Exam 2: Lecture 10: Collateral and Multiple Ligament Injury/Meniscal injury Flashcards
1
Q
Multiple Ligament Injury can also be defined as?
A
Deranged Stifle
2
Q
Define collateral ligament Injury
A
Complete or partial tear of medial or lateral collateral ligament
3
Q
Is ligament injury a sprain or strain
A
sprain
4
Q
Is Muscle tendon unit a sprain or strain
A
strain
5
Q
Do sprains or strains have grading
A
sprains = Ligament Injury
- 1st, 2nd and 3rd degrees
6
Q
Do sprains or strains have no grading and most resolve with conservative management with rest
A
strain = Muscle tendon unit
7
Q
What defines a 1st degree sprain
A
mild
8
Q
What defines a 2nd degree sprain
A
moderate
9
Q
What defines a 3rd degree sprain
A
complete tear
10
Q
What is the function of medial and lateral collateral ligaments?
A
limit varus +valgus motion of stifle joint
11
Q
Are isolated medial or lateral collateral ligament tears common or rare in small animals
A
rare
12
Q
What does #1 describe
A
Caudal head of sartorius muscle reflected
13
Q
What does #2 describe
A
Medial collateral ligament
14
Q
Injuries to medial or lateral collateral ligaments occur with injury to other primary + secondary restraints of which joint
A
stifle joint
15
Q
Multiple ligament injuries result from what type of trauma to the stifle joint and involve injury to other stifle joint ligaments
A
Severe trauma
16
Q
What does #1 in this image show?
A
lateral collateral ligament
17
Q
What is the signalment for animals with injuries to the medial or lateral collateral ligaments
A
- dog or cat
- any age or breed
- either gender
18
Q
What history may an animal present with when they come in for medial and lateral collateral ligament problems?
A
May occur while exercising
- without evidence of trauma
Traumatic incident (vehicular accident)
- where animal has sustained major injuries
19
Q
How do you diagnose collateral ligament injury
A
based on palpation
20
Q
Do you flex or extend the stifle joint to examine for collateral image and why?
A
extend
- to tighten the muscle belly
- THE BEST WAY TO TEST
21
Q
What is labeled as #1
A
lateral collateral ligament
22
Q
What is labeled as #2
A
Cranial cruciate ligament
23
Q
What is labeled as #3
A
lateral meniscus
24
Q
What is labeled as #4
A
caudal cruciate ligament
25
What is labeled as #5
medial meniscus
26
What is labeled as #6
Medial collateral ligament
27
Which type of stress test evaluates the medial collateral ligament
valgus stress test
28
Which type of stress test evaluates the lateral collateral ligament
Varus stress test
29
When you apply medial and lateral pressure to the tibia you are assessing integrity of?
collateral ligaments
30
What does this image show?
testing of the collateral ligaments
31
How should the patient be positioned for a valgus stress test
lateral recumbency
- One hand stabilizes femur
- other hand grasps distal tibia + applies upward force
- ABDUCTION
32
Which stress test check for abduction of the joint
valgus stress test
33
If the medial joint restraints are torn you can see the opening of medial joint line, which includes?
- medial collateral ligament (MCL)
- joint capsule
- peripheral meniscal ligaments
34
How should the patient be positioned for a Varus stress test
Patient in lateral recumbency
- one hand stabilizes femur
- other hand grasps distal tibia + applies inwards force
- ADDUCTION
35
Which stress test checks for adduction of the joint
varus stress test
36
If the lateral joint restraints are torn you will see the opening of the lateral joint, which includes?
- Lateral collateral ligament (LCL)
- Joint capsule
- Peripheral meniscal ligaments
37
Do isolated tears show minimal or maximal openings
minimal
- obvious opening occurs with more extensive injuries
38
What kind of problem does the image show?
MCL tear
39
What kind of test does the image show?
Valgus stress test
40
Which tool determines if bone fragements are associated with ligament damage
radiographs
41
When are craniocaudal + medial-lateral radiographs indicated?
Confirm the presence or absence of bony avulsions
42
What are stress radiographs for?
Show increase in medial or lateral joint space
43
What does this image show?
Stress radiograph of a cat with MCL injury
44
What type of test is used in the image below?
Valgus stress applied to joint
45
What laboratory findings are common in animals with MCL and LCL tears/rupture?
- consistent laboratory findings not seen
- Laboratory evaluation depends on signalment + physical findings in animals with trauma
46
What are the differential diagnosis for animals with MCL and LCL problems?
- Muscle strains
- Cranial or caudal cruciate ligament tears
- Nondisplaced physeal fractures in immature animals
47
Medical management of animals with MCL and LCL include?
- conservative or surgical treatment for isolated collateral ligament injury based on degree of injury
- Assessment based on palpation + radiographs
48
Conservative or surgical treatment for isolated collateral ligament injuries are based on the degree of injury. What is being assessed?
- collateral ligament itself
- Secondary joint restraints
= joint capsule
= peripheral meniscal ligaments
49
What is the criteria for medical management of animals with MCL and LCL
- minimal swelling + only slight opening of joint space with stress test
50
Minimal swelling + only slight opening of joint space with stress test are indications for what type of treatment and what degree of sprain
- Indications for conservative treatment
- 1st degree sprain
51
How would you treat a 1st degree sprain in an animal with minimal swelling and only slight opening of joint space with stress test?
- fibroglass cast applied for 2 weeks
- followed by controlled activity for 6 additional weeks
52
Moderate to severe swelling and significant opening of joint space with stress test indicates what issues and what degree of sprain?
- indicates greater injury to collateral restraints
- 2nd and 3rd degree sprains
53
Treatment of moderate to severe swelling and significant opening of joint space with stress test includes?
RECONSTRUCTION
- collateral ligaments
- meniscocapsular ligaments
- Joint capsule
54
What is the goal of surgical treatment in animals with MCL and LCL tear/rupture
**repair all injured ligaments, tendons, and joint capsule**
55
What ligament is responsible for holding the lateral meniscus to the femur
Meniscofemoral Ligament
56
What is labeled #1
cranial tibial ligment of the lateral meniscus
57
What is labeled #2
lateral collateral ligament
58
What is labeled #3
Meniscofemoral ligament
59
What is labeled #4
caudal ligament of the lateral meniscus
60
What is labeled #5
caudal cruciate ligament
61
What is labeled #6
caudal ligament of the medial meniscus
62
What is labeled #7
cranial cruciate ligament
63
What is labeled #8
medial collateral ligament
64
What is labeled #9
transverse ligament
65
What is labeled #10
cranial tibial ligament of the medial meniscus
66
What is labeled #11
Patellar Ligament
67
When is primary repair of collateral ligament done?
- Point of failure is origin or insertion of ligament
- An intrasubstance tear with large segments of ligament intact
68
Occasionally small fragment of bone is present on the ligament - can they be incorporated into the repair?
yes
69
What can be done preoperatively to prevent additional damage to articular cartilage or meniscus?
- place modified robert jones bandage on limb
- Limit activity to leash walking
**UNTIL SURGERY**
**animal evaluated for evidence of trauma to other ligaments or bones**
70
What areas of the animal should be evaluated in patients with injuries by HBC?
- thoracic
- cardiovascular
- abdominal evaluation
71
Perioperative antibiotics and pre-emptive pain managment include?
- NSAIDs
- Opioids
- epidural Analgesia
72
Perioperative antibiotics and preemptive pain management are indicated for which animals?
those undergoing stifle reconstruction
73
What is important for surgical anatomy of collateral ligaments?
origin and insertion
74
Where does the MCL originate?
medial femoral epicondyle
75
The MCL run distally to insert where?
proximal tibial metaphysis
76
As MCL crosses medial joint line, what strong attachment are important?
**Strong attachement to joint capsule and medial meniscus**
77
The MCL lies deep to which muscle
Sartorius
78
Where does the LCL originate?
oval area on lateral femoral epicondyle
79
Where does LCL insert?
fibular head
80
the LCL lies deep to which msucle
fascia lata
81
Be careful when dissecting near the lateral collateral ligament because of which nerve?
Peroneal (fibular) nerve
82
the Peroneal (Fibular) nerve is a branch of which nerve?
sciatic nerve
- obliquely crosses distal aspect of stifle joint
- superficial to gastrocnemius muscle
- send articular branch to LCL
83
How is the pt positioned for surgery with a LCL injury
lateral recumbency with affected leg up
84
How is the pt positioned for surgery with a MCL injury
dorsal recumbency
85
How do you position a pt with multiple ligament tears for surgery
- dorsal recumbency to facilitate exposure of both sides of limb
- Suspend limb and prepare for aseptic surgery
86
What does this image show (#1)
rupture of medial collateral ligament and joint capsule
87
How do you repair medial restraint injury
- incise insertion caudal head of sartorius muscle + deep fascia along craniomedial border of proximal tibia
88
If the bone is attached do we have a better or worse prognosis
repair is amazing and almost 100%
89
What does this image show?
Replace collateral ligament to its anatomic site + secure with screws and spiked washer
- used as an alternative to suture anchors
90
What does the image show?
If ligament injury is intrasubstance tear
- primary repair by suturing ligament ends with locking-loop suture pattern
- Supplement primary repair with screws and figure eight support
91
What is the most common ligament and tendon suture?
three-loop pulley
92
What suture type os used for flat tendons?
Locking-loop
93
What is shown by #1
Locking loop
94
What is shown by #2
three-loop pulley
95
What is shown by #3
Bunnell Suture
96
What is shown by #4
Far-near
near-far
97
Which approach is used to expose lateral collateral ligament
craniolateral
98
In the craniolateral approach for a LCL injury make a proximal to distal _______ incision throigh the fascia Lata.
- continue incision distally ____ cm below tibial crest parallel to joint line
(use caution isolate and protect peroneal nerve)
- reflect fascia lata caudally
(expose collateral ligament + lateral joint capsule
- repair ligament
Paratellar incision
4 cm
99
What is the prognosis for isolated collateral ligament tears?
good to excellent
100
What is the prognosis if multiple ligaments are torn?
fair
101
What is the prognosis for a LCL or MCL tear if bone is attached?
excellent
- almost 100%
102
What is said to be the cause of injuries where the cranial or caudal cruciate ligaments and collateral ligaments are damaged simultaneously?
caused by HBC or other major trauma
103
During surgical anatomy how does the tissue look surrounding the joint
swelling + bruising of soft tissue
104
Torn collateral ligaments are difficult to identify during surgical anatomy, why?
because they are encased in edematous connective tissue
105
During surgical anatomy of a cruciate ligament repair, which structure is often displaced from normal positions and folded cranially or caudally?
Menisci
- not a good situation
106
Knowledge of normal origins + insertions of ligaments in joints required which two concepts?
- collateral ligaments
- Meniscocapsular ligaments
107
What is shown by #1
medial meniscus
108
What is shown by #2
patellar ligament
109
What is shown by #3
caudal cruciate ligament
110
What is shown by #4
cranial cruciate ligament
111
What is shown by #5
Intermeniscal ligament
112
What is shown by #6
Lateral meniscus
113
What does the image show?
Loss of cranial and caudal cruciate ligaments and disruptions of the medial restraints
114
What is shown by #1
displaced meniscus
115
What is shown by #2
torn medial collateral ligament
116
What is shown by #3
torn caudal cruciate ligament
117
What is shown by #4
torn cranial cruciate ligament
118
What is shown by #5
Lateral collateral ligament
119
Common triad of injuries include?
- cranial and caudal cruciate ligament tears
- failure of primary and secondary medial restraints
- peripheral medial meniscal tears
120
What is the prognosis in animals with multiple ligament injuries / common triad of injuries
fair
121
What does the following image show?
Deranged Stifle
122
What does the term "Deranged Stifle" mean?
- when there are multiple ligamentous injuries
- often with meniscal injury
(resulting in luxation of stifle joint)
123
What is shown by #1
cranial tibial ligament of the lateral meniscus
124
What is shown by #2
lateral meniscus
125
What is shown by #3
Meniscofemoral ligament
126
What is shown by #4
caudal ligament of the lateral meniscus
127
What is shown by #5
caudal cruciate ligament
128
What is shown by #6
medial meniscus
129
What is shown by #7
caudal ligament of the medial meniscus
130
What is shown by #8
cranial cruciate ligament
131
What is shown by #9
transverse ligament
132
What is shown by #10
cranial tibial ligament of the medial meniscus
133
What is shown by #11
patellar ligament
134
What is shown by #12
cranial horn of the lateral meniscus
135
What is shown by #13
Body of the lateral meniscus
136
What is shown by #14
caudal horn of the lateral meniscus
137
How can we diagnose Meniscal Injuries
- Radiology
- Arthoscopy
- Surgical exploration
138
Which meniscus can you diagnose a injury on with radiology?
medial meniscus
139
What is shown by #1
medial femoral condyle
140
What is shown by #2
Medial meniscus
141
What is shown by #3
Tibial plateau
142
What does the image on the left show?
Isolated tear of the meniscus
143
What does the image on the right show?
Medial detachment with shredding
144
What does both of the images show overall
Meniscal tear
145
What does A show?
Transection of meniscotibial ligament
146
What does B show?
Transection of midbody of meniscus
147
What does this image overall describe?
Meniscal release
- locations of release of medial meniscus
148
What is a means of "protecting" medial meniscus following surgical stabilization of stifle
Meniscal release
149
Meniscal release was developed in association with?
TPLO surgery
150
Why is Meniscale release controversial?
controversial based on effects on meniscus / cartilage / uncertain efficacy
151
By transecting meniscus the function of meniscus is compromised by elimination of what type of stresses?
hoop stresses
152
With midbody release or transection of meniscotibial ligament the femoral condyle increases contact with articular cartilage of tibilar plateau. This impairs functions of meniscus to provide stability and congruence. What is the negative effect of this?
contributes to osteoarthritis
153
T/F: No clinical studies demonstrate efficacy of meniscal release in decreasing incidence of post TPLO meniscal injury; but technique remains in widespread use
true
154
Is conservative treatment an option with meniscal injuries
NOT an option
155
In Meniscal injuries the continued back and forth sliding of torn meniscus can cause?
- severe pain
- will not improve conservative management
156
What is the main / major impact of using Medical management to treat Meniscal Injures?
Accelerates DJD
157
What conservative treatment is used with Meniscal injuries
- rest plus or minus splint application? DOES NOT WORK WELL
- May be appropriate in stable joint
158
For Meniscal Injuries what are the 3 methods of treatment?
- partial meniscectomy
- Primary repair of peripheral meniscal injuries
- Total menisectomy
159
Out of the 3 methods for treating Meniscal injuries what is the most used, rarely used, and dont use
Most used = partial meniscectomy
rarely used = primary repair of peripheral meniscal injuries
dont use = total menicectomy
160
partial meniscectomy can be done by what approach?
- Removal of caudal horn
- Bucket handle tear excision
lateral approach
161
Is lateral or medial meniscectomy easiest to perform through a medial surgical approach
medial meniscectomy
162
What is the treatment of choice for bucket handle tears of the medial meniscus?
Partial Meniscectomy
163
Does a partial or total meniscectomy carry less morbidity?
partial meniscectomy
164
In human orthopedics some surgeons advocate for what type of repair of the torn meniscal body?
primary repair
165
In dogs (vet med) are primary repair reserved for peripheral tears common or uncommon? Support your answer
Uncommon
- Difficulty in suturing meniscal body tears in dogs bc joint is so small
- low morbidity associated with partial meniscectomy
166
What type of primary repair allows meniscocapsular tissue to heal (challenging)
repair with absorbable interrupted sutures
167
Damaged meniscus may not heal. Totoal or partial removal may be indicated. Why do they not heal?
low to very little blood supply
168
Total meniscal removal induces which disease in the stifle?
DJD
169
What does the image show?
Total Meniscectomy
170
When is a total meniscectomy considered?
only when peripheral rim of meniscus is so damaged that primary suturing of meniscocapsular tissue is not possible
171
The more meniscal tissue removed = the more rapidly what disease develops?
OA
