Left Knee, Leg Pain After A Hand Cycling Accident

Abstract

HISTORY: A 56 year old female with past medical history of Ehlers-Danlos Syndrome and stroke with residual left hemiparesis sustained a left knee and leg injury while hand cycling. Patient was on a ride when she collided with another cyclist, causing her to fall onto her left leg and thigh. She reported immediate pain, swelling and bruising of her left knee and leg. She presented to her primary care physician a few days later due to persistent pain. X-rays were negative for fracture. Patient had no new numbness or tingling. Her strength in her left lower extremity is minimal due to her stroke but she had noticed more difficulty with transfers due to pain PHYSICAL EXAMINATION: There was a large area of swelling on the lateral aspect of the distal left thigh that was firm and tender to palpation. Left knee showed no obvious deformity. There was diffuse tenderness to palpation over the medial and lateral knee and proximal tibia. There was no erythema or effusion. She had full knee range of motion in flexion/extension without pain. There was no ligamentous laxity in varus/valgus testing. Anterior and posterior drawer, Lachman’s/McMurry’s tests were negative. Strength was 1/5 in hip flexion, 0/5 in knee flexion/extension which, per patient report, was baseline. Sensation was intact to light touch. DIFFERENTIAL DIAGNOSIS: Femoral/tibial fracture, bone contusion, medial/lateral collateral ligament sprain, meniscus injury TEST AND RESULTS: MRI KNEE LT WO CONTRAST There is a T2 hyperintense 1.8 x 8.1 cm (transverse by AP) fluid collection layering over the iliotibial band and superficial fascial biceps femoris, with free floating internal fat lobules. Favored to represent a Morel-Lavallee lesion. The menisci, cruciate and medial collateral ligaments, lateral collateral ligamentous complex and extensor mechanism are intact. FINAL WORKING DIAGNOSIS: Morel-Lavallee lesion of left thigh TREATMENT AND OUTCOMES: Patient referred to plastic surgery who recommended percutaneous drainage. She underwent ultrasound guided drainage of 25 ml of serosanguinous fluid. At follow up no further fluid collection seen on ultrasound. Pain was resolving. Patient advised to wear compression garment to assist with healing. Cleared to return to activity as tolerated. Patient seen one year later with resolved symptoms and physical exam findings.