Diagnostic Imaging of Musculoskeletal Diseases: A Systematic Approach

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Lack of traumatic injury. Recent sexual encounter. History of abnormal joint.

Acute Knee Effusions: A Systematic Approach to Diagnosis - American Family Physician

Night pain. Night sweats. Unintentional weight loss. If trauma is involved, the clinician should inquire about the date and mechanism of injury, what sport, if any, was involved, and whether a direct blow caused the injury. The typical mechanism of injury of the PCL is a blow to the anterior proximal tibia with the knee flexed, such as tripping over a hurdle or striking the dashboard in a motor vehicle accident. Collateral ligament injuries present with effusion or localized swelling.

Lateral collateral ligament injuries result from a medial-to-lateral force on the knee, while medial collateral ligament injuries result from a force in the opposite direction. The amount of pain reported depends on the severity of the injury. A severe sprain is typically less painful than a partial tear, and instability is the major complaint. Meniscal injuries can occur in isolation or in combination with ligamentous injuries. The typical mechanism of injury involves weight bearing associated with a twisting of the knee, as in cutting or squatting movements.

The patient may describe postexertional swelling, clicking and locking, and pain with rotational movements. In all cases, it should be determined how quickly swelling occurred after the injury.

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If an effusion evolved within four hours of injury, there is a high likelihood of major osseous, ligamentous or meniscal injury. Another prospective study 3 of acutely injured yet clinically stable hemarthrotic knees revealed that patellar dislocation and ACL disruption accounted for 35 percent and 34 percent of the diagnoses, respectively.

If swelling occurred without a history of trauma, questioning should be directed at uncovering both local and systemic disorders. Overuse injuries, or repetitive microtrauma, occasionally present with knee swelling. Important questions to ask include which recreational or occupational activity was involved, how quickly the swelling occurred or resolved, and if any self-treatment had been attempted.

Systemic disorders often cause knee effusion. A variety of infectious diseases may present as monoarticular arthritis with joint redness, effusion and pain. Infiltrative disorders such as gout and pseudogout often present in a similar fashion. Immunologic diseases such as Reiter's syndrome, rheumatoid arthritis and rheumatic fever can also cause knee effusion.

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The knee is the most common joint involved in both benign and malignant tumors. As with any musculoskeletal assessment, a precise understanding of knee pathoanatomy is essential. The knee is a compound condylar joint formed by three articulations: the first, between the medial femoral and tibial condyles, the second, between the lateral femoral and tibial condyles, and the third, between the patella and the femur. The knee moves through flexion and extension, internal and external rotation and a small degree of anterior-posterior glide. Four major ligaments support the knee, which is the largest joint in the body.

The anterior and posterior cruciate ligaments provide anterior and posterior stability, preventing dislocation of the tibia on the femur. The medial and lateral collateral ligaments provide stability to lateral and medial stresses, respectively Figure 1.

The patella is the largest sesamoid bone in the body and provides increased mechanical advantage for knee extension. It is held in place by the medial and lateral retinaculae, and its posterior surface is covered with articular cartilage. The quadriceps muscles act on the knee through the quadriceps and patellar tendons. The medial and lateral menisci are curved fibrocartilaginous structures located between the tibial and femoral articulating surfaces.

They are connected to the joint capsule at their periphery and attached to the tibia via the coronary ligaments. The menisci act as shock absorbers within the knee joint.

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  6. They also assist in lubrication of the joint and increase its elasticity. The medial meniscus is much less mobile than the lateral meniscus, accounting for its higher rate of injury. The knee examination should be approached in a systematic manner, and comparison with the unaffected knee is essential.

    Examination of the entire lower extremity is required to assess alignment, sensory and motor function, and vascular integrity. Assessment begins with a careful inspection, looking for abrasions, ecchymosis and localized swelling, which provide clues to the magnitude of force and the mechanism of injury. Active range of motion is then attempted.

    If complete extension or degrees of flexion is not achieved, passive range of motion is then attempted and, again, compared with the normal knee. Palpation of the knee is best accomplished with the patient supine and the knee flexed to 90 degrees to enhance patient relaxation. The patella and its supporting structures, bilateral joint lines and collateral ligaments are palpated for tenderness, crepitus and localized swelling.

    The presence or absence of effusion must be determined and differentiated from edema or other extra-articular swelling. In the supine position, intra-articular effusion can be differentiated from conditions such as prepatellar bursitis, Baker's cyst, inferior fat pad irritation and patellar tendonitis, which can all present with swelling about the knee. Intracapsular swelling is evident over the entire joint, while extra-articular swelling tends to be more localized. If significant intra-articular fluid is present, the knee will assume a resting position of 15 to 25 degrees of flexion.

    A ballotable patella may be palpated after similar effusion milking and is positive with as little as 10 to 15 mL of fluid. Physical examination findings suggestive of fracture include a tense effusion, deformity, crepitation and ecchymosis. If a fracture is suspected, the hip and ankle joints should be examined, as should the leg's neurovascular status. Fractures about the knee may be open or closed, displaced or nondisplaced.

    Applications of musculoskeletal sonography.

    If a break occurred in the skin overlying the fracture, it must be considered an open fracture, necessitating orthopedic referral. Common injuries include supracondylar femur fractures, tibial plateau fractures and patellar fractures. Growth plate injuries Salter-Harris fractures and tibial tubercle avulsion fractures may occur in skeletally immature patients. The ACL is particularly prone to injury. Physical findings include effusion, positive ACL tests and chronic quadriceps atrophy. The Lachman's test is performed with the knee in 20 degrees of flexion. The tibia is pulled anteriorly on a secured femur.

    A positive test result is indicated by increased tibial translation compared with the unaffected knee. The quality of the end point should also be noted; a soft end point indicates an ACL tear. The anterior drawer test although much less specific is performed with the knee in 90 degrees of flexion. Similar to the Lachman's test, the tibia is drawn anteriorly, and asymmetric translation is an indicator of ACL injury Figure 2.

    The most specific test for ACL disruption is the pivot shift test, 9 but this test is often difficult to perform because of patient guarding and apprehension. Assessment of anterior cruciate ligament ACL stability. The anterior drawer test top is performed with the knee in 90 degrees of flexion. Similar to the Lachman's test bottom , where the knee is in 20 degrees of flexion, the tibia is drawn anteriorly, and asymmetric translation is an indicator of ACL injury.

    Physical findings of a PCL injury include effusion, positive posterior drawer and tibial sag tests, and abrasions or ecchymosis over the proximal anterior tibia. The posterior drawer test is performed with the knee in 90 degrees of flexion and the proximal tibia directed posteriorly. Comparison with the uninjured knee reveals increased tibial translation posteriorly. The sag test is performed with the patient supine, hips flexed to 45 degrees and both knees flexed to 90 degrees.

    In this position, the affected tibia drops back or sags on the femur if a PCL injury has occurred. Collateral ligament sprains often present with localized medial or lateral tenderness, along with ligamentous laxity to lateral or medial stress testing. The knee should be stressed in full extension and at 30 degrees of flexion Figure 3.

    cpanel.builttospill.reclaimhosting.com/marido-infiel-bianca.php Severity of injury is based on the amount of opening compared with the opposite knee. Laxity in full extension indicates major knee disruption. Assessment of collateral ligament stability. The knee should be stressed in full extension and at 30 degrees of flexion. The amount of opening compared with the opposite knee indicates severity of injury.

    Examination reveals joint line tenderness, inability to squat or hop because of pain, and positive results on the McMurray's test or the Apley's test. If an extension lag is present on motion testing, a displaced vertical tear, often called a bucket-handle tear, should be suspected. McMurray's test is performed with the patient supine and the knee flexed and extended, while medial and lateral tibial rotation are applied.

    ECR 2017 / C-0037

    In the Apley's compression test, the patient lies prone with the knee flexed to 90 degrees. An axial compressive load is applied to the foot, along with medial and lateral rotation. Pain on compression that is relieved with distraction is a positive test for meniscal injury. The use of plain radiographs is often necessary to assess a swollen knee.

    In an acute injury, selecting the appropriate radiographic series is critical. The most common views are the anteroposterior AP , lateral and axial patellar images to assess for fracture, dislocation and effusion. Standing AP views are helpful to assess compartment space narrowing associated with a chronic meniscal tear or osteoarthritis.