MCL. LCL.ALL injuries To understand the relevant anatomy of the side ligaments of the knee To study the mechanism of injury of each ligament and how to diagnose such injury To highlight the different treatment options in acute or chronic situations

1. MCL,LCL & ALL injuries
Mohamed Abulsoud (M.D)
Lecturer of orthopedic surgery
Al-Azhar university
Cairo- Egypt
AOTRAUMA international faculty

2. Learning outcomes
•To understand the relevant anatomy of the side
ligaments of the knee
•To study the mechanism of injury of each ligament
and how to diagnose such injury
•To highlight the different treatment options in acute
or chronic situations

3. MCL

4. Anatomical basis

5. Anatomical basis

6. Function
• The sMCL is the main valgus stabilizer of the knee in all flexion angles
• The dMCL ia a secondary valgus stabilizer and has a minor role in the
prevention of anterior tibial translation.
• The POL acts as a stabilizer of valgus, internal and external rotation of
the knee in extension.

7. Clinical Evaluation
Valgus stress test

8. Resting 0° 30°

9. • Pellegrini Stieda lesion

10. Radiological Evaluation
• The medial collateral ligament (MCL).
is evaluated primarily on the coronal
fat–saturated T2 or (STIR) sequences.

11. Radiological Evaluation
• Grade 1 intact ligament, normal in signal,
with surrounding edema and/or
hemorrhage .
• Grade 2 partial rupture, abnormal signal
within the ligament itself and/or fluid
surrounding the ligament in the MCL bursa
• Grade 3 complete rupture, frank
disruption and discontinuity of the
ligament

12. Radiological Evaluation

13. •Stener like lesion
Radiological Evaluation

14. Treatment
Non operative treatment
• Isolated injury to the MCL results in a robust healing response
• Rich blood supply,
• Relatively wide surface area,
• Association with other secondary stabilizers,
• Extra-articular location.
• 80 % return to sports within 9 weeks , 20 % hidden meniscal or ACL injuries
Holden DL, Eggert AW, Butler JE: The nonoperative treatment of grade
1 and 2 medial collateral ligament injuries to the knee. Am J Sports Med 1983.
• 91 % return to sports after grade 3 injury
Jones RE, Henley MB, Francis P: Non-operative management of
isolated grade III collateral ligament injury in high school football players. Clin Orthop 213:137, 1986.

15. Indications of operative treatment
• open injury
• MCL entrapment causing incongruent reduction of the
tibiofemoral joint
• fracture avulsion of the MCL origin
• distal MCL avulsion and pes anserinus interposition (a ‘Stener’
lesion)
• multi-ligament knee injury (the timing of this is controversial)
• other injuries requiring surgery (e.g. meniscal tear ,ACL)
• chronic instability after non-operative management

16. Anatomic double bundle MCL
reconstruction
Anatomic single bundle MCL
reconstruction
Non Anatomic double bundle MCL
reconstruction

17. Non Anatomic double bundle
transfer (modified Bosworth)

18. Internal bracing

19. Am J Sports Med 37(6):1123, 2009.

21. Wijdicks CA, Griffith CJ, LaPrade RF, et al. J Bone Joint Surg Am. 2009;91(3):521-529.

22. Rehabilitation
• Protected WB in hinged knee brace
• 0 to 90 ° for 2 weeks
• Gradual flexion 6 weeks
• Discontinue brace after 6 to 8 weeks
• Avoid pivoting for 16 weeks
• Jogging 16 to 20 weeks
• Return to play 9 months

23. LCL

24. LCL & PLC

25. • The LCL is the primary stabilizer to varus stress of the knee.
• The PFL provides an important restraint to external rotation.
• Popliteus is dynamic stabilizer +/- static
LCL & PLC

26. Mechanism of injury
• Varus, Rotation, extension
• 75% combined injury (PCL, ACL or both )
• CPN injury 15 %

27. Clinical Evaluation
• Varus stress test

28. Clinical Evaluation
• External Rotation–Recurvatum test

29. Clinical Evaluation
• The prone external rotation test (dial test )
• Performed at both 30 and 90 degrees of knee flexion

30. X ray
• Stress views
• Arcuate sign
• Avulsion fractures

31. Radiological Evaluation
• Most commonly, LCL injury manifests as complete
midsubstance disruption with surrounding soft tissue
edema.
• Injury to the LCL complex can be graded on MRI,
Grade 1 :- Edema surrounding an intact ligament .
grade 2 :-Intrasubstance ligamentous signal, possibly
with ligamentous thickening or thinning and
surrounding edema.
grade 3 :-Frank disruption and discontinuous fibers

32. Radiological Evaluation
• the popliteus muscle and tendon are best
evaluated with both sagittal and coronal MRI
sequences.
• They are most commonly injured at the
musculotendinous junction
• in the setting of a traumatic knee injury and
subsequent MRI, the popliteus can be
considered the “window to the
posterolateral corner.”

33. Fanelli A Fanelli B Fanelli C
Increase External rotation Increase external rotation and
mild varus instability
Significant rotational and varus
instability
Isolated injury to PFL Injury to PFL and partial FCL Complete injury to PFL, FCL,
and cruciate ligaments
PFL reconstruction Arciero Laprade Vs Arciero

34. Treatment
Repair
• Within 2-3 weeks
• Failure rate 38%
• Geeslin et al, AJSM 2016

35. Treatment
Reconstruction
Larssen KimArciero

36. •Laprade
Treatment
Reconstruction

37. Treatment
Reconstruction

38. Treatment
Chronic with malalignment

40. ALL

41. History
• As early as 1879, Paul Segond described a ‘‘pearly,
resistant, fibrous band’’ at the anterolateral
aspect of the knee.
• This eponymous Segond fracture was reported to
occur in the tibial region above and behind the
Gerdy’s tubercle

43. Anatomy

44. Anatomy

45. Indications for combined reconstruction
• Patients with high-grade pivot shifts on
preoperative examination
• Recurvatum > 10 °
• Chronic ACL lesion
• Revision cases
• Participation in pivoting sports
• Associated Segond’s fracture
• Lateral femoral notch sign
Feucht et al COP 2016

46. Combined ACL, ALL preconstruction

47. Technique