The ACL, or anterior cruciate ligament, is key for the stabilization of the knee joint, connecting the femur to the tibia. An ACL tear is one of the most common knee injuries, most often found in people who engage in demanding sports like soccer and skiing where there may be sudden changes in motion or direction. Immediate symptoms include a loss of range of motion and immense swelling. Since the ACL cannot heal on its own, reconstruction is often needed to assist the healing process and restore range of motion. In the clinic, we saw a few patients with problems related to their ACL. One woman hurt her left knee 3 months ago when a cow fell on top of her. The physical exam Dr. Agnieszka performed found edema, or swelling, as well as an unstable knee as the anterior drawer test was positive. This test saw the patient lie on the exam table with the hip up 45 degrees and the knee down 90 degrees. Dr. Agnieszka then pushed the tibia forward and saw that it moved more than 6 mm (excess anterior translation, or sliding). The MRI also showed fiber discontinuity, fluid in the knee, and swelling of the bone marrow, common signs of an ACL tear. Based on these signs and the patient’s young age, Dr. Agnieszka recommended surgery.
Another patient we saw had undergone ACL reconstruction in 2016 but unfortunately had an infection of the knee. Thus, in addition to giving IV antibiotics, an arthroscopy was done to clean the region up of infected tissue (debridement) and do some saline irrigation. The ACL graft was not removed then. Weakened by infection, the patient’s medial meniscus, an important shock absorber that helps to protect the cartilage of the knee, was torn when he inadvertently twisted his knee soon after this arthroscopy. The ACL may have torn again, Dr. Agnieszka thought, so she ordered an MRI to make sure.
Another case involving tenosynovitis was a patient who was diagnosed with trigger finger. Trigger finger is a condition where the A1 pulley at the base of the finger becomes thickened, causing the flexor tendon, which allows one to bend one’s fingers, to not be able to properly function. The A1 pulley lies at the beginning of the flexor tendon sheath, normally keeping the flexor tendon snugly in place, close to the bone. When the A1 pulley is inflamed, the tendon sheath becomes narrowed, “catching” and immobilizing the flexor tendon. Additionally, a swollen nodule may form as the flexor tendon itself becomes inflamed, thus causing more problems as the nodule can get stuck under the pulley. Thus, the finger gets locked in a bent position as if one is pulling the trigger of a gun. If the patient wanted to straighten his finger, it was very painful, and there was an audible “pop.” Splinting and corticosteroid injection did not resolve the patient’s issues, so Dr. Agnieszka recommended tenolysis surgery to release the A1 pulley. In this procedure, through a small incision, she would cut the thickened A1 pulley so that the flexor tendon can move freely without any obstruction.
We also saw another patient who was 89-years old. The patient had severe osteoporosis, which is a condition where the bone resorption (breakdown) surpasses bone deposition, leading to weak and brittle bones that are at an increased of fracture. A small fall resulted in a radius-ulna fracture in this patient, but, rather than having surgery like the last patient I talked about, she was doing conservative treatment, wearing a cast. Dr. Agnieszka described how she does not like doing surgery on patients who are old and have a slightly impaired neurological status as these patients tend to not follow through with physical therapy nor follow the surgeon’s instructions (noncompliance), leading to the surgery being largely unsuccessful in the end. Dr. Agnieszka described how she did not want to take the patient’s cast off yet because it risks ruining all the good progress they have achieved, so she resolved to meet again with her in 2 weeks.
A man, hit by a car, had a serious fracture of the pelvis as well as the lateral tibial plateau a year ago. The pelvic fracture was treated conservatively due to the complexity of the surgery as well as the inability to effect any meaningful outcome change. However, the lateral tibial plateau was fixated and reduced with the help of a plate. Because the patient continued to experience serious pain, Dr. Agnieszka removed the plate and did an arthroscopy to clean up the knee and put stiches on the torn lateral meniscus. The removal of the metal allowed for a more accurate assessment of the joint on imaging, and the MRI showed that a total knee replacement may be necessary since the patient had developed progressive post-traumatic arthritis, which was causing him a lot of pain. The patient was also feeling some paralysis of the right leg in the visit we witnessed, indicating that the pelvic fracture may have touched the spinal soft tissue. Thus, Dr. Agnieszka ordered an MRI of the spine and an electromyography of the right leg where electric shocks would be used to assess muscle and nerves to check for injury. She suspected that the sciatic nerve may be injured.
ACL Injury. Mayo Clinic, www.mayoclinic.org/diseases-conditions/acl-injury/symptoms-causes/syc-20350738. Accessed 2 Jan. 2019.
Anterior Drawer Test. 8 June 2016. Medisavvy, medisavvy.com/anterior-drawer-test/. Accessed 2 Jan. 2019.
AP Knee Radiograph Shows a Fracture of the Lateral Tibial Plateau (Arrows). Radiology in Thai, radiologyinthai.blogspot.com/2011/05/tibial-plateau-fracture.html. Accessed 2 Jan. 2019.
Distal Radioulnar Joint. GRIP Surgery, www.gripsurgery.com.au/treatments-procedures/distal-radioulnar-joint-surgery/. Accessed 2 Jan. 2019.
Extensor Tendon Ruptures of Ring and Small Fingers. Clinical Gate, clinicalgate.com/31-tendon-transfers-for-extensor-and-flexor-tendon-ruptures/. Accessed 2 Jan. 2019.
Finger Extensor Tendon Injury. Rehab My Patient, www.rehabmypatient.com/hand-fingers-thumb/finger-extensor-tendon-injury. Accessed 2 Jan. 2019.
Gap Medics. Twitter, twitter.com/gapmedics. Accessed 2 Jan. 2019.
(Left) X-ray Shows a Fibula Fracture (Blue Arrow) and a Tibial Shaft Fracture (Red Arrows) That Extends into the Ankle Joint. (Right) Both Fractures Have Been Treated with Plates and Screws. OrthoInfo, orthoinfo.aaos.org/en/diseases–conditions/tibia-shinbone-shaft-fractures/. Accessed 2 Jan. 2019.
PA Radiograph after Plate and Screw Fixation of the Radial Fracture and K-wire Fixation of the Joint. Radiology Key, radiologykey.com/hand-and-wrist-3/. Accessed 2 Jan. 2019.
Placement of EMG Electrodes on the Right Leg. Research Gate, www.researchgate.net/figure/Placement-of-EMG-electrodes-on-the-right-leg-Dynamic-surface-EMGs-of-the-M-peroneus_fig2_51614345. Accessed 2 Jan. 2019.
Radius and Ulnar Shaft Fractures. Ortho Bullets, www.orthobullets.com/trauma/1025/radius-and-ulnar-shaft-fractures. Accessed 2 Jan. 2019.
Rotator Cuff. WebMD, www.webmd.com/pain-management/what-is-my-rotator-cuff#1. Accessed 2 Jan. 2019.
The Skeletal System Chart. Universal Medical, www.universalmedicalinc.com/the-skeletal-system-chart.html. Accessed 2 Jan. 2019.
Supraspinatus Rupture. Aid My Rotator Cuff, www.aidmyrotatorcuff.com/rotator-cuff-tear/supraspinatus-tear-symptoms-and-recovery.php. Accessed 2 Jan. 2019.
Trigger Finger (A1) Pulley Release. 9 Feb. 2014. Youtube, www.youtube.com/watch?v=8LMg4PX1VJc. Accessed 2 Jan. 2019.
Trigger Release Surgery. OrthoInfo, orthoinfo.aaos.org/en/diseases–conditions/trigger-finger. Accessed 2 Jan. 2019.