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PCL Injury
From WikiSM
Contents
Other Names
- Posterior Cruciate Ligament Injury
- Posterior Cruciate Ligament Tear
- PCL Tear
Background
- This page refers to injuries of the Posterior Cruciate Ligament (PCL)
History
Epidemiology
- 3% of outpatient knee injuries, 38% of acute traumatic knee hemarthroses[1]
- 95% of PCL tears occur in combination with other ligament tears (need citation)
- Schultz et al (2003)[2]
- Mean age is 27
- Etiology Traffic accidents (45%), athletic injuries (40%)
Pathophysiology
- General
- Isolated injuries often go undiagnosed
- Pediatric considerations
- Rare, poorly described in pediatric population
- Often associated with avulsion fracture (femoral or tibial)
Etiology
- External trauma to tibia with posteriorly directed force
- Knee vs dashboard in motor vehicle crash
- In football, often blow to anterior tibia or fall onto knee with foot plantarflexed
- Non-contact mechanism
- Much less common
- Can occur due to hyperextension or hyperflexion
- E.g. falling off bicycle, knee hyperextension on trampoline, falling off playground equipment
Pathoanatomy
- Posterior Cruciate Ligament
- Responsible for restraining anterior translation of the tibia relative to the femur
Associated Injuries
- Meniscus Injury
- Osteochondral Defect
- Multiligament Knee Injury
- ACL Injury
- MCL Injury
- LCL Injury
- Posterolateral Corner Injury
- Bone contusion, less commonly fracture
- Knee Dislocation
Risk Factors
- Sports
- Football
- Soccer
- Rugby
- Skiing
- Basketball
- Track
- Gymnastics
Differential Diagnosis
- Fractures
- Dislocations & Subluxations
- Patellar Dislocation (and subluxation)
- Knee Dislocation
- Proximal Tibiofibular Joint Dislocation
- Muscle and Tendon Injuries
- Ligament Pathology
- Arthropathies
- Bursopathies
- Patellofemoral Pain Syndrome (PFPS)/ Anterior Knee Pain)
- Neuropathies
- Other
- Bakers Cyst (Popliteal Cyst)
- Patellar Contusion
- Pediatric Considerations
- Patellar Apophysitis (Sinding-Larsen-Johnansson Disease)
- Patellar Pole Avulsion Fracture
- Tibial Tubercle Avulsion Fracture
- Tibial Tuberosity Apophysitis (Osgood Schalatters Disease)
- Proximal Tibial Metaphyseal Fracture
- Proximal Tibial Physeal Injury
Clinical Features
- History
- Symptoms will vary due to acuity
- Important to clarify mechanism, in chronic patients they may not be able to identify specific injury
- Unlike ACL, no pop is typically reported
- Acute: will report Stiffness, swelling and pain on the posterior knee
- Chronic: anterior knee pain, instability when descending stairs, recurrent effusion
- Trouble squatting, sitting cross legged on the ground
- Physical Exam: Physical Exam Knee
- On inspection, look for evidence of direct trauma (lacerations, abrasions, bruising)
- Acutely: effusion
- Clancy Sign: loss of the normal anteromedial, lateral prominences of the tibial plateau beneath the femoral condyles
- Posterior Sag Sign: Supine, knee and hip flexed to 90°, look for posterior shift of tibia
- Special Tests
- Posterior Drawer Test: Supine, knee and hip flexed to 90°, translate tibia posteriorly
- Lachman Test: Can give a false positive ACL injury
- Quadriceps Active Test: Extend knee from 90° flexion to elicit quadriceps contraction
- Important to evaluate integrity of other ligaments, posterolateral corner
Evaluation
Radiographs
- Standard Radiographs Knee
- Typically used as a screening tool in suspected PCL injuries
- Potential findings
- Avulsion fractures (best seen on lateral views)[3]
- Posterior tibiofemoral subluxation
- Arthrosis in chronic cases
- Kneeling stress radiographs
- Can be used to objectively quantify posterior knee laxity
- Posterior tibial displacement can be used to classify injury compared to unaffected limb
- Partial tear (0–7 mm), Complete tear (8–11 mm), additional injuries suspected if ≥12 mm
- Posterior stress radiographs
MRI
- Acute diagnostic value
- Sensitivity: 100%[4]
- Specificity: 100%
- Chronic diagnostic value
- Decreased sensitivity, specificity compared to acute injuries[5]
- This is due to natural process of tissue healing after PCL tear mimicking the MRI appearance of a native, uninjured PCL
- Also important to evaluate other ligaments, meniscus and cartilage
Classification
- Grade 1 (partial)
- Injury has 0 to 5 mm of displacement
- Tibia remains anterior to the femoral condyles
- Grade 2 (complete)
- Injuries have 6 to 10 mm of displacement
- Anterior tibia is flush with the femoral condyles
- Grade 3 (posterolateral corner injury)
- Injury would have greater than 10 mm of displacemt
- Often ACL and/or PLC injury
Management
Nonoperative
- Indications for protected weight bearing, rehab
- Partial tear (grade I)
- Complete (grade II) isolated
- Indications for immobilization in extension for 4 weeks
- Isolated (grade III) injuries
- PCL Knee Brace
- May help keep the tibia reduced during healing by avoiding posterior tibial sag[6]
- Ideally, dynamic force brace which provide significantly greater applied force at 45º of flexion that increases with knee flexion angle
- Note: indicated both for nonoperative treatment and postoperative rehabilitation of PCL tears
- Physical Therapy
- Emphasis on quadriceps strengthening
Operative
- Indications - Acute
- Symptomatic patients (pain, instability)
- Tibial translation > 12 mm
- Associated repairable meniscal tears
- Knee dislocation or bony avulsions
- Combined capsuloligamentous injuries
- Indications - Chronic
- Posterior tibial translation > 8 mm
- Symptomatic patients (pain, instability)
- Combined capsuloligamentous injuries.
- Pediatric considerations
- Avulsion fracture > 5-7 mm displacement
- Crucial to preserve knee function to prevent future degenerative changes
- Technique
- PCL repair of bony avulsion fractures
- PCL Reconstruction
- High tibial osteotomy
- Concurrent ligament, meniscus, posterolateral corner injuries
- Surgical considerations
- Open vs Arthroscopic with the later being preferred in most cases
- Single vs double bundle technique
- Autograft vs allograft
- Tibial inlay vs Transtibial techniques
Rehab and Return to Play
Rehabilitation
- Key elements[7]
- Progressive weight-bearing
- Prevention of posterior tibial subluxation
- Early quadriceps strengthening
- Postoperative course
- Non weightbearing for 6 weeks (PCL graft healing time has been reported to be almost double that following ACL reconstruction)
- Initially knee immobilizer, converted to PCL Knee Brace
- PCL brace may be required for up to 6 months
- 5-phase rehabilitation program[7]
- Phase I: 0 to 6 weeks post-op
- Progressive range of motion (ROM) exercises
- Passive prone ROM from 0 to 90 degrees of knee flexion for the first 2 weeks after surgery
- Advance to full passive prone ROM as tolerated
- Prevent hyperextension and posterior tibial translation to protect the healing PCL graft from elongating.
- Phase II: 7 to 12 weeks post-op
- Progression to crutch weaning and weightbearing activities as tolerated
- Restricting the knee to less than 70º of flexion during weightbearing exercises.
- Phase III: 13 to 18 weeks post-op
- ROM weight-bearing exercise progressing past 70º of knee flexion after 16 weeks.
- Phase IV: 19 to 24 weeks post-op
- Includes the gradual introduction of sport-specific drills.
- Phase V: 25 to 36 weeks post-op
- Begin to wean from brace use if the 6 month postoperative PCL stress radiographs demonstrate sufficient healing
- Begin a straight-line jogging progression
- Goals: multiplanar agility exercises, return to preoperative activities
- Phase I: 0 to 6 weeks post-op
- 3-phase rehabilitation program (nonoperative and postoperative treatment)
- Phase 1
- Weeks 1-6: Immobilization, limited weight bearing
- Goals: optimize ligament healing, avoid posterior tibial translation
- Most patients will wear a hinged knee brace with progressive ROM
- Emphasis on quadriceps strengthening, hamstring stretching
- Phase 2
- Weeks 7-12: Restoration of full weight bearing
- Continue to work on knee, hip strength, range of motion
- Phase 3
- Weeks 12+: Return to sport specific activities can begin around week 12
- Phase 1
- Consider PCL stress radiographs to objectively measure postop progression
Return to Play
- Nonoperative
- May be as fast as 2-4 weeks
- Operative
- Needs to be updated
Complications and Prognosis
Prognosis
- General
- Degree of PCL Laxity does not predict who will develop deteriorating knee function[8]
- Nonoperative management
- Parolie found 80% of patients satisfied, 84% returned to sport with isolated PCL injuries[9]
- Shelbourne found 50% returned to same or higher level of sport, 33% returned to the same or lower level[10]
- Shino found 14/15 athlete were able to return to sport, 1 developed medial femoral chondral changes[11]
- Some studies report increase medial, patellofemoral degeneration, poor function[12][13]
Complications
- Popliteal Artery Injury
- Knee Osteoarthritis
- Seen as a result of chronic cases
- Residual instability
See Also
- Internal
- External
- Sports Medicine Review Knee Pain: https://www.sportsmedreview.com/by-joint/knee/
References
- ↑ Fanelli GC, Edson CJ. Posterior cruciate ligament injuries in trauma patients: Part II. Arthroscopy. 1995; 11(5):526–9.
- ↑ Schulz, M. S., et al. "Epidemiology of posterior cruciate ligament injuries." Archives of orthopaedic and trauma surgery 123.4 (2003): 186-191.
- ↑ Katsman, Anna, et al. "Posterior cruciate ligament avulsion fractures." Current reviews in musculoskeletal medicine 11.3 (2018): 503-509.
- ↑ Gross, Michael L., et al. "Magnetic resonance imaging of the posterior cruciate ligament: clinical use to improve diagnostic accuracy." The American journal of sports medicine 20.6 (1992): 732-737.
- ↑ Pache, Santiago, et al. "Posterior cruciate ligament: current concepts review." Archives of Bone and Joint Surgery 6.1 (2018): 8.
- ↑ Jacobi, M., et al. "Acute isolated injury of the posterior cruciate ligament treated by a dynamic anterior drawer brace: a preliminary report." The Journal of Bone and Joint Surgery. British volume 92.10 (2010): 1381-1384.
- ↑ 7.0 7.1 Pierce CM, O'Brien L, Griffin LW, Laprade RF. Posterior cruciate ligament tears: functional and postoperative rehabilitation. Knee Surg Sports Traumatol Arthrosc. 2013;21(5):e1071–84.
- ↑ Shelbourne KD, Muthukaruppan Y. Subjective results of nonoperatively treated, acute, isolated posterior cruciate ligament injuries. Arthroscopy. 2005;21(4):e457–61.
- ↑ Parolie, James M., and John A. Bergfeld. "Long-term results of nonoperative treatment of isolated posterior cruciate ligament injuries in the athlete." The American journal of sports medicine 14.1 (1986): 35-38.
- ↑ Shelbourne, K. Donald, Thorp J. Davis, and Dipak V. Patel. "The natural history of acute, isolated, nonoperatively treated posterior cruciate ligament injuries." The American journal of sports medicine 27.3 (1999): 276-283.
- ↑ Shino K, Horibe S, Nakata K, Maeda A, Hamada M, Nakamura N. Conservative treatment of isolated injuries to the posterior cruciate ligament in athletes. J Bone Joint Surg Br. 1995;77(6):e895–900.
- ↑ Boynton MD, Tietjens BR. Long-term followup of the untreated isolated posterior cruciate ligament-deficient knee. Am J Sports Med. 1996;24(3):e306–10.
- ↑ Geissler WB, Whipple TL. Intraarticular abnormalities in association with posterior cruciate ligament injuries. Am J Sports Med. 1993;21(6):e846–9
Created by:
John Kiel on 7 July 2019 05:43:47
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Last edited:
4 October 2022 15:49:49
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