Week 9: Post Surgical Flashcards
what is the most commonly injured ligament
MCL
what is the most commonly ruptured ligament
ACL
what is the most commonly injured part of the meniscus
medial
what is involved in a knee triad
MCL, Medial meniscus, ACL
how do acute meniscal tears occur
shear stress in knee flexion + compression with femoral rotation
Degenerative meniscus tears
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
Clinical features of meniscus injuries
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
physical examination of meniscal injury
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
Treatment of meniscal injury
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
Clinical indicators of conservative Rx for meniscal injury
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
clinical indications for surgical Rx of meniscal injury
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
management principles of meniscal injury
• Same for conservative vs. post-op • Prehab where possible – Decrease pain & swelling – Strengthen (quads, hamstrings, hip abductors, hip extensors) – Protect from further damage – Educate
phase 1 rehab of meniscal injury (0-1/52)
- ROM: full E, F to 100
- Quads = hams (4/5)
- E.g. VMO, cycle, calf raises, gait re-ed
phase 2 rehab of meniscal injury (1-2/52)
• Full ROM & strength (4+/5)
• E.g mini-squats, step-ups, single calf
raises, balance drills
phase 3 rehab of meniscal injury (2-3/52)
- Full squat, dynamic balance, return to run/jog
* E.g. progress plus jump-land-agility
Phase 4 rehab of meniscus injury (3-5/52)
endurance, sport specific, return to play
What is the reoccurrence rate like for ACL
44% with primary ACL injury had secondary injury within 5 years
ACL MOI + common sports
most common in sports with pivoting and deceleration
- football, basketball, netball, soccer, handball, gymnastics, downhill skiing
which sex has the highest rate of ACL injury
females athletes - 2.4-9.7 times greater
anatomical implications?
anthropometric risk factors for primary ACL injuries
potentially linked to narrower intercondylar notch width
smaller notch width index
increased tibial plateau slope
decreased medial tibial plateau depth
predispositions to primary acl injury
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
secondary acl injuries
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
clinical features of ACL injury
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
Physical examination for acl
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
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
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
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
write out acl rehabilitation
1
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
possible predispositions to achilles tendon ruptures
hypovascularity repetitive microtrauma corticosteroids tendon degeneration DM type 2
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
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
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
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
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
check out the rehab program on slide 39 for achilles rupture
39
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
what makes up zone 1 of the hand
FDP - distal to FDS insertion, adhesions A4 and A5 pulley
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
what makes up zone 3
prox edge of A1 pulley to carpal tunnel, lumbrical region, better results
what makes up zone 4
within carpal tunnel, zone covered by flexor retinaculum, nerve injury
what makes up zone 5
proximal to carpal tunnel/flex retinaculum, less frequent adhesions
most common injuries of the hand
traumatic
general management principles of hand injuries
wound management oedema control therapeutic exercise/manual therapy splintage scar management sensory re-education functional use
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
