Pediatric emergency medicine trisk 214
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head of the fibula, (iii) inability to flex to 90 degrees, (iv) inability to bear weight
both immediately after the injury and in the ED (four steps) regardless of limping.
Figure 42.8 summarizes an approach to the child with an acutely injured knee.
If the initial evaluation suggests vascular compromise, traction and reduction of
the knee should be attempted and an emergent orthopedics consultation should be
obtained. If the patella is obviously dislocated, it may be reduced before obtaining
radiographs. If the patient’s knee is too painful or swollen to allow a complete
examination, and radiographs are negative, ligament or meniscal damage should
be suspected. The patient should be instructed to use crutches and remain
completely non–weight bearing until medical or surgical follow-up or until the
patient improves. If radiographs demonstrate air in the joint, orthopedics should
be consulted to assess for penetrating intra-articular injury. If there is a puncture
wound or laceration near the knee joint, a saline load test or CT imaging should
be performed to assess for penetrating intra-articular injury (see Chapter 121
Musculoskeletal Emergencies ).
FIGURE 42.8 Approach to the patient with an acute knee injury.
FIGURE 42.9 Approach to the patient with a subacute knee injury. AP, anteroposterior.
Often, a patient may come to the ED with a history of trauma and knee pain
that has been present for more than 2 or 3 days (see Fig. 42.9 ). In addition to the
standard AP, lateral, and patellar views, a tunnel or intercondylar view should be
taken to exclude fracture, tumor, and OCD. If the initial knee and hip
examinations do not suggest a diagnosis and no signs of infection exist, the
diagnostic maneuvers in Table 42.2 should be completed. The patient may have a
subacute collateral ligament, cruciate ligament, or meniscal injury and require an
orthopedic referral.
Suggested Readings and Key References
Bulloch B, Neto G, Plint A, et al. Validation of the Ottawa knee rule in children: a
multicenter study. Ann Emerg Med 2003;42:48–55.
Cleland JA, Koppenhaver S. Netter’s Orthopaedic Clinical Examination: An
Evidence–Based Approach . 2nd ed. Philadelphia, PA: Saunders Elsevier; 2011.
Flynn JM, Skaggs DL, Waters PM, eds. Rockwood and Wilkins’ Fractures in
Children . 8th ed. Philadelphia, PA: Wolters Kluwer Lippincott Williams &
Wilkins; 2015.
Micheli LJ, Kocher MS, eds. The Pediatric and Adolescent Knee . Philadelphia,
PA: Saunders Elsevier; 2006.
Micheli LJ, Purcell L, eds. The Adolescent Athlete: A Practical Approach . New
York: Springer-Verlag; 2007.
Solomon DH, Simel DL, Bates DW, et al. Does this patient have a torn meniscus
or ligament of the knee? Value of the physical examination. JAMA
2001;286:1610–1620.
