Pediatric emergency medicine trisk 0850 0850
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may be normal, or the femoral condyle may be tender with the knee flexed.
Because AP and lateral radiographs may not show the lesion, a tunnel or
intercondylar view should be obtained.
Iliotibial (IT) band syndrome usually occurs in older runners who complain of
pain over the lateral femoral condyle. The repetitive movement of the IT band
across the lateral femoral condyle as the knee flexes and extends causes this pain.
When examined, the patient is tender over the lateral femoral epicondyle,
palpable 2 cm above the joint line. Radiographs are normal.
The Baker cyst is a herniation of the synovium of the knee joint or a separate
synovial cyst located in the popliteal fossa. The patient complains of popliteal
pain and swelling only if the cyst enlarges. The sac may be palpated in the
posterior medial aspect of the popliteal space. For the most part, radiographs will
be normal or show soft tissue swelling. Ultrasound may be needed to diagnosis
Baker cyst.
In any patient with knee pain, with or without a history of trauma, the
following must be considered: benign (e.g., osteochondroma and nonossifying
fibroma) and malignant tumors (e.g., osteosarcoma or Ewing sarcoma), the
various causes of monoarticular arthritis (see Chapter 60 Pain: Joints ) and hip
disease that may present with knee pain (e.g., slipped capital femoral epiphysis or
Legg–Calvé–Perthes disease, an idiopathic avascular necrosis of the proximal
femoral epiphysis).
EVALUATION AND DECISION
Four points are critical in the patient’s history: (i) the activity and forces that led
to the injury (e.g., direction of the force, whether the foot was fixed); (ii) the
initial location of the pain; (iii) any sensations or noises (e.g., “locking,” “pops,”
or “tears”); and (iv) the timing of any swelling.
Most severe injuries (e.g., ACL, collateral ligament, or meniscal injuries) occur
with high-velocity weight-bearing activities, especially running and pivoting, or
direct valgus or varus stress. Direct trauma to the front of the knee may cause
posterior cruciate ligament injuries or patellar fractures, whereas lateral or medial
forces may cause collateral or cruciate ligament damage or fractures.
Although the knee may “hurt all over” when seen in the ED, the patient may be
able to localize the initial pain. Meniscal or collateral ligament injuries cause pain
on the lateral or medial aspect of the knee, whereas ACL injuries hurt just inferior
to the patella, and Osgood–Schlatter disease is painful over the tibial tubercle.
Distinct popping noises or tearing sensations are reported in ACL injuries and
patellar dislocation. Locking of the knee may be reported in meniscal injuries but
