10. Collateral and Multiple Ligament Injury/Meniscal Injury

complete or partial tear of medial or lateral collateral ligament

what defines a collateral ligament injury

sprain

a ligament injury is considered a (sprain/strain)...

mild

a 1st degree sprain is considered ___

moderate

a 2nd degree sprain is considered ___

complete

a 3nd degree sprain is considered ___

strain

a muscle tendon unit injury is considered a (sprain/strain)... and has no form of grading

limit varus-valgus motion of stifle

general function for medial and lateral collateral ligaments

injury to other primary and secondary restrains of stifle joint

injuries to M/L collateral lig usually occur w/ ____ and typically are the result of multiple ligament injuries from severe trauma

extended

the stifle is (extended/flexed) to examine for collateral injury during PE

medial

the valgus stress test evaluates the ____ collateral ligament

patient in lateral, one hand stabilize the femur and the other grasps tibia and applies upward/abduction force

briefly explain how to perform the valgus stress test to assess the medial collateral lig/MCL

lateral

the varus stress test evaluates the ____ collateral ligament

patient in lateral, one hand stabilize the femur and the other grasps tibia and applies inward/ adduction force

briefly explain how to perform the varus stress test to assess the lateral collateral lig/LCL

craniocaudal and medial-lateral RADs to assess bone fragments/avulsion associated with lig. damage as well as stress RADS to assess joint space

diagnostic imaging associated with collateral ligament damage

stress RAD of cat with MCL injury

what is shown in this image

1. muscle strains

2. cruciate ligament tears

3. nondisplaced physeal fractures in immature animals

what are some of the differential dx. associated with collateral lig. injury

degree of injury

conservative or surgical tx. for isolate collateral lig injury based on _____

1. minimal swelling and only slight opening of joint space w/ stress test

2. 1st degree sprain

indications for medical management of collateral lig. injury

1. moderate to severe swelling and significant opening of join space w/ stress test

2. greater injury to collateral restraints

3. 2nd and 3rd degree sprains

indications for sx. tx. of collateral lig. injury

1. collateral ligaments

2. meniscocapsular lig

3. joint capsule

what is included in the RECONSTRUCTION during sx. for tx. of collateral lig damage

all injured ligaments, tendons, and joint capsule

when sx. tx. collateral lig damage, we must be sure to repair...

1. point of failure is origin or insertion of ligament

2. an intrasubstance tear w/ large segments of ligament intact

primary repair of collateral ligaments done if

1. apply modified Robert Jones to prevent further damage

2. HBC patients need thoracic, cardiovascular, and abdominal evaluation

3. perioperative antibiotics and preemptive pain meds like NSAIDs, opioids, epidural analgesia

important preoperative managements of collateral ligament damage

origin and insertion points

knowledge of ____ is important for sx. of collateral ligaments

1. strong attachment to joint capsule and medial meniscus as it crosses medial joint line

2. lies deep to caudal sartorius

3. origin from medial femoral epicondyle and inserts on proximal tibial metaphysis

noteable anatomy for medial collateral ligament

peroneal (fibular) nerve---->otherwise loss of proprioception

we should be careful of the ______ when dissecting near the lateral collateral ligament

1. incise insertion at caudal head of sartorius mm. and deep fascia along proximal tibia

2. replace lig w/ spiked washer and cancellous bone screws

3. primary repair w/ locking-loop suture pattern and supplemental primary repair w/ screws & figure 8 repair

explain general process of repair of medial collateral injury

locking loop

what ligament/tendon suture pattern is shown here that is ideal for flat tendon/ligaments

three loop pulley

what ligament/tendon suture pattern is shown here that is ideal for round tendon/ligaments

bunnell suture

what ligament/tendon suture pattern is shown here that is has fallen out of favor as it cuts off blood supply

far-near-near-far

what ligament/tendon suture pattern is shown here

craniolateral approach; parapatella incision

when repairing lateral collateral lig. we use a _____ approach to expose the lig. to make our proximal-to-distal ______ incision through the fascia lata

peroneal nerve

as we continue our parapatellar incision to access out L collateral lig. distally 4cm below the tibial crest, we must you caution to isolate and protect the ____

fascia lata

we must reflect the ____ caudally in order to expose the lateral collateral lig. and lateral joint capsule

same as for the MCL w/ spiked washers, cancellous bone screws, and interlocking loops

how might you describe the repair process for the LCL...

good to excellent

prognosis for isolated collateral ligament tears is...

fair to guarded

prognosis for multiple ligament tears is...

HBC or other major trauma

multiple ligament tear injuries are typically caused by what

1. moderate to severe swelling and bruising of ST surrounding joint

2. torn collateral lig. may be hard to ID due to edematous CT

3. menisci often displaced and folded either cranially or caudally

in terms of surgical anatomy of the stifle following damage due to trauma...

loss of cranial and caudal cruciate lig. and disruption of medial restraints

what damage is notable in this deranged stifle joint

1. cranial and caudal cruciate ligament tears

2. failure of primary and secondary medial restraints

3. peripheral medial meniscal tears

what is the common triad of multiple ligament injuries

deranged stifle...multiple lig. injuries often associated w/ meniscal injury and stifle luxation

what condition is shown here

reviewed

OK you REALLY need to know this so review it!

arthroscopy and surgical exploration

how can we dx meniscal injuries

1. transection of meniscotibial ligament...A in the image

2. transection of midbody meniscus....B in the image

what are the location of release of the medial meniscus...process of protecting medial meniscus following sx. stabilization of the stifle in a procedure such as a TPLO

compromises the function of the meniscus by eliminating hoop stresses

meniscal release is controversial and has uncertain efficacy based on the fact that it...

1. femoral condyle increases contact w/ articular cartilage of tibial plateau to contribute to osteoarthritis

2. impairs function of meniscus to provide stability

the result of a midbody release or transection of meniscotibial lig leads to...

there are no clinical studies demonstrating the efficacy but it is still a widely used technique

in terms of clinical studies demonstrating the efficacy of meniscal release in decreasing incidence of post TPLO meniscal injury....

IS NOT AN OPTION as it accelerates DJD through continues back and forth sliding

medical management/conservative tx. of meniscal injuries...

a stable joint

when might rest +/- a splint be applicable in meniscal injury tx.

1. partial meniscectomy

2. primary repair of peripheral meniscal injuries

3. total meniscectomy

sx. tx. options for meniscal injury

medial

medial meniscectomy is easiest to perform through a ____ surgical approach

partial

experimentally a ______ meniscectomy carries less morbidity than a total meniscectomy

bucket handle tears

a partial meniscectomy is the tx. for ______ of the medial meniscus

peripheral tears

in dogs, primary repair is uncommon but reserved for what kind of meniscal injury

servere DJD in stifle

total meniscus removal induces....

total meniscectomy

what procedure is shown here

only when peripheral rim of meniscus is so damaged that the primary suturing of meniscocapsular tissue is not possible

when is total meniscectomy considered

OA/osteoarthritis

the more meniscal tissue removed the more rapidly ______ develops