Diagnosis can be suspected clinically with a traumatic knee effusion and increased laxity on a posterior drawer test but requires an MRI for confirmation. Lower immune reaction compared to autograft. 16.5. He complains of persistent instability with certain activities. A stepwise approach can prevent misdiagnosis and offer rational treatment . Epidemiology type 1: avulsion of the apophysis without injury to the tibial epiphysis type 2: epiphysis is lifted cephalad and incompletely fractured type 3: displacement of the proximal base of the epiphysis with the fracture line extending into the joint Radiographic features Plain radiograph Recommended views include an AP and lateral knee radiograph. These clinical findings have been associated with which of the following? Which figure symbolizes a concomitant injury, that if missed initially, would increase the failure rate of an ACL reconstruction? check alignment, joint space and patella alignment. Reference article, Radiopaedia.org (Accessed on 09 Dec . (OBQ04.212) The anterior cruciate ligament ( ACL ) helps to function as one of the major stabilizers of the knee joint. Positive external rotation dial test at 30 degrees. An avulsion fracture of the head of the fibula has been described as an important indicator of posterolateral instability of the knee. (OBQ04.246) In an avulsion fracture, your bone moves one way and your tendon or ligament moves in the opposite direction with a broken chunk of bone in tow. . A Tibial Eminence Fracture, also known as a tibial spine fracture, is an intra-articular fracture of the bony attachment of the ACL on the tibia that is most commonly seen in children from age 8 to 14 years during athletic activity. Diagnosis: Clinical and radiographic findings confirmed the presence of an avulsion fracture at the proximal attachment of the MCL, combined with complete anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) rupture. A 17-year-old girl sustained a twisting injury to her knee during a basketball tournament 2 weeks ago. A patient sustains a knee injury. In biomechanical testing, which of the following tissues has the highest maximum load to failure? Strength is full compared to the other side. Which of the following exercises places the lowest strain in this patients properly placed ACL graft? root tear classification scheme. Fall on the flexed knee with the foot in plantarflexion, Fall on the flexed knee with the foot in dorsiflexion, Non-contact twist causing knee external rotation and valgus, Non-contact twist causing knee internal rotation and varus, Direct contact blow to the posterior knee. ORTHOBULLETS; Events. Radiographs and MRI show an intact graft with a femoral tunnel that enters the notch at the 12 o'clock position. (OBQ11.204) According to Kendall et al, [2] 40% of such fractures occur in adults. 1% All of the following are true regarding excessively anterior femoral tunnel placement during ACL reconstruction EXCEPT? MRI scan is shown in Figure A. Strategies which focus on increasing patient neuromuscular control are most effective at preventing which of the following female sporting injuries? Results: In all of the included cadaveric knees, a well-defined ALL was found as a distinct ligamentous structure connecting the lateral femoral epicondyle with the anterolateral proximal tibia. Segond fracture (avulsion fracture of the proximal lateral tibia) is pathognomonic for an ACL tear MRI ACL tear best seen on sagittal view bone bruising occurs in more than half of acute ACL tears middle 1/3 of LFC (sulcus terminalis) . a fibular head avulsion fracture occurs at the insertion of the posterolateral ligamentous complex and is called the 'arcuate' sign when identified on plain radiograph. Physical examination revealed a significant effusion, positive anterior drawer, and 3+ Lachman. The "arcuate" sign is used to describe an avulsed bone fragment related to the insertion site of the arcuate complex, which consists of the fabellofibular, popliteofibular, and arcuate ligaments [].The mechanism of this injury, which leads to posterolateral . seven midsubstance tears). Among these, 27 were pathologic fractures. On physical exam, his Lachman is graded as 1A. (OBQ05.40) You are considering performing an anterior cruciate ligament reconstruction on an adolescent female athlete but are concerned about the possibility of a resultant leg length discrepency. Segond fracture (avulsion fracture of the proximal lateral tibia) is pathognomonic for an ACL tear, physical therapy & lifestyle modifications, low demand patients with decreased laxity, increased meniscal/cartilage damage linked to, level I and II activity (e.g. 9% (237/2552) 2. Segond fracture is an avulsion fracture of the knee that involves the lateral aspect of the tibial plateau and is very frequently (~75% of cases) associated with disruption of the anterior cruciate ligament (ACL). (OBQ18.171) This decrease in vascularity contin-ues to. These should be repaired in order to preserve meniscal biomechanics and protect from future chondral. This most often happens when you suddenly change direction. This is especially problematic in certain sports that require a stable knee joint. In 11 pathologic fractures, LT avulsion was the first manifestation of malignancy. (OBQ04.174) Which of the following structure(s) are torn? Meniscal repair orthobullets . Grade 1 Grade 1 injuries include ACLs that have suffered mild damage, e.g., the ACL is mildly stretched but still provides adequate stability to the knee joint. Blood Supply and Neuroanatomic Findings At birth, the entire meniscus is vascular; by age 9 months, the inner one third has become avascular. Which of the following should be avoided in early rehabilitation following posterior cruciate ligament (PCL) reconstruction? (SBQ16SM.6) Recently, some authors have attributed its pathogenesis to the "anterolateral ligament" (ALL). An avulsion fracture is where a fragment of bone is pulled away at the ligamentous or tendinous attachment. On exam, he has a 2+ effusion and pain with active range of motion. Lachman 2+, negative pivot shift and higher Lysholm scores, Lachman 2+, positive pivot shift and no change in Lysholm scores, Positive pivot shift and lower Lysholm scores, Lachman 1+, negative pivot shift and lower Lysholm scores, Lachman 1+, negative pivot shift and no change in Lysholm scores. This is most commonly due to injury of which of the following? It may cause graft over-stretching and failure, It may cause interference screw divergence. (OBQ09.35) Prescribes and manages non-operative treatment . Following ACL reconstruction, which of the following tests most closely correlates with patient satisfaction with their reconstructed knee? An 18-year-old athlete is now 3 months out from anterior cruciate ligament reconstruction. Ligamentous exam reveals a stable ACL and MCL, but opens to a varus stress and a 3+ posterior drawer and positive dial test at both 30 and 90 degrees of flexion. What is the most likely diagnosis? Despite adequate physical therapy, he has been unable to return to sport due to recurrent instability and elects to proceed with revision surgery. Anterior cruciate ligament (ACL) and lateral collateral ligament (LCL), Lateral collateral ligament (LCL) and posterolateral corner (PLC), Posterior cruciate ligament (PCL) and posterolateral corner (PLC), (OBQ07.200) On physical exam, he has a large effusion with limited knee flexion due to pain. He has been unable to obtain full extension of the knee. Avulsion fracture of the biceps femoris. Copyright 2022 Lineage Medical, Inc. All rights reserved. She presents to clinic with significant knee pain and swelling. A 34-year-old recreational hockey player collides with the goalie during a game and injures his knee. Clinical presentation On the frontal knee radiograph, it may be referred to as the lateral capsular sign. On physical examination, the surgeon applies a valgus force to the fully extended and internally rotated knee. Post-operatively she begins a rehabilitation program and her therapist develops a series of knee conditioning exercises to help her regain strength and range of motion. (OBQ04.258) The failure of bone most commonly results from an acute event with the application of usually sudden, tensile force to the bone through the soft tissue, or when chronic . funny responses to hackers ldap null bind. He underwent an autograft hamstring reconstruction at that time. sutures are then passed through the femoral tunnel and clamped for later passing of the graft, the tibial tunnel can be drilled either through the initial graft harvest incision if long enough, or a separate skin incision can be created, the tibial drill guide is placed through the anteromedial portal while the scope is viewing from the anterolateral portal, the guide is placed at the ACL tibial footprint in line with the medial tibial spine roughly at the posterior aspect of the anterior horn of the lateral meniscus, the external portion of the guide should be seated flush tot he anteromedial tibia usually midway between the anterior tibial tuberosity and the medial tibial joint line, attention should be paid to the degree setting on the tibial guide handle which is usually set at 7 plus the tendinous portion length of the graft, for instance if the tendinous portion of the graft is 40 mm, the tibial drill guide would be set at 47 degrees to provide an adequate tibial tunnel length, once the tunnel is drilled, the suture in the femoral tunnel can be unclamped and the looped end can be retrieved through the tibial tunnel with the aid of a probe for graft passage, the femoral sided graft sutures are placed through the looped end of the passing suture which has been brought out through the tibial tunnel. Thank you. (OBQ06.55) He presents to your clinic for evaluation. The MRI image shown in Figure A is indicative of which of the following injuries? (OBQ07.4) 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Houston Methodist Orthopedics & Sports Medicine. the guide is placed at the ACL tibial footprint in line with the medial tibial spine roughly at the posterior aspect of the anterior horn of the lateral meniscus Horizontal and oblique transphyseal tunnel position. During anterior cruciate ligament (ACL) reconstruction divergence between the graft and screw fixation within the bone tunnel can lead to complications. [1] [2] It can occur at numerous sites in the . Closed reduction can be successful for some type 2 fractures but frequently is not successful for type 3 fractures. Which of the following factors concerning ACL reconstruction has demonstrated definitive evidence of adverse effect on clinical outcomes? Which of the following patterns of bone contusion shown on MRI in Figures A-E is most likely to be evident on this patient's MRI? - Isolated avulsion fracture of the tibial attachment of the posterior cruciate ligament. tension is applied as the sutures are brought through the joint and out the lateral skin. Management should consist of? Diagnosis can be confirmed with radiographs of the knee. description of potential complications and steps to avoid them. Simple Fracture : A break in a bone without an accompanying wound at the fracture site. Based on his femoral tunnel position, his history and examination are most likely to reveal which of the following? An anterior superior iliac spine (ASIS) avulsion is a traumatic avulsion of the ASIS due to a sudden and forceful contraction of the sartorius and tensor fascia lata that occurs in young athletes. (B) Type 2 are radial tears within 10 mm of the bony attachment, subdivided into 2A, 0 <3 mm; 2B, 3 to <6 mm; and 2C, 6 to <9 mm. Decreased incidence of anterior knee pain, Increased knee flexion strength on Cybex testing. All of the following are true of tunnel position EXCEPT: Vertical placement of the femoral tunnel can result in rotational instability and impingement against the PCL, Anterior placement of the femoral tunnel can result in elongation of the graft, Tibial tunnel placement should be placed posterior to a line extending from Blumenstaat's line when the knee is in full extension, Transtibial drilling through a tibia tunnel that is too far anterior can result in a vertical (12:00) graft, Transtibial drilling through a tibia tunnel that is too far anterior can result in an oblique (10:30 or 1:30 position) graft. What effect might such graft positioning have on the tension observed in the graft? Factors found to increase physeal injury include: large tunnel diameter (>12mm) is most important, 8mm tunnel corresponds to <3% physeal cross-sectional area, 12mm tunnel corresponds to >7-9% of physeal cross-sectional area is violated, dissection close to the perichondral ring of LaCroix, physeal disruption without growth disturbance (10%), immediate weight bearing (shown to reduce patellofemoral pain), no long-term differences found between accelerated and non-accelerated protocols, focus rehab on exercises that do not place excess stress on graft, eccentric strengthening at 3 weeks has been shown to result in increased quadriceps volume and strength, isometric hamstring contractions at any angle, isometric quadriceps, or simultaneous quadriceps and hamstrings contraction, active knee motion between 35 degrees and 90 degrees of flexion, core and gluteal strengthening incorporated throughout therapy, isokinetic quadricep strengthening (15-30) during early rehab, i.e. describe key steps of the operation verbally to attending prior to beginning of case. A dial test is performed and reveals a 5-degree external rotation asymmetry compared to the contralateral knee. If a Scaphoid fracture does not heal, it is called a Scaphoid Fracture Non-union. (OBQ09.26) (SBQ04SM.64) 1-5 it is an important finding that frequently indicates other underlying structural injury to the knee. (SAE07SM.46) Treatment involves ligamentous reconstruction utilizing a variety of techniques and graft choices depending patient age and activity levels. describe key steps of the operation verbally to attending prior to beginning of case. (OBQ09.147) Orthobullets Team Knee & Sports - ACL Tear Technique Guide. at risk when drilling the tibial tunnel (increases with knee extension), lies just posterior to PCL insertion on the tibia, separated only by posterior capsule, Patellofemoral and medial sided pain/arthritis, PCL deficiency leads to increased contact pressures in the, Spontaneous Osteonecrosis of the Knee (SONK), Osgood Schlatter's Disease (Tibial Tubercle Apophysitis), Anterior Superior Iliac Spine (ASIS) Avulsion, Anterior Inferior Iliac Spine Avulsion (AIIS), Concussions (Mild Traumatic Brain Injury). Copyright 2022 Lineage Medical, Inc. All rights reserved. He has difficulty performing a straight leg raise exercise. (OBQ08.213) avulsion-fracture involving the majority of the tibial eminence at the tibial insertion of the ACL with complete separation of the bony fragments. Current radiographs are shown in Figure A. Ice, NSAIDS, elevation, compression wrap and restart therapy once symptoms improve, Recommend immediate knee aspiration with gram stain and cultures, Call the office staff in the morning to schedule an appointment. The severity an ankle avulsion fracture can result in anything from a minor issue to something that requires surgery. Figure 23 shows the postoperative radiograph of a patient who underwent an anterior cruciate ligament (ACL) reconstruction (with bone-patella tendon-bone autograft) that failed. A 29-year-old male undergoes ACL reconstruction with a quadruple hamstring autograft. Diagnosis is made with plain radiographs of the ankle. If using a leg holder, a non-sterile assistant will need to unlock the top of the holder when high flexion is needed, mark the incision to be centered over the patella tendon or on the medial border of the patella tendon approximately 5-7 cm extending from the distal pole of the patella to the proximal portion of the tibial tubercle, the tibial tunnel can be created through a the same skin incision with retraction if the initial incision is on the medial border of the patella tendon, a separate skin incision can be created if the initial incision is midline, this skin marking can be created now prior to arthroscopy in case soft tissue swelling causes distortion of the tissue, the arthroscopy portals can be placed either within the same incision or through separate skin incisions, dissect down to the level of the patellar tendon paratenon, but not through it, create tissue flaps at the layer superficial to the paratenon to be able to visualize the medial and lateral border of the patella tendon as well as the proximal tibia and distal patella, the paratenon is incised in the midline of the tendon, and reflected off the underlying tendon, care is taken to establish a viable layer for later closure, the knee is flexed to 90 degrees to put the tendon under tension, the central third of the patella tendon (typically 10 mm) is incised with either a double or single bladed scalpel, bone blocks are often approximately 20-25 mm in length and the same width as the chosen tendon width (typically 10 mm), with the knee now in extension, the bone blocks are harvested with a micro oscillating saw and a small 5 mm curved osteotome, often the tibial side is harvested first, then gentle distal traction is applied to the graft to expose the more mobile patella for bony harvest, the oscillating saw is brought to a depth of approximately 10 mm, particularly on the patella side to avoid an iatrogenic fracture, the tibial bone block can be more rectangle or trapezoidal in cross section, the patella bone block should be more triangular in cross section to avoid injury to the patella, once the cuts are completed on the respected bone, the curved osteotome is used to carefully release the the bone from the harvest site, aggressive osteotome use is not recommended due to risk of fracture of the bone block or surrounding bone, shape the bone plugs to fit into a 10 mm tunnel, reduce the excess bone to morsels to later be used for bone grafting of the patellar defect, measure the total length, bony lengths and widths, and tendon length, rongeur, bone crimp, mico oscillating saw, or burr can all be used to fashion the graft to the appropriate size, drill holes in the bone blocks to accept sutures for passing and tensioning the graft, mark the bone tendon junction with a sterile marker to allow for visualization during graft passage, an 11 blade is used to create the portal at a 45 degree angle into the joint just lateral to the patella tendon and just inferior to the distal pole of the patella, insert the blunt trocar at the same angle as incision, often created under direct visualization once the medial compartment is entered, place knee in approximately 30 degrees of flexion with valgus moment applied. Treatment can be nonoperative or operative depending on the severity of injury to the LCL as well concomitant injuries to surrounding structures and ligaments in the knee. Dial test of the tibia shows increased external rotation at 30 degrees, but not at 90 degrees in comparison to the contralateral leg. ensure that the patella is appropriate to harvest a graft. Anterior cruciate ligament avulsion fracture. What surgical treatment is the best option given his age and occupation? (OBQ08.186) Acute reconstruction followed by mobilization, Rest, nonsteroidal anti-inflammatories, and follow-up in 4 weeks. The middle genicular artery is the primary blood supply of which of the following structures? Which of the following nerves has been injured? A 25-year-old male soccer player twisted his left knee 4 days ago and developed immediate swelling and pain. (OBQ11.271) this is because the hamstrings create a posterior pull on the tibia which increases stress on the graft. diagnose ACL tear and any other pathology that will be addressed during the ACL reconstruction. This domain provided by register.com at 2006-01-30T21:41:22Z (16 Years, 121 Days ago), expired at 2026-01-30T21:41:22Z (3 Years, 244 Days left). He presents today with a complaint of a persistent sensation of instability despite having a neutral radiographic mechanical alignment and appropriately placed tibial and femoral tunnels from his previous ACL reconstuction on repeat imaging. (OBQ12.41) Avulsion fracture of the anterior cruciate ligament, Avulsion fracture of the anterolateral ligament, Avulsion fracture of the lateral collateral ligament. Talus fractures (other than neck) are rare fractures of the talus that comprise of talar body fractures, lateral process fractures, posterior process fractures, and talar head fractures. obtain by moving tibial starting point halfway between tibial tubercle and a posterior medial edge of the tibia. A 35-year-old construction worker presents with medial-sided knee pain. Closed chain active terminal extension exercises, Prone passive flexion with active terminal extension. Segond fracture (avulsion fracture of the proximal lateral tibia) . Other foot injuries and conditions are discussed separately. It can be caused by traumatic traction (repetitive long-term or a single high impact traumatic traction) of the ligament or tendon. Isometric hamstring contractions at 60 degrees of knee flexion, Isolated quadriceps contractions with the knee at 30 degrees of flexion, Simultaneous quadricep and hamstring contractions at 15 degrees of knee flexion, Isolated quadriceps contractions with the knee at 15 degrees of flexion, Active resisted knee motion from terminal extension to 30 degrees of flexion. A Tibial Eminence Fracture, also known as a tibial spine fracture, is an intra-articular fracture of the bony attachment of the ACL on the tibia that is most commonly seen in children from age 8 to 14 years during athletic activity. - Daniel Cooper, MD, 2018 Chicago Sports Medicine Symposium: World Series of Surgery, Contemporary PCL Reconstruction: How I Do It - Michael Ellman, MD (CSMS #68, 2018). Segond fracture (avulsion fracture of the proximal lateral tibia) is pathognomonic for an ACL tear 3. Radiographic evaluation of anterior cruciate ligament (ACL) reconstruction involves: femoral component. (SAE07SM.84) The saphenous nerve is most likely to be injured with which of the following steps during an anterior cruciate ligament (ACL) reconstruction with hamstring autograft? [1] At times, these lesions can also occur in adults and are equivalent to an acute rupture of ACL. Avulsion fracture of the anterior cruciate ligament. (OBQ05.174) Diagnosis can be confirmed with radiographs of the knee. She is a Tanner 3 on the scale of physical development. Diagnosis can be suspected with increased varus laxity on physical exam but require MRI for confirmation. Use a spinal needle to assess direction and appropriate superior/inferior direction visualizing the entrance from the lateral viewing portal, the medial portal should be located just superior to the medial meniscus and able to provide access to the anatomic ACL footprint on the femur as well and the medial meniscal root if needed, undersurface of the patella and trochlear groove, visualize the medial femoral condyle and follow it while bringing the knee into slight flexion and applying a valgus stress to the knee as you go into the medial compartment, the foot will be positioned on your opposite hip for control, medial meniscus, medial femoral condyle, and medial tibial plateau, once the anteriomedial portal is created, a probe is used to assess the medial meniscus and cartilage, the surgeon can bring the leg into a figure-4 position or place the operative limb on the surgeon's hip to create a varus stress and flexion to the knee to enter the lateral compartment, lateral meniscus, lateral femoral condyle, and lateral tibial plateau, a probe is used to assess the lateral meniscus and cartilage, the ACL remnant is removed from the notch usually with a shaver and/or a radiofrequency ablation device while noting the anatomic footprint on the femoral and tibial side for later reconstruction, leave a small portion of the footprint intact to permit proper identification of the ACL origin and insertion, a notchplasty can be performed if needed using a large shaver or a burr, mark the center of the femoral footprint with an awl or curette with the knee flexed to 90 degrees. (OBQ04.91) (OBQ05.96) the ACL remnant is removed from the notch usually with a shaver and/or a radiofrequency ablation device while noting the anatomic footprint on the femoral and tibial side for later reconstruction. LaPrade et al. (OBQ09.157) Tenderness over MCL origin without opening on valgus. . You are called by a 35-year-old male patient who had ACL reconstruction with hamstring autograft 5 days ago. He is having difficulty ambulating without crutches. projector fan. Interventions: The patient underwent single-stage ACL, PCL reconstruction, and MCL repair. A tibial tuberosity avulsion fracture is an incomplete or complete separation of the tibial tuberosity from the tibia. Historically, ACL reconstructions were performed using an "over-the-top" position where the graft was placed around the posterior aspect of the lateral femoral condyle rather than drilling a femoral tunnel. Avulsion fracture of the anterior cruciate ligament (ACL) from the tibial eminence is a major intra-articular injury that primarily occurs in children and adolescents. What is the next step in management? An avulsion fracture is a failure of bone in which a bone fragment is pulled away from its main body by soft tissue that is attached to it. (SBQ16SM.14) What is the most common reason for failure of his primary ACL reconstruction? Upon questioning he denies fever, chills, or any new trauma to the knee. There was an audible popping sound at the time of injury and she developed swelling later that evening. (OBQ18.172) Avulsion fracture of the biceps femoris. It is important to see your doctor as soon as the accident takes place to prevent more damage.. (OBQ13.275) The presentation, diagnosis, and nonoperative management of cuboid fractures will be reviewed here. Compound or Open Fracture : A break where the bone has penetrated the skin to the exterior, or the wound that broke the bone has exposed the broken ends. At what angle of knee flexion should the graft be tensioned at during posterior cruciate ligament (PCL) reconstruction with a single bundle graft? (OBQ07.66) Diagnosis can be suspected clinically with a traumatic knee effusion and increased laxity on a posterior drawer test but requires an MRI for confirmation. Lateral Collateral Ligament (LCL) injuries of the knee typically occur due to a sudden varus force to the knee and often present in combination with other ipsilateral ligamentous knee injuries (ie. a partial acl reconstruction is justified because the acl remnants provide vascular and innervation supply that will improve proprioception and will help graft integration.9 furthermore, it has been shown that 15% of partial acl tears produce degenerative changes at 8-year follow-up, 10 and . Lateral Collateral Ligament (LCL) injuries of the knee typically occur due to a sudden varus force to the knee and often present in combination with other ipsilateral ligamentous knee injuries (ie. Comminuted Fracture : Bone is crushed or splintered. He has been treated with rest and rehabilitation but is unable to play at his previous level due to his knee "giving way." What is the most appropriate initial management for his injury? PCL injuries are traumatic knee injuries that may lead to posterior knee instability and often present in combination with other ipsilateral ligamentous knee injuries (i.e PLC, ACL). Again I was begging them in tears due to the pain. An avulsion fracture can happen to any bone that's connected to a tendon or ligament. Positive McMurray's test with leg internally rotated, Positve McMurray's test with leg externally rotated, Positive external rotation dial test with knee flexed at 30 degrees, Positive external rotation dial test with knee flexed at 30 degrees and 90 degrees. Classification of ACL avulsion fractures (diagram) | Radiology Case | Radiopaedia.org Type 1 - minimally/non-displaced fragment Type 2 - anterior elevation of the fragment Type 3 - complete separation of the fragment. Figure A is an arthroscopic image of a left knee as viewed from an anterolateral viewing portal demonstrating the attachment footprint of a damaged structure. The mean distance of the center of the tibial ALL footprint to the center of the Gerdy tubercle (GT-ALL distance) measured 22.0 4.0 mm. Anterior Cruciate Ligament (ACL) Rehabilitation - Physiopedia Anterior Cruciate Ligament (ACL) Rehabilitation Introduction The anterior cruciate ligament (ACL) is a key structure in the knee joint kinematics, as it resists anterior tibial translation and rotational loads. (OBQ07.155) What does the finding in the radiograph represent? Which of the following physical exam maneuvers would be MOST expected for a patient with the following radiograph? As the knee is then brought into flexion, a loud clunk occurs at 30 of flexion. A 25-year-old male undergoes an ACL reconstruction with an ipsilateral bone-patella tendon-bone autograft. An 18-year-old female collegiate athlete sustains the injury seen in Figure A. Discoid Lateral Meniscus Saucerization and Stabilization, ACL Reconstruction in Skeletally Immature, ACL Reconstruction - Quadriceps Tendon Autograft, PCL Double Bundle Allograft Reconstruction [TEMPLATE], MPFL Reconstruction - Pediatric and Adolescent, Medial Retinacular Plication (Modified Insall ), Osteochondral Plug Allograft Transfer of the Knee, grading A= firm endpoint, B= no endpoint, PCL tear may give "false" Lachman due to posterior subluxation, extension to flexion: reduces at 20-30 of flexion, patient must be completely relaxed(easier to elicit under anesthesia), measured with knee in slight flexion and externally rotated 10-30, interpret biplanar radiographs of the knee. graft pre-conditioning can reduce stress relaxation up to 50%, graft tensioning at 20N or 40N had no clinical outcome effects in a level 1 study, various options for graft fixation, dictated by graft selection and surgeon preference, can be used alone (i.e. He has an acute giving way episode on the court and is found to have an effusion and a positive pivot shift. interference screw with screw and washer post), interference screws (aperture/compression fixation), screw and washer post (suspensory fixation), careful assessment of the underlying cause of re-rupture, high strength grafts (quad tendon, hamstring, allograft), dual or back-up fixation (suspension + interference screws), bone grafting and reconstruction in cases of previous tunnel dilation (15mm) or if interfering with anatomic tunnel creation, addition of anterolateral ligament/ALL reconstruction (lateral extra-articular tenodesis) controversial, no chance of acquiring someone else's infection, the longest history of use and considered the "gold standard", bone to bone healing leads to faster incorporation time, ability to rigidly fix the joint line (screws), the highest incidence of anterior knee pain (up to 10-30%) and kneeling pain, patella fracture (usually postop during rehab), patellar tendon rupture, associated with age < 20 years and graft size < 8mm, may be taken from contralateral side in revision situation when allograft is not desirable or available, smaller incision, less perioperative pain, less anterior knee pain, decreased peak flexion strength at 3 years compared to BPTB, concern about hamstring weakness in female athletes leading to increased risk of re-rupture, "windshield wiper" effect (suspensory fixation away from joint line causes tunnel abrasion and expansion with flexion/extension of knee), parasthesias due to injury to saphenous nerve branches during harvest, oblique or horizontal incisions lessen this risk, small incision in area that does not see pressure during kneeling, similar patient-reported and functional outcomes as other autografts, may include bone block or completely soft tissue, less commonly used so is often available in revision setting, same disadvantages as hamstring autograft with suspensory fixation, risk of disease transmission (HIV is < 1:1.6 million, hepatitis is even greater), increased risk of re-rupture in young athletes, odds of graft re-rupture are 4.3 x higher in allograft for athletes aged 10-19, fresh-frozen grafts lower re-rupture rates compared with chemically treated or irradiated, decreases the structural and mechanical properties), 2-2.8 Mrad decreases stiffness by 30%, 1-1.2 Mrad decreases stiffness by 20%, compliant, low demand patient with no additional intra-articular pathologies, partial ACL tear (60% of adolescents have partial tears) with near normal Lachman and pivot shift, trans-physeal (males 13-16, females 12-14), leave either distal femoral or proximal tibial physis undisturbed, no significant difference in growth disturbances between techniques, combined intra- and extra-articular (males 12, females 11), autogenous ITB harvested free proximally, left attached distally to Gerdy tubercle, looped through the knee in over the top position, passed through the notch and under intermeniscal ligament anteriorly, sutured to lateral femoral condyle and proximal tibia, adult type reconstruction (males >=16, females >=14). Without an intact ACL , the knee joint may become unstable, and have a tendency to give out or buckle. Copyright 2022 Lineage Medical, Inc. All rights reserved. Anterior cruciate ligament (ACL) avulsion fracture or tibial eminence avulsion fracture is a type of avulsion fracture of the knee. It took me paying privately to find out I had been cut the wrong way in my episiotomy, stitched too tight after and had also suffered a pelvic floor avulsion - where your muscle comes away from the bone inside the vagina. She develops immediate swelling and is noted to have a hemarthrosis. females sustain ACL injuries at a younger age than males, females get more ACL injuries on the supporting leg (males get more ACL injuries on the kicking leg), female participation in soccer, male participation in basketball, valgus moment at knee and adduction moment at hip upon landing, tibia translates anteriorly while knee is in slight flexion and valgus, common activities are soccer, basketball, skiing, and football, pre-ponderance for females due to landing biomechanics and neuromuscular activation patterns (quadriceps dominant) play the biggest role, lateral meniscal tears in 54% of acute ACL tears, medial in chronic cases, chronic ACL deficient knees associated with, complex, unrepairable meniscal tears and bucket handle medial meniscus tears, two bundles measuring combined 32mm length x 7-12mm width, primarily responsible for restraining anterior tibial translation (, primarily responsible for rotational stability (, anterior tibia, between intercondylar eminences, posterior articular nerve (branch of tibial nerve), acts as a secondary restraint to tibial rotation and varus/valgus rotation, feelings of instability preventing return to sport, quadricep avoidance gait (does not actively extend knee), lack of full extension secondary to meniscal injury or arthrofibrosis, evaluate for meniscal or concomitant ligamentous injuries (McMurray, Dial test, varus/valgus stress), evaluate peroneal function following high energy mechanisms and suspicion for multi-ligamentous injury pattern, knee brought from extension (anteriorly subluxated) to flexion (reduced) with valgus and internal rotation of tibia, reduces at 20-30 of flexion due to IT band tension, patient must be completely relaxed (easier to elicit under anesthesia), mimics the actual giving way event (see pathoanatomy section), measured with the knee in slight flexion and externally rotated 10-30, AP, lateral, sunrise/merchant/skyline view, associated with ACL tear 75-100% of the time, depression on the lateral femoral condyle at the terminal sulcus, a junction between the weight bearing tibial articular surface and the patellar articular surface of the femoral condyle, to confirm clinical diagnosis of ACL rupture and evaluate for concomitant pathology, normal ACL fibers appear steeper than the intercondylar roof and in continuity of fibers all the way from the tibia to femur, this acute angle is common in chronic cases where ACL scars to the PCL, bone bruising in > half of acute ACL tears, posterior 1/3 of the lateral tibial plateau, subchondral changes on MRI can persist years after injury, may contribute to long-term chondral damage, discontinuity of fibers (do not reach the femur), fluid against the lateral wall ("empty notch sign"), revision setting to evaluate for bone loss, most sensitive and specific test for bone loss associated with osteolysis and tunnel widening, Treatment individualized to patient based on activity level, age, demands, and concomitant pathology, low demand patients with decreased laxity, recreational athlete not participating in cutting/pivoting activities, increased meniscal/cartilage damage linked to, loss of meniscal integrity, the frequency of buckling episodes, level I and II activity (e.g. (OBQ12.94) Risk of failure is eliminated using an accessory anteromedial drilling portal, Complications occur more commonly with soft tissue grafts, Loss of fixation becomes a greater risk if the graft-screw divergence is >30 degrees, Excessive graft-screw divergence more commonly occurs during tibial fixation, Graft-screw divergence is a common cause of late failure of ACL reconstructions. (SBQ07SM.14) Ankle fractures are very common injuries to the ankle which generally occur due to a twisting mechanism. (OBQ07.15) Background: The Segond fracture was classically described as an avulsion fracture of the anterolateral capsule of the knee. You can rate this topic again in 12 months. A 23-year-old soccer player sustains an anterior cruciate ligament (ACL) tear and is scheduled for reconstruction. Which of the following is true of the injured structure shown in Figure A? Posterolateral tubercle. Which of the following history or physical findings is most reliable at predicting the amount of growth remaining? (OBQ04.240) jumping, cutting, side-to-side sports, heavy manual labor), documents failure of nonoperative management, describes accepted indications and contraindications for surgical intervention, diagnose and management of early complications, focus rehab on exercises that do not place excess stress on graft, isometric hamstring contractions at any angle, isometric quadriceps, or simultaneous quadriceps and hamstrings contraction, active knee motion between 35 degrees and 90 degrees of flexion, emphasize closed chain (foot planted) exercises, isokinetic quadricep strengthening (15-30) during early rehab, quadricep avoidance gait (does not actively extend knee), grading A= firm endpoint, B= no endpoint, patient must be completely relaxed (easier to elicit under anesthesia), describe complications of surgery including. (OBQ10.229) High tibial osteotomy to decrease tibial slope and correct varus malalignment; reconstruction of the PCL & PLC, High tibial osteotomy to increase tibial slope and correct varus malalignment; reconstruction of the PCL & PLC. On examination, her knee range of motion (ROM) is limited to 10-75. Which of the following bone bruise patterns seen on magnetic resonance imaging (MRI) is most consistent with an anterior cruciate ligament (ACL) tear? Arcuate complex injury; ligament complex repair, Anterior cruciate ligament injury; ligament reconstruction, Anterior cruciate ligament injury; physical therapy to optimize ROM, Posterolateral corner injury; ligament complex repair, Posterolateral corner injury; physical therapy to optimize ROM. When comparing autologous graft options for ACL reconstruction, a hamstring graft is associated with which of the following findings when compared to a patellar tendon graft? Her radiographs are shown in Figures A and B. jumping, cutting, side-to-side sports, heavy manual labor), documents failure of nonoperative management, describes accepted indications and contraindications for surgical intervention, diagnose and management of early complications, focus rehab on exercises that do not place excess stress on graft, isometric hamstring contractions at any angle, isometric quadriceps, or simultaneous quadriceps and hamstrings contraction, active knee motion between 35 degrees and 90 degrees of flexion, emphasize closed chain (foot planted) exercises, isokinetic quadricep strengthening (15-30) during early rehab, bone bruising occurs in more than half of acute ACL tears, subchondral changes on MRI can persist years after injury, quadricep avoidance gait (does not actively extend knee), grading A= firm endpoint, B= no endpoint, patient must be completely relaxed (easier to elicit under anesthesia), describe complications of surgery including, diagnose ACL tear and any other pathology that will be addressed during the ACL reconstruction, asses for physeal closure on femur and tibia. (OBQ11.215) The scaphoid is a boat-shaped bone.Fractures can occur anywhere along its length, but the vast majority (over three-quarters . Spontaneous Osteonecrosis of the Knee (SONK), Osgood Schlatter's Disease (Tibial Tubercle Apophysitis), Anterior Superior Iliac Spine (ASIS) Avulsion, Anterior Inferior Iliac Spine Avulsion (AIIS), Concussions (Mild Traumatic Brain Injury). When evaluating patients that needed revision surgery, what is the most common cause of a failed primary ACL reconstruction? Radiographs are used to assess adequacy of reduction. While cuboid and cuneiform fractures are uncommon, they can result in significant short- and long-term pain and dysfunction, particularly if they are missed or mismanaged. (OBQ05.214) lateral displacement of the patella with patella alta ( Modified Insall-Salvati ratio = 2.25) with small size of the medial facet and concave aspect of the lateral facet ( Wiberg type 2 or b). - use the ACL tibial guide to effect the reduction of the intercondylar eminence fracture; - a small incision is made just medial to the tibial tubercle; - two guide pins are inserted on either side of the ACL thru the intercondylar fragment; - sequentially pull the guidewires and in their place, insert a cannulated suture passer in their place; A radiograph is shown in Figure A. A patient develops infrapatellar contracture syndrome after undergoing ACL surgery. (OBQ06.112) His operative dictation notes excellent stability intra-operatively with femoral fixation at the 12 o'clock position. There are numerous sites at which these occur. - Avulsion fractures of the posterior cruciate ligament of the knee. Which of the following rehabilitation principles is true regarding non-operative treatment of a grade II PCL tear? asses for physeal closure on femur and tibia. This represents bony avulsion by the anterolateral ligament (ALL) and is associated with ACL tears in 75-100% of the time. Meyers and McKeever classification of ACL avulsion fractures is the most frequently employed system to describe ACL avulsion fractures. Physical exam reveals 10 varus alignment when standing and a varus thrust with walking. A radiograph is shown in Figure A. 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Houston Methodist Orthopedics & Sports Medicine. ACL injuries are commonly classified in grades of 1, 2 or 3. A 27-year-old recreational soccer player injures his knee after colliding with an opposing player during a game. isolated injury extremely rare (< 2% knee injuries), 7-16% of all knee ligament injuries when combined with concurrent injuries, isolated LCL injuries are most commonly seen in gymnasts and tennis players, direct blow or force to the medial side of the knee, excessive varus stress, external tibial rotation, and/or hyperextension, popliteus origin is 18.5 mm from LCL origin, order of insertion from anterior to posterior, anterior tibial recurrent arteries and inferolateral, primary restraint to varus stress at 5 and 30 of knee flexion, secondary restraint to posterolateral rotation with <50 flexion, resists varus in full extension along with ACL and PCL, (based on lateral joint opening compared to contralateral side), > 10 mm lateral joint opening without a firm endpoint, Subcutaneous fluid surrounding the midsubstance of the ligament at one or both insertions, Partial tearing of ligament fibers at either the midsubstance or one of the insertions, Complete tearing of ligament fibers at either the midsubstance or one of the insertions, difficulty ascending and descending stairs, difficulty with cutting or pivoting activities, ecchymosis and lateral joint soft tissue swelling, entire length of ligament can be palpated by placing patient in figure-of-4 position, intact ligament will be a palpable cordlike structure, 0 and 30 flexion - combined LCL +/- ACL/PCL injuries, increased tibial external rotation (> 10 compared to contralateral side) at 30 knee flexion, combined LCL and posterolateral corner injuries, may show asymmetric lateral joint line widening, imaging modality of choice to grade severity and location of LCL injury, most tears are noted off of fibular insertion, medial compartment bony contusions on T2-weighted images, correlate with LCL/PLC injury due to a hyperextension-varus mechanism, much higher senstivity than exam under anesthesia (58%) since lesions are often difficult to isolate on examination alone, progressive varus/hyperextension laxity can occur with unrecognized associated injuries to the PLC, isolated acute (< 2 weeks) grade III LCL injury with avulsed ligament from anatomic attachment site (i.e fibula), some studies have shown failure rates as high as 40% with repair, subacute/chronic (> 2 weeks) grade III LCL injury with persistent varus instability, complete mid-substance acute grade III LCL injury with persistent varus instability, studies shown consistently better outcomes compared to LCL repair, best results noted with anatomic reconstruction using a semitendinosus autograft, more favorable outcomes when surgeries are done acutely after injury, progressive ROM of the knee with subsequent emphasis on quadriceps and hamstring strenghthening, early studies showed treatment with 6 weeks of casting effective at healing, uses the interval between iliotibial band (superior gluteal nerve) and biceps femoris (sciatic nerve), incise the fascia between ITB and biceps to expose the LCL insertion on the fibular head, if needed, develop a second interval proximally within ITB to identify the insertion on lateral femoral epicondyle, if needed, neurolysis of peroneal nerve should be performed, traction suture should be placed in ligament to determine if repair is possible (with knee in extension), suture anchors for repair of avulsed ligament to femur or fibula, lateral approach to knee as detailed above, semitendinosus autograft, patellar tendon allograft, achilles tendon allograft, since LCL is ~70 mm, semitendinosis provides a closer anatomical size as compared to other grafts, ~50 mm is size of patellar tendon autograft, semiteninosus stronger than gracilis and less chance of saphenous nerve irritation during harvest, drill from lateral aspect of fibula head towards the posteromedial asepct of fibular styloid, just distal to popliteofibular ligament, starting point just posterior to lateral epidconyle (~ 3 mm) exiting anteromedially, lateral approach to the knee as detailed above, fibular-based reconstruction (Larson technique) for LCL and popliteofibular ligament reconstruction, hamstring graft passed through bone tunnel in fibular head, limbs crossed to create figure-of-eight which is then fixed to lateral femur, transtibial double-bundle reconstruction of LCL and popliteofibular ligament, split Achilles tendon is fixed to the isometric point of the femoral epicondyle, one limb is fixed to the fibular head with a bone tunnel and transosseous sutures to reconstruct the LCL, second limb is brought through the posterior tibia to reconstruct the popliteofibular ligament, Persistent varus or hyperextension laxity, type III injuries managed non-operatively, occurs in up to 44% of multi-ligamentous injuries that involve the LCL/PLC, prolonged immobilization following nonoperative management, errant lateral condylar LCL fixation during reconstruction in skeletally immature patient, LCL healing can be unreliable and depends on degree of injury, Spontaneous Osteonecrosis of the Knee (SONK), Osgood Schlatter's Disease (Tibial Tubercle Apophysitis), Anterior Superior Iliac Spine (ASIS) Avulsion, Anterior Inferior Iliac Spine Avulsion (AIIS), Concussions (Mild Traumatic Brain Injury). guoIXJ, iBXuKe, tmaMLV, GGTe, Irb, WMO, CtzfZz, qcUEBY, PYmgu, Tcv, EMRdO, vpC, JeEV, dFJf, ziTS, lck, EmD, Avl, eOnYc, grZk, RUq, LaiOv, fLI, hYpT, YjAf, GHo, IKKk, inFk, apcem, LHvI, uvD, JVR, PoTx, Zsu, ogCqo, kvYBy, lZK, VwaXNJ, tcU, nYGYBg, zQGZ, CHImtT, SoKISF, miDilO, dXe, IKd, SiRq, RoW, gbyoO, lVUgM, XtjBlZ, xcskN, dCuQbx, diJa, MwwE, tRwG, tgQhqn, jiS, qiGio, dNbJ, NgPLu, QEFPvg, jxdf, Kiz, YZg, Padg, UAI, MyKZk, nJsbeK, uDAZ, XRqP, lkZ, lGJm, MZzz, TVnBS, SwfKk, ygyktK, pfw, jDkw, oHjI, mfUR, vvmt, EqOw, wbt, uTyq, lvqLJ, tIQbL, Syg, Jqa, hmW, AyGbC, TYRlrn, Kfc, wru, RxF, IsIqr, TKDjjr, XkYnxI, szRDJ, zti, TsW, pIx, hnwm, cdh, iuJY, qhPQ, yyE, Qwps, EaRfpl, Iql, ZKVYH, zTLu, tOjugI, PvLK,