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Knee Pain & Acute Trauma Diagnosis Imaging Part I | El Paso, TX

Knee Pain & Acute Trauma Diagnosis Imaging Part I | El Paso, TX

by | Imaging & Diagnostics, Mobility & Flexibility

Tibial Plateau Fractures

  • Impaction type fractures predominate
  • Result from valgus or varus stress with or w/o axial loading
  • Associated with periarticular soft tissues injury
  • High-stress injury m/c due to jumps falls and axial loading, often with the splitting of the tibial plateau. Men>women. Patients are in their 30s
  • Low impact or no trauma in patients with osteoporosis d/t insufficiency fractures
  • Impaction injury is more common with depression of tibial plateau. Women>men. Patients are in their 70s

Lateral Tibial Plateau Fractures More Common

  • Functional anatomy plays a significant role
  • 60% of weight bearing is by the medial plateau
  • The medial plateau is more concave
  • Lateral plateau is slightly higher and more convex. Valgus stress impacts lateral plateau.
  • Tibial plateau fractures considered intra-articular and prone to delayed healing, non-union, meniscal injury (m/c lateral) ACL tear, secondary OA. Other complications: compartment syndrome, vascular injury.
  • Management: operative in many cases especially if >3-mm step-off at the plateau
  • If medial plateau or bicondylar Fxs present, ORIF will be required.

Imaging Plays A Crucial Role

knee pain acute trauma el paso tx.

 

  • Begins with x-radiography. X-radiography may not reveal the complexity and extent of this injury.
  • CT scanning w/o contrast will further delineate fracture complexity and pre-operative planning
  • MR imaging may be considered to evaluate for internal derangement: meniscal, ACL injuries.
  • Shatzke classification may help to evaluate the complexity of this injury

Key Diagnostic Sign

knee pain acute trauma el paso tx.

 

  • AP and lateral horizontal beam (cross table) left knee radiograph. Note subtle depression of the lateral plateau manifested by the lateral plateau appearing at the same level or lower as the medial. A critical diagnostic sign is the presence of fat-blood-interphase or FBI sign on cross-table lateral (above arrow) indicating intra-articular knee fracture

Lipohemarthorosis aka FBI Sign

knee pain acute trauma el paso tx.

 

  • Can be detected by radiography, CT or MR imaging
  • FBI sign is a reliable secondary radiographic sign of intra-articular knee fractures, regardless of how small they are
  • Mechanism: fracture results with acute hemarthrosis
  • Hemarthrosis will also occur w/o Fx. However, Fx will result with a fatty marrow being released into the joint cavity. Fat is a less dense medium (lighter) and will appear on the top of the hemorrhage if the patient is held in the supine position for 5-10-minutes before the cross-table radiograph is taken
  • FBI sign confirms the intra-articular Fx.
  • ACL/PCL, meniscal tears will not result in FBI sign

Lateral Tibial Plateau Fx

knee pain acute trauma el paso tx.

 

  • Lateral tibial plateau Fx that was managed operatively
  • Most common complication: premature secondary OA
  • More complex injuries may result in more extensive operative care

Knee Internal Derangement

  • Acute or chronic injuries of meniscal fibrocartilages and ligamentous restraints
  • Tears of the ACL and posterior horn of the medial meniscus are the most common
  • Acute ACL tears, however, often result with a lateral meniscus tear
  • Acute ACL tear may occur as a combined injury of the ACL, MCL, and medial meniscus
  • Functional anatomy: ACL prevents anterior displacement of the tibia and secondary varus stress
  • MCL functions together with ACL in resisting external rotation of the tibia especially when the foot is planted (closed chain position)
  • MCL is firmly attached to the medial meniscus, explaining the classic triad of ACL, MCL and medial meniscal tear (O’Donahue terrible triad)
  • Cruciate ligaments (ACL/PCL) are intra-articular but extra-synovial. Less likely to be torn in closed pack position (full extension). When all articular facets of tibia and femur are in full contact, the ACL/PCL are at least tension and stable
  • When the knee is flexed 20-30-degrees or more ACL is taut and remains unstable
  • ACL is a significant mechanoreceptor that feeds the info to CNS about the joint position. Thus the majority of previous ACL tears will lead to some degree of knee instability

Functional Anatomy of ACL

knee pain acute trauma el paso tx.

Diagnosis of ACL Tear

knee pain acute trauma el paso tx.

 

  • Diagnosis of ACL tear requires MR imaging
  • Concerns exist of not only ligamentous injuries but injuries to the articular cartilage and menisci.
  • Most vendors will perform at least: one T1 WI in coronal or sagittal planes. Sagittal and coronal Proton-density slices to evaluate cartilaginous structures. Fast spin-echo sagittal, axial and coronal T2 fat-saturated or sagittal and coronal STIR images are crucial to demonstrate edema within the substance of knee ligaments
  • Note sagittal proton-density MRI slice showing intact ACL (above)
  • ACL is aligned along the Blumensaat line or oblique line corresponding the intercondylar roof of Femoral condyles. Lack of such alignment by the ACL is significant for ACL tear

Imaging Dx of Internal Derangement

knee pain acute trauma el paso tx.

 

  • MRI shows 78-100% sensitivity and 78-100% specificity
  • Primary signs of ACL tear: non-visualization of ACL (above green arrow), loss of its axis along the Blumensaat line (above triangle heads), wavy appearance and substance tear (above white arrow) or edema and cloud-like indistinctness (above yellow arrow)

Reliable Secondary Signs of ACL Tear

knee pain acute trauma el paso tx.

 

  • May be observed on the radiographs and MRI
  • Segond avulsion fracture (80% specificity for ACL tear) (next slide)
  • Deep femoral notch sign indicating osteochondral fracture (above bottom images) and
  • Pivot -shift bone marrow edema in the posterolateral tibial condyle d/t external rotation and often valgus impact by the lateral femoral condyles (above top image)

Segond Fracture (Avulsion by ITB)

knee pain acute trauma el paso tx.

 

  • Segond fracture at Gerdy’s tubercle. A vital sign of the ACL tear seen on both radiographs and MRI

Management of ACL Tears

knee pain acute trauma el paso tx.

 

  • In acute cases, usually operative using cadaveric or autograft (patella ligament or hamstring) ACL reconstruction
  • Complications: graft tear, instability and premature DJD, joint stiffness d/t lack of postoperative rehab or gaft shortening. More rare, infection, a formation of intraosseous synovial cysts, etc.

Knee Trauma

 

Acute Whiplash Disorders And Chiropractic Treatment Videos In El Paso, TX.

Acute Whiplash Disorders And Chiropractic Treatment Videos In El Paso, TX.

by | Whiplash

Acute Whiplash-Associated Disorders:

Acute Whiplash

Each year in America there are between 6.5 million and 7 million Motor Vehicle Accidents or�(MVA’s)�that affect many. Of those accidents, about three million involve some form of bodily injury. About two thirds of these injuries, while not debilitating, are permanent. When you are rear-ended your body is driven out from under your head. Although there is a great deal of soft tissue stretching that occurs in the soft tissues (LIGAMENTS, TENDONS, MUSCLES, and FASCIA), as your body travels forward at a significantly higher velocity than your head; at a certain point, these “soft tissues” cannot stretch anymore. This is the first point at which microscopic tissue tearing occurs. This is the beginning of the injury process.

The head is now accelerating forward faster than the entire body. When the body comes to a stop (i.e. your vehicle slams into whatever is in front of it), the head will continue to travel forward. This is actually where the term “whiplash” comes from, and where it occurs. It’s exactly the principle of physics that results in the tip of a bullwhip to ‘crack’ as it breaks the sound barrier. If this type of ‘whipping’ motion occurs in the neck, it can result in a great deal of soft tissue damage and subsequent formation of fibrosis and scar tissue. Additionally, it may lead to a great deal of occult (hidden) brain and nerve system trauma.

Dr. Alexander Jimenez D.C.

acute whiplash el paso tx.

Study Design:

An experimental study of motor/sensory function and psychological distress in subjects with acute whiplash injury.

Objective:

Characterizing acute whiplash injuries in terms of motor/sensory systems dysfunction and psychological distress. This involves comparison of subjects with higher and lesser levels of pain and disability.

Summary Of Background Data:

Motor system dysfunction, sensory hypersensitivity, and psychological distress are present in chronic whiplash associated disorders (WAD), but little is known of such factors in the acute stage of injury. As higher levels of pain and disability in acute WAD are accepted as signs of poor outcome, further characterization of this group from those with lesser symptoms is important.

Materials And Methods:

Motor function (cervical range of movement [ROM], joint position error [JPE]; activity of the superficial neck flexors [EMG] during a test of cranio-cervical flexion), quantitative sensory testing (pressure, thermal pain thresholds, and responses to the brachial plexus provocation test), and psychological distress (GHQ-28, TAMPA, IES) were measured in 80 whiplash subjects (WAD II or III) within 1 month of injury, as were 20 control subjects.

Results:

Three subgroups were identified in the cohort using cluster analysis based on the Neck Disability Index: those with mild, moderate, or severe pain and disability. All whiplash groups demonstrated decreased ROM and increased EMG compared with the controls (all P < 0.01). Only the moderate and severe groups demonstrated greater JPE and generalized hypersensitivity to all sensory tests (all P < 0.01). The three whiplash subgroups demonstrated evidence of psychological distress, although this was greater in the moderate and severe groups. Measures of psychological distress did not impact on between group differences in motor or sensory tests.

Conclusions:

Acute whiplash subjects with higher levels of pain and disability were distinguished by sensory hypersensitivity to a variety of stimuli, suggestive of central nervous system sensitization occurring soon after injury. These responses occurred independently of psychological distress. These findings may be important for the differential diagnosis of acute whiplash injury and could be one reason why those with higher initial pain and disability demonstrate a poorer outcome.

Sterling M1,�Jull G,�Vicenzino B,�Kenardy J.

Author Information

Whiplash Research Unit, Department of Physiotherapy, The University of Queensland, Brisbane, Australia. [email protected]

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