case presentation from orthopaedics surgery department maharat nakorn ratchasima hopital

1. Case presentation
ORTHOPEADICS KORAT| EXT. POONYAPORN PHANKOSOL

2. Cheif complaint
ผู้ป่วยชายอายุ 19 ปี
มาด้วย เข่าซ้ายบวม 1 ชั่วโมงก่อนมารพ.

3. Present illness
 1 ชั่วโมงก่อนมารพ. ผู้ป่วยเตะฟุตบอล กระโดดลงพื้น เข่า
ซ้ายบิดแล้วล้มลง เจ็บหัวเข่าด้านซ้ายทันที ลงน้าหนักได้ไม่
สุด กดเจ็บด้านนอกหัวเข่า ไม่มีขาผิดรูป เดินได้แต่กระเผลก
ไม่มีขาชา ไม่มีบาดแผลภายนอก pain score 8/10 เข่า
ซ้ายบวมและปวดมากขึ้น จึงมาโรงพยาบาล

4. Past history
 ปฏิเสธโรคประจาตัว
 ปฏิเสธแพ้ยา,แพ้อาหาร
 ปฏิเสธยาที่รับประทานประจา
 ปฏิเสธประวัติผ่าตัด

5. Physical examination
 V/S: BT 37°C PR 84 bpm RR 18 /min BP126/68 mmHg
 GA: A teenage Thai male, good consciousness
 HEENT: Not pale conjunctivae, anicteric sclerae
 Heart: Normal S1S2, No murmur
 Lung: Clear, no adventitious sound
 Abdomen: Normoactive bowel sound, soft, not tender
 Affected part:
 no deformity, swelling and tender Lt. knee, limit active
movement due to pain, full passive ROM, ballottement
test positive

6. Differential diagnosis
 ACL injury
 Meniscus injury
 Fracture distal femur/proximal tibia

7. Management at ER
 Film Knee AP, Lateral

10. Management at ER
 Immobilization: On posterior long leg slab
 D/C
 Pain control
 F/U 2 weeks

11. 2weeks later
ผู้ป่วยมาตรวจติดตามอาการ ยังมีปวดเข่าอยู่เล็กน้อย เข่าไม่บวม เดินพอได้
PE:
 Anterior drawer test : positive
 Posterior drawer test : negative
 Lachman's test : positive
 Pivot shift test : positive
 Varus stress test : negative
 Valgus stress test : negative
 McMurrey test : negative

12. Investigation
 MRI Lt. knee

13. MRI Lt. knee
 Full-thickness tear of ACL
 Sprain of MCL
 Grade1 meniscal tear at posterior body of lateral
meniscus
 Minimal bone marrow edema at lateral tibial
plateau

14. ACL injury

15. Anatomy
 ORIGIN
 posterior aspect of the
lateral femoral condyle
 INSERTION
 middle of the tibial plateau
 Blood supply
 Middle geniculate artery
 Innervation
 Tibial nerve
 Golgi tendon receptor

16. Anatomy
Functions:
- Restrain anterior
translation of tibia
- Prevent
hyperextension of
the knee
- Control rotation of
the tibia on femoral
extension of 0°-30°

17. Cause of ACL injury
 The anterior cruciate ligament can be injured in
several ways:
 Changing direction rapidly
 Stopping suddenly
 Slowing down while running
 Landing from a jump incorrectly
 Direct contact or collision, such as a football tackle

18. Anterior drawer
test
With the patient lying the
supine position, place the
knee in 90° of flexion
without rotation. Place
both hands on the
proximal tibia, and pull the
upper part of the calf
forward. An anterior
drawer test is positive when
the tibia moves anteriorly
without an abrupt, hard
endpoint.

19. Lachman test
With the patient lying in the
supine position, flex the
knee 20° to 30° while the
heel rests on the end of the
exam table. Grasp the
femur with the
nondominant hand to
prevent movement of the
upper leg. Then, grasp the
lower leg at the proximal
tibia and apply a forward
tug. This movement should
produce a firm endpoint. If
the endpoint is not firm or
there is increased anterior
translation of the tibia, the
Lachman test is positive.

20. Pivot shift test
When the lower leg is
stabilized in near full
extension. With increasing
flexion, a palpable
springlike reduction should
be observed. A positive
pivot shift test usually
produces a thud or jerk
around 10° to 20° of flexion.
During a positive exam, the
force created by the
examiner will cause the
knee joint to slip, giving a
positive visual for
identifying rotational knee
instability.

21. Associated injury
 Meniscus (50%)
 Articular cartilage (30%)
 Collateral ligament (30%)

22. Grading
 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.

23. Symptoms
 Popping sound
 Pain with swelling (within 24hr)
 Loss of full range of motion
 Tender along joint line
 Discomfort while walking

24. Treatment
 Initial treatment
 R.I.C.E
 Non surgical treatment
 Surgical treatment

25. Nonsurgical treatment
 A torn ACL will not heal without surgery. But
nonsurgical treatment may be effective for patients
who are elderly or have a very low activity level
 Bracing
 With axillary crutches
 Physical therapy.

26. Surgical treatment
 Allograft
 Patellar tendon graft
 Hamstring tendon graft

27. THANK YOU