Knee Pain and Monkeypox

Hey Team,

Better late than never. 

Acute Knee Injury Management. 

• See this 2024 review on non-operative management of acute knee injuries

  • Importantly, this article highlights a shift toward non-operative management for most acute knee injuries.

  • Initial management from the ED is the same regardless of whether the injury will ultimately require surgery. The recommended approach includes RICE (rest, ice, compression, elevation), NSAIDs for pain, and protected weightbearing with crutches.

  • The trend across all these injuries is toward early protected motion rather than strict immobilization, even when surgery is planned.

  • Consider a hinged knee brace or patellar stabilizer brace if available

Lever Test for ACL Tear

• See video: https://www.youtube.com/watch?v=4Nn6IyEW5X8

• You can listen to this EMA episode discussing a study assessing its test characteristics

• The Lever Sign offers practical advantages compared to the Lachman: it is relatively pain-free, easier to perform, requires less experience to interpret, and has a clear visual endpoint (heel rising or remaining flat).

Monkeypox

See this review article in JAMA that discusses diagnosis and management.

1. When to suspect it: Painful skin lesions (especially anogenital/perioral) in any patient with potential exposure. Lesions may be few, atypical, or absent — proctitis or pharyngitis alone can be the presenting complaint.

2. How to test: Vigorously swab at least 2 lesions for PCR. Always co-test for STIs and HIV.

3. Infection control is straightforward: Single room, gown, gloves, eye protection, N95. No airborne isolation needed. 

4. Treatment is supportive: NSAIDs/acetaminophen, topical lidocaine, sitz baths, stool softeners. There is no FDA-approved antiviral. Tecovirimat is available via clinical trial/expanded access for severe or high-risk cases but did not reduce lesion duration in a recent RCT.

5. Flag high-risk patients early: Those with advanced HIV (CD4 <200) or solid organ transplants are at risk for severe/fatal disease. These patients warrant infectious disease consultation and consideration of investigational antivirals.

References

1. Jadidi S, Lee AD, Pierko EJ, Choi H, Jones NS. Non-operative Management of Acute Knee Injuries. Curr Rev Musculoskelet Med. 2024 Jan;17(1):1-13. doi: 10.1007/s12178-023-09875-7. Epub 2023 Dec 14. PMID: 38095838; [pubmed]

2. Titanji BK, Hazra A, Zucker J. Mpox Clinical Presentation, Diagnostic Approaches, and Treatment Strategies: A Review. JAMA. 2024 Nov 19;332(19):1652-1662. doi: 10.1001/jama.2024.21091. PMID: 39401235. [pubmed]