Imaging Studies

Radiographs

Obtain anteroposterior, lateral, and oblique radiographs of the knee.^{[3, 18]}Four views have been shown to be superior to 2 views in detecting fractures.^[19]

Oblique views are particularly useful in detecting subtle tibial plateau fractures (internal oblique profiles lateral plateau, external oblique profiles medial plateau). Oblique views also better identify obliquely oriented femoral condyle fractures.

An axial (or sunrise) view of the patella is useful for detecting vertical patellar fractures, which frequently are missed and nondisplaced. Transverse fractures are most common, followed by comminuted and avulsion fractures. Adding a sunrise view increases the negative predictive value of radiographs for ruling out patellar fracture.

A fat-fluid level (lipohemarthrosis) may be identified on a lateral view of the knee; this finding indicates an intra-articular fracture.

Radiographic evidence of ligamentous injury may be present:

An avulsion fracture at the site of attachment of the lateral capsular ligament on the lateral tibial condyle (Segond fracture) is a marker for anterior cruciate ligament rupture.^[20]
Cortical avulsion fracture of medial tibial plateau (uncommon) is associated with tears of the posterior cruciate ligament and medial meniscus.^[21]

A patellar spur at the superior portion of the patella is associated with a ruptured quadriceps tendon.^[22]

Use of the Ottawa rules for obtaining knee radiographs have proven to be sensitive for fracture and have reduced ED waiting times and costs.^[23]The rules include the following patient findings^[24]:

Age 55 years or older
Tenderness at head of fibula
Isolated tenderness of patella
Inability to flex knee to 90 degrees
Inability to bear weight (4 steps) immediately after injury and in ED

CT scans and MRIs

CT scans may be necessary to fully delineate the extent of tibial plateau fractures and other complex knee fractures.

Computed tomography can be a useful diagnostic modality in preoperative planning for tibial plateau fractures. Tibial plateau fracture maps in one study showed recurrent patterns of fracture lines, revealing 4 major fracture characteristics: the lateral split fragment, found in 75%; the posteromedial fragment, seen in 43%; the tibial tubercle fragment, seen in 16%; and a zone of comminution that included the tibial spine and frequently extended to the lateral condyle, seen in 28%.^[25]

Compared to CT scans, plain radiography underestimates the amount of articular depression of tibial plateau fractures in most tibial regions. This is significant, as the amount of tibial plateau depression is an indicator for operative repair.^[26]

CT scans are also useful in severely injured patients when it is difficult to obtain radiographs in all angles.

MRIs also are useful and have the added benefit of depicting associated soft tissue injury (eg, ligamentous, meniscal).^[4]

Bedside ultrasound

Ulatrasonography can quickly detect injuries to the knee extensor mechanism, including the quadriceps tendon and inferior patellar ligament.^{[10, 27]}

Treatment & Management

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Author

Mark Steele, MD Professor, Department of Emergency Medicine, Chief Medical Officer, Truman Medical Center, University of Missouri-Kansas City School of Medicine

Mark Steele, MD is a member of the following medical societies: American Academy of Emergency Medicine, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Jeffrey G Norvell, MD, MBA, RDMS Associate Professor, Program Director, Department of Emergency Medicine, University of Kansas Medical Center

Jeffrey G Norvell, MD, MBA, RDMS is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency 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.

Eric L Legome, MD Professor and Chair, Department of Emergency Medicine, Mount Sinai St Lukes and Mount Sinai West; Vice Chair of Academic Affairs, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai

Eric L Legome, MD is a member of the following medical societies: American College of Emergency Physicians, Eastern Association for the Surgery of Trauma, New York American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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.

Acknowledgements

Michelle Ervin, MD Chair, Department of Emergency Medicine, Howard University Hospital

Michelle Ervin, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, National Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.