ligament injury of the Lower extremities

ligament injury of lower extremity

1. Ruptur tendon and ligaments in lower extremity

2. Ligament of the knee Diarthrodial joint Simultaneous rotation and translation

3. Ligament Primary Function Secondary Function Anterior Cruciate Ligament ( ACL) Resist anterolateral displacement of the tibia on the femur Resist varus displacement at 0 degrees of flexion Posterior Cruciate Ligament (PCL) Resist posterior tibial displacement, especially at 90 degress of flexion Resist varus displacement at 0 degrees of flexion Lateral Collateral Ligament (LCL) resists  varus  displacement at 30 degrees of flexion resists  posterolateral   rotatory displacement with flexion that is less than approximately 50 degrees Popliteofibular Ligament/Posterior Lateral Corner (PLC) resist  posterolateral  rotation of the tibia on the femur resists  varus   angulation and posterior displacement of the tibia on the femu Medial Collateral Ligament (MCL) resists  valgus   angulation works in concert with ACL to provide restraint to axial rotation

4. ACL Function : -prevents anterior translation of the tibia relative to the femur Anatomy : -33mm x 11mm in size -Goes from the LFC to the tibia  : tibial insertion : broad and irregular inserts just anterior and between the intercondylar eminences of the tibia -Two bundles- Anteromedial(AM ) and posterolateral(PL ) : PL bundle prevents pivot shifting of the knee

5. Blood Supply Middle geniculate artery Composition 90% Type I collagen 10 % Type III collagen

6. ACL Injury Presentation : Felt a “pop” Pain deep in knee Immediate swelling (70%) / hemarthrosis Physical exam : effusion quadriceps avoidance gait (does not actively extend knee) Lachman’s (most sensitive) Anterior drawer test Pivot shift test

7. Lachman Test

8. Anterior Drawer test

9. Pivot shift test

10. Radiographs -usually normal - Segond fracture ( avulsion of the proximal lateral tibia) pathognomonic for an ACL tear MRI -ACL tear best seen on sagital view -Bone bruising occurs in more than half of acute ACL tears - Subchondral changes on MRI can persist years after injury

11. Treatment Nonoperative Operative ACL reconstruction , indication : in younger, more active patients (reduces incidence of mensical or chondral injury ) older active patients (Age >40 is not contraindication if high demand athlete ) ACL reconstuction failure

12. PCL Function prevents posterior translation of the tibia relative to the femur PCL and PLC work in concert to resist posterior translation and posterolateral rotatory instability

13. Anatomy 38mm x 13mm in size MFC to tibial sulcus Two bundles Blood supply : middle geniculate artery

14. PCL injury Mechanism direct blow to proximal tibia with flexed knee (dashboard injury ) noncontact   hyperflexion with plantar-flexed foot Presentation history of a dashboard injury history of a hyperflexion athletic injury

15. Physical exam posterior drawer test quadriceps active test reverse pivot shift

16. Posterior drawer test

17. Quadriceps active test

18. Reverse pivot shift test

19. Treatment Nonoperative Protected weight bearing Extension brace for 2-4 weeks

20. Operative PCL repair or reconstruction, indication : combined ligament injury( PCL injury with ACL or PLC injury ) Isolated grade II or III with bony avulsion

21. MCL Origin :medial femoral epicondyle Insertion: long strip on tibia

22. MCL Medial Structures of Knee Layer 1 : sartorius and fascia ( patellar retinaculum ) gracilis,semitendinosis,and saphenous nerve run between layer 1 and 2 Layer 2 : semimembranosus , superficial MCL,posterior oblique ligament Layer 3 : deep MCL, capsule

23. Function to provide restraint to valgus angulation , works in concert with ACL to provide restraint to axial rotation. Two components Superficial portion ( tibial collateral ligament) lies just deep to gracilis and semitendinosus originates from medial femoral epicondule 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.

24. Deep portion (medial capsular ligament) -attaches to medial meniscus (coronary ligament ) -the deep MCL and posteromedial capsule act as secondary restraints at full knee extension.

25. MCL injury Mechanism is  valgus stress or external rotation to knee Rupture usually occurs at femoral insertion of ligament

26. Presentation Physical exam valgus opening 30 ° degrees only - isolated MCL ° and 30° degrees - combined MCL and ACL or PCL Classification Grade I: 0-5 mm opening Grade II: 6-10 mm opening Grade III: 11-15 mm opening

27. Imaging Xrays stress radiographs can be diagnostic Pellegrini -Stieda lesion: chronic MCL deficiency leads to calcification next to medial femoral epicondyle  

28. MRI little value over PE will show lateral bone bruises ( trabecular microfractures ) used to evaluate for other injuries (medial meniscal tear)

29. Treatment Nonoperative treat in hinged knee brace for 6-8 weeks only knee ligament injury the body can heal independently proximal ruptures have better healing potential than distal ruptures  

30. Operative indicated only in Grade III injuries as part of multiple ligament knee injuries (with ACL and/or PCL/PLC ) MCL repair MCL reconstruction

31. LCL Also known as "Fibular Collateral Ligament" . Functions to provide support to varus angulation works in concert with MCL to provide restraint to axial rotation Anatomy : originates on lateral femoral condyle  posterior and superior to insertion of  popliteus   runs superficial to popliteus inserts on the fibula anterior to the  popliteofibular ligament on the fibula

32. Lateral Structures of Knee Layer I : Iliotibial tract, biceps femoris  common peroneal nerve lies between layer I and II Layer 2 : patellar retinaculum , patellofemoral ligament Layer 3 : superficial : LCL, fabellofibular ligament lateral geniculate artery runs between deep and superficial layer deep :  arcuate ligament, coronary ligament,  popliteus tendon,  popliteofibular ligament, capsule

33. LCL injury Isolated injury extremely rare common when associated with other ligament injuriesparticularly a PLC injury Mechanism is  varus stress

34. Physical exam varus opening 30 ° degees only - islocated LCL ° and 30° degrees - combined LCL and ACL/PC

35. Treatment Isolated : bracing  Combined ligament injury : repair and reconstruction

36. PLC (Posterior Lateral Corner) PLC structures Universal LCL popliteus muscle and tendon popliteofibular ligament lateral capsule Variable - arcuate ligament - iliotibial track - fabellofibular ligament 

37. PLC injury Approximately 7-16% knee ligament injuries are to the lateral ligamentous complex isolated injuries to PLC are rare : usually combined with cruciate ligament injury (PCL > ACL ) missed PLC injury diagnosis is common cause of ACL reconstruction failure

38. Mechanisms blow to anteromedial knee varus blow to flexed knee contact and noncontact hyperextension injuries knee dislocation

39. Classification Grade I (0-5mm of lateral opening and minimal ligament disruption ) Grade II (5-10mm of lateral opening and moderate ligament disruption ) Grade III (>10mm of lateral opening and severe ligament disruption)

40. P resentation Symptoms : Often have instability symptoms when knee is in full extension, difficulty with reciprocating stairs,pivoting and cutting

41. Physical exam Gait exam Varus stress Dial test External rotation recurvatum Posterolateral drawer test Reverse pivot shift test

42. External rotation recurvatum test

43. Dial test Externally rotate the leg while watching for external rotation of the tibia tubercle in relation to femur.. Do it in 30 and 90 degrees of knee flexion. In isolated posterolateral knee injury, there should be a slight decrease in ext rotation on 90 degrees compared to 30 degrees However if there is a concurrent PCL tear, there will be an increase of external rotation at 90 degrees compares to 30 degrees.

44. Treatment Nonoperative Immobilize knee in full extension for 2 weeks Operative PLC repair PLC reconstruction

45. Ligaments of Ankle Primary ligaments of ankle include (see below for details ) Medial :Deltoid ligament,Calcaneonavicular ligament (Spring Ligament ) Lateral : Syndesmosis (includes AITFL, PITFL, TTFL, IOL, ITL ), Anterior talofibular ligament ( ATFL), Posterior talofibular ligament ( PTFL ), Calcaneal fibular ligament (CFL ), Lateral talocalcaneal ligament (LTCL)  

46. Ankle Sprains Ankle sprains are the most common reason for missed athletic participation High ankle sprain : involves the syndesmosis , mechanism is external rotation Low ankle sprain : involving ATFL and CFL, mechanism is plantarflexion and inversion