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INTRODUCTION
Strains A strain is an injury to a muscle or
tendinous attachment usually seen after
traumatic or sports injuries. Strain is a
general term for muscle or tendon damage
that often results from sudden, forced
motion causing it to be stretched beyond
normal
capacity.
Injury ranges
from
excessive stretch (muscle pull) to muscle
rupture. (See Muscle-tendon ruptures.) If the
muscle ruptures, the body of the muscle
protrudes through the fascia. A strained
muscle
can
usually
heal
without
complications.
Fracture
DEFINITION OF TERMS
Types of ligament injury
A ligament tear may affect only a few fibers
orthe entire ligament(Figure 2.8).In clinical
practice itis practical to distinguish between
partial and complete tears because the
treatment and prognosis are different.
Sprains
1. A partial tear involves only some of the A sprain is a complete or incomplete tear of
ligament fibers and may on occasion the supporting ligaments surrounding a
affect stability.
joint. It usually follows a sharp twist.
An immobilized sprain may heal in 2 to 3
Part of the ligament may be torn while the
weeks without surgical repair, after which
rest is undamaged.
the patient can gradually resume normal
Part of the ligament attachment may be activities. A sprained ankle is the most
torn away from its insertion, with or without common joint injury, followed by sprains of
the wrist, elbow, and knee.
a fragment of bone.
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2. A complete tear involves most or all of
the ligament fibers and the affected joint
A sprain is an injury to a ligament. A
is unstable.
The ligament may be completely torn ligament connects bone to bone or bone to
and the ends separated from each other. cartilage. Ligaments also strengthen a joint.
The entire ligament attachment may An injury to a ligament may occur as a
result of a twisting or stretching action that
become detached from the bone.
The fragment of bone to which the continues beyond the normal range of
ligament is attached may be torn away movement for that joint. The joints that are
from the rest of the bone. Figure 2.7 most commonly sprained are the ankle,
(Left) Example of the structure of a joint. knee and wrist. Sprains can be graded as
(Right) Knee joint: anterior view. Figure described in Table 40.1.
2.8 (Left) Normal ligament. (Top right)
bullock
Part of the ligament is torn while the rest
is undamaged; part is torn away without
bone; part is torn away with bone.
(Bottom right) Complete separation of
ends; complete detachment from bone;
complete detachment of fragment of
bone attached to ligament. 14
A partial tear may be classified as a
grade I tear (disruption of a few fibers)
or a minor grade II tear (disruption of
less than half the fibers); in both cases
the joint is stable. A major grade II tear
corresponds to disruption of more than
50% of the fibers; a grade III tear
corresponds to disruption of all the fibers
as a complete tear; in both cases the
joint is unstable to a varying degree.
A disruption of the fibers of the
ligament is often accompanied by
bleeding which spreads into surrounding
tissue and is frequently seen as bruising.
Fracture
Classification
Classification of PCL injuries is based on the
relationship of the medial tibial plateau to
the medial femoral condyle during a
posterior drawer test (Fig. 4-50).
Medial Ligaments
Fracture
Fracture
EPIDEMIOLOGY
ANATOMY/PHYSIOLOGY/KINESIOLOGY
Ligaments are attached to the two bones that compose the joint (Figure 2.7). Ligaments
provide stability to the joint, while still allowing motion. They cannot actively resist motion,
but provide a check rein against instability at the extreme range of motion of the joints.
Because of their microstructure ligaments resist tensile forces (pulling apart) well, but are
of little value for compressive forces. Ligaments are injured when forces exceed the
ligaments ability to resist a load, which may depend on the rate of injury. Ligaments
provide more strength when a load is applied slowly: this is why relatively slow injuries
may cause an avulsion fracture (where a small piece of bone breaks off at the ligament
attachment) rather than tearing the ligament itself. Fast injuries will cause the ligament to
fail before the bone, and resulting in a tear in the midsubstance of the ligament. When the
athlete sprains an ankle the two bones of the ankle joint, the tibia and talus, are rapidly
forced apart, causing rupture of the ligaments holding the tibia and talus together.
LIGAMENT
A ligament is a tough band of fibrous tissue that connects bone to bone or bone to
cartilage and supports and strengthens joints. The main function of ligaments are to keep
the bones of the skeleton in proper alignment and prevent abnormal movements of the
joints.
While ligaments are extremely strong, they can be stretched or even torn. This
usually occurs during an extreme force such as a fall or another high impact. When a
ligament is injured because it is stretched too far from its normal position it is called a
sprain.
Ligament of Knee
Fracture
ACL
Function
o
Anatomy
Fracture
origin
insertion
structure
two bundles
posterolateral
Blood supply
o
anteromedial
Innervation
o
function of innervation
Fracture
proprioception
Composition
o
Biomechanics
o
tensile strength
BTPB 3000N
PCL
Function
o
PCL and PLC work in concert to resist posterior translation and posterolateral
rotatory instability
Anatomy
o
origin
Fracture
insertion
tibial sulcus
structure
two bundles
anterolateral
posteromedial
insertions
blood supply
Fracture
Biomechanics
o
MCL
Function
o
Anatomy
o
origin
structure
two components
Fracture
Biomechanics
o
Function
o
Fracture
Anatomy
o
origin
path
structure
insertion
cord-like
Biomechanics
o
Fracture
ETIOLOGY
sprain
Causes of sprains include: sharply twisting
with force stronger than that of the
ligament, inducing joint movement beyond
normal range of motion concurrent fractures
or dislocations.
strain
Causes Possible causes of strain include:
vigorous muscle overuse or overstress,
causing the muscle to become stretched
beyond normal capacity, especially when
the muscle isn't adequately stretched before
the activity (acute strain) knife or gunshot
wound causing a traumatic rupture (acute
strain) repeated overuse (chronic strain).
Fracture
The
second
most
common
noncontact mechanism is forceful
hyperextension of the knee. With
prolonged ambulation on a knee that
has a deficient ACL, the secondary
restraints (lateral collateral ligament
and posterolateral joint capsule) are
stressed and become lax and a
quadriceps avoidance gait may
develop.
The quadriceps avoidance gait in
ACL-deficient knees was originally
documented
and
described
by
Berchuck and colleagues15 as a
reduction in the magnitude of the
flexion moment about the knee
during the limb loading phase of gait
due to the patients effort to reduce
contraction of the quadriceps.
PATHOPHYSIOLOGY/MECHANISM OF INJURY/PATHOLOGY
Sprains
Pathophysiology
occur
from
both
contact
and
noncontact mechanisms .
The
most
common
contact
mechanism is a blow to the lateral
side of the knee resulting in a 802
Ligament
Injuries:
Nonoperative
Management valgus force to the
knee.
This mechanism can result in injury
not only to the ACL but also to the
medial collateral ligament (MCL) and Medial Collateral Ligament
the medial meniscus.
This injury is termed the unholy
can occur from valgus forces being
triad or terrible triad injury
placed across the medial joint line of
because of the frequency with which
the knee. Whereas most injuries to
these three structures are injured
the ACL and PCL are complete tears
from a common blow.
of the ligament, injuries to the MCL
The
most
common
noncontact
can be partial or incomplete and are
graded utilizing a I, II, III grading
mechanism is a rotational mechanism
classification of ligament
in which the tibia is externally rotated
on the planted foot.
Literature
supports
that
this Lateral Collateral Ligament
mechanism can account for as many
infrequent and are usually the result
as 78% of all ACL injuries.
of a traumatic varus force across the
Fracture
Fracture
movement)
swelling
and
heat
due
to
Fracture
strain
(late
Signs and
include:
symptoms
of
chronic
strain
stiffness
soreness
generalized tenderness.
Complications Possible complications
of strain include:
complete muscle rupture requiring
surgical repair
myositis
ossificans
(chronic
inflammation with bony deposits) due
Fracture
DIAGNOSTIC TOOLS/TEST
LATERAL
Diagnosis Sprain may be diagnosed by:
Varus stress test at 30 degrees and 0
history of recent injury or chronic overuse X- degrees:
ray to rule out fractures stress radiography
to visualize the injury in motion arthroscopy Patient is in same position as for abduction
stress test. Reverse hand position so that
arthrography.
one hand applies varus stress, while
MEDIAL
opposite hand acts as fulcrum along medial
side of joint. Watch and feel for lateral joint
Valgus stress test at 30 degrees and 0 line opening. Perform at 30 degrees of fl
degrees:
exion and then at full possible extension or
hyperextension (see Fig. 49-3 ).
Patient is supine and relaxed, thigh
supported on table. Examiner applies valgus External rotation recurvatum test: Patient is
force at foot, while using other hand as supine and relaxed. Lift entire lower
fulcrum along lateral side of joint. Watch extremity by fi rst toe. Observe for
and feel for medial joint line opening. excessive recurvatum and external rotation
Perform fi rst with knee flexed 30 degrees, of proximal tibia (tibial tuberosity) and
then with maximum possible extension or apparent varus deformity of knee. Indicates
hyperextension ( Fig. 49-3 ).
posterolateral corner injury.
Anterior drawer test with external rotation of Posterolateral drawer test: Same position
tibia:
as for anterior drawer test with external
rotation of tibia. Examiners hands push
Patient is supine and relaxed, hip flexed to
posteriorly on proximal tibia. Positive test is
45 degrees and knee to 90 degrees.
excessive posterior rotation of lateral tibial
Externally rotate foot 30 degrees, then pin
condyle (see Fig. 49-3 )
foot to table with examiners thigh. Grasp
proximal tibia with both hands and pull Prone external rotation test (Dial test): The
toward examiner. Positive test is excessive patient is prone with knees together and the
anterior rotation of medial tibial condyle feet are externally rotated at 30 degrees of
(see Fig. 49-3 ).
knee fl exion and then at 90 degrees. The
external rotation of the foot relative to the
Medial Ligaments Examination:
thigh is compared with the contralateral
Positive valgus stress test at 30 degrees fl side. Test is positive if there is more than 10
exion. Compare with opposite knee. An degrees of rotation of affected side
injured medial collateral ligament (MCL) compared to normal side. If asymmetry is
along with disrupted ACL or PCL will result in present only at 30 degrees than isolated
more gap occurring with a valgus stress posterolateral corner injury is likely. If
test, particularly noticeable when knee is asymmetry is present at both 30 degrees
tested in extension. Frequently, but not and 90 degrees then a combined injury to
always, positive anterior drawer sign results posterior cruciate ligament (PCL) and
with tibia in external rotation. Medial tibial posterolateral corner is present (see Fig. 493 ).]
condyle rotates anteriorly.
Imaging: Abduction stress fi lm may be used
to
distinguish
ligament
injury
from
epiphyseal fracture in skeletally immature
athletes. Fracture opens at growth plate.
Ligament tear opens at joint line. Do in 20
to 30 degrees of fl exion.
Fracture
Fracture
Posterior
Cruciate
Ligament
(PCL)
Examination: Acute, if produced by varus or
valgus mechanism, may fi nd abduction or
adduction stress test positive in full
extension. If produced by blow to anterior
tibia, posterior drawer sign may be positive.
Chronic, rely on posterior drawer sign and
gravity test (see Fig. 49-4 ). I
maging: Cross-table lateral view x-rays may
show sag of tibia compared to opposite side;
may accentuate by doing posterior drawer
sign while taking cross-table lateral view.
May see bony avulsion with tibial
attachment of the posterior cruciate
ligament. MRI shows posterior cruciate well
and may help confi rm diagnosis and
evaluate for other injuries
strain
Diagnosis Diagnosis of strain may include:
Fracture
Fracture
DIFFERENTIAL DIAGNOSIS
MANAGEMENTS
Strains
Treatment
Possible
includes:
treatments
for
acute
strain
Chronic
strains
usually
don't
need
treatment. Discomfort may be relieved by:
heat application
nonsteroidal anti-inflammatory drugs
(such as ibuprofen [Motrin])
analgesic muscle relaxant.
okdokey
Fracture
Fracture
PHARMACOLOGICAL MANAGEMENT
Fracture
Joint mobility
Protective bracing
Fracture
Neuromuscular control
Neuromuscular control is compromised
when stabilizing muscles fatigue.113
Emphasize neuromuscular reeducation
(proprioceptive training) with
stabilization, acceleration, deceleration,
and perturbation training in weightbearing positions.149 Begin with lowintensity, single-plane movements and
progress to high-intensity, multiplane
movements.
Cardiopulmonary conditioning
Fracture
Fracture
Fracture
REFFERENCES