The effect of a force depends on all three of its properties and its point of application. Defining exactly what a sports injury is can be problematic and definitions are not consistent. Grade 1 (partial) Injury has 0 to 5 mm of displacement; Tibia remains anterior to the femoral condyles; Grade 2 (complete) Injuries have 6 to 10 mm of displacement; Anterior tibia is flush with the femoral condyles; Grade 3 (posterolateral corner injury) Injury would have greater than 10 mm of displacemt; Often ACL and/or PLC injury Rehabilitation during It can be described in an anteroposterior, medial lateral, or rotary position. For initial treatment of a PCL injury, … Together, the ACL and PCL bridge the inside of the knee joint, forming an "X" pattern that stabilizes the knee against front-to-back and back-to-front forces. These changes in fiber length correlate with their changing participation in total ACL action as the knee is flexed. In contrast to Hughston and Muller, Warren and coworkers. B, Layer 1, medial side of the knee. Effective systems of classification necessitate agreement on both the meaning and appropriate use of terms to describe abnormal knee kinematics such that there is no ambiguity. There is a ROM for each of the translational and rotational degrees of freedom. Hughston and colleagues36 Warren and Marshall,92 and LaPrade and colleagues50 have clearly described the supporting structures on the medial side of the knee (Fig. By convention, the limits of flexion and extension are described relative to the neutral position or extension of 0 degrees, with flexion described in positive terms and hyperextension in negative terms. Despite its subjectivity and a lack of relation to anatomic cutting studies, the Hughston classification31 is still very important for treatment guidance. Grade 2 PCL Tear: Usually more than 50% of the ligament is torn. The medial collateral ligament (MCL) and the posteromedial capsular ligament, termed the posterior oblique ligament, are augmented by the dynamic stabilizing effect of the capsular arm of the semimembranosus tendon and its aponeurosis, the oblique popliteal ligament. Many patients will be asymptomatic and their clinical examination is unremarkable. All rotatory instabilities indicate subluxation about the intact PCL. Although also once considered to be the “dark side of the knee”, increased knowledge of the posterolateral corner anatomy and biomechanics has led to improved diagnostic ability with better understanding of physical and imaging examinations. (2010) highlighted that definitions of sports injury can be discussed in both theoretical and operational terms. In this scenario, the knee will exhibit large tibial excursions and response to anterior force if it is unchecked by muscle action. Grade Three tears are also classified as complete ligament tears. These knees are not very loose. To avoid confusion, it is better to measure the amount of displacement in millimeters of translation and rotation. By reviewing the current and classic literature, this chapter discusses the relationship of knee anatomy and kinematics, defines terms, and attempts to classify knee ligament injuries in an understandable fashion. [ 10 ] divided fractures into three types based on major external forces placed on the vertebral body (compression, distraction, and rotation). Range of motion is defined as the displacement that occurs between the two limits of movement for each degree of freedom. Injuries of the PCL can be classified according to severity, timing (acute vs chronic) and associated injuries (isolated vs combined). for isolated grade I and II PCL injuries. This may aid in pre- and intraoperative assessment of surgical repairs and reconstructions of these structures. • Complete rest • Surgical intervention • Physiotherapy rehabilitaion 9. In classifying knee ligamentous instabilities, it is important that the terms be clearly understood and used in a lucid and universally accepted manner. Conversely, in extension, point C moves proximally, and the posterior margin of the ligament is tightened. Clin Orthop 106:216, 1975. They found that the fiber bundles were not isometric; the anteromedial bundle lengthens and the posterolateral bundle shortens during flexion (Fig. Posterior cruciate ligament. The amount of coupled rotation depends on where the force is applied to the tibia or on whether the center of rotation is constrained or allowed to move freely. Instability is characterized by increased or excessive displacement of the tibia caused by a traumatic injury. The iliotibial band may be damaged to a varying degree, with most of the injury occurring to the deep fibers, which are attached to the posterior cortex of the lateral femoral condyle. The posterior cruciate ligament is an important ligament because of its cross-sectional area, tensile strength, and location in the central axis of the knee joint. The anterior cruciate ligament (ACL; Fig. According to the IOC manual of sports injuries … Amis and Dawkins3,4 have supported this multifascicular structure of the ACL; although not necessarily separate entities, the bundles interact as three functional bundles. This finding, associated with a tear of the ACL, is pathognomonic for anterolateral rotatory instability. The anterior drawer test result with the tibia rotated externally will be negative because the tibia will not be able to rotate internally. Elongation or stretching of the ligament limits joint motion and is also supported by compressive joint contact forces that act in an opposite direction. Range of motion is defined as the displacement that occurs between the two limits of movement for each degree of freedom. Posterior cruciate ligament (PCL) injury is typically caused by direct trauma to a bent knee. Furthermore, clinical examination findings, operative findings, and anatomic studies must be correlated in an attempt to clarify the classification of these injuries. The PCL prevents posterior translation at all angles of flexion.13,26,34 Patients who have an isolated injury of the PCL may maintain fairly good function of the knee.25 Gollehon and associates30 have found that isolated sectioning of the PCL produces increased posterior translation of the tibia at all degrees of flexion of the knee, with the greatest increase occurring from 75 to 90 degrees. Rotation describes motion or displacement about an axis and, in the knee, has 3 degrees of freedom—flexion-extension, internal-external rotation, and abduction-adduction. Coupled displacement concerns motion in 1 or more degrees of freedom that is caused by a load applied in another degree of freedom. C, Layer 3, lateral side of the knee with the arcuate complex. Like the ACL, the PCL is a continuum of fascicles, with different portions being taut throughout ROM. The PCL is the least commonly injured ligament in the knee. PCL injuries can be severe or mild depending on the circumstances. Rotatory instability includes anteromedial, anterolateral, posterolateral, posteromedial, and combined (Fig. However, the main deterrent to external rotation is the posterior oblique ligament. Diagram of the anterior cruciate ligament in extension and flexion. A clinical study. Tibial rotation is better resisted by a combination of capsular structures, collateral ligaments, the joint surface, and meniscal geometry, whereas the cruciates play only a secondary role. Grade 3 PCL Tear: Represent a complete tear of the PCL. Position refers to the orientation of the tibia with respect to the femur and determines the tension in each of the ligaments and supporting structures. Denis further classified major spinal injuries into four different categories: compression, burst, seatbelt-type injuries, and fracture-dislocations. This study also claims that the MCL has some function in preventing external rotation of the tibia on the femur with the knee flexed. 37-3). Absence of the PCL has no effect on primary varus or external rotation of the tibia as long as the LCL and capsular structures are intact. The PCL is the strongest ligament in the knee joint and prevents excessive movement of the tibia in the posterior direction, assists with rotational stability of the knee as well as the shifting and/or tilting of the patella. A sprain is an injury to a joint ligament that stretches or tears ligamentous fibers but does not completely disrupt the ligament. On the femoral side, the anterior border of the ACL is a bony ridge on the medial wall of the lateral femoral condyle, commonly referred to as resident’s ridge.71 On the tibial side, the ACL posterior border lies at a ridge between the medial and lateral intercondylar tubercles at the base of the tibial eminence. Grade 2: Sprain in the ligament, also referred to as a partial tear, the PCL stretches and becomes loose. from the dashboard of a car during an accident. Note that in extension the posterolateral bulk is taut, whereas in flexion the anteromedial band is tight and the posterolateral bulk is relatively relaxed. Use crutches if necessary. Terry and colleagues85 have investigated the role of the iliotibial tract, iliopatellar band, and iliotibial band as dynamic and static stabilizers of the lateral side of the knee. 37-10). The anterior cruciate ligament (ACL; Fig. Norwood and Cross62 further divided the ACL into three functional bundles and described their different actions in resisting rotatory instability. They concluded that external rotatory instability is caused by a tear in the medial capsular ligament, with or without a partial or a complete tear of the MCL. For this reason, medical professionals developed a grading system to classify the injury. The ligaments of Humphrey and Wrisberg (Fig. External tibial rotation plus anterior translation is manifested as anteromedial rotatory instability, which causes the medial tibial plateau to subluxate anteromedially on the medial femoral condyle. Several terms have been used to describe an injury to a ligament. 37-1). A sprain is an injury to a joint ligament that stretches or tears ligamentous fibers but does not completely disrupt the ligament. 37-13). The amount of coupled rotation depends on where the force is applied to the tibia or on whether the center of rotation is constrained or allowed to move freely. 37-13).72 Combined instability is not as clearly defined as rotatory or straight instability. An injury to the PCL could involve straining, spraining, or tearing any part of that ligament. Classification. Depending on the severity and degree of injury, Posterolateral Corner (PLC) Injuries are divided into grade 1, 2 or 3. Grades one through four include partial tears to complete damage to the PCL and the presence of related knee ligament injuries. Revista Brasileira de Ortopedia (English Edition), https://doi.org/10.1016/j.rboe.2014.12.008. By continuing you agree to the use of cookies. Although somewhat lax as the knee goes into flexion, the posterior oblique ligament is dynamized by the muscular attachment to the semimembranosus tendon, and it has a significant influence on stability throughout the first 60 degrees of flexion (Fig. The classification of knee ligament instability is based on rotation of the knee about the central axis of the PCL. Injuries to posterolateral corner of the knee: a comprehensive review from anatomy to surgical treatment, Lesões do canto posterolateral do joelho: uma revisão completa da anatomia ao tratamento cirúrgico, Reconstructive surgical procedures/methods, Procedimentos de cirurgia reconstrutiva/métodos. Posterior cruciate ligament (PCL) avulsion fractures are a type of avulsion fracture of the knee that represent the most common isolated PCL lesion. The anterior drawer test result with the tibia rotated externally will be negative because the tibia will not be able to rotate internally. The limits of motion are defined as the extreme positions of movement that are possible in each of the 6 degrees of freedom. J Bone Joint Surg Am 89:2000, 2007.). A typical PCL injury mechanism is a blow to the anterior aspect of the tibia . These gradings are classified depending on Embora tenha sido considerado como o “lado negro do joelho”, o maior conhecimento da anatomia e da biomecânica do canto posterolateral levou à melhoria da capacidade diagnóstica e à melhor compreensão do exame físico e de imagem. Figure 37-12 Sprains have been characterized on the basis of ligament injury: first-degree (A), second-degree (B), and third-degree (C) sprains. indications . Translation is the parallel displacement of a rigid body or, in the case of the knee joint, the tibia with respect to the femur. The ACL has been described as a single ligament, with different portions taut throughout the range of motion (ROM). Hughston and colleagues36 have described the PCL as the fundamental stabilizer of the knee because it is located in the center of the knee joint and functions as the axis about which the knee moves in flexion and extension, as well as in rotation. Torn PCL rehabilitation program Phase 1: Immediately following injury. Injury to the ligamentous and osseous structures about the knee alters the limits of motion. Figure 37-7 Diagram of the anterior cruciate ligament in extension and flexion. Dislocations of the knee are classified by the final tibial position-anterior, posterior, medial, lateral, or rotary. Most authors suggest that displaced PCL avulsion fractures should undergo operative fixation and current data suggests excel … The most elaborate classification system of knee ligament instability was developed by Hughston and colleagues36,37 and the American Orthopaedic Society of Sports Medicine Research and Education Committee in 1976.2 This classification system attempts to describe the instability by the direction of tibial displacement and, when possible, by structural deficits. Motion is the process of changing position and describes the displacement between the starting and ending points. Classification of PCL Injuries PCL injuries are graded based on (1) Severity, (2) Time since injury, and (3) Presence of associated injuries. An example is the internal rotation that results when an anterior load is applied to the tibia. The superficial, central, and capsular arms of the posterior oblique ligament are readily identifiable, with the central arm forming the largest component of this structure. Figure 37-10 Close-up of an anatomic specimen seen from the anterior aspect demonstrating the relationship of the ACL (a), ligament of Humphry (h), and PCL (p) from anterior to posterior in the intercondylar notch. Figure 37-9 Posterior cruciate ligament. The force that displaces the knee has three properties, an orientation or line of action, a sense (forward or backward) along its line of action, and a magnitude. The subluxation hinges on the intact MCL or LCL. In the handbook, Sprains have been characterized on the basis of ligament injury: first-degree, The most elaborate classification system of knee ligament instability was developed by Hughston and colleagues. In contrast to Hughston and Muller, Warren and coworkers92 have noted that most fibers of the MCL are the prime static stabilizers on the medial side of the knee. 37-8) is believed to be the most important of the knee ligaments because of its cross-sectional area, tensile strength, and location in the central axis of the knee joint. The ACL has been described as a single ligament, with different portions taut throughout the range of motion (ROM).6 In investigating the functional anatomy of the ACL, Odensten and Gillquist67 found no anatomic separation of the ligament into different bundles. This instability results in excessive internal tibial rotation and anterior subluxation, which implies disruption of the lateral capsular ligament, the arcuate complex, and the ACL. Copyright © 2014 Sociedade Brasileira de Ortopedia e Traumatologia. Posterior cruciate ligament avulsion fracture. Figure 37-1 A, Medial knee bony anatomy. The femoral footprint consists of a medial intercondylar ridge at its proximal border and a medial bifurcate ridge that occasionally divides the two functional bundles.24 The insertion reaches approximately 1 cm below the articular surface in a nonarticular area that Jacobsen43 has termed the area intercondylaris posterior. Motion is the process of changing position and describes the displacement between the starting and ending points. midsubstance repair have 40% failure rate following repair Figure 37-3 The posterior oblique fibers become more tense in flexion. In 1994, Magerl et al. This instability results in excessive internal tibial rotation and anterior subluxation, which implies disruption of the lateral capsular ligament, the arcuate complex, and the ACL. Duration – 2 weeks.. Rest from aggravating activities. The central arm contributes most fibers for femoral attachment and adheres to the medial meniscus as it merges distally with the posteromedial capsule. Figure 37-6 The anterior cruciate ligament has been described as a single ligament with different portions taut throughout the range of motion. They confirmed that the medial epicondyle lies anterior and distal to the adductor tubercle. Isolated ACL or PCL reconstruction without addressing the PLC will ultimately fail. This classification depends on the degree of joint gapping when the lateral joint is manually stressed along with the end feel when doing this movement. The lateral collateral ligament (LCL) is the major static support to varus stress, whereas the iliotibial tract provides both dynamic and static support. The ligament of Wrisberg passes posterior to the PCL to attach on the PCL. The terms in the literature should be specific to define positions of the knee, motions of the knee, and ligamentous injury. St Louis, 1991, Mosby–Year Book.). The parallel anterior fibers of the superficial medial ligament are arranged around the axis of flexion so that tension remains constant throughout the arc of motion. Rotatory instability includes anteromedial, anterolateral, posteromedial, and posterolateral instability, which are described in terms of abnormal tibial rotation. Together, their function is augmented by the dynamic effects of the biceps femoris, popliteus, and lateral head of the gastrocnemius. PCL injuries are much less common than ACL injuries. Medial collateral ligament in flexion and extension. Although injuries to the posterolateral corner of the knee were previously considered to be a rare condition, they have been shown to be present in almost 16% of all knee injuries and are responsible for sustained instability and failure of concomitant reconstructions if not properly recognized. 37-7). Laxity is a term used to describe the looseness of the joint, which can be normal or abnormal. This is a thickening of the posteromedial capsule of the knee and it is firmly attached to and contiguous with the medial meniscus in this location. A subsequent study by Wijdicks and colleagues, The lateral supporting structures have been described by Hughston and associates. Figure 37-2 Medial collateral ligament in flexion and extension. The central arm contributes most fibers for femoral attachment and adheres to the medial meniscus as it merges distally with the posteromedial capsule.50. Translation of the tibia is composed of three independent components or translational degrees of freedom—medial lateral translation, anteroposterior translation, and proximal distal translation. A subsequent study by Wijdicks and colleagues94 has concluded that the attachments of medial ligamentous structures could be correlated to the location of osseous landmarks seen on plain radiographs. Dislocation is a term indicating a complete noncontact position of both the tibia and femur or the patellofemoral joint. In flexion, the bulk of the ligament becomes tight, whereas in extension it is relaxed. 37-5). They labeled this new structure the gastrocnemius tubercle and noted that the posterior oblique ligament attachment was actually closer to this structure than to the adductor tubercle. 25,92. (From Scott WN [ed]: The knee, St Louis, 1994, CV Mosby.). PLC repair . A PCL injury … Dislocations of the knee are classified by the final tibial position-anterior, posterior, medial, lateral, or rotary.52 Subluxation is defined as an incomplete partial dislocation and does not have limits. 37-9). Therefore, they believe that there are different functional portions of the ACL.93 Based on this concept of different functional portions of the ACL, Girgis and associates29 have divided the ACL into anteromedial and posterolateral bands. The anterior portion, which forms the bulk of the ligament, tightens in flexion, whereas the smaller posterior portion tightens in extension (Fig. The ligaments determine the constraint of the knee joint. (A redrawn from LaPrade, RF, Engebretsen AH, Ly TV, et al: The anatomy of the medial part of the knee. Both James and associates44 and Kennedy and coworkers48 have shown that the tensile strength of the PCL is almost twice that of the ACL. B, Layer 2, lateral side of the knee with the lateral collateral ligament. Grade 1 PCL Sprain: partial PCL tear. Figure 37-13 Rotatory instability includes anteromedial, anterolateral, posteromedial, and posterolateral instability, which are described in terms of abnormal tibial rotation. Subsequent modifications of the Denis classification have recognized that with an intact posterior ligamentous complex (PLC), two-column unstable injuries can be successfully treated non-surgically (3). On the femoral side, the LCL attaches to a small depression between the lateral epicondyle and supracondylar process, and it attaches distally to the posterior aspect of the fibular head. Hughston and associates35,36,41 have indicated that the posterior oblique ligament is the primary medial support against valgus stress to the knee. The anterior cruciate ligament has been described as a single ligament with different portions taut throughout the range of motion. • Complete rest is advised within a supportive brace for grade 1 and grade 2 tear of PCL, which generally heals on its own. The classification is as follows: Grade I: The PCL has a partial tear. Translation of the tibia is composed of three independent components or translational degrees of freedom—medial lateral translation, anteroposterior translation, and proximal distal translation. The anatomic and functional aspects of the ACL have undergone extensive investigation. Chapter 37 Classification of Knee Ligament Injuries, Christopher A. Hajnik, Craig S. Radnay, Giles R. Scuderi, W. Norman Scott. Many of these injuries are in the setting of a multi-ligamentous injury. Home Treatment of a Posterior Cruciate Ligament Injury. Claiming that the layered approach is not helpful for surgical exposure, because it often leads to an oversimplification of structures with frequent inaccuracies regarding ligamentous attachment sites, they sought to verify the relationships of medial knee structures to pertinent osseous anatomy through cadaveric dissection. On the femoral side, the LCL attaches to a small depression between the lateral epicondyle and supracondylar process, and it attaches distally to the posterior aspect of the fibular head.12,51 The popliteus originates from the posteromedial aspect of the proximal tibia, courses intra-articularly, and inserts anterior and distal to the LCL attachment. Critical to defining stability of the knee is understanding the relationship of the surrounding capsular and ligamentous structures. Sports injuries are diverse in terms of the mechanism of injury, how they present in individuals, and how the injury should be managed. Study conducted at the Steadman Philippon Research Institute, Vail, United States and Instituto Brasil de Tecnologias da Saúde, Rio de Janeiro, RJ, Brasil. ■ Describe the use of the TLICS Dislocation is a term indicating a complete noncontact position of both the tibia and femur or the patellofemoral joint. 37-11) are so intimately related that early authors described them as separate portions of a single ligament.55 Clancy and colleagues15 have noted that the meniscofemoral ligament may serve as a secondary stabilizer in a posterior cruciate-deficient knee. External tibial rotation plus anterior translation is manifested as anteromedial rotatory instability, which causes the medial tibial plateau to subluxate anteromedially on the medial femoral condyle.38 This motion implies disruption of the medial capsular ligament, MCL, posterior oblique ligament, and ACL.41,46,47,80 The medial meniscus is considered an important stabilizing structure and may also be injured.70 On clinical examination, the abduction stress test result is positive, with abnormal excess opening of the medial joint space at 30 degrees, along with positive anterior drawer and Lachman test results. In accordance with the rarity of these injuries, the literature is sparse regarding surgical outcomes. An example is the internal rotation that results when an anterior load is applied to the tibia.26 When assessing ligamentous stability, motion of the knee joint may occur freely or be constrained, based on the integrity of the ligamentous structures. In contrast other prospective studies considered mainly isolated PCL injuries and reported no strength deficits. If the motion is unconstrained, the tibia displaces into its maximum position. The management of posterolateral corner injuries has also evolved and good outcomes have been reported after operative treatment following anatomical reconstruction principles. ), Tibial rotation is better resisted by a combination of capsular structures, collateral ligaments, the joint surface, and meniscal geometry, whereas the cruciates play only a secondary role.3,4,65 However, recent evidence suggests a larger role for the ACL in rotational stability if both bundles remain functionally intact.14 Despite this, the MCL is anatomically better suited than the ACL and has the mechanical advantage to control torsion or laxity because its attachments are further removed from the axis of tibial rotation.77 The MCL will provide significant resistance to the anterior drawer test only after the ACL is gone and when both ligaments are lost.
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