A 19-year-old male university level collegiate player sustained an acute injury to his left knee after a collision with an opponent. The injury involved a direct blow to the lateral aspect of the knee. The player had immediate pain but was able to weight-bear and attempted to continue playing for a short time. Eventually he had to leave the field due to pain and the knee swelled within a few minutes. There was no history of prior knee injuries. A clinical examination conducted on the sidelines demonstrated a moderate effusion, tenderness along the lateral aspect of the knee and no ligamentous laxity.
X-rays of the left knee including AP, lateral, notch and skyline views, were obtained in clinic the following day. These showed a subtle cortical irregularity at the lateral aspect of the posterior and lateral tibial plateau. Further imaging with MRI demonstrated a non-displaced fracture involving the lateral tibial plateau with intra-articular extension (illustrated by the arrows) and pronounced increased signal associated associated with this (illustrated by the star).
The day following the injury the player had a tense effusion. The knee was aspirated to provide pain relief (with 130 ml of blood being removed). After the diagnosis was made, the player was treated conservatively with non-weightbearing for 3 weeks followed by progressive weight-bearing and rehabilitation. He was able to return to play two months following the injury.
The differential diagnosis for a traumatic haemarthrosis of the knee includes injuries to the anterior cruciate ligament (ACL), patella instability, fracture or osteochondral injury, and occasionally a peripheral meniscus tear. This case illustrates the need to carefully evaluate a player who presents with rapid knee swelling as this history suggests a significant knee injury. A careful clinical assessment is always needed. X-rays are frequently normal and should not falsely reassure the medical team. In most cases MRI is indicated for further investigation.
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