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PubMed1999

Communicating defects of the triangular fibrocartilage complex without disruption of the triangular fibrocartilage: a report of two cases.

Perforations or communicating defects of the triangular fibrocartilage complex have been more commonly identified after Palmer published his classification system (J Hand Surg 1989;14A:594-606). To his variants of class 1B (traumatic) ulnar avulsion with or without distal ulnar fracture, a third category may be added: defects of the ulnar collateral ligament without any associated disruption of the triangular fibrocartilage. The ulnar collateral ligament can be defined as an ulnar capsular structure between the more discrete elements of the triangular fibrocartilage and the ulnar ligaments, with the defect or perforation being distal to the intact triangular fibrocartilage and exiting into the floor of the extensor carpi ulnaris sheath. We present 2 cases that illustrate the diagnosis, the use of both magnetic resonance imaging and arthrography to confirm the diagnosis, the associated dorsal ulnar cutaneous nerve pain distribution, and the open direct and retinacular flap repair.

Adult↗
PubMed1979

Ligament injuries in the knees of children.

Injuries of the medial collateral ligament in children are rarely reported. We are describing six tears of the medial collateral ligament in which an operative repair was done. The patients' ages were six to eleven years. Five were boys and one, a girl. The follow-up (seven months to thirteen years) showed normal results in three; good, in two; and fair, in one. Three patients also had had an injury to the anterior cruciate ligament or an avulsion injury to the anterior tibial spine.

Child↗
PubMed2001

An uncommon injury of the thumb.

Ulnar collateral ligament rupture of the thumb is a relatively common injury that is often missed in the emergency department. This in combination with an interphalangeal joint dislocation of the ipsilateral thumb is rare and we report such a case. The importance of looking specifically for an associated ulnar collateral ligament laxity in any injury to the thumb is highlighted. The force producing a combination of ulnar collateral ligament rupture with ipsilateral simultaneous injury to the thumb is often severe enough to cause complete rupture of the ligament, necessitating open repair.

Accidental Falls↗
PubMed1997

The Norway elbow replacement. Design, technique and results after nine years.

The Norway elbow prosthesis is a non-constrained cemented total replacement. It depends on intact collateral ligaments for stability, and allows a full range of movement. The system includes several sizes of components, all freely interchangeable, and semi-constraint can be provided by a locking ring if damaged collateral ligaments make dislocation possible. The prosthesis has been used in more than 350 elbows in Norway and the detailed results for 118 elbows studied prospectively since 1987 are reported. It is inserted through a posterolateral triceps-splitting incision with minimal muscle disruption and bone resection, preserving the collateral ligaments. The results as regards pain relief and range of movement were comparable with those of other elbow prostheses, but there were fewer serious complications. At a mean follow-up of 4.3 years, the failure rate was 3.4%.

Adult↗
PubMed1998

In situ forces in the posterolateral structures of the knee under posterior tibial loading in the intact and posterior cruciate ligament-deficient knee.

The posterolateral structures of the knee consist of a complex anatomical architecture that includes several components with both static and dynamic functions. Injuries of the posterolateral structures occur frequently in conjunction with ruptures of the posterior cruciate ligament. To investigate the role of the posterolateral structures in maintaining posterior knee stability, we measured the in situ forces in the posterolateral structures and the distribution of force within the structures' major components, i.e., the popliteus complex and the lateral collateral ligament, in response to a posterior tibial load. Eight cadaveric knees were tested. With use of a robotic/universal force-moment sensor testing system, a posterior tibial load of 110 N was applied to the knee, and the resulting five-degree-of-freedom kinematics were measured at flexion angles of 0, 30, 60, 75, and 90 degrees. The knees were tested first in the intact state and then after the posterior cruciate ligament had been resected. These tests were also performed with an additional load of 44 N applied at the aponeurosis to simulate contraction of the popliteus muscle. In the intact knee, the in situ forces in the posterolateral structures were found to decrease with increasing knee flexion. After the posterior cruciate ligament was sectioned, these forces increased significantly at all angles of flexion. With no load applied to the popliteus muscle, the in situ forces in the popliteus complex were similar to those in the lateral collateral ligament. However, with a load of 44 N applied to the popliteus muscle, in situ forces in the popliteus complex were three to five times higher than those in the lateral collateral ligament. These results reveal that in response to posterior tibial loads, the posterolateral structures play an important role at full extension in intact knees and at all angles of flexion in posterior cruciate ligament-deficient knees. The popliteus muscle appears to be a major stabilizer under this loading condition; thus, the inability to restore its function may be a cause of unsatisfactory results in reconstructive procedures of the posterolateral structures of the knee.

Aged↗
PubMed1989

[Skier's thumb].

Over a period of 9 years (1979-1988), more than 1000 patients have been seen in the Department of Hand Surgery with a tentative diagnosis of skier's thumb or a painful metacarpophalangeal of the thumb. Most injuries were treated conservatively, but 562 operations on the ulnar collateral ligament were done during this period. An X-ray Film was taken in all cases to exclude a fracture. The indications for an operation depend on the clinical symptoms. Swelling, pain just over the ulnar collateral ligament, and instability of the joint with a widening of the ulnar aspect of the joint of more than 30 degrees in comparison to the other hand are typical clinical symptoms, which together with the widening in the flexion position, prove a rupture of the collateral ligament. As part of our standard examination we take X-ray films of the hand in two projections to exclude a fracture, followed by abducted stress views in comparison to the other side. The best results were obtained when surgical therapy was performed within the first 8 days. Fractures of the base of the proximal phalanx of the thumb were operated on by pin wire fixation of the bone fragment in the anatomically correct position along with temporary transarticular pin wire arthrodesis. In ligamentous ruptures, periostal sutures together with a temporary arthrodesis were carried out. Old injuries without sufficient regeneration of the ligament and capsule necessitated plastic surgery using the long pulmar tendon or a PDS wire. In each case the joint was immobilized with a cast for 5-6 weeks, followed by active physiotherapy.

Adolescent↗
PubMed1994

Knee injuries and Alpine skiing. Treatment and rehabilitation.

Alpine skiing is an increasingly popular recreational sport worldwide. While the overall injury rate has declined and the pattern of injury changed over the years, the incidence of knee injuries has not changed substantially and accounts for 20 to 30% of all alpine skiing injuries. Medial collateral ligament (MCL) injuries are the most common in skiing, accounting for 15 to 20% of all skiing injuries and 60% of knee injuries in skiers. Tears are commonly isolated, but may occur in association with other ligamentous injuries. Associated meniscal pathology is rare. Isolated MCL injuries are treated nonoperatively with a programme of initial immobilisation, early range-of-motion, and isometric quadriceps strengthening exercises. When full range of motion is achieved, a programme of progressive resistance exercises, isokinetic and closed chain exercises, and functional rehabilitation is instituted. Good results with return to skiing can be expected in most cases. Isolated lateral collateral ligament (LCL) injuries are rare in skiers. There is usually associated cruciate or arcuate ligament complex. Careful physical examination is essential to rule out associated ligament injuries and more complex instability patterns. In the rare case of isolated LCL injury, a similar approach to isolated MCL injury should be instituted. Anterior cruciate ligament (ACL) injuries have become increasingly common in skiers. This may reflect a true increase in the incidence or an improved awareness and ability to diagnose ACL injury. Physical examination and arthrometric analysis are important in assessing the integrity of the ACL. Radiographic and magnetic resonance imaging (MRI) evaluation may be helpful in assessing associated meniscal pathology. Treatment of the ACL-deficient knee is usually surgical. However, prior to reconstruction, a programme aimed at reducing effusion and regaining a full, pain-free range of motion is recommended. Surgical reconstruction is usually with the central third of the patella tendon using a bone-tendon-bone autograft. Postoperative rehabilitation employs a functional staged approach, requiring vigilant supervision by the surgeon. Isolated posterior cruciate ligament (PCL) injury is rare in skiing, constituting less than 1% of all knee injuries in most series. Careful physical examination must be employed to rule out associated arcuate ligament complex injury and more complex patterns of instability. Most isolated PCL injuries are treated nonoperatively with a programme of initial immobilisation in extension, ice, protected weight-bearing, early range-of-motion exercises and progressive isometric strengthening.(ABSTRACT TRUNCATED AT 400 WORDS)

Anterior Cruciate Ligament Injuries↗
PubMed2000

[Malleolar fractures. Predictive factors for secondary osteoarthritis. Retrospective study of 32 cases].

The authors report a series of 32 ankle fractures treated by internal fixation and reviewed with a follow-up of more than 15 years. The series includes 12 fibular, 14 bimalleolar and 6 trimalleolar fractures. Following Weber's classification, there were 4 type A, 18 type B and 10 type C fractures. The postoperative x-ray showed 28 anatomy reductions; shortening of the fibula from 3 to 5 mm was noted in 4 cases. Clinical results were evaluated according to Kitaoka's criteria, and radiological results according to Magnusson's criteria. Statistical analysis was made with a Chi-square test. The retrospective review at an average follow-up of 15 years showed 19 painfree ankles, normal mobility in 22 cases, absence of edema in 18. The shoe-wear was normal in 30 cases. Walking had returned to normal in 23 cases but radiography showed narrowing of the tibiotalar joint line in 12 cases and lengthening of the medial malleolus in 16. Narrowing of the tibiotalar joint space was associated with lengthening of the medial malleolus in 10 cases. The objective results were rated as follows: 23 good, 8 fair, and 1 poor. With a follow-up of 15 years, we noted degenerative changes in the ankle in 37% of cases in spite of an anatomic reconstruction which had been perfect in 28. Shortening of the fibula, observed in 4 cases, was associated with subsequent ossification below the medial malleolus corresponding to avulsion of the non sutured medial collateral ligament. Nevertheless, degenerative changes of the ankle were clinically well-tolerated. The long term result of internal fixation of malleolar fractures was good. This was achieved only through perfect restoration of the joint anatomy. Contrary to other series, non-operative repair of the medial collateral ligament was associated with long team degenerative changes and reduced mobility of the joint. We therefore now advocate surgical repair of the medial collateral ligament.

Adult↗
PubMed2001

Simulated active control produces repeatable motion pathways of the elbow in an in vitro testing system.

The purpose of this study was to determine if the repeatability and pattern of elbow kinematics are affected by changing the relative magnitudes of loads applied to muscles around the elbow in vitro. In eight cadaveric upper extremities, passive and three methods of simulated active elbow flexion were tested with the forearm maintained in both pronation and supination. Passive flexion involved moving the elbow manually through a full arc of motion. Simulated active flexion used a custom designed loading system to generate elbow motion by applying loads to various tendons via pneumatic actuators. Three different simulated active loading protocols, with loading ratios based on muscle activity and physiologic cross-sectional area, were tested. Testing was performed initially on an intact elbow, and then an unstable elbow model created by transection of the lateral collateral ligament (i.e. the radial and lateral ulnar collateral ligaments). An electromagnetic tracking device was used to measure rotation of the ulna relative to the humerus. Varus-valgus angulation and internal-external rotation were less repeatable during passive flexion than simulated active flexion, regardless of the loading ratio used, in both the intact (p<0.05) and unstable (p<0.05) elbows. Throughout the arc of flexion, the motion pathways were similar for the three simulated active motion protocols employed in this study (p>0.05). The pathways followed during passive motion were different from those generated with simulated active motion, especially in the unstable elbow with the forearm supinated (p<0.001). These results suggest that using simulated active motion rather than manual passive motion can improve the repeatability of elbow kinematics generated in the laboratory, and that a wide range of muscle loading ratios may produce similar kinematic output.

Aged↗
PubMed1994

Adhesion strength of human ligament fibroblasts.

The adhesive interactions of cells with other cells and the extracellular matrix (ECM) play a fundamental role in the organization of cells in differentiated organs, cell motility, and the healing process. The adhesion characteristics of ligament fibroblasts depend on the expression of cell surface molecules and their interaction with the ECM. Although many receptors mediating the effects of ECM components on ligament cell function remain poorly defined, it is known that fibronectin (FN) allows ligament cells to adhere through the VLA-5 receptor (alpha 5 beta 1). A direct measurement of the adhesion between anterior cruciate ligament (ACL) or medial collateral ligament (MCL) fibroblasts and fibronectin matrix proteins was achieved by using a micromanipulation technique to determine the force required to detach an ACL or MCL cell from fibronectin-coated glass. We have found that the adhesion strength is not random, but has well-defined functional relationships with the FN concentration and the seeding time (time allowed for the cell to establish attachment). The adhesion strength (i.e., force required to detach) of ACL cells shows a stronger dependence on FN concentration (1, 2, and 5 micrograms/ml) for short seeding times (15-30 min) than for long seeding times (38-75 min). For MCL cells, the effect of the seeding time on adhesion strength was apparent for all concentrations. For all the seeding times studied and FN concentrations used, MCL cells had higher adhesion strength than ACL cells. The adhesion strengths of ACL and MCL fibroblasts to FN are correlated to cell adhesion area.(ABSTRACT TRUNCATED AT 250 WORDS)

Anterior Cruciate Ligament↗
PubMedDate not supplied

Functional cast immobilization of thumb metacarpophalangeal joint injuries.

A prospective study was performed on 40 patients who were treated with a modified thumb spica cast (MTSC) for injuries involving the region of the metacarpophalangeal joint of the thumb. Twenty-seven of these injuries occurred during sports participation. The immobilization consisted of a fiberglass cast which incorporated the thumb in a balanced position and allowed full flexion and extension of the wrist. Twenty patients had injuries involving the ulnar collateral ligament (five surgical). Three patients had radial collateral ligament injuries (two surgical). Fourteen patients had fractures of the proximal phalanx, including five epiphyseal plate injuries. Two patients had dorsal dislocations and one patient had a metacarpal fracture. One patient with a nondisplaced distal metacarpal fracture was treated with simple immobilization. All patients had successful completion of their treatment within the usual time frame. There was no recurrence or increase in symptomatology during the treatment. There was no residual discomfort, loss of position or malunion of the fractures treated. The advantages of the MTSC include improved functional capabilities during immobilization, good patient acceptance, and no period of limited wrist motion or atrophy of forearm musculature. Our experience has been that the MTSC has been a reliable form of immobilization for treating injuries of the metacarpophalangeal joint of the thumb.

Adolescent↗
PubMed1996

Injuries in cross-country skiing: a critical appraisal of the literature.

This study comprehensively reviews and critically appraises recent literature on cross-country skiing injuries. Particular attention was paid to the study design when reviewing the literature, thereby producing a measure of internal and external validity. From these data, the factors associated with the aetiology, frequency, site distribution and types of cross-country skiing injuries are examined. The incidence of injury in cross-country skiing is estimated to be between 0.49 and 5.63 per 1000 skier days. The most common injuries are medial collateral ligament sprains of the knee, and ulnar collateral ligament sprains of the thumb. Overuse and cold injuries (e.g. hypothermia and frostbite) appear to be common as well, although the data do not provide an estimate of incidence. Comments in the literature on prevention of these injuries are mainly empirical: they recommend safer equipment, wise choice of terrain and a general increase in skier awareness of ways to prevent injury. However, rigorous studies that adequately evaluate preventive intervention strategies have yet to be conducted. Cross-country skiing is relatively safe and a suitable activity for physical fitness and rehabilitation. In the future, studies employing an analytical design will be required to evaluate the effectiveness of injury prevention intervention strategies.

Arm Injuries↗
PubMed1987

In-vitro ligament tension pattern in the flexed knee in passive loading.

Tensions generated in selected bands of the four major ligaments of the flexed knee (40-90 degrees) have been measured in vitro when the tibia is subjected to passive anterior translation and axial rotation with and without a compressive preload. The measurements were made in 30 fresh-frozen specimens using the buckle transducer attached to the anteromedial band of the anterior cruciate ligament [ACL (am)], the posterior fibres of the posterior cruciate ligament [PCL (pf)], the superficial fibres of the medial collateral ligament [MCL (sf)], and in the total lateral collateral ligament (LCL). Particular attention was placed on the evaluation of the performance of the transducer specific to such measurements in order to minimize the errors associated with the use of this transducer. The results indicate that, among the measured ligaments, substantial tension (greater than 20 N) is generated only in the ACL (am) in tibial anterior translation up to 5 mm. The tension pattern generated in response to tibial axial rotation, however, is complex and exhibits considerable variation between specimens. In general, both the MCL (sf) and LCL are tensed at all tested flexion angles, with the tension in external rotation being significantly greater than in internal rotation. At 40 degrees of flexion, the ACL (am) bears tension mainly in internal rotation, while at 90 degrees of flexion the PCL (pf) is tensed in both senses of rotation. The response of the LCL shows marked variation among specimens; very small tension (less than 15 N) is generated in internal rotation in 48% of the specimens, and in either sense of rotation in 20% of the specimens. The tension in the ACL (am) in internal rotation is invariably greater in those specimens in which LCL tension is negligible. This correlation between increased ACL (am) function and inadequate LCL restraint appears significant in terms of ACL injury and repair.

Humans↗
PubMed1992

Ligament tension pattern in the flexed knee in combined passive anterior translation and axial rotation.

Twenty-two fresh-frozen specimens were used to measure tensions generated in selected bands of the major ligaments of the flexed knee (40-90 degrees) when an axially prerotated tibia is subjected to passive anterior shear and when an anteriorly pretranslated tibia is subjected to passive axial torque. The tensions were measured using the buckle transducer attached to the anteromedial band of the anterior cruciate ligament [ACL (am)], the posterior fibers of the posterior cruciate ligament [PCL (pf)], the long fibers of the medial collateral ligament [MCL (lf)], and in the total lateral collateral ligament [LCL]. The knee specimens were subjected to the combined motions in a 6-df passive loading apparatus. The results indicated that the joint resistance to anterior translation increased markedly with internal prerotation and only marginally with external prerotation. This increase in joint resistance, however, was associated with a decrease in ACL function. It has been inferred that the posterior structures, capsular and meniscal, contribute significantly to joint resistance when the tibia is prerotated in either sense. For internal prerotation, the interference between the medial femoral condyle and the central tibial eminence was found to be an additional mechanism of resistance to anterior translation. Also, it has been found that although the ACL (am) tension increased with internal rotation in the normal case, it decreased with internal rotation in the presence of an anterior pretranslation. It is concluded that ACL response to combined joint motion cannot be ascertained by a simple summation of its responses to individual motions.

Adult↗
PubMedDate not supplied

Knee injuries in women collegiate rugby players.

We evaluated the prevalence and patterns of knee injuries in 810 women collegiate rugby players. Injuries that resulted in players missing at least one game were recorded and a questionnaire was used to delineate players' rugby and knee injury history. There were 76 total knee injuries in 58,296 exposures. This resulted in a 1.3 knee injury rate per 1000 exposures. Twenty-one anterior cruciate ligament tears were reported for a 0.36 incidence per 1000 exposures. Other injuries included meniscal tears (25), medical collateral ligament sprains (23), patellar dislocations (5), and posterior cruciate ligament tears (2). Sixty-one percent of the medial collateral ligament sprains occurred in rugby forwards and 67% of anterior cruciate ligament tears occurred in rugby backs. All other injuries occurred with equal frequency in backs and forwards. This study demonstrates that knee injury rates in women's collegiate rugby are similar to those reported for other women's collegiate sports. The overall rate of anterior cruciate ligament injury in women's rugby, however, is slightly higher than that reported for women soccer and basketball players.

Adolescent↗
PubMed2000

Anatomic and biomechanical aspects of pie crusting posterolateral structures for valgus deformity correction in total knee arthroplasty: a cadaveric study.

Correction of valgus deformity during total knee arthroplasty is usually carried out by releasing lateral supporting structures from the femoral side of the joint. A new technique has been advocated that involves multiple stabs of the scalpel blade or pie crusting of the posterolateral corner. It is the hypothesis of this study that the correction achieved by using this technique occurs when the lateral collateral ligament is effectively released and that the common peroneal nerve may be at risk. Using a cadaveric model with 6 knees tested, significant differences were determined between 2 separate pie crusting steps as well as between releasing the lateral collateral ligament and popliteus tendons. Anatomic dissection studies also showed that in full extension the peroneal nerve may be less than the depth of a number 11 blade (16 mm) from the posterolateral corner, and the nerve may be at risk during this technique. These results show that major deformity correction obtained using the pie crusting technique is probably through effective release of the lateral collateral ligament.

Arthroplasty, Replacement, Knee↗
PubMed1992

Reconstruction of ligaments with expanded polytetrafluoroethylene. An experimental study in rabbits.

The medial collateral ligaments in the knee joints of 15 rabbits were replaced with expanded polytetrafluoroethylene (E-PTFE). The joints were not immobilised postoperatively, and their structure and function were evaluated after 12 months. Range of motion was equal in all groups. Stability of the knee joints and breaking strength of the ligaments were similar in the group in which the ligament had been reconstructed and in the sham operated control group (n = 8). The group in which the ligament had been severed and left to heal by formation of scar tissue (n = 7) had significantly reduced joint stability and the breaking strength of the medial collateral ligament was significantly less. The E-PTFE ligaments were well incorporated into the surrounding tissues. There were no adverse tissue reactions and the articular cartilage looked normal both macroscopically and microscopically. These results indicate that E-PTFE might be a useful substitute for damaged ligaments, at least in smaller joints like metacarpophalangeal and interphalangeal joints.

Animals↗
PubMed2006

Arthroscopic evaluation of soft tissue injuries in tibial plateau fractures: retrospective analysis of 98 cases.

PURPOSE: This investigation arthroscopically assesses the frequency of soft tissue injury in tibial plateau fracture according to the severity of fracture patterns. We hypothesized that use of arthroscopy to evaluate soft tissue injury in tibial plateau fractures would reveal a greater number of associated injuries than have previously been reported. METHODS: From March 1996 to December 2003, 98 patients with closed tibial plateau fractures were treated with arthroscopically assisted reduction and osteosynthesis, with precise diagnosis and management of associated soft tissue injuries. Arthroscopic findings for associated soft tissue injuries were recorded, and the relationship between fracture type and soft tissue injury was then analyzed. RESULTS: The frequency of associated soft tissue injury in this series was 71% (70 of 98). The menisci were injured in 57% of subjects (56 in 98), the anterior cruciate ligament (ACL) in 25% (24 of 98), the posterior cruciate ligament (PCL) in 5% (5 of 98), the lateral collateral ligament (LCL) in 3% (3 of 98), the medial collateral ligament (MCL) in 3% (3 of 98), and the peroneal nerve in 1% (1 of 98); none of the 98 patients exhibited injury to the arteries. No significant association was noted between fracture type and incidence of meniscus, PCL, LCL, MCL, artery, and nerve injury. However, significantly higher injury rates for the ACL were observed in type IV and VI fractures. CONCLUSIONS: Soft tissue injury was associated with all types of tibial plateau fracture. Menisci (peripheral tear) and ACL (bony avulsion) were the most commonly injured sites. A variety of soft tissue injuries are common with tibial plateau fracture; these can be diagnosed with the use of an arthroscope. LEVEL OF EVIDENCE: Level III, diagnostic study.

Adult↗