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Approach to Knee Effusions

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Approach to Knee Effusions CME REVIEW ARTICLE Approach to Knee Effusions David J. Mathison, MD*Þ and Stephen J. Teach, MD, MPH*Þ was unable to bear weight at the scene and was subsequently Abstract: The presence of an intra-articular knee effusion requires an carried off the field. On examination, he has no obvious extensive differential diagnosis and a systematic diagnostic approach. deformity but has a large effusion in his right knee with limited Pediatric knee effusions occur most commonly as acute hemarthroses flexion. An anterior drawer test is limited by pain and swelling, after traumatic injury. However, the knee joint is susceptible to effusions but there is laxity on the Lachman maneuver. Results of both the secondary to a wide variety of atraumatic causes. Special attention is McMurray test and the Bounce test are positive. His collateral required in the atraumatic effusion to distinguish features of infectious, ligaments appear intact, and his patella does not appear to be postinfectious, rheumatologic, hematologic, vasculitic, and malignant subluxable. A radiograph of his knee is negative for fracture or disease. This review discusses the various etiologies of both traumatic dislocation. and atraumatic pediatric knee effusions highlighting the historical, phy- A 15-year-old adolescent girl presents to the emergency sical examination, and laboratory characteristics to aid the emergency department with several weeks of worsening left knee pain. She provider in diagnosis and initial management. denies fevers, foreign travel, sexual activity, or other joint Key Words: knee effusion, knee injury, septic arthritis, joint effusion, symptoms. She spent the recent summer camping although has fracture, anterior cruciate ligament, patellar dislocation, arthrocentesis, no known tick exposures. She has family members with lupus, Lyme disease but she is otherwise healthy and takes no medications. On exa- Y mination, she has limited flexion of her knee. There is notable (Pediatr Emer Care 2009;25: 773 790) swelling with a fluid wave appreciated in the suprapatellar pouch. There is no warmth or erythema. A lateral radiograph TARGET AUDIENCE shows signs of an effusion, but there are no bony abnormali- This CME activity is intended for physicians, nurse prac- ties. The remainder the results of her physical examination is titioners, and physician assistants who care for children in an unremarkable. emergency or primary care setting. Primary knee complaints are frequent in the pediatric emergency department, particularly among adolescent athletes LEARNING OBJECTIVES who injure the knee more than any other body part, except 1 After participating in the activity, the paticipant should the ankle. Most knee pathologic diseases are related to mi- be better able to: nor trauma such as muscle strains, ligamentous sprains, and 1. Outline a pragmatic approach to the child and adolescent apophyseal overuse injuries. Patients with large knee effusions, with either an acute or a chronic knee effusion. however, are distinct. Although these effusions are most fre- 2. Use distinguishing historical and physical examination fea- quently hemarthroses from acute traumatic injuries, the clinician tures to differentiate causes of traumatic knee effusions. needs a broad differential to exclude the various nontraumatic 3. Describe various etiologies of atraumatic effusions and the causes of knee effusions specific to the pediatric patient (Table 1). important laboratory and radiographic features that can aid in diagnosis. HISTORY ILLUSTRATIVE CASES Patients with large effusions often have painful joints that A 14-year-old adolescent boy presents to the emergency are difficult to examine. It is therefore crucial to obtain a department after injuring his knee playing soccer. He recalls thorough history to elucidate risk factors for certain diseases. pivoting and twisting his right knee, then hearing a Bpop.[ He The clinician should ascertain information about acuity, duration, severity, signs of systemic disease, associated symptoms, and risk factors for various diseases. Examples of *Fellow (Mathison), Associate Chief (Teach), Division of Emergency historical questions include the following: Medicine, Children’s National Medical Center; and †Instructor in Pediatrics & (Mathison), Professor of Pediatrics and Emergency Medicine (Teach), George Is the swelling acute, subacute, or chronic? Washington School of Medicine and Health Sciences, Washington, DC. & Has there been a traumatic event or repeated overuse? Reprints: David J. Mathison, MD, Division of Emergency Medicine, & Are other joints involved? Children’s National Medical Center, 111 Michigan Ave NW, Washington, & Are there signs of systemic illness (fevers, rash, etc)? DC 20010 (e-mail: [email protected]). & Has there been recent travel to high-risk areas (ie, Lyme, Unless otherwise noted below, each faculty’s spouse/life partner (if any) has nothing to disclose. brucellosis, tuberculosis)? The authors have disclosed that they have no significant relationship with or & Has there been any exposure to ticks? financial interests in any commercial companies that pertain to this & Have any new over-the-counter, herbal, or prescription educational activity. medicines been used? All staff in a position to control the content of this CME activity have disclosed that they have no financial relationships with, or financial & Have there been any recent unprotected sexual encounters? interests in, any commercial companies pertaining to this educational & Is there a coexisting chronic illness (ie, inflammatory bowel activity. disease [IBD], lupus)? Lippincott CME Institute has identified and resolved all faculty conflicts of & Is there a history of injury or surgery to the joint? interest regarding this educational activity. Copyright * 2009 by Lippincott Williams & Wilkins & Is there a family history of rheumatologic or autoimmune ISSN: 0749-5161 disease? Pediatric Emergency Care & Volume 25, Number 11, November 2009 www.pec-online.com 773 Copyright @ 2009 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Mathison and Teach Pediatric Emergency Care & Volume 25, Number 11, November 2009 femoral and tibial condyles, and the patella (Fig. 1). There are TABLE 1. Differential Diagnosis for Pediatric Knee Effusions 4 major ligaments that provide stability: the anterior and pos- terior cruciate ligaments (ACL and PCL, respectively), which Traumatic prevent dislocation of the tibia against the femur, and the me- Ligamentous (ACL, PCL) dial and lateral collateral ligaments, which withstand medial and Fracture lateral stressors. The major muscle groups surrounding the knee Patellar dislocation are the quadriceps, the hamstring, the plantaris, the popliteus, Meniscus injury and the gastrocnemius. The quadriceps femoris is the principal Nontraumatic component for leg extension and one of the most powerful Infectious muscle groups in the body. It is composed of 4 parts: rectus Osteomyelitis with effusion femoris, vastus lateralis, vastus intermedius, and vastus medi- Classic bacterial (Staphylococcus, Streptococcus, gonorrhea) alis. Leg flexion is principally accomplished by the hamstrings, Tick-borne disease (Lyme) composed of the semitendinosus, semimembranosus, and bi- ceps femoris muscles. The popliteus, plantaris, and gastrocne- Zoonoses (brucellosis) mius all offer additional support in leg flexion. Mycobacterial (tuberculosis) The patella’s anterior position allows the quadriceps tendon Fungal to insert further from the joint’s axis thus creating additional Viral joint leverage. This mechanical advantage allows the joint to Postinfectious withstand friction from flexion and extension during running Reiter syndrome (seronegative reactive arthritis) and to withstand compression of the quadriceps tendon during Acute rheumatic fever kneeling. The menisci (from the Greek word meniskos, meaning Poststreptococcal reactive arthritis crescent) are wedge-shaped plates of fibrocartilage that act as Rheumatologic shock absorbers for knee movements. The menisci are bridged Spondyloarthropathies (IBD, celiac, psoriatic arthritis) by the transverse ligament of the knee, which allows them to move together during knee motion. The medial collateral Systemic lupus erythematosus ligament at its midpoint inserts into the medial meniscus, Juvenile idiopathic arthritis helping to explain why injuries to this ligament often have Behc¸et disease concomitant meniscal tearing. The synovium is a thin membrane Vasculitis-associated that lines the knee capsule attaching to the lining of the articular Henoch-Scho¨nlein purpura Wegener granulomatosis Vitamin C deficiency Hematologic Hemophilia (factor deficiency) Other coagulopathy (drug-induced or systemic disease) Malignancy Leukemia Primary bone neoplasms (osteosarcoma, Ewing sarcoma) Synovial sarcoma Chondroblastoma Metastatic disease Other Benign tumors Infiltrative (gout, pseudogout) Serum-like sickness reaction Familial Mediterranean fever Examples of descriptive questions specific to a traumatic event include the following: & Was the injury a contact or a noncontact injury? & What was the joint position during injury (ie, flexion, extension)? & What was the mechanism of injury (ie, cutting, pivoting, twisting)? & Have there been any mechanical symptoms (ie, locking, popping, or catching)? & Was there any ability to bear weight after the injury? & Have there been signs of instability (ie, Bgiving-way[)? & Where is the location of the pain? ANATOMY The knee is the largest joint in the body. It
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