1. Approach to the knee radiograph for bony injuries Jasmin Fauteux August 25 th 2011

2. Objectives Review: Indications The views The approach Fractures Cases

3. Knee rules

4. PDR’s applicability has yet to be proven Pittsburgh Decision rule potentially more specific

5. The views

6. Lateral

7. Anteroposterior

8. Obliques

9. Tunnel view

10. Skyline

11. The approach

12. S-ABC Targeting your approach to look for suspected fracture OR Soft tissue Alignment Bone Cartilage and joints

13. Soft tissue Lipohemarthrosis Effusion

14. Lipohemarthrosis

15. Effusion May be caused by a bone injury in 53% of cases

16. Alignment Condyle with plateau Patellar alignment

17. Bone Cortices Trabecular pattern Intra-articular bodies

18. Cartilages and joints Patellofemoral Femorotibial

19. Tibial plateau Lipohemarthrosis Oblique views Low force required in osteoporosis

20. 16% are missed by EP

21. Tibial plateau Trabecular density Widening of joint space Lateral displacement

22. Schatzker classification

23. Segond’s fracture

24. Reverse Segond’s

25. Arcuate complex avulsion -Prox. Fibula -Horizontal -Posterolateral

26. Tibial spine -Children > Adults -ACL avulsion

27. Case 1 -26yo M -Fell onto flexed knee -Isolated patellar pain

28. Case 2 62yo F Twisted knee while moving Walking with cane Flexion to 60 degrees

29. Case 3 34yo M Snowboarding Painful lateral joint line

30. Case 4 -33yo F -High intensity MVA -Painful prox. fib

31. Thank you!

32. Bibliography Verma A, et al: A screening method for knee trauma. Acad Radiol 2001; 8:392. Stiell I, et Al: Implementation of the Ottawa Knee Rule for the Use of Radiography in Acute Knee Injuries. JAMA 1997;278(23):2075-2079 Simon LV, et al: The Pittsburgh Decision rule: triage nurse versus physician utilization in the emergency department. J Emerg Med 2006 Oct; 31(3) 247-50 Seaberg DC, et Al, Multicenter comparison of two clinical decision rules for the use of radiography in acute, high-risk knee injuries, Ann Emerg Med 1998 Jul; 32(1): 8-13 Seaberg DC, et al: Clinical decision rule for knee radiographs, Am J Emerg Med 1994 Sep; 12 (5):541-3 Steil IG, Wells GA, McDowell I, et al. Use of radiography in acute knee injuries: need for clinical decision rules. Acad Emerg Med 1995;2:966–973. Bauer SJ, Hollander JE, Fuchs SH, et al. A clinical decision rule in the evaluation of acute knee injuries. J Emerg Med 1995;13: 611–615. Imparanza JI, Aginaga JR. Validation of the Ottawa knee rules. Ann Emerg Med 2001;38:364–368. Stiell IG, Greenberg GH, Wells GA, et al. Prospective validation of a decision rule for the use of radiography in acute knee injuries. JAMA 1996;275:611–615. Gottsegen C, et al: Avulsion Fractures of the Knee: Imaging Findings and Clinical Significance, RadioGraphics October 1, 2008 28:1755-1770 Mettler: Essentials of Radiology, 2nd ed, Marx, John: Rosen ‘s Emergency Medicine: concepts and clinical practice, 7 th ed. Tintinalli, Judith; Tintinalli’s Emergency medicine, 7 th edition Krishnam, Mayil S: Emergency radiology Schwartz, David: Emergency radiology: case studies Marincek, Borut: Emergency radiology: Imaging and intervention