Post traumatic pain in knee
Short summary
A 37 years old female suffered from multiple traumas caused by road accident with admittance to emergency room- multiple contusions, cervicalgia(due to whiplash) and contusion-laceration injury to left knee. An MRI scan of the knee was performed two months later (MRI findings are attached below) and the patient was examined by a specialist who gave a diagnosis of medial meniscal tear and femur-kneecap pain in the left knee. A broken medial meniscus of the left knee diagnosis should lead to an arthroscopic operation. The patient’s physical therapist, however, does not share this approach, as he does not believe there is a lesion. Another MRI scan to check the left knee to assess the medial meniscus was therefore recommended. Images of a recent MRI are attached.
Patient's questions
1. In assessing the findings and enclosed images, do you agree that the meniscus is broken?
2. Do you think the surgical operation is necessary? In the event of an affirmative answer, what are the contraindications?
Medical Background
A 37 years old female.
The patient suffered from multiple traumas caused by road accident with admittance to emergency room. Findings during the examination: “cranial contusion with cervical pain, bruise on the right shoulder, trauma in both knees with contusion laceration injury to the left knee, nothing pathological on the abdominal level. The patient complains of pain at the lumbar level; trauma also to the 1st finger of the left hand.”
The patient discharged herself on the same day against the advice of the medical staff, which wanted to keep her under observation. Discharge diagnosis: “Multiple contusions. Cervicalgia due to whiplash. Contusion-laceration injury to left knee”.
An MRI scan of the knee was performed two months later. Its findings:
“Right knee MRI scan:Minimum joint effusion. The shape of the meniscuses is within normal limits. Slight degenerative alterations are seen in the posterior horn of the medial meniscus. Kneecap somewhat high, and appears to be slightly tilted. The cartilage of the kneecap crest has a dishomogeneous signal strength, compatible with modest chondromalacia. Edema in the medullary bone is not evident. Lateral meniscus, collateral ligaments, cruciate ligaments and patella tendon are within normal limits.
Left knee MRI scan: Minimum joint effusion. Kneecap somewhat high, and appears to be tilted. Edema in the midullary bone of the internal facet of the kneecap, attributable to bone contusion. Attendant signs of results of traumatic lesion of the internal alar ligament, which is thick and has altered signal strength.
Edema of the subcutaneous prepatellar bursa.The shape of the meniscuses is within normal limits. Slight degenerative alterations in the posterior horn of the medial meniscus. Lateral meniscus, collateral ligaments, cruciate ligaments and patella tendon are within normal limits. Small Baker’s cyst in the popliteal fossa”.
The patient was examined by several specialists and the last one, gave a diagnosis of "medial meniscal tear and femur-kneecap pain in the left knee following a road accident". Another MRI scan to check the left knee to assess the medial meniscus was therefore recommended. Images of a recent MRI are attached.
A broken medial meniscus of the left knee diagnosis should lead to an arthroscopic operation. The patient’s physical therapist ,however, does not share this approach, as he does not believe there is a lesion. He instead thinks there is just the simple need to strengthen the locoregional muscles to re-establish sufficient stability of the knee.
Medical opinion
I have been asked to look on MRI study and to give my opinion if there is a meniscus injury in the left knee, and according to that, is arthroscopic operation is indicated.
Although MRI is a very important tool for knee injury assessment, the indication for arthroscopic surgery should not base on MRI findings alone. It is very important to know if there are complains that suggest meniscial injury as locking events for example. It is also essential to make precise physical examination to asses this specific question.
If complains and physical findings are compatible with meniscus injury, then arthroscopy is indicated even without MRI. On the other hand, in case of positive MRI for meniscial tear but with no clinical correlation, then arthroscopy is not recommended. In the reportt those clinical details are missing.
I looked at MRI study and I'm not sure that this is the recent study that was mention on the report, but I could not recognize a meniscial tear in this study. Based on this examination alone I wouldn't recommend arthroscopy.
Nevertheless, as mentioned above, if the clinical picture (complains and physical findings) suggest meniscial tear, arthroscopy is strongly recommended. Practically, there is no specific contra-indication for this procedure.
