Current Management of Acute Knee Injuries. Catherine Hui MD, FRCSC CAEP Conference June 3, 2015

Transcription

1 Current Management of Acute Knee Injuries Catherine Hui MD, FRCSC CAEP Conference June 3, 2015

2 Faculty/Presenter Disclosure Faculty: Dr. Catherine Hui Assistant Clinical Professor, Department of Surgery, University of Alberta Acute Knee Injury Sub-Committee Co-Lead, Knee Transformation Working Group, Alberta Bone & Joint Health Institute Knee Team Lead, Glen Sather Sports Medicine Clinic Chair, Periprosthetic Joint Infection Committee, Division of Surgery, Department of Surgery Relationships with commercial interests: Grants/Research Support: None Speakers Bureau/Honoraria: None Consulting Fees: None Other: N/A

3 Disclosure of Commercial Support This program has not received any financial support. This program has not received any in-kind support. Potential for conflict(s) of interest: Dr. Catherine Hui has not received any payment/funding from any organization. There are no products that will be discussed in this program.

4 I have no disclosures therefore there are no potential bias to mitigate in this talk. Mitigating Potential Bias

5 Objectives Introduction How I approach acute knee injuries Cased-based approach to common acute knee injuries Questions

6 Introduction U of A Medical school and orthopaedic U of C 1 yr Comprehensive Knee Fellowship in Sydney, Australia (Dr. Leo Pinczewski) 6 month Adult Knee Reconstruction Fellowship in Toronto, ON (Drs. Dave Backstein, Al Gross) 6 month Knee Sports Medicine Fellowship in London, ON (Dr. Bob Giffin) Practice is 2/3 Knee Sports & 1/3 Adult Knee Reconstruction

7 What we know Annually, more than 1 million emergency department (ED) visits and 1.9 million primary care outpatient visits are for acute knee pain (US Data) Soft tissue knee injuries in the ED can be challenging

8 Goals Do good/do no harm Make the correct diagnosis Efficiently

9 How I approach acute knee injuries

10 NOW THAT S WHAT I CALL A BUM KNEE!

11 38 year old male presents to the ED with severe chest pain. Case CP

12 Auscultation

13 What is the diagnosis? Vasospasm Reflux Myocardial infarction Pericarditis Spontaneous pn Musculoskeletal chest wall pain Hepatiti Pulmonary embolus Pancreatitis Gall stones Aortic dissection Pneumonia Drug abuse Anxiety

14 HUH?! Isn t this a talk on knee injuries?

15 Learning MSK medicine can feel like a herculean task

16 Special Tests for the Knee Lachman Pivot shift Anterior drawer Posterior drawer Sag sign Quadricep s active Reverse pivot shift Dial Varus stress McMurray s Thessaly s Apley s Swipe Patellar tap Patellar grind Apprehension J-Sign Blazina sign Valgus stress

17 I would like to challenge you to change your approach to MSK conditions in the ED: Don t worry about all the orthopedic eponyms Don t worry about all the special tests and whether you remember what they are

18 My Back to Basics Approach to MSK Problems #1 1. Focus on the HISTORY. The diagnosis is made here. 2. Physical exam is often difficult in the acutely injured knee but is used to confirm the diagnosis suspected from the history. Bring the patient back in 7-14 days to re-examine them when the swelling and pain subsides 1. Investigations should be used to confirm the diagnosis and rule out fractures/tumors.

19 Not all knee injuries require MRI MRI scans should be reserved for specific indications/questions NOT to make the diagnosis Orthopedic surgeons usually do not need an MRI for referrals

20 My Back to Basics Approach to MSK Problems #2

21 Here s the common sense In patients presenting with an acute hemarthrosis, what is the differential diagnosis? In order to have an acute hemarthrosis IN the knee, something INSIDE the knee must be injured

22 What structures are inside the knee? Intraarticular Structures: Bones: Ligaments: Femur ACL Tibia PCL Patella Cartilage: Articular Meniscus

23 Common Mis diagnoses LCL injury MCL injury * Remember that these structures are EXTRAarticular structures and should not cause an acute hemarthrosis

24 If you see this following an injury/trauma

25 It will likely be 1 of these 4 things: 1. Fracture 2. ACL Tear 3. Patellar Dislocation 4. Quadriceps or Patellar tendon rupture

26 Case 1

27 Case 1 50F Fell onto knee after tripping on the curb Immediate pain Left knee Unable to weight bear

28 Case 1: Examination Left knee: Large effusion Bruising anteriorly Unable to move knee due to pain Unable to perform straight leg raise

29 X ray: Case 1: Imaging

30 Left patellar fracture Case 1: Diagnosis

31 Case 1: Patellar fracture Treatment Transverse fractures require surgery to restore the extensor mechanism of the knee Vertical fractures can be treated without surgery

32 Case 1: Other common fractures around the knee Tibial Plateau Distal Femur

33 Case 1: Fractures around the knee ED Management Fractures around the knee are intraarticular and often a CT scan can help better delineate the articular surface Consult orthopedics for displaced intraarticular fractures (~5mm) Reduce fracture into better alignment if needed Immobilize knee in full extension

34 Case 2

35 Case 2: History 18M soccer player Running down the field and tried to change directions Fell to the ground grasping his Left knee in severe pain Heard and felt a pop in his Left knee Difficulty weight bearing Unable to finish the game Knee very swollen by the end of the game

36 Case 2: Mechanism of Injury

37 Case 2: Examination Left Knee: Large effusion Restricted ROM Positive Lachman and Anterior Drawer Tests MCL/LCL/PCL stable Tender posterolaterally to palpation

38 Case 2: Imaging Xrays show fleck off lateral aspect of proximal tibia Most x-rays will be NORMAL Segond Fracture - Rarely seen - Pathognomonic for ACL tear

39 Left ACL Tear Case 2: Diagnosis?

40 Case 2: ACL Tear - Treatment Surgical ACL reconstruction Usually younger, active individuals Goal to prevent further damage to meniscus & cartilage Non surgical Activity modification Physio Bracing Usually older, less active individuals

41 Case 2: ACL Tear ED Management R.I.C.E Crutches NSAIDs Start physiotherapy next week Refer to Sport medicine or Orthopedics

42 But wait What about the knee immobilizer? Knees get stiff! Soft tissue knee injuries (eg. ACL, PCL, patellar dislocations, meniscal tears) should not be immobilized If you do immobilize it should be short term (2 weeks max!) *Grade II and III MCL injuries can be immobilized in a brace for 6 weeks

43 Canadian Journal of Surgery: Feb 2015

44 ACL tears are very common! Don t miss the diagnosis because the consequences can be devastating Medial meniscus injury (Bucket Handle Tear) Articular cartilage injury 80% non contact: 20% contact Deceleration, pivot/change of directions Landing from a jump Fell skiing and bindings did not release Commonly: females, soccer, football, rugby, basketball, volleyball Natural history is osteoarthritis Case 2: ACL Tear Take Home Points

45 Case 3

46 Case 3: History 16F soccer player Challenging for the ball Hit on inside of right knee by opposing player Immediate pain and deformity Felt like she dislocated her knee Father put her knee back in place on the sidelines 1 st time this injury occurred

47 Case 3: Mechanism of Injury

48 Case 3: Examination Right knee: Large effusion Positive patellar apprehension test Patella very unstable (easily pushed laterally) Knee is otherwise stable

49 Case 3: Imaging Xrays Loose bodies MRI may be helpful if loose bodies are seen

50 Right Patellar Dislocation Case 3: Diagnosis

51 Case 3: Patellar dislocation Treatment Non surgical Always 1 st line of treatment VMO strengthening Patellar stabilization brace Surgical Loose bodies (removal) Avulsion of MPFL (ORIF) Failed conservative management (MPFL reconstruction)

52 Case 3: Patellar Dislocation ED Management R.I.C.E Crutches NSAIDs Start physiotherapy next week Refer to: Family Physician/Sport medicine: most patients Orthopedics: Loose bodies MPFL avulsion Recurrent dislocators who have failed conservative management

53 Case 4

54 Case 4: History 50M lawyer Slipped going down stairs Tried to catch himself Fell at bottom of the stairs Unable to get up due to pain in Right knee Unable to weight bear

55 Case 4: Examination Right knee: Large hemarthrosis Palpable gap in quadriceps tendon Able to flex knee but no active knee extension Unable to perform a straight leg raise Ligaments stable

56 Case 4: Imaging X-rays: Patellar tendon rupture Quadriceps tendon rupture Ultrasound or MRI can help confirm diagnosis if still unclear

57 Quadriceps tendon rupture Case 4: Diagnosis

58 Case 4: Quads tendon rupture Treatment Treatment of any tendon rupture around the knee is surgical The quadriceps and patellar tendons must be reattached to restore the extensor mechanism

59 Case 4: Tendon ruptures Take Home Points General Risk Factors: Anabolic steroid use Fluroquinolone antibiotic use (eg. Cipro) Males > Females Rheumatoid arthritis Lupus Long term diabetes Quadriceps Tendon Patellar Tendon Age >40 Rapid eccentric contraction of quads (knee usually in flexion) Age <40 Usually an awkward landing following a jump Also associated with chronic tendinosis

60 Case 4: Tendon ruptures ED Management A proper diagnosis needs to be made in the ED Missed ruptures chronic tendon ruptures are a very difficult problem to manage Consider U/S or MRI for Partial or questionable ruptures Immobilize in extension for acute complete ruptures Refer to: Family Physician/Sport medicine/physio: Partial ruptures Orthopedics: Acute complete tendon ruptures

61 Take home points 1. Diagnosis of acute knee injuries is made on history 2. Think of 4 things when faced with a traumatic large acute hemarthrosis: Fracture ACL Tear Patellar Dislocation Quadriceps/Patellar Tendon rupture 3. ACL Tears and Patellar dislocations are very common 4. Soft tissue knee injuries (eg. ACL, patellar dislocations, meniscal tears) do not need to be immobilized 5. Tendon ruptures should be diagnosed acutely and referred immediately for surgery

62 C Thank You! Questions?