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Updated: May 18 2019

Posterior Cruciate Ligament (PCL) Injury


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  • Overview
  • Snapshot
    • A 22-year-old man presents to the emergency department after being involved in a motor vehicle accident. The patient is conscious but reports knee pain. He was wearing a seat belt, denies any head trauma, but says that his knees collided with the dashboard. Physical examination is significant for increased laxity of the proximal tibia with posterior force. A magnetic resonance imaging of the knee is consistent with a posterior cruciate ligament tear.
  • Introduction
    • Clinical definition
      • injury of the posterior cruciate ligament (PCL)
    • Epidemiology
      • risk factors
        • high-energy trauma (e.g., motor vehicle accident)
        • sport activities
    • Etiology
      • trauma that posteriorly translates the proximal tibia
    • Pathoanatomy
      • normal anatomy
        • the largest intraarticular ligament in the knee
        • originates from the lateral portion of the medial femoral condyle and inserts at the fovea centralis (PCL facet)
      • pathology
        • posteriorly directed shear force when the knee is flexed
          • "dashboard injury" (high-energy trauma)
            • when the proximal tibia collides with the dashboard of a car in a motor vehicle accident
          • sports injuries (low-energy trauma)
            • the player falls on their knee while it is flexed and the foot is plantarflexed
            • direct trauma to the anterior knee
    • Associated conditions
      • high-energy trauma can result in PCL injury as well as injury to the
        • posterolateral corner
        • anterior cruciate ligament
        • medial collateral ligament
    • Prognosis
      • insufficient evidence to determine the true prognosis
  • Presentation
    • Symptoms
      • may present with posterior knee pain
        • athletes may continue playing sports and not seek medical care
    • Physical exam
      • posterior drawer test
        • the proximal tibial is pushed posteriorly to assess for PCL laxity while the knee is flexed at 90 degrees
          • posterior translation is considered a positive test
      • mild-to-moderate effusion
      • slight limp or antalgic gait
      • may have impaired terminal knee flexion
  • Imaging
    • Radiography
      • indication
        • performed initially to assess for fractures
    • Magnetic resonance imaging (MRI)
      • indication
        • typically performed in all patients presenting with acute PCL injury
          • highly sensitive and accurate for acute PCL injury
  • Studies
    • Making the diagnosis
      • a presumptive diagnosis can be made based on clinical presentation
      • MRI can definitively diagnose acute or subacute PCL injury
  • Differential
    • Anterior cruciate ligament injury
      • distinguishing factor
        • patients typically hear a "pop" after injury and there is typically significant edema and joint effusion
        • patients have a positive anterior drawer test
  • Treatment
    • Conservative
      • rest, ice, compression, and elevation (RICE) therapy
        • indication
          • standard management of patients with an isolated PCL injury
            • in addition to RICE therapy, patients should receive
              • nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen for pain management
              • immobilization in extension (e.g., hinged knee brace)
    • Operative
      • reconstructive surgery
        • indication
          • typically reserved for acute and multi-ligamentous knee injuries
  • Complications
    • May result in osteoarthritis
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