Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Soft Tissue Knee Injury Treatment & Management

  • Author: David B Levy, DO, FAAEM; Chief Editor: Trevor John Mills, MD, MPH  more...
 
Updated: Feb 20, 2016
 

Prehospital Care

Basic responsibilities in the prehospital setting, if knee trauma is the primary injury, include stabilizing the lower extremity and monitoring the neurovascular status of the limb.

The deformed knee should be realigned only if associated neurovascular structures are compromised. Always recheck and document pulses after splinting or manipulation of the limb. If initial efforts meet with resistance, prehospital personnel should not force realignment.

Cover open wounds with saline-soaked sterile gauze.

Frequently, the joint reduces spontaneously or is reduced at the scene by trained emergency medical services (EMS) personnel; in such cases, the ED physician must obtain information about the time and mechanism of injury and the original position of the limb.

Next

Emergency Department Care

Adhere to the conventional dictums of emergency and trauma care by first corroborating the absence of life-threatening (primary survey) or limb-threatening (secondary survey) injuries before focusing on soft-tissue damage sustained by the knee. A cardinal error occurs when earliest attention is diverted to an obvious extremity injury, such as a knee dislocation, while neglecting possibly lethal trauma.

Always determine the mechanism of injury and verify hemodynamic stability.

Assess vascular perfusion and control any bleeding. Hard signs of vascular injury include absent or diminished pulses, active hemorrhage, and expanding or pulsatile hematoma. Signs of distal ischemia include pain out of proportion to the injury, pallor, paralysis, and paresthesias. For knee dislocations or grossly malaligned fractures with potential vascular compromise, attempt immediate reduction or realignment of the knee if an orthopedic specialist is not immediately available. Popliteal-artery injuries must be repaired within 6-8 hours to avoid amputation because of limb ischemia.

Splint all obvious fractures and unstable knee injuries, stabilizing the femur above and the tibia below.

Damage to essential nerves and vessels may be subtle on presentation.

Observe for signs and symptoms of compartment syndrome. Measurement of compartment pressures is often needed to exclude the possibility of compartment syndrome.

Remove any constricting clothes and bandages.

Make sure patients ingest nothing by mouth (NPO) until the need for emergency or urgent surgery is ascertained.

General treatment principles include the following:

  • Aside from the particular injury, treatment plans depend on the patient's age and activity level and the presence of additional injuries.
  • Obtain orthopedic consultation when appropriate.
  • Initial nonpharmaceutical treatment includes rest, ice, compression, and elevation (RICE).
  • For the first 1-3 days, use therapeutic measures that minimize incipient damage and reduce pain and inflammation.
  • Consider splinting the injured knee to provide support and to prevent further injury.
  • Serviceable devices include commercially available immobilizers and handcrafted compressive dressings, such as the Robert Jones dressing, which incorporates coaptation plaster.
  • Detrimental effects of immobilization include joint stiffness, degenerative changes in articular cartilage, muscle atrophy and weakness, and decreased vascularity.

Therapy for specific injuries include the following:

  • For first-degree sprains, provide symptomatic treatment, essentially the RICE regimen. Normal function usually returns quickly.
  • Second-degree sprains require protection by using a cast, cast brace, or a restrictive movement brace. Arrange for timely follow-up care.
  • Treatment of third-degree sprains depends on the severity and type of instability; some third-degree sprains of ligaments necessitate surgical repair. Factoring into the deliberation for surgery is the patient's age, relative health, associated injuries, activity demands, and individual desires.
  • Treatment for anterior cruciate ligament (ACL) injuries is individualized. Various conditions influence decisions on the optimum management of ACL tears, such as the presence or absence of comorbid pathology, age of the patient, baseline activity level, degree of instability, and associated ligamentous injuries miring the knee.
  • Presence of a meniscal tear does not automatically lead to surgical intervention. If the knee is not locked or unstable, conventional treatment (ie, RICE therapy) ordinarily suffices; however, the meniscus cartilage of the knee generally supports a precarious blood supply, and tears are prone to inadequate mending. Therefore, timely follow-up care is critical.

Emergency consultation with an orthopedic specialist is required for immediate reduction and evaluation of vascular integrity after a knee dislocation. If expedient orthopedic consultation is not obtainable and if signs of vascular compromise are present, the ED physician should undertake maneuvers to restore both integrity of the joint and perfusion. (See Dislocations, Knee for specific reduction techniques.) Angiography is imperative.

Reduction of knee dislocation includes the following:

  • Most knee dislocations reduce spontaneously before the patient's arrival in the ED. However, when examination findings suggest neurovascular compromise, an attempt to restore circulation with traction and/or reduction and emergency orthopedic consultation are needed.
  • Classify dislocations with respect to the relationship of the tibia on the femur.
  • Anterior dislocations occur most commonly.
  • In the ideal case, perform reductions in the operating room under general anesthesia. However, if circumstances preclude this scenario, an attempt in the ED is warranted.
  • Barring contraindications, administer conscious sedation.
  • With an assistant providing stabilization and countertraction of the thigh, a second person applies longitudinal traction to the leg. This maneuver usually suffices for reduction.
  • Reduction of an anterior knee dislocation may be aided by trying to transpose the femur anteriorly.
  • Avoid affixing pressure over the popliteal space as it may exacerbate arterial damage.
  • For posterior dislocations (where the tibia lies posterior to the femur), attempt to reinstate the tibia anteriorly by gently lifting the tibia forward.
  • After relocation of the knee, confirm neurovascular status and immobilize the knee in 15° of flexion.
  • Order postreduction images and consultation with the orthopedic surgeon, and obtain an emergency arteriogram.

Reduction of patellar dislocation includes the following:

  • Patellar dislocations typically occur in predisposed individuals and tend to recur.
  • Patellar dislocations are identified with respect to the patella's position on the knee joint, with lateral dislocations being most common.
  • If the joint has not already reduced spontaneously, verify the dislocation radiographically.
  • After administering necessary analgesia, place the hip in a mild amount of flexion, and gently press anteriorly and medially on the patella while extending the knee joint.
  • Postreduction films should include a sunrise view, as osteochondral fractures may result.
  • Other types of patellar dislocations tend to be resistant to closed reduction.
  • Aspiration of a Baker cyst may render temporizing relief. This procedure is best performed electively by a qualified physician.

Injection therapy

Ensure that the joint is not infected.

Pain secondary to aseptic inflammation of the prepatellar, suprapatellar, and pes anserine bursae may be relieved by instilling 2-4 mL of lidocaine mixed with 15-20 mg of a prednisolone suspension into the affected bursae.

Recent data have suggested that an intra-articular installation of morphine 1-5 mg confirms a local analgesic effect and possibly prolongs pain relief compared with systemic opioids.

Reducing the locked knee

Avoid undue manipulation because it may aggravate internal derangement.

A simple measure to reduce the locked knee involves positioning the patient with the knee dangling over the edge of the examination table in 90° of flexion.

Gravity usually expedites distraction of the tibia from the femur, thereby promoting unlocking.

If this technique fails after a reasonable time period, tempered rotation of the knee along with caution traction on the leg usually frees the knee joint.

Previous
Next

Consultations

Depending on the degree of knee instability, affected ligaments, and the patient's age and baseline activity level, early surgical intervention may be the best option.

Indications for emergency or urgent orthopedic consultation include the following:

  • Gross knee dislocation or unstable knee
  • All knee injuries with associated neurologic or vascular injury
  • Complete quadriceps tendon rupture or a complete patellar tendon rupture
  • First-time patellar dislocations and patellar displacements accompanied by an osteochondral fracture
  • Open joint injuries of the knee
Previous
 
 
Contributor Information and Disclosures
Author

David B Levy, DO, FAAEM Senior Consultant in Emergency Medicine, Waikato District Health Board, New Zealand; Associate Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine

David B Levy, DO, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, Fellowship of the Australasian College for Emergency Medicine, American Medical Informatics Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Howard I Dickey-White, MD Teaching Attending Physician, Department of Internal Medicine, St Elizabeth Hospital Medical Center

Howard I Dickey-White, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Physicians, American Institute of Ultrasound in Medicine, Sigma Xi, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine

Trevor John Mills, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Additional Contributors

Eric M Kardon, MD, FACEP Attending Emergency Physician, Georgia Emergency Medicine Specialists; Physician, Division of Emergency Medicine, Athens Regional Medical Center

Eric M Kardon, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Medical Association of Georgia

Disclosure: Nothing to disclose.

Acknowledgements

June E Sanson CNRP, MSN Nurse Practitioner, Take Care Health Systems

Disclosure: Nothing to disclose.

Tom Scaletta, MD President, Smart-ER (http://smart-er.net); Chair, Department of Emergency Medicine, Edward Hospital; Past-President, American Academy of Emergency Medicine

Tom Scaletta, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

References
  1. Gray AM, Buford WL. Incidence of Patients With Knee Strain and Sprain Occurring at Sports or Recreation Venues and Presenting to United States Emergency Departments. J Athl Train. 2015 Nov. 50 (11):1190-8. [Medline].

  2. Kapur S, Wissman RD, Robertson M, et al. Acute knee dislocation: review of an elusive entity. Curr Probl Diagn Radiol. 2009 Nov-Dec. 38(6):237-50. [Medline].

  3. Shah MK. Simultaneous bilateral rupture of quadriceps tendons: analysis of risk factors and associations. South Med J. 2002 Aug. 95(8):860-6. [Medline].

  4. Tuite MJ, Kransdorf MJ, Beaman FD, Adler RS, Amini B, Appel M, et al. ACR Appropriateness Criteria Acute Trauma to the Knee. J Am Coll Radiol. 2015 Nov. 12 (11):1164-72. [Medline].

  5. [Guideline] Pavlov H, Saboeiro GR, Campbell SE, Dalinka MK, Daffner RH, DeSmet AA, El-Khoury GY, Kneeland JB, Manaster BJ, Morrison WB, Rubin DA, Schneider R, Steinbach LS, Weissman BN, Haralson RH III, Expert Panel on Musculoskeletal Imaging. Acute trauma to the knee. [online publication]. Reston (VA): American College of Radiology (ACR); 2005. [Full Text].

  6. Parwaiz H, Teo AQ, Servant C. Anterior cruciate ligament injury: A persistently difficult diagnosis. Knee. 2015 Nov 6. [Medline].

  7. Hurdle MF, Wisniewski SJ, Pingree MJ. Ultrasound-guided intra-articular knee injection in an obese patient. Am J Phys Med Rehabil. 2012 Mar. 91(3):275-6. [Medline].

  8. Shaerf D, Banerjee A. Assessment and management of posttraumatic haemarthrosis of the knee. Br J Hosp Med (Lond). 2008 Aug. 69(8):459-60, 462-3. [Medline].

  9. Akseki D, Ozcan O, Boya H, Pinar H. A new weight-bearing meniscal test and a comparison with McMurray's test and joint line tenderness. Arthroscopy. 2004 Nov. 20(9):951-8. [Medline].

  10. Andersen RE, Crespo CJ, Ling SM, Bathon JM, Bartlett SJ. Prevalence of significant knee pain among older Americans: results from the Third National Health and Nutrition Examination Survey. J Am Geriatr Soc. 1999 Dec. 47(12):1435-8. [Medline].

  11. Arroll B, Goodyear-Smith F. Corticosteroid injections for osteoarthritis of the knee: meta-analysis. BMJ. 2004 Apr 10. 328(7444):869. [Medline].

  12. Bachmann LM, Haberzeth S, Steurer J, ter Riet G. The accuracy of the Ottawa knee rule to rule out knee fractures: a systematic review. Ann Intern Med. 2004 Jan 20. 140(2):121-4. [Medline].

  13. Bahk MS, Cosgarea AJ. Physical examination and imaging of the lateral collateral ligament and posterolateral corner of the knee. Sports Med Arthrosc. 2006 Mar. 14(1):12-9. [Medline].

  14. Berfeld J, Ireland ML, Wojtys EM. Pinpointing the cause of acute knee pain. Patient Care. 1997. 31(18):100-117.

  15. Calmbach WL, Hutchens M. Evaluation of patients presenting with knee pain: Part I. History, physical examination, radiographs, and laboratory tests. Am Fam Physician. 2003 Sep 1. 68(5):907-12. [Medline].

  16. Chandrashekar N, Mansouri H, Slauterbeck J, Hashemi J. Sex-based differences in the tensile properties of the human anterior cruciate ligament. J Biomech. 2006. 39(16):2943-50. [Medline].

  17. Christain EP. Extensor mechanism injuries of the knee. Top Emerg Med. 1995. 17(2):25-35.

  18. Christian SR, Anderson MB, Workman R. Imaging of anterior knee pain. Clin Sports Med. 2006 Oct. 25(4):681-702. [Medline].

  19. Davids JR. Pediatric knee. Clinical assessment and common disorders. Pediatr Clin North Am. 1996 Oct. 43(5):1067-90. [Medline].

  20. Emparanza JI, Aginaga JR. Validation of the Ottawa Knee Rules. Ann Emerg Med. 2001 Oct. 38(4):364-8. [Medline].

  21. Gupta A, Bodin L, Holmstrom B, Berggren L. A systematic review of the peripheral analgesic effects of intraarticular morphine. Anesth Analg. 2001 Sep. 93(3):761-70. [Medline].

  22. Ireland ML. The female ACL: why is it more prone to injury?. Orthop Clin North Am. 2002 Oct. 33(4):637-51. [Medline].

  23. Jackson JL, O'Malley PG, Kroenke K. Evaluation of acute knee pain in primary care. Ann Intern Med. 2003 Oct 7. 139(7):575-88. [Medline].

  24. Jacobson KE, Chi FS. Evaluation and treatment of medial collateral ligament and medial-sided injuries of the knee. Sports Med Arthrosc. 2006 Jun. 14(2):58-66. [Medline].

  25. Karachalios T, Hantes M, Zibis AH. Diagnostic accuracy of a new clinical test (the Thessaly test) for early detection of meniscal tears. J Bone Joint Surg Am. 2005 May. 87(5):955-62. [Medline].

  26. Karistinos A, Paulos LE. "Ciprofloxacin-induced" bilateral rectus femoris tendon rupture. Clin J Sport Med. 2007 Sep. 17(5):406-7. [Medline].

  27. Katz JN, Brophy RH, Chaisson CE, de Chaves L, Cole BJ, Dahm DL, et al. Surgery versus Physical Therapy for a Meniscal Tear and Osteoarthritis. N Engl J Med. 2013 Mar 18. [Medline].

  28. Louden K. Physical therapy as effective as surgery for meniscal tear. Medscape Medical News. March 20, 2013. Available at http://www.medscape.com/viewarticle/781102. Accessed: April 1, 2013.

  29. Munshi M, Davidson M, MacDonald PB, et al. The efficacy of magnetic resonance imaging in acute knee injuries. Clin J Sport Med. 2000. 10(1):34-9. [Medline].

  30. O'Shea KJ, Murphy KP, Heekin RD, Herzwurm PJ. The diagnostic accuracy of history, physical examination, and radiographs in the evaluation of traumatic knee disorders. Am J Sports Med. 1996 Mar-Apr. 24(2):164-7. [Medline].

  31. Perryman JR, Hershman EB. The acute management of soft tissue injuries of the knee. Orthop Clin North Am. 2002 Jul. 33(3):575-85. [Medline].

  32. Richman PB, McCuskey CF, Nashed A, et al. Performance of two clinical decision rules for knee radiography. J Emerg Med. 1997 Jul-Aug. 15(4):459-63. [Medline].

  33. Robertson A, Nutton RW, Keating JF. Dislocation of the knee. J Bone Joint Surg Br. 2006 Jun. 88(6):706-11. [Medline].

  34. Simon LV, Matteucci MJ, Tanen DA. The Pittsburgh Decision Rule: triage nurse versus physician utilization in the emergency department. J Emerg Med. 2006 Oct. 31(3):247-50. [Medline].

  35. Solomon DH, Simel DL, Bates DW, et al. The rational clinical examination. Does this patient have a torn meniscus or ligament of the knee? Value of the physical examination. JAMA. 2001 Oct 3. 286(13):1610-20. [Medline].

  36. Stannard JP, Sheils TM, Lopez-Ben RR, McGwin G Jr, Robinson JT, Volgas DA. Vascular injuries in knee dislocations: the role of physical examination in determining the need for arteriography. J Bone Joint Surg Am. 2004 May. 86-A(5):910-5. [Medline].

  37. Twaddle BC, Bidwell TA, Chapman JR. Knee dislocations: where are the lesions? A prospective evaluation of surgical findings in 63 cases. J Orthop Trauma. 2003 Mar. 17(3):198-202. [Medline].

  38. Wang CY, Wang HK, Hsu CY, Shieh JY, Wang TG, Jiang CC. Role of sonographic examination in traumatic knee internal derangement. Arch Phys Med Rehabil. 2007 Aug. 88(8):984-7. [Medline].

 
Previous
Next
 
Anatomy of the knee.
Knee ballottement.
Lachman test.
Anterior drawer sign.
Pivot test.
McMurray test.
Apley compression test.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.