Conservative treatment for knee injury

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Conservative treatment for knee injury

  1. 1. CONSERVATISM IN KNEE INJURIES-? ANY ROLE Dr. C. M. Krishnakumar, Consultant, Kozhikode District cooperative Hospital, Calicut. Formerly faculty, Christian Medical College, Ludhiana
  2. 2. Conservatism- preserve homeostasis  Interventional  Non interventional
  3. 3. CLASSIFICATION I .INTERNAL DERANGEMENT OF KNEE 1. Traum. synovitis & haemarthrosis 2. Injury to med, lat & cruciate ligts 3. Injury to semilunar cartilages 4. Dislocation of knee 5. Loose bodies of knee
  4. 4. Classification (contd) II. INJURIES TO EXT.MECH.OF KNEE 1. Avulsion of the quadriceps 2. # of patella 3. Avulsion of ligamentum patellae 4. Injuries to tib. tubercle & Schlatter’s 5. Dislocation of patella III .FRACTURES OF DISTAL FEMUR & PROX.TIBIA
  5. 5. CONSERVATIVE MANAGEMENT  Mild knee injury should be treated with R.I.C.E. (rest, ice, compression, elevation), and paracetamol (Caillient)  Avoid H.A.R.M. (heat, alcohol, running, massage) in first 72 hours.  Resume activities gradually as pain and swelling settle, with follow-up after 7 days if symptoms persist.
  6. 6. INDICATION  Stable injury  Elderly  Invalid (poor GC)  Poor skin & soft tissue condition  Refusing surgery
  7. 7. CONSERVATIVE MANAGEMENT  Redevelop Quadriceps: 5 min/ hr/day speed of loss > than gain wasting itself a disability  Early active non weight bearing exercise  Constant vigilance
  8. 8. TRAUMATIC SYNOVITIS  H/O twist or strain + effusion (max 6-8 hrs)  Crepe bandage - if effusion+ back splint in extension  Quadriceps Ex. at once  Wt. bearing in few days  ROP on 10th day  Recovery in 2-3 wks
  9. 9. TRAUMATIC SYNOVITIS
  10. 10. RECURRENT SYNOVITIS  In middle age with quadriceps wasting  Weight bearing ↓ed till muscle regain  R/O meniscal injuries
  11. 11. TRAUMATIC HAEMARTHROSIS  H/O severe blow/twist + rapid effusion (firm), painful, febrile  Aspiration + crepe + back splint  Quadriceps exercise after 10-14 days (to↓ spontaneous haemarthrosis)  R/O # Tibial Spine, Patella, Meniscal & ACL tear
  12. 12. MEDIAL COLLATERAL LIGAMENT  H/O abduction strain + external rotation of tibia  Med side open up with valgus strain in 20 flexion Rx PROTOCOL(Indelicato): I. Phase: Prefabricated orthosis in 30 flexion, isomet. quadri-later with resistance, PWB, Isokinetic quadri of opp. knee
  13. 13. MEDIAL COLLATERAL LIGAMENT  II. Phase (2nd -6th wk): Hinged knee brace(30 -90 flexion), full ext. prevented, Isokinetic quadri with increased resist’ , FWB  III. Phase(> 6wks):orthosis removed, iso kinet’ ex. With resistance to regain strength strength at 60%- running strength at 80%- full athletic activities
  14. 14. HAMSTRING & COLL. LIGT.EX
  15. 15. Hip ex. For flex,abd,add,ext → IFT,US,LASER Therapy→ pedalling backwards → resisted SLR ex using light weights → resisted isotonic knee ex.with ankle wt → wt bearing resisted ex usin step machine,step ups,lat step ups,50% squats → proprioceptive training using balance board&single leg stance ex. → gentle running in straight line,jog → sudden starts & stops,corners,lat gliding,lat bounding → polymetrics-jump ups,downs,stepping back & forth over a stool
  16. 16. Pellegrini–Stieda disease Immobilisation + Quadriceps Ex.
  17. 17. LATERAL COLLATERAL LIGAMENT  Less common, caused by varus strain  O/E opening of outer side on varus strain, may be assoc. with avulsion # fibula/lateral tibial condyle  Sprains – muscle exercises + avoid sports  Specific Rx not universally accepted  Complete rupture may be assoc. with other lig. injuries – needs repair
  18. 18. MENISCAL INJURY  Ext. rot/ int. rot + abd/add injury  Aspirate  REDUCTION OF LOCKED KNEE: must be done within 24 hrs to prevent loss of elasticity technique is easy but force should be guarded long’ traction + rot’ in both directions+ some valg/varus motion as knee is extended (ext. rot + ext – in lat. meniscus, int. rot + ext – in med. meniscus)
  19. 19. MENISCAL INJURY  Repeated unsuccessful manip’ avioded to prevent extension of tear into jt space  Immobilise with pressure bandage / plaster cylinder for 3-4weeks (assuming periph injury)  Quadri’ + hams’ ex, regain full ROM  Avoid deep knee bends, squats, rapid stair climb/descend  Avoid athletic activities – flex, ext, rot  rehabilitation for 6-8 weeks, and if symptoms persist/ locking- repair
  20. 20. ACL AVULSION INJURIES
  21. 21. ACL AVULSION INJURIES  Flexion + Int. rotation injury, may be assoc. with medial lig. Injury, inter condylar eminence #  Lachman test, Pivot shift test  Undisplaced # - POP cast (6weeks)  Min. disp.# - CR in ext. + POP cast
  22. 22. ACL SUBSTANCE INJURIES  R.I.C.E. (rest, ice, compression, elevation), and NSAID (Caillient)  Aspiration+ Ext. orthosis(6-8 wks), crutches, isomet’ quadri /hams ex , electrical stim  Use of a knee brace. sports with cutting and twisting motions are strongly discouraged.
  23. 23. ACL SUBSTANCE INJURIES 3-STAGE REHABILITATION (PALETTA):  Stage I (7-14 days) : immobilization for comfort, cryotherapy to control swelling, and crutch ambulation with progressive weight bearing and early ROM exercises  Stage II(2-6 wks): supervised regaining quadriceps strength and restoring normal quadriceps-hamstring balance  Stage III: gradual return to low and mod level demand sporting activities when the strength of the affected extremity approximates that of the unaffected
  24. 24. PCL TEAR (Sekiya,Giffin,Harner)  Caused by blow of front of a flexed knee  Undispl. Avulsion # - POP cast  Isolated Grade I &II: protected WB + quadri ex to counteract post/tibial sublux Recovery rapid(2-6 wks) to sports  Grade III: immobil’ in ext(2-4 wks)+ quadri ex, return to sports after 3 m
  25. 25. DISLOCATION OF THE KNEE JOINT  Usually assoc. with complete rupture of med., lat. & cruciate ligts / direct violence to head of tibia / indirect twist or hyper ext.  Ant., post., lat., med. & rotatory types  CR + POP cast(6-8weeks) in case of poor GC, skin cond., inadequate facility – foll. by surgery later if needed
  26. 26. OSTEOCHONDRAL # & LOOSEBODIES  Major loose bodies were the result of osteochondral fractures of either the femur (direct blow or twisting movement on a weight-bearing flexed knee) or the patella( 5% disloc) (Rosenberg & Mc Graw)
  27. 27. OSTEOCHONDRAL # & LOOSEBODIES  Adolesc boys & young adults ,  Haemarthrosis, med. retin tear, Loose body sensation, locking  Undisplaced osteochondral fractures in children often can be treated successfully with conservative methods – POP cast(4-6 wks)
  28. 28. RUPTURE OF EXT.MECHANISM  most commonly caused by fracture of the patella.  Disruption of quadriceps & patellar tendon are the next common causes.  eccentric overload to the extensor mechanism with the foot planted and the knee partially flexed.
  29. 29. PATELLAR TENDON RUPTURE  Patellar tendon rupture or avulsion common in patients < 40 yrs , especially athletes.  Less common than quadri’ tear  Common site: jn of distal pole of patella  Rx: Ac.partial tear-immobilisation in ext (2- 3wks) Once swelling subside brace
  30. 30. PATELLAR TENDON RUPTURE  PWB in ext with brace(2-3 wks), then gradual FWB in ext, SLR ex started  After 4-6 wks: active flex & passive ext ex  Knee flex: upto 30 for first 2 wks then 30 every 2 wks  6-8wks:active assist ext ex  >8 wks:prog quadri’ ex  Sports: when isokinetic quadri’ is 90%
  31. 31. COMPLICATION (PATELLAR TENDON RUPTURE)  Rerupture of patellar tendon  Quadriceps weakness  Patella alta
  32. 32. QUADRICEPS TENDON RUPTURE  Quadriceps rupture common in older patients and in those with systemic disease (lupus erythematosus, diabetes, gout, hyperparathyr oidism, uremia, and obesity) or degenerative changes or prior steroid injection Rx: Partial tear- Immobilise in ext (4-6 Wks), then gradual prog to active flexion
  33. 33. FRACTURE PATELLA
  34. 34. FRACTURE PATELLA  Undisplaced/ stellate patella # : Cylinder cast in extension (4-6 wks) , with weight- bearing allowed as tolerated  Boström considered 3 to 4 mm of fragment separation and 2 to 3 mm of articular incongruity to be acceptable for nonoperative treatment (Using these criteria in 212 nonoperatively treated fractures, 84 had no pain and 91 had normal or only slightly decreased function).  Rest types - surgery
  35. 35. COMPLICATION(# PATELLA)  90% good to excellent results (Brostrom)  Persistent ext. lag  arthrofibrosis
  36. 36. INJURIES TO TIB.TUBERCLE & OSGOOD SCHLATTER’S
  37. 37. INJURIES TO TIB.TUBERCLE & OSGOOD SCHLATTER’S  Being apex of triangular insertion takes first strain of ext. injury  # in adult : usually cracked/ mildly avulsed with ext. mech. intact- short immobilisation foll. by active ex. ,avoid stretching
  38. 38. AVULSION -TIBIAL EPIPHYSIS  Forcible flexion against resisting quadri  < 18 yrs  4 types- undisplaced, complete, partly avulsed, avulsed with wide area
  39. 39. EPIPHYSISAVULSION -TIBIAL Rx All except complete can be manipulated with cast in ext (6-8 wks)
  40. 40. AVULSION -TIBIAL EPIPHYSIS
  41. 41. OSGOOD SCHLATTER’S  Before fusion (18 yrs) epi. line is weak pt in ext mech  Flexion against quadri resistance  simple conservative measures such as the restriction of activities or cast immobilization for 3 to 6 weeks (Krause, Williams, and Catterall)
  42. 42. osd  Contoured knee pad during sports  Quadri & hams flexibility ex to decrease patellar forces  Avoid prolonged squat/kneeling-change of team position  COMPLICATION: Prominence of tubercle persisting symptoms & nonunion reactive bursitis
  43. 43. DISLOCATION OF PATELLA  If capsule is lax, poorly developed lat. fem condyle-tibia is forcibly abd +lat rot/glancing blow on med side of patella, when thigh mcs is relaxed-cause dislocation  CR + knee immobilizer/ cast for 2-6 wks.  Early range of motion - prevent arthrofibrosis and to promote the formation of strong collagen along the lines of stress.
  44. 44. COMPLICATION(DISLOCATION OF PATELLA)  Usually good to excellent results (91%)  Recurrent sublux/dislocation (15-49%)-brace with lat. Pad  Feeling of instability (20%)  Anterior knee pain (75%)  OA  stiffness
  45. 45. INTRA ARTICULAR # DISTAL FEMUR  Reduced by simple traction + manual compression of fragments between hands foll. by simple /UT Pin traction on thomas splint(4-5 wks) foll. by hinged cast brace till union  Maintain good reduction + ext. ex to prevent residual flex deformity  Dis adv: long IP stay
  46. 46. INTRA ARTICULAR # DISTAL FEMUR
  47. 47. COMPLICATION Malunion - fix flex def Arthrofibrosis Traction problems-pintract infection,bedsore
  48. 48. TIBIAL PLATEAU # DISLOCATION (Hohl and Moore)
  49. 49. TIBIAL PLATEAU # TREATMENT  depression <5 mm in stable #: early motion in a hinged knee brace / POP cast and delayed weight-bearing  depression 5 to 8 mm:  elderly and sedentary- nonoperative treatment young or active - surgical reconstruction  Non op Rx: Distal tibial pin traction + mobilisation on traction (3 rd wk) + hinged cast brace after 4-6 wks
  50. 50. r
  51. 51. TIBIAL PLATEAU #
  52. 52. COMPLICATION  Malunion  Nerve injury / compartment synd  Residual instability  OA  Arthrofibrosis  Traction/cast problems - pintract infection, bedsore etc.,
  53. 53. CONCLUSION  Operative treatment is not only option  Proper selection, constant vigilance, timely mobilisation of jts give as equal result as operative Rx  Rehabilitation should focus on functional treatment rather than electrotherapy

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