Examining the Bone Bruise Patterns in Multiligament Knee Injuries With Peroneal Nerve Injury

Abstract

Background: Tibiofemoral bone bruise patterns seen on magnetic resonance imaging (MRI) are associated with ligamentous injuries in the acutely injured knee. Bone bruise patterns in multiligament knee injuries (MLKIs) and particularly their association with common peroneal nerve (CPN) injuries are not well described. Purpose: To analyze the tibiofemoral bone bruise patterns in MLKIs with and without peroneal nerve injury. Study Design: Case series; Level of evidence, 4. Methods: We retrospectively identified 123 patients treated for an acute MLKI at a level 1 trauma center between January 2001 and March 2021. Patients were grouped into injury subtypes using the Schenck classification. Within this cohort, patients with clinically documented complete (motor and sensory loss) and/or partial CPN palsies on physical examination were identified. Imaging criteria required an MRI scan on a 1.5 or 3 Tesla scanner within 30 days of the initial MLKI. Images were retrospectively interpreted for bone bruising patterns by 2 board-certified musculoskeletal radiologists. The location of the bone bruises was mapped on fat-suppressed T2-weighted coronal and sagittal images. Bruise patterns were compared among patients with and without CPN injury. Results: Of the 108 patients with a MLKI who met the a priori inclusion criteria, 26 (24.1%) were found to have a CPN injury (N = 20 complete; N = 6 partial) on physical examination. For CPN-injured patients, the most common mechanism of injury was high-energy trauma (N = 19 [73%]). The presence of a grade 3 posterolateral corner (PLC) injury (N = 25; odds ratio [OR], 23.81 [95% CI, 3.08-184.1]; P = .0024), anteromedial femoral condyle bone bruising (N = 24; OR, 21.9 [95% CI, 3.40-202.9]; P < .001), or a documented knee dislocation (N = 16; OR, 3.45 [95% CI, 1.38-8.62]; P = .007) was significantly associated with the presence of a CPN injury. Of the 26 patients with CPN injury, 24 (92.3%) had at least 1 anteromedial femoral condyle bone bruise. All 20 (100%) patients with complete CPN injury also had at least 1 anteromedial femoral condyle bone bruise on MRI. In our MLKI cohort, the presence of anteromedial femoral condyle bone bruising had a sensitivity of 92.3% and a specificity of 64.6% for the presence of CPN injury on physical examination. Conclusion: In our MLKI cohort, the presence of a grade 3 PLC injury had the greatest association with CPN injury. Additionally, anteromedial femoral condyle bone bruising on MRI was a highly sensitive finding that was significantly correlated with CPN injury on physical examination. The high prevalence of grade 3 PLC injuries and anteromedial tibiofemoral bone bruising suggests that these MLKIs with CPN injuries most commonly occurred from a hyperextension-varus mechanism caused by a high-energy blow to the anteromedial knee.

Accuracy of Magnetic Resonance Imaging in the Diagnosis of Multiple Ligament Knee Injuries: A Multicenter Study of 178 Patients

“…However, all MRI reports were completed by experienced musculoskeletal radiologists, similar to previous studies. 1,21,23,24 Also, even the heterogeneity of the centers could be seen as a flaw; all the reviewers were experienced knee surgeons from referral centers, depicting a general scenario that could be similar to many specialized knee centers where these lesions are usually treated.…”

“…Multiple ligament knee injuries (MLKIs) are a rare entity, with an incidence of 0.02% to 0.2% of all orthopaedic injuries 18 but with a high rate of associated vascular (5%-18.4%) and nerve (19.2%-25%) injuries. 14,17,18,21 A better understanding of the diagnostic accuracy of magnetic resonance imaging (MRI) to identify MLKIs will improve surgical planning, avoiding a misdiagnosis and inadequate treatment, 2 of the main causes of failure when treating MLKIs. 15,29 Because a clinical diagnosis based on an examination is usually difficult to make because of pain and swelling, 3,10,16 stress radiography 1,9,13 and MRI are essential to establish an accurate diagnosis.…”

“…5,16,23,26 Later studies with larger sample sizes that systematically evaluated each structure of the knee on MRI and surgical reports have, however, shown a poor correlation between MRI and operative findings. 1,3,8,12 Most studies that have assessed the diagnostic accuracy of MRI to identify MLKIs are case series with small sample sizes ‡ or studies based on tertiary referral centers with only a single surgeon 13,21,22 or radiologist involved. 10,13,16 Thus, there is a lack of larger multicenter studies of better quality that will allow us to reach statistically significant conclusions that could be used as a guide in clinical practice.…”

Examining Preoperative MRI for Medial Meniscal Ramp Lesions in Patients Surgically Treated for Acute Grade 3 Combined Posterolateral Corner Knee Injury

“…For bone bruises, only fat-suppressed T2-weighted coronal and sagittal images were reviewed to determine the location of the bone bruises within the tibiofemoral compartment in the injured knee. For mapping bone bruises, a standardized technique described by Moran et al 23 – 25 was utilized to record the location of the bruise(s) on the tibia. For tibial plateau bruise mapping, contusions on the medial side were defined as any bruise that occurred in the tibial-medial-medial (TMM) and/or tibial-medial-central (TMC) zones in the coronal plane ( Figure 1A ).…”

Examining the Distribution of Bone Bruise Patterns in Contact and Noncontact Acute Anterior Cruciate Ligament Injuries

“…The sequence specifics for the images were an average repetition time (TR) of 6500 milliseconds, echo time (TE) of 45 milliseconds, field of view of 14 to 16 cm, and resolution of 256 3 256. [7][8][9] The location of bone bruises was mapped according to Moran et al, [7][8][9] whose approach has been used for analysis of bone bruising in previous studies. Medial femoral condyle (MFC) bone bruises were defined as those that occur within the medial, central, notch, and/or trochlear zones on the MFC (Figure 1).…”