Saturday 8 March 2014

Knee Differential Diagnosis

The Mechanism of Injury (MOI) is useful subjective information that can be used to direct the objective assessment. This includes discussing the location of contact, location of pain, history of previous injury, areas of anaesthesia/dysaesthesia or weakness and swelling. 

Anterior Cruciate Ligament (ACL)
  • Non-contact twisting injury in flexion
  • Blow to the hyperextended knee
  • In young patients, ACL tear is the most common cause of acute swelling
  • Tests include Lachman's, Anterior Drawer and Pivot Shift
  • Imaging includes a standing AP x-ray

Posterior Cruciate Ligament (PCL)
  • Blow to the flexed knee (e.g. dashboard injury)
  • Posterior knee pain
  • Tests include Posterior Drawer, Posterior Sag Sign and Quadriceps Active test

Medial Collateral Ligament (MCL)
  • Blow to lateral aspect of the knee (valgus injury)
  • Acute medial pain
  • Tests include valgus laxity at 0 to 30 degrees of knee flexion

Posterolateral Corner (PLC)
  • Blow to the hyperextended knee
  • Blow to the medial aspect of the knee
  • Acute lateral pain, including Lateral Collateral Ligament (LCL)
  • Tests include varus opening at 30 degrees of flexion, posterolateral drawer test, reverse pivot shift test and the figure-4 test.
  • Varus thrust gait

Meniscus
  • Non-contact twisting injury in flexion
  • Acute pain (med/lat)
  • Chronic pain (med/lat) indicates a degenerative meniscal tear
  • Acute swelling
  • Lack of full extension (bucket handle tear)
  • Lack of full flexion may be indicative of an injuy to the posterior horn of the mensci
  • Posterior knee pain on flexion

Patellofemoral
  • Anterior knee pain with flexion of the knee
  • Patella translation
  • Retropatellar Crepitation (indicative of chondromalacia)
  • Imaging includes a patellar sunrise x-ray
  • Weakness in quadriceps strength

Patella Subluxation or Dislocation
  • Non-contact twisting in extension
  • Increased risk with patella alta (when the patella is higher than normal, therefore disturbing the interactions with the trochlear groove)
  • Acute anterior pain
  • Acute swelling
  • Deformities (typically lateral)

Infections and Tumours
  • Chronic swelling (also indicative in osteoarthritis)
  • Joint warmth or redness may be indicative of infection (aspiration may be required to evaluate the synovial fluid)
  • Bloody effusions are more consistent with trauma or tumour
  • Non-bloody effusions are more consistent with infection or inflammatory arthritis
  • A Baker's Cyst normally indicates that swelling elsewhere in the joint has leaked posteriorly between the semimembranous tendon and the medial head of the gastrocnemius tendon
  • Knee effusion may limit full flexion
  • Imaging includes CT and bone scans for tumours or another bony pathology
  • Aspiration invasive testing may also be carried out with acute effusion

Chronic Pain
  • Chronic medial pain indicates a degenerative meniscal tear, medial compartment arthritis or pes anserine bursistis
  • Chronic lateral pain indicates a degenerative meniscal tear, lateral compartment arthritis or biceps bursitis
  • Chronic anterior pain indicates patellofemoral joint chondromalacia and patellar tendonitisa
  • Chronic posteroir pain indicates posterior horn meniscal tears or a Baker's (popliteal) cyst

History of Previous Injury

Patients who have had previous ligament injuries are at an increased risk of secondary injuries. Additionally, patients who have had menisci resections are at a high risk of developing arthritis, which could present with pain and swelling upon activity.

Anaestheia or Dysaesthesia or Weakness

Direct blows to the anterior aspect of the knee can cause sensory changes in the infrapatellar branch of the sapenous nerve, resulting in altered sensation on the anterolateral aspect of the knee.

Blows to the anteromedial knee or a varus of hyperextension injury can stretch the common peroneal nerve, resulting in reduced sensation in the first dorsal web space and lateral foot. There may also be motor weakness in the extensor hallucis longus, extensor digitorum longus, peroneals and tibialis anterior.

Medial knee injuries may have decreases sensation along the medial aspect of the leg due to the saphenous nerve.

It is important to assess the function of tibial nerve for severe injuries by assessing sensation on the sole of the foot as well as plantar flexion and inversion strength. 

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