Red Flags � Infection � Dislocated knee � Lateral structure injuries Knee Red Flags: what not to miss � Fractures ABCs of Musculoskeletal Care � Bucket handle meniscus tear C. Benjamin Ma, M.D. � Young patients with swelling Professor � Extensor mechanism injuries Chief, UCSF Sports Medicine and Shoulder Department of Orthopaedic Surgery University of California, San Francisco 1 2 What not to miss What not to miss � History � Diagnosis that can be significantly worse if missed • Age Medicine is: • Mechanism Fact finding � Timely treatment is important • Co morbidities Detective work � Response to injury History and presentation � It is just NOT right……! � Appearance is extremely important � Examination • Range of motion • Specific examinations 3 4
Presentation Presentation � 50 yo with h/o diabetes with acute worsening knee pain x 2 days � 50 yo with h/o diabetes with acute worsening knee pain x 2 days � No obvious trauma � No obvious trauma � Unable to bear weight � Unable to bear weight � Limited range of motion � Limited range of motion � Physical examination � Physical examination • Large effusion • Large effusion • Warm • Warm • Limited Range of motion • Limited Range of motion Infected Knee Aspiration Urgent/Emergent surgery 5 6 Infected joint Presentation � Increasing pain � 40 yo with acute injury � Limited ROM � Unable to bear weight � May not have systemic symptoms � Limited range of motion � Medical co morbidities � Physical examination � Aspiration • Large effusion • >50,000 WBC • Warm • Can be lower for immunocompromised patients • Limited Range of motion � Differential diagnosis • Gross deformity or laxity Fracture or Acute ligament injury • Inflammatory arthritis Immobilization • Gout – can still have secondary infection Further Imaging 7 8
Presentation Extremity Fracture � 40 yo with acute injury � Unable to bear weight � Limited range of motion � Physical examination • Large effusion • Warm • Limited Range of motion • Gross deformity or laxity 9 10 Fractures Presentation � Have to have mechanism � 23 yo pedestrian versus car injury � Treatment depends on location and severity � Unable to bear weight � Location � Limited ROM • Intra articular require better alignment because it is at the joint � Physical examination • Lower extremity require better alignment because of weight • Moderate effusion bearing • Unstable ligament examination � Severity Dislocated knee • Displacement Thorough neurovasular examination • Comminution Urgent referral 11 12
Presentation Dislocated a lot of joints! � 23 yo pedestrian versus car injury � Unable to bear weight � Limited ROM � Physical examination • Moderate effusion • Unstable ligament examination 13 14 Dislocated knee Presentation � Severe limb threatening injuries � 18 yo soccer player injured after being tackled � High rate of neurovascular injuries � “Kid flying across me” • 33% � Unable to bear weight � High rate of limb amputation � Physical examination • 33% of the vascular injured patients • Good ROM � May not be that swollen • Lateral sided knee pain • Torn capsule and blood goes down the leg • Difficult examination because of pain � Usually is the mechanism • ? Numbness down the leg Posterolateral corner injury • Ped vs car Thorough neurovasular examination • Obese patients with slip Likely multiligament injuries Urgent referral 15 16
Presentation Posterolateral corner injuries � 18 yo soccer player injured after being tackled � Difficult injury to treat � “Kid flying across me” � Different from MCL (95% heal with no issues) � Unable to bear weight � Outcome is dependent of location of ligament tears � Physical examination � Earlier repair results are better than late reconstructions • Good ROM � Earlier repair is within 3 weeks of injuries • Lateral sided knee pain • Initial visit • Difficult examination because of pain • Referral • ? Numbness down the leg • MRI • Surgery scheduling 17 18 Presentation Presentation � 26 yo history of knee injury a few years back � 26 yo history of knee injury a few years back � May have had “ligament injury” � May have had “ligament injury” � Has some occasional locking and pain � Has some occasional locking and pain � Knee locked after getting up from sitting position � Knee locked after getting up from sitting position � Painful with weight bearing � Painful with weight bearing � Physical examination � Physical examination • Locked knee, ROM 20-90 • Locked knee, ROM 20-90 • Painful medial side • Painful medial side Bucket Handle Meniscus tears Non weight bearing Urgent referral MRI 19 20
Bucket Handle meniscus tears Presentation � Medial more common than lateral � 12 yo with swelling of the knee � Related to chronic ACL injuries or � Not sure when it happened � History of ACL reconstruction � Increases after game � Difficult with weight bearing � Some limping but able to continue � Locked knee appearance � Physical examination � Urgent treatment • Fairly normal gait • Moderate effusion There has to be a diagnosis • No pain No benign pediatric knee • Stable ligament effusion 21 22 Differential for Effusion Radiographs � Traumatic � Osteochondritis Dessicans • Fracture � Location • Ligament tear • Lateral MFC • Bone and cartilage injuries • Central LFC • Dislocation • Trochlea lesion • Acute meniscus tears � Prognosis is related to skeletal maturity � Atraumatic • Synovitis – JRA, synovial process • Congenital cartilage injuries - OCD • Congenital meniscus injuries - discoid 23 24
Presentation Quadriceps Rupture � 60 yo misstep after party Mechanisms: � Difficult with gait, able to limp � Indirect Trauma: forced/eccentric muscle contraction with foot planted and knee flexed � Cannot go down stairs regular way � Physical examination � Typically patients older than 40 years • Mild limp � 3X more common than Patella tendon ruptures • FROM � Bilateral ruptures can occur • Usually for patients with chronic disease or steroid use Quadriceps tendon rupture � Normal tendons do not rupture under stress loading Brace and crutches Urgent referral Easily missed injury 25 Quadriceps Rupture Quadriceps Tendon Rupture � Extensor lag on straight leg raise � Tenderness at superior pole of patella � Patella may be displaced inferiorly or is sitting low � Swelling, bruising
Extensor mechanism injuries Knee extensor injuries � Quadriceps or patella tendon tears � Quadriceps tendon rupture � All full tears require surgical intervention • 40-60 years old � Inability to do straight leg raise is a sign of full tear � Patella tendon rupture � Early repair results much better than delay reconstruction • 30-40 years old � Tendons may have preexisting injuries or tendinosus � Patella tendinitis • 20-30 years old � Osgood Schlatter’s Disease • 10-16 years old 29 Red Flags C. Benjamin Ma Professor Chief, Sports Medicine and Shoulder Surgery � Infection maben@orthosurg.ucsf.edu � Dislocated knee 415-353-7566 � Lateral structure injuries � Fractures � Bucket handle meniscus tear � Young patients with swelling � Extensor mechanism injuries 31 32
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