acr appropriateness criteria® acute trauma to the knee

ACR Appropriateness Criteria® AcuteTrauma to the Knee

Michael J. Tuite, MDa, Richard H. Daffner, MDb, Barbara N. Weissman, MDc,Laura Bancroft, MDd, D. Lee Bennett, MD, MAe, Judy S. Blebea, MDf,Michael A. Bruno, MDg, Ian Blair Fries, MDh,i, Curtis W. Hayes, MDj,

Mark J. Kransdorf, MDk, Jonathan S. Luchs, MDl, William B. Morrison, MDm,Catherine C. Roberts, MDn, Stephen C. Scharf, MDo,p, David W. Stoller, MDq,

Mihra S. Taljanovic, MDr, Robert J. Ward, MDs, James N. Wise, MDt,Adam C. Zoga, MDu

There are more than 1 million visits to the ER annually in the United States for acute knee trauma. Many ofthese are twisting injuries in young patients who can walk and bear weight, and emergent radiography is notrequired. Several clinical decision rules have been devised that can considerably reduce the number of radio-graphic studies ordered without missing a clinically significant fracture. Although fractures are seen on only 5%of emergency department knee radiographs, 86% of knee fractures result from blunt trauma. In patients withfalls or twisting injuries who have focal tenderness, effusion, or inability to bear weight, radiography should bethe first imaging study performed. If radiography shows no fracture, MRI is best for evaluating for a suspectedmeniscal or ligament tear or patellar dislocation. Patients with knee dislocation should undergo radiographyand MRI, as well as fluoroscopic angiography, CT angiography, or MR angiography.

The ACR Appropriateness Criteria® are evidence-based guidelines for specific clinical conditions that arereviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include anextensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatmentprocedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion maybe used to recommend imaging or treatment.

Key Words: Appropriateness Criteria, knee injury, diagnostic imaging, radiograph, computed tomography,magnetic resonance imaging

J Am Coll Radiol 2012;9:96-103. Copyright © 2012 American College of Radiology

oLenox Hill Hospital, New Rochelle, New York.pSociety of Nuclear Medicine, Reston, Virginia.qCalifornia Pacific Medical Center, San Francisco, California.rUniversity of Arizona Health Sciences Center, Tucson, Arizona.sTufts Medical Center, Boston, Massachusetts.tUniversity of Kentucky, Lexington, Kentucky.uThomas Jefferson University, Philadelphia, Pennsylvania.

Corresponding author and reprints: Michael J. Tuite, MD, American Col-lege of Radiology, 1891 Preston White Drive, Reston, VA 20191; e-mail:[email protected].

The ACR seeks and encourages collaboration with other organizations onthe development of the ACR Appropriateness Criteria® through society rep-resentation on expert panels. Participation by representatives from collaborat-ing societies on the expert panel does not necessarily imply individual or

aUniversity of Wisconsin Hospital, Madison, Wisconsin.bAllegheny General Hospital, Pittsburgh, Pennsylvania.cBrigham and Women’s Hospital, Boston, Massachusetts.dFlorida Hospital, Orlando, Florida.eUniversity of Iowa Roy J. and Lucille A. Carver College of Medicine, IowaCity, Iowa.fCleveland Clinic, Cleveland, Ohio.gPenn State Milton S. Hershey Medical Center, Hershey, Pennsylvania.hBone, Spine and Hand Surgery, Chartered, Brick, New Jersey.iAmerican Academy of Orthopaedic Surgeons, Rosemont, Illinois.jVCU Health System, Richmond, Virginia.kMayo Clinic, Jacksonville, Florida.lWinthrop University Hospital, Mineola, New York.mThomas Jefferson University Hospital, Philadelphia, Pennsylvania.
nMayo Clinic, Phoenix, Arizona. society endorsement of the final document.
© 2012 American College of Radiology0091-2182/12/$36.00 ● DOI 10.1016/j.jacr.2011.10.013

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Tuite et al/Acute Trauma to the Knee 97

SUMMARY OF LITERATURE REVIEW

Introduction/BackgroundA 2001 report stated that there are 1.3 million annualvisits to US emergency departments because of acuteknee trauma, and �$1 billion is spent on radiography ofhe knee [1]. Knee radiography is the most commonadiographic study performed for trauma in the ER andas the lowest yield for diagnosing clinically significantractures [2-4]. A retrospective review of 1,967 patientsith acute knee injuries revealed that 74.1% underwent

adiography, and only 5.2% had fractures [3]. Fishwicket al [5] concluded that radiographs obtained for acuteknee trauma do not reliably depict all important injuriesand that the findings in 25% of knee radiographs ob-tained for acute trauma do not correlate with clinicalfindings.

RadiographyA prospective survey of the judgment and attitudes ofexperienced clinicians in the use of knee radiography in1,040 patients with acute knee injuries showed that de-spite its inability to accurately predict the probability offracture and to discriminate between fracture and non-fracture cases, radiographs were usually ordered [2]. Theproportion of patients referred for knee radiography var-ied from 65.9% to 84.6% [3]. According to the physi-cians, radiography was ordered for the following reasons:(1) patients expected it and would otherwise be dissatis-fied; (2) physicians lacked confidence in the clinical ex-amination, or orthopedic surgeons considered radiogra-phy routine; and (3) possible medicolegal repercussions[3]. These reasons and patients’ demand for imaging arerecognized as the reasons that the implementation ofordering guidelines was not overwhelming [1].

Caution should be used when relying on clinical ex-amination for diagnosing certain knee injuries. Neu-bauer et al [6] reported that the correct diagnosis ofbilateral quadriceps tendon rupture was established inonly 61% of cases (17 of 28) by history and clinicalexamination alone. Weber et al [4] reported that frac-tures missed on clinical examination included fracturesof the patella, tibial spine, and fibular head.

Clinical decision rules for the acutely injured kneesuggest that radiographic examination of the knee after

Variant 1. Patient any age (excluding infants); fall or twisfirst study

Radiologic Procedure RatingX-ray knee 2MRI knee without contrast 299mTc bone scan with SPECT lower extremity 1CT knee without contrast 1Ultrasound knee 1MRA knee with or without contrast 1

Note: Rating scale: 1, 2, and 3 � usually not appropriate; 4, 5, and 6 � ma
RRL � relative radiation level; SPECT � single-photon emission CT.
cute injury can be eliminated in most instances by ap-lying specific clinical guidelines [7] (see Variant 1). Arospective and retrospective study of 334 patients con-luded that patients between 12 and 50 years of age whoxperienced falls or blunt trauma and were unable tombulate or those who sustained multiple trauma shouldndergo radiography [7] (see Variant 2). These authorseported 92% sensitivity and 79% specificity for identi-ying clinically significant fractures. Their study also re-orted that applying the clinical decision rules couldeduce the number of radiographs taken in the ER by8%.Weber et al [4] concluded that clinically significant

ractures can be excluded in patients aged �18 years whoan walk without limping or in the case of a twistingnjury to the knee and no joint effusion. If an effusionas present on physical examination, the odds of a frac-

ure were 7.5 times greater. Using this clinical decisionule, the sensitivity for detecting a knee fracture was00%, and specificity was sufficient to eliminate the needor 29% of knee radiographs ordered in the ER.

Stiell et al [2] applied a clinical decision rule (theOttawa Knee Rule) using parameters based on age, pal-pable tenderness, and function. Under the rule, patientswith acute knee pain and one or more of the followingparameters should undergo radiography if they

● are �55 years of age,● have palpable tenderness over the head of the fibula,● have isolated patellar tenderness,● cannot flex the knee to 90°,● cannot bear weight immediately after the injury, or● cannot walk in the ER (after taking 4 steps).

This rule was applied prospectively in 1,047 adultswith acute knee injuries, and it was determined that itsapplication would result in a 28% relative reduction inthe number of radiographs ordered, a decrease from68.6% to 49.4% [2].

A later study [8] was performed to validate the OttawaKnee Rule [2], and prospective validation analyzing1,096 patients found it to be 100% sensitive for identi-fying knee fractures. The decision rule was interpretedcorrectly 96% of the time, and when applied, the prob-ability of missing a fracture was zero [8]. The decision

injury, no focal tenderness, no effusion; able to walk;

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98 Journal of the American College of Radiology/Vol. 9 No. 2 February 2012

rule was 100% sensitive for identifying fractures in pa-tients aged �18 years who were not referred from otherhospitals, returned for reassessment, had knee injuries for7 days, or had isolated skin lesions. The potential relativereduction in the use of radiography was estimated to be28% (from 74% to 53%) [3,8].

In a pooled analysis of data from 6 studies, Bachmannet al [9] concluded that a negative result using the OttawaKnee Rule accurately excluded knee fracture after acuteknee injury. A meta-analysis to determine the role ofradiography in evaluating knee fractures concluded thatamong the 5 decision rules evaluated, the Ottawa KneeRule had the strongest supporting evidence [10]. Furtherprospective analysis of the Ottawa Knee Rule showedthat it allowed a decrease in the number of radiographicstudies performed after knee trauma by 35%, with asensitivity of knee fracture detection of 100% [11].

Another study [12] compared the implementation ofhe Ottawa Knee Rule by triage nurses and emergencyedicine physicians. No fracture was missed by either

roup, but triage nurses were found to order 3.6 timesore radiographs than emergency physicians, maintain-

ng sensitivity at the expense of specificity and cost sav-ngs [12]. Ketelslegers et al [13] evaluated the use of the

ttawa Knee Rule when applied by users with differentevels of clinical training, including medical students andurgical residents, and found sensitivity and negative pre-ictive value of 1.0 for both groups and a reduced radi-graphy rate of 25% with application of the rule.

In a study of 214 patients, Verma et al [1] determinedthat the use of radiography in the setting of acute traumacould be further reduced by obtaining a single lateralview. It was reported that the probability of not having afracture if the lateral view was normal was 100%, thusreducing the need for additional radiographs by 67%.

With regard to mechanism of injury, history and phys-ical examination are key elements for determining theindication for radiography and the application of a deci-sion rule. The most common mechanisms for knee injuryare a direct blow, a fall, or a twisting injury [3,4]. Twist-ing injuries are responsible for three-fourths of all kneeinjuries; however, 86% of all knee fractures result fromblunt trauma [3,4]. The risk for fracture also increases

Variant 2. Patient any age (excluding infants); fall or twistenderness, effusion, inability to bear weight; first study


Note: Rating scale: 1, 2, and 3 � usually not appropriate; 4, 5, and 6 � maRRL � relative radiation level; SPECT � single-photon emission CT.

ith age; fracture is 4 times more likely in patients aged

50 years, presumably secondary to osteoporosis, in-reased frequency of blunt injury, and inability to protecthe knee during a fall [4].

The absence of immediate swelling, ecchymosis, effu-ion, deformity, increased warmth, and abrasion or lac-ration is a significant predictor of normal findings onadiography. It was generally agreed that radiographshould be obtained and the clinical decision rule shouldot be applied for patients with gross deformities [4],alpable masses [8], penetrating injury, prosthetic hard-are, unreliable clinical histories or physical examina-

ions secondary to multiple injuries [4,8], altered mentaltatus (eg, head injury, drug or alcohol use, dementia)4,8], neuropathy (eg, paraplegia, diabetes) [4,8], or his-ories suggesting increased risk for fracture. The physi-ian’s judgment and common sense, however, shouldupersede clinical guidelines [4].

Transient patellar dislocation is unsuspected clinicallyn 45% to 73% of patients with evidence of dislocationubsequently seen on MRI [14,15]. Radiographs mayemonstrate a fracture of the medial patella or lateralrochlear and can also show anatomic features that pre-ispose to dislocation such as a decreased sulcus angle,atella alta, patellar tilt, or patellar subluxation [16].RI is more sensitive than radiography for detecting

ateral patellar dislocation, including injury to the medialatellofemoral ligament, bone contusions, and osteo-hondral injuries [17].

MRIIn addition to clinically significant fractures, other inju-ries must be considered. Most patients (93.5%) whopresent with acute knee injuries in the ER have soft tissuerather than osseous injuries [2]. Even in patients withfractures, concomitant soft tissue injuries frequently arepresent [18]. Shepherd et al [18] found that in 90% ofpatients with otherwise nonoperative tibial plateau frac-tures, there were significant soft tissue injuries diagnosedby MRI, including ligament and meniscal tears (see Vari-ant 3). Mustonen et al [19] reported unstable meniscaltears in 36% of patients with tibial plateau fractures. Anaccurate clinical examination is essential to identify pa-tients at high risk for delayed function recovery because

injury, with one or more of the following: focal

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bell et al [20] showed that the first clinical examinationfter acute knee trauma has a low diagnostic value andhat the incidence of anterior cruciate ligament (ACL)njuries is higher than previously described. It is recog-ized that MRI is the optimal imaging modality for iden-ifying soft tissue, cartilaginous surface, and bone injuriesround the knee.

To image internal knee derangement, MRI has beenhe technique of choice since the 1990s [21]. The accu-acy and reliability of MRI depend on experience andraining [22]. Nonetheless, numerous studies havehown that MRI has high diagnostic accuracy in identi-ying traumatic intra-articular knee lesions [23-25]. Thiss particularly true when strict diagnostic criteria are used23], and this applies to both spin-echo imaging and fastpin-echo imaging [23] as well as imaging at both lownd high field strengths [24,25]. MRI has been shown toemonstrate minor meniscocapsular tears when per-ormed with understanding of anatomy [26]. Character-stic findings on MRI, including specific bone marrowdema patterns and osteochondral defects [27], can allowccurate diagnosis of injuries such as transient dislocationf the patella that cannot be detected by radiography.

MRI is a valuable tool in the decision-making process,ltering the treatment plan in 18% of patients with me-iscal or chondral surface injuries and allowing earlierurgical intervention because of the more accurate diag-osis obtained [28-30]. Multiple authors and studiesave validated that unnecessary diagnostic arthroscopyan be avoided because of the high predictive value ofegative results on MRI [31,32]. One study [30] foundRI to have a positive predictive value twice that of

linical examination for meniscal tears. It also found thatRI would decrease negative diagnostic arthroscopy to

% and would help reduce the need for a second thera-eutic arthroscopic procedure. Another study [33] re-orted MRI’s accuracy to be approximately 94%, show-ng that it can effectively replace diagnostic arthroscopyor evaluating meniscal and ligament tears. Yet anothertudy [34] reported that when the clinical examination isquivocal within 6 weeks of sudden trauma with a hem-rthrosis present, MRI could have prevented diagnosticrthroscopy in 22% of patients. In randomized studies ofatients with knee injuries [35,36], MRI findings have

Variant 3. Patient any age (excluding infants); fall or twison a radiograph, with one or more of the following: focal

Radiologic Procedure RatingMRI knee without contrast 9CT knee without contrast 599mTc bone scan with SPECT lower extremity 1Ultrasound knee 1MRA knee with or without contrast 1


een shown to shorten the time to completion of diag-

ostic workup, reduce the number of additional diagnos-ic procedures, improve quality of life in the first 6 weeks,nd potentially reduce costs associated with lost produc-ivity. MR images should be read with caution in traumaatients without mechanical signs who have osteoarthri-is [37].

Anterior cruciate ligament rupture is responsible for70% of all acute hemarthrosis in young athletes and

7% in a mixed sedentary and athletic population38,39]. Locking, the presence of a loose body on radi-graphy, and hemarthrosis within 12 hours of injuryave previously been reported as indications for arthros-opy instead of MRI [33,38]. However, McNally et al40] found that in 48% of patients presenting withcutely locked knees, management was changed fromurgical to conservative on the basis of MRI findings.

Single-Photon Emission CTIn addition to MRI, single-photon emission CT has beenproposed for diagnosing meniscus injuries [41,42]. Aspecific crescentic pattern of uptake on the transaxialview has been described as having sensitivity of 77% andspecificity of 74%. With the additional criterion of in-creased equilibrium activity in the adjacent femoral con-dyles, these values increase to 90% and 84%, respectively[41]. Considerable concordance has been shown be-tween single-photon emission CT results and those ofother modalities for assessing meniscal tears and the bonecontusions from an ACL tear in acute knee trauma [43].

UltrasoundSonography has been reported to be 91% sensitive and100% specific for diagnosing an acute ACL tear within10 weeks of an acute hemarthrosis when there is no priortrauma and no bone abnormalities [44]. Sonography canbe used both for initial detection and confirmation of thisinjury and for follow-up [45]. Furthermore, a compari-son of sonography and radiography using lipohemar-throsis as a criterion of acute intra-articular fractureyielded sensitivity and specificity of 94% for sonographicdetection of such fractures [46]. Wang et al [47] showedthat the presence of an effusion at sonography in theacutely injured knee has 91% positive predictive value for

injury with either no fracture or a segond fracture seenderness, effusion, inability to bear weight; next study

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sonography should only be performed and interpreted bypersonnel with the appropriate expertise in its application.

CTCT with 3-dimensional reconstruction has been shownto reflect the severity of tibial plateau fractures moreaccurately than radiography in 43% of cases and to mod-ify the surgical plan in 59% of operative cases [48] (seeVariant 4). In severely injured patients, diagnosticallysufficient radiographs are sometimes difficult to obtain,and therefore negative results on radiography are notreliable in ruling out fractures [49]. In these patients,multidetector CT is a fast and accurate examination forevaluating tibial plateau fractures and other complexknee injuries [49]. In a 2007 study, Mui et al [50] con-cluded that in the acute setting, CT offers 80% sensitiv-ity and 98% specificity for depicting osseous avulsionsand a high negative predictive value for excluding liga-ment injury.

Patellar DislocationTransient patellar dislocation is unsuspected clinically in45% to 73% of patients with evidence of dislocationsubsequently seen on MRI [14,15]. Radiographs maydemonstrate a fracture of the medial patella or lateraltrochlear and can also show anatomic features that pre-dispose to dislocation, such as a decreased sulcus angle,patella alta, patellar tilt, or patellar subluxation [16] (seeVariant 5). MRI is more sensitive than radiography forimaging findings of lateral patellar dislocation, including

Variant 4. Patient any age (excluding infants); fall or twiswith one or more of the following: focal tenderness, effus

Radiologic Procedure RatingCT knee without contrast 9

MRI knee without contrast 799mTc bone scan with SPECT lower extremity 1Ultrasound knee 1MRA knee with or without contrast 1


Variant 5. Patient any age (excluding infants); injury to kntenderness, effusion, able to walk; first study


Note: Rating scale: 1, 2, and 3 � usually not appropriate; 4, 5, and 6 � ma
RRL � relative radiation level; SPECT � single-photon emission CT.
njury to the medial patellofemoral ligament, bone con-usions, and osteochondral injuries [17].

Knee DislocationDislocation of the knee results from a fall from a height,a motor vehicle accident, a vehicle striking a pedestrian,or contact sports [51,52]. This injury, which often re-duces spontaneously, constitutes a true orthopedic emer-gency because of possible nerve or arterial damage. Vas-cular injury may be found in one-third of patients afterposterior knee dislocation [51]. Physical signs of clini-cally significant vascular injury are the absence of pulses,ischemia, active bleeding, and bruit or thrill. These signshave been reported to have 100% accuracy for determin-ing the need for surgical exploration [51]. Although onestudy [53] concluded that angiography is unnecessary inthe routine evaluation of patients with blunt lower ex-tremity trauma who present with normal results on neu-rovascular examination, a systematic review suggestedthat the isolated presence of abnormal pedal pulses oninitial examination after knee dislocation is not sensitiveenough to detect a vascular injury that necessitates sur-gery and that the workup after knee dislocation shouldinclude angiography [54] (see Variant 6). CT angiogra-phy may be used as an alternative to conventional angiog-raphy in these patients [55,56].

Yu et al [52] endorsed the use of MRI when evi-dence of an acute popliteal artery injury is absent, butin the presence of ischemia or lack of pulses to thelower extremity, surgical exploration is suggested.

injury with a tibial plateau fracture on a radiograph,, inability to bear weight; next study

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MRI should also be performed to identify ligamentousinjuries and associated pathology [57-59]. Potter et al[60] found an excellent correlation between MRI find-ings and surgical findings in patients with knee dislo-cation. Furthermore, these authors reported 100%correlation between MR angiography findings andconventional angiography findings in multiple-liga-ment injured knees, including knee dislocations [60].

SUMMARYClinical decision rules for evaluating the acutely injuredknee have been studied by various investigators who havedetermined that their application can considerably re-duce the number of radiographs ordered without missinga clinically significant fracture. Although different pa-rameters and definitions were used for the various deci-sion rules, there were sufficient similarities between theinvestigations to allow usable conclusions to be drawn.

In patients of any age, except for infants, the clinicalparameters used for not requiring radiography after kneetrauma are as follows:

● The patient is able to walk without a limp [3].● The patient had a twisting injury, and there is no

effusion [3].

The clinical parameters for ordering knee radiography inthis population after trauma are as follows:

● joint effusion within 24 hours of a direct blow orfall [3],

● palpable tenderness over the fibular head or patella [2],● inability to walk (4 steps) or bear weight immedi-

ately or in the ER [2] or within 1 week of thetrauma [1],

● inability to flex the knee to 90° [2], and● altered mental status [4,9].

It has also been reported that a fracture can beexcluded if a single lateral view of the knee is normal,eliminating the need for additional radiographic

Variant 6. Patient any age (excluding infants); significantposterior knee dislocation; first study

Radiologic Procedure RatingX-ray knee 9 InitiMRI knee without contrast 9 Nec

oArteriography lower extremity 7 TheMRA knee with or without contrast 7 PerCTA lower extremity with contrast 7 Per

R99mTc bone scan with SPECT lower extremity 2CT knee without contrast 2 TheUltrasound knee 2

Note: Rating scale: 1, 2, and 3 � usually not appropriate; 4, 5, and 6 � mMRA � MR angiography; RRL � relative radiation level; SPECT � single-

views [1].

In general, these studies excluded patients with super-cial skin injuries, gross deformities, palpable masses,enetrating injuries, prosthetic hardware, altered con-ciousness (from alcohol or drug use), multiple injuries,ecreased limb sensation, or histories indicating elevatedisk for fracture. They also excluded pregnant patients,atients returning for reassessment, and patients whosenjuries occurred �7 days before initial evaluation [3,8].

Soft tissue injuries (meniscal injuries, chondral surfacenjuries, and ligamentous disruption) are best evaluatedy MRI [21,28-33]. Although lateral patellar dislocationay be reduced at the time of presentation in the ER,

haracteristic findings on MRI, including specific bonearrow edema patterns and osteochondral defects [27],

an allow accurate diagnosis.Knee dislocation, even if spontaneously reduced, con-

titutes a potential threat to the popliteal nerve or artery.systematic review [54] has suggested that the isolated

resence of abnormal pedal pulses on initial examinationfter knee dislocation is not sensitive enough to detect aascular injury that necessitates surgery and that theorkup should include angiography. One study [60]

howed a 100% correlation between MR angiographicndings and conventional angiographic findings in mul-iple-ligament injured knees, including knee disloca-ions. MRI should also be performed to identify ligamen-ous injuries and associated pathology [57-59].

RELATIVE RADIATION LEVEL INFORMATIONPotential adverse health effects associated with radiationexposure are an important factor to consider when select-ing the appropriate imaging procedure. Because there is awide range of radiation exposures associated with differ-ent diagnostic procedures, a relative radiation level indi-cation has been included for each imaging examination.The relative radiation levels are based on effective dose,which is a radiation dose quantity that is used to estimatepopulation total radiation risk associated with an imag-ing procedure. Patients in the pediatric age group are at

uma to knee from motor vehicle accident, suspect

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organ sensitivity and longer life expectancy (relevant tothe long latency that appears to accompany radiationexposure). For these reasons, the relative radiation leveldose estimate ranges for pediatric examinations are lowercompared with those specified for adults (Table 1). Ad-ditional information regarding radiation dose assessmentfor imaging examinations can be found in ACR Appro-priateness Criteria®: Radiation Dose Assessment Introduc-ion [61].

For additional information on the ACR Appropriate-ess Criteria, refer to http://www.acr.org/ac .

EFERENCES

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3. Stiell IG, Wells GA, McDowell I, et al. Use of radiography in acute kneeinjuries: need for clinical decision rules. Acad Emerg Med 1995;2:966-73.

4. Weber JE, Jackson RE, Peacock WF, Swor RA, Carley R, Larkin GL.Clinical decision rules discriminate between fractures and nonfractures inacute isolated knee trauma. Ann Emerg Med 1995;26:429-33.

5. Fishwick NG, Learmonth DJ, Finlay DB. Knee effusions, radiology andacute knee trauma. Br J Radiol 1994;67:934-7.

6. Neubauer T, Wagner M, Potschka T, Riedl M. Bilateral, simultaneousrupture of the quadriceps tendon: a diagnostic pitfall? Report of threecases and meta-analysis of the literature. Knee Surg Sports TraumatolArthrosc 2007;15:43-53.

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Table 1. Relative radiation level designations

RelativeRadiation Level

Adult EffectiveDose EstimateRange (mSv)

PediatricEffective

DoseEstimate

Range (mSv)O 0 0

�0.1 �0.030.1-1 0.03-0.3

1-10 0.3-310-30 3-1030-100 10-30

Note: Relative radiation level assignments for some of the examinationscannot be made because the actual patient doses in these proceduresvary as a function of a number of factors (eg, region of the body exposedto ionizing radiation, the imaging guidance that is used). The relativeradiation levels for these examinations are designated as not specified.

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18. Shepherd L, Abdollahi K, Lee J, Vangsness CT Jr. The prevalence of softtissue injuries in nonoperative tibial plateau fractures as determined bymagnetic resonance imaging. J Orthop Trauma 2002;16:628-31.

19. Mustonen AO, Koivikko MP, Lindahl J, Koskinen SK. MRI of acutemeniscal injury associated with tibial plateau fractures: prevalence, type,and location. AJR Am J Roentgenol 2008;191:1002-9.

20. Frobell RB, Lohmander LS, Roos HP. Acute rotational trauma to theknee: poor agreement between clinical assessment and magnetic reso-nance imaging findings. Scand J Med Sci Sports 2007;17:109-14.

21. Chissell HR, Allum RL, Keightley A. MRI of the knee: its cost-effectiveuse in a district general hospital. Ann R Coll Surg Engl 1994;76:26-9.

22. White LM, Schweitzer ME, Deely DM, Morrison WB. The effect oftraining and experience on the magnetic resonance imaging interpretationof meniscal tears. Arthroscopy 1997;13:224-8.

23. De Smet AA, Tuite MJ. Use of the “two-slice-touch” rule for the MRIdiagnosis of meniscal tears. AJR Am J Roentgenol 2006;187:911-4.

24. Magee T, Williams D. 3.0-T MRI of meniscal tears. AJR Am J Roent-genol 2006;187:371-5.

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