General description of ligament injury

Ligament: A short band of tough, flexible fibrous connective tissue which connects two bones or cartilages or holds together a joint.

Function of ligament:  Stability of the joint Hence, injury (especially complete) to the ligament leads to  Instability of the joint  Pain

How a joint remains stable? By virtue of support provided by  Bony conformation  Ligaments and capsule  Muscle and tendon complexes around

Clinical features of ligament injury 1. Instability 2. Pain 3. Loss of function

Investigations: 1. Plain xray: to look for - Associated fracture - Mal-alignment - Soft tissue edema

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Treatment: Acute stage: RICE is the mainstay of treatment in acute stage R-Rest I-Ice C-Compression E-Elevation 1. NSAIDs for pain relief 2. Serratiopeptidase for three days for edema reduction Definitive treatment of ligament injury depends upon the grade of injury of ligament Grade 1 & 2 Rest, bracing, rehabilitation followed by resumption of full activity Grade 3 Rest, braces and rehabilitation Or Repair/reconstruction of ligament if symptomatic (instability) Grade of injury

Structural damage Instability

Functional loss

1st degree

Few fibres sprained

Nil

Nil

2nd degree

Partial damage

Nil/mild

Mild

3rd degree

Complete tear

Severe

Moderate-severe

Table: grade of ligament tear

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Ligaments of the knee 1. Cruciates (Anterior and posterior) 2. Collaterals (medial and lateral) 3. Menisci (medial and lateral)

Anterior cruciate ligament (ACL) injury Anatomy:    

ACL connects Tibia and Femur at knee joint Proximally attached to medial wall of lateral femoral condyle (LFC) Distally attached to tibia just anterior to intercondylar eminence 90% Type 1 collagen

There are two bundles of ACL 1. Anteromedial bundle (AMB): tight in flexion 2. Posterolateral bundle (PLB): tight in extension (responsible for rotational stability)

Bundles of ACL

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Blood supply: Middle geniculate artery Nerve supply: posterior articular nerve (branch of tibial nerve) Function:  Prevents undue anterior translation of the Tibia over the Femur

Injured in 1. Sports injury- Twisting injury especially twisting force over a semi flexed knee. Often seen in contact sports like football, basketball, volleyball 2. Road traffic accidents

Clinical features of acute ACL tear Symptom 1. 2. 3. 4. 5.

Often a ‘pop’ is heard Pain Swelling of the knee (Haemarthrosis) Inability to bear weight over injured extremity/walk Feeling of instability

Sign: 1. Anterior drawer test positive 2. Lachman test positive: most sensitive among all tests 3. Pivot shift test positive Symptom of Chronic ACL tear Recurrent instability especially while performing pivoting or cutting activity, running, jumping. Walking on a flat ground is NOT a problem.

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Investigations 1. Plain xray of the knee: AP and Lateral view  Avulsion fracture  Segond fracture** (hallmark of ACL tear- it is a small avulsion injury seen just lateral to lateral tibial plateau 2. MRI of the knee: diagnostic for the ACL tear To detect concomitant injuries of the meniscus, collateral, cartilage or other injuries of the knee

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Treatment: 1. Acute ACL tear: conservative treatment  RICE: rest, ice pack, compression, elevation  NSAIDs Followed by rehabilitation  Knee mobilisation  Hamstring strengthening exercises 2. Chronic ACL tear  If symptomatic: recurrent instability Arthroscopic ACL reconstruction  If asymptomatic/low demand patient Conservative ACL tear

Acute ACL tear

Chronic ACL tear

 RICE  Rehabilitation

If recurrent instability

ACL reconstruction Flowchart for management of ACL tear

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ACL avulsion

Avulsion fixation

Posterior cruciate ligament (PCL) Anatomy:    

PCL connects Tibia and Femur at knee joint Proximally attached to lateral wall of medial femoral condyle Distally attached to tibia posteriorly below the tibial plateau in midline Two bundles: Anterolateral (tight in flexion), posteromedial (tight in extension)

Function:  Prevents undue Posterior translation of the Tibia over the Femur  Responsible for screw home mechanism of the knee during full extension

Injured in  Road traffic accidents: dashboard injury  Direct blow to the tibia from front

Clinical features Symptom 1. 2. 3. 4.

Pain Swelling Inability to bear weight over injured extremity/walk Feeling of instability especially while climbing downstairs/walking the ramp downward

Sign: 4. 5. 6. 7.

Posterior drawer test positive Sag sign positive Quadriceps active test Reverse Pivot shift test positive (if associated posterolateral laxity)

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Investigations 1. Plain xray of the knee: AP and Lateral view  Avulsion fracture 2. MRI of the knee

Treatment: 1. Acute PCL tear  RICE: rest, ice pack, compression, elevation  NSAIDs Followed by rehabilitation  Knee mobilisation  Quadriceps strengthening exercises 2. Chronic PCL tear  If symptomatic: recurrent instability Arthroscopic PCL reconstruction  If asymptomatic/low demand patient Conservative

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Meniscal injuries Anatomy:  Two menisci: medial and lateral  Fibrocartilagenous semilunar tissues over the tibial plateau  Anterior and posterior horn and body  Lateral more circular than medial  Lateral meniscus is more mobile than medial; hence, former is less prone to tears  The periphery of the meniscus is quite vascular. The middle third is partially vascular and inner third is avascular. It is divided in three zones.

abl

Vascular zones of meniscus The practical application of zones is that the vascular areas of meniscus are repairable in case of meniscal tear whereas avascular areas need excision as repair won’t work in absence of vascularity. Suggestions/queries @

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Function:    

Shock absorber Load transmission Increases joint congruity Passive stabilisation of joint

Mechanism of injury: Twisting injury to the knee in the semiflexed knee

Clinical features       

Pain Recurrent swelling Clicks Painful deep flexion Joint line tenderness McMurray’s test positive Appley’s grinding test positive

Investigation:  Plain xray: meniscal calcification in CPPD (pseudogout)  MRI Radiological/morphological type of tears 1. 2. 3. 4. 5.

Longitudinal Bucket handle: can cause locking of the knee Radial Horizontal Parrot beak

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Treatment: 1. 2. 1. 2.

Non-operative: NSAIDs, muscle strengthening exercises Operative: Peripheral tear or middle third tears: arthroscopic repair of meniscus Inner third tear: arthroscopic partial meniscectomy

Collateral ligaments of knee Anatomy Medial collateral ligament (MCL) Proximal attachment: medial femoral epicondyle Distal attachment: proximal medial tibia Lateral collateral ligament (LCL) Proximal attachment: lateral femoral epicondyle Distal attachment: fibular head

Injured in: 1. Contact sports 2. Road traffic accidents

Clinical features: 1. 2. 3. 4. 5.

Pain, swelling Inability/difficulty to bear weight Tenderness over joint line/attachment points Painful ROM Special test a) MCL- valgus stress test b) LCL- varus stress test

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Investigations: 1. Plain xray of the knee 2. MRI

Treatment:  RICE for all grades  NSAIDs  Grade 1, 2 collateral ligament injury - Gradual mobilisation in hinged brace - Knee Muscle strengthening exercise  Grade 3 collateral ligament injury - Primary repair OR - Brace or above knee cast immobilisation for 2-3 weeks. Followed by rehabilitation

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Ankle ligament injury/sprain Anatomy of ankle ligament: Lateral side ligament1. Anterior talofibular:  Weakest of all lateral ligament  Resists “inversion in plantar flexion” and anterolateral translation of ankle 2. Posterior talofibular  Strongest  Resists posterior translation of ankle 3. Calcaneofibular  Resists inversion in neutral or dorsiflexion 4. Calcaneotalar 5. Syndesmotic ligaments Medial side ligament: 1. Deltoid ligament 2. Calcaneonavicular ligament (spring ligament)

Mechanism of injury 1. Inversion injury: most common 2. Eversion injury:

Clinical features (of inversion injury which is most common) 1. 2. 3. 4.

H/O twisting injury Pain and swelling over lateral aspect of ankle Inability to bear weight/weight bearing increases pain Tenderness over the lateral aspect of ankle (anterior, inferior or posterior to the lateral malleolus) 5. Plantar flexion and inversion is painful Suggestions/queries @

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Grade of ankle sprain Grade 1: stretch of lateral ligaments Grade 2: partial tear Grade 3: complete tear of one or more lateral ligaments

Investigations: 1. Plain xray of ankle: AP, lateral view Associated #, mal-alignment 2. MRI of ankle

Treatment Ankle sprain

RICE for all grades NSAIDs

Grade 1

Ankle binder Rehabilitation

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Grade 2

Below knee CAST for 2 weeks Later, ankle binder & rehabilitation

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Grade 3

Below knee CAST for 4 weeks followed by rehabilitation. Later, if recurrent instability, ligament reconstruction OR Primary repair of ligament followed by rehabilitation

Complications 1. Recurrent instability 2. Persistent ankle edema 3. Persistent pain

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