Rev. bras. ortop. vol.50 número6

rev bras ortop.2015;50(6):743–746

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Case

report

Avulsion

fracture

of

the

posterior

cruciate

ligament

in

an

uncommon

location

associated

with

distal

injury

to

the

patellar

ligament

夽

Rodrigo

Pires

e

Albuquerque

_,

_Idemar

_Monteiro

_da

_Palma,

_Hugo

_Cobra,

Alan

de

Paula

Mozella,

Victor

Vaques

CentrodeCirurgiadoJoelho,InstitutoNacionaldeTraumatologiaeOrtopedia(Into),RiodeJaneiro,RJ,Brazil

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t

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o

Articlehistory:

Received4October2014 Accepted26November2014 Availableonline18October2015

Keywords: Knee

Posteriorcruciateligament Bonefractures

a

b

s

t

r

a

c

t

Avulsionfracturesoftheposteriorcruciateligamentinunusuallocationsarerareinjuries. Wereportthefirstcaseintheliteratureofanavulsionfractureoftheposteriorcruciate ligamentassociatedwithdistalinjurytothepatellarligament.Theaimofthisstudywasto presentanovelcase,thetherapyusedandtheclinicalfollow-up.

©2015SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.

Fratura

avulsão

do

ligamento

cruzado

posterior

em

uma

localizac¸ão

incomum

associada

a

lesão

distal

do

ligamento

patelar

Palavras-chave: Joelho

Ligamentocruzadoposterior Fraturasósseas

r

e

s

u

m

o

Afraturaavulsãodoligamentocruzadoposterioremlocalizac¸ãonãousualéumalesão rara.Relatamosoprimeirocasodaliteraturadeumafraturaavulsãodoligamentocruzado posteriorassociadaalesãodistaldoligamentopatelar.Oobjetivodesteestudofoiapresentar umcasoinédito,aterapêuticaadotadaeoseguimentoclínico.

©2015SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevierEditora Ltda.Todososdireitosreservados.

夽

StudycarriedoutatCentrodeCirurgiadoJoelho,InstitutoNacionaldeTraumatologiaeOrtopedia(Into),RiodeJaneiro,RJ,Brazil. ∗ _{Correspondingauthor.}

E-mail:rodalbuquerque19@gmail.com(R.P.eAlbuquerque).

http://dx.doi.org/10.1016/j.rboe.2015.10.004

744

Fig.1–Preoperativeradiographyoftherightknee(A)AP viewand(B)profileview.

Introduction

Theavulsionfractureoftheposteriorcruciateligament(PCL) isconsideredarareinjury.1_{Theunusuallocationofthislesion,}

aswellasthefactthatitoccurred simultaneouslywiththe distalavulsionoftheipsilateralpatellarligament,makesthis caseevenmoreunusual.

Theobjectiveofthisresearchwastopresentthefirstcaseof theavulsionfractureofPCLinanunusuallocation,associated withdistalruptureoftheipsilateralpatellarligament.

Case

report

A17-year-oldmale,healthyindividual,whosufferedtrauma duetoamotorcycleaccident, immediatelydevelopedpain, hemarthrosisand inability to walk. Thepatient wastaken totheemergencyroomandwastransferredtoourinstitute oneweekaftersufferingtheinjury.Physicalexamination dis-closed++/++++edemainhisrightkneeandrangeofmotionof 30–70◦_.

Therightkneeradiographyshowedatibialbonefragment located in the intercondyle with preserved patellar height (Fig.1).Magneticresonanceimaging(MRI)oftherightknee wasperformedtobetterclarifythelesionandplanthesurgical approach,consideringthatclinicalexaminationwashindered bythepresenceofhemarthrosisandjointlimitation.Theright knee MRI showed distalpatellar ligament rupture, and an avulsionfractureofthePCLwithabonefragmentlocatedin theintercondyle(Fig.2).

Thesurgicalproceduretookplacetwodaysafter admis-sion,withthepatientinthesupineposition.Atourniquetwas usedandananteriorstraightincisionwasmadeintheknee toreachthepatellarligament,whereasanotherposteromedial incisionwasmadewiththekneebenttoreachtheavulsion fractureofthePCL.Thesurgicaltechniqueemployedwasthe openreductionandosteosynthesis,witha3.5mmcannulated screwwithafullscrewthreadboltfortheavulsionfractureof PLC(Fig.3).Osteosynthesiswastestedbycarefulbendingthe kneejoint.Regardingthepatellarligament,adistalrupture

Fig.2–PreoperativeMRIoftherightknee.

wasobserved,whichwassuturedwithtransosseousholesand 2.0ethibondwire.

A long kneeimmobilizer was usedforsix weeksofthe postoperativeperiod,whichwasremovedtoperformactive rehabilitation exercisestoprevent quadricepsatrophy.The rangeofmotionwentfrom0to120◦_{andtotalkneefunction}

wasattainedwithinsixmonths.

Thepatientwasreevaluatedafteroneweek,15days,one month,45days,twomonthsandafterthat,monthlyuntilthe sixth monthofevolution, whenthe consultationsoccurred quarterly. Patient follow-up was carried out for one year byclinical andradiographiccontroland hereturnedtohis usualactivities. Theseregularactivitieswerewalking with-outpaincomplaintsandrecreationalsoccertwiceaweek.In thefunctionalkneeevaluation,weusedthemodifiedLysholm

rev bras ortop.2015;50(6):743–746

745

Fig.4–Surgicalaccessroutesinthelatepostoperative periodoftherightknee(A)anteriorand(B)posteromedial.

system,2 _{whichhadshownpoorresultsinthe preoperative}

analysis.Incontrast,inpostoperativeanalysis,anaverageof 95pointswasobtained,whichisconsideredanexcellent aver-ageaccordingtothesameevaluationsystem(Figs.4and5A,B).

Discussion

Amongthe isolated lesions of the PLC,the one caused by tibialboneavulsionistheonewiththegreatestconsensus intheliteratureregardingthesurgicalindicationandearly intervention,3_{aconceptweagreewithandsupport.}

Theisolatedlesion byavulsionofthetibial insertionof thePCLismorefrequentinyoungindividualsanditsnature isessentiallytraumatic.4_{Motorcycleaccidentsarethemajor}

cause ofsuch lesions.4 _{Our casereport corroboratesthese}

claims.According toTrickey,5 _{the usualmechanism ofthe}

avulsionfractureofthePCLisananteriortibialtraumawith thekneeflexed.Webelievethiswasthemechanismofinjury sufferedbyourpatient.Theliteratureshowedonlyonearticle thatmentionedtheunusuallocationoftheavulsedPCL frag-mentintheintercondyle.6_{Asaresult,weobservedtherarity}

ofthiscaseandtherelevanceofitspublication.

Fig.5–Postoperativeclinicalevaluation.(A)Knee extensionand(B)kneeflexion.

Thecontroversyregardingthe treatmentoftheavulsion fractureofthePCLliesinthechosenaccessroute.Asaresult, wechosetheposteromedialsurgicalapproachoftheknee.7

Wechosetheapproachwithtwoincisionsduetothe simul-taneouspresenceofthedistalinsertionlesionofthepatellar ligamentandavulsionfractureofthePCL.Furthermore,the posteromedial access avoidspositioning the patient in the proneposition,andthereisnoneedforgeneralanesthesia.

Clinicalevaluationisessential,butimagingassessmentis complementaryand ofutmostimportanceinassessingthe sizeandlocationofthefragment.Kneeradiographiesarethe firstcomplementaryteststobeordered.Radiographic exami-nationshowedthepatellainitsnormalheight.Itisnoteworthy thatanisolatedPCLlesionisrareandtheMRIcandisclosethe presenceofassociatedlesions.Inourcasereport,thekneeMRI confirmed theavulsed fragmentofPCLintheintercondyle andthedistalpatellarligamentinjury.MRIwasessentialto preventthepatellarligamentlesionfrombeingneglected.

Anothercontroversyisthetypeoffixationintheavulsed fragmentofPLC.7_{Asaresult,wealwayschosetouseimaging}

testswithimproveddetailingofthebonefragmentwhen com-paredtoconventionalradiographies.WethinkthattheMRIor CThelpinsurgicalplanning.Itisnotunusualtousetwotypes ofdevicesintheintraoperativeperiodandduringsurgery,we choosebetweenscrewsoranchors.

Postoperatively,thereisacontroversybetweenkeepingthe kneeimmobilizedornot,duetotheassociatedlesions.One must rememberthatthislesion occurredinanadolescent. Inpatientsinthisagegroup,medicalrecommendationsare morelikelytobedisregarded.8 _{Theimmatureskeletonhas}

alowerriskofjointstiffnesswhencomparedtothatofthe adultpopulation.8_{Asaresult,wesupporttheuseofabrace}

forsixweeks,withdailyremovaltoperformrangeofmotion exercisesandmusclestrengthening.

Themainobjectives ofagoodtreatmentare thecorrect diagnosisand earlyrepairofthelesionstoachieveabetter functionaloutcome.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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2.TegnerY,LysholmJ.Ratingsystemsintheevaluationofknee ligamentinjuries.ClinOrthopRelatRes.1985;198:

43–9.

3.ChiuFY,WuJJ,HsuHC,LinL,LoWH.Managementofavulsion injuryofthePCLwithreattachment.Injury.1994;25(5): 293–5.

4.HughstonJC,BowdenJA,AndrewsJR,NorwoodLA.Acutetears oftheposteriorcruciateligament.Resultsofoperative treatment.JBoneJointSurgAm.1980;62(3):438–50.

5.TrickeyEL.Injuriestotheposteriorcruciateligament:

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tibialavulsionfractureoftheposteriorcruciateligament. Knee.2013;20(2):96–9.