Extern conference สุรพรชัย สาโยธา 27 มิ.ย. 61

1. AFTERNOON
PRESENTATION
Ext.สุรพรชัย สาโยธา PI 5622120

2. PATIENT IDENTIFICATION
v Case : ผู้ป่วยหญิงไทย อายุ 57ปี
v No knownunderlyingdisease
ØChief Complaint :
ถูกรถกระบะชน30 นาที PTA

3. PRIMARY SURVEY
A : can speak, can flex neck
B : lungclear bothlungs,equal bothlungs
C : BP 147/81Pulse72 cap refill < 2sec
D : E4M6V5,pupil3 mm. RTLBE
E : noactive external bleeding,left kneetender, limit ROM of left knee
dueto pain

4. SECONDARY SURVEY
A : No historyof foodor drugallergy
M : No current medication
P : No knownunderlyingdisease
L : Last meal 20.00น.
E : 30 นาที PTAขณะเดินอยู่ข้างถนนถูกรถกระบะชนทีBเข่าซ้าย หลังจากถูก
ชนมีอาการปวดทีBเข่าซ้ายมาก ไม่มีเข่าซ้ายผิดรูปแล้วกลับเข้าทีBเดิม เดิน
ไม่ได้ งอเข่าไม่ได้ ไม่มีชาขา ไม่มีอ่อนแรง

5. PHYSICAL EXAMINATION : HEAD TO TOE
Vital sign : BT= 36 , PR= 72 bpm , BP= 147/81 mmHg RR= 20
GA : A Thai female, good consciousness, well cooperative
HEENT : not pale conjunctivae , anicteric sclerae
Heart : normal S1, S2, no murmur
Lungs : normal breath sounds, equal both lungs
Abdomen :soft, no tender, normoactive bowel sound
Neurological : E4V5M6 , pupil 3 mm RTLBE

6. PHYSICAL EXAMINATION : HEAD TO TOE
Extriemities : Left knee à tender at posterolateral, no tender at medial & lateral
joint line, ballottement negative, valgus stress test positive, anterior drawer
positive, varus stress test negative, posterior drawer negative limit ROM due to pain
( can passive) DPA left 2+

7. PROBLEM LISTS
ü Left knee tenderness
ü Valgus stress test : positive
ü Anterior drawer : positive

8. Radiographic finding :
• Chest X-ray
• Pelvis AP
• Knee AP & Lateral & Skyline view
• Leg AP & Lateral

9. Chest X-ray

10. Pelvis AP

11. Knee AP

12. Knee Lateral

13. Knee Skyline

14. Leg AP

15. Leg Lateral

16. Radiographic finding :
• Not seen fracture

17. Management at ER MNRH
Ø Impression : MCL & ACL injury
• Tramol 50 mg IV stat
• On posterior long leg slab Lt.leg
• D/C นัด follow up 2 wks
v Home medication
– Paracetamol (500) 1 tab po prn q 6 hr. #20
– Tramol (50) 1 x 3 po pc #10

18. Topics
• Knee anatomy review
• Approach to traumatic knee pain
• Ligamentous Injuries of the Knee
• Knee Dislocation

19. Knee anatomy
The knee is the largest joint in the body, and one of the most
easily injured. It is made up of four main things:
1. Bones
2. Cartilage
3. Ligaments
4. Tendons

20. Bones
Three bones meet to form your knee joint: your thighbone
(femur), shinbone (tibia), and kneecap (patella).

21. Cartilage
Articular cartilage. The ends of the femur and tibia, and the
back of the patella are covered with articular cartilage. This
slippery substance helps your knee bones glide smoothly across
each other as you bend or straighten your leg.
Meniscus. Two wedge-shaped pieces
of meniscal cartilage act as
"shock absorbers" between your
femur and tibia. The meniscus is
tough and rubbery to help cushion
and stabilize the joint.

22. Ligaments
Bones are connected to other bones by ligaments. The four
main ligaments in your knee act like strong ropes to hold the
bones together and keep your knee stable.

23. Tendons
Muscles are connected to bones by tendons. The quadriceps
tendon connects the muscles in the front of your thigh to your
patella. Stretching from your patella to your shinbone is the
patellar tendon.

26. Ligamentous Injuries of the Knee
Four major ligaments about the knee: medial and lateral
collateral ligaments (MCL, LCL), anterior and posterior cruciate
ligaments (ACL, PCL)

30. vMCL provides restraint to valgus force at the knee and is the
most commonly injured knee ligament
vLCL provides restraint to varus force at the knee; injuries are
not common and usually are associated with injuries to
cruciate ligaments
vACL injuries are common and acutely present with large
hemarthrosis and pain; the Lachman test (anterior drawer at
20 degrees of flexion) is the most valid test for diagnosing ACL
tears
vPCL is the primary restraint to posterior translation of the
tibia on the femur and is approximately twice as strong as the
ACL; PCL injuries are not as common as those of the ACL

31. Isolated ligament examination
• ACL
– Lachman at 30 degrees
– Anterior Drawer Test
– Pivot Shift Test
• PCL
– Posterior drawer Test
• Lateral collateral ligament (LCL)
– Varus stress Test
• Medial collateral ligament (MCL)
– Valgus stress Test

36. Treatment
• Treat acute injuries with rest, ice, elevation, and
a knee immobilizer until consultation is arranged;
a careful, normal neurovascular exam rules out
the need for emergency/urgent consultation
• Refer all suspected injuries to ligaments about
the knee to an orthopaedic surgeon; treatment
varies, depending on which ligament(s) are
involved and on the needs of the patient

37. Knee Dislocation (Femorotibial)
• Traumatic knee dislocation is an uncommon injury that may
be limb-threatening; it should therefore be treated as an
orthopaedic emergency.
• A knee dislocation is a potentially limb-threatening condition.
Because of the high incidence of neurovascular compromise
• True incidence is probably underreported. From 20% to 50%
spontaneously reduced.
• A careful neurovascular examination is critical
– Vascular injury—popliteal artery disruption (20% to 60%)
– Neurologic injury—peroneal nerve (10% to 35%)

38. References