EXTERN CONFERENCEExt.Tanyanop Techasupaboon

Case Case : ผปวยชายไทย อาย ป สญชาตไทย เชอชาต

ไทย ภมลำาเนาจงหวด อาชพนกกฬา สทธการรกษา เขา รบการรกษาเมอวนท 11 พ.ย. 2559

Chief complaint : ปวดเขาซายกอนมาโรงพยาบาล3 เดอน

Primary survey A : Patent airway , no tender along

midline of neck B : Normal chest movement , equal

breath sound , Chest compression test negative

C : BP mmHg , Capillary refill < 2 second D : E4V5M6 , pupil 2 mm RTLBE E : No external bleeding , no wound ,

tender at

Secondary survey A : No drug allergy M : No current medication P : No underlying disease L : Last meal at 12.00 น. E : Tenderness at left knee

Secondary survey Present illness : 10 years PTA – ไดไปเตะฟตบอล

ตอนอาย 16 ป เตะบอลพลาดในทาเหยยดเขาสด ผปวยรสก ปวดทเขาซายทนทและรสกเหมอนมเสยงดงขนในขอเขา หลง

จากนนผปวยกไมสามารถเดนลงนำาหนกไดเตมทดงเดมอก 3 month PTA – ผปวยไดไป

เลนตะกรอ ในขณะทกำาลงจะรบลกตะกรอมอาการขาลอคในทา เหยยด เดนแลวมอาการเจบและรสกเหมอนเขายบตวลง ยง

สามารถงอเขาได และสามารถเหยยดเขาไดสด มอาการเขาลอคบาง เปนบางครง ไมมเขาบวม

Past history : - ไมมโรคประจำาตว - ไมเคยประสบอบตเหตรายแรงอนๆ

Secondary survey Personal history : - ไมแพยาหรออาหาร

- ไมสบบหร - ไมดมสรา - ไมใชยาตม,ยาหมอ,ยาลกกลอน, สมนไพร Family history : - ไมมโรค

ถายทอดทางพนธกรรม เชน โรคมะเรงหรอโรคทางโลหตวทยา

Secondary survey Head to toe examination Vital sign BP 140/74 mmHg PR 80 bpm

BT 37.5 °C RR 20 /min General appearance : Good consciousness HEENT : Not pale conjunctivae , Anicteric

sclerae CVS : Normal S1S2 , No murmur Lung : Clear both lung Abdomen : Soft , not tender

Secondary survey Extremities : Affected part Left knee - No deformities

- Tenderness at left knee - No joint line tenderness - No swelling at left knee - Anterior drawer test positive

Pertinent finding Tenderness at left knee History of knee joint instability ( Giving

way ) Left knee locking Anterior drawer test positive

Problem Left knee athralgia with Anterior drawer

test posive

Adjunctive to secondary survey

Film AP left knee

Adjunctive to secondary survey

Film lateral left knee

Adjunctive to secondary survey

MRI of the left knee Finding : - Complete tear ACL ,Intact PCL .

Small joint fluid is observe - Medial meniscus : Contusion with complex tear at posterior horn of medial meniscus.

Adjunctive to secondary survey

MRI of the left knee

Diagnosis Left ACL injury with left medial and lateral

meniscus tear

Treatment Supportive treatment

1. Pain control : MO 4 mg v prn q 4 hr Plasil 10 mg v prn q 6 hr Paracetamol ( 500 ) 1 tab oral prn q 6 hr

2. Rehabilitation Hinge knee brace Walking with crutches

Treatment Specific treatment

1. ACL reconstruction with meniscus repair

Progress note 12/11/2559 S : ผปวยตนด พดคยรเรอง มไข รสกคลนไส O : V/S BT 38°C Lt.Leg on elastic bandage, Cap.refill 2

sec., DPA 2+ A : Fever post op P : Observe BT Control pain – MO 4mg v prn q 4 hr - Plasil 10mg v prn q 6 hr

Progress note 13/11/2559 S : ผปวยตนด พดคยรเรอง มไข เจบคอ ไมมปสสาวะแสบขด

ไมมอาการปวดทอง O : V/S BT 38.3°C Lt.Leg on elastic bandage, Cap.refill 2 sec., DPA

2+ A : Fever post op P : Nasal swab for influenza Control pain – MO 4mg v prn q 4 hr - Plasil 10mg v prn q 6 hr Wound dressing

Progress note 14/11/2559 S : ผปวยตนด พดคยรเรอง ไมมไข รบประทานอาหารไดปกต

ไมมคลนไส O : V/S Stable Lt.Leg on elastic bandage, Cap.refill 2 sec.,

DPA 2+ A : ACL reconstruction with meniscus repair

POD 3 P : Control pain – MO 4mg v prn q 4 hr - Plasil 10mg v prn q 6 hr Consult PT

Progress note 15/11/2559 S : ผปวยตนด พดคยรเรอง ไมมไข รบประทานอาหารไดปกต ไมม

คลนไส O : V/S Stable Lt.Leg on elastic bandage, Cap.refill 2 sec., DPA 2+ A : ACL reconstruction with meniscus repair

POD 3 P : Control pain – MO 4mg v prn q 4 hr - Plasil 10mg v prn q 6 hr Consult PT – Quadricep exercise , Knee flexion exercise , walking with axillary crutches ( NBW ) Plan D/C

Knee anatomy

Knee anatomy 3 bone Thighbone (femur) Shinbone (tibia) Kneecap (patella) 2 Group of ligament Cruciate ligament : Anterior and posterior Collateral ligament : Medial and lateral

ACL The anterior cruciate ligament runs

diagonally in the middle of the knee. It prevents the tibia from sliding out in front of the femur, as well as provides rotational stability to the knee.

Function : provides 85% of the stability to

prevent anterior translation of the tibia relative to the femur

acts as secondary restraint to tibial rotation and varus/valgus rotation

ACL injury ACL injury : One of the most common

knee injuries is an anterior cruciate ligament sprain or tear.

incidence~400,000 ACL reconstructions / year

ACL injury Injured ligaments are considered "sprains" and are

graded on a severity scale. Grade 1 Sprains. The ligament is mildly damaged

in a Grade 1 Sprain. It has been slightly stretched, but is still able to help keep the knee joint stable.

Grade 2 Sprains. A Grade 2 Sprain stretches the ligament to the point where it becomes loose. This is often referred to as a partial tear of the ligament.

Grade 3 Sprains. This type of sprain is most commonly referred to as a complete tear of the ligament. The ligament has been split into two pieces, and the knee joint is unstable.

ACL injury Acute ACL injury often associate with lateral meniscal tears in 54% Chronic ACL deficient knees associated

with chondral injuries complex unrepairable meniscal tears relation with arthritis is controversial

ACL injury Diagnosis : Physical examination 1.Lachman test 2.Pivot shift test 3.Anterior drawer test 4.KT 100

Lachman’s test most sensitive exam test ( Sense 85% ,

Spec 98% ) grading

A= firm endpoint, B= no endpoint Grade 1: 3-5 mm translation Grade 2 A/B: 5-10mm translation Grade 3 A/B: > 10mm translation

PCL tear may give "false" Lachman due to posterior subluxation

Lachman’s test

Pivot shift test Sense 24% , Spec 98% extension to flexion: reduces at 20-30° of

flexion patient must be completely relaxed

(easier to elicit under anesthesia) mimics the actual giving way event

Pivot shift test

Anterior drawer test Sense 92% , Spec 91%

KT-1000  useful to quantify anterior laxity measured with knee in slight flexion and

externally rotated 10-30° 

KT-1000 

ACL injury Imaging Arthroscopy ( Gold standard diagnosis ) MRI X RAY : Usually normal Segond fracture (avulsion fracture of the

proximal lateral tibia) is pathognomonic for an ACL tear 

represents bony avulsion by the anterolateral ligament (ALL)

associated with ACL tear 75-100% of the time

Segond fracture

ACL injury Clinical presentation Pain with swelling. Within 24 hours, your knee

will swell. If ignored, the swelling and pain may resolve on its own. However, if you attempt to return to sports, your knee will probably be unstable and you risk causing further damage to the cushioning cartilage (meniscus) of your knee.

Loss of full range of motion Tenderness along the joint line Discomfort while walking

ACL injury Changing direction rapidly Stopping suddenly Slowing down while running Landing from a jump incorrectly Direct contact or collision, such as a

football tackle

ACL injury Treatment Non operative Treatment Operative Treatment

Non operative Treatment1. Physical therapy & lifestyle

modifications low demand patients with decreased laxity increased meniscal/cartilage damage

linked to loss of meniscal integrity frequency of buckling episodes level I and II activity (e.g. jumping, cutting,

side-to-side sports, heavy manual labor)2. Knee Brace

Operative Treatment1. ACL reconstruction indications younger, more active patients (reduces

incidence of meniscal or chondral injury) children (strongly consider operative as

activity limitation is not realistic) older active patients (age >40 is not

contraindication if high demand athlete) prior ACL reconstruction failure

Associated injuries1.MCL injury allow MCL to heal (varus/valgus stability) and then

perform ACL reconstruction varus/valgus instability can jeopardize graft

2.Meniscal tear perform meniscal repair at same time as ACL

reconstruction increased meniscal healing rate when repaired at

the same time as ACL3.Posterolateral corner injury reconstruct at the same time as ACL or as 1st

stage of 2 stage reconstruction

Graft selection Patella tendon Hamstring tendon Semitendinosus Allograft

Operative Treatment2. Ligament repair traditionally has high failure rate arthroscopic bridge-enhanced ACL repair

(BEAR) trial with a bridging scaffold is ongoing

Rehabilitation Early postoperative Injury prevention

Early postoperative Immediate aggressive cryotherapy (ice) immediate weight bearing (shown to reduce

patellofemoral pain) emphasize early full passive extension

(especially if associated with MCL injury or patella dislocation)

Early rehab Isometric hamstring and quadricep Active motion of knee 35-90° flexion Closed chain exercise

Injury prevention ACL bracing

Reference ธรชย อภวรรธกล , Ortopaedic Trauma : หจก.เชยงใหมโรง

พมพแสงศลป 195-197 ถ. พระปกเกลา อ. เมอว จ. เชยงใหม2547 , Fracture and dislocation of lower extremity

หนา 68-70 www.orthobullet.com/ACL tear orthoinfo.aaos.org/topic.cfm?topic=a00549 emedicine.medscape.com/article/89442-overview Anne Benjaminse, Alli Gokeler, Cees P. van der

Schans, PT, PhD3 , Clinical Diagnosis of an Anterior Cruciate Ligament Rupture: A Meta-analysis , Journal of orthopaedic and sport physical therapy 2016

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