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Case of the month

32 years old gentle man had been traumatized in RTA (dash board injury) 4 month ago. He received the primary aids in one of the orthopedic casualty. He had been found suffering from bilateral femoral fractures but no other associated abdominal, chest or head injuries. He had been operated on for fracture fixation with interlocking nails. Then after, he passed through uneventful post operative course. 6weeks later, he found himself unable to bear weight on his right lower limb and then started to suffer from severe Rt. knee pain which was exaggerated by bearing weight not associated with swelling. There was no giving no locking.
On examination the knee was swollen uniformly, no effusion, there was obvious sagging of the Rt. Tibia, no point tenderness, positive posterior drawer test. Otherwise anterior drawer, valgus stress, varus stress and Mc Mury s test were negative.

His initial X-rays

Then CT scan of the knee

PCL avulsion fracture injury
He had been treated surgically. Firstly diagnostic arthroscopy done to exclude associated injuries. The fracture line was identified involving part of the medial tibial plateau, no meniscal injuries and ACL was normal in its course and tension. Then after, the position was changed to prone and redraping done. We approached the knee through BUIRK posterior approach for open reduction and fixation of the fragment using AO malleollar screw 3.5mm.

Postoperative treatment
The patient put in a back slab for 2 weeks, and then stitches removed. The slab returned back for another 4 weeks in a strict non wt bearing rehabilitation program. After 6 weeks the patient was allowed to put partial wt as tolerated using walking aids and started quadriceps and increased ROM exercises. 6 weeks later he allowed full wt bearing.
In the last follow up visit, visual analogue score was 2, flexion was 110 degrees, extension is 0 degree and posterior tibial translation using posterior drawer test was <5mm
PCL injury review
The posterior cruciate ligament (PCL) is the main restraint against posterior translation of the tibia on the femur. It also resists internal rotation of the tibia on the femur because it winds around the anterior cruciate ligament. The PCL does not attach to the posterior tibial spine but rather to a fovea 1 cm below the tibial plateau. The so-called “isolated” PCL avulsion from the tibia is not a common injury to the knee. Anatomical reduction and fixation of the avulsed fragment with a screw is the treatment of choice for this injury1.
Injuries of the posterior cruciate ligament (PCL) are now gaining recognition as disabling problems that are often overlooked , and many times the treatment is deferred due to an apprehension that the approach to the posterior aspect of the knee is difficult. In spite of their common association with ipsilateral injuries, intra-substance tears are usually not primarily diagnosed nor treated at initial presentation. Avulsion injuries from the tibial attachment constitute a small subgroup that differs from other PCL injuries in two ways.
Firstly an early diagnosis is usually possible on standard radiographs where a bony fragment may be visible, and secondly the treatment protocol is fairly standardised. Surgical fixation of the bony avulsion by either a screw is advocated and it has given almost uniformly excellent results, whereas non-surgical treatment has a significant incidence of morbidity in form of residual instability and early degenerative arthritis. Some orthopaedic surgeons are apprehensive about treating tibial avulsions of the PCL because of their unfamiliarity with the standard posterior approach to the knee and the potential for damage to the important neurovascular structures. Many series dealing with PCL injuries have followed the standard posterior approach through the popliteal fossa as described by Abbott , which is a complex approach requiring a meticulous and time consuming dissection of the neurovascular bundle in the popliteal fossa. Trickey described a modification of the above mentioned approach with the aim of decreasing the surgical dissection and time. However the medial head of gastronemius needed to be divided and the neurovascular bundle was still at risk due to its proximity. Ogata and McCormick described a posterolateral approach of the knee for the treatment of PCL injuries. It required osteotomy of the fibular neck which endangered the nerve and required extensive mobilisation of the tendon of the popliteus. These factors increased the complexity of the approach besides affecting the postoperative rehabilitation. Keeping this in mind, Burk and Schaffer in1988 described a simplified approach to the PCLwhich avoided the problems associated with the standard posterior approach. This has become the standard approach for approaching the PCL, either for fixing avulsions or for onlay reconstructive grafting. We have used this approach for the fixation of tibial avulsions of PCL in 2 cases and present our experience with this technically safe and easy exposure2.

2. Pariyut Chiarapattanakom MD. Isolated PCL Avulsion from the Tibial Attachment:
Residual Laxity and Function of the Knee
after Screw Fixation.

Dr. Mohammed Babiker Abdelwahab, MD
Department of orthopedic surgery
Faculty of medicine
National Ribat University hospital


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