1. Anuchit Nawatthakul
Sixth year medical student
Phramongkutklao college of medicine

2.  HN : 11593/56
Case : A young Thai man 22 yrs , an officer
CC : 1 yr PTA
PI : 1 yr PTA
Pop

3. PH : - no underlying disease
- no history of previous
surgery
- no history of drug
allergy
- no current medication

4. Physical examnination
 GA : good conscious , not pale , no
jaundice
 HEENT : normal
 Heart : normal s1s2 , no murmur
 Lung : clear , no adventitious
sound
 Abdomen : soft , not tender

5.  Affected part ( Right knee)
Swelling , pain on motion
Full ROM , normal length
valrus / valgus : nrgative
ballotment : negative
Lachman test : negative
Anterior drawer test : positive 2+
Pivot shift test : negative
Mc Murray test : negative
Apley ’s test : negative
Neurovascular : ok

6. 90

7. 30
proximal tibia
distal femur proximal tibia
distal femur

9. Pertinent finding
 Rt knee in jury in football match
 Swelling
 Anterior drawer test positive
 No deformities
 Normal Neurovascular status

10. Problem list
 Rt knee injury in football match with anterior drawer
test positive

11. Differential Diagnosis
 Knee ligamentous injury
 Fracture

12. Ligamentous Injuries
 ACL injuries
 PCL injuries
 MCL injuries
 LCL injuries

13. ACL Injuries
 Most MOI are non-contact
rotational forces
 Tibia displaced anteriorly on
femur (or vice versa), rotational
stress (cutting) or
hyperextension
 May be isolated, but typically
due to MOI, other structures
(joint capsule, menisci) also
injured
 Positive anterior drawer and/or
Lachman’s tests

14. PCL Injuries
 Most common MOI is fall on flexed knee driving tibia
posterior on femur
 May also occur with rotational and/or hyperextension MOI
 Often treated non-operatively as quadriceps muscles are
able to minimize posterior displacement of tibia on femur
 Positive posterior drawer and/or posterior sag tests

15. MCL Injuries
 Most common MOI is
blow to lateral knee with
resulting valgus tension
forces
 May also be injured by
non-contact and/or
rotational stresses
 Positive valgus stress test

16. LCL Injuries
 Most common MOI is
blow to medial knee
with resulting varus
tension forces
 Internal rotation of tibia
may be secondary
contributor to LCL injury
 Positive varus stress test

17. Meniscal Injuries
 May be isolated from
flexion/hyperflexion with
rotation of the knee – “pinched”
between tibia and femur
 Often injured in association
with cruciate ligament injury
 “Classic” symptoms include
joint line pain and clicking or
locking – helpful but not
definitive evaluative tools
 Limited reliability of special
tests

18. Investigation
 X-ray
 MRI

19. X-ray

20. MRI
Torn of Anterior Cruciate
Lingament (complete tear)
Torn medial miniscus ( Basket
handle)

21. Diagnosis
Complete torn Anterior Cruciate
Lingament with torn medial
meniscus

22. ACL
hyperextension
tibia.
3. valgus varus
internal rotation external rotat
4. screw home

23. ACL Injuries
 Most MOI are non-contact
rotational forces
 Tibia displaced anteriorly on
femur (or vice versa), rotational
stress (cutting) or
hyperextension
 May be isolated, but typically
due to MOI, other structures
(joint capsule, menisci) also
injured
 Positive anterior drawer and/or
Lachman’s tests

24. Grading ligamentous injury
 Grade 1 : Ligament
Swelling, localized tenderness
 Grade 2 : Ligament stretching partial tear
Swelling
 Grade 3 : Ligament complete tear
May 12,2009 24

25. Management

26. knee brace
jone s bandage
NSAID

27. Commercial
Hinge-Knee
Brace

28. Anterior Cruciate Ligament Injury
 International Knee Documentation
Committee
activity level 4
level 1 jumping, pivoting football ,soccer )
level 2 heavy manual work or side-to- side
sports (skiing, tennis)
level 3 light manual work or noncutting
sports (jogging, running)
May 12,2009 28

29. Non operative treatment ACL injury
 level 3 level 4
level 1 level 2
sport activity
reconstruction physical therapy
Functional brace
 rehabilitation
swelling effusion ,
hamstrings muscle
atrophy
May 12,2009 29

30. Non operative treatment
 Rehabilitation ROM
 swelling , effusion
 strengthening of hamstring muscle
for balance power of quadriceps instability

31. Non operative treatment ACL injury
 brace
brace physical therapy control stability
 conservative minimal
surgery debridement of articular cartilage
defect, trimming or repairing meniscus excising
ligament stump procedures
ligament reconstruction
May 12,2009 31

32. Surgical treatment ACL injury

intraarticular reconstruction
 ACL reconstruction
arthroscopic assisted
endoscopic techniques
transfixation technique
hamstring graft
fixation femoral tunnel
May 12,2009 32

33. Surgical treatment ACL injury
 fixation graft
interference screw
titanium
bioabsorbable screw
stable fixation
transfix pin screw
May 12,2009 33

34.  Operation : Arthroscopic ACL reconstruction with
medial meniscus repair
 Indication complete
tear(grade 3)
Medial meniscus tear
instability

35. Patient Education

 ,
 , ,

36. Progress note
 v/s pain control
Morphine , Dynastat
 on continuous passive
motion
,
 Axillary Crutch

37. Reflection
Approch Knee ligament injury
-
- knee ligament injury
-