Acute Knee Injuries ligaments injuries.pdf

Internal derangement of knee
ACL
PCL
Fractures
Ligaments
Tendons

1. Pediatrics
Joseph Chorley, M.D.
Associate Professor of Pediatrics
Baylor College of Medicine
Primary Care Sports Medicine
ACUTE
KNEE
INJURIES

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Pediatrics Pediatrics
Goals and Objectives
•To be able to recognize the causes of the acutely
injured knee.
‐Know the big 7 acute knee injuries
‐Know the historical points that differentiate these injuries
•To be able to see imaging to substantiate the
correct diagnosis

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Pediatrics Pediatrics
THE BIG 7
•ACL
•MCL
•Meniscus
•Patellar dislocation
•Fracture
•PCL with or without LCL
•Fat Pad Impingement

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Pediatrics Pediatrics
Mechanism of Injury
•Twist, pivot
•Irregular landing
•Valgus
•Direct trauma
•Hyperextension

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Twist pivot cut (non-contact)
•ACL
•MCL
•Meniscus
•Patellar Instability

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•ACL
•Fat pad impingement
with posterior
capsule/oblique
popliteal ligament
strain, Kissing lesion
bone bruises
•PCL
Hyperextension

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Twist with a flexed knee
•Patellar instability
•ACL

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Valgus blow to the knee
•ACL
•MCL
•meniscus

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Direct blow to the front of the tibia
•PCL injury
Dashboard injury
Slip and fall on the front of the tibia

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PCL, ACL, and Meniscus

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ANTERIOR CRUCIATE
LIGAMENT TEAR
•SYMPTOMS
•loud sometimes audible pop
•instability or shifting sensation "knee went out"
•pain
•SIGNS
•effusion
•decreased range of motion
•positive anterior drawer, Lachman's maneuver,
and/or pivot shift
•Pearls
•must be weight bearing to tear

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•Valgus
•Pivot
•Hyperextension
ACL injury

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KISSING LESIONS
SEGOND FRACTURE
AVULSION FRACTURE AT THE
TIBIAL SPINE

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PCL +LCL

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Arcuate Ligament

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KNEE FRACTURES
•DISTAL FEMUR
•epiphyseal
•PROXIMAL TIBIAL
•tibialeminence
•epiphyseal
•PATELLAR
•OSTEOCHONDRAL
•CHONDRAL

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KNEE FRACTURES
•SYMPTOMS
•pain
•immediate disability
•SIGNS
•obvious deformity
•rapid effusion
•neurovascular compromise
•PEARLS
•20% of patients with a hemarthosishave some
chondral/osteochondral fracture

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Ottowa Knee Rules

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Pittsburgh Knee Rules
•Primary criteria (required)
‐Blunt trauma or fall type injury
•Secondary criteria (one of the following present)
‐Age younger than 12 years or over 50 years
‐Inability to walk four weight bearing steps in ER

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Salter Harris Fracture
Classification System

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Avulsion Fracture of the Tibial
Tuberosity

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ACL IN KIDS= THINK AVULSION
FRACTURE TIBIAL SPINE

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Pediatrics

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MENISCAL TEAR
•Incidence 60 per 100,000
•peak [men 20-40, women 11-20]
•medial meniscus torn twice as often as the
lateral meniscus
•80% of all meniscus tears involve the posterior
meniscus
•higher potential for healing if tear located in
the vascular peripheral 1/3
•80% of those with chronic ligament tears have
meniscal tear

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MENISCAL TEAR
•SYMPTOMS
•tearing or tightness feeling
•pain sudden and sharp
•locking or loose body feeling
•SIGNS
•effusion
•pain to palpation along the joint line
•decreased range of motion
•positive McMurray's test
•Pearls
•must be weight bearing to tear

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Meniscus

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Complex tears

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MEDIAL COLLATERAL
LIGAMENT TEAR
•SYMPTOMS
•medial pain
•little to no effusion
•SIGNS
•pain to palpation medially
•positive valgus testing
•Pearls
•there is no joint opening with valgus testing at 0
degrees with an isolated MCL injury

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PATELLAR DISLOCATION/
SUBLUXATION
•"THE GREAT IMITATOR"
•SYMPTOMS
•pain often medial
•immediate disability
•spectacular ripping sensation
•SIGNS
•immediate massive hemarthosis/no swelling
•palpable medial defect
•pain to palpation medially especially over medial retinaculum
•positive patellar apprehension test

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Hyperextension with fat pad
impingement
•Pain with hyperextension
‐Jumping
‐Laying prone off end of
the bed
•Pain is both anterior
and posterior

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Components of the posteromedial
corner.
At this level the
semimembranosus (SM)
can be seen contributing fibers
to the oblique popliteal
ligament (OPL) and to the
posterior capsule. The posterior
oblique ligament (POL)
is found between the
superficial
medial collateral ligament
(SMCL) and the
semimembranosus tendon on
this view.

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OSTEOCHONDRITIS DISSECANS
•SYMPTOMS
•locking
•loose body feeling
•may or may not have pain
•may or may not have effusion
•SIGNS
•positive Wilson's test
•may have positive McMurray's test
•may be normal

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Diagnostic Imaging
•Magnetic Resonance Imaging

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•Immediate rapid effusion
•Obvious deformity
•Acute locking of the joint
•Penetrating wound into the joint,
muscle or tendon
•Neurovascular comprise
•Joint instability
IMMEDIATE REFERRAL

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•Knee effusion
•If able to get to a sports medicine trained
specialist within the first 2 hours, do so.
•If unable to get to a sports medicine trained
specialist within the first 2 hours, start acute
rehab and refer during the first week.
•Athletes with a knee injury
•Inconsistent mechanism of injury and
physical exam
URGENT REFERRAL

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ACUTE TREATMENT
•Minimize swelling
•Minimize pain
•Minimize loss of strength
•Minimize loss of range of motion

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•P-Protection
•R-Relative Rest
•I-Ice
•C-Compression
•E-Elevation
•M-Medications
•M-Modalities
•M-Motion
•S-Strengthening
PRICEMMMS

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PROTECTION
•Crutches
•proper technique
•nonweightbearinguntil able to do a
good quad set
•wean from crutches when able to perform normal
heel toe gait
•Knee Immobilizer
•questionable benefit in most situations
•Return to play criteria

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RELATIVE REST
•DO NOTHING THAT HURTS
•pain is your body's way of saying that you are
doing an activity that is too demanding for it to
perform
•IF YOU LIMP, YOU NEED CRUTCHES
–not allowing the healing process to strengthen
weak damaged tissues
–biomechanical changes in normal gait will cause
abnormal stresses to other point up the kinetic
chain
–improper gait may predispose to secondary injury

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ICE
•Benefits of ice:
•How long do use ice?
Pain Control
Decrease swelling
As long as there is pain and swelling

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ICE
•20 MINUTES EVERY HOUR when possible
•use a bag of crushed ice or frozen peas
•put bag directly on the skin
•anticipate mild burning stinging sensation at 3-5
minutes before onset of anesthesia
•THINGS TO AVOID
–contraindications to ice (Raynaud's, impaired
sensation, peripheral vascular disease, cold
hypersensitivity)
–avoid refreezing cold gel packs
–never sleep with ice
–watch the peroneal nerve laterally

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DIRECTED COMPRESSION
•Get edema out of the vital areas and back into
the circulation
•doughnut shaped 1/4 inch felt pads
•elastic wrap,compressionhose
•be sure wrap from the midcalfto the midthigh

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ELEVATION
•Get edema moving back toward the heart and
away from getting stuck in the lower leg
•Optimally above the level of the heart

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MEDICATIONS
•ANALGESICS
•acetaminophen with or without codeine
•ANTIINFLAMMATORIES (initially
scheduled, then as needed)
•ibuprofen 10mg/kg or 800mg TID
•OTC 200mg tabs-4 pills TID
•naproxen 500mg BID
•OTC 220mg tabs-2 pills BID
•TAKE WITH MEALS TO DECREASE GI
SIDE EFFECTS
•cytotec200 micrograms QID

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MODALITIES
•electrical muscle stimulation may assist with
analgesia and in maintaining quadriceps
muscle strength in those patients who cannot
organize a "quad set"

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RANGE OF MOTION
•Extension
•legs propped up
•quad contractions
•prone with leg over edge of bed
•Flexion
•supine heel slides to buttocks
•chair slides

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STRENGTH
•Concentrate on the Quadriceps
•quad sets [5 repetitions of 10 seconds AT LEAST 5
times a day]
•straight leg raises
•Hamstrings
•isometric hamstring curls
•hamstring curls with resistance

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SUMMARY
•Know the knee anatomy
•Remember the 7 most common causes of
acute knee injuries
•Take a good history
•Go systematically through your physical
exam
•Get X rays when necessary
•Refer when necessary
•Start rehab as soon as you discharge the
patient