[15] Cruciate Ligament Tears Flashcards

1
Q

What is the importance of the ACL?

A

It is an important stabilising ligament of the knee joint, being the primary restraint to limit anterior translocation of the tibia (relative to the femur) and also contributing to knee rotational stability (internal)

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2
Q

What is the clinical result of the importance of the ACL?

A

A tear of the ACL can result in significant functional impairment of the joint

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3
Q

Who does an ACL tear typically occur in?

A

An athlete with a history of twisting the knee whilst weight-bearing

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4
Q

Do ACL ligaments occur with contact?

A

The majority occur without contact

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5
Q

What does an ACL tear most commonly result from?

A

Landing from a jump

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6
Q

Will an athlete be able to continue to play after an ACL tear?

A

No

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7
Q

How does an ACL tear typically present?

A

With a rapid joint swelling and significant pain

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8
Q

What may be evident if the presentation of an ACL tear is delayed?

A

Instability, in which the patient describes the leg as ‘giving way’

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9
Q

Why is there rapid joint swelling with an ACL tear?

A

Due to the ligament being highly vascular, hence the damage to the ligament results in haemarhrosis being clinically apparent within 15-30 minutes

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10
Q

What specific clinical tests can identify potential ACL damage?

A
  • Lachman Test
  • Anterior Draw Test
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11
Q

What is the more sensitive of the two tests for ACL?

A

Lachman’s test

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12
Q

What does Lachman’s test involve?

A

Placing the knee in 30 degrees of flexion and, with one hand stabilising the femur, pulling the tibia forward to assess the amount of anterior movement of the tibia compared to the femur. The other knee is then examined for comparison

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13
Q

What does the anterior draw test involve?

A

Flexing the knee to 90 degrees, placing the thumbs on the joint line and the index fingers on the hamstring tendons posteriorly. Force is then applied anteriorly to demonstrate any tibial excursion, which is then compared to the opposite site

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14
Q

What are the differential diagnoses of an ACL tear?

A
  • Fracture
  • Meniscal tear
  • Collateral ligament tear
  • Quadriceps or patellar ligament tear
  • Septic arthritic or crystal arthropathy
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15
Q

What investigations are done in suspected ACL tear?

A
  • X-ray of the knee (AP and lateral)
  • MRI scan of knee
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16
Q

What is the purpose of an x-ray of the knee in a suspected ACL tear?

A

To exclude bony injuries, any joint effusion, or a lipohaemarthrosis

17
Q

How sensitive is an MRI scan of the knee?

A

>90%

18
Q

What additional use may MRI scanning of the knee have in suspected ACL tear?

A

It may also pick up any associated menisceal tears (50% of ACL tears will also have a meniscal tear)

19
Q

Which meniscus is more commonly affected in ACL tears?

A

Lateral

20
Q

What is involved in the immediate management of a suspected ACL tear?

A

RICE (rest, ice, compression, elevation)

21
Q

What are the options for the specific treatment of an ACL rupture?

A

Either conservative or surgical

22
Q

What does the decision to manage ACL rupture conservatively or surgically depend on?

A
  • The suitablity of the patient for surgery
  • Their current levels of activity
23
Q

What does the conservative treatment of an ACL tear involve?

A

Rehabilitation, which utilises strength training of the quadriceps to stabilise the knee

24
Q

Is inpatient admission required for a torn ACL?

A

Rarely

25
Q

Why is inpatient admission rarely required in the emergency setting for torn ACL?

A

The patient can often fully weight bear, and a canvas knee splint can be applied for comfort

26
Q

What does a surgical repear of the ACL involve?

A

The use of a tendon or artificial graft

27
Q

What will the surgical repair of the ACL always be preceded by?

A

Prehabilitation

28
Q

What happens in prehabilitation before surgical repair of ACL tear?

A

The patient will engage with a physiotherapist for a period of months prior to the surgery

29
Q

What are the complications of ACL tear?

A

Post-traumatic osteoarthritis - well-establsihed complication of both ACL injury and ACL reconstructive surgery

30
Q

What is more common, anterior or posterior cruciate ligament tear?

A

Posterior cruciate ligament

31
Q

What does the PCL do?

A

It is the primary restraint to posteiror tibial translation, and works to prevent hyperflexion of the knee

32
Q

When do PCL tears typically occur?

A

In high energy-trauma, such as a direct blow to the proximal tibia during a RTA

33
Q

When do PCL tears less commonly occur?

A

In low-energy trauma when there is hyperflexion of the knee with a plantar-flexed foot

34
Q

What will a torn PCL present with?

A

Immediate posterior knee pain

35
Q

What will be found on examination with a torn PCL?

A
  • Instability of the joint
  • Positive posterior draw test (with posterior sag)
36
Q

What is the gold standard for the diagnosis of torn PCL?

A

MRI scanning

37
Q

How are PCL tears managed in the first instance?

A

Often conservatively, with a knee brace and physiotherapy

38
Q

When might a patient require surgical management of a PCL tear?

A

If they continue to be symptomatic after conservative treatment and has recurrent instability of the knee joint

39
Q

What is involved in PCL tear repair surgery?

A

The insertion of a graft