Posterior cruciate ligament injuries: evaluation and management

Posterior cruciate ligament (PCL) injuries commonly occur during sports participation or as a result of motor vehicle accidents. Careful history taking and a comprehensive physical examination are generally sufficient to identify PCL injuries. Most authors recommend nonoperative treatment for acute isolated PCL tears. This involves initial splinting in extension followed by range-of-motion and strengthening exercises. Recovery of quadriceps strength is necessary to compensate for posterior tibial subluxation and to facilitate return to preinjury activity levels. In isolated PCL tears, surgical treatment is reserved for acute bone avulsions and symptomatic chronic high-grade PCL tears. Arthroscopic single-tunnel reconstruction techniques will improve posterior laxity only moderately. Newer double-tunnel and tibial-inlay techniques offer theoretical advantages, but the available clinical results are only preliminary. When a PCL injury occurs in combination with other ligament injuries, most patients will require surgical treatment.     

Clinical diagnosis of triquetrolunate ligament injuries

The clinical diagnosis of peritriquetral injuries is difficult. We describe our diagnostic technique based on specific questions and three clinical tests. The accuracy of our diagnostic technique was compared prospectively with the definitive diagnosis made at arthroscopy. Preoperatively, 19 patients were diagnosed as having triquetrolunate dissociation. This was confirmed at arthroscopy in 17. Another five patients not diagnosed preoperatively were also diagnosed at arthroscopy as having mainly triquetrolunate dissociation. The sensitivity of our diagnostic protocol was 0.77 and the positive predictive value was 0.89.     

Whiplash injuries: diagnosis and early management

The objective of the present study is to quantify the position of the Centre of Mass (COM) during quiet standing using a force plate and compare this technique to the quantification of the COM with an anthropometric model. The postural control of 18 healthy adolescents and 22 IS patients was evaluated using an Optotrak 3D kinematic system, and two AMTI force plates during quiet standing. The position of anatomical landmarks tracked by the Optotrak system served to estimate the position of the COM of both groups using an anthropometric model (COM_anth). The force plate served to estimate the position of the COM through double integration of the horizontal ground reaction forces (COM_gl). The mean position and root mean square (RMS) amplitude of COM_gl, in reference to the base of support (BOS) and the first sacral prominence (S1) were quantified in the Anterior–Posterior (A/P) and Medial–Lateral (M/L) directions. There was a significant difference between the control subjects and IS patients for the displacement of the COM_gl in reference to the BOS in both the A/P and M/L directions. There was no difference between groups for the mean position of the COM_gl, however, 63% of the IS and 43% of the controls had a lateral position of the COM_gl in reference to S1 of greater than 5 mm. There was a significant difference between groups in the A/P and M/L directions for the amplitude of error between the COM_gl and COM_anth techniques.     

Renal injuries: diagnosis and current management

Abdominal trauma is relatively frequent and around 5% of the cases correspond to renal trauma. At present, a large percentage of cases can be managed conservatively. Generalised use of CT and cumulative experience have defined the cases that can be treated with good prospects. The currently accepted indications for imaging techniques and the most frequent ratings used are described. Similarly, the indications for surgical renal examination are listed and the principles for renal reconstruction described in the most recent publications of the most experienced medical centres.     

Athletes' ankle injuries: diagnosis and management

Ankle injuries are common in the general and athletic populations. These injuries constitute 21% of all sports-related injuries. The wide spectrum of sports-related ankle injuries includes ligamentous injuries, soft-tissue and osseous impingement, osteochondral lesions of the talus, tendon injuries, and fractures. Occult lesions (eg, fractures of the lateral process of the talus, fractures of the anterior process of the calcaneus, fractures of the base of the fifth metatarsal, os trigonum, stress fractures) may be missed on initial physical examination, and patients with such injuries often present to a sports clinic with persistent pain around the ankle. Because of increasing participation in sporting events, health care professionals involved in the care of athletes at all levels must have a thorough understanding of the anatomy, pathophysiology, and initial management of ankle injuries. In this review, we describe the pertinent anatomy, pathology, diagnosis, and treatment of sports-related injuries of the ankle.     

Deltoid ligament arthroscopic repair in ankle fractures: Case series

IntroductionDiagnosis and treatment of ankle medial ligament lesions in malleolar fractures has always been a matter of controversy. Even when deltoid involvement is clear, the direct repair of this structure is not a consensus. Recently, deltoid repair through an arthroscopic technique was described aiming to potentialize better clinical results and minimize complications.ObjectiveDemonstrate safety and functional results on patients with ankle fractures submitted to open reduction and internal fixation and arthroscopic deltoid repair.MethodsThis is a retrospective study in patients diagnosed with ankle fractures associated with acute deltoid injuries submitted to open malleolar fixation and deltoid arthroscopic repair between June 2016 and January 2020. All patients were evaluated for pain and functionality according to the Visual Analogue Scale (VAS) and the American Orthopedic Foot and Ankle Society Score (AOFAS) at a minimum of 6 months follow-up.ResultsFrom January 2016 to January 2020, 20 ankles with fractures or dislocations were operated and the deltoid ligament rupture was repaired arthroscopically. A mean follow-up of 14.45 months (6-48) was observed, and patients presented an average AOFAS of 93.5 (SD 7.25) and a VAS of 0.75 (SD 1.05). Three minor complications were noticed and no signs of medial chronic instability, loss of reduction or osteoarthritis were observed.DiscussionThe repair of the deltoid complex and the low morbidity of the arthroscopic technique used may improve the clinical outcomes of these patients. Additional studies, with a prospective and comparative methodology are required to sustain this proposal.DesignLevel IV. Retrospective case series.     

Surgical management of multiple knee ligament injuries

Objectives

To summarize our experience and mid-term results of reconstruction with Iliotibial tract grafts for multiple ligament injuries.

Methods

Between July 1997 and December 2003, multiple ligament injuries of 15 patients were reconstructed with Iliotibial tract grafts in arthroscopy. There were 5 women and 10 men. The mean age at the time of the surgery was 30.5 years (range 25–43 years). There were 7 cases who were injured with combined ACL rupture and the PCL, and 8 cases were with disruption of both the ACL and the PCL, combined with damage of the medial collateral ligament.

Results

Fifteen patients were followed up for a mean of 7.5 years (range 6–12 years). The overall mean postoperative Lysholm score was 84.3 ± 5.7. At final IKDC qualification, 60.0 % of the knees were normal or nearly normal. The overall average Tegner activity score decreased significantly at the re-examination compared to the activity score before accident (3.6 ± 0.5 vs. 5.1 ± 0.6).

Conclusions

Reconstruction with Iliotibial tract grafts in arthroscopy was a reliable treatment for multiple ligament injuries.     

Deltoid and spring ligament lesions in flat foot treatment

BackgroundMedial instability at the ankle and hindfoot may present in isolation and in combination with an adult flat foot deformity or may prevail as an overlooked lesion after lateral ankle ligament injury. Failure to detect and treat these lesions can lead to a progressive deformity, pain and residual instability.MethodsA systematic review of the literature was performed regarding anatomy, biomechanics and clinical findings of deltoid ligament and calcaneo-navicular (spring) ligament complex lesions related to pes planus valgus and sports. Beside some classical papers, all included references, were published from 2000 to present.Results and ConclusionsTreatment of ligamentous lesions of the medial side of the ankle and subtalar joint must be considered in patients with a posterior tibial tendon dysfunction in order to provide stability to the medial side and prevent progression of the deformity. Although bony procedures such osteotomies and arthrodesis can provide axial alignment, repair and balancing of the soft tissues of the medial side also has the potential to provide stability, improve alignment and relieve pain.     

Distal biceps tendon injuries: diagnosis and management.

Rupture of the distal biceps tendon occurs most commonly in the dominant extremity of men between 40 and 60 years of age when an unexpected extension force is applied to the flexed arm. Although previously thought to be an uncommon injury, distal biceps tendon ruptures are being reported with increasing frequency. The rupture typically occurs at the tendon insertion into the radial tuberosity in an area of preexisting tendon degeneration. The diagnosis is made on the basis of a history of a painful, tearing sensation in the antecubital region. Physical examination demonstrates a palpable and visible deformity of the distal biceps muscle belly with weakness in flexion and supination. The ability to palpate the tendon in the antecubital fossa may indicate partial tearing of the biceps tendon. Plain radiographs may show hypertrophic bone formation at the radial tuberosity. Magnetic resonance imaging is generally not required to diagnose a complete rupture but may be useful in the case of a partial rupture. Early surgical reattachment to the radial tuberosity is recommended for optimal results. A modified two-incision technique is the most widely used method of repair, but anterior single-incision techniques may be equally effective provided the radial nerve is protected. The patient with a chronic rupture may benefit from surgical reattachment, but proximal retraction and scarring of the muscle belly can make tendon mobilization difficult, and inadequate length of the distal biceps tendon may necessitate tendon augmentation. Postoperative rehabilitation must emphasize protected return of motion for the first 8 weeks after repair. Formal strengthening may begin as early as 8 weeks, with a return to unrestricted activities, including lifting, by 5 months.     

Penetrating vascular injuries: principles of diagnosis and management

This article reviews the principles of management of penetrating vascular injuries based on experience with 4346 patients treated on the Vascular Service of the University of Natal Hospitals,Durban, South Africa over a 20year period.The limbs were involved in 74% of patients, the neck and superior mediastinum in 17% and the thorax and abdomen in 9%.In 37% stab wounds were responsible and in 46% gunshots.The remainder followed blunt or iatrogenic trauma. The ballistics and pathology of penetrating trauma are discussed.Specific clinical presentation in the different anatomical regions is discussed.Angiography is the gold standard in diagnosis.Duplex Doppler is useful in the extremities and in the mid-zone (zone 2) of the neck. Most injuries require operative management and the definitive treatment is discussed.The role of interventional catheter techniques is presented. Management of specific problems, such as the infected operative field, soft tissue trauma and venous injuries, are also discussed.     

Cervicothoracic arterial injuries: Recommendations for diagnosis and management

Management of arterial injuries at the thoracic outlet and neck presents a major challenge to the trauma surgeon; hemorrhagic shock, neurologic deficit, and limb loss are the serious sequelae. Over a 13-year period, 118 patients with injuries to the innominate, carotid, subclavian, and axillary arteries were evaluated. Most injuries were penetrating (78%). Half of the patients were diagnosed by physical examination and half by angiography. Patients were treated by either primary repair (35%), interposition graft (31%), ligation (8%), or anticoagulation (26%). Two patients required amputations (1 digit, 1 above elbow). Overall mortality was 14%, with 5% due to consequences of hemorrhagic shock, 7% due to cerebral ischemia, and 2% due to other causes. Claviculectomy, median sternotomy, and trap door incisions were routinely used for proximal vascular control and repair. We conclude that liberal use of angiography is indicated in stable patients for penetrating wounds near major arteries, and for blunt injuries associated with neurologic deficits unexplained by computed tomography. Patients with obvious arterial injury should have immediate exploration. Extensile exposure is mandatory for appropriate management. Blunt carotid dissections are generally best managed nonoperatively with anticoagulation.

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Resumen El manejo de las lesiones arteriales a nivel del estrecho torácico superior y cuello representan un desafío mayor para el cirujano de trauma; el shock hemorrágico, el déficit neurológico y la péridida de la extremidad son secuelas graves. Se estudiaron 118 pacientes con lesiones arteriales del tronco braquiocefálico (innominado), la carótida, la subclavia, y la axilar. La mayor parte de las lesiones fue de tipo penetrante (78%). La mitad de los pacientes fue diagnosticada por el examen físico y la mitad mediante angiografía. Los pacientes fueron tratados con reparación vascular primaria (35%), injerto de interposición (31%), ligadura (8%), o anticoagulación (26%). Dos pacientes requirieron amputación (1 dedo, 1 brazo por encima del codo). La mortalidad global fue 14%, con 5% debido a consecuencias del shock hemorrágico, 7% debido a isquemia cerebral y 2% a otras causas. Se utilizaron, en forma rutinaria, la claviculectomía, la esternotomía mediana, y las incisiones de portezuela torácica para el control vascular proximal y la reparación. Nuestra conclusión es que el uso liberal de la angiografía esta indicado en pacientes estables con heridas penetrantes en la vecindad de arterias mayores y con trauma cerrado asociado con un déficit neurológico no explicable a la luz de tomografía computadorizada. Aquellos pacientes con una lesión arterial obvia debe ser sometidos a exploración inmediata. Se requiere una amplia exposición para el adecuado manejo quirÚrgico. Las lesiones por trauma cerrado de la carótida pueden ser manejadas en forma óptima con anticoagulación.

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Résumé Le traitement des lésions artérielles au niveau du cou et du défilé costoclaviculaire du thorax représente un défi difficile pour le chirurgien de traumatologie: les conséquences possibles sont choc hémorragique, déficit neurologique ou perte d'une extrémité. Pendant une période de 13 ans, nous avons traité 118 patients ayant eu une lésion traumatique des artères axillaires, sous-clavières, carotides, ou du tronc brachiocéphalique. Pour la plupart, il s'agissait de lésions pénétrantes (78%). Le diagnostique a été apporté pour la moitié par la clinique, et pour l'autre moitié par l'angiographie. Le traitement a consisté en réparation primitive (35%), greffon ou prothèse interposée (31%), ligature (8%), ou traitment anticoagulant (26%). Deux patients ont eu besoin d'une amputation au niveau du doigt pour l'un, et du bras, pour l'autre. La mortalité globale a été de 14%, 5% dus aux conséquences du choc hémorragique, 7% à l'ischémie cérébrale, et 2% à d'autres causes. La résection de la clavicule, une sternotomie médiane ou une incision en volet (selon Sauerbruch) ont été utilisées pour obtenir le contrôle vasculaire proximal et la réparation. Nous concluons qu'il faut faire une angiographie au moindre doute de lésions artérielle chez le patient stable présentant une plaie pénétrante sur le trajet des axes vasculaires majeurs et une tomodensitométire pour tout patient présentant un déficit neurologique non expliqué. Tout patient avec une pliae artérielle doit Être opéré immédiatement. Il est indispensable de prévoir un agrandissement de la voie d'abord. Les dissections de l'artère carotide par traumatisme fermé sont traités au mieux par anticoagulants.

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Presented at the Société Internationale de Chirurgie in Toronto, Ontario, Canada, September, 1989.     

Common knee injuries,diagnosis and management

The knee is a frequently injured joint, and the incidence of injury is increasing. Young adults are most likely to injure their knee through sports participation, and this can result in long-term debility without appropriate early and deferred management. A detailed history and clinical examination, supplemented with radiographic evaluation of the joint and magnetic resonance imaging, assist in the diagnosis and can guide acute and definitive management. Early clinical assessment by an appropriately trained clinician is recommended. Fractures should be managed through orthopaedic trauma services, and soft tissue injuries are often best triaged into specialist acute knee clinics. Early management includes the use of plaster casts, splints or braces according to the injury pattern, and the principles or rest, ice, compression and elevation are followed. Early functional motion should be instituted when safe to do so to prevent arthrofibrosis and secondary complications. Fractures, including osteochondral lesions are typically best dealt with acutely, along with disruptions of the extensor mechanism and displaced meniscal tears causing locking. Non-acute surgical management of other soft tissue injuries is generally preferred, allowing the joint to recover before additional operative insult. Appropriate early intervention by specialist knee services is associated with improved long-term outcomes.     

Urological injuries during cesarean section: intraoperative diagnosis and management

PURPOSE: We report a single center experience with emergency urological consultations and interventions during cesarean sections, and provide several guidelines for the intraoperative diagnosis and management of urological trauma in this specific clinical setting. MATERIALS AND METHODS: From 1996 to 2003 urological consultations were required in 29 of 10,439 abdominal deliveries (0.3%). Patient files were reviewed for obstetric, surgical and followup data. RESULTS: In 20 patients (69%) cesarean section was done on an emergency basis for fetal distress or placental abruption. Of the 29 urological consults 12 (42%) were for inadvertent cystotomy and 17 (58%) were for suspected injuries to the ureter. Patients with inadvertent cystotomy underwent concomitant assessment of ureteral patency by direct insertion of ureteral catheters through the ureteral orifice. Ureteral obstruction was identified in 1 case and promptly repaired by dissecting the ureter and releasing offending sutures that were angulating the ureter and occluding the lumen. Patients with suspected ureteral damage and an intact bladder were studied by endoscopic means (14) or direct surgical dissection and exposure of the ureter (3). Endoscopic assessment was performed by cystoscopic inspection of stained urine flow from the orifices following the administration of intravenous dye (indigo carmine) or by retrograde ureteral catheterization. One patient was found to have incomplete ureteral transection, which was repaired primarily over a self-retaining ureteral stent. CONCLUSIONS: Key factors to obtain optimal results in the management of urological injuries during cesarean sections are the early recognition and immediate repair of damage. Ureteral catheterization via a cystoscope or directly through the orifices should be considered the modality of choice to assess ureteral intactness. Algorithms for urological assessment in this clinical setting are provided.     

踝关节三角韧带损伤的诊断和治疗进展

踝关节三角韧带损伤的发病机制已经比较明确且分歧较少,但关于其诊断与治疗尚没有统一的标准。应力下X线片能否作为主要的诊断的依据、核磁检查是否早期应用、以及手术探查的指征等,这些都是目前诊断踝关节三角韧带损伤的难题;治疗上存在保守治疗和手术治疗两大分歧,且在手术治疗方式的选择方面国内外专家各有侧重,近年来国内学者偏重于带线锚钉修复,而国外则一直以重建三角韧带为主。     

Value of posterior cruciate ligament index in the diagnosis of anterior cruciate ligament injuries

Assessment of the diagnostic value of the posterior cruciate ligament index (PCL index) for injuries of the anterior cruciate ligament (ACL) was done. Magnetic resonance imaging (MRI) and knee joint arthroscopy of 170 patients were evaluated. The shortest distance between the femoral and tibial attachment of PCL (x) and the distance from that line to the tip of the arc marked by the PCL (y) on the sagittal plane images were measured. The quotient of these two parameters (x/y) defined the PCL index. In 100 patients, for whom arthroscopy ruled out ACL injury, the mean PCL index was 5.01 +/– 0.76. In 30 patients in whom arthroscopy showed total ACL rupture, the mean PCL index was 2.88 +/– 0.74, and in 10 patients with ACL partial rupture, 3.09 +/– 0.23. The conclusion is that injury to the ACL changes the PCL index markedly. In diagnostically unreliable MR images, deterioration of the PCL index could help in the diagnosis of ACL injury. Received: 19 July 1996