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Sunday 22 April 2018



  • longitudinal bundles of collagen in fasciular subunits with larger functional bands
  • surrounded by synovium – extra synovial
  • inserts to tibial plateau – anterolateral to ant tibial spine – depressed area – just medial to the insertion of ant horn of lat meniscus – oval insertion – tibial insertion more stronger than femoral
  • pass posteriorly – laterally - cephalad
  • inserts to femur – posterior on lat wall of intercondylar notch – circular insertion
  • both insertions nearly planar
  • insertional area – three times the cross sectional area of ACL
  • 31-35mm long – 31.3mm2 cross sec area
  • fibers of ACL are not of same length – least variation along anteromedial aspect of ligt
  • large areas of insertions – results in various lengths of fibers
  • extension – all fibers in tension
  • flexion – relax – posterior and lateral fibers relax more
  • 90flexion – ligament rotates 1800 – ie. Anterior fibers at their attachment at femur reaches posterior
  • injury to one portion of the ligament results in total functional abnormality
  • Drawer test – anterior portion of ACL- increased laxity
  • Lachman test – posterior portion of ACL – increased anterior translation
  • blood supply
    • resides completely inside the femur notch
    • no capsular attachments
    • 10 supply – middle geniculate artery – pierces the post capsule – enters intercondylar notch near femoral attachment
    • additional supply – retropatellar fat pad – inferior , medial, lateral geniculate arteries – more important when ligt injures
  • posterior articular nerve – br of tibial nerve – innervates
  • have proprioceptive function
  • knee – 6 degrees of freedom of motion – 3 rotations and 3 translations
    • translations – anteroposterior (5-10mm), compression and distraction (2-5mm), mediolateral (1-2mm)
    • rotations – flexion and extension, varus and valgus, IR and ER
ACL Injury
  • occurs when bone of l/l twist in opposite directions
  • non contact deceleration mechanism – sudden stopping, cutting, jumping – pop is heard – may be able to continue activity – knee swelling – hemarthrosis
  • h/o + hemarthrosis – 70% hemarthrosis
  • contact injuries – multi ligament injuries – O'Donoghue's triad – valgus load on knee – ACL, MCL and med meniscus
  • acute traumatic hemarthrosis – r/o patellar subluxation/ dislocation, osteochondral injury, peripheral meniscus tear, intra articular fracture
  • femoral intercondylar notch width index =
  • tunnel view of X ray knee
  • normal is .231
  • higher in men
  • non contact ACL injuries more in athletes with less width index
  • meniscal tears associated with 50-70% ACL injury – lat meniscus more common
  • ACL deficient knee – abnormal load sharing – puts lat meniscus at more risk in early injury
    • late injury – medial meniscal tear common - firmer attachment to capsule

  • Clinical test
    • Anterior Drawer test
      • supine – hip flex 450 – knee 900 – sit on dorsum foot – pull tibia forward - >6-8mm – ACL rupture
      • differentiate between PCL tear – ie. Tibia from post subluxation to neutral than neutral to anterior displacement
        • both knees placed in Drawer test position – thumb placed on anteromedial jt line of each knee
        • tibial margin palpated prominently as an anterior step off (nearly 10mm) in relation to anterior aspect of medial femoral condyle
        • posterior drop back – PCL tear
        • in flush with the condyle – grade II laxity
    • Lachman test
      • knee 20-300 flexion – one hand support thigh just above knee – other grasp tibia upper end – extend of glide noted
      • Grade I
        • end feel appreciation – 0-5mm displacement
      • Grade II
        • visible displacement tibia – 5-10mm
      • Grade III
        • gross anterior tibial translation - >10mm
    • Jerk test of Hughston
      • supine – 900 knee flex – valgus force on knee – IR tibia – slow extension
      • lateral tibial condyle subluxates at 300 – relocates as extends further
    • Pivot shift test
      • supine – knee extension – valgus stress on knee – tibia IR – knee flexed
      • subluxation at 30-400
      • false negative in bucket handle meniscal tears – complete MCL tear – lateral extra articular tenodesis
    • Slocum anterior rotatory drawer test
      • anterior drawer – anterior translation of tibia noted
      • test done in 150 IR, 300ER and neutral rotation
      • posterior drawer – increased in 30IR – reduced in 150 IR – anteromedial instability
  • Knee ligament arthrometers
    • compare the maximal anterior displacement on both knees
    • difference >3mm high chance of ACL injury
  • Imaging studies
    • X ray – may be normal – tibial eminence # - avulsion of tibial attachment of ACL
      • Segond # or avulsion # of lateral capsule also seen in ACL injury
      • stress X ray in c/c PCL injuries
    • MRI
      • tears 70-100%
      • non orthogonal plane – entire ACL in one frame – external rotating knee 150
  • Arthroscopy

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