GADLINE PRSENTATION

A. POSTERIOR CRUCIATE LIGAMENT INJURY

1. Definition
A posterior cruciate ligament injury is a partial or complete tearing or
stretching of any part of the posterior cruciate ligament (pcl), which is
located inside the knee joint.
Rupture tendon Achilles adalah roben atau putusnya hubungan tendon
(jaringan penyambung) yang disebabkan oleh cidera dari perubahan
posisi kaki secara tiba-tiba atau mendadak dalam keadaan dorsifleksi
pasif maksimal. (muttaqin, A. 2011)
2. Anatomy and physiology
Anatomically the knee joint is formed by the proximal tibia, the distal
femur and the patella. the joint knee consists of three parts joints, medial
and lateral between the condyle femur and the tibia and intermediate
joints between the patella and the femur. The distal femur consists of
medial condyle and lateral condyle, femora ltrochlear groofe and
intercondylar notcth.Ligaments that mele + ati anterior, medial and distal
joints from the femur to the tibia. ligaments spinning over self formed
spiral slightly outside (lateral), ligamentum tranial meniscal tibialis. some
fascicides may coalesce with anterior attachment with lateral meniscus.
The tibial bundle is wider and stronger than femoral attachment.

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3. Etiology

The posterior cruciate ligament (PCL) is the strongest ligament in

the knee. It extends from the top-rear surface of the tibia (bone between
the knee and ankle) to the bottom-front surface of the femur (bone that
extends from the pelvis to the knee). The ligament prevents the knee joint
from posterior instability. This means it prevents the tibia from moving
too much and going behind the femur. The PCL is usually injured by
overextending the knee (hyperextension). This can happen if you land
awkwardly after jumping. The PCL can also become injured from a direct
blow to the flexed knee, such as smashing your knee in a car accident
(called "dashboard injury") or falling hard on a bent knee. Most PCL
injuries occur with other ligament injuries and severe knee trauma. Often
the knee is dislocated and the nerves and blood vessels are injured. If you
suspect PCL injury, it is important to be seen by a doctor right away.
4. Pathopysiology
The posterior cruciate ligament originates from the anterolateral aspect of
the medial femoral condyle in the area of the intercondylar notch and
inserts extra-articularly onto the posterior aspect of the tibial plateau. It is
1.3 to 2 times as thick and about two times the strength of the ACL. It can
be further separated into anterolateral and posteromedial bundles. The

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 anterolateral and posteromedial bands are respectively 65% and 35% of
the body of the PCL. The anterolateral bundle is taught in knee flexion
and lax in knee extension where the posteromedial bundle is tight in knee
extension and lax in knee flexion. The function of the PCL is to prevent
posterior translation of the tibia on the femur. Because a majority of the
injuries occur in knee flexion, the anterolateral portion is more commonly
injured. The PCL is the primary restraint to posterior tibial translation
between 30 degrees and 90 degrees. At 90 degrees, the PCL accepts 95%
of posterior translational forces. It resists posterior translation with the
assistance of the posterolateral joint capsule, popliteus, medial collateral
ligament, and posterior oblique ligament. The Posterior cruciate ligament
receives blood supply from the middle geniculate artery and is innervated
by the tibial nerve.
5. Signs and symptoms
Signs and symptoms of a posterior cruciate ligament injury may include:

a. Mild to moderate pain in the knee

b. Rapid knee swelling and tenderness (within three hours of injury)
c. Pain by kneeling or squatting
d. A little limp or difficulty walking
e. Feel the instability or looseness of the knee, or the knee gives way
during the activity
f. Pain by walking, slowing down, or walking up or down stairs or
ramps
g. Sometimes patients may have little or no complaints until much later
6. Management
If instability is minimal a PCL rupture may be managed conservatively
with a rehabilitation program. However,if there is significant instability or
damage to multiple structures the player may need to be referred to an
orthopaedic consultant to discuss surgical reconstruction. The
conservative approach to treatment, which may take 12-20 weeks
depending on degree of injury, usually consists of a program containing
the following elements:

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 a. PRICE if necessary for pain and swelling
b. Intensive quads strengthening program
c. gait re-education
d. manual therapy and stretches to regain range of movement
e. a strengthening program including lower limb, core stability and
upper body conditioning
f. lower limb flexibility (stretching)
g. balance program
h. low weight bearing cardiovascular program (static cycling)
progressing to full weight bearing activities like walking –jogging –
running etc.
i. plyometric program
j. Sports specific skills (in the later stage of rehabilitation e.g. sprinting,
twisting, turning, cutting, ball skills, etc...)
7. Complications
Complications of Achilles tendon rupture are infections. disease that
accompanies with clinical symptoms, entry and breeding of disease or
parasite seeds, microorganisms into the human body. Diseases caused by
a seed disease such as bacteria, viruses, fungi and others
(Anonym, 2012).
8. Diagnostic treatment
a. Physical examination
Perform a general examination of the foot and ankle, concentrating on
the specific area as follows:
1) Check for tenderness of the posterior ankle, swelling, or palpable
pause in the tendon.
2) Check muscle strength. The patient may still be able to plantarflex
the ankle with compensation with other muscles, but the strength
will be weak.Single-extremity increased heel will not be possible.
3) Knee flexion test:
Check the ankle break position with the knees flexed and the
patient 90 °. A normal gastrocnemius reste stress break will allow

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 the ankle to assume a more dorsiflexed position than that on the
injured side.

b. Thompson test (simmonds)

The patient's position is prone with clear table legs. Squeezing the calf
usually results in a passive plantarflexion of the ankle. if the Achilles
tendon is not in continuity, the ankle will not passively flex with calf
muscle compression. Simmonds' test (aka Thompson test) will be
positive, squeezing the calf muscles from the affected side while the
patient is lying prone, face down, with his legs hanging loose results
no movement (no passive plantarflexion) legs, while the movement is
expected with the Achilles tendon intact and should be observed on
manipulation of the involved calves. Walking will usually be very
disturbed, as the patient will be able to step off the ground using an
injured foot. The patient will also be able to stand at the tip of the
foot, and point the foot down (plantarflexion) will be disrupted. Pain
can be severe and swelling is common (muttaqin, A.2011).

c. Tes O'Brien

The O'brien test can also be done which requires placing a sterile
needle through the skin and into the tendon. If the needle hub moves
in the opposite direction of the tendon and the same direction as the
toes as the leg moves up and down the tendon is at least partially
intact.

d. Radiografi

to evaluate bone structure if evidence is present from fracture of the

calcaneal tuberosity and the Achilles tendon avulsion, radiography
usually uses X-rays to analyze the point of injury. It is not very
effective to identify soft tissue injury. X-rays are created when high-
energy electrons hit the metal source. X-ray images are obtained by
utilizing different damping characteristics (eg calcium in bone) and
less dense tissue (eg muscle) when the light passes through the tissue
and is recorded in the film. X-rays are generally exposed to optimize

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 the visualization of solid objects such as bone, while soft tissue is still
relatively undifferentiated in the background. Radiography has little
role in assessing Achilles tendon injury and is more useful to rule out
other injuries such as calcaneal fractures.
e. USG
Ultrasound can be used to determine the thickness of the tendon, the
character, and the presence of tears. It works by sending very high
frequency sounds through your body. Some sounds are reflected back
from the space between interstitial fluid and soft tissue or bone. These
reflected images can be analyzed and calculated into the picture.
These images are taken in real time and can be very helpful in
detecting tendon movements and visualizing injuries or possibly tears.
This device makes it very easy to find structural damage to soft
tissues, and a consistent method for detecting this type of injury.

f. Magnetic resonance imaging (MRI)

MRI can be used to distinguish complete rupture from Achilles

tendon degeneration, and MRI can also distinguish between
paratenonitis, tendinosis, and bursitis. This technique uses a strong
magnetic field to align the uniforms of millions of protons running
through the body. These protons are then bombarded with radio
waves that knock some of them out of alignment. When these protons
return they emit their own unique radio waves that can be analyzed by
a 3D computer to create a sharp cross-section of the area of interest.
MRI can provide unparalleled contrast in soft tissue for extremely
high quality photos making it easy for technicians to see tears and
other injuries.

g. Musculoskeletal ultrasonografi

Musculoskeletal ultrasound can be used to determine the thickness of

tendons, characters, and the presence of tears. It works by sending a
very high frequency of sound through your body. Some sounds are
reflected back from the space between interstitial fluid and soft tissue

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 or bone. The reflected images can be analyzed and counted into the
picture. The pictures are taken in real time and can be very helpful in
detecting tendon movement and visualizing the possibility of injury or
tears. This device makes it very easy to see structural damage to the
soft tissues, and a consistent method for detecting the type of injury.
This imaging modality is inexpensive, does not involve ionizing
radiation and, in the hands of skilled ultrasonographers, may be very
reliable.

h. X ray
X ray used to see the damaged tendons on the muscles of the body.

B. NURSING MANAGEMENT
1. Patient identity

2. The main complaint and history of the disease

In the early phase of injury, the legs look swollen and bruises arise in
the area behind the bottom of the foot. In prolonged conditions and the
swelling has diminished, the clinical condition is not very clear and
leaves only a trauma to the Achilles tendon although examination may
describe abnormalities in the Achilles tendon. The second chapter
examines the presence of a tender complaint. Third phase review
disability and severe pain in the plantation of the foot.

3. Physical examination

Perform a general examination of the foot and ankle, concentrating on a

specific area as follows:
a. Check for tenderness of the posterior ankle, swelling, or palpable pause
in the tendon.
b. Check muscle strength. The patient may still be able to plantarflex the
ankle with compensation with other muscles, but the strength will be
weak.Single-extremity increased heel will not be possible.

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c. Knee flexion test:
Check the ankle break position with the knees flexed and the patient
90°. A normal gastrocnemius reste stress break will allow the ankle to
assume a more dorsiflexed position than that on the injured side.
4. Nursing diagnose
Possible diagnoses are:
a. Pain b.d nerve confression, neuromuskuloskeletal damage
b. High risk of trauma b.d inability to move the lower limbs and
ignorance of adequate mobilization.
c. High risk of infection b.d port de entrée post-surgical wound
d. Obstacles to physical mobility b.d damage to Achilles tendon.
e. Ansietas b.d surgical plan, physical condition, family role change,
socioeconomic status condition.
5. Nursing plan
a. Pain b.d injury agents (biological, chemical, physical,
psychological), tissue damage
1) Goal objectives and criteria (NOC)
After a nursing action for 1x24 hours the patient did not
experience pain with the outcome criteria:
a) Able to control pain
b) Reporting that pain is reduced by using pain management
c) Be able to recognize pain (scale, intensity, frequency, and
pain sign)
2) Intervensi (NIC)
a) Perform a comprehensive pain assessment including
location, characteristics, duration, frequency, quality and
precipitation factors
b) Observation of nonverbal reactions from discomfort
c) Help patients and families to seek and find support
d) Control environments that can affect pain such as room
temperature, lighting and noise
e) Assess the type and source of pain to determine

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 f) Teach about nonpharmacology techniques: deep breathing,
relaxation, distraction, warm or cold compresses
g) Give analgesics to reduce pain
h) Increase rest
i) Provide information about pain-like causes of pain, how
long the pain will be reduced and anticipate the discomfort
of the procedure
j) Monitor vital signs before and after first analgesic
b. Internal trauma risk: weakness, decreased vision, decreased tactile
sensation, muscle loss, hand-eye, lack of safety education, mental
retardation, External:environment.
1) Goal objectives and criteria (NOC)
After 2x24 hours of nursing action the client is not traumatized
by the outcome criteria: Patient is free from physical trauma
2) Intervensi (NIC)
a) Provide a safe environment for patients
b) Identification of the patient's safety needs according to the
physical condition and cognitive function of the patient and
history of the patient's prior illness
c) Avoid dangerous environments
d) Install the bedside rails
e) Provide a comfortable and clean bed
f) Placing a light switch that is easily accessible to the patient
g) Restrict visitors
h) Control the environment from noise
i) Provide an explanation to the patient and family or visitors
to change the health status and causes of the disease.
c. Physical mobility disorders associated with: cell metabolism
disorders, developmental delay, treatment, lack of environmental
support, limitations of cardiovascular endurance, loss of bone
structure integrity.

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 1) Goal objectives and criteria (NOC)
After performed nursing actions for 7x24 hours of impaired
physical mobility resolved with the results criteria:
a) Client increases in physical activity
b) Understand the purpose and increase mobility
c) Verbalize feelings in improving the strength and ability to
move
d) Demonstrate the use of tools for mobilization
2) Interevnsi (NIC)
a) Monitor vital signs before or after exercise and see patient
response during exercise
b) Consult with physical therapy about ambulation plans as
needed
c) Help the client to use a stick and be prevented from injury
d) Teach patients or health workers about ambulation
techniques
e) Assess patient's ability in mobilization
f) Train patients in the needs of ADLs independently
according to ability
g) Accompany and assist patients during mobilization and
help meet the needs of ADLs ps.
h) Provide tools if the client requires
i) Teach the patient how to change the position and give help
if needed
d. Anxiety associated with heredity, situational factors, stress,
changes in health status, death threats, self-concept changes,
hospitalization
1) Goal objectives and criteria (NOC)
After care for 1x24 hours of anxiety the client resolved with the
results criteria:
a) Clients are able to identify and express anxiety symptoms
b) Vital sign within normal limits

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 c) Posture, facial expressions, body language, and activity
levels indicate less anxiety
2) Intervensi (NIC)
a) Use a soothing approach
b) State clearly expectations of patient behavior
c) Describe all procedures and what is felt during the
procedure
d) Accompany the patient to provide security and reduce fear
e) Provide factual information on the diagnosis, action
prognosis
f) Involve families to assist clients
g) Instruct the patient to use relaxation techniques
h) Listen attentively
i) Identify the level of anxiety
j) Help the patient to recognize an anxiety-related situation
k) Encourage the patient to express feelings, fears,
perceptions.
l) Manage anti-anxiety medication

C. RESEARCH EVIDENCE
Anteroposterior translation and range of motion after total knee arthroplasty

using posterior cruciate ligament‑retaining versus posterior cruciate

ligament‑substituting prostheses

By :Yoshinori Ishii1 · Hideo Noguchi1 · Junko Sato1 · Tetsuya Sakurai1 ·

Shin‑ichi Toyabe2

Purpose It is still controversial whether anteroposterior (AP)

translation magnitude after total knee arthroplasty (TKA) affects clinical
outcomes, particularly range of motion (ROM). This study examined the
following two questions: (1) are AP translations at the mid- and longterm
follow-up different for knees within the same patient treated with posterior
cruciate ligament-retaining (PCLR) versus posterior cruciate ligament-

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 substituting (PCLS) mobile-bearing TKA prosthesis designs? (2) Is the ROM
at the mid- and long-term follow-up for knees treated with PCLR and PCLS
designs correlated with the AP translation?
Results The implant design (p < 0.001), but not flexion angle (n.s.),
had a significant effect on AP translation. AP translation values were larger
in PCLR knees than in PCLS knees at both flexion angles (p < 0.0001). The
ROM at the final follow-up in the two implant designs was similar (both115°,
n.s.). There was a weak correlation between ROMand AP translation at 30° in
the PCLR knees (r = 0.397,p = 0.015), but no correlation at 75° or in the
PCLS knees.

D. BIBLIOGRAPHY
Ishii, Yoshinori, Hideo Noguchi, Junko Sato, Tetsuya Sakurai, and Shin-ichi
Toyabe. “Anteroposterior Translation and Range of Motion after Total
Knee Arthroplasty Using Posterior Cruciate Ligament-Retaining versus
Posterior Cruciate Ligament-Substituting Prostheses.” Knee Surgery,
Sports Traumatology, Arthroscopy 25, no. 11 (November 2017): 3536–
42. https://doi.org/10.1007/s00167-016-4257-0.
Maxey, L and Magnusson, J, (2007),‘Rehabilitation for the Postsurgical
Orthopaedic Patient -second edition’.
Muttaqin, A. 2011. Buku saku gangguan musculoskeletal. EGC. jakarta

Ningsih, lukman nurna. 2011. Asuhan keperawatan pada klien dengan

gangguan system musculoskeletal. Salemba medika. Jakarta.
Price, Sylvia Anderson. 1995. Patofisiologi konsep klinis Proses Penyakit.
Jakarta: EGC
Rosyidi, kholid. 2013. Musculoskeletal. TIM. jakarta
Syaifuddin, Drs.H (2002). Anatomi Fisiologi untuk Mahasiswa Keperawatan.
Edisi 3. Penerbit Buku Kedokteran. EGC, Jakarta.
V. sammarco. 2009. Perbaikan bedah tibialis anterior rupture tendon akut
dan kronis. EGC. jakarta

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