COMBINED LIGAMENTOUS KNEE INJURY IN A SKIIER

Abstract

HISTORY: R.Z. is a 36-year-old white female executive who injured her right knee while skiing. She heard and felt a “pop” and was unable to continue. She was brought down the mountain by the ski patrol and evaluated at the mountain clinic. She then presented to an orthopaedist near her home and a subsequent work-up included an MRI. She was then referred for treatment about one month after the injury complaining of giving way, swelling, dysfunction, and discomfort. The PAST MEDICAL HISTORY was notable for an injury to the same knee in college athletics several years ago. The patient remembers a “pop” and swelling following that injury and felt that her knee was never quite the same although she remained active with recreational sports. The remainder of the past history and review of systems were unremarkable. PHYSICAL EXAMINATION: Findings were limited to the right knee. There was normal alignment, no ecchymosis, and a mild effusion. The patient ambulated with an antalgic gait and a lateral thrust. Hyperextension was noted in both knees with flexion to 138 degrees bilaterally. The Lachman exan was positive as was the anterior drawer sign (2+) and pivot-shift (2+). The posterior drawer sign was negative. The posterolateral drawer and dial test were both positive. Collateral ligament testing demonstrated lateral opening at 30 degrees and at 0 degrees. The McMurray exam was negative. The lateral joint line was tender, medial joint line and patella non-tender. The skin and distal neurovascular exam was intact. DIFFERENTIAL DIAGNOSIS: Acute anterior cruciate ligament tear. Acute lateral collateral ligament tear. Torn lateral meniscus. Torn posterolateral corner. Chronic anterior cruciate ligament tear. Combined ligamentous disruptions. TESTS AND RESULTS: X-ray included an AP, lateral, and Merchant's view. These demonstrated an effusion but not acute boney changes. The MRI demonstrated a torn ACL with bone bruising of the posterior tibial plateau, a partial tear of the lateral collateral ligamentous complex, intrameniscal changes and a large joint effusion. WORKING/FINAL DIAGNOSIS: Chronic tear of the ACL with a recent tear of the posterolateral corner. TREATMENT: Anterior cruciate reconstruction. Due to delayed presentation a posterolateral reconstruction was also performed as a delyed primary repair of the posterolateral structures was deemed not possible at the time of surgery.