Orthopedics Book

Joint dislocation





Anterior Cruciate Ligament Tear

Aka: Anterior Cruciate Ligament Tear, ACL Tear, Anterior Cruciate Deficiency, Anterior Cruciate Ligament Rupture, ACL Rupture
  1. See Also
    1. Knee Pain
    2. Knee Injury
  2. Epidemiology
    1. Common injury associated with Contact Sports
    2. Uncommon in children and younger teens
      1. Growth Plate injuries are more common in this age group due to relative weakness
  3. Risk Factors
    1. Female Gender (Relative Risk: 1.4 to 9)
    2. Play intensity (risk increased >3 fold during games compared with practice)
    3. High risk sports
      1. Skiing or snow boarding (esp. ankles locked with fall backwards)
      2. Soccer (esp. sudden cutting maneuvers)
      3. Basketball
      4. Football
      5. Volleyball
  4. Mechanism
    1. Contact Sport related injury (30% of ACL injuries)
      1. Foot planted or otherwise in fixed position
      2. Torque from a blow results in tearing of the ACL
    2. Knee hyperextension injury
      1. Occurs when sudden deceleration with knee fully extended
      2. Sudden foot plant with cut to opposite side
      3. Valgus stress causes tibial anterior displacement
      4. ACL Ruptures as tibia displaces anteriorly
  5. Symptoms
    1. Painful "popping" Sensation at time of injury
    2. Swelling (hemarthrosis) within 1-2 hours of injury
    3. "Giving way" or buckling Sensation of knee
  6. Exam
    1. See Knee Exam
  7. Signs
    1. Hemarthrosis (loss of peri-Patellar groove)
      1. Typically develops within hours of injury and often limits the remainder of the Knee Exam
        1. Loss of hyperextension (due to torn ACL fragment catching) in the presence of hemarthrosis is most sensitive for ACL Tear
      2. Associated with significant pain, guarding and limited range of motion
      3. Acute Knee Injury and hemarthrosis in athletes is correlated with ACL Tear
        1. Hardaker (1990) South Med J 83(6):640-44 [PubMed]
    2. Anterior Cruciate Ligament (ACL) Stability Tests
      1. Lachman Test (highest Test Sensitivity approaching 84%)
      2. Knee Anterior Drawer Test (test sesitivity 62%)
      3. Pivot Shift Test - MacIntosh Test (Test Sensitivity 62%)
  8. Associated Conditions
    1. Meniscal tear (>60% of cases)
    2. Collateral ligament tear (5-24% of cases)
  9. Radiology
    1. Knee XRay (3 view)
      1. Evaluate for Tibial Spine Avulsion Fracture
        1. Treat with Knee Immobilizer and urgent orthopedic follow-up
      2. Evaluate for Segond Fracture
        1. Avulsion of lateral capsular margin of tibia
    2. Knee MRI
      1. Efficacy in detecting ACL Tear
        1. Test Sensitivity: 86%
        2. Test Specificity: 95%
        3. Crawford (2007) Br Med Bull 84:5-23 [PubMed]
      2. Indications
        1. Preparation for ACL reconstruction
        2. Assess pediatric patient with suspected ACL Tear
  10. Management: Conservative
    1. Quadriceps strengthening Exercises
    2. Knee Brace
    3. Activity modification
      1. Avoid cutting sports
      2. Avoid jumping sports
  11. Management: Adults Surgical ACL Reconstruction
    1. Acute surgical repair is associated with poor results
    2. Athletic patient
      1. Participating in "cutting" or jumping sports
    3. Requires 9-12 weeks of rehabilitation post-operatively
    4. Bracing after ACL repair is not effective
      1. Does not prevent reinjury or speed recovery
      2. McDevitt (2004) Am J Sports Med 32:1887-92 [PubMed]
  12. Management: Children
    1. Non-displaced Type I Avulsion Fracture
      1. Long-leg Cast Immobilization for 4-6 weeks
    2. Displaced Type II to III Avulsion Fractures
      1. Open Reduction and Internal Fixation
      2. Long-leg Cast Immobilization for 4-6 weeks
    3. Intrasubstance Tears
      1. Operative Management
        1. Indicated for older children near skeletal maturity
      2. Non-operative Management (See above)
        1. Indicated in Young Children (Open Growth Plates)
        2. Perform operative reconstruction when mature
  13. Complications of Un-repaired ACL
    1. Meniscal Injury
    2. Knee Osteoarthritis
  14. Prevention: Athletes
    1. Landing Error Scoring System (LESS)
      1. Identifies athletes at risk of ACL Tear
      2. Hanzikova (2020) Sports Health 12(2): 181-8 [PubMed]
    2. Enhance Performance Program
      1. Reduces ACL injuries by >75%
      2. Focuses on neuromuscular training and proprioception Exercises
      3. Mandelbaum (2005) Am J Sports Med 33(7): 1003-10 [PubMed]
  15. References
    1. Mercier (1995) Practical Orthopedics, Mosby, p. 217-9
    2. Cimino (2010) Am Fam Physician 82(8):917-22 [PubMed]
    3. Smith (1995) Am Fam Physician 51(4): 799-806 [PubMed]
    4. Lastihenos (1996) Phys Sportsmed, 24(4):59-70 [PubMed]

Rupture of anterior cruciate ligament (C0409312)

Concepts Injury or Poisoning (T037)
ICD10 S83.53
SnomedCT 239725005
English ACL - Ant cruciate lig rupture, Ant cruciate ligament rupture, Anterior cruciate ligament tear, Tear of ant cruciate ligament, anterior cruciate ligament tear, anterior cruciate ligament tears, Cranial cruciate ligament tear, ACL - Anterior cruciate ligament rupture, Anterior cruciate ligament rupture, Rupture of anterior cruciate ligament, Tear of anterior cruciate ligament, Rupture of anterior cruciate ligament (disorder)
Dutch scheur in ligamentum cruciatum anterius
French Déchirure du ligament croisé antérieur
German Riss des vorderen Kreuzbandes
Italian Lacerazione del legamento crociato anteriore
Portuguese Laceração do ligamento cruzado anterior
Spanish Rotura del ligamento cruzado anterior, ruptura del ligamento cruzado anterior (trastorno), ruptura del ligamento cruzado anterior
Japanese 前十字靱帯裂傷, ゼンジュウジジンタイレッショウ
Czech Natržení předního zkříženého vazu
Hungarian Elülső keresztszalag szakadás
Derived from the NIH UMLS (Unified Medical Language System)

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