Essentials of Orthopedic Surgery, third edition / 14-Answers to Questions

566 M.A. Haque

FIGURE 1. This is a typical extended posture of the ring finger after an FDP tendon avulsion or laceration.

back through the pulley system (see Fig. 2), and reattaching it to bone with a pull-out suture going through the distal phalanx and tied over a button on the dorsum of the nail (see Figs. 3, 4). He started a passive flexion range

FIGURE 2. Surgical exposure: The avulsed tendon (with a suture attached) has been mobilized through the pulley on the right and is ready for reattachment to the bony bed of the distal phalanx on the left.

Flexor Tendon Avulsion

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FIGURE 3. The reattached tendon.

FIGURE 4. The pullout suture is tied dorsally over an acrylic button after being passed throught the distal phalanx and the nail.

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FIGURE 5. The active range of motion 3 months after surgery.

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of motion protocol with therapy on postoperative day 1, and he advanced to full use of the finger (including sports) over 3 months. His final result was excellent with only a slight flexion contracture of the DIP joint and full flexion of the digit (Fig. 5).

Discussion

Avulsions of the flexor digitorum profundus (FDP) tendon are also known as jersey fingers because they frequently occur when patients are trying to grasp an opponent’s jersey to make a tackle. The eccentric extension load on the actively flexing digit leads to failure of the FDP tendon insertion into the distal phalanx. The Leddy and Packer classification categorizes these injuries by the level of retraction of the tendon and the presence or absence of a distal phalanx fracture. The treatment of choice is surgical fixation, either through reattachment of the tendon to bone using a pull-out suture through bone, a bone anchor, or newer tendon repair systems. This repair is optimally done within a few days of injury to limit retraction and scarring of the tendon. After flexor tendon repairs, early protected motion and an extensive therapy protocol are necessary to avoid severe problems with stiffness.

Acute Anterior Cruciate Ligament Rupture with Strain of the Medial Collateral Ligament

JOHN J. KLIMKIEWICZ

History

This patient is a 20-year-old college football player who sustained an injury to his left knee. He is a lineman and stated another player had fallen on the lateral aspect of his left knee. He stated that his knee was extended at the time of the injury and described a “pop” within his knee. He was unable to continue playing, and required assistance off the field. He stated that his knee subsequently swelled over the next few hours and is currently unable to bear weight without significant discomfort. He denies any prior injury to his knee.

Physical Examination

His height is 6 feet 3 inches and his weight 245 lbs. He is unable to ambulate without crutches. His knee shows no signs of bruising or ecchymoses. His range of motion is 5 degrees to 90 degrees of flexion. He has a significant effusion (see Fig. 1). There is no patellar tenderness and no crepitation with range of motion, and no patellar apprehension. Patient has tenderness over the medial epicondyle of the distal femur and over the lateral joint line. There is no medial joint line tenderness. McMurray sign is positive for pain at 90 degrees of flexion over the lateral joint line. He is stable to varus stress maneuvers at both full extension and 30 degrees of flexion. Although stable to valgus stress maneuvers in full extension, at 30 degrees the patient has 1+ laxity with pain during this maneuver. He has a grade

II Lachman with no endpoint, and also has grade II laxity to anterior drawer maneuvers at 90 degrees of flexion. There is a positive pivot shift. There is no increased laxity to posterior drawer maneuver at 90 degrees of flexion. His neurologic examination and vascular examination are unremarkable.

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FIGURE 1. Acutely swollen knee after injury.

Radiographic Evaluation

Posteroanterior weight-bearing and lateral radiographs demonstrate no abnormality (see Figs. 2, 3). Magnetic resonance imaging (MRI) demonstrates disruption of the anterior cruciate ligament (see Fig. 4), in combination with partial injury of the medial collateral ligament (see Fig. 5). There is also a tear of the lateral meniscus.

Treatment

This patient has sustained a complete rupture to the anterior cruciate ligament (ACL) associated with a grade II strain of the medial collateral ligament (MCL) and lateral meniscal tear. As the patient is young and athletic, the preferred treatment would include initial physical therapy to regain full motion, followed by surgical reconstruction of the anterior cruciate ligament and lateral menisectomy versus repair (see Figs. 6, 7). This intervention is usually performed after 4 to 6 weeks of physical therapy to allow the medial collateral ligament to heal and for the patient to regain full

FIGURE 2. Posteroanterior radiograph of knee.

FIGURE 3. Lateral radiograph of knee.

FIGURE 4. Magnetic resonance image (MRI) of knee demonstrating anterior cruciate ligament (ACL) injury.

FIGURE 5. MRI of knee demonstrating medial collateral ligament (MCL) injury.

FIGURE 6. Arthroscopic view of ACL reconstruction using patellar tendon autograft for reconstruction.

FIGURE 7. Arthroscopic view of lateral meniscal repair.

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range of motion. Although different graft options exist to reconstruct the anterior cruciate ligament, a central third patellar tendon autograft was chosen. Intense physical therapy is necessary postoperatively to allow a return to sport at 6 months after the procedure.

Discussion

This patient suffered an injury to the ACL, MCL, and lateral meniscus. The mechanism for this injury involved a valgus load to the extended knee. The patient often recalls hearing a pop that is shortly followed by significant swelling. There is often an immediate inability to ambulate or a significant antalgic (painful) gait. These injuries can also be associated with injuries to the collateral ligaments and injuries to the menisci or articular cartilage. This patient suffered the triad of injuries that include: an ACL rupture, strain or rupture of the MCL, and a lateral meniscal tear.

This patient’s examination is significant for increased laxity to anterior stress tests including the Lachman exam at 30 degrees and anterior drawer at 90 degrees. These tests are categorized by grades based on the degree of translation. Grade I injuries are those with laxity 0 to 5 mm greater than the contralateral side, grade II, 5 to 10 mm, and grade III, more than 10 mm. There is also a positive pivot shift that results when a valgus load is applied to the knee through a range of motion, and there is a palpable shift at 30 degrees to full extension when the tibia translates from an unreduced position secondary to ACL disruption to a reduced position in full extension. This is pathognomonic for an ACL rupture. This patient also demonstrates a partial injury to his MCL with pain at its origin (medial epicondyle). Grade I injuries involve a strain with no increased laxity on exam, grade II injuries involve increased laxity with an endpoint of this structure, and grade III injuries involve increased laxity of this structure with no endpoint present, thus representing a complete tear. This was the case for this patient. The presence of lateral joint line tenderness with a positive McMurray test is consistent with the lateral meniscal tear.

Current treatment for anterior cruciate ligament injuries involves an initial period of physical therapy to emphasize range of motion and modalities to decrease swelling. After this initial period of rest, a reconstruction is the recommended form of treatment to allow the patient to return to cutting sports. Conservative modification of activity and bracing can be considered for less active individuals. Reconstruction can be performed with the patient’s own tissue (autograft) or through the use of cadaveric tissue (allograft). At the time of surgery, associated injuries to the articular cartilage or meniscus are also addressed. This patient sustained a tear of the lateral meniscus in the vascular zone of this structure, making meniscal