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Acute Knee Ligament Injuries in Athletes
Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD ACSM TPC Part 2 Miami, Florida • February 9, 2013 Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD Associate Professor Dept. of Orthopaedic Surgery & Sports Medicine University of Kentucky Lexington, Kentucky ACSM TPC Part 2 • February 9, 2013 1 Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD Acute Knee Dislocations • Uncommon, but . . . May be underdiagnosed • If knee opens up to varus/valgus stress testing in extension, assume a knee dislocation • Direction of dislocation • Anterior: hyperextension mechanism • Posterior: direct blow anterior proximal tibia ACSM TPC Part 2 • February 9, 2013 2 Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD KNEE ACSM TPC Part 2 • February 9, 2013 3 Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD Knee Dislocation • • • Happens on fields – not often, but: Don’t miss Assess vascular status • • • • Physical exam Pulse ratios MRI scan Arteriogram ACSM TPC Part 2 • February 9, 2013 4 Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD Marcus Lattimore, running back, MOI: South Carolina vs. Tennessee ACSM TPC Part 2 • February 9, 2013 5 Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD Football: Knee Dislocation ACSM TPC Part 2 • February 9, 2013 6 Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD Knee dislocation ACL/PCL/MCL tears Skin only stabilizing medial side of the knee ACSM TPC Part 2 • February 9, 2013 7 Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD Medial meniscus ACSM TPC Part 2 • February 9, 2013 8 Acute Knee Ligament Injuries in Athletes ACSM TPC Part 2 • February 9, 2013 Mary Lloyd Ireland, MD 9 Acute Knee Ligament Injuries in Athletes ACSM TPC Part 2 • February 9, 2013 Mary Lloyd Ireland, MD 10 Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD Knee Dislocation Algorithm Algorithm for treatment of the Multiple Ligament Injured Knee, from Harner, CD, “Complex Knee Injuries including dislocation: Preoperative planning, evaluation and pitfalls,” AAOS, Phoenix AZ, Feb. 3-6, 2000. ACSM TPC Part 2 • February 9, 2013 11 Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD Willis McGahee, Univ. of Miami 2003 ACSM TPC Part 2 • February 9, 2013 12 Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD Instabilities • • • • • • • Anteromedial rotatory instabilities (AMRI) Combined AMRI and ALRI Anterolateral rotatory instabilities (ALRI) Straight posterior Posterolateral rotatory instabilities (PLRI) Combined ALRI and PLRI Straight instabilities ACSM TPC Part 2 • February 9, 2013 13 Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD Knee Dislocations • Most knee dislocations reduce spontaneously • Refer to center with vascular surgeon • Communicate with ER • • • Use your cell phone to call the ER Put a note on the patient Transfer to facility with angiography suite and vascular surgeon on call • If high suspicion, do arteriogram ACSM TPC Part 2 • February 9, 2013 14 Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD Vascular Injury Arteriogram Gold Standard Injury ranges from : Thrombus Tear: Intimal Partial Complete Late Vascular compromise from: Thrombus Propagation of Intimal Tear ACSM TPC Part 2 • February 9, 2013 15 Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD History • 16YO white male, high school football player • Football game, valgus twisting blow to body injury • Unable to keep playing • Evaluated on sideline, seen in ER • Seen in office 3 days later ACSM TPC Part 2 • February 9, 2013 16 Acute Knee Ligament Injuries in Athletes ACSM TPC Part 2 • February 9, 2013 Mary Lloyd Ireland, MD 17 Acute Knee Ligament Injuries in Athletes ACSM TPC Part 2 • February 9, 2013 Mary Lloyd Ireland, MD 18 Acute Knee Ligament Injuries in Athletes ACSM TPC Part 2 • February 9, 2013 Mary Lloyd Ireland, MD 19 Acute Knee Ligament Injuries in Athletes ACSM TPC Part 2 • February 9, 2013 Mary Lloyd Ireland, MD 20 Acute Knee Ligament Injuries in Athletes ACSM TPC Part 2 • February 9, 2013 Mary Lloyd Ireland, MD 21 Acute Knee Ligament Injuries in Athletes ACSM TPC Part 2 • February 9, 2013 Mary Lloyd Ireland, MD 22 Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD Surgery: Arthroscopy ACSM TPC Part 2 • February 9, 2013 23 Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD Surgery: MCL Repair ACSM TPC Part 2 • February 9, 2013 24 Acute Knee Ligament Injuries in Athletes Knee Instabilities ACSM TPC Part 2 • February 9, 2013 Mary Lloyd Ireland, MD AMRI 25 Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD Gymnastics ACSM TPC Part 2 • February 9, 2013 26 Acute Knee Ligament Injuries in Athletes ACSM TPC Part 2 • February 9, 2013 Mary Lloyd Ireland, MD 27 Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD ACL Tear ACSM TPC Part 2 • February 9, 2013 28 Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD Basketball ACSM TPC Part 2 • February 9, 2013 29 Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD Basketball ACSM TPC Part 2 • February 9, 2013 30 Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD Basketball: non-contact, unexpected, not thinking ACSM TPC Part 2 • February 9, 2013 31 Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD Knee Knee Instability Instability ACSM TPC Part 2 • February 9, 2013 32 Acute Knee Ligament Injuries in Athletes Knee Instabilities ACSM TPC Part 2 • February 9, 2013 Mary Lloyd Ireland, MD ALRI 33 Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD EUA: Correlate mechanism of injury, anatomy, surgical findings to study design in the lab ACSM TPC Part 2 • February 9, 2013 34 Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD Pivot Shift Lateral tibial plateau internally rotating, anteriorly subluxing at 30 to 0 degrees ACSM TPC Part 2 • February 9, 2013 35 Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD Medial compartment: compressive forces posterior medial meniscus, typical tear pattern vertical, posterior ACSM TPC Part 2 • February 9, 2013 36 Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD Injury Mechanisms – Body Positions ACSM TPC Part 2 • February 9, 2013 37 Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD Team Handball Olsen OE, Myklebust G, Engebretsen L, and Bahr R, “Injury Mechanisms for Anterior Cruciate Ligament Injuries in Team Handball: A Systematic Video Analysis,” in Am J Sports Med 32(4); June 2004, 1002-1012. ACSM TPC Part 2 • February 9, 2013 38 Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD ACL Injury occurred, Foot fixed and externally rotated Wide stance, 15° knee flexion, 20 ° valgus, tibia IR 10 ° ACSM TPC Part 2 • February 9, 2013 39 Acute Knee Ligament Injuries in Athletes ACL injury occurred Foot fixed and externally rotated, knee 20°, tibia ER 10°, valgus 10° ACSM TPC Part 2 • February 9, 2013 Mary Lloyd Ireland, MD Off-balance, in the air 40 Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD Soccer ACSM TPC Part 2 • February 9, 2013 41 Acute Knee Ligament Injuries in Athletes Knee Instabilities ACSM TPC Part 2 • February 9, 2013 Mary Lloyd Ireland, MD PLRI 42 Acute Knee Ligament Injuries in Athletes ACSM TPC Part 2 • February 9, 2013 Mary Lloyd Ireland, MD 43 Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD Normal Knee Exam: PCL Exam ACSM TPC Part 2 • February 9, 2013 44 Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD PCL – 22 YO Offensive Lineman ACSM TPC Part 2 • February 9, 2013 45 Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD PCL • Mechanism • Low velocity – sports blow to anterior tibia, foot plantarflexed • Exam • Grades I-II-III based on relation to medial femoral condyle • Assess collateral ligaments • Most commonly posterolateral instability • Greater tibial external rotation • Acute reconstruction • Knee dislocation • Grade III collateral ligament injuries ACSM TPC Part 2 • February 9, 2013 46 Acute Knee Ligament Injuries in Athletes ACSM TPC Part 2 • February 9, 2013 Mary Lloyd Ireland, MD 47 Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD Sideline Assessment of Injuries To Make the Diagnosis: Use observation of mechanism, physical exam skills, and talk to the athlete ACSM TPC Part 2 • February 9, 2013 48 Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD Non-contact ACL tear, professional football athlete Injuries occur at all levels of talent and experience ACSM TPC Part 2 • February 9, 2013 Jerry Jerry Rice Rice 49 Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD Who Who is is driving driving the the sideline sideline decision decision and and return return to to play play train? train? ACSM TPC Part 2 • February 9, 2013 50 Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD The End . . . Thank You! Acute Knee Ligament Injuries in Athletes Mary Lloyd Ireland, MD Associate Professor Dept. of Orthopaedic Surgery & Sports Medicine University of Kentucky Lexington, Kentucky ACSM TPC Part 2 Miami, Florida • February 9, 2013 ACSM TPC Part 2 • February 9, 2013 51 ACUTE KNEE LIGAMENT INJURIES IN ATHLETES ACSM TPC II Miami, Florida February 9, 2013 Mary Lloyd Ireland, M.D. UK Healthcare - Orthopaedics & Sports Medicine 601 Perimeter Drive #200 Lexington, KY 40517 (859) 218-3131 Fax: (859) 323-2255 _________________________________________________________________________ BIBLIOGRAPHY American Medical Association: Standard Nomenclature of Athletic Injuries. Chicago, American Medial Association, 1966. Arendt e, Dick R. Knee injury patterns among men and women in collegiate basketball and soccer: NCAA data and review of literature. Am J Sports Med 1995;23(6):694-701. 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