injuries poisoning
Knee Sprains and Meniscal Injuries
Diagnosis of Knee Sprains and Meniscal Injuries
Clinical evaluation X-rays to exclude fractures Sometimes MRI Diagnosis of knee sprains and meniscal injuries is primarily clinical. Stress testing is usually delayed because the pain is so great initially. A spontaneously reduced Knee (Tibiofemoral) Dislocations should be suspected in patients with a large hemarthrosis, gross instability, or both; detailed vascular evaluation, including Immediately check for vascular injuries if patients have a large knee hemarthrosis, gross knee instability, or both. Stress testing to evaluate ligament integrity helps distinguish partial from complete tears. However, if patients have significant pain and swelling or muscle spasm, testing is typically delayed until x-rays exclude fractures. Also, significant swelling and spasm may make joint stability difficult to evaluate. Such patients should be examined 2 to 3 days later (after swelling and spasm have subsided). A delayed physical examination of the knee is more sensitive than MRI of the knee (86% vs 76% [ Diagnosis references ]) for diagnosis of meniscal and anterior cruciate ligament injuries. Bedside stress testing is done to check for specific injuries, although most of these tests are not highly accurate or reliable. For bedside stress testing, clinicians move the joint in a direction in which the ligament being tested normally prevents excessive joint movement. For theApley test,the patient is prone, and the examiner stabilizes the patient’s thigh. The examiner flexes the patient’s knee 90°and rotates the lower leg while pressing the lower leg downward toward the knee (compression), then rotates the lower leg while pulling it away from the knee (distraction). Pain during compression and rotation suggests a meniscal injury; pain during distraction and rotation suggests a ligamentous or joint capsule injury. Forevaluation of the medial and lateral collateral ligaments,the patient is supine, with the knee flexed about 20°and the hamstring muscles relaxed. The examiner puts one hand over the side of the knee opposite the ligament being tested. With the other hand, the examiner cups the heel and pulls the lower leg outward to test the medial collateral ligament or inward to test the lateral collateral ligament. Moderate instability after acute injury suggests that a meniscus or cruciate ligament is torn as well as the collateral ligament. is the most sensitive physical test for acute anterior cruciate ligament tears ( Diagnosis references ). With the patient supine, the examiner supports the patient’s thigh and calf, and the patient’s knee is flexed 20 Not every patient requires x-rays. However, anteroposterior, lateral, and oblique x-rays are often taken to exclude fractures. The Ottawa knee rules are used to limit x-rays to patients more likely to have a fracture that requires specific treatments. X-rays should be taken only if one of the following is present: Age > 55 Isolated tenderness of the patella (with no other bone tenderness of the knee) Tenderness of fibular head Inability to flex the knee 90° Inability to bear weight both immediately and in the emergency department for 4 steps (with or without limping) MRI is usually not needed at the initial evaluation. A reasonable approach is to do MRI if symptoms do not resolve after a few weeks of conservative management. However, MRI is often done when severe injury or significant intra-articular injury is suspected or cannot be otherwise excluded. Other tests may be done to check for related injuries: Arteriography or CT angiography to check for suspected arterial injuries if knee dislocation or severe hyperextension are suspected Electromyography and/or nerve conduction studies, which are rarely done immediately but more typically done when nerve symptoms persist weeks to months after the injury 1.Rayan F, Bhonsle S, Shukla DD: Clinical, MRI, and arthroscopic correlation in meniscal and anterior cruciate ligament injuries.Int Orthop2009 33 (1):129–132, 2009. doi: 10.1007/s00264-008-0520-4 2.Benjaminse A, Gokeler A, van der Schans CP: Clinical diagnosis of an anterior cruciate ligament rupture: A meta-analysis.J Orthop Sports Phys Ther36 (5):267–288, 2006. doi:10.2519/jospt.2006.2011 