From: <¥Ñ Microsoft Internet Explorer 5 Àx¦s> Subject: Acute Knee Injuries: Use of Decision Rules for Selective Radiograph Ordering - December 1, 1999 - American Academy of Family Physicians Date: Mon, 12 Apr 2004 18:18:27 +0800 MIME-Version: 1.0 Content-Type: multipart/related; boundary="----=_NextPart_000_0000_01C420BA.8D271090"; type="text/html" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2727.1300 This is a multi-part message in MIME format. ------=_NextPart_000_0000_01C420BA.8D271090 Content-Type: text/html; charset="big5" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.aafp.org/afp/991201ap/2599.html Acute Knee Injuries: Use of Decision Rules for = Selective Radiograph Ordering - December 1, 1999 - American Academy of = Family Physicians
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Acute Knee Injuries: Use of Decision Rules for Selective = Radiograph=20 Ordering

HOWARD B. TANDETER, M.D., and
PESACH SHVARTZMAN, M.D.=20
Ben-Gurion University of the Negev, Beer-Sheva, Israel=20
MAX A. STEVENS, M.D.=20
University of Iowa Hospitals and Clinics, Iowa City, Iowa =

Family physicians often encounter = patients with=20 acute knee trauma. Radiographs of injured knees are commonly = ordered, even=20 though fractures are found in only 6 percent of such patients and = emergency=20 department physicians can usually discriminate clinically between = fracture=20 and nonfracture. Decision rules have been developed to reduce the=20 unnecessary use of radiologic studies in patients with acute knee = injury.=20 The Ottawa knee rules and the Pittsburgh decision rules are the = latest=20 guidelines for the selective use of radiographs in knee trauma. = Application=20 of these rules may lead to a more efficient evaluation of knee = injuries and=20 a reduction in health costs without an increase in adverse outcomes. = (Am Fam=20 Physician 1999;60:2599-608.)

Family physicians are = frequently called=20 on to evaluate patients who have acute knee injuries.1 Each year, knee trauma is also = responsible for an=20 estimated 1.3 million visits to emergency departments in the United=20 States.2 The anatomic = characteristics of the=20 knee, its exposure to external forces and the functional demands = placed on the=20 joint may explain the frequency of injury.

3D"{short
Only 6 = percent of=20 patients with knee trauma have a fracture. =
3D"{short

Standard emergency medicine textbooks imply that radiographs should = be=20 routinely obtained for every patient who presents with a knee = injury.3-5 Consequently, radiographs are among = the most=20 commonly ordered imaging studies for traumatic injury to the knee = joint.6,7 This situation persists despite the = absence of=20 clear supporting data and the fact that only 6 percent of patients = with knee=20 trauma have a fracture.6-9

Even though emergency department physicians can discriminate = clinically=20 between fracture and nonfracture, they order radiographs for most = patients=20 with acute knee injury. Reasons for the unnecessary use of radiography = include=20 fear of lawsuits, failure to obtain an adequate history and = expectations on=20 the part of patients.10-12

3D"Figure
FIGURE 1. = Anterior view of=20 the osseous, ligamentous and fibrocartilaginous structures of = the=20 knee.

Overuse of radiologic studies has become a significant economic = problem in=20 the United States.11,13 Although = knee=20 radiographs are relatively inexpensive, high volume of a low-cost test = has the=20 same overall financial impact as low volume of a high-cost = procedure.14,15 Unnecessary radiation exposure and = prolonged=20 waiting times are other reasons to decrease the use of radiologic = studies. The=20 application of decision rules for the selective ordering of = radiographs may=20 result in a more efficient evaluation of patients with acute knee = injuries and=20 may reduce the use of radiography in these patients.

This article briefly reviews the anatomy of the knee joint as well = as the=20 most common knee fractures and ligament injuries. Clinical decision = rules for=20 ordering diagnostic radiographs following knee injuries are also = discussed,=20 with special emphasis given to the guidelines developed in Ottawa, = Ontario,=20 and Pittsburgh, along with their potential use in the management of = knee=20 injuries.

Anatomy of the Knee

The anatomy and function of the knee are quite complex, and only = the basics=20 are described in this article. The osseous structures of the knee = include the=20 distal femoral condyles, proximal tibial plateau and patella = (Figure=20 1). The tibial plateau articulates with the femoral condyles, and = the=20 patellofemoral groove (located anteriorly between the femoral = condyles)=20 accepts the patella. The tibia and patella do not articulate. The = gliding=20 motion of the patella across the femur allows smooth extension at the = knee and=20 increases the mechanical advantage of the quadriceps.

The extra-articular muscle-tendon units include the quadriceps and = patellar=20 tendons (responsible for knee extension), medial and lateral = hamstrings=20 (chiefly responsible for knee flexion), gastrocnemius muscle, = popliteal=20 ligament and iliotibial band (Figure 2).

The extra-articular ligamentous structures include the tibial and = fibular=20 collateral ligaments (Figure 1). These ligaments act as the = principal=20 extra-articular static stabilizing structures (i.e., they provide = stability=20 for the medial and lateral aspects of the knee).

3D"Figure
FIGURE 2. = Anterior and=20 posterior views of the extra-articular tendinous structures and = muscles=20 associated with the knee.

The intra-articular structures include the medial and lateral = menisci and=20 the anterior and posterior cruciate ligaments (Figure 1). The = menisci=20 are fibrocartilaginous wedges that rim and cushion each tibiofemoral=20 articulation. The anterior and posterior cruciate ligaments provide = stability=20 for the knee joint.

3D"Figure
FIGURE 3. = Fractures of the=20 patella. This bone can be fractured through one of its poles or = through=20 its central body. Patellar fractures can be simple or=20 comminuted.

Knee Fractures

Fractures may occur in the patella, femoral condyles or tibial=20 plateau.16 Patellar fractures are = divided into=20 transverse, vertical, upper pole, lower pole, comminuted and = osteochondral=20 fractures (Figure 3). Each type can be undisplaced or displaced = (Figure 4). The two main mechanisms of patellar fracture are = direct=20 trauma to the anterior aspect of the knee or a powerful contraction of = the=20 quadriceps muscle (transverse, upper pole and lower pole = fractures).

Radiographs are essential to assess traumatic patellar injury. In = addition=20 to anteroposterior, notch and lateral views, Merchant and = infrapatellar views=20 with the knee in 45 degrees of flexion may be necessary to identify an = osteochondral fragment (Figure 5).

Fractures of the femoral condyles involve the distal 9 to 15 cm of = the=20 femur (Figure 6). Both the diaphyseal and metaphyseal regions = may be=20 involved. Fractures may also show intra-articular extension. Most = condylar=20 fractures occur as a result of motor vehicle accidents. Other causes = include=20 falling on a flexed knee or falling from a height. In young people, = higher=20 energy is necessary for a fracture to occur; consequently, more soft = tissue=20 damage is also present. In older patients with osteoporosis, less = energy is=20 needed to produce a fracture; therefore, less associated soft tissue = damage is=20 present.

Fractures of the tibial plateau are of special importance because = they=20 occur in one of the most important weight-bearing areas (Figure = 7).=20 These fractures may involve the metaphysis, epiphysis and/or articular = cartilage. The forces that produce fractures in this area are = compression,=20 valgus force (outward twisting [away from the midline]) or a = combination of=20 both. The fractures primarily involve the lateral plateau, the medial = plateau=20 or both structures (bicondylar fractures).


3D"Figure
FIGURE 4. = Displaced=20 fracture of the lower pole of the patella = (arrow).		 3D"Figure
FIGURE 5. = Osteochondral=20 fragment (bottom arrow), which represents a small = fracture of the=20 patella with hemarthrosis. A fluid collection is also seen = (top=20 arrow).		 3D"Figure
FIGURE 6. = Oblique view of=20 a lateral femoral condyle fracture that extends to the articular = surface=20 (arrows).

3D"Figure 3D"Figure

FIGURE 7. Fractures of the tibial plateau. = These=20 fractures can be comminuted (left) or can be limited to = the=20 depression of the tibial plateau, or they can also involve the=20 displacement of both plateaus and can be associated with fibular = head=20 fracture = (right).

Knee Ligament = Injuries

No validated rules have been formulated for the use of radiography = in=20 patients with suspected ligament injuries, but a decision tree can be = used as=20 a guide (Figure 8).17 = Although plain=20 radiographs may be useful in the initial diagnosis of these injuries, = magnetic=20 resonance imaging (MRI) is becoming the preferred diagnostic = method18 and is rapidly replacing other = techniques as the=20 study of choice for the evaluation of knee injuries.19 However, the routine use of MRI has = been=20 questioned because of its significant cost ($600 to $1,200) and the = high=20 accuracy of clinical examination in diagnosing some injuries.20

3D"{short
Evaluation of Collateral Ligament = Injury=20
3D"Figure
3D"{short
FIGURE=20 8.Suggested decision tree for the evaluation of = collateral=20 ligament injury. (RICE =3D rest, ice, compression and=20 elevation)
Adapted with = permission from=20 Smith BW, Green GA. Acute knee injuries: Part II. = Diagnosis and=20 management. Am Fam Physician=20 = 1995;51:800.

Anterior Cruciate Ligament
Rupture of the anterior = cruciate=20 ligament (ACL) is a serious injury, and the diagnosis may be = missed.18 This type of injury can be produced by = pure=20 hyperextension or by a combination of valgus force and external = rotation of=20 the tibia relative to the femur.

3D"{short
Magnetic = resonance=20 imaging is becoming the preferred mode for diagnosing = ligamentous=20 injuries of the knee.
3D"{short

The immediate development of a hemorrhagic effusion is an important = point=20 in the history of ACL injury (Figure 9). The stability of the = ACL may=20 be clinically assessed with the use of the Lachman test (modified = anterior=20 drawer test). More than 90 percent of ACL injuries can be detected = based on=20 the history and physical examination.17=20 However, even the best specialists may fail to recognize the joint = laxity of=20 an ACL injury. Therefore, radiographic signs are useful in making the=20 diagnosis.

ACL injury has three main radiographic signs: (1) avulsion of the=20 intercondylar tubercle (Figure 10), (2) anterior displacement = of the=20 tibia with respect to the femur, termed the "radiographic drawer = sign," and=20 (3) Segond fracture (a thin sliver of bone avulsed from the proximal = lateral=20 tibia with the lateral capsular ligament), termed the "lateral = capsular=20 sign"16 (Figure 11). Note, = however,=20 that these radiographic signs are frequently absent in patients with = ACL=20 injuries.

The gold standard for the diagnosis of ruptured ACL is arthroscopy. = Compared with this procedure, MRI has a diagnostic accuracy of more = than 90=20 percent. In addition, ultrasound examination has been shown to be a = useful and=20 inexpensive mode of detecting a ruptured ACL in the clinical setting = of a=20 traumatic hemarthrosis.21

3D"Figure
FIGURE 9. = Fluid level=20 (arrows) seen on a cross-table lateral radiograph. This = indicates=20 the presence of hemarthrosis from injury of the anterior = cruciate=20 ligament.		 3D"Figure
FIGURE 10. = Avulsion of the=20 intercondylar tubercle (arrow), indicating injury of the = anterior=20 cruciate ligament.		 3D"Figure
FIGURE 11. = Segond fracture=20 (arrow), which is a cortical avulsion of the proximal = lateral=20 tibial plateau that also involves the lateral=20 capsule.

Posterior Cruciate Ligament
Injuries of the posterior = cruciate=20 ligament (PCL) are relatively uncommon, apparently because this is the = strongest major knee ligament. The mechanism of isolated PCL injury is = blunt=20 trauma to the anterior proximal tibia ("dashboard injury").

Several maneuvers can be helpful in diagnosing PCL injuries = (Figure=20 12). In one study,22 the gravity = sign near=20 extension correctly diagnosed PCL injury in 20 of 24 patients, and = active=20 reduction of posterior tibial subluxation correctly identified PCL = injury in=20 18 of 24 patients. The gravity test is performed at 20 degrees of knee = flexion. Neither maneuver requires anesthesia.

3D"Figure
FIGURE 12. = Two maneuvers to=20 detect posterior cruciate ligament injury. (A) Gravity = sign near=20 extension test. In a resting position with the distal femur on a = 15-cm=20 support and the heel resting on the examination table (20 = degrees of=20 flexion), the unsupported proximal tibia displays a concave = anterior=20 contour. (B) Active reduction of posterior tibial = subluxation.=20 When the patient raises the heel 2 to 3 cm, a normal anterior = contour is=20 restored.

Nonetheless, clinical diagnosis may be difficult, and radiographic = signs=20 are important.18 The most common = radiographic=20 sign of PCL injury is avulsion at the site of the ligament's origin on = the=20 posterior tibia (Figure 13). Less commonly, avulsion can be = seen at the=20 site of PCL insertion at the medial femoral condyle. When the PCL = fails,=20 posterior sagging of the tibia relative to the femur may be seen on = the=20 lateral radiograph.

3D"Figure
FIGURE 13. = Avulsion at the=20 site of origin on the posterior tibia (arrow), resulting = from=20 injury of the posterior cruciate = ligament.

MRI is accurate in diagnosing PCL injuries. It can also show = associated=20 injuries of the ACL and medial collateral ligament (MCL), as well as = bone=20 contusions.

Medial Collateral Ligament
Knee injuries involving valgus = force,=20 with or without a rotational element, are suggestive of MCL injury. = The=20 physical examination may demonstrate effusion or local soft tissue = swelling=20 and ecchymosis.18 Injuries to the = MCL usually=20 occur at the ligament's proximal origin. Therefore, tenderness is = usually=20 localized along the distal femur and extends to the joint line.17

The major secondary radiographic sign of MCL injury is widening of = the=20 medial joint space. A lateral tibial plateau fracture may also suggest = MCL=20 injury.

MRI demonstrates MCL injury as well as associated injuries of the = medial=20 meniscus, capsule and ACL.

Lateral cCollateral Ligamentous Domplex
Injuries of the = lateral=20 collateral ligamentous complex (LCL) are estimated to account for only = 5=20 percent of all knee ligament injuries.18,23=20 Radiographic signs suggesting LCL injury include lateral joint space = widening=20 and medial tibial plateau fracture.18

Decision Rules for Radiography in = Acute Knee=20 Injury

For several years, researchers have been working to design = protocols that=20 may reduce the number of radiographs used in the evaluation of = extremity=20 injuries. A good example of a successful protocol is the one now known = as the=20 "Ottawa ankle rules."24-27 Protocols = have also=20 been designed for the radiologic evaluation of knee injuries.28-30 The clinical decision rules created = in Ottawa=20 and Pittsburgh are the best known guidelines for the appropriate use = of=20 radiographs in acute knee injuries (Table 1).

3D"{short
TABLE 1 =
Characteristics of=20 Patients Who Should Undergo Radiography After Knee = Trauma=20
Ottawa = knee=20 rules
Age 55 years or older
Tenderness at head = of=20 fibula
Isolated tenderness of patella
Inability to = flex knee=20 to 90 degrees
Inability to walk four weight-bearing = steps=20 immediately after the injury and in the emergency=20 department
Pittsburgh decision rules
Blunt = trauma or=20 a fall as mechanism of injury plus either of the = following:
Age=20 younger than 12 years or older than 50 years
Inability = to walk=20 four weight-bearing steps in the emergency = department=20
3D"{short

Ottawa Knee Rules
Investigators in Ottawa conducted a=20 retrospective chart review of all patients with acute knee injuries = who=20 presented to an emergency department over a 10-month period.8 The knees of 74 percent of these = patients were=20 evaluated radiographically, but only 5.2 percent were found to have = fractures.=20 All charts were evaluated for the presence of 11 clinical variables: = age,=20 gender, mechanism of injury (blunt trauma or fall versus twisting), = history of=20 swelling, history of deformity, ability to ambulate (i.e., to walk = four=20 steps), swelling, effusion, ligamentous instability, decreased range = of motion=20 and pain on palpation.

Logistic regression analysis found that a fall or blunt trauma = mechanism of=20 injury had a sensitivity of 92 percent and a specificity of 57 percent = for the=20 presence of a knee fracture.8 The = addition of=20 inability to ambulate and age (younger than 12 years and older than 50 = years)=20 improved the specificity. The prospective part of the study found that = the=20 combination of all three criteria was 100 percent sensitive and 79 = percent=20 specific for knee fracture.29

In a later study,27 attending = physicians in=20 the emergency departments of two university hospitals assessed every = adult=20 patient with an acute knee injury for 23 standardized clinical = findings. The=20 Ottawa knee rules were derived from this study. The presence of one or = more of=20 these findings would have identified the 68 fractures in the study = population.=20 Furthermore, application of the Ottawa knee rules would have led to a = 28=20 percent relative reduction in the use of radiography in the study=20 population.

A prospective validation of the Ottawa knee rules was published in=20 1996.2 Attending emergency = department=20 physicians assessed each patient for standardized clinical variables = and=20 determined the need for radiography based on the decision rules. The = rules=20 were assessed for their ability to correctly identify the criterion = standard,=20 which was fracture of the knee. The study found that the decision = rules were=20 100 percent sensitive for identifying knee fractures, were reliable = and=20 acceptable, and had the potential to allow physicians to reduce the = use of=20 radiography in patients with acute knee injuries. If the decision = rules were=20 negative, the probability of a knee fracture was zero percent.

3D"{short
In a recent = prospective=20 study, the Pittsburgh decision rules were 99 percent = sensitive and=20 60 percent specific for the diagnosis of knee = fractures.=20
3D"{short

Pittsburgh Decision Rules
The Pittsburgh decision rules = for=20 optimizing the use of radiography in patients with acute knee injuries = were=20 presented in 1995.31 A prospective=20 observational study was conducted over a 10-month period in the = emergency=20 department of a university hospital. A standardized closed-question = data=20 collection instrument that recorded 12 historical and 26 physical = examination=20 criteria was used in the study. A clinical algorithm for the use of=20 radiography that requires the presence of an inability to bear weight, = an=20 effusion or an ecchymosis was 100 percent sensitive for the detection = of knee=20 fractures. No fractures were found in patients who did not meet one or = more of=20 the criteria. Limiting knee radiography to patients who met these = criteria=20 would have reduced the use of radiography by 39 percent without = missing a=20 fracture.

Comparison of Decision Rules
The Ottawa knee rules and = the=20 Pittsburgh decision rules were compared in a prospective study of = patients=20 evaluated in the emergency departments of three teaching=20 hospitals.32 The Pittsburgh decision rules were 99 percent=20 sensitive and 60 percent specific for the diagnosis of knee fractures = and=20 could have reduced the use of radiography by 52 percent, with one = missed=20 fracture. If the rules indicated a fracture, 24.1 percent of patients = actually=20 had a knee fracture (positive predictive value); if the rules = indicated no=20 fracture, 99.8 percent of patients did not have a knee fracture = (negative=20 predictive value). The Ottawa knee rules were 97 percent sensitive and = 27=20 percent specific for knee fractures, with three fractures missed. The = authors=20 of the comparative study concluded that the Pittsburgh decision rules = were=20 more specific, with no loss of sensitivity.

The authors thank Daniel Fick, M.D., = University=20 of Iowa College of Medicine, Iowa City, for reviewing the manuscript = and=20 assisting in the editing process.

Coordinators of this series are = Thomas J.=20 Barloon, M.D., associate professor of radiology, and George R. = Bergus, M.D.,=20 associate professor of family practice, both at the University of = Iowa=20 College of Medicine, Iowa City.

The editors of AFP welcome = the submission=20 of manuscripts for the Radiologic Decision-Making series. Send = submissions=20 to Jay Siwek, M.D., following the guidelines provided in = "Information for=20 Authors."

The Authors

HOWARD B. TANDETER, M.D.,
is a lecturer in family medicine at = Ben-Gurion=20 University of the Negev, Beer-Sheva, Israel. After graduating from the = Faculty=20 of Medicine at the University of Buenos Aires, Dr. Tandeter completed = a family=20 medicine residency in Beer-Sheva and an academic fellowship at the = University=20 of Toronto, Ontario.

PESACH SHVARTZMAN, M.D.,
is an associate professor and chairman = of the=20 Department of Family Medicine at Ben-Gurion University of the Negev. = He=20 received his medical degree from the Medical School at the Technion, = Haifa,=20 Israel, and completed a family medicine residency in Afula, Israel. = Dr.=20 Shvartzman was a visiting professor at McGill University Faculty of = Medicine,=20 Montreal, Quebec.

MAX A. STEVENS, M.D.,
is currently in private practice at Iowa = Lutheran=20 Hospital, Des Moines. He received his medical degree from the = University of=20 Iowa College of Medicine in Iowa City. After a transitional-year = internship at=20 the University of South Dakota School of Medicine, Sioux Falls, Dr. = Stevens=20 completed a residency in diagnostic radiology at Creighton University = School=20 of Medicine and Saint Joseph Hospital, Omaha. He also completed a = fellowship=20 in musculoskeletal radiology at the University of Iowa Hospitals and = Clinics,=20 Iowa City.

Address correspondence to Howard B. = Tandeter,=20 M.D., Department of Family Medicine, Ben-Gurion University of the = Negev,=20 P.O. Box 653, Beer-Sheva 84105, Israel. Reprints are not available = from the=20 authors.

REFERENCES

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  27. Stiell IG, Greenberg GH, Wells GA, McKnight RD, = Cwinn AA,=20 Cacciotti T, et al. Derivation of a decision rule for the use of = radiography=20 in acute knee injuries. Ann Emerg Med 1995;26:405-13.=20
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  29. Seaberg DC, Jackson R. Clinical decision rule = for knee=20 radiographs. Am J Emerg Med 1994;12:541-3.=20
  30. Weber JE, Jackson RE, Peacock WF, Swor RA, = Carley R,=20 Larkin GL. Clinical decision rules discriminate between fractures = and=20 nonfractures in acute isolated knee trauma. Ann Emerg Med=20 1995;26:429-33.=20
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  32. Seaberg DC, Yealy DM, Lukens T, Auble T, Mathias = S.=20 Multicenter comparison of two clinical decision rules for the use of = radiography in acute, high-risk knee injuries. Ann Emerg Med=20 1998;32:8-13.

Copyright © 1999 by the American Academy of = Family=20 Physicians.
This content is owned by the AAFP. A person viewing = it=20 online may make one printout of the material and may use that = printout only=20 for his or her personal, non-commercial reference. This material may = not=20 otherwise be downloaded, copied, printed, stored, transmitted or = reproduced=20 in any medium, whether now known or later invented, except as = authorized in=20 writing by the AAFP. Contact afpserv@aafp.org for copyright = questions=20 and/or permission requests.

December = 1, 1999=20 Contents | AFP Home=20 Page | AAFP = Home |=20 Search
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