The Acute Knee : A Handbook for Sports Medicine Physicians

This handbook presents a concise, practical approach to the physical examination and diagnosis of acute injuries of the knee. While radiological diagnostic tools like CT and MRI are important tools for orthopedic and sports medicine injuries, the skills of history taking and an accurate physical exam are no less important in educated decision-making when it comes to injury management. The goal of this book is to make it easier for a beginning knee practitioner to take an educated history and then perform a thorough physical examination. This will invariably steer them to the course of the correct diagnosis. The focus here is on a consistent and thorough examination, including taking a full history of the injury, utilizing common physical tests, and limiting differential diagnoses. To this end, the book opens with a review of these general considerations. Subsequent chapters discuss these considerations across a number of acute knee injuries tothe patella, ACL, MCL, PCL, meniscus, and multiligamentous and extensor mechanism injuries and conditions. Additional chapters describe osteochondral injuries and mimickers such as PVNS and tumors. Video clips demonstrating examination techniques are included throughout the text. While The Acute Knee is aimed primarily at younger practitioners, it is an excellent resource for any orthopedic surgeon or sports medicine physicians looking to refamiliarize themselves with the "lost art" of physical examination for the acute knee. Reviews of This Book Acknowledgments Contents Introduction 1: General Considerations 1.1 The History 1.2 The Physical Examination 1.3 Treatment Considerations 1.3.1 Early Care (First Visit) 1.3.2 Second Visit 2: Acute Patella Injury 2.1 Introduction 2.2 Acute Patella Dislocation 2.2.1 History 2.2.1.1 How Did You Hurt Your Knee? 2.2.1.2 Was It a Fall? 2.2.1.3 Did You Twist Your Knee? 2.2.1.4 Did You Hear a Pop or a Snap? 2.2.1.5 Did Your Kneecap Feel Like It Popped Out of Place? 2.2.1.6 Were You Able to Continue Your Activity? 2.2.1.7 When Did the Knee Swell? 2.2.1.8 Did This Ever Happen to You Before? 2.2.1.9 Did Your Other Knee Ever Pop Out of Socket? 2.2.1.10 Did Anyone Else in Your Family Ever Dislocate Their Patellae? 2.2.2 Physical Examination 2.2.2.1 Examine the Unaffected Knee (See Video 1.3, Chap. 1 and Table 2.1) 2.2.2.2 Examine the Injured Knee Observation Palpation The Apprehension Test (Video 2.1) 2.2.3 Treatment Plan 2.2.3.1 Early Care 2.2.3.2 Second Visit 2.2.4 Factors Influencing Your Decision-Making 2.2.4.1 Predisposing Factors Age Activity Level Occupation Family History/Bilateral Associated Injury Rehability 2.2.5 Differential Diagnosis of an Acute Patella Dislocation 2.2.6 Treatment Recommendation 2.3 Acute Patella Subluxation 2.3.1 History 2.3.2 Physical Examination (See Table 2.2) 2.3.3 Treatment Plan 2.3.3.1 Early Care 2.3.3.2 Second Visit and Treatment Recommendation 3: Medial Collateral Ligament (MCL) Injury 3.1 Introduction 3.2 The History 3.2.1 How Did You Get Hurt? 3.2.2 Did You Hear a Pop? 3.2.3 Were You Able to Continue Your Sport or Activity? 3.2.4 When Did the Knee Swell? 3.2.5 Were You Treated for the Injury? 3.2.6 Did You Ever Hurt This Knee Before? 3.3 Physical Examination 3.3.1 Observation 3.3.2 Palpation 3.3.3 Valgus Stress Testing (Video 3.1) 3.4 Differential Diagnosis 3.5 Treatment 3.5.1 Early Care 3.5.2 Second Visit and Treatment Plan 4: Anterior Cruciate Ligament Injury 4.1 Introduction 4.2 The History 4.2.1 How Did You Hurt Your Knee? Was It a Twist or Direct Fall? Did You Hear a Pop? Could You Continue Your Activity? Did You Need Help Tin Getting Up? Were You Able to Walk On It? If Yes, How Did It Feel? Wobbly? 4.2.2 Did your Knee Swell? When? 4.2.3 Have You Ever Hurt Your Knee Before? 4.2.4 Are You Active in Sports? What Do You Play? How Often? 4.2.5 What Type of Work Do You Do? 4.2.6 Have You Hurt Your Other Knee? Anyone Else in Your Family Hurt Their Knee? 4.2.7 What Level of School Are You In? 4.3 Physical Exam 4.3.1 Observation 4.3.2 Examine the Unaffected Knee 4.3.3 Neurovascular Assessment 4.3.4 Palpation 4.3.5 Apprehension Test 4.3.6 The Lachman Test (Video 4.1) 4.3.7 The Pivot Shift (Video 4.2) 4.3.8 The Dial Test (Video 4.3) 4.3.9 The Anterior Drawer Sign (Video 4.4) 4.3.10 Meniscal Evaluation 4.3.11 Differential Diagnosis 4.4 Treatment Plan 4.4.1 Early Care 4.4.2 The Second Visit 4.5 Factors Influencing Your Decision-Making 4.5.1 Age 4.5.2 Activity Level 4.5.3 Associated Injuries 4.5.4 Rehability 4.5.5 Family History 4.5.6 Gender 4.5.7 Occupation 4.5.8 Body Habitus/Laxity 4.6 Treatment Recommendations 5: Posterior Cruciate Ligament (PCL) Injury 5.1 Introduction 5.2 History 5.2.1 How Did You Get Injured? 5.2.2 Did You Hear a Pop or Snap? 5.2.3 Were You Able to Continue Your Activity? 5.2.4 Did Your Knee Swell? When? 5.2.5 Did You Ever Hurt the Knee Before? 5.2.6 Any Numbness or Pins and Needles in Your Leg? 5.3 Physical Examination 5.3.1 Observation 5.3.2 Neurovascular Assessment 5.3.3 ROM 5.3.4 Joint Line Tenderness 5.3.5 Drop-Back Sign (Video 5.1) 5.3.5.1 Lachman Test and Anterior Drawer Sign 5.4 A Negative Lachman and a Positive Anterior Drawer Sign 5.4.1 Represents a PCL Tear Until Proven Otherwise! 5.4.1.1 Posterior Drawer Sign (Video 5.2) 5.4.2 Differential Diagnosis 5.5 A Negative Lachman and a Positive Anterior Drawer Sign Is a PCL TER Until Proven Otherwise 5.5.1 Treatment 5.5.1.1 Early Care 5.5.2 Second Visit and Treatment Recommendations 6: Multi-Ligamentous Knee Injury 6.1 Introduction 6.2 Posterolateral Ligament Disruption 6.2.1 History 6.2.1.1 How Did the Injury Happen? 6.2.1.2 Did You Hear a Pop? 6.2.1.3 Could You Continue Your Activity? 6.2.1.4 Did Your Knee Swell? When? 6.2.1.5 Did You Ever Hurt Your Knee Before? 6.2.2 Physical Examination 6.2.2.1 Observation 6.2.2.2 Neurovascular Assessment 6.2.2.3 Tenderness 6.2.2.4 Pseudo-Varus Deformity 6.2.2.5 Varus Stress 6.2.3 Treatment 6.2.3.1 Early Care 6.2.4 Treatment Recommendations 6.3 Multi-Ligament Injuries (Dislocated Knee) 6.3.1 History 6.3.1.1 What Happened? 6.3.1.2 Did You Hear a Pop? 6.3.1.3 Could You Continue Your Activity? 6.3.1.4 Did It Swell? When? 6.3.1.5 Neurovascular Questions 6.3.1.6 Can You Feel Your Toes? Do You Have Any Tingling? Where Is the Tingling? Can You Feel the Big Toe? Does Your Entire Foot Feel Sleepy? Can You Move Your Toes? 6.3.1.7 How Would You Grade Your Pain? Is the Pain Getting Worse? Does It Hurt to Move Your Foot, Toes, Ankle? Is the Pain Getting Worse and Worse Despite Being Immobilized? 6.3.1.8 Did You Ever Hurt Your Knee Before? 6.3.2 Physical Examination 6.3.2.1 Observation 6.3.2.2 Neurovascular Assessment 6.3.2.3 Tenderness 6.3.2.4 Ligament Evaluation 6.3.3 Treatment 6.3.3.1 Early Care 6.3.4 Treatment Recommendations 7: Meniscus Tear 7.1 Introduction 7.1.1 History 7.1.1.1 How Did You Get Injured? 7.1.1.2 Did You Hear a Pop or a Snap? 7.1.1.3 Could You Continue Your Activity? 7.1.1.4 Did It Swell? When? 7.1.1.5 Where Does Your Knee Hurt? Point with One Finger! 7.1.1.6 Do You Have Night Pain? 7.1.1.7 Did Your Knee Lock? 7.1.1.8 Did You Ever Hurt Your Knee Before? 7.1.1.9 Family History? 7.1.1.10 Did You Ever Hurt the Other Knee? 7.1.2 Physical Examination 7.1.2.1 Observation 7.1.2.2 Range of Motion 7.1.2.3 Joint Line Tenderness 7.1.2.4 Meniscal Tests 7.1.3 Differential Diagnosis 7.1.4 Treatment 7.1.4.1 Early Care 7.1.4.2 Second Visit 7.1.5 Factors Affecting Your Decision-Making 7.1.5.1 Age 7.1.5.2 Activity Level 7.1.5.3 Alignment 7.1.5.4 The Degree of Arthritis 7.1.6 Treatment 7.1.7 Pearl of Wisdom 8: Extensor Mechanism Disruptions 8.1 Introduction 8.2 TIBIAL Tubercle Injuries 8.2.1 History 8.2.1.1 How Did You Get Hurt? 8.2.1.2 Did You Hear a Pop? 8.2.1.3 Can You Continue Your Activity? 8.2.1.4 Did Your Knee Bother You Before? 8.2.1.5 Did Your Knee Swell? 8.2.1.6 Family History 8.2.2 Physical Examination 8.2.2.1 Observation 8.2.2.2 Neurovascular Assessment 8.2.2.3 Range of Motion 8.2.2.4 Tenderness 8.2.2.5 Ligament/Meniscal Tests 8.2.2.6 Differential Diagnosis 8.2.2.7 Early Care 8.2.3 Treatment Recommendations 8.3 Patella Tendon Ruptures 8.3.1 History 8.3.1.1 How Did You Get Hurt? 8.3.1.2 Did Your Knee Ever Bother You Before? 8.3.1.3 What Sports Do You Play? What Kind of Work Do You Do? 8.3.1.4 Did You Hear a Pop? 8.3.1.5 Were You Able to Continue Your Activity? 8.3.1.6 Did You Need Help to Get Up and Walk Away? 8.3.1.7 Did It Swell? When? 8.3.1.8 Did You Notice a Deformity? 8.3.1.9 Did You Go to the Hospital? 8.3.2 Physical Examination 8.3.2.1 Observation 8.3.2.2 Neurovascular Assessment 8.3.2.3 Range of Motion 8.3.2.4 Tenderness 8.3.2.5 Palpation 8.3.2.6 Ligament/Meniscal Tests 8.3.3 Differential Diagnosis 8.3.4 Treatment 8.3.4.1 Early Care 8.3.5 Treatment Recommendations 8.4 Patella Fractures 8.4.1 History 8.4.1.1 How Did You Get Hurt? 8.4.1.2 Did You Hear a Pop? 8.4.1.3 Could You Continue Your Activity? 8.4.1.4 Did It Swell? When? 8.4.1.5 Did You Notice a Deformity? 8.4.1.6 Did You Ever Hurt Your Knee Before? 8.4.2 Physical Examination 8.4.2.1 Observation 8.4.2.2 Neurovascular Assessment 8.4.2.3 Range of Motion 8.4.2.4 Tenderness 8.4.2.5 Palpation 8.4.2.6 Meniscal/Ligamentous Tests 8.4.3 Differential Diagnoses 8.4.3.1 Early Care 8.4.4 Treatment Recommendations 8.5 Quadriceps Tendon Ruptures 8.5.1 History 8.5.1.1 How Did You Get Hurt? 8.5.1.2 Did You Hear a Pop? 8.5.1.3 Could You Continue Your Activity? 8.5.1.4 Did Your Knee Swell? 8.5.1.5 Did You Notice a Defect? 8.5.1.6 Did You Notice a Deformity? 8.5.1.7 Any Previous Knee Problems? 8.5.1.8 Any Prior Injections to the Knee? 8.5.1.9 What Type of Work Do You Do? Do You Participate in Any Sports or Gym Activities? 8.5.1.10 Past Medical History 8.5.2 Physical Examination 8.5.2.1 Observation 8.5.2.2 Neurovascular Assessment 8.5.2.3 Range of Motion 8.5.2.4 Tenderness 8.5.2.5 Palpation 8.5.2.6 Meniscal/Ligamentous Tests 8.5.3 Differential Diagnosis 8.5.4 Treatment 8.5.4.1 Early Care 8.5.5 Treatment Recommendations 9: Contusions and Chondral Injury 9.1 Introduction 9.2 History 9.2.1 How Did You Get Hurt? 9.2.2 Did You Hear a Pop? 9.2.3 Could You Continue Your Activity? 9.2.4 When Did It Swell? 9.2.5 Did It Get “Black and Blue”? 9.3 Physical Examination 9.3.1 Observation 9.3.2 Neurovascular Assessment 9.3.3 Range of Motion 9.3.4 Tenderness 9.3.5 Associated Ligament Disruption 9.4 Differential Diagnosis 9.5 Treatment 9.5.1 Early Care 9.5.2 Treatment Recommendations 10: The Mimickers 10.1 Introduction 10.2 Gout 10.2.1 History 10.2.1.1 Was There An Injury? 10.2.1.2 Could You Continue Your Activity? 10.2.1.3 When Did the Pain Begin? Did It Swell? 10.2.1.4 Past Medical History? 10.2.2 Physical Examination 10.2.2.1 Observation 10.2.2.2 Tenderness 10.2.2.3 Range of Motion 10.2.3 Treatment 10.2.3.1 Early Care 10.2.4 Treatment Recommendations 10.3 PVNS 10.3.1 History 10.3.1.1 Was There An Injury? 10.3.2 Physical Examination 10.3.2.1 Observation 10.3.2.2 Tenderness 10.3.2.3 Range of Motion 10.3.3 Treatment 10.3.3.1 Early Care 10.3.4 Treatment Recommendations 10.4 Bone Tumors 10.4.1 History 10.4.1.1 Was There An Injury? 10.4.1.2 Did the Knee Swell? 10.4.1.3 Do You Have Night Pain? 10.4.2 Physical Examination 10.4.2.1 Observation 10.4.2.2 Tenderness 10.4.2.3 Range of Motion 10.4.3 Treatment 10.4.3.1 Early Care 10.4.4 Treatment Recommendations 11: The Whole Gestalt (i.e., Conclusion) Index