Pediatric emergency medicine trisk 0851 0851
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usually not immediately after the injury. The sensation of the knee “giving out”
may occur with meniscal injuries or PFD.
Swelling after acute injury should raise concern for significant pathology.
Swelling within 2 hours strongly suggests hemarthrosis from an ACL injury,
meniscal injury, or osteochondral fracture, while swelling with other knee
fractures is commonly seen later.
The possibility of abuse in young children must always be considered,
especially if the injury is unexplained, the history is implausible, or the delay in
seeking medical care was unreasonable.
In subacute injuries, ask about hip or groin pain because the hip and knee share
sensory nerves. Legg–Calvé–Perthes disease or a slipped capital femoral
epiphysis may cause anterior thigh or knee pain. Patellar pain and the sensation of
the knee giving way without actually falling when going down stairs or inclines
suggest PFD.
Examination of the patient should include walking and standing, if possible, to
check for medially deviated “squinting” patellae. Inspect and palpate the knee in
two positions, sitting relaxed with the knees at 90 degrees and supine. When
sitting, inspect the knees for swelling and tenderness (e.g., swelling and
tenderness over the tibial tubercle in Osgood–Schlatter disease, or joint line
tenderness in meniscal injuries). With the patient supine, repeat inspection and
palpation over the joint line, collateral ligaments, patella, proximal fibula, tibial
tuberosity, and popliteal space. If the knee appears swollen, check for an effusion
by milking any joint fluid centrally toward the patella. Normally, synovial fluid
coats the patellar surface but does not separate the patella and femur. When fluid
separates the two bones, a sharp pat on the patella results in the sensation of a tap
as the two bones meet. If the joint contains a large amount of fluid, the patella
will not touch the femur but will feel as if it is sitting on a cushion. Assess both
active and passive ROM of the knee.
The physician should test for collateral and cruciate ligament damage, meniscal
injuries, patellar subluxation, and PFD, using the appropriate maneuvers ( Table
42.2 ) although most maneuvers have poor diagnostic accuracy when used in
isolation after an acute injury.
