of the patella. (2), the tibial plateau. (3) or the femoral condyle. (9). We found no age- ... producing a traumatic haemarthrosis of the knee is a twist of the flexed joint, ... less by what it can achieve than by the failure of other diagnostic measures ... had an ACL tear, but they did not perform routine arthroscopy and their main.
ACUTE
HAEMARTHROSIS
PROSPECTIVE
A
NICOLA
From
STUDY
MAFFULLI,
Newham
We made mature (16.8
with
presented
the knee
due to sporting
patellar articular
dislocations, ligamentous
same
106
JOHN
London,
with
B.
KING,
study
of 106 skeletally age of 28.35
an acute
haemarthrosis
We excluded
of
those
radiographic bone injuries, lesions or a previous injury
with extrato the
The anterior cruciate ligament (ACL) was intact in 35 patients, partially disrupted in 28 and completely ruptured in 43. In the patients with an ACL lesion, associated injuries
patella
tears minimal
(2), the tibial
We
found
injuries.
no of
disruption
injuries
included
patella,
and
posterior
had cartilaginous
loose
cartilaginous fractures
(3) or the femoral trend
the
ofthe
plateau
age-related
Isolated
fracture
(17 patients), osteochondral
in the
partial
one
bodies,
ligament. and
loose of the
condyle
(9).
of
ACL
pattern
one small
cruciate
osteochondral and
one
Three
total
patients
nation. hours is
All cases of injury
confirmed,
with should
a tense have
urgent
developing
an aspiration.
admission
and
within
12
If haemarthrosis arthroscopy
Joint Surg [Br]
Received
5 February
1993 ; 75-B
1993
are
:945-9.
; Accepted
22 April
Patients
may
producing
a traumatic
of the flexed joint, of the position or
at the time
be unable
sport (King and Aitken describe merely a popping
of injury
to continue
(Noyes
playing
et their
1988), but about two-thirds sensation and swelling of the
joint
within two hours (Noyes et al 1980, 1983). Such a story alone may indicate the diagnosis (Feagin, Abbott and Rokous 1972), and early clinical examination is unreliable (Noyes et al 1980; Rand 1984; Simonsen et al 1984). A tense effusion with muscle guarding severely limits the range ofmotion, and stability is therefore
difficult
reasons
(ACL)
only
tears
to evaluate
(DeHaven
9% to 29% ofanterior
which diagnosed
are found
(DeHaven
For
1980).
cruciate
arthroscopically
clinically
Arthroscopy provides reliable indicated less by what it can achieve of other diagnostic measures (Glinz, 1980). Previous reports on traumatic North
America
continental
indicated. J Bone
of movement
the direction al 1980).
mechanism
of the knee is a twist patients are uncertain
ligament have
1980
been
; Noyes
et al 1980).
indicates a serious and arthroscopy is and clinical exami-
effusion
GOOD
common
most
previously
no injury was detected
haemarthrosis proved otherwise, careful history
ATHLETES
J.
haemarthrosis although many
these
in five. Acute traumatic ligament injury until needed to complement
IN
CHRISTOPHER
The
years
joint.
included meniscal bodies (6), and
KNEE
England
an average
activities.
THE
CASES
BINFIELD,
arthroscopic
sportsmen
to 44) who
M.
Hospital,
a prospective male
OF
PETER
General
OF
Oretorp Murdoch
1977). (1983),
athletic
population,
tear, their
1993
(DeHaven
Europe
1980;
are available From the reporting found
information and is than by the failure Segantini and K#{228}gi haemarthrosis from Noyes
et al 1980)
(Gillquist,
Hagberg
UK, Jam, on a mixed that
only
Swanson sedentary
17%
had
and and and and
an
ACL
but they did not perform routine arthroscopy and main line oftreatment was aspiration and splintage,
which
is no longer
an accepted
practice
(Mariani,
Puddu
and
Ferretti 1982). Our aim was to make a longitudinal study of athletes with acute haemarthrosis, using arthroscopy and examination under anaesthesia (EUA). Our hypothesis was that an acute traumatic haemarthrosis in an athlete implies significant intra-articular injury which should be N. Maffulli, MD, PhD, Senior Registrar and Clinical Lecturer in Orthopaedics P. M. Binfield, FRCS, Career Registrar in Orthopaedics J. B. King, FRCS, Senior Lecturer and Consultant in Orthopaedics C. J. Good, FRCS, Consultant in Orthopaedics Department of Orthopaedics, Newham General Hospital, Glen Road, Plaistow, London E13 85L, UK. Correspondence should be sent to Dr Orthopaedic Surgery, UniversityofAberdeen Building, Foresterhill, Aberdeen AB9 ©l993 British Editorial Society 0301 -620X/93/6656 $2.00
VOL.
75-B,
No. 6, NOVEMBER
ofBone
1993
N. Maffulli at the Department of MedicalSchool, Polwarth 2ZD, UK. and
Joint
Surgery
accurately
diagnosed.
PATIENTS
AND
METHODS
From January 1986 to April 1992, 106 male, skeletally mature athletes with acute haemarthrosis sustained during a sporting activity were admitted to Newham General Hospital, London. Patients with a history of a previous injury to the same those with obvious patellar
joint were dislocation,
excluded, as were a radiologically
945
946
N. MAFFULLI,
evident
bone
lesion. 8.13
injury,
The (16.8
ofthe
or
average
age
Fig.
to 44,
an
P. M. BINFIELD,
extra-articular
of the
I). The
ligamentous
patients
right
knee
was was
28.35
C. J. GOOD
diagnosis
±
injured
J. B. KING,
SD
in 81
106 patients.
of a meniscal
patients
were
surgeon without The other without
clinic
injury
referred
an initial 1 3 patients joint
was
made.
immediately aspiration. were
aspiration
The orthopaedic examination, and
management aspiration
performed. Patients view to arthroscopy
were within
orthopaedic
referred and
to
a trauma
without
included if this had then the
Twenty-two
to an
diagnosis.
a full clinical already been
not
offered admission next 24 hours.
with
a
Examination under anaesthesia. No patient showed isolated medial or isolated lateral laxity on examination with or without anaesthesia. The Lachman test (Torg, Conrad
and
Kalen
1976)
and
the pivot
shift
test
Beaupr#{233}and MacIntosh 1972) were performed general anaesthesia before a tourniquet was
(Galway,
under applied.
full
Arthroscopy. All EUAs and arthroscopies were performed or supervised by one of the senior authors (JBK and CJG). At arthroscopy under tourniquet, anteromedial, anterolateral, posteromedial entry portals were used as required
..
Age at presentation Fig. Age
distribution
The (33),
of 106 athletes
sports
rugby
played
(15),
1 with
at the
hockey
(years)
(14),
haemarthrosis
time
ofthe
of injury
were
American
or horizontal used in five
knee.
(12),
track-and-field nastics (7), recreational
athletics (12), combat sports (10), gymand cricket (6). Sports were played at level (47), county level (12), national level (28), and international level ( 19). This distribution reflects the association oftwo ofthe authors (NM and JBK) with a National organisations.
Sports
Centre
and
various
national
Mechanism of injury. In 73 patients the injury caused by a non-contact event which involved
sports had been twisting,
turning or jumping off the planted foot. In 18 patients there had been a direct blow on the upper third of the lower leg, with the knee slightly flexed. The other 15 athletes were unable at the time of injury. Symptoms. injury was
The most common sudden pain with
collapse
of the
and was Sixty-four
followed patients
activity hours
to describe
leg.
This
was
the position symptom a popping described
by a fall to the ground were able to resume
oftheir
knee
at the time of sensation and by
and
within
1 2 hours
in all of them.
When first seen, additional complaints included way (24), an insecure feeling (2 1 ) and true locking knee, defined as inability to extend it fully (16). Before arthroscopy. The patients were first seen
giving of the in the
Accident and Emergency Department at an average 3.2 ± 1 .6 days (0 to 4) from the injury. Anteroposterior and lateral radiographs were taken in all cases. All an effusion, confirmed
and the
in 71 aspiration by a casualty presence of a haemarthrosis. In
had gravity irrigation was used to wash out
others saline
The Ethilon remainder.
wounds
posterolateral vertical (83)
Tourniquets were not trait, as determined
without the joint.
were
closed
with
suture in 34 A modified
patients Robert
and Jones
in some ethnic with normal were used ; the a drain.
Normal
a single
Dexon
unsutured compression
or
in the band-
age was applied before removing the tourniquet, and patients were discharged on the same day when they were able to perform an unaided straight-leg raise. When a drain had been left in place, it was removed in the daycare
unit
discharge.
before
two and at six weeks, ACL tears. A blunt
Outpatient
or for any hook-shaped
reviews
clinical
problem. probe was
examine the ACL through an appropriate Any synovial tissue which obscured the was lifted or partially removed (Noyes Tension in the with the hook.
fibres ACL
of the ACL tears were
were
at
used
to
entry portal. cruciate fibres et al 1980).
was judged by pulling classified as partial or
complete
72 patients,
in 26 of them. the sporting
immediately after injury, but had to stop later. Swelling and joint effusion were evident within two in 83 patients,
stab wounds. with sickle-cell
by family history and Hb electrophoresis groups. In 81 patients gravity irrigation saline and a medial suprapatellar drain
soccer
football
5 mm patients
and through
of had
officer 28 the
on the basis of visual inspection and probing. Meniscal tears have been classified by appearance as horizontal, longitudinal, vertical, etc (Barber 1992), by the thickness of the tear (full or partial Meniscal
injuries.
split)
and
by location
etc:
Irvine
and
in the meniscus
Glasgow
1992).
We
(peripheral,
central,
classified
meniscal
tears according to the involved side and the shape and the location within the meniscus. All data were collected prospectively on a proforma (Fig. 2). This was completed in triplicate by the operating surgeon at the time of the procedure, for the patient’s general practitioner, notes,
and one for this study. The data were entered into
IBM-compatible
computer THE
JOURNAL
and
providing one copy one for the operating a dBIII
data
were
OF BONE
base
analysed AND
JOINT
on an using
SURGERY
ACUTE
HAEMARTHROSIS
KNEE Dear
Dr.
[G
I enclose
OF
THE
KNEE
ARTHROSCOPY
IN
ATHLETES
947
PINK YELLOW
1
P
a copy
of your
patient’s
arthroscopy
-
WHITE
RECORD
record.
Yours
Records J.B.K G.P.
sincerely.
Name
No
Date
Phone
Address: Surgeon
Age
COMPLAINTS:
I
I
Trauma
Side
Overuse
Hospital
Spontaneous
I
SPORT
Recreatjon
PAIN ANT POST MED LAT PARAPAT
GIVING SPONTANEOUS TWISTING STAIRS RUNNING
FLEX FIXED
I HIGH
CLASS
AFTER
RECREATION DIFFICULT IMPOSSIBLE
AT REST ATNIGHT
EXAMINATION FLUID VALGUSO VARUSO VALGUS 30 VARUS 30 LACHMAN PIVOT OTHER REC/EXTROT
CONTACT IMMEDIATESWELLING
DISABILITY
EPISODE
OK
0-3 FLUID VALGUSO VARUSO VALGUS 30 VARUS 30 LACHMAN PIVOT LATTHRUST TENDERI BAYONET REC/EXTROT
I
I DRAIN
V/N
FLUID
(RECOGNISES ANT
v/
DRAW NEUTRAL ER IR POST DRAW POST LAT DRAW REVERSE PIVOT LOCKED
OK
KNOCKKNEE BOWLEG STRAIGHT
CYST-MEN SM BAKER
CLEAR,
-
SEROUS,
MED RECESS ACL PCL PLICA FATPAD
SYNOVIUM
_
-
_
-
_
-
BLOOD
_
LAT FEMUR MED
_
-
GRADE
OK
DRAW
ON CHART
0-3
LAT LOOSE OCD
-
FULL
BODY
NO WHERE
DESCRIBE
Fig. The
VOL.
75-B, No. 6, NOVEMBER
1993
WHERE
0 P D DATE LINES
proforma
used
to record
2 details
ofeach
patient.
NOTSEEN I NORMAL HIGH I LOW
(
PORTALS
_
TIBIAMED
)
FXAMINFP
PATELLAMED LAT FACET
o
PAIN FROGEVE APPREHENSION CLARKE
LAT RECESS
ON CHART
IMPOSSIBLE
X. NOTOK HYPER EXIT( PATELLATRACK
cPP
DRAW
DISARIUTY
DIFF
LM
#{149}
SWELLING
EXAMINATION
ASLEEP
NOT
PROCEDURE
SWELLING DISABILITY
-. SWELLING -.-.DISABILITY
DELAYED
DRAW NEUTRAL ER IR POST DRAW POST LAT DRAW REVERSE PIVOT LOCKED PATELLADISLOC
SCOPE
NON
WORK(
ANT
,scoPY
-
SWELLING ALWAYS INTERMITTENT-
SPORTSNOW
SITTING SQUATTING TWISTING
IMMEDIATE DELAYED
M L
STAIRS
ACCIDENT CONTACT
LOCKING CANNOTEXT
-
DOTTED
LINES
948
Systat
(Leland
for trend
1988)
tests.
N. MAFFULLI,
P. M.
tests
chi-square
for chi-squared
Significance
was
and
set at the 0.05
BINFIELD,
J. B. KING,
C. J. GOOD
Table thesia ACL
level.
I. Results of examination under of 7 1 sportsmen with haemarthrosis injury Partial (n=28)
RESULTS Examination disruption
under anaesthesia. of the ACL, both
In knees Lachman
tests were reliable (Table I). In those rupture of the ACL, the pivot shift test
with only partial was more reliable
than
were
no
was
intact
the
Lachman
test.
There
-ye
Pivot shift +ve
tear
21 7
34 9
9
43
test
-ye
false-positive
Complete (n=43)
test
Lachman +ve
with complete and pivot shift
tear
anaesand
19
results. ACL
(Table
lesions
II).
The
ACL
partially ruptured in 28 and completely In 29 patients, the partial or complete
Table II. ACL lesions and associated 106 sportsmen with haemarthrosis
in 35 knees,
disrupted disruption
in 43. of the
ACL was an isolated injury. In the other 42 patients an ACL injury, associated injuries included meniscal
Lesion/injury
with tear
Intact
in
the
pattern
of
square
ACL-associated
of a partial
for trend
injuries,
or complete
or
ACL
in
lesion
total
or
ACL
(DeHaven
disruption.
The
lateral
1980).
These
were
repaired
mies.
Haemarthrosis with no ACL lesion. No intra-articular injury could be detected in five patients, and it was assumed that the haemarthrosis was due to synovial tears. Apart from the six isolated peripheral meniscal tears, other isolated injuries which appeared to have haemarthrosis of the patella,
were and
disruption of the posterior ginous loose bodies were removed
one small one partial
osteochondral and one total
cruciate ligament. Cartilafound in three patients and
arthroscopically.
The average age (28.35 ± 8. 13)in ourseries with that of other studies, but our upper than
that
in most
other
Gillquist et al 1977; Lysholm, 1981 ; Jam et al 1983; Harilainen incidence
of knee
injury
during
reports
is comparable age (44 years) (O’Connor
Gillquist and et al 1988). sporting
activities
of ACL
of ACL disruption
43 17
of ACL
is
1974; Liljedahl The high is well
I7
6
bodies
loose
Osteochondral fractures Patella Tibial plateau Femoral condyle
2 3 9
Partial
I
disruption
Complete
of PCLt
disruption
S
anterior
t
posterior
cruciate
I
of PCL ligament
cruciate
ligament
documented (Gillquist et al 1977; Lysholm et al 1981) but in some reports of ACL injury only 20% were caused by sporting activities and 60% by simple falls (Jam et al 1983). Road-traffic accidents are a less common cause of knee
injuries
(Lysholm
et al 1981).
all our patients, within 12 hours of an differentiate these by
the haemarthrosis injury. It is usually the history from
developed possible to minor, non-
haemorrhagic injury.
that
or later
In
with activity
DISCUSSION
lower
disruption complete
Cartilaginous
partial
of ACL disruption
tears
Meniscal
test).
Three patients required arthrotomy after arthroscopy, two for subtotal lateral meniscectomy, and one for partial medial meniscectomy. The other eight patients with meniscal tears had arthroscopic partial meniscecto-
caused fracture
35 28 12
the (chi-
meniscus was injured significantly more often (p = 0.042, chi-squared test). There were nine bucket-handle tears (six lateral); all the others were posterior-horn tears. In six cases, an isolated peripheral tear was the cause of the haemarthrosis arthroscopically.
ACL
Complete Isolated
Meniscal lesions. Of the 16 patients with a clinically locked knee, I 2 had a meniscal tear and four had an isolated ACL rupture. All 1 7 meniscal injuries ( 1 1 lateral, 5 medial, one of both menisci) were associated with either
in
Number
Partial disruption Isolated partial
(1 7), cartilaginous loose bodies (6), or minimal osteochondral fracture of the patella (2), the tibial plateau (3), or the femoral condyles (9). We found no age-related trend development
injuries
effusions
occur
A significant proportion ACL disruption were immediately
after
of our patients, able to resume their
had little or no initial pain. injury may not be apparent, of non-contact
twisting
24 hours
injury:
after
64 of 106, sporting
some
The serious nature and this is particularly
patients of the true
injuries.
Examination of an acutely swollen knee is difficult and unrewarding, but the easiest and most reliable test is said to be that of Lachman (Torg et al 1976). The result of this test may be subjective in that it relates to the hardness of the stop (King and Aitken 1988). Our results show that a positive Lachman test with a negative pivot shift tests
test are indicative of partial ACL rupture. The two do not give significantly different results in complete
ACL
tears,
more
sensitive.
but we found
the pivot
THE JOURNAL
shift
OF BONE
test to be slightly
AND
JOINT
SURGERY
ACUTE
Acute urgent complete
traumatic
haemarthrosis
arthroscopy and precise
HAEMARTHROSIS
OF
is an indication
with the diagnosis
aim of (O’Connor
for
establishing a 1974; Noyes
et al 1980; Rand 1984; Harilainen et al 1988). Delay in arthroscopy may allow synovial hypertrophy, which makes it difficult to visualise the ACL. Avulsion of the ACL from its femoral attachment is visible for up to two weeks, but by then mid-ligament tears are difficult to see because 1980).
synovium conceals Urgent arthroscopy
arthrosis repair
is therefore justified. is not needed, full
planning
management
rupture instability,
of
the and
the for
torn acute
of our
(King
and
ACL may lead therefore these
series,
agreeing
et al haem-
Even if immediate surgical assessment is important in Aitken
1988).
Partial
to a total rupture and patients require careful
follow-up (King 1991). We found partial or complete 70%
ends (Noyes traumatic
rupture
with
other
of the ACL
studies
in
of athletes
(DeHaven 1980; Noyes et al 1980, 1989; King 1991). Series of mixed origin show a lower incidence (Lysholm
THE
KNEE
IN
et al 1981
;
other
tear
et al 1988).
(28 of 7 1 , 39%)
series, 28% et al 1980)
(Noyes
949
Harilainen
ACL
partial
ATHLETES
The
proportion
is also
similar
Wetterfors as medial
1965). meniscal
of our patients) has also been reported Dandy 1976; Farquharson-Roberts and We conclude that acute traumatic be regarded
as due
until ment
proved otherwise. a careful history
with
a tense
effusion
acute injury haemarthrosis
should the
with
to admission
a view
a of
of 84 patients with haemarthrosis and 34% in a series of ACL ruptures
(Liljedahl, Lindvall and tion of ACL disruptions
should
with to that
The presentainjuries (four (Jackson and Osborne 1983). haemarthrosis
to a serious
ligament
Arthroscopy and clinical
is needed examination.
of the
within
knee
have an aspiration. patient should be and
injury
to complePatients
1 2 hours
of an
If this confirms a referred urgently
arthroscopy.
We thank Mr 0. A. Jamall, FRCS Ed, Mr J. K. Klosok, FRCS G, and Mr B. Levack, FRCS, for allowing us to study patients under their care. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
REFERENCES
Barber
FA.
What
is the
terrible
triad?
DeHaven KE. Diagnosis of acute JSports Med 1980: 8:9-14. Farquharson-Roberts cruciate ligament B :32-4. Feagm
JA, cruciate
Arthroscop;-
knee
MA, Osborne of the knee.
with
Leland
8:19-22.
hemarthrosis.
AH. Partial rupture J Bone Joint Surg
Am
of the anterior [Br] 1983, 65-
Abbott HG, Rokous JR. The isolated tear of the anterior ligament. J Bone Joint Surg [Am] 1972 ; 54-A :1340-1.
Galway RD, Beaupr#{233} A, MacIntosh symptomatic anterior cruciate Surg[Br] 1972: 54-B :763-4. Gillquist J, Hagberg kneejoint. Acta Glinz
1992:
injuries
W, Segantini joint. Endoscopy
DL. Pivot shift : a clinical sign of ligament insufficiency. J Bone Joint
G, Oretorp N. Arthroscopy in acute Orthop Scand 1977; 48:190-6. P, K#{228}gi P. Arthroscopy 1980: 12:269-74.
Harilainen A, Myllynen P, Antila arthroscopy and examination of fresh injury haemarthrosis
in acute
trauma
of the
Lysholm J, ofinjuries Mariani and
MMS.
insufficiency 74-B :403-5.
history
of the analysis.
: arthroscopic
Jackson
RW, Dandy DJ. and Stratton, 1976.
Arthroscopvofthe
knee.
Jam
AS, Swanson Injury 1983;
AJG, Murdoch 15:178-81.
King
J. Indications IntJOrthop
for surgery in the anterior Trauma 1991 ; I :138-40.
King
JB, Aitken SportsMed
M. Treatment 1988: 5:203-8.
New
York,
meniscus J Bone
VOL.
75-B, No. 6, NOVEMBER
of the
1993
Hemarthrosis
torn
cruciate anterior
of the
knee
deficient cruciate
ligament.
statistics.
Evanston,
J. Early cruciate cases.
IL : Systat
diagnosis ligament
Inc.
and treatment : a clinical and
J Bone Joint
Surg
[Am]
Arthroscopy in the early diagnosis Orthop Scand 1981 : 52:1 1 1-8.
Acta
PP, Puddu P, Ferretti A. Hemarthrosis casting: how to condemn the knee.
treated Am
J Sports
by aspiration Med 1982;
tears
and
other
Mooar PA, Grood ES. The symptomatic knee. Part II. The results of rehabilitaand counselling in functional disability. 1 983 : 65-A : 163-74.
Grood ES, Butler DL. Arthroscopy in acute of the knee : incidence of anterior cruciate injuries. J Bone Joint Surg [Am] 1980; 62-A:
687-95. FR, Mooar LA, Moorman CT III, McGinniss GH. Partial tears ofthe anterior cruciate ligament : progression to complete ligament deficiency. J Bone Joint Surg [Br] I 989 ; 71 -B :825-33.
O’Connor RL. Arthroscopy ligament injuries of the A :333-7.
joint. knee.
kneejoint.
FR, Bassett RW, traumatic hemarthrosis
Rand G.
for
J, Liljedahl SO.
to the
Noyes
in Joint
etc : Grune
Gillquist
FR, Matthews DS, anterior cruciate-deficient tion, activity modification J Bone Joint Surg [Am]
H, Seitsalo S. The significance of under anaesthesia in the diagnosis of the knee joint. Injury 1988: 19:
The natural
system
I0:343-5.
Noyes
GB, Glasgow anterior cruciate Surg[Br] 1992;
: the
Noyes
knee
2 1-4. Irvine
Svstat
Liljedahl S-O, Lindvall N, Wetterfors of acute ruptures of the anterior arthrographic study of forty-eight 1965; 47-A:l503-13.
of the
injuries
W. 1988.
JA. in the
The role athlete.
of arthroscopy Mayo C/in Proc
Simonsen 0, Jensen J, clinical examination 96-101. Torg
in the diagnosis and treatment knee. J Bone Joint Surg [Am]
JS, Conrad W, ligament instability
Mouritsen of injury
in the management 1984; 59 :77-82. P, Lauritzen of the knee
Kalen V. Clinical in the athlete.
of knee
J. joint.
diagnosis Am J Sports
of acute 1974; 56injuries
The accuracy Injury 1984;
of anterior cruciate Med 1976 ; 4:84-93.
of 16:
