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==General==
==Background==
- torn menis or lig can cause sig disability, so expeditious repair needed
{{Knee ligaments}}


- knee largest articulating joint in body- is modified hing with extensive ROM
==Clinical Features==
*History of locking episodes suggests a meniscal tear
*A sensation of popping at the time of injury suggests ligamentous injury, probably complete rupture of a ligament (third-degree tear)
*Episodes of giving way are consistent with some degree of knee instability and may indicate patellar subluxation or ligamentous rupture
*Rapid onset (within two hours) of a large, tense effusion suggests rupture of the anterior cruciate ligament or fracture of the tibial plateau with resultant hemarthrosis, whereas slower onset (24 to 36 hours) of a mild to moderate effusion is consistent with meniscal injury or ligamentous sprain. Recurrent knee effusion after activity is consistent with meniscal injury.


- stability provided by sof tissue- cruciate ligs and  collateral
{{ACL clinical features}}


ligs, menisci, capsule and muscles
===PCL===
*Posterior Drawer Sign
**Patient supine, knee flexed 90', attempt to displace tibia from femur in backward direction
===Meniscus===
*Symptoms
**"Locking" of joint or sensation of popping, clicking, or snapping
*Signs
**Effusions that occur after activity
**Joint-line tenderness
*Tests
**McMurray, grind test only 50% Sn


- acl and pcl add stability and proprioception
==Differential Diagnosis==
{{Knee DDX}}


- ligs passively limit motion therfore providing stability
==Evaluation==
[[File:Segond.jpg|thumb|Segond Avulsion Fracture (ACL tear)]]
{{Ottawa knee rules}}
{{Knee x-rays}}


- acl- pcl limit  ant and post desplacement of tibia on femur respectivelly
===Diagnosis of Ligamentous and/or Meniscus Injury===
*Normally clinically diagnosed initially or referred for re-exam in 4-5 days after decrease of swelling
**Primary medical doctor or orthopedics may later use MRI for definitive diagnosis


- acl limits ant motion of tibia on femur- if tibial plateau keeps going forward get relative int rotation of tibia at terminal extention and can result in sensation knee is buckling or giving out- most common during pivoting.
==Management==
*Knee brace, ice, elevation, ambulation as soon as comfortable
**Full knee immobilization generally not indicated for single ligament injuries


- acl inj also gives "loss of confidence" due to lack of proprioception input.
==Disposition==
*Discharge with orthopedic surgery follow-up


- pcl provides stability  regardless of position of knee- if disrupted, tibia goes posteriorly- may get hyperextension of knee, post displacement of tibial during flexing and varus and valgus angulation with knee extenstion.
==See Also==
*[[Knee Diagnoses]]
*[[Acute knee injury]]


- symptomatic pcl inj more common in pt with chronic tear or acute tear with other lig inj
==References==
<references/>


- Meniscus- increase joint stability, nutrition, lubrication, shock absorption or articular cartilage.
[[Category:Orthopedics]]
 
[[Category:Sports Medicine]]
- lat meniscus larger and less firmly attached- more mobile
 
- medial menis immobilie and attached to MCL and capsule
 
- med menis greater chance of inj since bears more weight and immobile
 
- knee flexion pushes menisc posteriorly
 
==MECHANISMS OF INJ==
- position of knee at time of inj dictates which structures inj
 
- acl- inj during traumatic twisting with valgus stress- may hear pop
 
- pcl- foot planted, twist with force directed posteriorly against tibia with knee flexed
 
- col lig- from abduction and ext rotation
 
- with age menisc tissure degenerates and splits and get horizontal tears- this leads to more loads on articular cartilage and arthritis.
 
- menisc are without pain fibres so pain from tearing and bleeding into perif attachments and capsule that causes pain.
 
- locked knee in flexed position by bucket handle tear in mcl- more common in youger pt
 
- lcl more mobile so less locking when torn- may get clicking
 
- women have more acl inj than men
 
==Diagnosis==
- examine healthy knee first- relaxes pt and ensures trust.  also needed for comparison
 
- inspection- gait- effusion
 
- palpation- warmth, eff, swelling, crepitance
 
#function-
##ACL tests
###lachman, ant drawer and lat pivot shift- should not cause pain in subacute setting Lachman- pt supine, knee 20- 30' extended- hold dista femur with one hand and prox tibia with other and pull up- should feed discreet stop- is positive test if no stop felt or too much motion
###Ant Drawer- pt supine, knee flexed 90', pull up on prox tibia
###Lateral Pivot Shift- valgus stress to knee with twisting force while flexing knee. one hand on lat part of knee pushing in.  other hand on foot with lateral force.  As start to extend knee, will get thud or jerk at 10- 20' representing ant subluxation of tibia on femur
## pcl stability
###post drawer test
####pt supine, both knees flexed 90'.  In knee with pcl tear tibia will sag posteriorly.  If putting force on  post calf corrects sag is positive test.
##Meniscal integrity
###McMurray
####pt supine, one hand on foot, other gives valgus force to knee- extend knee and int  and ext rotating tibia.  Positive if  get popping, sensation of symptoms along joint line and inablity to extend knee fully.
###Apley Compression test
####pt prone, put your knee on pts thigh and flex knee and  ext rotate tibia- then compress tibia downward- if more pain is postive
###Medial Lateral Grind
####supine, cradle calf in one hand. other on tibial joint line- apply varus and valgus stresses during flex and extending knee. if get grinding sensaiton from hand on joint line if positive
 
==RESULTS==
- composite test of acl, pcl meniscus reasonable sens and specific.
 
acl/ pcl test better predictors than menisc tests.
 
- no data to judge test for mcl/ lcl inj
 
==Source==
6/06  MISTRY
 
[[Category:Ortho]]

Revisión actual - 01:33 10 may 2019

Background

Knee ligaments

Knee anatomy. Right knee shown from anterio-lateral view.
  • Anterior Cruciate Ligament
    • Limits anterior translation of tibia
    • 75% of all hemarthroses are caused by disruption of ACL
  • Posterior Cruciate Ligament
    • Limits posterior translation of tibia
    • Isolated injuries are rare
  • Medial Collateral Ligament
    • Provide restraint against valgus (outward) stress
  • Lateral Collateral Ligament
    • Provide restraint against varus (inward) stress

Clinical Features

  • History of locking episodes suggests a meniscal tear
  • A sensation of popping at the time of injury suggests ligamentous injury, probably complete rupture of a ligament (third-degree tear)
  • Episodes of giving way are consistent with some degree of knee instability and may indicate patellar subluxation or ligamentous rupture
  • Rapid onset (within two hours) of a large, tense effusion suggests rupture of the anterior cruciate ligament or fracture of the tibial plateau with resultant hemarthrosis, whereas slower onset (24 to 36 hours) of a mild to moderate effusion is consistent with meniscal injury or ligamentous sprain. Recurrent knee effusion after activity is consistent with meniscal injury.


<translate>

ACL Injury

  • Hearing/feeling a "pop" during injury with ensuing knee instability is pathognomonic
  • Lever Sign or Lelli’s test (highest sensitivity at 94[1]-100%[2]). Demonstrated to be effective and 100% sensitive in a small ED study, especially compared to traditional methods[3].
    • Place a fist under the proximal third of the calf, opposite from tibial tuberosity
    • Apply moderate force to the anterior quadriceps
    • Heel should raise off table if there is not a complete rupture of ACL
Lever Test
  • Anterior Drawer Sign
    • Pt supine, knee flexed 90', attempt to displace tibia from femur in a forward direction
    • Displacement of >6mm compared w/ opposite knee indicates injury
  • Lachman Test
    • Pt supine, knee flexed 30', femur held w/ one hand, prox tibia pulled up w/ other hand
    • Displacement >5mm or soft end-point indicates injury
  • Pivot Shift Test
  • Segond Fracture
    • Pathognomonic for ACL tear but rare

</translate>

PCL

  • Posterior Drawer Sign
    • Patient supine, knee flexed 90', attempt to displace tibia from femur in backward direction

Meniscus

  • Symptoms
    • "Locking" of joint or sensation of popping, clicking, or snapping
  • Signs
    • Effusions that occur after activity
    • Joint-line tenderness
  • Tests
    • McMurray, grind test only 50% Sn

Differential Diagnosis

Knee diagnoses

Acute knee injury

Nontraumatic/Subacute

Evaluation

Segond Avulsion Fracture (ACL tear)

Ottawa knee rules

Ottawa knee rules points of tenderness (image of left knee).

X-ray is only required in patients who have an acute injury and one or more of the following:

  • Age >55
  • Isolated tenderness of the patella
  • Tenderness at the fibular head
  • Inability flex to 90 degrees
  • Inability to walk 4 steps BOTH immediately after the injury and in the ED

Knee x-rays

  • Anteroposterior and lateral views
    • Consider sunrise if pain over patella

Diagnosis of Ligamentous and/or Meniscus Injury

  • Normally clinically diagnosed initially or referred for re-exam in 4-5 days after decrease of swelling
    • Primary medical doctor or orthopedics may later use MRI for definitive diagnosis

Management

  • Knee brace, ice, elevation, ambulation as soon as comfortable
    • Full knee immobilization generally not indicated for single ligament injuries

Disposition

  • Discharge with orthopedic surgery follow-up

See Also

References

  1. ↑ Deveci A, Cankaya D, Yilmaz S, Özdemir G, Arslantaş E, Bozkurt M. The arthroscopical and radiological correlation of lever sign test for the diagnosis of anterior cruciate ligament rupture. SpringerPlus. 2015; 4:830. doi:10.1186/s40064-015-1628-9.
  2. ↑ Lelli A, Di Turi RP, Spenciner DB, et al. Knee Surg Sports Traumatol Arthrosc. 2016; 24:2794. https://doi.org/10.1007/s00167-014-3490-7
  3. ↑ Mcquivey, K. S., Christopher, Z. K., Chung, A. S., Makovicka, J., Guettler, J., & Levasseur, K. (2019). Implementing the Lever Sign in the Emergency Department: Does it Assist in Acute Anterior Cruciate Ligament Rupture Diagnosis? A Pilot Study. The Journal of Emergency Medicine, 57(6), 805–811. doi: 10.1016/j.jemermed.2019.09.003
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