CONSERVATISM IN CONSERVATISM IN KNEE KNEE INJURIES-? ANY INJURIES-? ANY ROLEROLE

Dr. C. M. KrishnakumarDr. C. M. Krishnakumar,,

Consultant, Kozhikode District Consultant, Kozhikode District cooperative Hospital, Calicut.cooperative Hospital, Calicut.

Formerly faculty, Christian Medical Formerly faculty, Christian Medical College, Ludhiana College, Ludhiana

Conservatism- Conservatism- preserve homeostasispreserve homeostasis

InterventionalInterventional

Non interventionalNon interventional

CLASSIFICATIONCLASSIFICATION

II .INTERNAL DERANGEMENT OF KNEE.INTERNAL DERANGEMENT OF KNEE

1.1. Traum. synovitis & haemarthrosisTraum. synovitis & haemarthrosis

2.2. Injury to med, lat & cruciate ligtsInjury to med, lat & cruciate ligts

3.3. Injury to semilunar cartilagesInjury to semilunar cartilages

4.4. Dislocation of kneeDislocation of knee

5.5. Loose bodies of kneeLoose bodies of knee

Classification Classification (contd)(contd)

II. INJURIES TO EXT.MECH.OF KNEEII. INJURIES TO EXT.MECH.OF KNEE

1.1. Avulsion of the quadricepsAvulsion of the quadriceps

2.2. # of patella# of patella

3.3. Avulsion of ligamentum patellaeAvulsion of ligamentum patellae

4.4. Injuries to tib. tubercle & Injuries to tib. tubercle & Schlatter’sSchlatter’s

5.5. Dislocation of patellaDislocation of patella

III .FRACTURES OF DISTAL FEMUR & III .FRACTURES OF DISTAL FEMUR & PROX.TIBIAPROX.TIBIA

CONSERVATIVE CONSERVATIVE MANAGEMENTMANAGEMENT Mild knee injury should be treated with R.I.C.E. (rest, ice, compression, elevation), and paracetamol (Caillient)

Avoid H.A.R.M. (heat, alcohol, running, massage) in first 72 hours.

Resume activities gradually as pain and swelling settle, with follow-up after 7 days if symptoms persist.

INDICATIONINDICATION

Stable injuryStable injury

ElderlyElderly

Invalid (poor GC)Invalid (poor GC)

Poor skin & soft tissue conditionPoor skin & soft tissue condition

Refusing surgeryRefusing surgery

CONSERVATIVE CONSERVATIVE MANAGEMENTMANAGEMENT

Redevelop Quadriceps: 5 min/ hr/dayRedevelop Quadriceps: 5 min/ hr/day

speed of loss > than gainspeed of loss > than gain

wasting itself a disabilitywasting itself a disability

Early active non weight bearing Early active non weight bearing exercise exercise

Constant vigilanceConstant vigilance

TRAUMATIC SYNOVITISTRAUMATIC SYNOVITIS

H/O twist or strain + effusion (max 6-8 H/O twist or strain + effusion (max 6-8 hrs)hrs)

Crepe bandage - if effusion+ back splint Crepe bandage - if effusion+ back splint in extensionin extension

Quadriceps Ex. at onceQuadriceps Ex. at once Wt. bearing in few daysWt. bearing in few days ROP on 10ROP on 10thth day day Recovery in 2-3 wksRecovery in 2-3 wks

TRAUMATIC SYNOVITISTRAUMATIC SYNOVITIS

RECURRENT SYNOVITISRECURRENT SYNOVITIS In middle age with quadriceps wastingIn middle age with quadriceps wasting

Weight bearing Weight bearing ↓↓ed till muscle regained till muscle regain

R/O meniscal injuriesR/O meniscal injuries

TRAUMATIC TRAUMATIC HAEMARTHROSISHAEMARTHROSIS

H/O severe blow/twist + rapid effusion H/O severe blow/twist + rapid effusion (firm),(firm),

painful, febrilepainful, febrile Aspiration + crepe + back splintAspiration + crepe + back splint Quadriceps exercise after 10-14 days Quadriceps exercise after 10-14 days

(to(to↓↓ spontaneous haemarthrosis) spontaneous haemarthrosis) R/O # Tibial Spine, Patella, Meniscal & ACL R/O # Tibial Spine, Patella, Meniscal & ACL

teartear

MEDIAL COLLATERAL MEDIAL COLLATERAL LIGAMENTLIGAMENT H/O abduction strain + external H/O abduction strain + external

rotation of tibiarotation of tibia Med side open up with valgus strain in Med side open up with valgus strain in

2020°° flexion flexion

Rx PROTOCOL(Indelicato):Rx PROTOCOL(Indelicato): I. Phase:I. Phase: Prefabricated orthosis in 30 Prefabricated orthosis in 30° °

flexion, isomet. quadri-later with flexion, isomet. quadri-later with resistance, PWB, Isokinetic quadri resistance, PWB, Isokinetic quadri of opp. kneeof opp. knee

MEDIAL COLLATERAL MEDIAL COLLATERAL LIGAMENTLIGAMENT

II. Phase (2II. Phase (2ndnd -6 -6thth wk): wk): Hinged knee Hinged knee brace(30 ° brace(30 ° -90 ° flexion), full ext. -90 ° flexion), full ext. prevented, Isokinetic prevented, Isokinetic quadri with quadri with increased resist’ , FWBincreased resist’ , FWB

III. Phase(> 6wks):III. Phase(> 6wks):orthosis removed, iso orthosis removed, iso kinet’kinet’

ex. With resistance to regain strengthex. With resistance to regain strength

strength at 60%- runningstrength at 60%- running

strength at 80%- full athletic activitiesstrength at 80%- full athletic activities

HAMSTRING HAMSTRING & COLL. & COLL. LIGT.EXLIGT.EX

Hip ex. For flex,abd,add,extHip ex. For flex,abd,add,ext →→ IFT,US,LASER TherapyIFT,US,LASER Therapy→→ pedalling backwardspedalling backwards →→ resisted SLR ex using light weights resisted SLR ex using light weights

→ → resisted isotonic knee ex.with ankle wtresisted isotonic knee ex.with ankle wt →→ wt bearing resisted ex usin step machine,step wt bearing resisted ex usin step machine,step

ups,lat step ups,50% squats ups,lat step ups,50% squats →→ proprioceptive training using balanceproprioceptive training using balance board&single board&single

leg stance ex. leg stance ex. → → gentle running in straight line,joggentle running in straight line,jog →→ sudden starts & stops,corners,lat gliding,lat sudden starts & stops,corners,lat gliding,lat

boundingbounding →→ polymetrics-jump ups,downs,stepping back & forth polymetrics-jump ups,downs,stepping back & forth

over a stoolover a stool

Pellegrini–Stieda Pellegrini–Stieda disease disease

Immobilisation Immobilisation

++

Quadriceps Ex. Quadriceps Ex.

LATERAL COLLATERAL LATERAL COLLATERAL LIGAMENTLIGAMENT

Less common, caused by varus strainLess common, caused by varus strain O/E opening of outer side on varus O/E opening of outer side on varus

strain, may be assoc. with avulsion # strain, may be assoc. with avulsion # fibula/lateral tibial condylefibula/lateral tibial condyle

Sprains – muscle exercises + avoid Sprains – muscle exercises + avoid sportssports

Specific Rx not universally acceptedSpecific Rx not universally accepted Complete rupture may be assoc. with Complete rupture may be assoc. with

other lig. injuries – needs repairother lig. injuries – needs repair

MENISCAL MENISCAL INJURYINJURY Ext. rot/ int. rot + abd/add injuryExt. rot/ int. rot + abd/add injury

AspirateAspirate REDUCTION OF LOCKED KNEE:REDUCTION OF LOCKED KNEE: must be done within 24 hrs to prevent must be done within 24 hrs to prevent

loss of elasticityloss of elasticity technique is easy but force should be technique is easy but force should be

guardedguarded long’ traction + rot’ in both long’ traction + rot’ in both

directions+ some valg/varus motion as directions+ some valg/varus motion as knee is extendedknee is extended

(ext. rot + ext – in lat. meniscus, int. (ext. rot + ext – in lat. meniscus, int. rot + ext – in med. meniscus)rot + ext – in med. meniscus)

MENISCAL INJURYMENISCAL INJURY

Repeated unsuccessful manip’ avioded Repeated unsuccessful manip’ avioded to prevent extension of tear into jt to prevent extension of tear into jt spacespace

Immobilise with pressure bandage / Immobilise with pressure bandage / plaster cylinder for 3-4weeks plaster cylinder for 3-4weeks (assuming periph injury) (assuming periph injury)

Quadri’ + hams’ ex, regain full ROMQuadri’ + hams’ ex, regain full ROM Avoid deep knee bends, squats, rapid Avoid deep knee bends, squats, rapid

stair climb/descendstair climb/descend Avoid athletic activities – flex, ext, rotAvoid athletic activities – flex, ext, rot

rehabilitation for 6-8 weeks, and if symptoms persist/ locking- repair

ACL AVULSION ACL AVULSION INJURIESINJURIES

ACL AVULSION INJURIESACL AVULSION INJURIES Flexion + Int. rotation injury, may be Flexion + Int. rotation injury, may be

assoc. with medial lig. Injury, inter assoc. with medial lig. Injury, inter condylar eminence #condylar eminence #

Lachman test, Pivot shift testLachman test, Pivot shift test

Undisplaced # - POP cast (6weeks)Undisplaced # - POP cast (6weeks)

Min. disp.# - CR in ext. + POP cast Min. disp.# - CR in ext. + POP cast

ACL SUBSTANCE ACL SUBSTANCE INJURIESINJURIES

R.I.C.E. (rest, ice, compression, elevation), and NSAID (Caillient)

Aspiration+

Ext. orthosis(6-8 wks), crutches, isomet’ Ext. orthosis(6-8 wks), crutches, isomet’ quadri /hams ex , electrical stimquadri /hams ex , electrical stim

Use of a knee brace. sports with cutting Use of a knee brace. sports with cutting and twisting motions are strongly and twisting motions are strongly discouraged. discouraged.

ACL SUBSTANCE ACL SUBSTANCE INJURIESINJURIES

3-STAGE REHABILITATION (PALETTA): Stage I (7-14 days) : immobilization for

comfort, cryotherapy to control swelling, and crutch ambulation with progressive weight bearing and early ROM exercises

Stage II(2-6 wks): supervised regaining quadriceps strength and restoring normal quadriceps-hamstring balance

Stage III: gradual return to low and mod level demand sporting activities when the strength of the affected extremity approximates that of the unaffected

PCL TEAR PCL TEAR (Sekiya,Giffin,Harner)(Sekiya,Giffin,Harner)

Caused by blow of front of a flexed kneeCaused by blow of front of a flexed knee Undispl. Avulsion # - POP castUndispl. Avulsion # - POP cast

Isolated Grade I &II: protected WB + Isolated Grade I &II: protected WB + quadri ex to counteract post/tibial subluxquadri ex to counteract post/tibial sublux

Recovery rapid(2-6 wks) to sportsRecovery rapid(2-6 wks) to sports

Grade III: immobil’ in ext(2-4 wks)+ Grade III: immobil’ in ext(2-4 wks)+ quadri ex, return to sports after 3 mquadri ex, return to sports after 3 m

DISLOCATION OF THE KNEE DISLOCATION OF THE KNEE JOINTJOINT

Usually assoc. with complete rupture Usually assoc. with complete rupture of med., lat. & cruciate ligts / direct of med., lat. & cruciate ligts / direct violence to head of tibia / indirect twist violence to head of tibia / indirect twist or hyper ext.or hyper ext.

Ant., post., lat., med. & rotatory typesAnt., post., lat., med. & rotatory types

CR + POP cast(6-8weeks) in case of CR + POP cast(6-8weeks) in case of poor GC, skin cond., inadequate poor GC, skin cond., inadequate facility – foll. by surgery later if neededfacility – foll. by surgery later if needed

OSTEOCHONDRAL # & OSTEOCHONDRAL # &

LOOSEBODIESLOOSEBODIES Major loose bodies were the result of Major loose bodies were the result of

osteochondral fractures of either the osteochondral fractures of either the femur (direct blow or twisting femur (direct blow or twisting movement on a weight-bearing flexed movement on a weight-bearing flexed knee) or the patella( 5% disloc) knee) or the patella( 5% disloc) (Rosenberg & Mc Graw)(Rosenberg & Mc Graw)

OSTEOCHONDRAL # & OSTEOCHONDRAL # & LOOSEBODIESLOOSEBODIES

Adolesc boys & young adults ,Adolesc boys & young adults ,

Haemarthrosis, med. retin tear, Loose Haemarthrosis, med. retin tear, Loose body sensation, lockingbody sensation, locking

Undisplaced osteochondral fractures in Undisplaced osteochondral fractures in children often can be treated children often can be treated successfully with conservative successfully with conservative methods – POP cast(4-6 wks)methods – POP cast(4-6 wks)

RUPTURE OF RUPTURE OF EXT.MECHANISMEXT.MECHANISM most commonly caused by fracture of

the patella.

Disruption of quadriceps & patellar tendon are the next common causes.

eccentric overload to the extensor mechanism with the foot planted and the knee partially flexed.

PATELLAR TENDON PATELLAR TENDON RUPTURERUPTURE Patellar tendon rupture or avulsion

common in patients < 40 yrs , especially athletes.

Less common than quadri’ tearLess common than quadri’ tear Common site: jn of distal pole of patellaCommon site: jn of distal pole of patella Rx: Ac.partial tear-immobilisation in ext (2- Rx: Ac.partial tear-immobilisation in ext (2-

3wks)3wks)

Once Once

swelling swelling subsidesubside

bracebrace

PATELLAR TENDON RUPTUREPATELLAR TENDON RUPTURE

PWB in ext with brace(2-3 wks), then PWB in ext with brace(2-3 wks), then gradual FWB in ext, SLR ex startedgradual FWB in ext, SLR ex started

After 4-6 wks: active flex & passive After 4-6 wks: active flex & passive ext exext ex

Knee flex: upto 30Knee flex: upto 30° for first 2 wks ° for first 2 wks then 30°every 2 wksthen 30°every 2 wks

6-8wks:active assist ext ex6-8wks:active assist ext ex >8 wks:prog quadri’ ex>8 wks:prog quadri’ ex Sports: when isokinetic quadri’ is Sports: when isokinetic quadri’ is

90%90%

COMPLICATIONCOMPLICATION (PATELLAR(PATELLAR TENDON RUPTURE)TENDON RUPTURE)

Rerupture of patellar tendonRerupture of patellar tendon

Quadriceps weaknessQuadriceps weakness

Patella altaPatella alta

QUADRICEPS TENDON QUADRICEPS TENDON RUPTURERUPTURE

Quadriceps rupture common in older patients and in those with systemic disease (lupus erythematosus, diabetes, gout, hyperparathyroidism, uremia, and obesity) or degenerative changes or prior steroid injection

Rx: Partial tear- Rx: Partial tear- Immobilise Immobilise

in ext in ext (4-6 Wks), (4-6 Wks), then then gradual gradual prog to prog to active active flexionflexion

FRACTURE PATELLAFRACTURE PATELLA

FRACTURE PATELLAFRACTURE PATELLA Undisplaced/ stellate patella # : Cylinder Undisplaced/ stellate patella # : Cylinder

cast in extension (4-6 wks) , with weight-cast in extension (4-6 wks) , with weight-bearing allowed as toleratedbearing allowed as tolerated

Boström considered Boström considered 3 to 4 mm of 3 to 4 mm of fragment separation and 2 to 3 mm of fragment separation and 2 to 3 mm of articulararticular incongruity to be acceptable for incongruity to be acceptable for nonoperative treatment (Using these nonoperative treatment (Using these criteria in 212 nonoperatively treated criteria in 212 nonoperatively treated fractures, 84 had no pain and 91 had fractures, 84 had no pain and 91 had normal or only slightly decreased normal or only slightly decreased function). function).

Rest types - surgeryRest types - surgery

COMPLICATIONCOMPLICATION(#(# PATELLA)PATELLA)

90% good to excellent results 90% good to excellent results (Brostrom)(Brostrom)

Persistent ext. lagPersistent ext. lag

arthrofibrosisarthrofibrosis

INJURIES TO INJURIES TO TIB.TUBERCLE & OSGOOD TIB.TUBERCLE & OSGOOD SCHLATTER’SSCHLATTER’S

INJURIES TO INJURIES TO TIB.TUBERCLE & OSGOOD TIB.TUBERCLE & OSGOOD SCHLATTER’SSCHLATTER’S Being apex of triangular insertion Being apex of triangular insertion

takes first strain of ext. injurytakes first strain of ext. injury

# in adult : usually cracked/ # in adult : usually cracked/ mildly avulsed with ext. mech. mildly avulsed with ext. mech. intact- short immobilisation foll. intact- short immobilisation foll. by active ex. ,avoid stretchingby active ex. ,avoid stretching

AVULSION -TIBIAL AVULSION -TIBIAL EPIPHYSISEPIPHYSIS

Forcible flexion against resisting Forcible flexion against resisting quadriquadri

< 18 yrs< 18 yrs 4 types- undisplaced,4 types- undisplaced,

complete, complete,

partly avulsed,partly avulsed,

avulsed with wide areaavulsed with wide area

EPIPHYSISEPIPHYSISAVULSION -TIBIALAVULSION -TIBIAL

RxRx

All except complete can be manipulated All except complete can be manipulated with cast in ext (6-8 wks)with cast in ext (6-8 wks)

AVULSION -TIBIAL AVULSION -TIBIAL EPIPHYSISEPIPHYSIS

OSGOOD SCHLATTER’SOSGOOD SCHLATTER’S Before fusion (18 yrs) epi. line is weak Before fusion (18 yrs) epi. line is weak

pt in ext mechpt in ext mech

Flexion against quadri resistanceFlexion against quadri resistance

simple conservative measures such as simple conservative measures such as the restriction of activities or cast the restriction of activities or cast immobilization for 3 to 6 weeks immobilization for 3 to 6 weeks (Krause, Williams, and Catterall) (Krause, Williams, and Catterall)

osdosd

Contoured knee pad during sportsContoured knee pad during sports Quadri & hams flexibility ex to Quadri & hams flexibility ex to

decrease patellar forcesdecrease patellar forces Avoid prolonged squat/kneeling-Avoid prolonged squat/kneeling-

change of team positionchange of team position

COMPLICATION:COMPLICATION:

Prominence of tubercleProminence of tubercle

persisting symptoms & nonunionpersisting symptoms & nonunion

reactive bursitisreactive bursitis

DISLOCATION OF DISLOCATION OF PATELLAPATELLA If capsule is lax, poorly developed lat. fem If capsule is lax, poorly developed lat. fem

condyle-tibia is forcibly abd +lat condyle-tibia is forcibly abd +lat rot/glancing blow on med side of patella, rot/glancing blow on med side of patella, when thigh mcs is relaxed-cause dislocationwhen thigh mcs is relaxed-cause dislocation

CR + knee immobilizer/ cast for 2-6 wks. CR + knee immobilizer/ cast for 2-6 wks.

Early range of motion - prevent Early range of motion - prevent arthrofibrosis and to promote the formation arthrofibrosis and to promote the formation of strong collagen along the lines of stress. of strong collagen along the lines of stress.

COMPLICATIONCOMPLICATION(DISLOCATION OF(DISLOCATION OF PATELLA)PATELLA)

Usually good to excellent results (91%)Usually good to excellent results (91%)

Recurrent sublux/dislocation (15-49%)-Recurrent sublux/dislocation (15-49%)-brace with lat. Padbrace with lat. Pad

Feeling of instability (20%)Feeling of instability (20%) Anterior knee pain (75%)Anterior knee pain (75%) OAOA stiffnessstiffness

INTRA ARTICULAR # INTRA ARTICULAR # DISTAL DISTAL FEMUR FEMUR Reduced by simple traction + manual Reduced by simple traction + manual

compression of fragments between compression of fragments between hands foll. by simple /UT Pin traction on hands foll. by simple /UT Pin traction on thomas splint(4-5 wks) foll. by hinged thomas splint(4-5 wks) foll. by hinged cast brace till unioncast brace till union

Maintain good reduction + ext. ex to Maintain good reduction + ext. ex to prevent residual flex deformityprevent residual flex deformity

Dis adv: long IP stayDis adv: long IP stay

INTRA ARTICULAR # INTRA ARTICULAR # DISTAL DISTAL FEMURFEMUR

COMPLICATIONCOMPLICATIONMalunion - fix flex defMalunion - fix flex defArthrofibrosisArthrofibrosisTraction problems-pintract Traction problems-pintract infection,bedsore infection,bedsore

TIBIAL PLATEAU # TIBIAL PLATEAU # DISLOCATIONDISLOCATION (Hohl and Moore) (Hohl and Moore)

TIBIAL PLATEAU #TIBIAL PLATEAU #

TREATMENT depression <5 mm in stable #:depression <5 mm in stable #:

early motion in a hinged knee brace / early motion in a hinged knee brace / POP cast and delayed weight-bearing POP cast and delayed weight-bearing

depression 5 to 8 mm:depression 5 to 8 mm: elderly and sedentary- nonoperative elderly and sedentary- nonoperative

treatment young or active - surgical treatment young or active - surgical reconstruction reconstruction

Non op Rx: Distal tibial pin traction + Non op Rx: Distal tibial pin traction + mobilisation on traction (3 rd wk) + mobilisation on traction (3 rd wk) + hinged cast brace after 4-6 wkshinged cast brace after 4-6 wks

rr

TIBIAL PLATEAU #TIBIAL PLATEAU #

COMPLICATIONCOMPLICATION

MalunionMalunion Nerve injury / compartment syndNerve injury / compartment synd Residual instabilityResidual instability OAOA ArthrofibrosisArthrofibrosis

Traction/cast problems - pintract Traction/cast problems - pintract infection, bedsoreinfection, bedsore etc.,etc.,

CONCLUSIONCONCLUSION Operative treatment is not only

option

Proper selection, constant vigilance, timely mobilisation of jts give as equal result as operative Rx

Rehabilitation should focus on functional treatment rather than electrotherapy