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Fracture

A sprain is an injury to the ligaments and


tendons that surround a joint. It is caused by
a twisting motion or hyperextension
(forcible) of a joint. The function of a
ligament is to stabilize a joint while
permitting mobility. A torn ligament causes
a joint to become unstable. Blood vessels
rupture and edema occurs; the joint is
tender, and movement of the joint becomes
painful. The degree of disability and pain
increases during the first 2 to 3 hours after
the injury because of the associated
swelling
and
bleeding,
especially
if
treatment is delayed. Sprains are graded in
a manner similar to the grading system
used for strains: A first-degree sprain is
caused by stretching the ligamentous fibers,
resulting in minimum damage. It is
manifested
by
mild
edema,
local
tenderness, and pain that is elicited when
the joint is moved. A second-degree sprain
involves partial tearing of the ligament. It
results in increased edema, tenderness,
pain with motion, joint instability, and
partial loss of normal joint function. A
third-degree sprain occurs when a ligament
is completely torn or ruptured. A thirddegree sprain may also cause an avulsion of
the bone. Symptoms include severe pain,
tenderness, increased edema, and abnormal
joint motion.

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.

A strain, or a pulled muscle or tendon, is


an injury caused by overuse, overstretching,
or excessive stress. Strains are graded along
a continuum based on postinjury symptoms
and loss of function and reflect the degree
of injury. Three types of strain are
recognized: A first-degree strain is mild
stretching of the muscle or tendon. Signs
and symptoms may include minor edema,
tenderness, and mild muscle spasm, without
noticeable loss of function. A seconddegree strain involves partial tearing of the
muscle or tendon. Signs and symptoms
include loss of load-bearing strength with
accompanying edema, tenderness, muscle
spasm, and ecchymosis. A third-degree
strain is severe muscle or tendon stretching
with rupturing and tearing of the involved
tissue. Signs and symptoms include
significant pain, muscle spasm, ecchymosis,
edema, and loss of function. An x-ray should
be obtained to rule out bone injury, because
an avulsion fracture (in which a bone
fragment is pulled away from the bone by a
tendon) may be associated with a thirddegree strain. Magnetic resonance imaging
(MRI) will reveal a third-degree strain, but xrays do not reveal injuries to soft tissue or
muscles, tendons, or ligaments.

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.

An injury to a ligament within the joint or


to the joint capsule may cause
hemorrhage into the joint space. Injuries
to ligaments can also be accompanied
by damage to the articular cartilage
surface.

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.
okdokey
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

A strain is a stretching or tearing injury to a


muscle or tendon. A tendon connects
muscle
to
bone.
Tendons
facilitate
movement by transmitting the force of a
muscle contraction. An injury to a tendon or
muscle generally occurs as a result of an
action that continues beyond the normal
range of movement for that joint. The joints
that are most commonly strained are the
ankle, knee and wrist.
bullock

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

Grade I injuries have 0 to 5 mm of


posterior translation and maintain the
position of the medial tibial plateau anterior
to the medial femoral condyle.

Injury to medial (tibial) collateral ligament


Grade II injuries have 5 to 10 mm of
and/or medial capsular ligament
posterior translation and the medial tibial
Medial Ligaments
plateau rests flush to the medial femoral
condyle.
Classification
Various classifications systems have been
Grade III injuries have more than 10 mm
proposed. The underlying basis
of posterior translation and the medial tibial
of most of the classification systems is the
plateau falls posterior to the medial femoral
degree of laxity (medial joint
condyle.
opening) in response to a valgus stress.
netter
Clinically, the medial instability can be
graded as follows:
Injury Laxity
Grade I Mild 15 mm
Grade II Moderate 510 mm
Grade III Severe >10 mm
(Some authors prefer to include Grade O
and IV as well, where Grade O is
normal and Grade IV is medial laxity greater
than 15 mm.)
It must be remembered that the chances of
damage to other ligaments
(mainly, anterior cruciate and ligament) are
high with severe medial ligament
disruptions and this may have a bearing on
treatment.

Anterior Cruciate Ligament (ACL)


Classification
Anterior cruciate ligament injuries may be
classified as:
Grade I: Stretching
Grade II: Partial rupture
Grade III: Complete rupture.

Posterior Cruciate Ligament (PCL)

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

prevents anterior translation of the tibia relative to the femur

Anatomy

Fracture

intraarticular and intrasynovial

origin

lateral femoral condyle

PL bundle originates posterior and distal to AM bundle (on femur)

insertion

broad and irregular

anterior and between the intercondylar eminences of the tibia

structure

33mm x 11mm in size

two bundles

fibers are parallel in extension

fibers are externally rotated in flexion

tight in both flexion and extension

posterolateral

PL bundle prevents pivot shift

prevents internal tibial rotation with knee near extension

tight in extension, loose in flexion

Blood supply
o

anteromedial

middle geniculate artery

Innervation
o

contains significant innervation by posterior articular branches of tibial nerve

contains mechanoreceptors (Ruffini, Pacini, Golgi tendon organs, free-nerve


endings)

function of innervation

Fracture

proprioception

modulation of quadriceps function

Composition
o

90% Type I collagen

10% Type III collagen

Biomechanics
o

tensile strength

native ACL 2200 N

BTPB 3000N

quadrupled hamstring 4000N

PCL

Function
o

prevents posterior translation of the tibia relative to the femur

PCL and PLC work in concert to resist posterior translation and posterolateral
rotatory instability

Anatomy
o

origin

Fracture

medial femoral condyle

insertion

tibial sulcus

structure

38mm x 13mm in size

two bundles

anterolateral

shorter, thicker and stronger

in double bundle reconstruction, tensioned in mid flexion

posteromedial

longer, thinner, weaker

in double bundle reconstruction, tensioned in extension


and high flexion

insertions

medial intercondylar ridge

may separate the AL from AM bundle

variable meniscofemoral ligaments originate from the posterior horn of


the lateral meniscus and insert into the substance of the PCL. These
include

Ligament of Humphrey (anterior to PCL)

Ligament of Wrisberg (posterior to PCL)

blood supply

Fracture

marks proximal border of femoral insertion

medial bifurcate ridge

tensioning in extension protects against


hyperextension

middle geniculate artery

Biomechanics
o

strength: 2500 N (vs posterior translation)

MCL

Function
o

to provide restraint to valgus angulation

works in concert with ACL to provide restraint to axial rotation

Anatomy
o

origin

MFC to medial tibia extending down several centimeters

structure

two components

Fracture

superficial portion (tibial collateral ligament)

lies just deep to gracilis and semitendinosus

originates from medial femoral epicondyle and inserts


into periosteum of proximal tibia (deep to pes anserinus)

the superficial portion of the MCL contributes 57% and


78% of medial stability at 5 degrees and 25 degrees of
knee flexion, respectively.

the superficial MCL is the primary stabilizer to valgus


stress at all angles

deep portion (medial capsular ligament)

separated from supficial portion by a bursa

attaches to medial meniscus (coronary ligament)

divided into meniscofemoral and meniscotibial portions

posterior fibers of the deep MCL blend with posteromedial


capsule and POL

the deep MCL and posteromedial capsule act as


secondary restraints to valgus stress at full knee
extension.

Biomechanics
o

strength: 4000 N (vs valgus stress)

LCL (Lateral Collateral Ligament)

Function
o

to provide support to varus angulation

works in concert with MCL to provide restraint to axial rotation

also known as "Fibular Collateral Ligament".

Fracture

Anatomy
o

origin

path

on the fibula anterior to the popliteofibular ligament on the fibula


capsule's most distal extent is just posterior to the fibula

structure

runs superficial to popliteus

insertion

on lateral femoral condyle posterior and superior to insertion


of popliteus

cord-like

Biomechanics
o

tight in extension and lax in flexion

strength: 750 N (vs varus stress)

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

When a ligament is torn, an inflammatory


exudate develops in the hematoma between
the torn ends. Granulation tissue grows
inward from the surrounding soft tissue and

cartilage. Collagen formation begins 4 to 5


days after the injury, eventually organizing
fibers parallel to the lines of stress. With the
aid of vascular fibrous tissue, the new tissue
eventually fuses with surrounding tissues.
As further reorganization takes place, the
new
ligament
separates
from
the
surrounding tissue, and eventually becomes
strong enough to withstand normal muscle
POSTERIOR CRUCIATE LIGAMENT (PCL)
tension.
MECHANISM OF INJURY

Anterior Cruciate Ligament ACL injuries

most commonly occurs as the result


of a forceful blow to the anterior tibia
while the knee is flexed, such as a
blow to the dashboard or falling onto
a flexed knee.
A study by Schulz247 evaluating 587
acute and chronic PCL-deficient knees
reported that the three most common
mechanisms
of
injury
were
a
dashboard/anterior
injury
mechanism (38.5%), followed by a fall
on the flexed knee with the foot in
plantarflexion (24.6%), and lastly, a
sudden, violent hyperflexion of the
knee joint

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

knee. It is not uncommon that more


than one ligament or joint capsule
and sometimes the menisci are
damaged as the result of a single
injury
creating
posterolateral
instability.
Medial Ligaments
Mechanism of injury: Valgus force applied to
knee with external tibial rotation; may be
noncontact twist or a blow to lateral side of
joint.
Lateral Ligaments
Mechanism of injury: Varus or twisting
injury; may be contact or noncontact.
Posterolateral ligaments often injured by
hyperextension mechanism, frequently with
blow to anteromedial tibia.
Anterior
Cruciate
Ligament
(ACL)
Mechanism
of
injury:
Hyperextension,
varus/internal rotation, and extremes of
valgus and external rotation are possible
causes.
Posterior
Cruciate
Ligament
(PCL)
Mechanism of injury: Valgus/varus in full
extension; in rare cases, severe twist; direct
blow to anterior proximal tibia, as in fall on
artifi cial turf or other hard playing surface.

Ligaments heal by the same response as


other tissues. Initially, an influx of
inflammatory cells brings repair cells to the
region; the cells clean up dead tissue and
prepare the region for new tissue. Following
this, new blood vessels develop in the area,
eventually leading to new cell formation and
finally production of new structural tissue
between the living cells. The initial tissue is
immature, so a period of maturation must
take place before healing is complete. This
entire
process
takes
many
months.
However, for most ligament injuries
sufficient strength is achieved by about 6
12 weeks to begin strengthening exercises
around the joint. This process can begin
much earlier for cases of partial tears.

Fracture

CLINICAL SIGNS & SYMPTOMS/PHYSICAL DISABILITIES/IMPAIRMENTS


Sprains
Signs and symptoms Possible signs and
symptoms of sprain are:

Anterior Cruciate Ligament ACL injuries

Popping noise-initial tear


Feel your knee give out from under
you
Pain with swelling
Loss of full range of motion
Tenderness along the joint line
Discomfort while walking

localized pain (especially during joint

movement)

swelling
and
heat
due
to

inflammation loss of mobility due to

pain (may not occur until several


hours after the injury)
skin
discoloration
from
blood
extravasating
into
surrounding Medial Ligaments
tissues.
Initial pain on medial side of knee; with
complete tear, complaints of knee giving
way into valgus.
COMMON STRUCTURAL AND FUNCTIONAL
IMPAIRMENTS, ACTIVITY LIMITATIONS, AND Lateral Ligaments
PARTICIPATION RESTRICTIONS (FUNCTIONAL
LIMITATIONS/DISABILITIES)
Pain is present over lateral ligament
complex. Knee may give way on twisting,
cutting, or pivoting. In chronic cases,
posterolateral corner injury gives feeling of
Following trauma, the joint usually giving way into hyperextension when
does not swell for several hours. If standing, walking, or running backward.
blood vessels are torn, swelling is
usually immediate.
Anterior Cruciate Ligament (ACL)
If tested when the joint is not swollen,
the patient feels pain when the Usually loud pop occurs; may be followed
by autonomic symptoms of dizziness,
injured ligament is stressed.

If there is a complete tear, instability sweating, faintness, slight nausea. Large


is detected when the torn ligament is swelling usually occurs within fi rst 2 hours
after
acute
injury
(hemarthrosis).
tested.
When effused, motion is restricted, Conversely, most acute hemarthroses
(_85%) are anterior cruciate tears. In chronic
the joint assumes a position of
cases, complaints of giving way on twisting,
minimum stress (usually flexed 25),
pivoting, cutting.
and the quadriceps muscles are
inhibited (shut down).
Posterior Cruciate Ligament (PCL)
When acute, the knee cannot bear
weight, and the person cannot
Usually less swelling than with anterior
ambulate without an assistive device. cruciate ligament; otherwise, in acute stage,
particularly
distinguishing.
With a complete tear, there is nothing
Chronically,
feeling
of
femur
sliding
instability, and the knee may give
anteriorly
off
tibia,
especially
when
rapidly
way during weight bearing, which
would prevent the individual from decelerating or descending slopes or stairs.
returning to specific work or sport and
recreation activities that require Complications Possible complications of
sprain include:
dynamic knee stability.
kisner
recurring dislocation due to torn
ligaments that don't heal properly,
requiring surgical repair (occasionally)

Fracture

to scar tissue calcification


loss of function in a ligament (if a
complication).
strong muscle pull occurs before it
heals and stretches it, it may heal in a
lengthened shape with an excessive Ligament injuries
amount of scar tissue).
Symptoms and diagnosis

strain

(late

The following symptoms suggest that a


Pathophysiology Bleeding into the muscle ligament injury has occurred:
and surrounding tissue occurs if the muscle
bruising, swelling and tenderness around
is torn. When a tendon or muscle is torn, an
the affected joint caused by bleeding;
inflammatory exudate develops between
the torn ends. Granulation tissue grows pain when the limb is moved or loaded;
inward from the surrounding soft tissue and there can also be pain on palpation;
cartilage. Collagen formation begins 4 to 5
days after the injury, eventually organizing instability of the joint depending on the
fibers parallel to the lines of stress. With the type of joint and the extent of the injury.
aid of vascular fibrous tissue, the new tissue
eventually fuses with surrounding tissues. An MRI scan can often show the extent of
As further reorganization takes place, the the ligament injury if the diagnosis is
new tendon or muscle separates from the unclear. In all cases of suspected ligament
surrounding tissue and eventually becomes injuries the joint should be tested for
strong enough to withstand normal muscle stability.
strain. If a muscle is chronically strained,
calcium may deposit into a muscle, limiting
movement by causing stiffness, and muscle
fatigue.
Signs and symptoms
Signs and symptoms of acute strain include:

sharp, transient pain (myalgia)


snapping noise
rapid swelling that may continue for
72 hours
limited function
tender muscle (when severe pain
subsides)
ecchymoses (after several days).

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

Reverse pivot shift test: Performed with tibia


in external rotation rather than internal
rotation. With knee fl exed 90 degrees,
lateral tibial condyle is subluxed posteriorly.
With further knee extension, tibia reduces
with
detectable
clunk.
(See
later
discussion of pivot shift test.)

Lateral Ligaments Examination:

subluxation of lateral tibial condyle. Tibia


suddenly reduces with further fl exion (pivot
Compare with opposite knee. In acute case, shift test) or extension (jerk test) (see Fig.
may be increased varus stress test at 30 49-3 ).
degrees
of
fl
exion
and
positive
posterolateral drawer sign; chronic case Anterior
Cruciate
Ligament
(ACL)
shows positive reverse pivot shift test and Examination:
external rotation recurvatum test. External
rotation recurvatum may also be apparent Acute, large hemarthrosis, positive Lachman
on standing, giving increased varus test. Chronic, positive Lachman test,
positive pivot shift test or jerk test. Perhaps
appearance to knee.
positive anterior drawer sign, but not
Imaging: Lateral capsular sign shows reliable. Do not rely on anterior drawer sign.
avulsion of midportion of lateral capsular
ligament with small fragment of proximal Imaging: Lateral capsular sign; avulsion of
lateral tibia. Associated with high incidence tibial spine may be seen in young patients.
of anterior cruciate tear and indicates Magnetic resonance imaging (MRI) useful in
anterolateral instability (see Fig. 49-4 ). acute injury to confi rm diagnosis and
Arcuate sign shows avulsion of proximal fi evaluate for injuries to other structures;
bula with posterolateral ligament complex. reported accuracy rates as high as 95% in
detecting ACL tears .
Indicates posterolateral instability.

ANTERIOR CRUCIATE LIGAMENT (ACL)

POSTERIOR CRUCIATE LIGAMENT (PCL)

Lachman test: Patient is supine and


relaxed. Examiner grasps distal femur with
one hand, while other hand grasps proximal
tibia. Knee fl exed to approximately 15 to 20
degrees. Apply anterior force to proximal
tibia. Positive test is excessive anterior
translation of tibia beneath femur and lack
of fi rm endpoint

Posterior drawer test: Same position as for


anterior drawer test in neutral rotation.
Posterior force is applied to proximal tibia.
Positive
test
is
straight
posterior
displacement of both tibial condyles (see
Fig. 49-3 ). Caution: Make sure of neutral
position as starting point. Compare position
of tibia relative to femur with normal knee.
It is easy to start from posteriorly displaced
position and interpret reduction to neutral
as positive anterior drawer sign rather than
starting at neutral and interpreting as
positive posterior drawer sign.

Anterior drawer test in neutral rotation:


Same position as for anterior drawer with
external rotation of tibia, except that foot
and tibia are in neutral rotation. Anterior
pull is applied to proximal tibia. Positive test
is anterior translation of both tibial condyles
from beneath femur (see Fig. 49-3 ). Note:
This test is infl uenced by structures other
than anterior cruciate ligament. Do not rely
on this test for diagnosis of ACL tear.
Pivot shift test and jerk test: Patient is
supine and relaxed. Begin with knee fully
extended (pivot shift test) or fl exed to 90
degrees (jerk test). Foot and tibia internally
rotated. Valgus applied at knee. Knee
progressively fl exed (pivot shift test) or
extended (jerk test). At approximately 30
degrees, watch and feel for anterior

Fracture

The degree of posterior


instability can be graded as follows:
Gr I: 5 mm posterior displacement
Gr II: 510 mm posterior displacement
Gr III: >10 mm of posterior displacement
Gravity or sag test: Patient is supine and
relaxed. Flex hips to 45 degrees and knees
to 90 degrees with feet fl at on table. With
quadriceps relaxed, observe from lateral
side for posterior displacement of one tibial
tuberosity compared to the other. Then fl ex
hips to 90 degrees, support both legs by
ankles and feet, and observe again (see Fig.
49-3 ).

Valgus or varus stress test at 0 degrees: As


described for abduction and adduction
stress tests at 30 degrees and 0 degrees.
Positive test in full extension in acute case is
often due to posterior cruciate ligament
rupture in addition to injury to associated
collateral ligaments

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:

history of a recent injury or chronic


overuse
X-ray to rule out fracture
stress radiography to visualize the
injury in motion
biopsy showing muscle regeneration
and connective tissue repair (rarely
done).

Fracture

Fracture

DIFFERENTIAL DIAGNOSIS

MANAGEMENTS
Strains
Treatment
Possible
includes:

treatments

for

acute

strain

compression wrap to immobilize the


affected area
elevating the injured part above the
level of the heart to reduce swelling
analgesics
application of ice for up to 48 hours,
then application of heat to enhance
blood flow, reduce cramping, and
promote healing
surgery to suture the tendon or
muscle ends in close approximation.

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

MEDICAL AND SURGICAL MANAGEMENT

Improve Joint Mobility and


Protection

PHYSICAL THERAPY MANAGEMENT


Ligament Injuries: Nonoperative
Management

Joint mobility

NONOPERATIVE MANAGEMENT: MAXIMUM


PROTECTION PHASE

Follow the principles described for an acute


joint lesion earlier in this chapter.

If possible, examine before effusion


sets in.
Utilize cold and compression with rest
and elevation.
Teach protected weight bearing with
use of crutches and partial weight
bearing as tolerated.
Teach safe transfer activities to avoid
pivoting on the involved extremity.
Initiate quadriceps-setting exercises.
The knee may not fully extend for
end-range muscle-setting exercises,
so begin the exercises in the range
most comfortable for the patient. As
the swelling decreases, initiate ROM
within tolerance.

NONOPERATIVE MANAGEMENT: MODERATE


PROTECTION (CONTROLLED MOTION)
THROUGH RETURN TO ACTIVITY PHASES

Use supine wall slides , patellar


mobilizations, and stationary cycling;
encourage as much movement as
possible. Unless there has been an
extended period of immobilization,
there should be minimal need to stretch
contractures.

Protective bracing

Bracing may be necessary for


weightbearing activities to decrease
stress to the healing ligament or to
provide stability when ligament integrity
has been compromised. Bracing can be
one of two types: (1) range-limiting
postoperative type braces that are used
to protect healing tissues and then
discontinued during later phases of
rehabilitation; or (2) functional braces
that are used during advanced
rehabilitation and also when returning to
functional activities. The patient must
be advised to modify activities until
appropriate stability is obtained.

Improve Muscle Performance

Strength and endurance


As swelling decreases, examine the patient
for impairments and functional losses.
Initiate joint movement and exercises to
improve muscle performance, functional
status, and cardiopulmonary conditioning.

Fracture

Initiate isometric quadriceps and


hamstring exercises, and progress to
dynamic strength and muscular
endurance training. Quadriceps strength
is important for knee stability.
Utilize both open-chain and closedchain resistance.

Open-chain resistance has


been shown to be more
effective for increasing
quadriceps strength than
closedchain single-leg squat in
patients with an ACL injury.
- Progress closed-chain exercises
using partial squats, step-ups,
leg press, and heel raises.
Reinforce quadriceps contractions
with high-intensity electrical
stimulation if there is an extensor lag.
-

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

Utilize a program that is consistent with


the patients goals such as biking (begin
with a stationary bike), jogging (begin
with walking on a treadmill), ski
machine, or swimming.
Functional training
Progress neuromuscular training.
Develop activity-specific drills that
replicate the demands of the
individuals outcome goals.

Fracture

Medial Ligaments Treatment:


Grades I and II sprains: RICE (rest, ice,
compression, elevation), crutches,
rehabilitation.
Grade III sprain (complete ligament tear):
With other associated injuries, surgery may
be considered (currently rare). If no surgery
indicated, immobilization should be used for
short period after acute injury. Begin
rehabilitation program as soon as possible.
With only mild instability, rigid
immobilization may not be necessary. RICE
and functional rehabilitation may be
adequate treatment.
Lateral Ligaments Treatment:
Grade I and II sprains: RICE, crutches,
rehabilitation.
Grade III sprain (complete ligament tear):
Surgical repair is usually preferable if injury
involves more than just lateral (fi bular)
collateral ligament. Immobilization is not
really useful by itself. Mild instability may be
treated by RICE and functional
rehabilitation.
Anterior Cruciate Ligament (ACL) Treatment:
Acute
Various methods delineate degree of
damage and associated injuries.
Knee may be treated symptomatically
followed by repeated evaluations over fi rst
2 to 3 weeks following injury.
Most active patients engaged in agility
sports require surgical reconstruction.
Reconstruction is now usually delayed at
least 3 weeks after injury to allow decrease
in swelling and increase in range of motion.
For mild laxity with fi rm endpoint (partial
ACL injury) and no other associated injury,

Fracture

may treat with PRICES, functional


rehabilitation, protective bracing.
Apparent partial injury often progresses to
more obvious complete tear.
Chronic
May attempt functional stabilization
through rehabilitation, bracing, lifestyle
modifi cation; often requires surgical
reconstruction. Posterior Cruciate Ligament
(PCL) Treatment: Acute, most important to
delineate degree of injury; may require
examination under anesthesia and
arthroscopy. For mild laxity (isolated PCL
tear), may treat with PRICES, functional
rehabilitation, protective bracing. For
moderate or severe laxity, surgical
repair/reconstruction is usually required.
Chronic, may attempt functional
stabilization through rehabilitation and
bracing; often requires surgical
reconstruction if instability is more than
mild.

Fracture

REFFERENCES

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