{"id":2590,"date":"2026-04-16T23:56:28","date_gmt":"2026-04-16T23:56:28","guid":{"rendered":"https:\/\/emultrasound.ucsd.edu\/?p=2590"},"modified":"2026-04-16T23:57:16","modified_gmt":"2026-04-16T23:57:16","slug":"case-65-knee-pain","status":"publish","type":"post","link":"https:\/\/emultrasound.ucsd.edu\/index.php\/2026\/04\/16\/case-65-knee-pain\/","title":{"rendered":"Case 65:  Knee Pain"},"content":{"rendered":"\n<p class=\"wp-block-paragraph\">Colleen Sweeney, Akash Desai<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A&nbsp;55-year-old female&nbsp;with no pertinent past medical or surgical history&nbsp;was brought in by ambulance after a bicycle accident&nbsp;with left knee pain.&nbsp;&nbsp;She was&nbsp;unhelmeted&nbsp;while&nbsp;riding a bicycle going 10mph when she collided into&nbsp;an e-bike.&nbsp;Her&nbsp;left knee was caught in her handlebars;&nbsp;she denied head trauma&nbsp;and had no LOC.&nbsp;&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Vitals:&nbsp;BP 168\/120, HR 70, T 96.0F, RR&nbsp;22, SpO2 95% on RA, BMI 24.41&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Physical\u00a0Exam:\u00a0<br>General\/Neuro:\u00a0alert, in acute distress, diaphoretic\u00a0<br>HEENT: normocephalic, atraumatic, EOMI\u00a0<br>CV:\u00a0normal rate\u00a0<br>Resp:\u00a0tachypneic\u00a0<br>Abdomen:\u00a0flat, soft, no tenderness\u00a0<br>MSK: RLE normal\u00a0<br>L knee:\u00a0+swelling, +deformity.\u00a0Skin intact, small ecchymosis to\u00a0left lateral\u00a0knee.\u00a0Knee\u00a0diffusely\u00a0tender to palpation. Sensation intact\u00a0to light touch throughout. Palpable popliteal, PT, and DP pulses.\u00a0Able\u00a0to wiggle toes. Compartments\u00a0compressible. Patient unable to tolerate any movement\u00a0of L knee\u00a0secondary to pain.\u00a0<br>L lower leg: +swelling\u00a0from knee distally, no lacerations\u00a0<br>L ankle\/foot: normal pulse, sensation intact to light touch throughout\u00a0<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Radiographs were\u00a0indicated\u00a0and initially\u00a0attempted\u00a0at bedside, however were unsuccessful as the patient was unable to tolerate the pain. Radiography was delayed until two hours due to pain management and census.\u00a0 In the interim, a POCUS was performed<\/p>\n\n\n\n<figure class=\"wp-block-image size-full\"><img data-recalc-dims=\"1\" loading=\"lazy\" decoding=\"async\" width=\"525\" height=\"394\" src=\"https:\/\/i0.wp.com\/emultrasound.ucsd.edu\/wp-content\/uploads\/2026\/04\/image.png?resize=525%2C394&#038;ssl=1\" alt=\"\" class=\"wp-image-2591\" srcset=\"https:\/\/i0.wp.com\/emultrasound.ucsd.edu\/wp-content\/uploads\/2026\/04\/image.png?w=764&amp;ssl=1 764w, https:\/\/i0.wp.com\/emultrasound.ucsd.edu\/wp-content\/uploads\/2026\/04\/image.png?resize=300%2C225&amp;ssl=1 300w\" sizes=\"auto, (max-width: 706px) 89vw, (max-width: 767px) 82vw, 740px\" \/><figcaption class=\"wp-element-caption\">Figure\u00a01. Transverse view of infrapatellar\u00a0lipohemarthrosis.\u00a0<\/figcaption><\/figure>\n\n\n\n<figure class=\"wp-block-image size-full\"><img data-recalc-dims=\"1\" loading=\"lazy\" decoding=\"async\" width=\"525\" height=\"429\" src=\"https:\/\/i0.wp.com\/emultrasound.ucsd.edu\/wp-content\/uploads\/2026\/04\/image-1.png?resize=525%2C429&#038;ssl=1\" alt=\"\" class=\"wp-image-2592\" srcset=\"https:\/\/i0.wp.com\/emultrasound.ucsd.edu\/wp-content\/uploads\/2026\/04\/image-1.png?w=849&amp;ssl=1 849w, https:\/\/i0.wp.com\/emultrasound.ucsd.edu\/wp-content\/uploads\/2026\/04\/image-1.png?resize=300%2C245&amp;ssl=1 300w, https:\/\/i0.wp.com\/emultrasound.ucsd.edu\/wp-content\/uploads\/2026\/04\/image-1.png?resize=768%2C627&amp;ssl=1 768w\" sizes=\"auto, (max-width: 706px) 89vw, (max-width: 767px) 82vw, 740px\" \/><figcaption class=\"wp-element-caption\">Figure\u00a02.\u00a0Longitudinal view of infrapatellar\u00a0lipohemarthrosis.\u00a0\u00a0<\/figcaption><\/figure>\n\n\n\n<figure class=\"wp-block-image size-full\"><img data-recalc-dims=\"1\" loading=\"lazy\" decoding=\"async\" width=\"525\" height=\"413\" src=\"https:\/\/i0.wp.com\/emultrasound.ucsd.edu\/wp-content\/uploads\/2026\/04\/image-3.png?resize=525%2C413&#038;ssl=1\" alt=\"\" class=\"wp-image-2594\" srcset=\"https:\/\/i0.wp.com\/emultrasound.ucsd.edu\/wp-content\/uploads\/2026\/04\/image-3.png?w=763&amp;ssl=1 763w, https:\/\/i0.wp.com\/emultrasound.ucsd.edu\/wp-content\/uploads\/2026\/04\/image-3.png?resize=300%2C236&amp;ssl=1 300w\" sizes=\"auto, (max-width: 706px) 89vw, (max-width: 767px) 82vw, 740px\" \/><figcaption class=\"wp-element-caption\">Figure\u00a03.\u00a0Longitudinal view of tibia with cortical\u00a0break\u00a0(arrow).\u00a0<\/figcaption><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\">Xray findings: \"Acute,\u00a0comminuted,\u00a0displaced proximal tibial fracture extending to the lateral and central tibial plateau.\u00a0\u00a0Acute, mildly displaced and\u00a0impacted\u00a0fibular neck fracture.\u00a0\u00a0No fracture or malalignment of the left ankle.\u00a0\"<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The patient&nbsp;was admitted to the trauma surgery service.&nbsp;The next day, she underwent a left knee spanning external fixator&nbsp;for stabilization of the tibial plateau fracture. One week later, she had an ORIF for long-term fixation of the fracture as well as a hamstring tendon repair.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Discussion<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">POCUS is&nbsp;increasingly&nbsp;utilized&nbsp;in acute musculoskeletal trauma.&nbsp;The patient\u2019s gross knee deformity after a traumatic event led to POCUS&nbsp;utilization&nbsp;to&nbsp;provide&nbsp;rapid clinical guidance.&nbsp;&nbsp;In this patient,&nbsp;ultrasound&nbsp;was complete half an hour prior to the first attempt at radiographs and over 2 hours prior to their completion,&nbsp;thus proving&nbsp;useful&nbsp;in differentiating the severity of a&nbsp;patient\u2019s injury&nbsp;during&nbsp;prolonged&nbsp;wait times&nbsp;and&nbsp;facilitating&nbsp;early orthopedic surgery consultation.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Ultrasound, though not a primary diagnostic modality for acute fractures, offers&nbsp;sensitivity of&nbsp;87% and&nbsp;specificity&nbsp;of 70%&nbsp;for proximal tibial fractures specifically in cadaveric models&nbsp;[3].&nbsp;In Figure&nbsp;3,&nbsp;the cortical break&nbsp;visible&nbsp;on&nbsp;the left side of the image&nbsp;corresponds&nbsp;to the proximal tibial fracture seen on X-ray.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Figures&nbsp;1&nbsp;and&nbsp;2&nbsp;both demonstrate&nbsp;lipohemarthrosis. The&nbsp;presence of&nbsp;hemarthrosis, rather than a simple joint effusion, raises the suspicion for an intra-articular injury or fracture, with ultrasound&nbsp;demonstrating&nbsp;a sensitivity of 90% and specificity of 86% for this finding [2]. When&nbsp;lipohemarthrosis&nbsp;is&nbsp;identified\u2014most clearly visualized in Figure&nbsp;2&nbsp;as hypoechoic fat \u201cbubbles\u201d originating from the bone marrow\u2014it is even more indicative of an intra-articular fracture, carrying&nbsp;97% sensitivity and 100% specificity for such fractures&nbsp;[4]. In its early stage,&nbsp;lipohemarthrosis&nbsp;appears as scattered fat globules, which later settle into the characteristic triple-layer pattern of fat, serum, and blood products [5].&nbsp;Recognition of hemarthrosis or&nbsp;lipohemarthrosis&nbsp;on ultrasound may help risk-stratify patients for joint&nbsp;aspiration, potentially reducing unnecessary aspirations and associated infection risk.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The&nbsp;presence&nbsp;of&nbsp;lipohemarthrosis&nbsp;is highly suggestive of&nbsp;a&nbsp;distal femur or proximal tibial fracture.&nbsp;Recognizing these findings early allows&nbsp;clinicians&nbsp;to&nbsp;maintain&nbsp;a high index of suspicion for periarticular fracture prior to radiographic confirmation, enabling prompt immobilization, consultation, and fracture management.&nbsp;This early&nbsp;identification&nbsp;facilitates&nbsp;more efficient triage&nbsp;and throughput&nbsp;in the ED and&nbsp;underscores&nbsp;POCUS&nbsp;as a worthwhile adjunct in knee trauma&nbsp;in addition to traditional imaging such as X-ray, CT, and MRI [6].&nbsp;&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">References:&nbsp;&nbsp;<\/p>\n\n\n\n<ol start=\"1\" class=\"wp-block-list\">\n<li>Stannard JP, Lopez R,\u00a0Volgas\u00a0D. Soft tissue injury of the knee after tibial plateau fractures.\u202f<em>J Knee Surg<\/em>. 2010;23(4):187-192. doi:10.1055\/s-0030-1268694\u00a0<\/li>\n\n\n\n<li>Taljanovic\u00a0MS, Chang EY, Ha AS, et al. ACR appropriateness criteria\u00ae acute trauma to the knee.\u202f<em>Journal of the American College of Radiology<\/em>. 2020;17(5).\u00a0doi:10.1016\/j.jacr.2020.01.041\u202f\u00a0<\/li>\n\n\n\n<li>Demers G, Migliore S, Bennett DR, et al. Ultrasound evaluation of cranial and long bone fractures in a cadaver model.\u00a0<em>Mil Med<\/em>. 2012;177(7):836-839. doi:10.7205\/milmed-d-11-00407\u00a0<\/li>\n\n\n\n<li>Bonnefoy, O.,\u00a0Diris, B.,\u00a0Moinard, M.\u202f<em>et al.<\/em>\u202fAcute knee trauma: role of ultrasound.\u202f<em>Eur\u00a0Radiol<\/em>\u202f16,\u00a02542\u20132548 (2006).\u00a0Doi:10.1007\/s00330-006-0319-x\u00a0<\/li>\n\n\n\n<li>Levrini\u00a0G, Reggiani G,\u00a0Vacondio\u00a0R,\u00a0Zompatori\u00a0M, Nicoli F. Post-traumatic knee\u00a0lipohemarthrosis: Temporal evolution with progressive separation of the three layers of the joint effusion by ultrasonography and computed tomography.\u202f<em>European Journal of Radiology Extra<\/em>. 2006;60(1):37-41.\u00a0doi:10.1016\/j.ejrex.2006.06.011\u202f\u00a0<\/li>\n\n\n\n<li>De\u00a0Maeseneer\u00a0M, Marcelis S, Boulet C, et al. Ultrasound of the knee with emphasis on the detailed anatomy of anterior, medial, and lateral structures.\u202f<em>Skeletal\u00a0Radiol<\/em>. 2014;43(8):1025-1039. doi:10.1007\/s00256-014-1841-6\u00a0<\/li>\n<\/ol>\n\n\n\n<ol start=\"2\" class=\"wp-block-list\"><\/ol>\n\n\n\n<ol start=\"3\" class=\"wp-block-list\"><\/ol>\n\n\n\n<ol start=\"4\" class=\"wp-block-list\"><\/ol>\n\n\n\n<ol start=\"5\" class=\"wp-block-list\"><\/ol>\n\n\n\n<ol start=\"6\" class=\"wp-block-list\"><\/ol>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n","protected":false},"excerpt":{"rendered":"Colleen Sweeney, Akash Desai A&nbsp;55-year-old female&nbsp;with no pertinent past medical or surgical history&nbsp;was brought in by ambulance after a bicycle accident&nbsp;with left knee pain.&nbsp;&nbsp;She was&nbsp;unhelmeted&nbsp;while&nbsp;riding a bicycle going 10mph when she collided into&nbsp;an e-bike.&nbsp;Her&nbsp;left knee was caught in her handlebars;&nbsp;she denied head trauma&nbsp;and had no LOC.&nbsp;&nbsp; Vitals:&nbsp;BP 168\/120, HR 70, T 96.0F, RR&nbsp;22, SpO2 95% &hellip; <p class=\"link-more\"><a href=\"https:\/\/emultrasound.ucsd.edu\/index.php\/2026\/04\/16\/case-65-knee-pain\/\" class=\"more-link\">Continue reading<span class=\"screen-reader-text\"> \"Case 65:  Knee Pain\"<\/span><\/a><\/p>","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_eb_attr":"","_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[4],"tags":[137,136,29,8],"class_list":["post-2590","post","type-post","status-publish","format-standard","hentry","category-clinical-cases","tag-knee-effusion","tag-knee-pain","tag-musculoskeletal","tag-trauma"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.3 - 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