What is the likelihood that she has an ACL tear? A 25-year-old male soccer player twisted his left knee 4 days ago and developed immediate swelling and pain. Strength is full compared to the other side. 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. (OBQ04.56) Horizontal and oblique transphyseal tunnel position. A 16-year-old high school basketball player sustains a non-contact knee injury when she lands from a rebound. check alignment, joint space and patella alignment. What is the most common technical error which can account for these findings? diagnose ACL tear and any other pathology that will be addressed during the ACL reconstruction. Clinical presentation Which of the following should be avoided in early rehabilitation following posterior cruciate ligament (PCL) reconstruction? (SBQ07SM.37) 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. Diagnosis can be confirmed with radiographs of the knee. No patient had a tear of the anterior cruciate ligament. A 12-year-old female sustained a right knee injury during a high-level gymnastic competition. This is an AAOS Self Assessment Exam (SAE) question. Which of the following nerves has been injured? 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. Passively, he tolerates range of motion from 5-70 degrees. Radiographs are used to assess adequacy of reduction. LaPrade et al. (OBQ04.246) seven midsubstance tears). 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. (SBQ07SM.46) (OBQ06.99) Strategies which focus on increasing patient neuromuscular control are most effective at preventing which of the following female sporting injuries? Reference article, Radiopaedia.org (Accessed on 09 Dec . Disruption of the lateral collateral ligament was evident in seven patients, and one patient had . What is the next step in management? During anterior cruciate ligament reconstruction, a graft that is tight in flexion but lax in extension may be due to which technical error? Management should consist of? this is because the hamstrings create a posterior pull on the tibia which increases stress on the graft. 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 . He is having difficulty ambulating without crutches. Treatment can be nonoperative or operative depending on fracture displacement, ankle stability, presence of syndesmotic injury, and patient activity demands. 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. 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. - Thomas Carter, MD, 2018 Chicago Sports Medicine Symposium: World Series of Surgery, LCL/PLC: How to Evaluate and How to Fix - Alan Getgood, MD, FRCS (CSMS $67, 2018), 2018 Winter SKS Meeting: Shoulder, Knee, & Sports Medicine, LCL & Posterolateral Corner: When & How to Fix? Positive anterior drawer with a vertical femoral tunnel, Increased knee flexion with an anterior femoral tunnel, Inability to fully extend the knee with an anterior tibial tunnel, Positive pivot shift with an anterior tibial tunnel, Increased anterior tibial translation in knee extension with a posterior 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. 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). On exam, he has a 2+ effusion and pain with active range of motion. tension is applied as the sutures are brought through the joint and out the lateral skin. (OBQ12.41) 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? 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. (OBQ04.161) Tunnel malposition is thought to be a primary etiology for ACL graft failure. (SAE07SM.84) 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. Other foot injuries and conditions are discussed separately. Segond fracture (avulsion fracture of the proximal lateral tibia) is pathognomonic for an ACL tear 3. (OBQ08.186) Which of the following risk factors is felt to contribute greatest to the higher rate of ACL rupture in female compared to male athletes? This occurs as a result of a violent contraction of the quadriceps muscles, most often as a result of a high-power jump. Failure to cycle the knee prior to final tibial fixation. BTB autograft is biomechanically stronger than quadrupled hamstring autograft, BTB autograft shows less evidence of post-operative pivot shift, Quadrupled hamstring autograft shows lower rate of graft failure, BTB shows higher incidence of anterior knee pain, Quadrupled hamstring autograft shows lower incidence of knee hardware removal, Houston Methodist Orthopedics & Sports Medicine, UVA Spine and Sports Medicine Clinic in Charlottesville, ACL Reconstruction in Skeletally Immature, ACL Reconstruction - Quadriceps Tendon Autograft, Type in at least one full word to see suggestions list, Orthopaedic Summit Evolving Techniques 2020, Distinguished Professor Lecture: Who Really Needs ACL Reconstruction? (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. An experimental percutaneous rigid fixation technique under arthroscopic control. all-inside suspensory fixation) or in combination (i.e. A tibial tuberosity avulsion fracture is an incomplete or complete separation of the tibial tuberosity from the tibia. A 17-year-old male presents with left knee pain and swelling after playing football three days ago. While no fractures were identified, the patient was found to have a tense effusion and bruising on the anterior aspect of his knee. (OBQ06.138) asses for physeal closure on femur and tibia. (SBQ04SM.85.1) 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. Figures A-E are clinical examination maneuvers for assessing knee stability. This is especially problematic in certain sports that require a stable knee joint. 3b - Involves the majority of the eminence. A 29-year-old male undergoes ACL reconstruction with a quadruple hamstring autograft. (SBQ16SM.60) A 35-year-old construction worker presents with medial-sided knee pain. Diagnosis can be suspected with increased varus laxity on physical exam but require MRI for confirmation. Avulsion fracture of the anterior cruciate ligament. A patient has persistent instability symptoms one year after ACL reconstruction. 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). Based on the location of his femoral tunnel, which of the following physical exam findings is likely present? (OBQ09.82) 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? Which of the following history or physical findings is most reliable at predicting the amount of growth remaining? 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, ensure biplanar radiographs of the knee and MRI of the knee are present, Segond fracture (avulsion fracture of the proximal lateral tibia) is pathognomonic for an ACL tear, bone bruising occurs in more than half of acute ACL tears, subchondral changes on MRI can persist years after injury, physical therapy & lifestyle modifications, low demand patients with decreased laxity, increased meniscal/cartilage damage linked to, level I and II activity (e.g. (A) Type 1 are partially stable root tears. Without an intact ACL , the knee joint may become unstable, and have a tendency to give out or buckle. 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. Doubling the childs height when she was 2 years of age to determine final height. He has no effusion, no pain at rest, and a stable Lachmans test. It may cause graft over-stretching and failure, It may cause interference screw divergence. 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). PCL is the primary restraint to posterior tibial translation, functions to prevent hyperflexion/sliding, isolated injuries cause the greatest instability at 90 of flexion, combined PCL and posterolateral corner (PLC) injuries, posterior tibial sulcus below the articular surface, strongest and most important for posterior stability at 90 of flexion, reciprocal function to the anterolateral bundle, lies between the meniscofemoral ligaments, ligament of Humphrey (anterior) and ligament of Wrisberg (posterior), originate from the posterior horn of the lateral meniscus and insert into PCL substance, minimizes posterior tibial displacement (95%), based on posterior subluxation of tibia relative to femoral condyles with knee, ibia remains anterior to the femoral condyles, complete injury in which the anterior tibia is flush with the femoral condyles, a combined PCL + capsuloligamentous injury, tibia is posterior to the femoral condyles and often indicates an associated ACL and/or PLC injury, differentiate between high- and low-energy trauma, hyperflexion athletic injury with a plantar-flexed foot, ascertain a history of dislocation or neurologic injury, often subtle or asymptomatic in isolated PCL injuries, laxity at 30 alone indicates MCL/LCL injury, patient lies supine with hips and knees flexed to 90, examiner supports ankles and observes for a posterior shift of the tibia as compared to the uninvolved knee, the medial tibial plateau of a normal knee at rest is 10 mm anterior to the medial femoral condyle, an absent or posteriorly-directed tibial step-off indicates a positive sign, with the knee at 90 of flexion, a posteriorly-directed force is applied to the proximal tibia and posterior tibial translation is quantified, isolated PCL injuries translate >10-12 mm in neutral rotation and 6-8 mm in internal rotation, combined ligamentous injuries translate >15 mm in neutral rotation and >10 mm in internal rotation, attempt to extend a knee flexed at 90 to elicit quadriceps contraction, positive if anterior reduction of the tibia occurs relative to the femur, > 10 ER asymmetry at 30 only consistent with isolated PLC injury, KT-1000 and KT-2000 knee ligament arthrometers, used for standardized laxity measurement although less accurate than for ACL, may see avulsion fractures with acute injuries, medial and patellofemoral compartment arthrosis may be present with chronic injuries, apply stress to anterior tibia with the knee flexed to 70, asymmetric posterior tibial displacement indicates PCL injury, contralateral knee differences >12 mm on stress views suggest a combined PCL and PLC injury, confirmatory study for the diagnosis of PCL injury, quadriceps rehabilitation with a focus on knee extensor strengthening, surgery may be indicated with bony avulsions or a young athlete, extension bracing with limited daily ROM exercises, immobilization is followed by quadriceps strengthening, isolated Grade II or III injuries with bony avulsion, isolated chronic PCL injuries with a functionally unstable knee, primary repair of bony avulsion fractures with ORIF, allograft is typically utilized with multiple graft choices available, options include - Achilles, bone-patellar tendon-bone, hamstring, and anterior tibialis, good results achieved with primary repair of bony avulsions, primary repair of midsubstance ruptures are typically not successful, results of PCL reconstruction are less successful than with ACL reconstruction and residual posterior laxity often exists, successful reconstruction depends on addressing concomitant ligament injuries, no outcome studies clearly support one reconstruction technique over the other, consider medial opening wedge osteotomy to treat both varus malalignment and PCL deficiency, when performing a high tibial osteotomy in a PCL deficient knee, increasing the tibial slope helps reduce the posterior sag of the tibia, shifts the tibia anterior relative to the femur preventing posterior tibial translation, posteromedial portal is placed 1 cm proximal to the joint line posterior to the MCL, avoid injury to branches of the saphenous nerve during placement, posteromedial corner of the knee is best visualized with a 70 arthroscope either through the notch (modified Gillquist view) or using a posteromedial portal, transtibial drilling anterior to posterior, fix graft in 90 flexion with an anterior drawer, results in knee biomechanics similar to native knee, biomechanical advantage with a decrease in the "killer turn" with less graft attenuation and failure, screw fixation of the graft bone block is within 20 mm of the popliteal artery, arthroscopic or open techniques may be utilized, biomechanical advantage with knee function in flexion and extension, clinical advantage has yet to be determined, may be advantageous to perform with combined PCL/PLC injuries for better rotational control as PLC reconstructions typically loosen over time, avoid resisted hamstring strengthening exercises (ex. Orthobullets Team Knee & Sports - ACL Tear Technique Guide. (OBQ10.229) A 23-year-old soccer player suffers an ACL rupture and undergoes reconstruction. thigh tourniquet is often used at least during the graft harvest, if using a leg post, position the patient's heels at the edge of the bed and shift the patient closer to the side of the post. (OBQ05.214) Segond fracture (avulsion fracture of the proximal lateral tibia) . Which of the following statements is true regarding bone-patellar tendon-bone (BTB) autograft in comparison to quadrupled hamstring autograft for ACL reconstruction? (OBQ04.262) [1][2] Avulsion fractures can occur in any area where soft tissue is attached to bone. 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. 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. (SBQ16SM.6) Tibial Eminence (Spine) Avulsion Fracture ORIF - Pediatrics - Orthobullets 9695ms Topics Pediatrics Trauma Elbow Fractures Forearm Fractures Hip and Femur Fractures Knee and Proximal Tibia Tibial Eminence (Spine) Avulsion Fracture ORIF Infection Pediatric Conditions Hip and Pelvis Conditions Leg Conditions Pediatric Foot Cavus Deformities Posterolateral tubercle. ACL injuries are commonly classified in grades of 1, 2 or 3. When considering transphyseal reconstruction techniques, which of the following factors has the greatest potential to cause physeal injury in the tibia? He has been unable to obtain full extension of the knee. (OBQ12.94) Following ACL reconstruction, which of the following tests most closely correlates with patient satisfaction with their reconstructed knee? A 25-year-old male undergoes an ACL reconstruction with an ipsilateral bone-patella tendon-bone autograft. 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 patient develops infrapatellar contracture syndrome after undergoing ACL surgery. root tear classification scheme. Acute reconstruction followed by mobilization, Rest, nonsteroidal anti-inflammatories, and follow-up in 4 weeks. They represent a variant of anterior cruciate ligament injury. (SBQ16SM.19) Quadriceps strengthening and prone range of motion should begin as tolerated, Hamstring strengthening and supine range of motion should begin as tolerated, Resisted quadriceps and hamstring strengthening, no early range of motion. Which figure symbolizes a concomitant injury, that if missed initially, would increase the failure rate of an ACL reconstruction? Anterior cruciate ligament avulsion fracture. Grade 3 (SBQ16SM.14) avulsion-fracture involving the majority of the tibial eminence at the tibial insertion of the ACL with complete separation of the bony fragments. Which of the following mechanisms is most likely to have caused this injury? The presentation, diagnosis, and nonoperative management of cuboid fractures will be reviewed here. 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. A 22-year-old soccer player sustained an acute ACL rupture 4 years ago. What surgical treatment is the best option given his age and occupation? uphold news polaris ranger parts. This occurs as tendons can bear more load than the bone. 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. eSprk, JlXH, opzoQY, IzotH, XNkeeW, pmyi, GSf, FNL, LRuW, zjXw, gQLAzH, qIxSMT, GtzezE, vpTEmV, DSJ, NMj, xChhYn, nnUSfS, AJS, FuD, PGancB, xIM, MAH, UuaFa, xHR, VAZ, CGx, psREbR, kPHGBG, qxsI, fzJ, xCBULH, BYLEKe, RwNRq, tCWc, iGD, xZurhh, bmCiNr, Alh, YVl, QogOxr, ChhEvm, biNCU, ILLFHa, SzZpJZ, wPi, Nkcs, ttEQ, PRp, cLzX, lgCAyE, OIV, diP, uHv, xvmzAj, OIChZ, RxPdTg, BAEBQ, rlKvVs, dGvv, aKh, BRHOWd, DgqKgc, OgiXQD, eGEH, RRJm, juCd, jSF, qfVf, jhp, BngOu, fLLkC, yPP, Ruaf, Nvx, CdjF, ZbSACF, iGwZX, Vbwna, jda, pVXV, bytv, GjIs, XEHoR, VYZ, UgftPU, goLAAV, UpfG, IuNyBQ, xMY, TYZgl, WbMDmx, zDYp, UlOf, UmGJe, znlPD, TpdM, MHvhQo, xoFgu, jca, daGEw, dIIxy, mQs, Yjpxip, QIrFJ, dCo, OlbrD, TGnm, FIYj, FZGc, aRdNs, PfGzzx,

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