A 24 year old Rugby player presents to clinic with a limp. The previous day, during a match he was being tackled around his left calf when two other opponents joined in to drag him down. He felt pain in his knee immediately and had difficulty getting up from the pitch. He has experienced no buckling.
Patient enters room with an antalgic gait using one crutch to support himself.
There is a large warm effusion of his left knee. He holds his knee in 20 degrees of flexion. There is no boney tenderness, he does not have any joint line tenderness. His flexion is limted to 100 degrees on the left and 10 degrees of extension. On passive range of motion he complains of global knee pain. Valgus and varus testing for his MCL and LCL reveal no laxity and no pain. Unable to perform a pivot shift test. Unable to do a lachman due to apprehension and hamstring engagement. Anterior drawer feels solid on exam. There is no patellar tenderness and there is no patellar femoral apprehension. His distal pusles and sensation are normal.
Would you order any tests? If so which tests?
How would you manage this patient in the mean time?
Complete ACL rupture with lateral meniscal tear, and lateral femoral condyle impaction fracture.
The xrays reveal a defect on the lateral femoral condyle which is confirmed on MRI as an impact fracture of the lateral femoral condyle. There’s a lateral vertical meniscal tear see on both coronal and sagital MRI images. Finally there is a complete rupture of the ACL with anteriorly flipped proximal strands which are likely resulting in the patient’s knee being locked.
Plan: An urgent referral for arthroscopy and ACL reconstruction. Patient was advised to use crutches for protected weight bearing. Physiotherapy for decreasing swelling. Bracing for swelling and reduction of pain.
Dr. Neil Dilworth CCFP Dip Sport Med (May 1, 2014)