| Abstract|| |
To analyse the mechanism of anterior cruciate ligament injury occurring in Mumbai suburban train commuters, 25 patients with history of knee injury on Mumbai suburban railway platform, were studied over the last 10 years. The mode of injury is classified into three types based on biomechanical considerations. Most of the injuries occurred in young population and were of the deceleration variety. The mechanisms of injury were, however, similar to those occurring in various sports.
Keywords: Anterior cruciate ligament injury.
|How to cite this article:|
Kadakia A P, Sabnis S K. Mumbai suburban railway platform injury - A new mode of anterior cruciate ligament injury. Indian J Orthop 2003;37:4-13
|How to cite this URL:|
Kadakia A P, Sabnis S K. Mumbai suburban railway platform injury - A new mode of anterior cruciate ligament injury. Indian J Orthop [serial online] 2003 [cited 2019 Dec 6];37:4-13. Available from: http://www.ijoonline.com/text.asp?2003/37/3/4/48538
| Introduction|| |
Anterior cruciate ligament (ACL) rupture is now becoming increasingly common though of less magnitude then what is found in the West, probably due to the less sporting activity amongst Indians. Very commonly the immediate disability and functional instability may not be so great following the ACL rupture, resulting in the patient not going to the doctor for the treatment. Moreover, the primary care doctors are less aware of this injury and its sequel and thus do not take it so seriously to investigate the patient further resulting in non-diagnosis of the same.
We have come across a new mode of ACL injury occurring in Mumbai suburban railway commuters. It is necessary to make everyone aware of such injuries so that these are diagnosed and treated early.
| Materials and Methods|| |
This retrospective study includes 25 patients, over the last 10 years, with injuries to the knee joint of moderate severity having a specific history of getting injured on the railway platform. Most of these were office-going workers, who travelled everyday by the over-crowded suburban trains.
Once the patient was suspected of having an internal knee derangement, a detailed history of the pattern of injury was taken at the time of the first visit. It was studied in detail, by actual observation of events taking place at the railway platforms and was analysed with respect to similar injuries occurring in different sporting activities. Routine physical examination was carried out by the senior author to assess ligament and meniscal injuries.
All the patients were arthroscoped and joint lavage was done. Whenever there was a stump of ACL sitting on the tibia, it was shaved off. Meniscal lesions were tackled. Post-operatively, the patients were put on a rehabilitation program as for ACL deficient knees.
Classification of the injury patterns: Patients described their injury in interesting details. With this in mind and the actual observation of events occurring at the platforms, we could divide them in three broad groups:
Type A: The person is pushed out on to the platform, when the train is slowing down, by the maddening crowd. The person does not know when he actually lands on the platform. He lands on the platform at 90 degrees to the motion of the train and rotates on his flexed knee due to his momentum.
Type B: The person tries to get off the train as it is slowing down to halt at the platform. Here the person tries to suddenly decelerate after landing on the platform.
Type C: The person instead of using the overhead bridges to go from one platform to another tries to take a short-cut and jumps off the platform on the tracks or the gravel in a hurry to go to the other side. As he lands on the irregular ground the foot slips or turns.
| Results|| |
There were 20 males and five females in the study. Three cases presented on the same day, 17 cases presented within five days, and five cases presented after more than five days of injury. Twelve patients (all males) belonged to the 20 to 30 year age group, 8 patients (2 females) belonged to the 30-40 age group and 5 patients (3 females) belonged to the 40-50 age group. Four patients (2 females) had Type A injury, 15 patients (two females) Type B injury, and 6 patients (1 female) sustained Type C injury.
Arthroscopic findings: Haemarthrosis was present in 17 cases. ACL injury was complete in 20 cases, but was partial or incomplete in five cases. Other associated injuries were present in 10 cases, all of which involved the medial meniscus, One bucket-handle tear, five flap tears, and four small peripheral tears. No collateral ligament injuries were found.
It was very difficult to correlate the type of injury to the anatomical site of injury. But certain relevance could be found which probably shows the severity of injury or the sequence of events. 1. All youngsters had femoral avulsions, which were complete in majority, partial once had some intrasubstance element. 2. Three out of five females had avulsion of femoral attachments. 3. All the type C injuries had intrasubstance complete ACL tears. 4. No one had tibial avulsions.
| Discussion|| |
There are various mechanisms responsible for ACL injury. Broadly they can be classified into two categoriesNon-contact and Contact. , Non-contact injuries are in the form of deceleration, cutting manoeuvres, and landing from a jump. Contact injuries are in the form of direct blow to the flexed knee, hyperextension or hyperflexion. Biomechanically, it is interesting to understand the various forces acting on the knee during the above mechanisms, as discussed later. ACL disruption without injury to the other ligaments can occur with hyperextension, marked internal rotation of the tibia on the femur (as in side-step cutting manoeuvre), and pure deceleration.  On analysing the above actions biomechanically, it is found that:
Type A is a flexion rotation (Pivot) injury. Here the knee can rotate in valgus or varus. If one is getting off from the left side of the moving train, if his left leg touches the platform first, it will cause flexion, valgus, external rotation of tibia on femur and if the right leg touches down first, it will cause flexion, varus, internal rotation of tibia on femur. In internal rotation the ACL is pressed against the posterior cruciate ligament and in external rotation against the lateral femoral condyle. Most injuries occur during the flexion range of 0 to 30 degrees. In this range, the angle between the quadriceps and the patellar tendon increases, thus increasing the effect of the extensor mechanism, which is a functional antagonist of the ACL. 
Type B is a deceleration injury. There is a sudden deceleration force acting on the knee joint as the partially flexed knee and the posteriorly tilted body (in order to counteract the momentum of the forward moving train) hit the platform. A shift of the centre of gravity dorsal to the axis of the leg leads to a movement of the thigh and the body directed centrifugally, vertically and in a plantar direction against the rotational axis of the knee. This is compounded by the reactionary force from the platform causing a forward movement of the tibia. This combination of movements effectively produces an anterior posterior shift of the tibia as in the anterior drawer manoeuvre thereby putting the ACL into tremendous stress.  In this situation, rotation injury can also take place if the person slips on landing.
Type C is a protective injury. The unexpected foot position, due to the uneven surface of the tracks, alters the knee motor recruitment patterns, placing the ACL at high risk. The loss of balance gives rise to protective violent eccentric contraction of the quadriceps muscle, which as the foot is on the ground would cause a forward subluxation of the tibia with respect to the femur, thus risking the ACL. At the same time, there is some incoordination of the firing of the hamstrings, which normally protect the tibia from subluxing forwards.  If we try to compare these injuries with those that occur on the football field, basketball court or during skiing, then we realise that they are not different. ,,
The fact that there were no collateral ligament injuries puts these as low velocity injuries. The quadriceps is considered functional antagonist of the ACL while the hamstrings are considered as functional agonists. The persons here did not have the athletic neuromuscular and proprioceptive training required for the coordinated firing of the quadriceps and the hamstrings.
The role of cyclic loading cannot be ruled out as an associated cause for isolated ACL ruptures. Cyclic loading whether acute and repetitive or as a result of ageing would eventually cause loss of visco-elasticity, which in turn would lead to stiffening of the ACL.  A preliminary effort is made to classify these injuries. Usefulness of such a classification system needs further prospective evaluation. Most injuries occurred in younger individuals who tend to take risks by jumping off the platform or alighting on the platform before the train stops. Most patients were from type B injury, meaning that more people get these injuries trying to get off the moving train.
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A P Kadakia
3/27, New Ghaswala Building, 493, Sane Guruji Marg. Tardeo. Mumbai 400 034
Source of Support: None, Conflict of Interest: None