Posterior Cruciate Ligament Injury Workup

  • Author: Charles S Peterson, MD; Chief Editor: Craig C Young, MD   more...
 
Updated: Jan 12, 2010
 

Laboratory Studies

  • Perform laboratory studies as indicated per patient age.
Next

Imaging Studies

  • Radiographs
    • Acute injuries
      • Routine radiographs usually are negative in acute injuries.
      • Bony avulsions may be evident on lateral radiographs.
      • New radiological view: Axial radiograph as described by Puddu et al. Patient is supine with knees flexed to 70°, feet are plantigraded in moderate plantar flexion, and the tibia is in neutral rotation. With patient holding cassette, the radiographic beam is directed distal to proximal and parallel to the longitudinal axis of the patella. The length of the perpendicular line between the anterior tibial profile and the femoral groove is measured. If the side-to-side difference is >3 mm, posterior laxity is indicated.
    • Chronic lesions
      • Weight-bearing anteroposterior (AP) or Rosenberg view (posteroanterior [PA] with knees flexed) may demonstrate early medial joint arthrosis.
      • Tangential patellofemoral view (Laurin/Merchant view) may demonstrate patellofemoral arthrosis.
      • Long-film AP weight-bearing views are essential for preoperative alignment.
  • Magnetic resonance imaging (MRI)
    • If physical examination reveals multiple injured ligaments, or if degree of injury is in question, an MRI may be justified.
    • MRI helps identify and confirm the location of the lesion; in addition, occult osteochondral lesion/fractures and meniscal lesions may be identified. MRI of acute injury is more accurate than for chronic injury, as the ligament may appear healed but be functionally deficient.[5] (See the images below.) This MRI of the knee shows a torn posterior cruciaThis MRI of the knee shows a torn posterior cruciate ligament. This MRI (coronal section) shows a posterior cruciThis MRI (coronal section) shows a posterior cruciate ligament tear. This transverse MRI shows edema to the torn posterThis transverse MRI shows edema to the torn posterior cruciate ligament.
Previous
Next

Other Tests

  • Occasionally, a patient with a posterior knee injury may present with calf pain and signs of an impending compartment syndrome, possibly due to soft tissue injury or signs of an occult vascular injury. The calf symptoms may be more pronounced than the knee symptoms. Compartment pressures need to be measured, and vascular surgery consultation must be considered for an arteriogram.
Previous
Next

Procedures

  • Perform an arteriogram in patients with suspected vascular injury, such as an injury that might be seen with knee dislocation.
Previous
Proceed to Treatment & Management
 
 
Contributor Information and Disclosures
Author

Charles S Peterson, MD  Consulting Staff, Arizona Sports Medicine Center; Instructor in Family Medicine, Mayo Clinic College of Medicine; Clinical Instructor, Midwestern University Medical School

Charles S Peterson, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, and American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Thomas Agesen, MD  Assistant Clinical Professor, Department of Physical Medicine and Rehabilitation, UMDNJ, New Jersey Medical School; Consulting Staff, Mountainside Hospital, Summit Overlook Hospital

Thomas Agesen, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, and Physiatric Association of Spine, Sports and Occupational Rehabilitation

Disclosure: Nothing to disclose.

Janos P Ertl, MD  Assistant Professor, Department of Orthopedic Surgery, Indiana University School of Medicine; Chief of Orthopedic Surgery, Wishard Hospital

Janos P Ertl, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, Hungarian Medical Association of America, and Sierra Sacramento Valley Medical Society

Disclosure: Nothing to disclose.

Gyorgy Kovacs, MD  Consulting Surgeon, Department of Orthopedic Surgery, GOC Clinic

Disclosure: Nothing to disclose.

Specialty Editor Board

Gerard A Malanga, MD  Director of Pain Management, Overlook Hospital; Director of PM&R Sports Medicine Fellowship, Atlantic Health; Clinical Professor, Department of Physical Medicine and Rehabilitation, UMDNJ-New Jersey Medical School; Clinical Chief, Rehabilitation Medicine and Electrodiagnosis, St Michael's Medical Center; Fellow, American College of Sports Medicine

Gerard A Malanga, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, North American Spine Society, and Physiatric Association of Spine, Sports and Occupational Rehabilitation

Disclosure: Cephalon Honoraria Speaking and teaching; Endo Honoraria Speaking and teaching; Forest Labs Honoraria Speaking and teaching

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Russell D White, MD  Professor of Medicine, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center Lakewood

Disclosure: Nothing to disclose.

Jon B Whitehurst, MD  Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner and Executive Board Member, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital

Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America

Disclosure: Nothing to disclose.

Chief Editor

Craig C Young, MD  Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Sports Medicine Fellowship Director, Medical College of Wisconsin

Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, and Phi Beta Kappa

Disclosure: Nothing to disclose.

References

  1. Wang CJ. Injuries to the posterior cruciate ligament and posterolateral instabilities of the knee. Chang Gung Med J. May 2002;25(5):288-97.

  2. Margheritini F, Rihn J, Musahl V, Mariani PP, Harner C. Posterior cruciate ligament injuries in the athlete: an anatomical, biomechanical and clinical review. Sports Med. 2002;32(6):393-408.

  3. Sheps DM, Otto D, Fernhout M. The anatomic characteristics of the tibial insertion of the posterior cruciate ligament. Arthroscopy. Jul 2005;21(7):820-5.

  4. Amis AA, Gupte CM, Bull AM, Edwards A. Anatomy of the posterior cruciate ligament and the meniscofemoral ligaments. Knee Surg Sports Traumatol Arthrosc. Mar 2006;14(3):257-63.

  5. Servant CT, Ramos JP, Thomas NP. The accuracy of magnetic resonance imaging in diagnosing chronic posterior cruciate ligament injury. Knee. Aug 2004;11(4):265-70.

  6. Chen B, Gao S. Double-bundle posterior cruciate ligament reconstruction using a non-hardware suspension fixation technique and 8 strands of autogenous hamstring tendons. Arthroscopy. Jul 2009;25(7):777-82. [Medline].

  7. Lim HC, Bae JH, Wang JH, et al. Double-bundle PCL reconstruction using tibial double cross-pin fixation. Knee Surg Sports Traumatol Arthrosc. Jan 2010;18(1):117-22. [Medline].

  8. Lenschow S, Zantop T, Weimann A, Lemburg T, Raschke M, Strobel M. Joint kinematics and in situ forces after single bundle PCL reconstruction: a graft placed at the center of the femoral attachment does not restore normal posterior laxity. Arch Orthop Trauma Surg. May 2006;126(4):253-9.

  9. Kim SJ, Kim TE, Jo SB, et al. Comparison of the clinical results of three posterior cruciate ligament reconstruction techniques. J Bone Joint Surg Am. Nov 2009;91(11):2543-9. [Medline].

  10. Jung TM, Höher J, Weiler A. Screw fixation of a 4 1/2-year-old PCL avulsion injury. Knee Surg Sports Traumatol Arthrosc. May 2006;14(5):469-72.

  11. Ahn JH, Yoo JC, Wang JH. Posterior cruciate ligament reconstruction: double-loop hamstring tendon autograft versus Achilles tendon allograft--clinical results of a minimum 2-year follow-up. Arthroscopy. Aug 2005;21(8):965-9.

  12. Ahn JH, Nha KW, Kim YC, Lim HC, Nam HW, Wang JH. Arthroscopic femoral tensioning and posterior cruciate ligament reconstruction in chronic posterior cruciate ligament injury. Arthroscopy. Mar 2006;22(3):341.e1-4.

  13. Jung YB, Jung HJ, Tae SK, Lee YS, Yang DL. Tensioning of remnant posterior cruciate ligament and reconstruction of anterolateral bundle in chronic posterior cruciate ligament injury. Arthroscopy. Mar 2006;22(3):329-38.

  14. Sekiya JK, West RV, Ong BC, Irrgang JJ, Fu FH, Harner CD. Clinical outcomes after isolated arthroscopic single-bundle posterior cruciate ligament reconstruction. Arthroscopy. Sep 2005;21(9):1042-50.

  15. Goudie EB, Will EM, Keating JF. Functional outcome following PCL and complex knee ligament reconstruction. Knee. Sep 29 2009;[Medline].

  16. Hermans S, Corten K, Bellemans J. Long-term results of isolated anterolateral bundle reconstructions of the posterior cruciate ligament: a 6- to 12-year follow-up study. Am J Sports Med. Aug 2009;37(8):1499-507. [Medline].

  17. Strobel MJ, Weiler A, Schulz MS, Russe K, Eichhorn HJ. Arthroscopic evaluation of articular cartilage lesions in posterior-cruciate-ligament-deficient knees. Arthroscopy. Mar 2003;19(3):262-8.

  18. Baker CL Jr, Norwood LA, Hughston JC. Acute combined posterior cruciate and posterolateral instability of the knee. Am J Sports Med. May-Jun 1984;12(3):204-8. [Medline].

  19. Bergfeld JA, McAllister DR, Parker RD, et al. The effects of tibial rotation on posterior translation in knees in which the posterior cruciate ligament has been cut. J Bone Joint Surg Am. Sep 2001;83-A(9):1339-43. [Medline].

  20. Browner BD. Skeletal Trauma: Fractures, Dislocations, Ligamentous Injuries. Philadelphia, Pa: WB Saunders Co; 1998.

  21. Cain TE, Schwab GH. Performance of an athlete with straight posterior knee instability. Am J Sports Med. Jul-Aug 1981;9(4):203-8. [Medline].

  22. Clancy WG Jr, Shelbourne KD, Zoellner GB, et al. Treatment of knee joint instability secondary to rupture of the posterior cruciate ligament. Report of a new procedure. J Bone Joint Surg Am. Mar 1983;65(3):310-22. [Medline].

  23. Cosgarea AJ, Jay PR. Posterior cruciate ligament injuries: evaluation and management. J Am Acad Orthop Surg. Sep-Oct 2001;9(5):297-307. [Medline].

  24. Cross MJ, Powell JF. Long-term followup of posterior cruciate ligament rupture: a study of 116 cases. Am J Sports Med. Jul-Aug 1984;12(4):292-7. [Medline].

  25. Daniel DM, Stone ML, Barnett P, Sachs R. Use of the quadriceps active test to diagnose posterior cruciate-ligament disruption and measure posterior laxity of the knee. J Bone Joint Surg Am. Mar 1988;70(3):386-91. [Medline].

  26. Delee JC. Orthopaedic Sports Medicine, Principles and Practice. Vol 2. Philadelphia, Pa: WB Saunders Co; 1994.

  27. Donovan. Posterior cruciate ligament injury on artificial turf. Orthop. 1977;1:20.

  28. Fowler PJ, Messieh SS. Isolated posterior cruciate ligament injuries in athletes. Am J Sports Med. Nov-Dec 1987;15(6):553-7. [Medline].

  29. Harner, Miller. Complex topics in knee surgery. Clin Sports Med. 1999;18(1).

  30. Janousek AT, Jones DG, Clatworthy M, et al. Posterior cruciate ligament injuries of the knee joint. Sports Med. Dec 1999;28(6):429-41. [Medline].

  31. Ogata K, McCarthy JA, Dunlap J, Manske PR. Pathomechanics of posterior sag of the tibia in posterior cruciate deficient knees. An experimental study. Am J Sports Med. Nov-Dec 1988;16(6):630-6. [Medline].

  32. Paddu G, Gianni E, Chambat P. The axial view in evaluating tibial translation in cases of insufficiency of the posterior cruciate ligament. Arthroscopy. 2000;16(2):217-220.

  33. Parolie JM, Bergfeld JA. Long-term results of nonoperative treatment of isolated posterior cruciate ligament injuries in the athlete. Am J Sports Med. Jan-Feb 1986;14(1):35-8. [Medline].

  34. Safran MR, Allen AA, Lephart SM, et al. Proprioception in the posterior cruciate ligament deficient knee. Knee Surg Sports Traumatol Arthrosc. 1999;7(5):310-7. [Medline].

  35. Shelbourne KD, Davis TJ, Patel DV. The natural history of acute, isolated, nonoperatively treated posterior cruciate ligament injuries. A prospective study. Am J Sports Med. May-Jun 1999;27(3):276-83. [Medline].

  36. Shelbourne KD, Jennings RW, Vahey TN. Magnetic resonance imaging of posterior cruciate ligament injuries: assessment of healing. Am J Knee Surg. 1999;12(4):209-13. [Medline].

  37. Siliski JM. Traumatic Disorders of the Knee. New York, NY: Springer-Verlag; 1994.

  38. St Pierre P, Miller MD. Posterior cruciate ligament injuries. Clin Sports Med. Jan 1999;18(1):199-221, vii. [Medline].

  39. Veltri DM, Warren RF. Isolated and combined posterior cruciate ligament injuries. J Am Acad Orthop Surg. Nov 1993;1(2):67-75.

 
Previous
Next
 
A normal lateral radiograph of a knee. In a normal knee, a line drawn along the posterior femoral condyle will not intersect the posterior tibial condyle.
A lateral radiograph of a knee with a posterior cruciate ligament injury. Note that the same line as in the above image will bisect the posterior tibial condyle due to a posterior sag and an incompetent posterior cruciate ligament.
The posterior tibial sag sign. The photo on the left demonstrates the clinical finding of the posterior tibial sag sign. A line drawn parallel to the patella accentuates the posterior tibial sag. The photo on the right demonstrates the quadriceps active drawer test described by Daniels. With the knee in 70-90° of flexion, the extensor mechanism is contracted, pulling the tibia anteriorly into a reduced position.
A close-up view of a posterior tibial sag with an incompetent posterior cruciate ligament.
This MRI of the knee shows a torn posterior cruciate ligament.
This MRI (coronal section) shows a posterior cruciate ligament tear.
This transverse MRI shows edema to the torn posterior cruciate ligament.
A view of the broad origin of the posterior cruciate ligament (PCL) on the medial femoral condyle of a left knee. The anterior cruciate ligament has been removed for surgical reconstruction.
An additional view of the posterior cruciate ligament broad origin and insertion in a knee pending anterior cruciate ligament reconstruction.
A right knee pending posterior cruciate ligament (PCL) reconstruction. A minimal notchplasty is completed. Two guide pins are advanced into the medial femoral condyle for tunnel placement to reconstruct the 2 bundles of the PCL.
The 2 tunnels are created by reaming from outside in; 8- to 9-mm tunnels are made depending on patient size and the graft that will be used.
Two red Robinson catheters are advanced through the femoral tunnels.
The catheters have premade holes, which are used for suture retrieval.
The catheters are advanced and threaded out the posterior knee. In this case, a posterior tibial onlay graft from an Achilles tendon allograft is used. The 2 bundles are secured to the catheters and advanced into the joint through the tunnels.
The 2 Achilles tendon bundles are secured with a baseball whipstitch, are threaded through the catheter holes, and are advanced into the femoral condyle tunnels.
Additional view of the placement and advancement of the Achilles allograft.
Completion and seating of the femoral allograft reconstruction. The 2 bundles are secured or stabilized by suturing over a post and washer. Note the reestablishment of the broad surface area for the reconstructed posterior cruciate ligament origin.
Completion of the tibial onlay, 2-bundle Achilles tendon allograft/posterior cruciate ligament (PCL) reconstruction. The bony calcaneus remnant is secured to the posterior tibia with 1 or 2 interfragmentary compression screws into a trough into the posterior tibia at the level of the PCL insertion. Care is taken to not penetrate the anterior tibial cortex with these screws. Note the intact original anterior cruciate ligament.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.