Avulsion Fracture of the Medial Collateral Ligament

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RADIOLOGY REVIEW 1.0 ANCC Contact Hours Avulsion Fracture of the Medial Collateral Ligament

Patrick Graham

Introduction to use” and thus he had discontinued their use and pur- chased a knee sleeve. He noted continued feeling of insta- The medial collateral ligament (MCL), with its proximal bility with weight-bearing activities, continued daily knee and distal divisions superfi cially, meniscofemoral and swelling, sometimes involving the lower leg, and bruising meniscotibial divisions deep, is one of the primary of the medial knee that had subsequently resolved. Pain structures of the medial knee ( Wijdicks, Griffi th, improved, but not completely resolved, when at rest. He Johansen, Engbretsen, & LaPrade, 2010). This complex described aching and throbbing sensations at night that ligament is the primary medial stabilizer, providing sometimes kept him from sleep. He denied numbness, static and dynamic resistance to direct valgus stress as tingling, or other distal symptoms. well as contributing to the resistance of rotary forces On physical examination, he was found to be alert, and anterior–posterior translation (Marchant et al., oriented, affect appropriate, and in no apparent dis- 2011 ). tress. He displayed an antalgic gait, lacking appropri- Damage to the MCL is one of the most common ate knee extension into heel strike, without use of an knee injuries, especially in those patients reporting an assistive device. Tenderness about the medial knee, external trauma or forces resulting in valgus stress, most notable overlying the medial aspect of the me- with or without rotation of the knee (Kastelein et al., dial femoral condyle. Pain limited his range of mo- 2008 ; Phisitkul, James, Wolf, & Amendola, 2006 ; tion, initially tolerating 10° –100 ° with painful end Schein et al., 2012). Similar mechanisms of injury are ranges. Knee was grossly unstable with valgus stress reported with meniscus and anterior and posterior with reported pain on testing. Although painful, he cruciate ligament, as well as posterior–medial corner was able to perform a straight leg raise without exten- injuries that may occur in conjunction with MCL in- sor lag. He displayed a positive bounce home, jury ( Fetto & Marshall, 1978 ; Jacobson & Chi, 2006 ; McMurray and pivot-shift. He was found to be distally Schein et al., 2012 ). Prognosis following MCL injury neurovascularly intact. inversely correlates with severity and is signifi cantly Radiographic evaluation included anteroposterior, infl uenced by concurrent compromise of other liga- lateral, and sunrise views of the left knee. Findings were ments, particularly the anterior cruciate ligament evident for an avulsion fracture of the femoral attach- ( Azar, 2006 ; Fetto & Marshall, 1978 ; Jacobson & Chi, ment of the MCL as well as moderate to severe, tricom- 2006 ). partmental degenerative joint disease/osteoarthritis (see Figure 1). With these physical examinations and radiographic fi ndings, the patient was referred for mag- Case Presentation netic resonance imaging. A 50-year-old man presented to this orthopaedic pro- Magnetic resonance imaging is the most useful ad- vider approximately 1 month after sustaining injury to junct modality to evaluate the full extent of soft tissue, the left knee. He reported tripping over a metal support cartilage, and/or osseous injury ( Jacobson & Chi, 2006; beam, causing a forceful twisting and valgus-type injury Schein et al., 2012). Medial knee injuries are often as- of the knee. He noted immediate pain and swelling that sociated with concomitant ligament injuries, as well as prevented him from weight bearing. He was taken to a meniscus pathology, which must also be treated appro- local emergency department and told that he had priately to achieve optimal outcomes ( Azar, 2006). This “pulled something.” The healthcare providers provided patient’s magnetic resonance image confi rmed the pres- a knee immobilizer, crutches, and pain medication. He ence of MCL avulsion and tricompartmental was instructed to follow up with orthopaedics. He noted issues with pending worker’s compensation claim as to the delayed follow-up. Patrick Graham, MSN, RN, ANP-BC, Advanced Practice Nurse, Upon presentation, he reported continued medial knee Department of Orthopaedic Surgery, Northwestern Medicine, pain requiring Norco for management. Symptoms aggra- Chicago, IL. vated with any weight-bearing activities. Immobilizer and The author has disclosed no confl icts of interest. crutches were described as “uncomfortable” and “diffi cult DOI: 10.1097/NOR.0000000000000340

164 Orthopaedic Nursing • March/April 2017 • Volume 36 • Number 2 © 2017 by National Association of Orthopaedic Nurses Copyright © 2017 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited. F IGURE 1. Anteroposterior, lateral, and sunrise views of the left knee. On anteroposterior image, note the medial collateral ligament (MCL) avulsion from the femoral attachment (ellipse #1). Also note old, healed proximal fi bula fracture (ellipse #2). On sunrise, note the MCL avulsion. osteoarthritis, without convincing evidence of other discussion of MCL repair versus the potential for ligament pathology (see Figure 2). total knee arthroplasty (Azar, 2006; Marchant et al., 2011 ; Wijdicks et al., 2010). Management Nonoperative treatment has long been reported with Discussion favorable outcomes, consensus being it is the fi rst A thorough understanding of anatomy and biome- step in the management of acute, isolated MCL inju- chanics of the knee, in conjunction with physical ex- ries ( Azar, 2006 ; Fetto & Marshall, 1978 ; Phisitkul amination fi ndings, is paramount in ascertaining the et al., 2006; Wijdicks et al., 2010) The patient was pro- full extent of injury, thus guiding treatment decisions vided a hinged knee brace and referral to physical ( Jacobson & Chi, 2006; Phisitkul et al., 2006). The ex- therapy with goals of improving range of motion, isting consensus is that isolated MCL injuries can be quadriceps strength, and gait mechanics. treated nonoperatively ( Azar, 2006 ; Fetto & Marshall, Unfortunately, approval via his worker’s compensa- 1978 ; Phisitkul et al., 2006 ; Wijdicks et al., 2010 ). The tion claim was delayed and thus was unable to initi- goals of conservative treatment are the alleviation of ate therapy previous to his 1-month follow-up. At the symptoms and return to prior level of function. The 1-month follow-up, he noted continued pain and feel- advanced practice nurse should be aware that chronic ing of instability. Radiographic evaluation showed no instability, or fi nding concurrent ligament injuries, evident healing and examination confi rmed contin- may require operative intervention, and those patients ued instability of the knee. Given these fi ndings, in are best served being referred to an orthopaedic sur- conjunction with the presence of osteoarthritis of the geon for consultation ( Azar, 2006 ; Jacobson & Chi, knee, he was referred to an orthopaedic surgeon for 2006 ; Marchant et al., 2011).

F IGURE 2. Coronal and axial T2-weighted magnetic resonance images. Arrows on coronal image and ellipse on axial image high- lighting medial collateral ligament avulsion. Note the bright ﬂ uid signal between the avulsed fragment and the femur.

© 2017 by National Association of Orthopaedic Nurses Orthopaedic Nursing • March/April 2017 • Volume 36 • Number 2 165 Copyright © 2017 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited. R EFERENCES Marchant , M. H. , Tibor , L. M. , Sekiya , J. K. , Hardaker , W. T. , Garrett , W. E. , & Taylor , D. C. (2011 ). Management Azar , F. M. (2006 ). Evaluation and treatment of chronic of medial-sided knee injuries, part 1: Medial collateral medial collateral ligament injuries of the knee . Sports ligament . The American Journal of Sports Medicine , Medicine and Arthroscopy Review , 14 ( 2 ), 84 – 90 . 39 ( 5 ), 1102 – 1113 . Fetto , J. F. , & Marshall , J. L. ( 1978 ). Medial collateral liga- Phisitkul , P. , James , S. L. , Wolf , B. R. , & Amendola , A. ment injuries of the knee: A rationale for treatment. ( 2006 ). MCL injuries of the knee: Current concepts re- Clinical Orthopedics and Related Research , 132, view . Iowa Orthopedics Journal , 26 , 77 – 90 . 206 – 218 . Schein , A. , Matcuk , G. , Patel , D. , Gottsegen , C. J. , Jacobson , K. E. , & Chi , F. S. (2006 ). Evaluation and treat- Hartshorn , T. , Forrester , D. , & White , E. (2012 ). ment of medial collateral ligament and medial-sided Structure and function, injury, pathology, and treat- injuries of the knee . Sports Medicine and Arthroscopy ment of the medical collateral ligament of the knee. Review , 14 ( 2 ), 58 – 66 . Emergency Radiology , 19 ( 6 ), 489 – 498 . Kastelein , M. , Wagemakers , H. P. , Luijsterburg , P. A., Wijdicks , C. A. , Grifﬁ th , G. J. , Johansen , S. , Engbretsen , L. , Verhaar , J. A. , Koes , B. W. , & Bierma-Zeinstra , S. M. & LaPrade , R. F. (2010 ). Injuries to the medial collat- ( 2008 ). Assessing medical collateral ligament knee le- eral ligament and associated medial structures of the sions in general practice . American Journal of Medicine , knee . The Journal of Bone & Joint Surgery , 92 ( 5 ), ( 11 ), 982 – 988. 121 1266 – 1280 .

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166 Orthopaedic Nursing • March/April 2017 • Volume 36 • Number 2 © 2017 by National Association of Orthopaedic Nurses Copyright © 2017 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.