Acute Knee Pain Case Presentation - Andrew Bernhard

8/3/2019 Acute Knee Pain Case Presentation - Andrew Bernhard

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ED Case PresentationAndrew Bernhard, MS III


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Presents to South Pointe Emergency Department viaambulance.

He has a 30 minute history of knee pain, stemmingfrom a basketball game.

Patient states that he jumped up for a ball and his leftleg gave out when he came to the ground.

Patient states that pain is a 10/10 and continuouslygrabs at his knee, to try to relieve pain.

He appears to be in acute distress, but maintains hisability to send text messages.

26 year old, African American Male


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Past Medical History

Unremarkable

Past Surgical History No history of surgeries

Family History

Gout Hypertension

Diabetes, Type 2

Social History

Admits pack/day smoking

Social drinker, with no

urge to cut back

No illicit drug use

Allergies

NKDA

Medications

None

Subjective


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Patient denies any recent history of fever, chills,nausea, vomiting, urinary changes, diarrhea,headaches, dizziness, blurred or double vision.

Patient states that his only complaint is his left kneepain.

Review of Systems


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Patient appears awake, alert, and oriented to person,place, and time.

Vascular: DP, PT, and popliteal pulses palpable b/l. Mild edema noted to lateral aspect of left knee

Neuro: Gross and Epicritic sensation intact

Derm: Hyperhydrosis. No lesions noted to legs.

Musculoskeletal: Pain to palpation of lateral knee joint Patient unable to bear weight

No pain to palpation noted anywhere else

Strength: Knee extenders 5/5, knee flexors 4/5

Objective


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Anterior drawer testNegative

The tibia was unable to be moved anteriorly on the femur.

Lachman test - Negative The tibia was unable to be moved anteriorly

Pain to palpation locally, at the lateral joint line.

Radiographs ordered

Clinical Exam


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With the knee at 90 degrees, the tibia is pulledanteriorly

NegativeNo forward motion available or motion without

asymmetrical twisting of the tibia.

Indicative of an intact Anterior Cruciate Ligament PositiveTibia able to be

pulled forward with soft

endpoint or asymmetric

twisting of the tibia. Indicates ruptured ACL

Anterior Drawer Test


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More sensitive than the Anterior Drawer Test With knee bent between 20-30 degrees, tibia is pulled

anteriorly on the femur

NegativeLack of forward motion of the tibia

Suggests intact ACL

Positive - Anterior translation of the tibia (2 mm compared to

uninvolved knee or 10 mm total) associated with a soft or a

mushy endpoint.

Indicative of ruptured ACL

Lachman Test


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Clinical Radiographs


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Segond fracture

Avulsion fracture of the lateral tibial condyle, just distal to

the articular surface

Typically the result of varus knee stress. In this case, from

falling in on the leg.

The soft tissue structure avulsed is generally the IT band or

the anterior oblique band of the fibular collateral ligament

This fracture is generally seen in association with:

Torn ACL: 75-100%

Medial Meniscal injury: 66-75%

Lateral capsular ligament injuries

Assessment


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In the ED, radiographs were ordered and evaluated.

After a consult with ortho, the patient was placed ina non-weightbearing splint and allowed to leaveusing crutches.

A referral to an orthopedist was given.

Plan


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What other clinical tests should be ordered prior totreatment?

MRI

Typical Segond Fractures


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What is the treatment of choice, especially in ayoung adult athlete?

Arthroscopic surgery to address soft tissue damage is

required.

If there are tears of the knee ligaments, arthroscopic repair

and immobilization are required.

Three weeks non-weightbearing with a functional knee brace,

followed by three weeks partial weight bearing.

Typical Segond Fractures


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Thanks for coming

Acute Knee Pain Case Presentation - Andrew Bernhard

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