Epidemiology Posterior cruciate ligament Injury (PCL)

Epidemiology about a rupture / tear of  the posterior cruciate ligament (PCL)

PCL rupture tear / rupture PCL injuries are relatively rare, accounting for only 5 to 10% of all knee ligament injuries
Incidence: The incidence of PCL injuries is difficult to assess because of the large percentage that remain undiagnosed in the acute setting, a reported 1–44%10
Function PCL: Resists forces pushing the tibia posteriorly relative to the femur.
Sex: Male > Female 4:12
Age: The mean age at the time of injury was 27.5±9.9 years.2
Pain location: Knee joint
Pain sensation/ Symptoms: In the acute phase of a tear, physical examination of the PCL can be difficult because of the presence of a hemarthrosis, pain, and concomitant ligamentous injuries8. It is not unusual for the findings at physical examination to be normal after acute tear of the PCL9, and patients rarely describe hearing the pop common with ACL tears7.
History of injury / Etiology of labral tears: A posterior cruciate ligament tear is usually the result of a significant trauma. In secondary care, this injury is not only found after sports injury but also after traffic injury.1, 2 There is evidence that posterior cruciate ligament injuries recover spontaneously.3,4,5,6
Injury to the posterior cruciate ligament is usually the result of a significant trauma whereas the tibia moving dorsally of the femur at flexion or forced hyperextension of the knee.1
Literature
  1. Verhaar JAN, Van Mourik JBA. Orthopedie. Houten: Bohn Stafleu Van Loghum, 2008.
  2. Schulz MS, Russe K, Weiler A, Eichhorn HJ, Strobel MJ. Epidemiology of posterior cruciate ligament injuries. Arch Orthop Trauma Surg 2003;123:186-91.
  3. Shelbourne KD, Gray T. Natural history of acute posterior cruciate ligament tears. J Knee Surg 2002;15:103-7.
  4. Shelbourne KD, Muthukaruppan Y. Subjective results of nonoperatively treated, acute, isolated posterior cruciate ligament injuries. Arthroscopy 2005;21:457-61.
  5. Boks SS, Vroegindeweij D, Koes BW, Hunink MGM, Bierma-Zeinstra SMA. Follow-up of posttraumatic ligamentous and meniscal knee lesions detected at MR imaging: systematic review. Radiology 2006a;238:863-71.
  6. Peccin MS, Almeida GJ, Amaro J, Cohen M, Soares BG, Atallah AN. Interventions for treating posterior cruciate ligament injuries of the knee in adults. Cochrane Database Syst Rev 2005;CD002939.
  7. Wind WM Jr, Bergfeld JA, Parker RD. Evaluation and treatment of posterior cruciate ligament injuries: revisited. Am J Sports Med 2004; 32:1765 –1775
  8. Margheritini F, Mariani PP. Diagnostic evaluation of posterior cruciate ligament injuries. Knee Surg Sports Traumatol Arthrosc 2003; 11:282 –288
  9. Burger RS, Larson RL. Acute ligamentous injury. In: Larson RL, Grana WA, eds. The knee: form, function, pathology, and treatment. Philadelphia, PA: Saunders, 1993:565 –576
  10. Shelbourne KD, Davis TJ, Patel DV. The natural history of acute, isolated, nonoperatively treated posterior cruciate ligament injuries: a prospective study. Am J Sports Med 1999; 27:276–283

 

 Physical Examination

Posterior Drawer Test(PCL Tear)
With the knee flexed to approximately 80°, verification of complete relaxation of the hamstrings is achieved by hamstring palpation. With the foot in neutral rotation and stabilized, a firm, but gentle posterior translation force is applied to the proximal tibia. Initial starting point for a posterior drawer test in a patient. ( foot in neutral, knee flexed to 80° ). Application of a posterior translation force results in posterior subluxation of the tibia on the femur in a patient with a PCL-deficient knee.

Quadriceps Active Test(PCL Tear)
The quadriceps active test is performed with the knee flexed to 80° and in neutral rotation. Its starting point is in effect the tibial drop back test. From its initial relaxed position at 80°, the patient is asked to fire their quadriceps muscle (“straighten out your leg”) while the examiner applies counter pressure against the ankle. The quadriceps pulls anteriorly through the tibial tubercle to reduce any posterior translation in the knee.

 

Evidence Based Practice

Quadas: Quality Assesment of Diagnostic Accuracy Studies
The Quadas helps the reader to gain clarity about what impact the BIAS had in a study. When a Quadas score is low, a critical look at the value of the study should be taken. The Quadas consists of a scoring system of 14 points that are tested.
Utility scores:
  1. Evidence strongly supports the use of this test.
  2. Evidence moderately supports the use of this test
  3. Evidence minimally supports or does not support the use of this test
  4. ? < The Test has not been researched sufficiently so we are unsure of its value
Posterior Drawer Test(PCL Tear) Utility 2
Study Sensitivity (show) Specificity (exclude) QUADAS Score 0-14
Rubinstein4 90 99 9
Fowler & Messieh3 100 NT 10
Clendenin et al.1 100 NT 9
 Quadriceps Active Test(PCL Tear) Utility 2
Study Sensitivity (show) Specificity (exclude) QUADAS Score 0-14
Rubinstein4 54 97 9
Daniel et al.2 98 100 8
Staubli & Jakob5 75 NT 10
Literature
  1. Clendenin MB, DeLee JC, Heckman JD. Interstitial tears of the posterior cruciate ligament of the knee. Orthopedics. 1980;3:764-772.
  2. Daniel DM, Stone ML, Barnett P, Sachs R. Use of the quadriceps active test to diagnose posterior cruciate-ligament disruption and measure posterior laxity of the knee. J Bone Joint Surg Am. 1988;70-A:386-391
  3. Fowler PJ, Messieh SS. Isolated posterior cruciate ligament injuries in athletes. Am J Sports Med. 1987;15:553-557
  4. Rubinstein RA, Jr.,Shelbourne KD, McCarroll JR, VanMeter CD, Rettig AC. The accuracy of the clinical examination in the setting of posterior cruciate ligament injuries. Am J Sports Med. 1994;22:550-557
  5. Staubli H-U, Jakob RP. Posterior instability of the knee near extension. J Bone Joint Surg Br. 1990;72-B:225-230

 

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