The patient was provided symptomatic relief with traditional rest/ice/NSAIDs/elevation and a 3-week outpatient follow up with orthopedic surgery was recommended. There was no indication for acute surgical intervention. Orthopedic surgery was consulted who recommended that the patient be placed in a hinged knee brace with no weight bearing for 12 weeks. X-ray performed in the ED was notable for moderate joint effusion but no visible fractures (image 1).
#Occult tibial plateau fracture full#
Full range of motion of right knee joint with noticeable varus laxity and a positive anterior drawer sign. Swelling and tenderness to palpation of the right knee with intact motor, sensation, and distal pulses. Additionally, the patient had a history of an unknown type of knee reconstruction on the affected knee one year prior.ĮtOH use disorder, hepatitis C, and tobacco use disorder She had been unable to follow up in a clinic due to insurance issues which led to her multiple presentations. She reports that she was diagnosed with a “broken bone” in her leg but was unsure of which one. The patient stated that she fell approximately 1 week prior to arrival and had been to several hospitals since the fall.
CaseĪ 55-year-old female presented to the emergency department due to right knee pain.
#Occult tibial plateau fracture how to#
So! Let’s show you how to put these ingredients together using your handy POCUS in the following case. Ultimately, visualization of fluid levels on sonographic imaging is a very specific and reliable indicator that there is likely an intraarticular fracture. Another point to add to ultrasound is that in some traumatic knee injuries, CT or MRI may not be the best initial option to diagnose intraarticular fractures. Yes, you may see a LH on x-ray as well as CT or MRI as the double fluid level/parfait sign, but we at USF Emergency Medicine are ultrasound geeks and thus the imaging modality discussed to diagnose this type of fracture today will be ultrasound. CT, MRI and US can also aid in the visualization of LH as either a double fluid-fluid level (fat and blood) or a three-layered effusion in the joint (fat, serum and red blood cells). However, seeing the parfait sign on x-ray has a relatively low sensitivity for detecting an intraarticular fracture.
Traditionally, the initial evaluation of a knee injury in the ED consists of a plain radiograph, which can visualize a fat-fluid level. This parfait gets created by the release of marrow fat into a joint secondary to an intraarticular fracture of a marrow containing bone.
Voila! The ingredients to a lipohemarthrosis (LH) parfait! They swell, bruise, and when there is an intraarticular fracture associated with it, blood and fat can introduce themselves into the joint. Knee injuries can have many characteristics to their presentation. This goes to show that ED physicians really “kneed” to have a good understanding of these types of injuries (see what we did there). Wesley Priddy, MD, USF MCOM - Emergency Medicine ResidencyĬharlotte Derr, MD, RDMS, FACEP University of South Florida - Emergency MedicineĪ little bit of a background on the subject before we dive into the recipe…Īn estimated 1 million patients with knee injuries present to the Emergency Department, which represents about 2.5% of the patients seen in ED’s. Amir Khiabani, MS4, Alabama College of Osteopathic Medicineĭevon Khiabani, MS4, Alabama College of Osteopathic Medicine
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