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Posterior Cruciate Ligament (PCL) Injury

Topic updated on 11/08/17 9:51am

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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