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Findings Numerous injuries are present in this case which will be listed but for the purposes of this case, the focus will be on the medial aspect of the knee. On the radiographs, there is a joint effusion, fracture along the anterior aspect of the tibia, and bone fragments of the knee joint. The MRI demonstrates the fracture of the tibia, proximal disruption of the PCL, and low grade injury of the ACL. Extensive injury is present of the posterior medial aspect of the knee with a root tear of the PHMM, disruption of the semimembranosus (SM) tendon, and a disruption of the posterior oblique ligament (POL) extending into the oblique popliteal ligament. Prominent edema is present about the medial soft tissues.
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Diagnosis: Posteromedial Corner Injury (in the setting of complex injury) This case illustrates numerous injuries but for our purposes I was trying to highlight the injuries to the posteromedial corner (PMC) of the knee. Not focused on nearly as much as the posterolateral corner (PLC), unaddressed injuries of the PMC can lead to chronic valgus instability and premature arthritis. The PMC is injured with a valgus force to the knee and external rotation of the knee. It is most frequently injured, as in this case, in the setting of complex trauma and often with multiple ligaments being injured. The tibia fracture and PCL injury in this case related to the patient landing on a flexed knee which is a common mechanism for PCL injury ( the other being hyperextension of the knee). The posteromedial corner includes the POL, the oblique popliteal ligament (OPL), the posteromedial capsule, the PHMM, and the semimembranosus (SM). The POL is a very complex structure which begins at the adductor tubercle and then has three distal limbs. The most prominent is the limb that attaches to the PHMM about the posterior aspect of the tibia. That is the portion that is disrupted in this case. The SM is also extremely complicated with 5 limbs extending from the main tendon to different attachments.
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Diagnosis Continued: Injuries to the PMC of greatest consequence tend to be PHMM tears, a disruption of the tibal limb if not more of the POL, and a tear of the main SM tendon or the large capsular attachment. Although PMC injuries can frequently be treated conservatively, given the extent of injuries, the involvement of the PCL, and the avulsive nature of some of the injuries, operative management was employed in this case.
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References Cinque, Mark E. MS; Chahla, Jorge MD, PhD; Kruckeberg, Bradley M. BA; DePhillipo, Nicholas N. MS, ATC, OTC; Moatshe, Gilbert MD; LaPrade, Robert F. MD, PhD. Posteromedial Corner Knee Injuries: Diagnosis, Management, and Outcomes: A Critical Analysis Review. JBJS Reviews 5(11):p e4, November 2017. | DOI: 10.2106/JBJS.RVW.17.00004 Martha A. Norris, M.D. Posteromedial Corner Injury of the Knee. Radsource MRI Web Clinic - April 2011
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