SOFT TISSUE INJURY OF THE KNEE

Done by : baha’a abdulhameedgroup D 2015

INTRODUCTION

Soft tissue injuries of the knee are some of the most common and clinically challenging musculoskeletal disorders in patients presenting to the ED.

soft tissue structures that stabilize and cushion the knee joint including ligaments

muscles tendons menisci

SPRAIN VS STRAIN

Definitions of sprains and strainsSprains:characterized by the stretching or tearing of non-contractile structures, such as the investing ligaments or of the joint capsule itself.

strain :characterized by stretching or severing along the course of muscles or tendons.

*Both collateral ligament and cruciate ligament sprains, as well as muscular strains, are

relatively common .

GRADES OF SPRAINS AND STRAINS

Grade I sprain Stretching but no tearing of the ligament, local tenderness, minimal edema, no gross instability with stress testing, firm end point

Grade II sprain Partial tears of the ligaments, moderate local tenderness, mild instability with stress testing (but firm end point), moderately incapacitating

Grade III sprain - Complete tear, discomfort with manipulation but less than expected for degree of injury, variable amount of edema (ranging from negligible to grossly conspicuous), clear instability with stress testing (expressing a mushy end point), severe disability

knee ligaments

Of the all ligaments there are 4 ligaments which are commonly injured , they can be classified as following : 1-intra-articular-anterior cruciate ligament ACL -posterior cruciate ligament PCL

2-extra-articular -medial (tibial ) collateral ligament MCL

-lateral (fibular) collateral ligament LCL

ANTERIOR CRUCIATE LIGAMENT

The anterior cruciate ligament (ACL) , it resists the anterior translation of the tibia relative to the femur. - it originates on the anterior intercondylar area of the tibia and passes upward backward and laterally to be inserts to posteromedial aspect of the lateral condyle of the femur - ACL includes two functional bundles: 1- anteromedial bundle, which tightens in flexion, 2-posterolateral bundle, which tightens in extension

-ACL prevents posterior displacement of the femur on the tibia -with the knee joint flexed the ACL prevents the tibia from being pulled anterior -tight in hyperextension of the knee.

MECHANISM OF INJURY

The posterior cruciate ligament (PCL) resists against posterior translation of tibia over femur .

It originates on the posterior intercondylar area of the tibia and passes upward forward and medially and insert to the anterolateral aspect of the medial

femoral condyle -The PCL also is made up of two functional bundles.

1- anterior meniscofemoral 2- posterior meniscofemoral ligament originate from the posterior horn of the lateral meniscus and contribute to the function of the PCL. - PCL prevent anterior displacement of femur on tibia -with the knee joint flexed the PCL prevent the tibia from being pulled posteriorly - tight in hyperflexion

CLINICAL PICTURE

Complete tear partial tear

a complete tear thepatient may have little or no pain,

a partialtear the knee is painful.

Swelling is less with complete tear

Swelling also is worse withpartial tears

Abnormal movement of a complete tear is often painless orprevented by spasm

attempted movement is always painful

DIAGNOSIS

A- CLINICALLY ,by physical examination

ACL examination

A- lockman test

*position of the patient :

supine *position of the examiner: - he or she stand on the side of affected limb -the proximal hand attaches to the patient femur and stabilizes it.- the distal hand attaches to proximal part of the tibia position it in 20 of flexion and push it forward .- not forget to examine the other limb for comparison .

*results:positive test indicated by noticing abnormal ant displacement of the

tibia forward .

B- PIVOT SHIFT TEST*position of the patient:

supine *position of examiner :.  The examiner should lift the tested leg off the table with the knee fully extended. Place the heel of one hand behind the fibular head of the patient. Use the other hand to grasp the tibia, while palpating the medial joint line. While maintaining a valgus force and internal rotation of the tibia throughout the test, slowly flex the patient's knee (note: the test starts by putting the tibia in the abnormal position!). 

*results:  if there is an anterior subluxation felt during extension the test is positive for instability

C-ANTERIOR DRAWER TEST

The patient lies supine on a plinth with their hips flexed to 45degrees, his/her knees flexed to 90degress and feet flat on the plinth. The examiner sits on the toes of the tested extremity to help stabilize it. The examiner grasps the proximal lower leg, just below the tibial plateau or tibiofemoral joint line, and attempts to translate the lower leg anteriorly. The test is considered positive if there is a lack of end feel or excessive anterior translation relative to the contralateral side.

2 -PCL examination

2-POSTERIOR DRAWER TEST

The patient lies supine on a plinth with their hips flexed to 45degrees, his/her knees flexed to 90degress and feet flat on the plinth. The examiner sits on the toes of the tested extremity to help stabilize it. The examiner grasps the proximal lower leg, just below the tibial plateau or tibiofemoral joint line, and attempts to translate the lower leg posteriorly . The test is considered positive if there is a excessive posterior translation relative to the contralateral side.

1-POSTERIOR SAG TEST *position of the patient :

supine *position of the examiner:- the examiner stand on the side of the patient and passively bring the hip and knee to 90 of flexion ,and compare the level of tibial tubersiteies of both knee.

*results:a positive test is indicated when posterior displacement of tibal tuberosity is more

in the affected limb .

2 -IMAGING *knee x ray

 Although x-rays do not show meniscal tears, they may show other causes of knee pain, such osteoarthritis and demonstrate bone avulsion if present .

*Magnetic resonance imaging (MRI) This study can create better images of the soft tissues of your knee joint, like a meniscus

Treatment

TREATMENT A- conservative RICE. The RICE protocol is effective for most sports-related injuries. RICE stands for Rest, Ice, Compression, and Elevation.

Aspiration of hemartharosis to relive pain .

Exercises and physiotherapy must start since the diagnosis is approved to prevent adhesion . using knee brace until pain is disappear.

B- SURGICAL TREATMENT

Unfortunately, the cruciate ligaments -- ACL and PCL -- cannot be repaired. Once they are completely torn or stretched beyond their limits, The only option a reconstruction. In this procedure, tendons are taken from other parts of your leg or a cadaver to replace the torn ligament.

Collateral ligaments

Medial collateral ligament is flat band and attached above to the medial epicondyle of the femur and below to the shift of the tibia it is firmly attached to the edge of the medial meniscus -(MCL) is the primary restraint to valgus stress.

*The MCL is the most commonly injured knee ligament.

LATERAL COLLATERAL LIGAMENT

is cordlike and is attached above to the lateral condyle of the femur and below to the head of fibula the tendon of the popliteus muscle intervenes between the ligament and the lateral meniscus - (LCL) is the primary restraint to varus stress

MECHANISM OF INJURY

Medial collateral ligament tears often occur as a result of a direct blow to the outside of the knee. This pushes the knee inwards (toward the other knee).

lateral collateral ligamenttears often occur as a result of a direct Blows to the inside of the knee that push the knee outwards.

MCL LCL

CLINICAL PICTURE:

1-Pain at the sides of knee. If there is an MCL injury, the pain is on the inside of the knee; an LCL injury may cause pain on the outside of the knee.

2-Swelling over the site of the injury3-Instability : the feeling that your knee is

giving way.

diagnosis

A-BY PHYSICAL EXAMINATION

Valgus vs varus stress tests*position of the patient:supine *position of the patient leg :hip is abducted and knee flexed with 20 degree

*position of the examiner:-the examiner stands on the side of the affected leg ,with one hand on the medial and lateral (respectively for LCL,MCL) line of the knee and the other hand on the lateral aspect of the ankle .1- a varus force pushing toward the Medline is applied to the ankle for testing LCL injury2- a valgus force pushing away from Medline is applied through the ankle for testing MCL injury

RESULTS OF THE TESTS

1 -in MCL injury pain and excessive gaping is positive indicator for the injury

2 -in LCL injurypain and excessive gaping is positive indicator for the injury

DIAGNOSIS

IMAGING 1-MCL ON MRI

2-LCL ON MRI

The menisci

WHAT IS KNEE MENISCI??

they are fibrocartilagenous structurespresent In the intercondylar fossa between.femur and tibia condyles .- functions: 1- disperse the Wight of the body 2-stabalization of knee joint 3- reduce friction between articular surfacesof tibia and femur condyle.

4-shock absorber

CAUSES OF MENISCI TEAR

What is a meniscus injury?Patients describe meniscal tears in a variety of ways. Knowing where and how a meniscus was torn helps the doctor determine the best treatment.Location :- A tear may be located in the anterior horn, body, or posterior horn. A posterior horn tear is the most common. The meniscus is broken down into the outer, middle, and inner thirds. The third in which the tear is located will determine the ability of the tear to heal, since blood supply in that area is critical to the healing process. Tears in the outer 1/3 have the best chance of healing.

Pattern - Meniscal tears come in many shapes. The pattern of the tear influences the doctor's decision on treatment. Examples of the various patterns are:

longitudinal

-bucket handle

displaced bucket handle

parrot beak

radial

displaced flap

CLINICAL PICTURE

1 -severe pain2-joint locking3-limited movement of knee joint 4-swelling 5-inablity to stand on affected limb6-popping or clicking within knee

DIAGNOSIS•A – clinically by :

1-physical examination ,including the following tests

a- muc Murray's testb- Thessaly's test c- apley’s test

HOW TO INSURE UR DIAGNOSIS BY

EXAMINATION??

1-muc Murray's test *Position of the patient

supine *position Of the examiner: -stand on the side of the patient , the proximal hand on knee joint and the distal one on the heel of the same limb - the knee should be fully flexed ,the examiner passively rotate the tibia and extend the knee for examining medial menisci , internal rotation and extension of the tibia for examining the lateral menisci

*resultsa positive test indicated by hearing a crepitus associated with pain.

2-THESSALY’S TEST

*position of the patient :stand on the affected leg *position of the examiner:stand in front of the patient and provide his or her hands for stability *principle:- knee is flexed 5 and femur is rotate medially and laterally for 3 times- the same step is repeated with knee flexed 20

*results :a positive test is indicated if there is locking of

movement .

3-APLEY’S TESTFor this test, the patient is positioned prone, with his or her knee flexed. Compression and external or internal rotation may be painful, showing that the medial or the lateral meniscus are torn. This test is always checked, by performing rotation without compression

B- IMAGING *knee x ray

 Although x-rays do not show meniscal tears, they may show other causes of knee pain, such osteoarthritis.

*Magnetic resonance imaging (MRI) This study can create better images of the soft tissues of your knee joint, like a meniscus.

TREATMENT Conservative Treatment

RICE. The RICE protocol is effective for most sports-related injuries. RICE stands for Rest, Ice, Compression, and Elevation.

If the joint is not locked, it is reasonable to hope that the tear is peripheral and can therefore heal spontaneously. After an acute episode, the joint is held straight in a plaster backslab for 3–4 weeks; the patient uses crutches and quadriceps exercises are encouraged.

by arthroscopy :

Meniscectomy In this procedure, the damaged meniscal tissue is trimmed away.

Meniscus repair. Some meniscal tears can be repaired by suturing (stitching) the torn pieces together

SURGICAL TREATMENT

RUPTURE OF QUADRICEPS TENDON

The four quadriceps muscles meet just above the kneecap (patella) to form the quadriceps tendon. Tendons attach muscles to bones. The quadriceps tendon attaches the quadriceps muscles to the patella. The patella is attached to the shinbone (tibia) by its tendon, the patellar tendon. Working together, the quadriceps muscles, quadriceps tendon and patellar tendon straighten the knee.

QUADRICEPS TENDON TEARSQuadriceps tendon tears more common in people more 40 year , can be either partial or complete.

Partial tears. Many tears do not completely disrupt the soft tissue. This is similar to a rope stretched so far that some of the fibers are torn, but the rope is still in one piece.Complete tears. A complete tear will split the soft tissue into two pieces.

When the quadriceps tendon completely tears, the muscle is no longer anchored to the kneecap. Without this attachment, the knee cannot straighten when the quadriceps muscles contract.

CauseInjuryA quadriceps tear often occurs when there is a heavy load on the leg with the foot planted and the knee partially bent. Think of an awkward landing from a jump while playing basketball. The force of the landing is too much for the tendon and it tears.Tears can also be caused by falls, direct force to the front of the knee, and lacerations (cuts).Tendon WeaknessA weakened quadriceps tendon is more likely to tear.

CLINICAL PICTURE 1-The typical injury is followed by tearing

pain and giving way of the knee. 3-There is bruising and local tenderness;

3-Active knee extension is either impossible (suggesting a complete rupture) or weak (partial rupture)

BY EXAMINATION SOMETIMES A GAP CAN BE FELT PROXIMAL TO THE PATELLA.

DIAGNOSIS

X-rays. The kneecap moves out of place when the quadriceps tendon tears. This is often very obvious on a "sideways" X-ray view of the knee. Complete tears can often be identified with these X-rays alone.

MRI diagnosis can be confirmed by MRI.

DIAGNOSIS

TREATMENT

Partial tears Non-operative treatment with plaster cylinder is applied for 6 weeks, followed by physiotherapy that concentrates on restoring knee.

Complete tears Early operation is needed, End-to-end suturing can be reinforced by turning down a partial-thickness triangular flap of quadriceps tendon proximal to the repair (Scuderi).

RUPTURE OF PATELLAR LIGAMENT

This is an uncommon injury; it is usually seen inyoung athletes and the tear is almost always at theproximal or distal attachment of the ligament.

CLINICAL PICTURE

* The patient gives a history of : 1-sudden pain on forced extension of the knee 2- bruising 3-swelling

4 -tenderness at the lower edge of the patella or more distally.

DIAGNOSIS X-rays may show a high-riding patella (patella alta ).

MRI .

TREATMENT Partial tears : can be treated by applying a plaster cylinder.

Complete tears : need operative repair or reattachment to bone, and keep the knee in extension position and use knee immobilizer for 4-6 weeks Immobilization in full extension may precipitate stiffness – after all, it is a joint injury – and it may be better to support the knee in a hinged brace with limits to the amount of flexion permitted. This range can be gradually increased after 6 weeks.