Plateau fractures or condylar, spine, tuberosity, subcondylar, epiphyseal
AP/LAT/Oblique
Consider Compartment Syndrome
Long Leg Splint-2 slabs
Assoc c soft tissue disorders of knee
Jumper’s Knee
Patella tendonitis
Baker’s Cyst
Swelling behind knee, if ruptures, can get swelling of lower
legs appears like a dvt. If sx of
coincident arthritis of knee and thrombophlebitis of calf should have baker’s
cyst ruled out by arthrogram
Exam
Thorough history
Examine good leg first
Inspection-examine quads for atrophy
Palpation: for temperature, An effusion can be detected
by noticing the loss of the peripatellar groove and by palpation of the fluid.
Smaller effusions may be detected by compressing the medial and superior
aspects of the knee, then pressing or tapping the lateral aspect to create a
fluid wave. A perceptible bulge on the medial aspect suggests a small effusion;
this sign may not be present with larger effusions. Ballottement of the patella
may also be a useful technique for detecting an effusion. The examiner quickly
pushes down on the patella. In the normal knee joint with minimal free fluid,
the patella moves directly into the femoral condyle and there is no tapping
sensation underneath the examiner's fingertips. However, in the knee with
excess fluid, the patella is "floating"; thus, ballottement causes
the patella to tap against the femoral condyle. This sensation is transmitted
to the examiner's fingertips. Localized swelling over specific knee structures,
such as the MCL or LCL, can also be noted. Crepitus, a palpable grating
sensation, may be produced during certain motions in joints with cartilage
disruption The maneuvers producing crepitus, the location of the crepitus, and
any pain elicited should be recorded. Joint line tenderness can also be
detected by palpating medial and lateral to the patella in the groove between
the femoral condyle and the tibia.
Lachman-is typically performed while the patient lies supine with the knee flexed to 20° to 30° The examiner stands to the side of the patient's leg with the patient's heal on the examination table. The femur is grasped with one hand just above the knee. While the examiner grasps the femur firmly to prohibit motion of the upper leg and to relax the hamstrings, the other hand grasps the proximal tibia. The lower leg is then given a brisk forward tug and a discrete end point should be felt. A positive test is one in which the end point is not discrete or there is increased anterior translation of the tibia.
Finally, meniscal integrity is assessed using several specific examination maneuvers, including McMurray test, the Apley compression test, and the medial-lateral grind test (Figure 2). McMurray test is performed with the patient supine. The examiner stands on the side of the affected knee and places one hand on the heel and another along the medial aspect of the knee, providing a valgus force. The knee is extended from a fully flexed position while internally rotating the tibia. The test is repeated while externally rotating the tibia. A positive sign is indicated by a "popping" and sensation of symptoms along the joint line, often accompanied by an inability to fully extend the knee.
The Apley compression test is performed with the patient laying in a prone position on a low examination table. The examiner applies his/her knee into the posterior thigh of the leg to be examined, then flexes and externally rotates the tibia while gripping the ankle. The examiner then compresses the tibia downward. If this compression produces an increase in pain, the test is considered positive.
The medial-lateral grind test is performed with the patient supine on the examination table. The examiner cradles the affected leg's calf in one hand and places the index finger and thumb of the opposite hand over the joint line. Valgus and varus stresses are applied to the tibia during flexion and extension. If a grinding sensation is palpated by the hand placed over the joint line, the medial-lateral grind test is deemed positive.
(JAMA 286:13 Oct 2001 JB24)
Medial Collateral Ligament Testing is done by applying valgus stress with the knee in full extension and then in 30 of flexion. If there is laxity in full extension, then there is a complete rupture of the MCL.
Age>55
Fibular Head Tenderness
Isolated Tenderness of Patella
Inability to flex 90 degrees
Inability to weight bear for four steps after injury and in the ED
Validated in children age 2-16 (Annals EM 42:1, 2003)
AP/LAT
Sunrise to better evaluate the patella
Tunnel view for the intercondylar notch for tibial spine fractures or loose foreign bodies
KNEE
Plain radiographs of the knee usually include an AP and lateral view. With
this two-view imaging protocol, the sensitivity of detecting knee fractures is
only 79%. The addition of two oblique views for a four-view imaging protocol
increases this sensitivity to 85% (22). To reduce the number of overlooked knee
fractures, consider obtaining oblique plain radiographs and possibly even CT
imaging for high-risk patients. The normal AP and lateral anatomy of the knee
is shown in Figures 19 and 20.
Figure 18. AP radiograph and diagram of normal right knee
Figure 19. Lateral radiograph and diagram of normal right knee
Using the “DOH” mnemonic again, a knee “D”islocation is not a clinically or
radiographically subtle diagnosis (Figure 20). The radiographic pitfall is not
considering an associated popliteal artery injury. They occur in 23-60% of knee
dislocations (23-25).
Figure 20. Anterior dislocation of knee (Lateral view)
There are three high-risk, “O”ccult fractures of the knee. The first is a
tibial plateau fracture, which alone accounts for one-third of all knee
fractures. These fractures usually occur after a valgus force is applied with
axial loading, such as when a pedestrian is struck by the bumper of a car.
Because of the relative insensitivity of two-view plain radiographs, if a
high-risk patient is unable to bear weight on the affected knee, two additional
oblique views will help elucidate the injury. Figure 21 radiographically
appears grossly normal on the two-view series but one can appreciate the
impressive fracture pattern through the medial tibial plateau on one of the
oblique views. CT imaging is necessary to evaluate the extent of any tibial
plateau fracture and should be considered in the rare high-risk patient who has
a normal four-view radiographic series. Such a high-risk patient might be a
pedestrian struck in the knee by a car, has significant point-tenderness over
the medial or lateral joint line, and is unable to bear any weight on the leg.
Figure 21. Tibial plateau fracture of left knee (A) AP view, (B) Lateral
view, (C) Oblique view, (D) Diagram
A
 |
B |
C |
D |
The second “O”ccult knee fracture is a Segond fracture—a proximal lateral tibial
avulsion fracture (Figure 22). The fractured piece was the insertion site of
the lateral capsular ligament. Although the fracture piece appears clinically
insignificant, be wary that Segond fractures have a significant concurrent risk
for anterior cruciate ligament (ACL) tears. These patients should be discharged
with a knee immobilizer and urgent follow-up with an orthopedist.
Figure 22. Segond fracture of the left knee (AP view)
For further images of a Segond fracture visit the
EMedHome.com Archives for the clinical case discussing this injury.
And the third “O”ccult fracture is a patella fracture,
which comprises 40% of all knee fractures. It is usually the result of direct
blunt trauma to the patella. Because of the overlapping femoral condyles, the
AP view is poor in detecting patellar fractures. The best radiographic
perspective is the lateral view. Figures 23 and 24 show the AP and lateral
views of a patella fracture, respectively. Additional images such as the
“sunrise view”, which is a tangential view of the patella with the knee flexed
approximately 60 degrees, may be helpful especially in visualizing vertical
patella fractures.
Figure 23. Left transverse patella fracture (AP view)
Figure 24. Left transverse patella fracture (Lateral view)
The primary “H”alf pathology for the knee is a Maisonneuve fracture (Figures 25
and 26). In this injury, a fracture of the proximal fibula is associated with a
fracture of the medial malleolus or deltoid ligament of the ankle. Often the
ankle mortise is widened, and the tibiofibular syndesmosis is disrupted.
Finding a proximal fibula fracture necessitates the need for an ankle exam and
radiograph, and conversely finding a medial malleolus fracture and/ or widened
mortise necessitates the need for a tibia-fibular exam and radiograph.
Figure 25. Maisonneuve fracture: Right knee proximal fibula fracture (AP
view of knee)
Figure 26. Maisonneuve fracture: Right ankle medial malleolus fracture (AP view
of ankle)
8-15 y/os
Pn/swelling at tibila tuberosity
Box the peroneal nerve-get foot drop
Anterior disloc-popliteal injury
Medial/Lat/Rotational-must go to OR
Patellar Dislocation-can be easily reduced, do patella apprehension test, push patella laterally, if pt reacts or tenses quad then positive
Ankle/Brachial pressure ratio less than 0.8 (using doppler) requires arteriography.
The presence of pulses and equal ankle-brachial indices is nearly 100% sensitive in excluding operative vascular injury (Am J EM, 2/07, pg. 241)
(Injury
2008;39:710)Can not do straight leg raise. Need surgical repair within 58-72 hours. Put in immobilizer
there is no way to differentiate it from DVT on clinical grounds, get an ultrasound.
if the cyst is ruptured and you give heparin, can get massive bleeding and even one case of posterior compartment syndrome
may see hemorrhagic ring surrounding ankle
you almost never will feel a mass
since the cyst contains inflammatory fluid, if it ruptures, entire calf will get red, swollen and painful. Knee pain which gets relieved but then the calf begins to hurt is classic
Differential: thrombophlebitis, baker's cyst, muscle tear (gastroc), plantaris tendon rupture, cellulitis, fasciitis, compartment syndrome, popliteal aneurysm, ganglia, neural tumors, sarcoma, hemangioma
Here are my tips re shin splints and exhaustion:
1) While you can usually acutely double your short duration exercise time, a
marathon does not "scale" the same way for many, if not most people. Next time
take your training up to 2/3rds of the marathon distance.
2) Shin splints and stitches usually come either early or late in a run. If
early it is usually because you haven't warmed up properly or are trying to
increase the pace to fast. They also are almost universal in new runners or
reconditioning ones. In both cases slowing down and running or walking through
them is fine.
When they occur late in the run they usually indicate an acute electrolyte
disturbance. I had good results with continuous supplementation with magnesium
(oxide) which most diets (including middle class Indian ones) are sorely
deficient in and which is associated with atherosclerosis and SCD. Trying to
maintain a fairly constant sodium in addition to hydration level is also
important. Some runners with persistent problems report relief with Mg++ plus
400 IU q.d. vitamin E and at least 100 mg q.d. of CoQ10.
If, as you say, you were completely drained and exhausted you may want to not
only increase the length of your training runs (and take the supplements I list
above), but also consider tanking up your muscle fuel reserves with p.o,
creatine supplementation. I once employed a guy who was both a superb athlete
and did consulting with big name athletes on nutrients. I can tell you that ALL
world class athletes are stuffed full of legal performance enhancing nutrients
and that these nutrients do make a positive difference. Creatine supplementation
can have a dramatic effect on muscle mass and endurance and seems very safe (and
also to reduce injury).
While I realize you are not aspiring to be a professional athlete, I think that
improving adaptation and tolerance for training through good nutrition
(including judicious use of supplements) is both good sense and good for the
body. It is interesting to note that superb athletes rarely live to anywhere
near the maximum lifespan for humans. There are no great centenarian athletes,
yet. One clue as to why this is the case is to look at the T-Bar levels and free
radical adducts in the urine and serum of athletes after a good workout: they
are astronomical -- often higher than seen after 10 minutes of global systemic
ischemia! Years before it was being considered as a marker of
ischemia-reperfusion injury the cytochrome C levels of conditioned athletes
after exercise were shown to be elevated. Runners also get a blast of Fenton
reaction mediated radicals as a result of the release of free hemoglobin due to
hemolysis (in part from foot impact on the pavement).