Laboratory Studies

Arthrocentesis

Blood with fat globules are indicative of an osteochondral or tibial fracture.

Tapping of the knee is rarely performed with the advent of other less invasive and more specific diagnostic tests (magnetic resonance imaging [MRI]).

Plain radiographs

Radiographic findings are usually negative. Anteroposterior, lateral, merchant, sunrise, and notch views may be used by the physician to diagnose certain radiographic findings that are associated with ACL ruptures. Oblique radiographs may be helpful to exclude tibial plateau fractures.

The Segond fracture (lateral capsular avulsion fracture) may be visualized on an anteroposterior view. This is an avulsion fracture of the lateral tibial plateau, located near the joint line and posteriorly to the Gerdy tubercle. The Segond fracture represents a disruption of the meniscotibial portion of the lateral capsule. Segond fracture is direct evidence of a lateral capsule injury and indirect evidence of an ACL injury.

The lateral notch fracture (lateral view) is located in the lateral femoral condyle. This type of fracture is more commonly seen in chronic ACL-deficient knees, resulting from anterior subluxation of the lateral tibial plateau. The physician must differentiate lateral notch fractures from osteochondral defects or fractures.

Arthrograms

These studies have generally been replaced by MRI. Arthrograms are mostly of historical interest, having occasionally been used by physicians to diagnose ACL ruptures; they must be performed by a radiologist who is highly skilled in double-contrast arthrography.

MRI

MRI has a sensitivity of 90-98% for ACL tears. MRI also may identify bone bruising, which is present in approximately 90% of ACL injuries. An MRI scan allows the physician to confirm an ACL tear, but it should not be used as a substitute for a good history and physical examination. According to the Dutch Orthopaedic Association clinical guidelines for the treatment of ACL injury, MRI has no additional value when physical examination has shown anterior-posterior or rotational instability of the knee. However, MRI is reliable for establishing other intraarticular lesions.^[18]

Instrumented ligament testing

KT-1000 compares the difference in tibial excursion between the injured and the unaffected knee of a patient.

An excursion greater than 3 mm as measured by the KT-1000 is classified as pathologic.

Treatment & Management

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Media Gallery

Proper technique for the Lachman test.
Anterior drawer test: Note the anterior excursion of the tibia in relationship to the femur.
The pivot shift test.
MRI displaying a ruptured anterior cruciate ligament.

of 4

Author

Matthew Gammons, MD Assistant Clinical Professor, Department of Family and Community Medicine, Medical College of Wisconsin; Medical Director, Castleton State College; Consulting Staff, Vermont Orthopaedic Clinic and Killington Medical Clinic

Matthew Gammons, 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, American Society of Mechanical Engineers

Disclosure: Received income in an amount equal to or greater than $250 from: Up to Date.

Coauthor(s)

Evan Schwartz, MD Director of Orthopedic Surgery, St John's Queens Hospital, New York Medical College; Assistant Professor, Department of Surgery, Albert Einstein School of Medicine

Evan Schwartz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports 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

Sherwin SW Ho, MD Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Arthroscopy Association of North America, Herodicus Society, American Orthopaedic Society for Sports Medicine

Disclosure: Received consulting fee from Biomet, Inc. for speaking and teaching; Received grant/research funds from Smith and Nephew for fellowship funding; Received grant/research funds from DJ Ortho for course funding; Received grant/research funds from Athletico Physical Therapy for course, research funding; Received royalty from Biomet, Inc. for consulting.

Additional Contributors

David T Bernhardt, MD Director of Adolescent and Sports Medicine Fellowship, Associate Professor, Department of Pediatrics/Ortho and Rehab, Division of Sports Medicine, University of Wisconsin School of Medicine and Public Health

David T Bernhardt, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the contributions of previous author John D Hubbell, MD, to the development and writing of this article.