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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
Q

clinical investigations for CL injury

A

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
Q

Treatment for ACL injury

A

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
Q

surgical indications for ACL rupture

A 
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
Q

write out acl rehabilitation

A

1

29
Q

6 facts about achilles tendon rupture

A 
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
Q

possible predispositions to achilles tendon ruptures

A 
hypovascularity 
repetitive microtrauma 
corticosteroids
tendon degeneration 
DM type 2
31
Q

clinical presentation of achilles tendinopathy

A

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
Q

Physical examination of Achilles rupture

A

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
Q

surgical treatment for achilles tendon

A

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
Q

choice of surgery for achilles tendon rupture

A 
dependant on 
-surgeon preferences and experience 
judgements based upon patient specific factors 
- physical demands 
-healing capacities 
-cosmetic concerns 
- rehabilitation requirements
35
Q

rehabilitation of achilles rupture

A

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
Q

check out the rehab program on slide 39 for achilles rupture

A

39

37
Q

important hand structures (6)

A 
fibrous digital sheath 
digital synovial sheath 
annular &amp; cruciate pulley 
FDP &amp; FDS
- extrinsic tendons esp FDP 
lumbricals 
thumb oblique and annular pulley
38
Q

what makes up zone 1 of the hand

A

FDP - distal to FDS insertion, adhesions A4 and A5 pulley

39
Q

what makes up zone 2

A

no man’s land - FDS insertion to prox edge of A1 pulley, increased rupture and adhesions, low margin of error

40
Q

what makes up zone 3

A

prox edge of A1 pulley to carpal tunnel, lumbrical region, better results

41
Q

what makes up zone 4

A

within carpal tunnel, zone covered by flexor retinaculum, nerve injury

42
Q

what makes up zone 5

A

proximal to carpal tunnel/flex retinaculum, less frequent adhesions

43
Q

most common injuries of the hand

A

traumatic

44
Q

general management principles of hand injuries

A 
wound management
oedema control 
therapeutic exercise/manual therapy 
splintage 
scar management 
sensory 
re-education 
functional use
45
Q

orthopaedic approach to hand injuries

A

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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