Knee pain and injury: When is a surgical consult needed?
This review identifies clinical scenarios—such as unstable or displaced fractures, major tendon ruptures, and significant mechanical issues—that likely warrant surgical consultation.
PRACTICE RECOMMENDATIONS
› Consider surgical management, potentially emergently, for acute knee injuries that result in significant joint instability, unstable fractures, or neurovascular compromise. A
› Avoid arthroscopy for chronic, degenerative sources of knee pain, such as osteoarthritis and degenerative meniscus tears, as it is no longer routinely recommended. A
› Treat osteoarthritis surgically after nonsurgical treatments have failed. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Patella fractures
These fractures occur as a direct blow to the front of the knee, such as falling forward onto a hard surface, or indirectly due to a sudden extreme eccentric contraction of the quadriceps muscle. Nondisplaced fractures with an intact knee extension mechanism, which is examined via a supine straight-leg raise or seated knee extension, are managed with weight-bearing as tolerated in strict immobilization in full extension for 4 to 6 weeks, with active range-of-motion and isometric quadriceps exercises beginning in 1 to 2 weeks. Serial x-rays also are obtained to ensure fracture displacement does not occur during the rehabilitation process.9
High-quality evidence guiding follow-up care and comparing outcomes of surgical and nonsurgical management of patella fractures is lacking, and studies comparing different surgical techniques are of lower methodological quality.10 Nevertheless, displaced or comminuted patellar fractures are referred urgently to orthopedic surgical care for fixation, as are those with concurrent loose bodies, chondral surface injuries or articular step-off, or osteochondral fractures.9 Inability to perform a straight-leg raise (ie, clinical loss of the knee extension mechanism) suggests a fracture under tension that likely also requires surgical fixation for successful recovery. Neurovascular injuries are unlikely in most patellar fractures but would require emergent surgical consultation.9
Ligamentous injury
Tibiofemoral joint laxity occurs as a result of ligamentous injury, with or without tibial plateau fracture. The anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL), and lateral collateral ligament (LCL) comprise the 4 main ligaments of the knee. The ACL resists anterior tibial translation and rotational forces, while the PCL resists posterior tibial translation. The MCL and LCL resist valgus and varus stress, respectively.
Ligament injuries are classified as Grades 1 to 311:
- Grade 1 sprains. The ligament is stretched, but there is no macroscopic tearing; joint stability is maintained.
- Grade 2 sprains. There are partial macroscopic ligament tears. There is joint laxity due to the partial loss of the ligament’s structural integrity.
- Grade 3 sprains. The ligament is fully avulsed or ruptured with resultant gross joint instability.
Continue to: ACL tears
