Slide 134 — ACL avulsion fracture

Clean FRCS notes with inline figures

•Xray showing tibial eminence fracture, displaced, no hinge in skeletally immature patient

•ACL avulsion fracture

Meyers and McKeever classification

•1 undisplaced (<3mm)

•2 hinged

•3 displaced

•4 displaced + comminuted

•Clinically look for open wound, rule out other injuries

•Association(40%)

•meniscal injury

•collateral ligament injury

•capsular damage

•OC fracture

•MRI to rule out associated injuries, look for interposed meniscus, intermeniscal ligament → need OT

•Open/ arthroscopic reduction and fixation

•Young with pin / pullout suture, old with screw

•(common mechanism is hyperextension, 8-14y)

•Type 1, reducible Type 2: immobilize at 20deg

•CR in type II before casting by hyperextension to reduce

•Cast in 20deg flexion to minimize distraction forces

Indication x OT

•Type 3, 4

•Mechanical block

•Entrapped soft tissue

•Other injuries

Procedure:

•Supine + tourniquet

•AM and AL portal

•Diagnostic scope

•Debride hematoma + interposed meniscus + intermeniscal ligament

•2 strand repair with nonabsorbable sutures, wrap around midsubstance of ACL

•Drill hole with ACL tibial jig

•Before closing, need to make sure there is no impingement at full extension

Direct Q&A

Q1 How is ACL avulsion fracture classified here?

•1 undisplaced (<3mm)

•2 hinged

•3 displaced

•4 displaced + comminuted

•Clinically look for open wound, rule out other injuries

•Association(40%)

•meniscal injury

•collateral ligament injury

•capsular damage

•OC fracture

•MRI to rule out associated injuries, look for interposed meniscus, intermeniscal ligament → need OT

•Open/ arthroscopic reduction and fixation

•Young with pin / pullout suture, old with screw

•(common mechanism is hyperextension, 8-14y)

•Type 1, reducible Type 2: immobilize at 20deg

•CR in type II before casting by hyperextension to reduce

•Cast in 20deg flexion to minimize distraction forces

Q2 What are the indications listed for ACL avulsion fracture?

•Type 3, 4

•Mechanical block

•Entrapped soft tissue

•Other injuries

Q3 What operative steps, indications, and risks are listed for Procedure?

Supine + tourniquet

•AM and AL portal

•Diagnostic scope

•Debride hematoma + interposed meniscus + intermeniscal ligament

•2 strand repair with nonabsorbable sutures, wrap around midsubstance of ACL

•Drill hole with ACL tibial jig

•Before closing, need to make sure there is no impingement at full extension

Raw speaker-note hierarchy audit

#	marL	indent	logical	original note line
1	None	None	0	Xray showing tibial eminence fracture, displaced, no hinge in skeletally immature patient
2	None	None	0	ACL avulsion fracture
3	0	0	0	Meyers and McKeever classification
4	0	0	0	1 undisplaced (<3mm)
5	0	0	0	2 hinged
6	0	0	0	3 displaced
7	0	0	0	4 displaced + comminuted
8	None	None	0	Clinically look for open wound, rule out other injuries
9	None	None	0	Association(40%)
10	171450	-171450	1	meniscal injury
11	171450	-171450	1	collateral ligament injury
12	171450	-171450	1	capsular damage
13	171450	-171450	1	OC fracture
14	0	0	0	MRI to rule out associated injuries, look for interposed meniscus, intermeniscal ligament → need OT
15	0	0	0	Open/ arthroscopic reduction and fixation
16	0	0	0	Young with pin / pullout suture, old with screw
17	0	0	0	(common mechanism is hyperextension, 8-14y)
18	0	0	0	Type 1, reducible Type 2: immobilize at 20deg
19	0	0	0	CR in type II before casting by hyperextension to reduce
20	0	0	0	Cast in 20deg flexion to minimize distraction forces
21	0	0	0	Indication x OT
22	171450	-171450	1	Type 3, 4
23	171450	-171450	1	Mechanical block
24	171450	-171450	1	Entrapped soft tissue
25	171450	-171450	1	Other injuries
26	0	0	0	Procedure:
27	0	0	0	Supine + tourniquet
28	0	0	0	AM and AL portal
29	0	0	0	Diagnostic scope
30	0	0	0	Debride hematoma + interposed meniscus + intermeniscal ligament
31	0	0	0	2 strand repair with nonabsorbable sutures, wrap around midsubstance of ACL
32	0	0	0	Drill hole with ACL tibial jig
33	0	0	0	Before closing, need to make sure there is no impingement at full extension

lvl

marL

indent

logical

original note line

None

Xray showing tibial eminence fracture, displaced, no hinge in skeletally immature patient

None

ACL avulsion fracture

Meyers and McKeever classification

1 undisplaced (<3mm)

2 hinged

3 displaced

4 displaced + comminuted

None

Clinically look for open wound, rule out other injuries

None

Association(40%)

171450

-171450

meniscal injury

171450

-171450

collateral ligament injury

171450

-171450

capsular damage

171450

-171450

OC fracture

MRI to rule out associated injuries, look for interposed meniscus, intermeniscal ligament → need OT

Open/ arthroscopic reduction and fixation

Young with pin / pullout suture, old with screw

(common mechanism is hyperextension, 8-14y)

Type 1, reducible Type 2: immobilize at 20deg

CR in type II before casting by hyperextension to reduce

Cast in 20deg flexion to minimize distraction forces

Indication x OT

171450

-171450

Type 3, 4

171450

-171450

Mechanical block

171450

-171450

Entrapped soft tissue

171450

-171450

Other injuries

Procedure:

Supine + tourniquet

AM and AL portal

Diagnostic scope

Debride hematoma + interposed meniscus + intermeniscal ligament

2 strand repair with nonabsorbable sutures, wrap around midsubstance of ACL

Drill hole with ACL tibial jig

Before closing, need to make sure there is no impingement at full extension

Improved semantic hierarchy used for the study notes

#	semantic level	section?	rewritten line
1	0		Xray showing tibial eminence fracture, displaced, no hinge in skeletally immature patient
2	1		ACL avulsion fracture
3	0	yes	Meyers and McKeever classification
4	1		1 undisplaced (<3mm)
5	1		2 hinged
6	1		3 displaced
7	1		4 displaced + comminuted
8	1		Clinically look for open wound, rule out other injuries
9	1		Association(40%)
10	1		meniscal injury
11	1		collateral ligament injury
12	1		capsular damage
13	1		OC fracture
14	1		MRI to rule out associated injuries, look for interposed meniscus, intermeniscal ligament → need OT
15	1		Open/ arthroscopic reduction and fixation
16	1		Young with pin / pullout suture, old with screw
17	1		(common mechanism is hyperextension, 8-14y)
18	1		Type 1, reducible Type 2: immobilize at 20deg
19	1		CR in type II before casting by hyperextension to reduce
20	1		Cast in 20deg flexion to minimize distraction forces
21	0	yes	Indication x OT
22	1		Type 3, 4
23	1		Mechanical block
24	1		Entrapped soft tissue
25	1		Other injuries
26	0	yes	Procedure:
27	1		Supine + tourniquet
28	1		AM and AL portal
29	1		Diagnostic scope
30	1		Debride hematoma + interposed meniscus + intermeniscal ligament
31	1		2 strand repair with nonabsorbable sutures, wrap around midsubstance of ACL
32	1		Drill hole with ACL tibial jig
33	1		Before closing, need to make sure there is no impingement at full extension

semantic level

section?

rewritten line

Xray showing tibial eminence fracture, displaced, no hinge in skeletally immature patient

ACL avulsion fracture

yes

Meyers and McKeever classification

1 undisplaced (<3mm)

2 hinged

3 displaced

4 displaced + comminuted

Clinically look for open wound, rule out other injuries

Association(40%)

meniscal injury

collateral ligament injury

capsular damage

OC fracture

MRI to rule out associated injuries, look for interposed meniscus, intermeniscal ligament → need OT

Open/ arthroscopic reduction and fixation

Young with pin / pullout suture, old with screw

(common mechanism is hyperextension, 8-14y)

Type 1, reducible Type 2: immobilize at 20deg

CR in type II before casting by hyperextension to reduce

Cast in 20deg flexion to minimize distraction forces

yes

Indication x OT

Type 3, 4

Mechanical block

Entrapped soft tissue

Other injuries

yes

Procedure:

Supine + tourniquet

AM and AL portal

Diagnostic scope

Debride hematoma + interposed meniscus + intermeniscal ligament

2 strand repair with nonabsorbable sutures, wrap around midsubstance of ACL

Drill hole with ACL tibial jig

Before closing, need to make sure there is no impingement at full extension

134. ACL avulsion fracture

Clean FRCS notes with inline figures

Meyers and McKeever classification

Indication x OT

Procedure:

Direct Q&A

Supine + tourniquet

Raw speaker-note hierarchy audit

Improved semantic hierarchy used for the study notes