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Assessment and management of acute soft tissue knee injuries
by Francois Tudor



Scenario: called to A&E to assess a 20 year old man who hurt his knee whilst playing soccer today. No other injuries.

History
  • Age
  • Occupation – useful for deciding treatment
  • Sports level and aspirations – very important for deciding definitive treatment plan
  • Time/date of injury
  • Mechanism
  • Immediate problem – pain/swelling/knee collapsing
  • Able to continue playing – can indicate severity of injury (but not always - beware)
  • Immediate treatment – ice, strapping, physio
  • Problem now – particularly if not an acute injury – pain, swelling, instability, locking (unable to get knee fully straight)
  • Past medical/surgical history
  • Previous knee problems/surgery
  • Medication/drugs and allergies
Mechanism

Contact to knee:
Fracture
Posterior cruciate ligament (PCL) injury
Multiple ligament disruption
Knee dislocation

Contact from lateral side of knee:
Medial collateral ligament (MCL) injury ± other ligament injury
meniscal tear

Non-contact:
Anterior cruciate ligament (ACL) injury
Meniscal tear

Twist on planted leg:
Anterior cruciate ligament (ACL) injury
Meniscal tear
Patella dislocation


Impact on anterior knee/shin:
Posterior cruciate ligament (PCL) injury
Patella fracture

Impact to knee cap:
Patella fracture
Patella dislocation

Paediatric knee injury:
Ligament avulsion
Growth plate injury

Hyperflexion/resisted extension:
Quadraceps/patella tendon rupture (often >30 years old)
Examination
Antalgic gait or non-weight bearing - Fracture, meniscal tear, ligament injury
Unable to straight-leg raise - Quadriceps/patella tendon rupture or patella fracture
Large effusion - Intra-articular fracture, ACL rupture, meniscal tear
Reduced range of motion (Normal -2 to 130 degrees) - Fracture, meniscal tear, ligament injury, isolated effusion
Block of full extension - Locked bucket-handle tear of meniscus
Joint line tenderness - fracture, meniscus tear
Anterior drawer/Lachman +ve - ACL rupture, (possible false +ve with PCL injury)
Opening to valgus stress - MCL injury
Opening to varus stress - LCL injury
Investigation
ALWAYS send for knee x-rays, even when suspicion is of isolated soft-tissue injury.
Request – AP (weight-bearing if possible), lateral and skyline x-rays of knee.

Look for:
  • Lateral view:
            - Fluid/blood interface (FBI) – evidence of haemarthrosis. If present, suspect intra-articular fracture or ACL/meniscus injury
            - Fracture – tibial plateau, distal femur, minor fractures (Segond fracture of lateral plateau seen with ACL rupture)
            - Patella fracture/dislocation
  • AP view:
            - Intra-articular fracture of femur or tibia
            - ACL bony avulsion from tibia
Management

Knee dislocation (with or without fracture)
Assess neuro-vascular status – IF ANY DOUBT, call vascular surgeons
Call senior urgently
Reduce and backslab/brace (may require theatre)
Admit for further investigation/treatment
Monitor for vascular compromise

Fracture (tibial plateau, patella, distal femur), growth plate injury or avulsion
Analgesia
Assess neuro-vascular status
Assess for open fracture
Apply backslab
Elevate and non-weight bearing
Admit to ward
Monitor for compartment syndrome
Discuss with senior

Suspected quadriceps/patella tendon rupture
Analgesia
Backslab/brace if painful
Admit
Investigate with Ultrasound

Locked bucket handle meniscus tear
Analgesia
Non-weight bearing (brace if very painful)
Urgent investigation with MRI and review <1 week
Discuss with senior

ACL/PCL injury
Analgesia
Crutches and brace as necessary
Ice and gentle range of motion
Review in clinic 1 week
Investigate with MRI as outpatient

ACL injury with valgus/varus opening (suspected MCL/LCL injury)
Analgesia
Crutches and brace
Ice and elevation
Review clinic < 1 week

Meniscus tear (with full ROM)
Analgesia
Crutches non-weight bearing
Review in clinic 1 week
Investigate with MRI as outpatient

Any patients with high energy injury or severe mechanism but with a seemingly innocuous injury should be reviewed by senior orthopaedic doctor before discharge.

knee dislocation
Lateral x-ray knee demonstrating knee dislocation. THIS IS AN EMERGENCY
ACL avulsion fracture
Lateral x-ray of knee of skeletally immature patient demonstrating displaced avulsion fracture of the ACL origin
patella tendon rupture
Lateral x-ray knee demonstrating high riding patella due to patellar tendon rupture
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