JOURNAL READING :

Initial Assessment of Acute and Chronic Multiple Ligament-Injured Knee

Peter S. Borden, M.D., and Darren L. Johnson, M.D.

Presenter :
Komala Appalanaidu
1002005217
Supervisor :
Dr. IGN Wien Aryana, SpOT

 Journal II : The Multiple-Ligament Injured

Knee : Evaluation, Treatment, and Results
Gregory C. Fanelli, MD., Daniel R. Orcutt, M.D.,
M.S., and Craig J. Edson, M.S., P.T., A.T.C.
Journal III : Radiologic Review of Knee
Dislocation : From Diagnosis to Repair
Richard E. A. Walker, David McDougall, Shamir
Patel, John A. Grant, Peter D. Longino, Nicholas
G. Mohtadi
Journal IV : Diagnosis and Management of
the Multiligament-Injured Knee
Jack G. Skendzel, M.D., Jon K. Sekiya, M.D.,
Edward M. Wojtys, M.D.

JOURNAL I :
Initial Assessment of Acute and
Chronic Multiple LigamentInjured Knee
Peter S. Borden, M.D., and Darren L.
Johnson, M.D.

Patients History

Visual Inspection
Gross alignment
Swelling
Tight compartments of
thigh, leg and foot

Anterior

Journal II
The Multiple-Ligament Injured
Knee : Evaluation, Treatment,
and Results
Gregory C. Fanelli, MD., Daniel R. Orcutt,
M.D., M.S., and Craig J. Edson, M.S., P.T.,
A.T.C.

General Consideration

Obvious deformity
Abrasions/contusions
Gross crepitus/laxity
Vascular examination (white, cold,
pulseless limb)

Imaging Studies
Before any manipulation, anteroposterior and lateral
radiographs of the affected extremity must be
completed because it is important to confirm the
direction of dislocation and any associated fractures,
and aids in planning reduction maneuver.
Arteriography if cyanosis, pallor, weak capillary refill
and decreased peripheral temperature following
reduction is present.
Venography if clinical picture indicates adequate limb
perfusion but obstruction of outflow.
MRI to confirm and aid in planning the
reconstruction.

Physical Examination
PLI type A : increased external rotation(injury to popliteofibular
ligament and popliteus tendon)
PLI type B : increased external rotation, mild varus of approx.
5mm increased lateral jointline opening to varus stress at 30
knee flexion(injury to popliteofibular ligament, popliteus tendon,
and reduction of fibular collateral ligamnet)
PLI type C : increased tibial external rotation, and varus instability
of 10mm greater than the normal knee tsted at 30 of knee flexion
with varus stress(injury to popliteofibular ligament, and lateral
capsular avulsion, in addition to cruciate ligament disruption
MCL : stress at 0 and 30 of knee flexion to assess the superficial
MCL, the posterior oblique ligament, and the posterior medial
capsule

Vascular Injury
If arterial damage indicated,
reduction is performed to see if this
restores blood flow to the limb.
Arteriography

Journal III
Radiologic Review of Knee
Dislocation : From Diagnosis to
Repair
Richard E. A. Walker,
David
McDougall, Shamir Patel, John A. Grant,
Peter D. Longino, Nicholas G. Mohtadi

Neurologic Assessment
Peripheral nerve injuries are common in knee
dislocations and most frequently involved is the
common peroneal nerve
Common peroneal nerve pasly radiologic
assessment for a posterolateral corner injury/fibular
head avulsion fracture will have peroneal nerve
damage
On MRI, the common peroneal nerve can be clearly
identified at the posterolateral aspect of the knee,
visualized immediately posterior to the biceps
femoris muscle and deep in relation to the crucial
fascia.

Figure 1 : Common peroneal nerve

(black arrowheads) is thickened and
edematous in this patient with

Vascular Assessment
The mechanism of popliteal artery injury
occurs predominantly by excessive
stretching, direct trauma to the vessels
by adjacent bony structures
Careful assessment for signs of impaired
circulation, such as asymmetric or absent
pulses and skin discoloration or
temperature changes below the knee,
should be performed at initial assessment

Figure 2 : Axial
source images from
CT angiography of
lower extremities
show contrastopacified right
popliteal artery at
level of femoral
condyles (arrow), but
at level of tibial
plateau, no
intraluminal contrast
Figure 3 : Threeenhancement
is seen
dimensional
(arrowhead),surfacerendered
reformatted
consistent
with
images
rightand
knee show
arterial of
injury
right
popliteal
artery
occlusion.
No contrast
occlusion
just below
level
extravasation
is seen.
of tibiofemoral joint
(arrows) with opacification
of small collateral
branches.

Journal IV
Diagnosis and Management of the
Multiligament-Injured Knee
Jack G. Skendzel, M.D., Jon K. Sekiya,
M.D., Edward M. Wojtys, M.D.

Clinical Evaluation
Deformity, misalignment, massive soft
tissue swelling and disproportionate pain
Highly suspicious knee dislocation
In cases of low-energy trauma, immediate
reduction should be attempted before
performing imaging studies, splinted and
radiographs should be obtained to check
for associated fractures of the femur and
tibia and to confirm a reduced
tibiofemoral joint.

Vascular Injuries
High-energy injuries possible
artery injury
Vascular examination capillary
refill, warmth, and color, palpation of
dorsalis pedis and posterior tibial
pulses
If pulses are absent or abnormal and
the knee is grossly dislocated, a
reduction should be attempted and
the pulses should be re-evaluated

Nerve Injury
Most common peroneal nerve
Lateral and posterolateral injuries may
place increased stretch on the nerve
Physical examination testing tactile
sensation in all nerve distribution of the
lower leg and foot. Strength is tested for all
muscle innervated by the peroneal and
tibial nerves(ankle dorsiflexion and plantar
flexion, foot inversion and eversion, and
great-toe extension)

Imaging
2 planes of plain radiography (anteroposterior and
lateral)
Low energy mechanism reduction is done first and
then radiography
High energy mechanism radiography is done first
prior reduction
In all situations, radiographs should be done after
reduction
MRI is helpful after dislocation to determine which
ligaments were involved and to define the injury
pattern, can evaluate chondral surfaces, menisci, and
other soft tissues