Matt Baker Consultant in Emergency Medicine Knee injuries Matt Baker Consultant in Emergency Medicine

Knee injuries Fractures Dislocations Soft tissue injury Extensor tendon rupture Bursae Meniscus Collateral ligaments Cruciates

Points in history Mechanism FWB? Swelling – immediate or delayed Locking or giving way Recurrent or new?

Red flag Neurovasc damage Extensor mechanism rupture Infection Bleeding disorders Possibility of Ca (known tumour, severe pain, night pain)

Ottawa XR XR if: Age 55+ Tender fibula head Isolated patella tenderness Unable to flex >90 Inability to FWB 4 steps at time of injury & examination

Normal

Fractures Patella fractures Tender, crepitus, bruising, unable to SLR Most commonly direct trauma ie fall or dashboard Indirect from sudden muscular contraction Tender, crepitus, bruising, unable to SLR Differential of tibial tuberosity avulsion, patella or quadricep tendon rupture

Patella fractures Vertical fractures seen on AP Horizontal fractures on Lat Vertical & nondisplaced horizontal cylinder plaster Displaced refer to ortho Tendon rupture refer to ortho

Patella dislocations Traumatic but maybe habitual If confident of diagnosis reduce then XR If spontaneous reduced may have apprehension & discomfort over vastus medialis Cylinder plaster or canvas/cricket splint 6/52

Other fractures Femoral condyle – AK backslab & ortho (May need traction if displaced) Tibial plateau – AK backslab & ortho Knee dislocation – significant injury Ortho! Beware of occult fractures

Soft tissue Mild injury – no structural or XR abnormality RICE & analgesia Avoid HARM (Heat, Alcohol, Running, Massage) 72hrs Activities guided by pain 1 week follow up if not settled

MCL & LCL injuries Grade 1 – pain & tenderness over ligament but no increased laxity & firm end point Grade 2 – Some increased laxity but still firm end point Grade 3 – Complete rupture, no end point. May not be tender

MCL & LCL Grade 1 RICE and avoid HARM Grade 2 RICE, avoid HARM, ?bracing Crutches Physio & fracture clinic Grade 3 – refer - ?conservative ?repair

ACL/PCL rupture Rehab & ?repair versus acute repair – local guideline All need ortho review ?Splint, fracture clinic and physio

Meniscal injury If locked – can sometimes reduce If unable to unlock Simple analgesia & enthonox only If unlocks fracture clinic If unable to unlock Local protocol Some admit Some crutches & fracture or knee clinic

Meniscal injury No locking or giving way but clinically meniscal injury Trial of physio

Special notes Note medial meniscus & ligament attached to each other – co pathology Note grade 3 ligament & cruciate rupture Note tibial spine # Always advise follow up if just sprain as special tests difficult acutely

Should i aspirate? Local protocol of ED v’s ortho Only for ?infection ??if tense effusion but generally recur!