1. TIBIAL PLATEAU FRACTURE WITH A MCL TEAR AND HAMSTRING AVULSION IN A MALE COLLEGE FOOTBALL PLAYER
Edwards, RL, Pearson, LA, Hardeman, GJ & Scifers, JR
Western Carolina University, Cullowhee, NC
Objective: The objective of this case is to educate athletic trainers regarding multiple knee structure involvement following a traumatic knee injury.
Subjective History
The patient is a 23 year-old football tailback with complaints of left knee pain secondary to being hit in the left lower leg by an opposing lineman during a football game. The patient reported a “pop in his knee” and felt “intense pain” over the medial aspect of his knee immediately after onset. The subject was unable to weight bear following the injury and had to be carried off of the field. He denied past medical history of knee pathology bilaterally.
Objective Finding
The patient was removed from the sidelines for further assessment. Clinical examination, approximately fifteen minutes after injury, demonstrated gross effusion upon visual inspection. Palpation revealed point tenderness over the MCL. Range of motion and resistive testing were differed secondary to pain. Special tests demonstrated a positive Valgus Stress Test with severe pain and abnormal end feel. All other ligamentous testing were negative for laxity.
Diagnostic Testing and Initial Care
The athlete underwent a course of treatment consisting of rest, ice, compression and elevation immediately following the injury. He was also instructed in non-weight bearing crutch gait and fitted with a range of motion brace locked in 30° of knee flexion. Plain radiographs and MRI performed 48 hours after injury revealed a fractured tibial plateau, a Grade III MCL sprain, and a lateral meniscus injury. The athlete was scheduled for surgery the following day. During surgical intervention, an additional injury, not visualized on diagnostic testing was observed. The patient also suffered from an avulsed semitendinosis hamstring tendon at the time of trauma. Surgical repair of the MCL, medial meniscus and semitendinosis tendon were performed, along with an ORIF of the tibial plateau fracture.
Differential Diagnosis
Differential diagnosis included ruling out ACL, PCL, and LCL injuries. Fracture tests did not demonstrate bony involvement at onset. Knee effusion and laxity were the primary initial concerns regarding this patient’s pathology. However, his report of continuous, intense pain during a follow-up exam 48 hours after onset lead the clinicians to suspect bony involvement.
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Rehabilitation and Follow-up
Immediately following surgery, the patient began treatment for pain modulation and edema control. One week after surgical repair, a Continuous Passive Motion device (CPM) was prescribed to the patient to use 6-8hrs per day to assist in regaining normal ROM. The patient reported to the Athletic Training Room daily for treatment focusing on decreasing pain, decreasing edema and increasing ROM for the first several weeks following surgery. Russian stimulation was implemented in order to re-educate the patient’s quadriceps musculature secondary to neural inhibition and disuse atrophy. Hamstring exercises were contraindicated for the initial four weeks of rehabilitation to allow for healing of the semitendinosis tendon repair. After pain and edema were significantly decreased, the patient began a lower extremity strengthening and stretching program. Currently, the patient, twenty weeks post-surgery, is completing lower extremity closed kinetic chain proprioception exercises and continues to strengthen his quadriceps, hamstrings, and lower leg musculature. He is scheduled to begin progression to functional activity over the next eight to ten weeks.
Uniqueness & Conclusion: Tibial plateau fractures are unusual, comprising approximately only 1% of all fractures. Tibial plateau fractures typically result from motor vehicle accidents or a fall on a flexed knee, rather than from minimal impact sports trauma. Additionally hamstring avulsion injuries typically occur at the origin or ischial tuberosity, rather than the insertion. The mechanism for a hamstring avulsion typically involves forced hip flexion along with eccentric contraction of the hamstrings which did not occur in this case. The complexity and multitude of pathologies in this case demonstrate the importance of conducting a thorough evaluation of athletic injuries.