Approach to the knee radiograph for bony injuries
Approach to the knee radiograph for bony injuries Jasmin Fauteux August 25 th 2011
Objectives Review: • Indications • The views • The approach • Fractures • Cases
Knee rules
Pittsburgh Decision rule potentially more specific PDR’s applicability has yet to be proven
The views
Lateral
Anteroposterior
Obliques
Tunnel view
Skyline
The approach
S-ABC • Targeting your approach to look for suspected fracture OR • • Soft tissue Alignment Bone Cartilage and joints
Soft tissue • Lipohemarthrosis • Effusion
Lipohemarthrosis
Effusion May be caused by a bone injury in 53% of cases
Alignment • Condyle with plateau • Patellar alignment
Bone • Cortices • Trabecular pattern • Intra-articular bodies
Cartilages and joints • Patellofemoral • Femorotibial
Tibial plateau • Lipohemarthrosis • Oblique views • Low force required in osteoporosis
16% are missed by EP
Tibial plateau • Trabecular density • Widening of joint space • Lateral displacement
Schatzker classification
Segond’s fracture
Reverse Segond’s
Arcuate complex avulsion - Prox. Fibula - Horizontal - Posterolateral
Tibial spine - Children > Adults - ACL avulsion
Case 1 - 26 yo M - Fell onto flexed knee - Isolated patellar pain
Case 2 • 62 yo F • Twisted knee while moving • Walking with cane • Flexion to 60 degrees
Case 3 • 34 yo M • Snowboarding • Painful lateral joint line
Case 4 - 33 yo F - High intensity MVA - Painful prox. fib
Thank you!
Bibliography • • • • Verma A, et al: A screening method for knee trauma. Acad Radiol 2001; 8: 392. Stiell I, et Al: Implementation of the Ottawa Knee Rule for the Use of Radiography in Acute Knee Injuries. JAMA 1997; 278(23): 2075 -2079 Simon LV, et al: The Pittsburgh Decision rule: triage nurse versus physician utilization in the emergency department. J Emerg Med 2006 Oct; 31(3) 247 -50 Seaberg DC, et Al, Multicenter comparison of two clinical decision rules for the use of radiography in acute, high-risk knee injuries, Ann Emerg Med 1998 Jul; 32(1): 8 -13 Seaberg DC, et al: Clinical decision rule for knee radiographs, Am J Emerg Med 1994 Sep; 12 (5): 541 -3 Steil IG, Wells GA, Mc. Dowell I, et al. Use of radiography in acute knee injuries: need for clinical decision rules. Acad Emerg Med 1995; 2: 966– 973. Bauer SJ, Hollander JE, Fuchs SH, et al. A clinical decision rule in the evaluation of acute knee injuries. J Emerg Med 1995; 13: 611– 615. Imparanza JI, Aginaga JR. Validation of the Ottawa knee rules. Ann Emerg Med 2001; 38: 364– 368. Stiell IG, Greenberg GH, Wells GA, et al. Prospective validation of a decision rule for the use of radiography in acute knee injuries. JAMA 1996; 275: 611– 615. Gottsegen C, et al: Avulsion Fractures of the Knee: Imaging Findings and Clinical Significance, Radio. Graphics October 1, 2008 28: 1755 -1770 Mettler: Essentials of Radiology, 2 nd ed, Marx, John: Rosen ‘s Emergency Medicine: concepts and clinical practice, 7 th ed. Tintinalli, Judith; Tintinalli’s Emergency medicine, 7 th edition Krishnam, Mayil S: Emergency radiology Schwartz, David: Emergency radiology: case studies Marincek, Borut: Emergency radiology: Imaging and intervention
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