Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are an Emergency Department Doctor. Your next patient is a 28-year-old gentleman, Gerald Beckham, presenting with knee pain. Please take a history and perform an appropriate examination.
Patient History:
Your name is Gerald Beckham - a 28-year-old male- accountant.
You remember while playing football on a grass pitch about 2 hours ago when you were tackled by an aggressive player wearing cleats from your front. It was raining heavily, and you slipped following the tackle and heard a pop sound. Following this, you suddenly developed pain in your right knee, which is worsening. 9/10 pain score. No radiation. Pain is worsened by movement, and you try to take some simple pain killers i.e. paracetamol and ibuprofen, without much effects. Your knee has also been getting more swollen rapidly at the same time when the pain started, and you were unable to carry on with the match and therefore decided to go to the hospital.
You feel unsteady in the right knee. You do not have the confidence to walk without any support. You feel your right knee is weak and is giving way.
No locking. No fever. No weight loss. No previous night pains. No previous knee pain before the injury. No back pains. No other previous injuries. No neurological symptoms
Ideas, Concerns, Expectations:
You think you might have snapped a tendon or something, but you are not sure. You are concerned about how this will affect your future ability to play sports and walk. You hope to find out what is happening – maybe have a scan or something.
Past Medical History:
Nil significant
Drug History:
Nil NKDA
Family History:
Osteoarthritis
Social History:
You work as an accountant. You live by yourself. You smoke 5 cigarettes daily for 2 years but aim to stop smoking. You occasionally drink a few pints of beer over the weekend.
Examination Findings:
Right knee – swelling, tenderness on touch + worsened by movement.
Anterior drawer test (right) – positive (tibia moving excessively anterior with no clear endpoint while being pulled).
Lachman test (right)- positive (increased movement/laxity between tibia and femur).
Pivot shift test (right) – positive (internally rotate foot and tibia and apply abduction force at the knee + then flex the knee from 0° to 30° to detect any reduction between femur and tibia).
Antalgic Gait/ unsteady gait. Tenderness at lateral femoral condyle, lateral tibial plateau. (right)
McMurray Test negative (to check for a tear in the meniscus).
Differentials:
ACL Tear / Damage
Fracture
Patellar subluxation / dislocation
Meniscal Tear
Posterior capsular sprain
To rule out other ligament / articular chondral/ osteochondral injuries
Investigations:
MRI Scan (first-line imaging for evaluating internal derangement of the knee)
XR knee (can use Ottawa Knee Rules to decide if this is indicated: if patient unable to bear weight, flex knee to 90°, tenderness at the head of the fibula, isolated tenderness in patella, age 55 or over) – to look for impaction fracture of lateral femoral condyle + posterior aspect of lateral tibial plateau, anterior subluxation of tibia on femur, effusion, bony avulsion of ACL
Arthroscopy (to visualise ligaments – gold standard).
Consider knee joint aspiration for both diagnostic i.e. infection + therapeutic
Management: