AANA/SOMOS Course Materials (August 2021)-Case Presentation

Case Presentation

Pdf Summary

This case involves a 33-year-old male who suffered an isolated right knee injury from an ATV rollover. Initial evaluation showed inability to dorsiflex the foot and toes, with an ankle-brachial index (ABI) of 1.0. Imaging diagnosed a medial tibial plateau fracture, complete posterior cruciate ligament (PCL) tear, medial meniscal tear, posterolateral corner (PLC) injury including lateral collateral ligament (LCL), popliteus, fibular styloid avulsion, and peroneal nerve injury.<br /><br />The first surgical intervention occurred 11 days post-injury and included open reduction internal fixation (ORIF) of the medial tibia, meniscal repair, PLC reconstruction, biceps femoris repair, and peroneal nerve neurolysis. At 6 weeks post-op, the patient was non-weight bearing with limited range of motion (ROM) of 0-40 degrees and unable to dorsiflex the foot; knee was stable on varus and valgus testing.<br /><br />At 8 weeks post-injury, the patient underwent an exam under anesthesia (EUA) and arthroscopic lysis of adhesions, improving ROM to 0-110 degrees. Four months post-injury, the patient exhibited persistent PCL laxity, medial knee pain, and EMG showed severe peroneal neuropathy. An ankle-foot orthosis (AFO) was fitted, and return to light duty work was permitted. The possibility of PCL reconstruction and nerve graft was discussed.<br /><br />At 5 months post-injury, the patient underwent an all-inside PCL reconstruction using an allograft. At 6 weeks post-PCL reconstruction, pain was minimal (1/10), ROM improved to 0-95 degrees, with slight improvement in tibialis anterior strength on EMG. Further manipulation under anesthesia improved ROM to 0-105 degrees. Three months post-PCL reconstruction, ROM was 0-110 degrees, tibialis anterior strength improved to 4/5, AFO was discontinued, and the patient was cleared to return to work with a PCL brace.<br /><br />One year after injury, the patient returned to full duty working 12-hour shifts, with stable knee ligaments, ROM of 0-120 degrees, almost full tibialis anterior and extensor hallucis longus strength (5-/5), and only mild posterior drawer laxity. The case illustrates staged management of complex knee trauma with associated nerve injury, involving surgical fixation, ligament repair, rehabilitation, and nerve monitoring to achieve functional recovery.

Keywords

right knee injury

ATV rollover

medial tibial plateau fracture

posterior cruciate ligament tear

medial meniscal tear

posterolateral corner injury

peroneal nerve injury

open reduction internal fixation

PCL reconstruction

ankle-foot orthosis