarely need surgery (unless failed conservative Rx and no OA

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7
Q

Clinical features of meniscus injuries

A

common MOI twisting with foot on the ground - rotational force applied
- may be slow speed but usually high velocity MOI

degree of pain on presentation varies

smaller tears can be asymptomatic over 24hr

severe bucket handle tears - more severe symptoms
- often assoc with ACL injuries
- catching, clicking, instability, effusion
displaced = joint locking

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8
Q

physical examination of meniscal injury

A 
joint tenderness
- esp TOP at knee flex 45-90 degrees 
joint effusion (6-12hr) 
pain with squatting 
= esp with posterior horn 
Restricted ROM - FFD 
McMurrays +ve with pain or clunk 
- ICC inter-rater = 0.01-0.33
sens (0.55), spec (0.77) 
after thorough clinical exam - MRI - 90% accurate
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9
Q

Treatment of meniscal injury

A

minimal tears
- conservative management

severe tears + concomitant injuries
1 repair if possible, longitudinal tears outer 1/3 have good success rate
- else arthroscopic partial menisectomy

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10
Q

Clinical indicators of conservative Rx for meniscal injury

A 
unable to recall MOI, able to WB
FROM  +pain end only 
symptoms develop over 24-48 hrs 
minimal swelling 
pain inner range mcMurrays 
previous hx of quick recovery 
no or early degenerative changes
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11
Q

clinical indications for surgical Rx of meniscal injury

A

severe twisting, unable to continue
locked knee or severe loss of ROM
papable clunk of McMurray’s
Pain on McMurray’s with minimal knee flex
presence of ACL tear
little improvement after 3 weeks conservqative Rx

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12
Q

management principles of meniscal injury

A 
• Same for conservative vs. post-op
• Prehab where possible
– Decrease pain & swelling
– Strengthen (quads, hamstrings, hip
abductors, hip extensors)
– Protect from further damage
– Educate
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13
Q

phase 1 rehab of meniscal injury (0-1/52)

A
  • ROM: full E, F to 100
  • Quads = hams (4/5)
  • E.g. VMO, cycle, calf raises, gait re-ed
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14
Q

phase 2 rehab of meniscal injury (1-2/52)

A

• Full ROM & strength (4+/5)
• E.g mini-squats, step-ups, single calf
raises, balance drills

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15
Q

phase 3 rehab of meniscal injury (2-3/52)

A
  • Full squat, dynamic balance, return to run/jog

* E.g. progress plus jump-land-agility

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16
Q

Phase 4 rehab of meniscus injury (3-5/52)

A

endurance, sport specific, return to play

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17
Q

What is the reoccurrence rate like for ACL

A

44% with primary ACL injury had secondary injury within 5 years

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18
Q

ACL MOI + common sports

A

most common in sports with pivoting and deceleration

- football, basketball, netball, soccer, handball, gymnastics, downhill skiing

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19
Q

which sex has the highest rate of ACL injury

A

females athletes - 2.4-9.7 times greater

anatomical implications?

20
Q

anthropometric risk factors for primary ACL injuries

A

potentially linked to narrower intercondylar notch width
smaller notch width index
increased tibial plateau slope
decreased medial tibial plateau depth

21
Q

predispositions to primary acl injury

A

deficits in neuromuscular control during dynamic movements
- for both 1o and 2o ACL

excessive out of plane knee loads
- increased external knee abd moments in young female athletes (high spec and sens)
-frontal plane trunk displacement + reduced core proprioception - female athletes
side to side lower limb biomechanical differences
-reduced relative lower extremity flexor activation during drop vertical jump test

22
Q

secondary acl injuries

A 
moi still non contact 
higher post aclr physical activity 
gender
- males > re-rupture rate 
- females have lower postsurgical activity levels + decreased likelihood of RTS 
females >contralateral ACL

younger athlete

  • higher re-injury rate
  • increased risk of contralateral injury

neuromuscular impairments
- increased rotation hip moment in uninvolved limb
-increased frontal plane knee motion during landing
-sagittal plane knee moment asymmetries at initial contact
deficits in postural stability on ACLR limb
RTS <7 months
outcomes after revision ACLR reportedly worse - essential to avoid re-injury

23
Q

clinical features of ACL injury

A

majority occur in non-contact situation

  • landing from jump, pivot, sudden deceleration
  • often simple, commonly performed manoeuvre
  • knee flex + valgus + tibia IR +compression

typical features
- audible pop/crack or feeling of joint displacement
complete tears - generally extremely painful
inability to continue athletic activity
swelling may be minimal & delayed at times - but more commonly large tense effusion after 1 hr = haemarthroses
sensation of instability

24
Q

Physical examination for acl

A

restricted ROM
widespread mild tenderness
lateral joint tenderness
- impact related pain from collision of tibia and femur

medial joint line tenderness
- esp if meniscus injured

lachman’s, pivot shift are most specific vs anterior draw
- need intact MCL and ITB for pivot shift

25
clinical investigations for CL injury
x ray - avulsion of ligament from tibia or segond # possible detection of increased joint fluid MRI - useful if uncertain clinically but mainly for diagnosing meniscal tears and cartilage injury
26
Treatment for ACL injury
most patients (especially young and/or active ) likely to need surgical treatment some evidence to support high quality rehab with experienced clinician athletic population unlikely to RTS at same level without surgery
27
surgical indications for ACL rupture
``` instability after 3/12 patient age degree of functional instability repairable meniscus tear associted injuries - MCL, meniscus desire to RTS - esp jumping, pivoting - running in straight line, not so much active occupation ```
28
write out acl rehabilitation
1
29
6 facts about achilles tendon rupture
``` strongest tendon in the body most frequently ruptured major tendons often asymptomatic pre-injury increasing incidence most commonly amongst middle aged men during recreational sporting activitie - males : female = 10:1 30-40% return to pre injury level MOI - sudden acceleration from dorsiflexed position ```
30
possible predispositions to achilles tendon ruptures
``` hypovascularity repetitive microtrauma corticosteroids tendon degeneration DM type 2 ```
31
clinical presentation of achilles tendinopathy
rupture usually during activity - eccentric load during explosive acceleration, sudden direction changes, maximal effort with foot loading often not at start of activity (game) but after 30-40 mins - fatigue may also play a factor (muscle and or tendon) often C/O feeling like being kicked in back of leg may hear loud sound reduced function - immediate, difficulty walking - patient may be quite functional walking but unable to walk on toes
32
Physical examination of Achilles rupture
simple examination for achilles rupture - patient prone, both ankles hanging off the bed - ruptured tendon = foot hangs straight down vs normal sl PF position of 15-25 degrees palpable gap present immediately post injury - if exam delayed this may be difficult to note due to swelling PF strength markedly reduced Thompson's test +ve
33
surgical treatment for achilles tendon
currently no consensus on best repair method for acute achilles tears - options for non-surgical to open surgical repair - surgery - re-rupture rate 2-3% vs 13% conservative surgical repair preferred in young healthy active population percutaneous techniques (performed since 1995) may reduce open complications (infection) emerging evidence to support non-surgical
34
choice of surgery for achilles tendon rupture
``` dependant on -surgeon preferences and experience judgements based upon patient specific factors - physical demands -healing capacities -cosmetic concerns - rehabilitation requirements ```
35
rehabilitation of achilles rupture
progressive and more aggressive than previously administered - previous treatment regularly involved immobilisation in cast for 6-8 weeks post op or functional brace progressed to approx 2/52 immobilisation but evidence supports earlier mobilisation early and active protocol becoming more accepted & supported by evidence - walking without brace/splint/shoe 1 day post op weeks 1-6 : NM exercises for lower extremities and ankle week 6 : begin resistance, gentle active stretching exercises 12 weeks - sports specific program
36
check out the rehab program on slide 39 for achilles rupture
39
37
important hand structures (6)
``` fibrous digital sheath digital synovial sheath annular & cruciate pulley FDP & FDS - extrinsic tendons esp FDP lumbricals thumb oblique and annular pulley ```
38
what makes up zone 1 of the hand
FDP - distal to FDS insertion, adhesions A4 and A5 pulley
39
what makes up zone 2
no man's land - FDS insertion to prox edge of A1 pulley, increased rupture and adhesions, low margin of error
40
what makes up zone 3
prox edge of A1 pulley to carpal tunnel, lumbrical region, better results
41
what makes up zone 4
within carpal tunnel, zone covered by flexor retinaculum, nerve injury
42
what makes up zone 5
proximal to carpal tunnel/flex retinaculum, less frequent adhesions
43
most common injuries of the hand
traumatic
44
general management principles of hand injuries
``` wound management oedema control therapeutic exercise/manual therapy splintage scar management sensory re-education functional use ```
45
orthopaedic approach to hand injuries
all flexor tendons should be repaired - irrespective of zone ideally fix # & repair tendon if delayed - tendon graft may be repaired over tendon A2 and A4 pulleys should be repaired if possible - avoids bowstring & flexion deformities

Musculoskeletal Physiotherapy 3 (9 decks)

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