Approach to knee injury

Anatomy
Bone of the knee are the distal
femur, the proximal tibia, and the
patella
Menisci and Joint Capsule
Menisci provide shock absorption,
allow for increased congruency
between joint surfaces, enhance joint
stability, and aid in distribution of
synovial fluid.
Anterior cruciate Posterior cruciate
ligament ligament
 Meniscal injury
The medial meniscus is more frequently torn than the lateral
meniscus because the medial meniscus is securely attached
around the entire periphery of the joint capsule, whereas the
lateral meniscus has a mobile area where it is not attached
Clinical Findings
The patient is usually a young person who sustains a
twisting injury to the knee on the sports field. Pain (usually on
the medial side) is often severe and further activity is avoided;
occasionally the knee is locked in partial flexion. Almost
invariably, swelling appears some hours later, or perhaps the
following day. With rest the initial symptoms subside, only to
recur periodically after trivial twists or strains. Sometimes the
knee gives way spontaneously and this is
again followed by pain and swelling.
 most important physical examination findings in the
knee with a meniscus tear are joint line tenderness
and an effusion. Other specialized tests include the
McMurray, flexion McMurray, and Apley grind tests.
The McMurray test is performed with the patient lying
supine with the hip and knee flexed to approximately
90 degrees. While one hand holds the foot and twists
it from external to internal rotation, the other hand
holds the knee and applies compression (see Figure 4
12). A positive test is one that elicits a pop or click
that can be felt by the examiner when the torn
meniscus is trapped between the femoral condyle and
tibial plateau.
Mc Murray test
 MRI is a reliable method of
confirming the clinical diagnosis, and
mayeven reveal tears that are
missed by arthroscopy.
Arthroscopy has the advantage that,
if a lesion is identified, it can be
treated at the same time.
 Treatment

Dealing with the locked knee Usually the knee

unlocks spontaneously; if not, gentle passive flexion
and rotation may do the trick. Forceful manipulation
is unwise (it may do more damage) and is usually
unnecessary; after a few days rest the knee may well
unlock itself. However, if the knee does not unlock, or
if attempts to unlock it cause severe pain, arthroscopy
is indicated. If symptoms are not marked, it may be
better to wait a week or two and let the synovitis settle
down, thus making the operation easier; if the tear
is confirmed, the offending fragment is removed.
Conservative treatment If the joint is not locked, it is
reasonable to hope that the tear is peripheral and can
therefore heal spontaneously. After an acute episode,
the joint is held straight in a plaster backslab for 34
weeks
the patient uses crutches and quadriceps exercises
are encouraged. Operation can be put off as long
as attacks are infrequent and not disabling and the
patient is willing to abandon those activities that provoke
them. MRI will show if the meniscus has healed.
Operative treatment Surgery is indicated (1) if the
joint cannot be unlocked and (2) if symptoms are
recurrent. For practical purposes, the lesion is often
dealt with as part of the diagnostic arthroscopy.
Tears close to the periphery, which have the capacity
to heal, can be sutured; at least one edge of the tear
should be red (i.e. vascularized). In appropriate cases
the success rate for both open and arthroscopic repair
is almost 90 per cent.
Tears other than those in the peripheral third are
dealt with by excising the torn portion (or the
bucket
handle).
Total meniscectomy is thought to cause
more instability and so predispose to late
secondary
osteoarthritis; certainly in the short term it causes
greater morbidity than partial meniscectomy and
hasno obvious advantages.
 Postoperative pain and stiffness are
reduced by prophylactic non-
steroidal anti-inflammatory drugs.
Quadriceps-strengthening exercises
are important
 Medial Collateral Ligament Injuries
Clinical Findings
An MCL tear typically presents with medial knee pain after either a noncontact rotational injury or a direct valgus
blow to the lateral knee. Instability may or may not be present, depending on the severity of the injury.
Symptoms (History)
How and when the patient was hurt are important parts of the history. Lower grade MCL injuries typically occur in a
noncontact external rotational injury, whereas higher grade injuries generally involve lateral contact to the thigh or
upper leg. Other important pieces of historical information include the location and presence of pain, instability,
timing of swelling, and sensation of a pop or tear. Surprisingly, grade I and II injuries are often more painful than
complete MCL rupture. Immediate swelling should make one suspicious of an associated cruciate ligament injury,
fracture, and/or patellar dislocation. A prior history of knee injuries or instability should always be sought when
evaluating a new knee injury.
Signs (Physical Examination)
MCL injuries are evaluated with a complete knee examination to evaluate for any other coexisting injuries. This is
especially true with ACL and PCL evaluation because an injury to either of these ligaments would significantly change
the treatment. Given the frequency of coexisting patellar dislocations in MCL injuries, palpation of the patella and the
medial parapatellar stabilizing ligaments should be performed in addition to patellar apprehension testing.
Medial joint line tenderness along the course of the MCL is typical at the location of the tear. Laxity to valgus stresses
is assessed by the amount of medial joint space opening that occurs at 30 degrees of flexion. It is important to stress
the knee at 30 degrees of flexion because with the knee in full extension, the posterior capsule and PCL stabilizes the
knee to valgus stress. This stability to valgus stress in full extension could mislead the examiner to believe that the
MCL is intact. Zero opening is considered normal, with 14 mm indicating a grade I injury; 59 mm indicating a grade
II injury; and 1015 mm indicating a complete or grade III injury. Additionally, grade I and II injuries typically have a
firm endpoint, whereas a grade III injury tends to have a soft endpoint to valgus stress.
 Lateral Collateral Ligament Injuries
Symptoms (History)
The most consistent symptom of an acute LCL injury is lateral knee pain. However, the symptoms of lateral
and posterolateral instability are quite variable and depend on the severity of injury, patient activity level,
overall limb alignment, and other associated knee injuries. For example, a sedentary individual with minimal
laxity and overall valgus alignment typically has few if any symptoms. However, if LCL laxity is combined
with overall varus alignment, hyperextension, and an increased activity level, symptoms are quite
pronounced. These patients may complain of lateral joint line pain and a varus thrust of their leg with
everyday activities. This is often described as the knee buckling into hyperextension with normal gait.
Signs (Physical Examination)
Patients with a LCL and/or posterolateral corner injury often also have additional ligamentous injuries to the
knee. Therefore, a thorough knee examination should be performed to evaluate for coexistent knee
pathology. Additionally, a careful neurovascular examination should be performed because the incidence of
neurovascular injury, particularly peroneal nerve injury, is reported in 1229% of posterolateral knee injuries.
The integrity of the LCL is assessed with a varus stress with the knee in full extension and 30 degrees of
flexion. Baseline varus opening is widely variable and should be compared to the contralateral leg. The
average baseline for varus opening is 7 degrees. Exam findings with an isolated LCL injury should include
varus laxity at 30 degrees of flexion and no instability in full extension. This is because of the stabilizing
effect that the intact cruciate ligaments provide in full extension.
Note that a significant posterolateral knee injury can be present without significant varus laxity. The most
useful test to evaluate for posterolateral instability is the dial test, which is done by externally rotating each
tibia and noting the angle subtended between the thigh and the foot. The dial test is performed at 30
degrees and 90 degrees of flexion with a significant difference being an angle 5 degrees or greater than the
contralateral leg.
 Anterior Cruciate Ligament Injuries
Symptoms (History)
The mechanism of injury should be elicited in any knee injury evaluation. This can guide the examination to additional structures that may also
be injured. ACL injury can occur in a variety of ways; a few mechanisms predominate, however. The most common noncontact ACL injury
mechanism involves a deceleration and rotational injury during running, cutting, or jumping activities. The most common contact injury
involves either hyperextension and/or valgus forces to the knee by a direct blow.
ACL injury is often associated with a pop heard by the patient at the time of injury. This piece of history is not ACL specific, however. Upon
return to competition, the patient often notices instability of the knee or describes the knee "giving out" with twisting activities. Substantial
knee swelling secondary to a hemarthrosis typically occurs within the first 4 to 12 hours following the injury.
Signs (Physical Examination)
With the history obtained and a proper physical examination, an ACL tear should be able to be diagnosed without any additional tests. A
complete examination of the knee should be performed to evaluate for any other associated injuries. The uninjured knee is examined first to
familiarize the patient with the knee examination.
The Lachman test is the most useful test for anterior laxity of the knee. It is performed with the knee in 2030 degrees of flexion as an anterior
force is applied to the tibia while the other hand stabilizes the distal femur. The degree of anterior translation, as well as the presence and
character of an endpoint, is assessed. The laxity is graded based on comparison to the uninjured contralateral knee. Grade 1 laxity is 15 mm
of increased translation. Grade 2 laxity is 610 mm of increased translation. Grade 3 laxity is more than 10 mm of translation as compared to
the injured contralateral knee.
The anterior drawer test is another test to evaluate anterior tibial translation. This is performed with the knee in 90 degrees of flexion as an
anterior force is applied to the tibia. This test is less sensitive than the Lachman test.
In the acute setting of an ACL tear, there is often a window where an accurate examination can occur before extensive knee swelling and
guarding inhibit examination. Aspiration of a hemarthrosis can help decrease pain and improve the quality of the examination in the acute
setting as well.
The pivot shift test is performed to test the rotational instability associated with an ACL tear. The test is based on the lateral tibial plateau
subluxing anteriorly with extension and reduction of the lateral compartment with flexion. The most effective method of achieving this result is
by flexing the knee with an axial load from full extension with valgus stress at the knee and internal rotation of the tibia. The reduction of the
subluxation should occur at approximately 30 degrees of flexion. MCL injury and some meniscal tears may produce a false-negative test.
The pivot shift test is considered the most functional test to evaluate knee stability after ACL injury. An examination under anesthesia is also
often useful in obtaining a more accurate pivot shift test. This can be useful in a patient with an unclear history of instability and an equivocal
examination in the office.
 Posterior Cruciate Ligament Injuries
Symptoms (History)
When evaluating a patient for a PCL injury, it is important to obtain the mechanism of injury, the severity of the injury, and any potential associated
injuries. In contrast to an ACL tear, it is rare for patients with PCL injuries to report hearing a pop or report any feelings of subjective instability. More
commonly, patients complain of knee pain, swelling, and stiffness.
The presentation of a patient with a subacute or chronically injured PCL can range from asymptomatic to significant instability and pain. Patients with
significant varus alignment or injury to the lateral structures of the knee often complain of feelings of instability and giving way. There are a few
characteristic mechanisms of PCL injury that differ significantly from the mechanism of ACL injuries. One of the most common mechanisms of PCL
injury is the so-called dashboard, injury during which the anterior tibia sustains a posteriorly directed force from the dashboard with the knee in 90
degrees of flexion. Sports injuries to the PCL result from an outside force or blow, in contrast to the typical deceleration twisting mechanism of an
ACL injury. The most common methods of a sports PCL injury include a direct blow to the anterior tibia or via a fall onto the flexed knee with the foot
in plantar flexion. The most common mechanism for isolated PCL injury in the athlete is a partial tear associated with hyperflexion of the knee.
Additionally, significant knee multiligamentous injuries with PCL tears can be seen after a varus or valgus stress is applied to the hyperextended
knee.
Signs (Physical Examination)
As with other ligamentous injuries, a thorough knee examination is necessary. Specific cues to injury to the PCL on initial inspection include abrasions
or ecchymosis around the proximal anterior tibia and ecchymosis in the popliteal fossa. Assessment for meniscal damage and associated
ligamentous injury should be performed. Evaluation of ACL laxity in the presence of an acute PCL injury is challenging because of the lack of a stable
reference point to perform a Lachman or anterior drawer test.
Examination of the PCL in the acutely injured knee can be challenging. Despite increased awareness of the injury, many PCL injuries go undiagnosed
in the acute setting. The most accurate clinical test of PCL integrity is the posterior drawer test. The knee is flexed to 90 degrees with the patient
supine, and a posteriorly directed force is applied to the anterior tibia. The amount of posterior translation and the presence and character of the
endpoint is noted. The extent of translation is assessed by noting the change in the distance of the step-off between the anteromedial tibial plateau
and the medial femoral condyle. The tibial plateau is approximately 1 cm anterior to the medial femoral condyle on average. However, the
contralateral knee must be examined to establish a baseline.
Another test for examination of the PCL is the posterior sag or Godfrey test. This test involves flexing the knee and hip and noting the posterior pull
of gravity creating posterior "sag" of the tibia on the femur. An adjunct to this test involves watching for a reduction of this subluxation with active
quadriceps contraction.
The reverse pivot shift is the analogue to the pivot shift in the evaluation of an ACL injury. This is performed by placing a valgus stress on the knee
with the foot externally rotated. The knee is then extended from 90 degrees of flexion and a palpable reduction of the posterolateral tibial plateau is
noted between 20 and 30 degrees of flexion.
It is extremely important to evaluate the posterolateral structures of the knee in the setting of a suspected PCL injury. Injury to the posterolateral
structures is reported to occur in up to 60% of PCL injuries.
 Patella Dislocation
Dislocation of the patella is a potential cause of acute hemarthrosis and must be considered when
evaluating a patient with an acute knee injury. The injury occurs when valgus force and external rotation of
the tibia is applied to a flexed leg. It is most common in females in the second decade of life.
Clinical Findings
The patella almost always dislocates laterally. The patient may notice the patella sitting laterally or might
say that the rest of the knee has shifted medially. It is unusual to see actual dislocation of the patella
except at the time of injury. Reduction occurs when the knee is extended.
Examination demonstrates tenderness over the medial retinaculum and adductor tubercle, which is the
origin of the medial patellofemoral ligament. The patient also has pain and apprehension when the patella
is pushed laterally with the knee slightly bent. Radiographs, including an axial patellar view, should be
obtained to determine whether there are osteochondral fractures. Often, a small fleck of bone is avulsed
by the capsule on the medial aspect of the patella. This is not intraarticular and does not require removal.
A displaced osteochondral fracture require excisions or internal fixation. Examination of the uninjured knee
is recommended to determine whether there are predisposing factors for dislocation, such as patella alta,
genu recurvatum, increased Q angle, and patellar hypermobility. Patella alta, or high-riding patella, is
identified by measuring the length of the patellar tendon and dividing by the length of the patella. The
upper limit of normal is 1.2. The Q angle is formed by a line through the patellar tendon intersecting a line
from the anterior superior iliac spine in the center of the patella. A normal Q angle is approximately 10
degrees, with a range of approximately plus or minus 5 degrees. Patients with generalized hypermobility
have increased extension of the knee, or genu recurvatum, which in effect gives them patella alta. They
also often have hypermobility of all the capsular ligamentous structures, including the static stabilizers of
the kneecap, giving them significant patellar hypermobility.