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Acute Knee Injuries

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8/9/19 Acute Knee Injuries Scott D. McKay, MD Associate Professor Orthopaedic Surgery Texas Childen’s Hospital Baylor College of Medicine Objectives • Identify knee effusion • Recognize common mechanisms for acute knee injuries – Mechanism can often tell you as much as the physical exam 1 8/9/19 • 64% ACL or patellar dislocation • >40% had surgery for their injury Outline Recognize Knee Effusion Anterior Cruciate Ligament (ACL) Patellar Dislocation Avulsion Fractures Meniscus Tears Bone Bruising 2 8/9/19 Outline Recognize Knee Effusion Anterior Cruciate Ligament (ACL) Patellar Dislocation Avulsion Fractures Meniscus Tears Bone Bruising Knee Effusion • Abnormal fluid accumulation in a joint • Normal outline of patella gone • Most of fullness superior to patella https://WWW.bjchealth.com.au/connected-care/the-most-common-cause-for-a-swollen-knee-in-a-young-woman 3 8/9/19 Sagittal View NOT Knee Effusion Prepatellar bursitis https://musculoskeletalkey.com/prepatellar-bursitis-housemaids- knee/ 4 8/9/19 Outline Recognize Knee Effusion Anterior Cruciate Ligament (ACL) Patellar Dislocation Avulsion Fractures Meniscus Tears Bone Bruising ACL Tears • Most tears are “noncontact” • More common in Women • 3 positions: – Slightly flexed (<30) – TWisting – Valgus • Feel a POP 5 8/9/19 6 8/9/19 7 8/9/19 Physical Exam • Effusion + • Lachman + • Anterior Drawer +/- • Pivot Shift Lachman 8 8/9/19 Anterior Drawer Workup • Exam is diagnostic • X-rays – Usually normal – Segond fractures • MRI – Look for associated injuries 9 8/9/19 Treatment • Recommend surgical treatment for cutting/pivoting athletes • Return to sport 6-12 months – Criteria-driven – NOT merely time driven – Time to return is influenced by “prehab” • High risk of re-injury: – 10-15% re-tear rate, and 10-15% contralateral tear rate 10 8/9/19 Outline Recognize Knee Effusion Anterior Cruciate Ligament (ACL) Patellar Dislocation Avulsion Fractures Meniscus Tears Bone Bruising Patella Dislocation • Underlying anatomic cause • Often non-contact • High rate of recurrence (70%) https://WWW.orthobullets.com/knee- and-sports/3020/patellar-instability 11 8/9/19 Mechanism • Knee flexed • Trunk rotation toWards affected side • Femur rotates inWard • Foot fixed • Valgus Coviello M., Mazzola C. (2016) Management of the First • Quadriceps contraction Patellar Dislocation. In: Volpi P. (eds) Arthroscopy and Sport Injuries. Springer, Cham S. Brent Brotzman, Chapter 56 Patellofemoral Disorders, Editor(s): Charles E. Giangarra, Robert C. Manske, Clinical Orthopaedic Rehabilitation: a Team Approach (Fourth Edition),2018, Pages 376-388.e1, ISBN 9780323393706, 12 8/9/19 J-sign • Video of J-sign • https://casereports.bmj.co m/content/2018/bcr-2017- 222887 Risk Factors for Patellar Dislocation • J-sign • Femoral anteversion • Increased Q-angle • Ligamentous laxity • Lateral patellar tilt • Family history • Genu valgum • Personal history on other side 13 8/9/19 Presentation • Usually already spontaneously reduced • If still dislocated, straighten knee • Large knee effusion, negative lachman • Examine the other knee! – Valgus, j-sign Imaging XR: • Medial avulsion fractures common • Osteochondral loose bodies MRI: • Typical bone bruise pattern • Find loose bodies 14 8/9/19 Treatment (First Time) • Supportive – RICE – Crutches as needed • Patellar stabilizing brace • Physical therapy • Return to sport 6-12 Weeks Surgical Treatment • Recurrent dislocation interfering With desired activities • Osteochondral loose bodies • Surgical treatment addresses underlying anatomic abnormalities 15 8/9/19 Outline Recognize Knee Effusion Anterior Cruciate Ligament (ACL) Patellar Dislocation Avulsion Fractures Meniscus Tears Bone Bruising Avulsion Fractures • Ligamentous or tendinous avulsions • Ligamentous avulsion mechanisms match ligament stress – Varus force = LCL tear or avulsion – Valgus force = MCL tear or avulsion • Tendinous avulsions can happen With forceful contraction 16 8/9/19 Tibial Tubercle Fracture (Patellar Tendon) • Often have pre-existing pain • Jumping mechanism most common • Surgically treated • Excellent result. Back to sport 3-6 months 17 8/9/19 Fibular Avulsions • Biceps/LCL avulsion – High energy injury – Direct bloW to anteromedial tibia – Can have peroneal nerve injury • Usually part of multiligamentous knee injury requiring complex reconstruction ACL Avulsion • Same ACL mechanism • Ideally treated With early repair • Excellent outcome • Back to sports in 3-6 months 18 8/9/19 PCL Avulsion • Fall on a flexed knee • Feel better quickly • Not alWays treated surgically • Good outcomes • Popliteus tendon avulsions heal With supportive treatment • Return to sport in 6 Weeks 19 8/9/19 Outline Recognize Knee Effusion Anterior Cruciate Ligament (ACL) Patellar Dislocation Avulsion Fractures Meniscus Tears Bone Bruising Meniscus Tears • C-shaped cartilage structures • Distribute force throughout the knee • Provide some rotational stability https://WWW.health.harvard.edu/a_to_z/torn-meniscus-a- to-z 20 8/9/19 Meniscus Tear Case – May 2019 • 17 yr old young Woman • Knee forcefully rotated While squatting in Wrestling. Felt a pop. SWollen after the match • Physical exam: – Effusion, medial joint line tenderness, pain With mcmurray’s. MRI 21 8/9/19 Management • Chose a period of conservative treatment • No improvement in pain, especially With hiking/running/trampolines • Treated With arthroscopic repair 2 Weeks ago • Goal is Naval academy next summer? Wrestling this Winter? Meniscus Summary • Generally rotation and flexion cause injury • Effusion is present • After acute phase, provocative tests reproduce flexion/rotation: – Mcmurray’s test – Thessaly test – Apley compression test • Diagnosis is by MRI • Treatment is usually surgical in children & adolescents 22 8/9/19 Discoid Meniscus • Instead of a “C” it’s a “Frisbee” • Easily torn • Can cause the entire knee to shift and clunk if unstable • Treatment is surgical When symptoms Warrant Geffroy L., Bouguennec N. (2016) Meniscal Lesions in Children: Classification, Discoid Meniscus, Traumatic Lesions. In: Hulet C., Pereira H., Peretti G., Denti M. (eds) Surgery of the Meniscus. Springer, Berlin, Heidelberg Outline Recognize Knee Effusion Anterior Cruciate Ligament (ACL) Patellar Dislocation Avulsion Fractures Meniscus Tears Bone Bruising 23 8/9/19 More Than Just Bumps & Bruises Case • 16-yr-old young lady Who got caught in a Wave swimming in Mexico and somehoW hit her legs on rocks & sand in May 2019 • Immediate diffuse pain & swelling • Persistent pain With Weight bearing (medial proximal tibia) • Physical exam normal last Week in my office • XR normal MRI – Nondisplaced Fractures and Contusion 24 8/9/19 Treatment – Bone Contusions • Limited Weight bearing for 4-8 Weeks • Excellent result • Don’t need folloW-up MRI...Signal takes a long time to resolve Summary • Identify effusion after injury – Important sign of significant injury • Recognize common mechanisms for acute knee injuries: – ACL tears – Patellar dislocations – Avulsion fractures & sprains – Meniscus tears – Bone bruising 25.
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