Clinical Evaluation and Presentation
Evaluation begins with a thorough history and physical examination. The knee should be inspected for signs of trauma, such as swelling, abrasions, or blistering and closely inspected for effusion from the knee capsule. TPFs, especially high-energy injuries, are associated with extensive soft-tissue and neurovascular damage, and the possibility of an open fracture must be considered.[12,34–36] Compartment syndrome can occur in association with TPFs, and clinical evaluation should include evaluation for tense anterior, lateral, and posterior tibial compartments as well examination for pain with passive stretch. These findings are suggestive of compartment syndrome and may require compartment pressure checks or fasciotomy.
There should be a high index of suspicion for vascular injury when evaluating a young patient with knee trauma. Signs of major vascular injury and indication for immediate surgical exploration are pulsatile hemorrhage, expanding hematoma, palpable thrill, or pulseless limb. In the absence of emergent signs of injury, physical examination is subject to high interobserver variability and is unreliable for screening of arterial injury.[48,49] The ankle brachial index (ABI) is the screening test of choice for evaluation of these injuries. This test can be done quickly and is more cost-effective than arteriography. The ABI has a negative predictive value of 99% with an ABI greater than 0.9 and has a sensitivity of 95% and specificity of 97% when the ABI is less than 0.9. If the ABI is less than 0.9, further evaluation with duplex ultrasound or arteriogram is indicated to determine the need for surgical exploration.
Curr Orthop Pract. 2022;33(1):85-93. © 2022 Lippincott Williams & Wilkins