1. CONSERVATISM IN KNEE
INJURIES-? ANY ROLE
Dr. C. M. Krishnakumar,
Consultant, Kozhikode District
cooperative Hospital, Calicut.
Formerly faculty, Christian Medical
College, Ludhiana

2. Conservatism- preserve
homeostasis
 Interventional
 Non interventional

3. CLASSIFICATION
I .INTERNAL DERANGEMENT OF KNEE
1. Traum. synovitis & haemarthrosis
2. Injury to med, lat & cruciate ligts
3. Injury to semilunar cartilages
4. Dislocation of knee
5. Loose bodies of knee

4. Classification (contd)
II. INJURIES TO EXT.MECH.OF KNEE
1. Avulsion of the quadriceps
2. # of patella
3. Avulsion of ligamentum patellae
4. Injuries to tib. tubercle & Schlatter’s
5. Dislocation of patella
III .FRACTURES OF DISTAL FEMUR &
PROX.TIBIA

5. CONSERVATIVE MANAGEMENT
 Mild knee injury should be treated with
R.I.C.E. (rest, ice, compression, elevation), and
paracetamol (Caillient)
 Avoid H.A.R.M.
(heat, alcohol, running, massage) in first 72
hours.
 Resume activities gradually as pain and
swelling settle, with follow-up after 7 days if
symptoms persist.

6. INDICATION
 Stable injury
 Elderly
 Invalid (poor GC)
 Poor skin & soft tissue condition
 Refusing surgery

7. CONSERVATIVE MANAGEMENT
 Redevelop Quadriceps: 5 min/ hr/day
speed of loss > than gain
wasting itself a disability
 Early active non weight bearing exercise
 Constant vigilance

8. TRAUMATIC SYNOVITIS
 H/O twist or strain + effusion (max 6-8 hrs)
 Crepe bandage - if effusion+ back splint in
extension
 Quadriceps Ex. at once
 Wt. bearing in few days
 ROP on 10th day
 Recovery in 2-3 wks

9. TRAUMATIC SYNOVITIS

10. RECURRENT SYNOVITIS
 In middle age with quadriceps wasting
 Weight bearing ↓ed till muscle regain
 R/O meniscal injuries

11. TRAUMATIC HAEMARTHROSIS
 H/O severe blow/twist + rapid effusion (firm),
painful, febrile
 Aspiration + crepe + back splint
 Quadriceps exercise after 10-14 days
(to↓ spontaneous haemarthrosis)
 R/O # Tibial Spine, Patella, Meniscal & ACL
tear

12. MEDIAL COLLATERAL LIGAMENT
 H/O abduction strain + external rotation of
tibia
 Med side open up with valgus strain in 20
flexion
Rx PROTOCOL(Indelicato):
I. Phase: Prefabricated orthosis in 30
flexion, isomet. quadri-later with
resistance, PWB, Isokinetic quadri
of opp. knee

13. MEDIAL COLLATERAL LIGAMENT
 II. Phase (2nd -6th wk): Hinged knee brace(30
-90 flexion), full ext. prevented, Isokinetic
quadri with increased resist’ , FWB
 III. Phase(> 6wks):orthosis removed, iso kinet’
ex. With resistance to regain strength
strength at 60%- running
strength at 80%- full athletic activities

15. HAMSTRING &
COLL. LIGT.EX

16. Hip ex. For flex,abd,add,ext
→ IFT,US,LASER Therapy→ pedalling backwards →
resisted SLR ex using light weights
→ resisted isotonic knee ex.with ankle wt →
wt bearing resisted ex usin step machine,step
ups,lat step ups,50% squats →
proprioceptive training using balance board&single leg
stance ex. →
gentle running in straight line,jog →
sudden starts & stops,corners,lat gliding,lat bounding
→ polymetrics-jump ups,downs,stepping back & forth
over a stool

17. Pellegrini–Stieda disease
Immobilisation
+
Quadriceps Ex.

18. LATERAL COLLATERAL LIGAMENT
 Less common, caused by varus strain
 O/E opening of outer side on varus
strain, may be assoc. with avulsion #
fibula/lateral tibial condyle
 Sprains – muscle exercises + avoid sports
 Specific Rx not universally accepted
 Complete rupture may be assoc. with other
lig. injuries – needs repair

19. MENISCAL INJURY
 Ext. rot/ int. rot + abd/add injury
 Aspirate
 REDUCTION OF LOCKED KNEE:
must be done within 24 hrs to prevent loss
of elasticity
technique is easy but force should be
guarded
long’ traction + rot’ in both directions+
some valg/varus motion as knee is extended
(ext. rot + ext – in lat. meniscus, int. rot +
ext – in med. meniscus)

21. MENISCAL INJURY
 Repeated unsuccessful manip’ avioded to
prevent extension of tear into jt space
 Immobilise with pressure bandage / plaster
cylinder for 3-4weeks (assuming periph
injury)
 Quadri’ + hams’ ex, regain full ROM
 Avoid deep knee bends, squats, rapid stair
climb/descend
 Avoid athletic activities – flex, ext, rot
 rehabilitation for 6-8 weeks, and if
symptoms persist/ locking- repair

22. ACL AVULSION INJURIES

23. ACL AVULSION INJURIES
 Flexion + Int. rotation injury, may be assoc.
with medial lig. Injury, inter condylar
eminence #
 Lachman test, Pivot shift test
 Undisplaced # - POP cast (6weeks)
 Min. disp.# - CR in ext. + POP cast

25. ACL SUBSTANCE INJURIES
 R.I.C.E.
(rest, ice, compression, elevation), and
NSAID (Caillient)
 Aspiration+
Ext. orthosis(6-8 wks), crutches, isomet’
quadri /hams ex , electrical stim
 Use of a knee brace. sports with cutting and
twisting motions are strongly discouraged.

26. ACL SUBSTANCE INJURIES
3-STAGE REHABILITATION (PALETTA):
 Stage I (7-14 days) : immobilization for
comfort, cryotherapy to control
swelling, and crutch ambulation with
progressive weight bearing and early ROM
exercises
 Stage II(2-6 wks): supervised regaining
quadriceps strength and restoring normal
quadriceps-hamstring balance
 Stage III: gradual return to low and mod
level demand sporting activities when the
strength of the affected extremity
approximates that of the unaffected

27. PCL TEAR (Sekiya,Giffin,Harner)
 Caused by blow of front of a flexed knee
 Undispl. Avulsion # - POP cast
 Isolated Grade I &II: protected WB + quadri
ex to counteract post/tibial sublux
Recovery rapid(2-6 wks) to sports
 Grade III: immobil’ in ext(2-4 wks)+ quadri
ex, return to sports after 3 m

29. DISLOCATION OF THE KNEE JOINT
 Usually assoc. with complete rupture of
med., lat. & cruciate ligts / direct violence to
head of tibia / indirect twist or hyper ext.
 Ant., post., lat., med. & rotatory types
 CR + POP cast(6-8weeks) in case of poor
GC, skin cond., inadequate facility – foll. by
surgery later if needed

31. OSTEOCHONDRAL # &
LOOSEBODIES
 Major loose bodies were the result of
osteochondral fractures of either the femur
(direct blow or twisting movement on a
weight-bearing flexed knee) or the patella(
5% disloc) (Rosenberg & Mc Graw)

32. OSTEOCHONDRAL # & LOOSEBODIES
 Adolesc boys & young adults ,
 Haemarthrosis, med. retin tear, Loose body
sensation, locking
 Undisplaced osteochondral fractures in
children often can be treated successfully
with conservative methods – POP cast(4-6
wks)

33. RUPTURE OF EXT.MECHANISM
 most commonly caused by fracture of the
patella.
 Disruption of quadriceps & patellar tendon
are the next common causes.
 eccentric overload to the extensor
mechanism with the foot planted and the
knee partially flexed.

34. PATELLAR TENDON RUPTURE
 Patellar tendon rupture or avulsion common
in patients < 40 yrs , especially athletes.
 Less common than quadri’ tear
 Common site: jn of distal pole of patella
 Rx: Ac.partial tear-immobilisation in ext (2-
3wks)
Once
swelling
subside
brace

35. PATELLAR TENDON RUPTURE
 PWB in ext with brace(2-3 wks), then
gradual FWB in ext, SLR ex started
 After 4-6 wks: active flex & passive ext
ex
 Knee flex: upto 30 for first 2 wks then
30 every 2 wks
 6-8wks:active assist ext ex
 >8 wks:prog quadri’ ex
 Sports: when isokinetic quadri’ is 90%

36. COMPLICATION
(PATELLAR TENDON RUPTURE)
 Rerupture of patellar tendon
 Quadriceps weakness
 Patella alta

37. QUADRICEPS TENDON RUPTURE
 Quadriceps rupture common in older
patients and in those with systemic disease
(lupus
erythematosus, diabetes, gout, hyperparathyr
oidism, uremia, and obesity) or degenerative
changes or prior steroid injection
Rx: Partial tear-
Immobilise in ext
(4-6 Wks), then
gradual prog to
active flexion

38. FRACTURE PATELLA

39. FRACTURE PATELLA
 Undisplaced/ stellate patella # : Cylinder
cast in extension (4-6 wks) , with weight-
bearing allowed as tolerated
 Boström considered 3 to 4 mm of fragment
separation and 2 to 3 mm of articular
incongruity to be acceptable for
nonoperative treatment (Using these criteria
in 212 nonoperatively treated fractures, 84
had no pain and 91 had normal or only
slightly decreased function).
 Rest types - surgery

40. COMPLICATION(# PATELLA)
 90% good to excellent results (Brostrom)
 Persistent ext. lag
 arthrofibrosis

41. INJURIES TO TIB.TUBERCLE
& OSGOOD SCHLATTER’S

42. INJURIES TO TIB.TUBERCLE
& OSGOOD SCHLATTER’S
 Being apex of triangular insertion
takes first strain of ext. injury
 # in adult : usually cracked/ mildly
avulsed with ext. mech. intact- short
immobilisation foll. by active ex. ,avoid
stretching

43. AVULSION -TIBIAL EPIPHYSIS
 Forcible flexion against resisting quadri
 < 18 yrs
 4 types- undisplaced,
complete,
partly avulsed,
avulsed with wide area

44. EPIPHYSISAVULSION -TIBIAL
Rx
All except complete can be manipulated with
cast in ext (6-8 wks)

45. AVULSION -TIBIAL EPIPHYSIS

46. OSGOOD SCHLATTER’S
 Before fusion (18 yrs) epi. line is weak pt in
ext mech
 Flexion against quadri resistance
 simple conservative measures such as the
restriction of activities or cast immobilization
for 3 to 6 weeks (Krause, Williams, and
Catterall)

47. osd
 Contoured knee pad during sports
 Quadri & hams flexibility ex to decrease
patellar forces
 Avoid prolonged squat/kneeling-change of
team position
 COMPLICATION:
Prominence of tubercle
persisting symptoms & nonunion
reactive bursitis

49. DISLOCATION OF PATELLA
 If capsule is lax, poorly developed lat. fem
condyle-tibia is forcibly abd +lat rot/glancing
blow on med side of patella, when thigh mcs
is relaxed-cause dislocation
 CR + knee immobilizer/ cast for 2-6 wks.
 Early range of motion - prevent
arthrofibrosis and to promote the formation
of strong collagen along the lines of stress.

50. COMPLICATION(DISLOCATION OF PATELLA)
 Usually good to excellent results (91%)
 Recurrent sublux/dislocation (15-49%)-brace
with lat. Pad
 Feeling of instability (20%)
 Anterior knee pain (75%)
 OA
 stiffness

51. INTRA ARTICULAR # DISTAL
FEMUR
 Reduced by simple traction + manual
compression of fragments between hands
foll. by simple /UT Pin traction on thomas
splint(4-5 wks) foll. by hinged cast brace till
union
 Maintain good reduction + ext. ex to prevent
residual flex deformity
 Dis adv: long IP stay

54. INTRA ARTICULAR # DISTAL
FEMUR

58. COMPLICATION
Malunion - fix flex def
Arthrofibrosis
Traction problems-pintract infection,bedsore

59. TIBIAL PLATEAU # DISLOCATION
(Hohl and Moore)

60. TIBIAL PLATEAU #
TREATMENT
 depression <5 mm in stable #: early
motion in a hinged knee brace / POP cast and
delayed weight-bearing
 depression 5 to 8 mm:
 elderly and sedentary- nonoperative
treatment young or active - surgical
reconstruction
 Non op Rx: Distal tibial pin traction +
mobilisation on traction (3 rd wk) + hinged
cast brace after 4-6 wks

61. r

64. TIBIAL PLATEAU #

65. COMPLICATION
 Malunion
 Nerve injury / compartment synd
 Residual instability
 OA
 Arthrofibrosis
 Traction/cast problems - pintract
infection, bedsore etc.,

66. CONCLUSION
 Operative treatment is not only
option
 Proper selection, constant
vigilance, timely mobilisation of jts
give as equal result as operative Rx
 Rehabilitation should focus on
functional treatment rather than
electrotherapy