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Approach to acute knee injuries (knee injury)
- 1. Approach To AcuteKnee Injuries Insp Dr Mahadev Deuja NPH Wednesday, April 11, 2018
- 2. Case 29/M basic technicalpolice trainee History Rt knee injury during shuttle race (frequent change in direction) Rt knee pain, swelling, difficultly weight bearing and unable to extend Rt knee completely P/H/O recurrent b/l knee joint instablity
- 3. Examination of Rtknee Look Gait- antalgic, minimal joint effusion Feel Mid-line joint tenderness Move Extension lag and restricted ROM
- 4. DNVS-intact Specialtest Valgus stress test- positive Lachman test and anterior drawer- doubtful
- 5. MRI Complete ACLtear + bucket handle MM tear + MCL sprain Grade-2 of Rt knee Unhappy triad
- 6. Management Arthoscopic ACLreconstruction + MM repair Physiotherapy
- 7. After 9 weeks Samepatient came to opd in wheel chair History Following twisting injury of the next (left) knee while steeping down from stairs
- 8. Examination of leftknee Look Gait- antalgic, minimal joint effusion Feel Mid - line joint tenderness Move Extension lag and restricted ROM
- 9. DNVS-intact Specialtest Valgus stress test- positive Lachman test and anterior drawer- doubtful
- 10. MRI Complete ACL tear+ bucket handle MM tear- left knee
- 11. Management Arthoscopic Aclreconstruction + MM repair Physiotherapy
- 12. Knee injuries Commoninjury Unstable design Exposure to external environment Functional demand Being major weight bearing joint knee injuries have significant disability Annually >1 million ER visits and 1.9 million OPD visits are of acute knee injuries.(US)
- 13. Patients presenting withan acute effusion/hemarthrosis Diagnosis ?
- 14. In order tohave an acute hemarthrosis IN the knee, something INSIDE the knee must be injured D.D’s 1. Intra-articular Fracture 2. ACL / PCL Tear 3. Patellar Dislocation/ Subluxation 4. Meniscus Tear
- 15. Remember that MCLand LCL are EXTRAarticular structures and isolated collateral ligament injuries donot cause an acute hemarthrosis
- 16. Approach to kneeinjuries History Focused knee exam Imaging/invasive procedure May be difficult in acute setting, reevaluation can be done once swelling and pain subsides
- 17. History Diagnosis ismade at history most of the times Mechanism of Injury Location of Pain Mechanical Symptoms Swelling/ Effusion Past history Available at: http://www.orthobullets.com/knee-and-sports/3003/history-and-physical-exam-of-the-knee. Accessed February 11, 2018.
- 18. Mechanism of injury Helps predict injured structure Contact Non contact
- 19. contusion, fracture PCL/joint capsulesprain ACL/joint capsule sprain
- 20. MCL/ meniscus LCL/meniscus ACL/ meniscus
- 21. Location of pain Anterior, medial, lateral, posterior Over joint line, bone and soft tissue structure
- 22. Mechanical symptoms H/olocking episodes suggests a meniscal tear. A sensation of popping at the time of injury suggests ligamentous injury Episodes of giving way are consistent with some degree of knee instability and may indicate patellar subluxation or ligamentous rupture.
- 23. Effusion / swelling Rapid onset of a large, tense effusion suggests ACL rupture or tibial plateau fracture Slower onset mild to moderate effusion is consistent with meniscal injury or ligamentous sprain. Recurrent knee effusion after activity is consistent with meniscal injury
- 24. Past History Kneeinstability, knee surgery and use of medication for knee pain
- 25. Knee examination Alwayscompare with normal knee Look abrasions, ecchymosis and localized swelling provide clues to the magnitude of force and the MOI Feel patella and its supporting structures Joint lines and collateral ligaments ,bones for tenderness, crepitus and localized swelling
- 26. Move Assess activeand passive ROM Locking or extension lag may suggest meniscal injury, intra articular loose bodies Assess DNVS
- 27. Special test Anterior DrawerTest. Lachman's Test. Posterior Drawer Test. McMurray's Test. Apley's Test. Collateral Ligament Stress Test. Patallo femoral assessment.
- 28. Anterior Drawer Test Supine andknee flexed to 90 Sit on the patient's foot and grasp around the calf Anterior force Tibial glide > 5mm – ACL laxity •Least reilable- influenced by hamstring spasm
- 29. Lachman test Flexknee 20-30 Stabilize thigh Tibia is pulled forward >3mm displacement & soft end point- +ve lachman •Most sensitive test
- 30. Posterior drawer test Supineand knee flexed to 90 Sit on the patient's foot and grasp around the calf Posterior force Tibial glide is compared
- 31. McMurray’s test Knee joint–completely flexed Foot is rotated externally and leg abducted Knee is slowly extended keeping leg externally rotated and abducted Patient may experience pain or a click may be heard- MM tear Posterior tear – pain at more flexed position Similar test with foot internally rotated and leg adducted is carried out – LM tear
- 32. Collateral Ligament Stress Test Painat ligament – partial tear Minimal pain at ligament with wide joint opening- complete tear Knee is flexed to 20-30· Gently abducted(test MCL) and adducted (test LCL) Look for pain and use finger at joint line for joint opening
- 33. Clinical evaluation cluesto ACL injury History • Non-contact injury • Landed awkwardly • Felt "pop” • Immediate swelling PE • Large hemarthrosis • Lachman • Anterior drawer positive
- 34. Clues to PCLinjury History • Struck dashboard • Fall with PF foot • Posterior knee pain PE • Posterior sag sign • Posterior drawer
- 35. Clues to meniscalinjury History • Mechanical symptoms (catching, locking), • Pain at joint line • Delayed swelling PE • Joint line tenderness • McMurray positive
- 36. Clues to patellarinjury History • Fall with DF foot • May feel 2 "pops“ • Swelling • Anterior pain, Pain with stairs PE • Patellar apprehension • Tender over MPFL • Effusion, Patellar crepitus • Pain with active compression
- 37. Clues to fracture History •High velocity injury • Inability to bear weight immediately PE • Abrasion • Ecchymosis • Deformity • Crepitus
- 38. Imaging Plain radiograph MRI CT scan USG
- 39. Plain radiography Initialimaging modality of choice Baseline views are anteroposterior (AP) and lateral If the lateral view is normal in the setting of acute trauma a fracture is unlikely
- 40. MRI If examinationand initial imaging studies are inconclusive or intra-articular and ligamentous injuries are suspected Significantly affects the clinical decision-making process Often prevent unnecessary knee arthroscopy
- 41. CT-scan Useful in Complex kneeinjuries to reveal fracture anatomy Cases where fracture is suspected but radiographs are negative Assessment of tibial plateau fractures (comparable accuracy to MRI) Along with MRI can improve surgical planning
- 42. USG Quick andinexpensive Useful in dynamic evaluation of superficial soft tissue structures tendon lesions, joint effusions, bursitis, and cysts
- 43. ACL injury USstatics 200,000 ACL-related injuries 100,000 ACL reconstructions each year. Incidence is higher among basketball, football, skiing, and soccer player. Females >> males 1.6-fold greater rate of ACL tears per athletic exposure in high school female athletes than males. A study by Gornitzky
- 44. Associated withmeniscal tears in up to 50% of patients Acute >> Lateral Chronic >> Medial Risk of reinjury is 15 times higher than general population Don’t miss the diagnosis - consequences can be devastating Medial meniscus injury (Bucket Handle Tear) Articular cartilage injury
- 45. Anatomy Fibrous collagenousconnective tissue that attaches the femur to the tibia. Primary (85%) restraint to anterior translation of the tibia. Secondary restraint to tibial rotation and varus/valgus angulation at full extension.
- 46. Mechanism of injury Noncontact injury (80%) Deceleration, changing direction, cutting injuries, or landing from a jump Contact and high-energy traumatic injuries (20%) With other ligamentous and meniscal injuries.
- 47. Hx: Hearing orfeeling a “pop” & knee gives way Significant swelling quickly (< 1 hour) Unable to continue play or activities due to pain, swelling and instability or giving away ↓ range of motion (ROM) Achy, sharp pain with movement
- 48. Physical examination Look Immediateeffusion = significant intra-articular trauma. Feel Joint line and bony tenderness- associated injury Assess ROM: Lack of complete extension- bucket handle MM tear/ associated loose fragments Special tests- lachman and anterior drawer test positive
- 49. Xray Segond Fracture - Rarelyseen - Pathognomonic for ACL tear - Avulsion # Most x-rays will be NORMAL
- 50. Mri Gold standard Sensitivity -90 to 98%. Fiber discontinuity, altered course, abnormal signal of ligament- acl tear Bone bruising- 90% Also helps to identifying associated ligament, meniscal, or articular cartilage injury Normal ACL Torn ACL Bone bruising
- 51.
- 52. Surgical Replacing tornACL with a tendon graft 2 most common grafts are Patellar tendon graft Hamstring graft Goal Prevent further damage to meniscus &cartilage and osteoarthritis.
- 53. The ACL reconstructionwith a bone- patellar-tendon-bone auto graft Passed drill Section of patella and tendon removed Patella tendon inserted
- 54. ACL reconstruction witha semitendinosis and/or gracilis- tendon auto graft Passage drilledHamstring graft prepared Hamstring graft inserted
- 55. the expectedlong-term success rate of ACL reconstruction is between 75-95%. Upto 80% of people return to pre injury state Failure is mainly due to: recurrent instability, graft failure, or arthrofibrosis. Return to all sports activity may take 6-9 months
- 56. Meniscus injury mostcommon indication for knee surgery higher risk in ACL deficient knees
- 57. Medial tears morecommon - less mobile Lateral tears more common in acute ACL tears
- 58. Causes: Sudden twisting Young athletes Simple movements Older knee
- 59. Hx: Clicking, catchingor locking Worse with activity Tends to be sharp pain at joint line Effusion
- 60. PE: mild-moderate effusion pain with full flexion tender at joint line + McMurray’s
- 61. Mri Low-signal intensity blacktriangle =normal White interruption =lesion
- 62. Take home message Think of 4 things when faced with a traumatic large acute hemarthrosis: 1. Fracture 2. ACL /PCL Tear 3. Patellar Dislocation 4.Quadriceps/Patellar Tendon rupture Clinical evaluation gives diagnosis most of the times MRI are helpful in diagnosing doubtful cases of ligament and meniscal injuries Fractures can be easily diagnosed on X-ray Ct scan is helpful for suspected cases of intra articular fractures ACL Tears and meniscal injuries are very common
- 63. Mcq Most sensitivetest to diagnose ACL tear is 1. Anterior drawer test 2. Lachman test 3. Posterior drawer test 4. McMurray test
- 64. Unhappy triadin knee injury is combination of 1. ACL + MCL+ LM injury 2. ACL + MCL + MM injury 3. ACL + LCL + LM injury 4. ACL + PCL + MM injury
- 65. Medial meniscustear is more common than lateral because it is 1. Larger in size 2. Less mobile 3. Medial rotation is more than lateral rotation 4. Fibroelastic
- 66. Refrences Available at:http://bestpractice.bmj.com/topics/en-gb/575. Accessed February 11, 2018. Available at: http://caep.ca/sites/caep.ca/files/caep/CAEP2015/Presentations/hui_caep _2015. Accessed February 16, 2018. Campbell's Operative Orthopaedics International Edition. 2016. http://www.imagingpathways.health.wa.gov/index.php/imaging- pathways/musculoskeletal-trauma/bone-and-joint-trauma/post-traumatic- knee-pain. Accessed February 11, 2018. http://www.orthobullets.com/knee-and-sports/3003/history-and-physical- exam-of-the-knee. Accessed February 11, 2018.
- 67.
Editor's Notes
- #42 CT, with its superior spatial resolution, is useful in acute knee trauma in