EXTERNCONFERENCEEXT. UPRIMPORN SUTHIWONG

CHIEF COMPLAINT ผปวยชายไทยค อาย 41 ป อาชพ รบจางมอาการปวดบรเวณเขาขวา 7 ชวโมง กอนมาโรงพยาบาล

PRESENT ILLNESS

7 ชวโมงกอนมาโรงพยาบาล ขณะทผปวยกำาลงยกกระสอบขาวสารหนกประมาณ 35 กโลกรม ไดหยดยนพรอมเอยวตวไปทางขวา หลงจากนนรสกไดยนเสยงดง กรอบ ในขอเขาดานขวาทนท ‘ ’เขาขวาเรมบวมขน จากนนพอเดนกะเผลกได ลงนำาหนกพอได รสกปวดแบบตงๆทเขาขวา โดยรสกวาปวดเขาทางดานขางมากกวา สงเกตวาเขาขวาบวมมากขน จงมาโรงพยาบาล

PAST HISTORY ปฏเสธประวตโรคประจำาตว (ไมเคยตรวจสขภาพ

ประจำาป) ปฏเสธประวตไดรบอบตเหตกระทบกระแทกทบรเวณ

เขามากอนหนาน ไมเคยมอาการเชนนมากอน ไมเคยมอาการขอเขา

หลวม ปฏเสธประวตเลอดออกงายหรอหยดยากกอนหนาน ปฏเสธประวตผาตด ปฏเสธประวตแพยา/แพอาหาร

PERSONAL HISTORY & FAMILY HISTORY

Social drinking ปฏเสธประวตสบบหร ปฏเสธประวตโรคทางพนธกรรม โดยเฉพาะ

โรคเลอดออกงายในครอบครว

PHYSICAL EXAMINATION V/S : BT 37 c, PR 100 bpm, BP 130/85

mmHg, RR 18 bpm GA : good consciousness, well co-

operated, not pale, no jaundice HEENT : not pale conjunctivae, anicteric

sclerae Heart : pulse full and regular, normal

S1S2, no murmur Lungs : clear both lungs Abdomen : soft, not tender

PHYSICAL EXAMINATION (Cont.) Extremities : Right knee-- marked

swelling, no ecchymosis, no erythema, mild tender at lateral > medial side, Ballottement positive, slightly limit ROM, neurovascular intact

PHYSICAL EXAMINATION (Cont.) Lachmann’s test negative 

Pivot shift test negative Posterior drawer test negative Valgus stress test negative Varus stress test negative McMurray test negative

Imaging

Film right knee AP, Lateral

DIAGNOSIS Hemarthrosis suspected from knee

ligament injury

MANAGEMENT

Posterior long leg slab at Lt. leg

LIGAMENT & MENISCUS INJURY

ANATOMY

HISTORY TAKING Machanism of injury Location of pain Onset of swelling Instability Locking Felt sound in joint

PHYSICAL EXAMINATION Inspection and palpitation:

Erythema, swelling, bruising and diiscoloration

Palpating and checking for pain, warmth, and effusion

Point tenderness Patella, tibial tubercle, patella tendon,

quadriceps tendons, anterolateral and anteromedial joint line, medial joint line, and lateral joint line

Range of motionExtending and flexing the knee as far as

possible

SPECIAL EXAMINATION Anterior cruciate ligament

Pivot shift test

Anterior drawer test

Lachmann’s testGradingA= firm endpoint, B= no endpointGrade 1: 3-5 mm translationGrade 2 A/B: 5-10mm translationGrade 3 A/B: > 10mm translation

SPECIAL EXAMINATION Posterior cruciate ligament

Posterior drawer test Posterior

sagging

SPECIAL EXAMINATION Medial collateral ligament

Valgus stress test

SPECIAL EXAMINATION Lateral collateral ligament

Varus stress test

SPECIAL EXAMINATION Meniscus

McMurray test ในทา internal rotation (การตรวจ lateral meniscus tear)

McMurray test ในทา external rotation(การตรวจ medial meniscus tear)

SPECIAL EXAMINATION Meniscus

Apley’s compression test

Apley’s distraction test

IMAGING

MRI arthroscopy

MANAGEMENT ACL injury : Nonoperative

physical therapy & lifestyle modificationslow demand patients with decreased laxityincreased meniscal/cartilage damage linked to

loss of meniscal integrityfrequency of buckling episodeslevel I and II activity (e.g. jumping,

cutting, side-to-side sports, heavy manual labor)

MANAGEMENTOperative

ACL reconstructionindications

younger, more active patients (reduces incidence of meniscal or chondral injury)

children (strongly consider operative as activity limitation is not realistic)

older active patients (age >40 is not contraindication if high demand athlete)

prior ACL reconstruction failureassociated injuries

MCL injurymeniscal tear

MANAGEMENTligament repair

traditionally has high failure ratearthroscopic bridge-enhanced ACL

repair (BEAR) trial with a bridging scaffold is ongoing  

revision ACL reconstructionindications

failure of prior ACL reconstruction

MANAGEMENT PCL injury : Quadriceps exercise, reconstruction MCL injury : isolated MCL injury cylindrical cast 2

wks. then progressive range of motion exercise and strengthening exercise (return to function in 3-4 wks.)

LCL injury : isolated LCL injury ice pack 1-2 days and apply knee brace 2-4 weeks to prevent varus stress

MANAGEMENT Meniscus injuryNon-operative : rest, NSAIDS, rehabilitation

Indications : indicated as first line of treatment for degenerative tears

MANAGEMENTOperative

partial meniscectomyindications

tears not amenable to repair (complex, degenerative, radial tear patterns)

repair failure >2 timesoutcomes

>80% satisfactory function at minimum follow-up

predictors of successage <40yonormal alignmentminimal or no arthritissingle tear

MANAGEMENT meniscal repair 

indicationsperipheral in the red-red zone

(vascularized region)  rim width is the distance from the tear

to the peripheral meniscocapsular junction (blood supply).

rim width correlates with the ability of a meniscal repair to heal (lower rim width has better blood supply)  

vertical and longitudinal tear rather than radial, horizontal or degenerative tear

1-4 cm in lengthacute repair combined with

ACL reconstructionOutcomes

70-95% successful

meniscal transplantation indications  

young patients with near-total meniscectomy, especially lateral contraindications

inflammatory arthritis instability marked obesity grade IV chondrosis (if not concurrently addressed) malalignment (if not concurrently addressed) diffuse arthritis

technique (see below) outcomes

requires 8-12 months for graft to fully heal return to sports by 6-9 months  10 year follow-up showed:

persistent improvement in subjective pain and function scores most had radiographic progression of degenerative changes

re-tears or extrusion are common 

total meniscectomy

of historical interest only outcomes

20% have significant arthritic lesions and 70% have radiographic changes three years after surgery

100% have arthrosis at 20 years severity of degenerative changes is proportional to % of the meniscus that

was removed

MANAGEMENT meniscal transplantation

indications  : young patients with near-total meniscectomy, especially lateral

contraindicationsinflammatory arthritisinstabilitymarked obesitygrade IV chondrosis (if not concurrently

addressed)malalignment (if not concurrently

addressed)diffuse arthritis

MANAGEMENToutcomes

requires 8-12 months for graft to fully healreturn to sports by 6-9 months 10 year follow-up showed:

persistent improvement in subjective pain and function scores

most had radiographic progression of degenerative changes

re-tears or extrusion are common  total meniscectomy

outcomes20% have significant arthritic lesions and 70%

have radiographic changes three years after surgery

100% have arthrosis at 20 yearsseverity of degenerative changes is proportional

to % of the meniscus that was removed

เอกสารอางอง

ORTHOBULLETS Orthopedic trauma ,อ.ธรชย อภวรรธก

กล