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Updated: Nov 30 2019

Anterior Cruciate Ligament (ACL) Injury

Images insertion.jpg contusion.jpg
  • Snapshot
    • A 21-year-old man presents to the emergency department for severe pain in the right knee. A few hours prior to presentation, an opposing football player hits his leg from his right side. Afterwards, he felt a "pop" sound that was followed by severe knee pain and a sensation of knee instability. On physical exam, there is anterior translation of the proximal tibia when pulled as the patient has the knee flexed at 90° and supine. Ice is applied to the knee and ibuprofen is prescribed. Orthopedic surgery is consulted to evaluate if ligamental reconstruction is needed.
  • Introduction
    • Clinical definition
      • injury in the form of tear or rupture affecting the anterior cruciate ligament (ACL) in the knee
    • Associated conditions
      • unhappy triad which consists of injury to the
        • ACL
        • medial collateral ligament
        • medial meniscus
  • Prognosis
    • The majority of athletes are able to return to their sports activities with ACL reconstruction
  • Epidemiology
    • Incidence
      • non-contact ACL injuries are more common
    • Demographics
      • more common in female athletes
    • Risk factors
      • sports (e.g., football, soccer, skiers, and basketball)
      • motor vehicle accidents
    • Pathoanatomy
      • Pathology
        • contact mechanisms
          • injury that causes hyperextension or valgus deformation of the knee
            • e.g., football injury
          • high-speed motor vehicle accident
        • non-contact mechanisms
          • changing direction, pivoting, or landing that leads to rotation or valgus stress of the knee after sudden deceleration
      • Normal anatomy
        • the ACL course
          • originates in the posteromedial aspect of the lateral femoral condyle
          • reaches the anteromedial aspect of the tibia
        • the ACL plays an important role in knee stability
          • it controls anterior translation of the tibia
            • it also restrains against tibial rotation, varus, and valgus stress
  • Presentation
    • Symptoms
      • feeling a "pop" in the knee
        • thereafter, there is acute swelling and pain
      • instability or "giving out" knee
    • Physical exam
      • anterior drawer test
        • the proximal tibia is anteriorly pulled while the patient is supine and the knee is flexed at 90 degrees
          • if there is anterior translation then the test is positive
      • Lachman test
        • the proximal tibia is anteriorly pulled with one hand, while the other hand stabilizes the distal femur while the knee is flexed at 30 degrees
      • hemarthrosis
  • Imaging
    • Magnetic resonance imaging (MRI)
      • indication
        • an imaging modality that can confirm the diagnosis
        • if reconstruction is a possibility or to identify concomitant knee pathology
  • Studies
    • Making the diagnosis
      • can be made based on typical clinical presentation alone
      • can be confirmed by MRI or knee arthroscopy
  • Differential
    • Meniscal tear
      • differentiating factor
        • patients can have a positive
          • Thessaly test
          • McMurray test
          • Apley test
    • Posterior collateral ligament (PCL) injury
      • differentiating factor
        • patients can have a positive posterior drawer test
  • Treatment
    • Conservative
      • rest, ice, compression, and elevation (RICE) therapy
        • indication
          • management to reduce pain, edema, and hemarthrosis in the acute stage of the injury
            • nonsteroidal anti-inflammatory drugs are typically added
    • Operative
      • surgical reconstruction
        • indications
          • performed in
            • young and active patients with high demand sports or jobs
            • significant knee instability
              • such as injuries affecting multiple knee structures (e.g., unhappy triad)
  • Complications
    • Osteoarthritis
    • Arthrosis
    • Sports disability
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