What Is the Best Way to Evaluate an Acute Traumatic Knee Injury?

From the Clinical Inquiries Family Physicians Inquiries Network

Matthew L. Silvis, MD, C. Randall Clinch, DO, MS, What is the best way and Janine S. Tillet, MSLS Wake Forest University, to evaluate an acute Winston-Salem, NC traumatic knee injury?

Evidence-based answer Use the Ottawa Knee Rules. When there or ligamentous injury (SOR: C, based on is a possibility of fracture, they can guide studies of intermediate outcomes). the use of radiography in adults who sonographic examination of a present with isolated knee pain. However, traumatized knee can accurately detect information on use of these rules in the internal knee derangement (SOR: C, pediatric population is limited (strength based on studies of intermediate of recommendation [SOR]: A, based on outcomes). Magnetic resonance imaging systematic review of high-quality studies (MRI) of the knee is the noninvasive and a validated clinical decision rule). standard for diagnosing internal knee Specific physical examination maneuvers derangement, and it is useful for both adult (such as the Lachman and McMurray tests) and pediatric patients (SOR: C, based on fast track may be helpful when assessing for meniscal studies of intermediate outcomes). Employ the Clinical commentary Ottawa Knee Rules Ottawa rules for ankles—yes, test, Drawer sign, and McMurray test to determine but they’re good for knees, too are useful in diagnosing the presence of whether plain The evidence presented here suggests internal ligamentous injuries without MRI, x-rays are needed a number of practical and useful and an ultrasound can help to detect knee to rule out fracture approaches for the evaluation of acute effusion when it is not clinically obvious. knee injury—something that’s especially A good physical examination and an helpful for family physicians and those ultrasound can effectively rule out serious who, like me, have worked a lot of knee injury with high specificity. When sporting events. serious injury is suspected, x-ray and MRI The Ottawa rules, which can be used are very useful for fracture and ligamentous to rule out fracture without an x-ray, are injury, respectively.

fairly well known for ankle injuries, but are Daniel Spogen, MD not as well known for knees. A Lachman University of Nevada, Reno

z Evidence summary of these criteria:1 These criteria help determine 1. ≥55 years of age who needs an x-ray 2. Tenderness over the head of the The Ottawa Knee Rules recommend fibula or isolated to the patella without knee x-rays for any patient meeting one other bony tenderness

116 vol 57, No 2 / FEBRUARY 2008 The Journal of Family Practice Should you order an x-ray? Ottawa rules for knee x-ray A knee x-ray is required only for knee injury patients with any of these findings: • 55 years of age or older • isolated tenderness of the patella (no bone tenderness of the knee other than the patella) • tenderness at the head of the fibula • inability to flex the knee to 90° • inability to weight bear both immediately and in the ED (4 steps, unable to transfer weight twice onto each lower limb regardless of limping). (www.gp-training.net/rheum/ottawa.htm)

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3. Unable to flex the knee to 90°, these conditions.4 or unable to bear weight (for at least In a small nonrandomized study 4 steps) both immediately and in the of adult knee trauma, sonographic di- emergency department. agnosis of an effusion (by an expert) fast track In a systematic review,2 the Ottawa had an LR+ for diagnosing an internal Physical exam by rules had a pooled negative likelihood derangement of the knee of 2.0 (95% CI, ratio (LR–) of 0.05 (95% confidence 0.67–5.96) and an LR– of 0.33 (95% CI, an orthopedist interval [CI], 0.02–0.23). A prospec- 0.12–0.96), as compared with the gold or FP with sports tive study of the Ottawa rules among standard of MRI.5 medicine training children with acute knee injury dem- In a nonrandomized prospective is highly sensitive onstrated a positive likelihood ratio study of adults receiving MRI of the (LR+) of 1.81 (95% CI, 1.47–2.21) and knee prior to arthroscopy, MRI identi- and specific an LR– of 0.16 (95% CI, 0.02–1.04).3 fied meniscal and ligamentous lesions However, limited information is avail- of the knee satisfactorily (Table 1).6 able in the pediatric population. In a retrospective study of adolescents (11 to 17 years of age) having knee MRIs Ultrasound and MRI and undergoing knee surgery, MRI com- both perform well pared favorably with the operative (gold Physical examination (including the standard) diagnosis (Table 2).7 Lachman test, Drawer sign, and McMurray test) by an orthopedist or Recommendations from others sports medicine–trained physician was University of Michigan Health System8 74% to 88% sensitive and 72% to 95% guidelines indicate the following: specific for suspected meniscal or liga- • Most knee pain is caused by patel- mentous injuries; MRI added marginal lofemoral syndrome and osteoarthritis. value in referral decisions regarding • MRI of the knee has not been prov-

www.jfponline.com vol 57, No 2 / FEBRUARY 2008 117 Clinical Inquiries 118 *Adapted from V I Posterior cruciate ligament A L M I MRI, magneticresonance imaging;LR,likelihoodratio. MRI, magneticresonance imaging; LR,likelihoodratio;CI,confidenceinterval. *Adapted from Majoretal, 2003. A L M I n meniscal ntra-articular cartilage lesion n t t ateral meniscus ateral meniscus nterior cruciate ligament nterior cruciate ligament edial meniscus j edial meniscus

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