Knee Injuries Scott Van Steyn, MD Knee One of the most complex - - PowerPoint PPT Presentation

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Knee Injuries Scott Van Steyn, MD Knee One of the most complex - - PowerPoint PPT Presentation

Feb 28, 2023 511 likes •1.08k views

Knee Injuries Scott Van Steyn, MD Knee One of the most complex joints, 3 articulations Commonly injured Microtrauma tendonitis Macrotrauma ligaments, fractures Receives enormous stresses Knee complex includes

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Knee Injuries

Scott Van Steyn, MD

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Knee

◼ One of the most complex joints, 3 articulations ◼ Commonly injured

– Microtrauma – tendonitis – Macrotrauma – ligaments, fractures

◼ Receives enormous stresses ◼ Knee “complex” includes pelvis and ankle

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Anatomy is key to the knee

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Anatomy

◼ Bony ◼ Joint ◼ Muscles ◼ Tendons ◼ Ligaments

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Muscle Tendon Anatomy

◼ Quadriceps ◼ Hamstrings ◼ IT band ◼ Adductors ◼ Gastrocnemius muscles ◼ Patellar tendon

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Issues

  • No consensus
  • Uniplanar exam
  • Focus on ligaments
  • Exam findings vs

functional deficits

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History, Physical Exam & Treatment

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History

◼ Acute vs. chronic ◼ Mechanism of injury ◼ Feel or hear a pop ◼ Swelling ◼ Disability

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Exam

◼ Gait pattern ◼ Alignment/mechanical axis ◼ Atrophy ◼ Swelling ◼ Ecchymosis

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Physical Exam Ligaments

◼ ACL ◼

  • Anterior Drawer, Lachman, Pivot Shift

◼ PCL ◼

  • Posterior Drawer, Posterior Sag, Quad Active

Test

◼ MCL ◼

  • Valgus Stress

◼ LCL ◼

  • Varus Stress
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Diagnostic Studies

◼ Plain radiographs ◼ MRI ◼ CT scan ◼ EMG/NCV

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Injuries

Common Terms

◼ ACL Tear ◼ ACL/MCL ◼ ACL/LCL ◼ PCL ◼ ACL/PCL ◼ Etc,etc ◼ What does it all mean?

Uncommon Terms

◼ Anterolateral rotatory instability ◼ Anteromedial rotatory instability ◼ Posterolateral rotatory instability ◼ Posterolateral Corner

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Collateral Ligament Injuries

◼ Grade I – tender stable, 0-2mm, 0-5mm ◼ Grade II – tender, opens, 2-4mm, 5-10mm ◼ Grade III – gross laxity, 5-10mm, >1cm ◼ No Consensus, intra-observer variability ◼ Gross laxity implies significant other pathology ◼ Worry about dynamic inputs/muscle tendon units

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Treatment Considerations

◼ Age ◼ Limitations ◼ Health ◼ Weight ◼ Mechanical axis ◼ Expectations ◼ Risk vs. reward ◼ Graft options, repair vs reconstruction

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Collateral Ligament Injuries

◼ Grades I & II ◼

  • Rest, Ice, Brace, Rehab

◼ Grade III ◼

  • May need surgical repair
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Rules To Live By

◼ No knee is so bad it cant be made worse with

surgery

◼ Avoid cutting normal anatomy ◼ No such thing as minor surgery…unless its done on

somebody else

◼ Know your handicap ◼ Bone broke me fix

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Anteromedial Rotatory Instability

◼ AMRI ◼ Grade III medial compartment injury ◼ +/- Anterior Cruciate Ligament injury ◼ More common with tibial sided injury

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AMRI

◼ 23yo OSU medical student ◼ Two failed ACL surgeries in under 12 months ◼ Hamstring graft/cadaver graft ◼ Moms a professor at Ohio State ◼ Unrecognized AMRI ……..now chronic ◼ Hamstring graft? ◼ Valgus knee

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AMRI

◼ 20 yo Professional Soccer Player ◼

  • Contact injury

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  • Valgus mechanism

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  • Reduced on field

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  • Combined injury ACL with Grade III medial

compartment off tibia

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Posterolateral Rotatory Instability

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  • PLRI

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  • Combined injury to static and dynamic

stabilizers

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  • May be much worse in varus knee

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  • Isolated or combined with ACL and or PCL

injuries

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PLRI

◼ Initial injury may cause only slight discomfort and

swelling, able to continue playing

◼ Frequent complaint of knee giving way backwards ◼ Present with medial knee pain ◼ Prior partial medial menisectomy----worse

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Posterolateral Instability

◼ Dr Hughston 1985

– 18 pts isolated PLRI 140 pts total – 2-44 months injury to diagnosis/surgery – Prior operations 20 – 70% patients suffered severe socioeconomic disasters, loss of jobs, bankruptcies, divorces

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PLRI

◼ Requires immediate diagnosis and treatment ◼ Low grade injuries

– Brace, rehab

◼ High grade injuries

– Immediate surgical repair vs delayed reconstruction

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PLRI

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  • 38 yo laborer 1 year after injury

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  • On crutches complains of pain and instability

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  • Prior “normal” arthroscopy and 2 normal MRI s

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  • In tears in office
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PLRI

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  • 35 yo Physical therapist from northern Ohio

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  • On crutches 4 months after injury

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  • Workers compensation

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  • Normal MRI
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PLRI

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  • 24yo nursing student

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  • Injured knee 10 days ago

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  • By the way going back to school tomorrow

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  • My mom is an OB at RMH

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  • Combined ACL and Posterolateral Corner
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