LCL INJURY WITH A BICEPS FEMORIS RUPTURE?

Abstract

HISTORY: A 20 year old female college freshman soccer forward sustained a right knee injury after a one-on-one breakaway. She was dribbling into the penalty box to shoot with her left foot when the keeper slid out onto her planted right leg hyperextending her knee. She felt a stretching and a “snap”. She was examined on the field by the trainer, ice was applied, and she was then sent to the emergency department. In the emergency department, she complained of numbness and tingling in her leg, foot, and toes. X-rays were completed and were negative, she was placed in a knee immobilizer and she was instructed to follow up Sunday morning in the Sports Medicine Injury Clinic for further evaluation at which point I became involved in the case. PHYSICAL EXAMINATION: Inspection at the Injury Clinic revealed varus malalignment of the bilateral lower extremities. 1+ effusion of the left knee with general swelling in the posterior aspect of the knee and at the proximal head of the fibula. Ecchymosis was noted along the posterior lateral aspect of the knee. There was tenderness along the lateral joint line, over the head of the fibula, and posteriorly. Her ROM was diminished to 75 degrees of flexion due to swelling and tenderness. She had a positive anterior drawer, negative posterior drawer, and a 2+ Lachmans without a discernible endpoint. Varus stressing revealed 30 degrees of opening with no end point. Valgus stress of the knee was intact. McMurray's and Apley's testing were not performed due to patients discomfort. She had 2+ dorsalis pedis and posterior tibialis pulses with decreased sensation along the anterior tibia and dorsum of the foot(photos will be presented). DIFFERENTIAL DIAGNOSIS: Traumatic rupture of the ACL and LCL with a lateral meniscal tear Occult Fibular head fracture and superficial peroneal nerve injury TESTS AND RESULTS: Right Knee Complete Series Radiographs: Negative with no evidence of fracture. Right Knee Magnetic Resonance Imaging: Grade III LCL tear, Grade I MCL sprain, severe interstitial or complete disruption of the ACL, partial tear of the PCL, no medial or lateral tear of the meniscus identified, bone contusion of the medial femoral condyle, and possible biceps femoris tendon disruption (photos will be presented). FINAL WORKING DIAGNOSIS: Rupture of the ACL and LCL with biceps femoris tendon rupture Partial PCL tear with a MCL grade I sprain Superficial peroneal nerve injury. TREATMENT AND OUTCOMES: Passive ROM with a hinge brace and non-weight bearing prior to surgery Surgical repair of the lateral complex with a arthroscopic repair of the ACL and surgical release of the impinged peroneal nerve (intraoperative photos will be presented).