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

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

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

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

5. 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

6. Normal

8. 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

9. 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

11. 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

12. 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

15. 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

17. 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

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

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

20. 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

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

22. 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

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