Pediatric emergency medicine trisk 0842 0842
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FIGURE 42.3 Testing for anterior cruciate ligament injury with the Lachman test. Flex the
knee 20 to 30 degrees, support the thigh with one hand, and grasp the calf with the other hand.
Move the tibia forward on the femur. Observe the tibial tubercle for movement and feel for
excessive forward movement of the tibia in relation to the femur.
If the history is consistent with dislocation but the patient is no longer in pain
and has a normal examination, the patella may have subluxated or dislocated and
self-reduced. On examination, the patella may be high riding or laterally
displaced. The patellar apprehension test can be performed by gently attempting
to move the patella laterally. If the patient has guarding or apprehension, this
suggests a previously subluxated (or fully dislocated) patella. Radiographs should
be obtained to look for an associated osteochondral fracture.
Soft Tissue Injuries
Significant medial collateral ligament (MCL) or lateral collateral ligament (LCL)
injuries are rare when the physis is open because the involved ligaments are
stronger than the growth plate. The LCL inserts on the fibular head proximal to
the physis, and the MCL inserts on the tibia distal to the physis. In older patients,
the MCL or LCL may be damaged by a blow to the lateral or medial side of the
knee, respectively. This can occur during contact sports, or when stressed during
noncontact injuries such as with skiing or activities that involve pivoting. Severe
collateral ligament injury may be associated with ACL or meniscal damage. On
examination, the knee may be swollen or tender over the involved ligament. The
knee should be tested for lateral laxity (i.e., valgus and varus stress tests) in full
