Common Injuries to the Knee

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Common Injuries to the Knee
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ANTERIOR CRUCIATE INJURIES
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ACL injuries also commonly occur with
hyperextension of the knee, deceleration and
valgus stress.
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INDICATIONS FOR SURGERY Complete tear
associated meniscal pathology Well motivated
person who will do the rehab program
physiologically young Unwilling to change
lifestyle job and sports require twisting,
cutting Minimal evidence of DJD
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• WHEN TO DO SURGERY Wait at least 3-4 weeks
  after injury
• Decrease the swelling
• Decrease Quad inhibition
• Decrease hamstring overfiring
• Decrease scarring
• Increase ROM decrease stiffness

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• SURGERIES PERFORMED
• Bone-tendon-bone with middle 1/3 of patellar
  tendon
• Semitendinosis and gracilis fold them in ½ so
  have a 4 tendon bundle
• Allograph bone-tendon-bone patellar tendon from
  cadaver
• Key in surgery is correct isometric placement of
  the graph.

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80-90 of patients have a good result with
surgery going back to previous levels of
activity. Some complications that may arise and
give a less than favorable result are

• Patellar tendonitis
• Patellofemoral pain/chondromalacia
• Limited ROM at extremes loss of even a few
  degrees of terminal extension is a problem
• Stretching out of graph

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COLLATERAL LIGAMENT INJURIES
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MCL tears most common mechanism is a blow to the
outside of the knee followed by planting of the
foot and twisting of the knee.
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There is a high risk of injury to the medial
meniscus with MCL tears.
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KNEE REHAB
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PATELLOFEMORAL PAIN SYNDROME
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The patella must have balanced muscular forces
around it to ride properly in the femoral
groove. The VMO should fire before the VL. The
VMO/VL ratio should be 11 Tight ITB, hamstrings
and calf can disrupt muscular balance.
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• OTHER FACTORS CAUSING PFPS
• Overpronation
• Anteversion
• Weak Hip ER ABD
• Tibial Varum
• Increased Q angle

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ILIOTIBIAL BAND SYNDROME
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Complains of pain on knee flexion May complain of
snapping Pain gets worse on ROM from full flexion
to full extension.
Often result of genu varum over pronation
femoral anteversion spinal problems.
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SHIN SPLINTS
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Most common area affected is antereomedial shin.
Starts out as muscle/tendon injury Can
progress to periosteal injury Can end up as a
stress fracture
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ANKLE SPRAINS
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Ottawa ankle rules
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JOBST INTERMITTENT COMPRESSION DEVICE
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ROM exercises Strengthening Proprioception Agil
ity Running/jumping
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Syndesmotic Injury
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ACHILLES TENDONITIS
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ACHILLES TENDON RUPTURE
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LONG REHAB Average 6-9 months
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PLANTAR FASCITIS
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Over pronation Pes cavus foot Tight calf
muscles Tibial varum Anteversion Weak ER of hip
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Pharmacology

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DRUGS USED FOR MUSCULOSKELETAL
PATHOLOGY

• Analgesics
• Drugs that directly affect the healing process
• Drugs that do both

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NON STEROIDAL
ANTIINFLAMMATORY DRUGS (NSAIDS)

• Treatment of inflammatory arthritic diseases
• Treatment of the itises

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NSAIDS SIDE EFFECTS

• Gastrointestinal Irritation and Ulceration
• Decreased Blood Clotting
• Kidney Trouble
• Other

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• Common NSAIDs (OTC)
• Bayer (aspirin)
• Tylenol (acetaminophen)
• Aleve or Naprosyn (naproxen)
• Advil (ibuprofen)

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Common NSAIDS (Rx)

• Celebrex (celecoxib)
• Voltaren (diclofenac)
• Lodine (etodolac)
• Nalfon (fenoprofen)
• Indocin (indomethacin)
• Orudis, Oruvail (ketoprofen)

• Toradol (ketoralac)
• Daypro (oxaprozin)
• Relafen (nabumetone)
• Clinoril (sulindac)
• Tolectin (tolmetin)
• Vioxx (rofecoxib

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Dosing

• Depends on Goal
• Avoid negative drug reactions
• Trial and Error
• Every patient has a different response
• Must keep blood levels constant for
  antiinflammatory response

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CORTICOSTEROIDS

• Synthetic derivative of cortisol
• Mobilizes energy stores
• Circulatory changes
• Changes in liver and kidney function
• Subdue inflammation and immune response

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ACTION

• Stabilizes cell membranes which decreases release
  of inflammatory mediators
• Inhibits migration of inflammatory cells that are
  attracted to the injured area.

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INDICATIONS

• INFLAMMATORY DISEASES RA, Lupus, Ankylosing
  Spondylitis
• NO! Acute musculoskeletal injuries
• ???? Chronic musculoskeletal injuries

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ADMINISTRATION

• ORAL Used in tx of diseases which affect
  multiple joints Dose pack for chronic
  musculoskeletal problems
• LOCAL INJECTION Used for tendinitis, bursitis,
  fasciitis
• TOPICAL USE Dermatologic effects only

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SIDE EFFECTS ORAL

• Osteoporosis pathologic fractures
• Avascular Necrosis
• Disturb fat and carbo metabolism increase risk
  of diabetes increased fat distribution in trunk
  and face
• Hypertension due to NA and H20 retention
• Steroid myopathy
• Steroid psychosis

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SIDE EFFECTS LOCAL INJECTION

• No systemic effects
• False sense of recovery
• Local tendon/muscle atrophy rupture
• Skin changes

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ANALGESICS

• Allow early initiation of rehab
• Improve quality of life for persons with chronic
  pain
• Allow patients to tolerate surgery

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NON-NARCOTIC

• Acetaminophen Has central nervous system effect
  through cental inhibition of prostaglandins
• Aspirin Has peripheral effect through
  peripheral inhibition of prostaglandins
• NSAIDS Have analgesic effect on nervous system
  as well as decreased inflammation

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NARCOTIC

• Common property bind to opioid receptors in
  brain
• Results in significant elevation of pain
  threshold can be addictive

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INDICATIONS

• Mild/moderate musculoskeletal pain
  non-narcotics acetaminophen first choice NSAIDS
  may be more logical if inflammation is causing
  pain, ie acute injuries and inflammatory
  arthritis
• Osteoarthritis acetaminophen
• Chronic musculoskeletal pain acetaminophen

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Continued

• Acute postoperative pain narcotics can be given
  IV or IM
• Chronic, Severe pain narcotics
• See Table 3 for commonly used analgesic drugs

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SIDE EFFECTS

• ACETAMINOPHEN generally safe liver toxicity
• ASPIRIN/NSAIDS as previously covered
• NARCOTICS respiratory suppression sedation,
  nausea and vomiting urinary retention
  euphoria/dependence

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ANTIBIOTICS

• Used to treat or prevent bacterial infections
  which can occur postoperatively or post compound
  fracture
• Classified based on chemical structure and
  effectiveness against certain bacteria (Table 4)

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INDICATIONS FOR USE

• Use drug best suited to fully eradicate the
  bacteria causing the infection
• Infection must be cultured to determine what kind
  it is
• Sometimes used prophylactically at time of
  surgery mostly with patients with compromised
  immune system
• Always used with patients with open fractures