Jackson Jeffrey L, O'Malley Patrick G, Kroenke Kurt
Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
Ann Intern Med. 2003 Oct 7;139(7):575-88. doi: 10.7326/0003-4819-139-7-200310070-00010.
The evaluation of acute knee pain often includes radiography of the knee.
To synthesize the literature to determine the role of radiologic procedures in evaluating common causes of acute knee pain: fractures, meniscal or ligamentous injuries, osteoarthritis, and pseudogout.
MEDLINE search from 1966 to October 2002.
We included all published, peer-reviewed studies of decision rules for fractures. We included studies that used arthroscopy as the gold standard for measuring the accuracy of the physical examination and magnetic resonance imaging (MRI) for meniscal and ligamentous knee damage. We included all studies on the use of radiographs in pseudogout.
We extracted all data in duplicate and abstracted physical examination and MRI results into 2 x 2 tables.
Among the 5 decision rules for deciding when to use plain films in knee fractures, the Ottawa knee rules (injury due to trauma and age >55 years, tenderness at the head of the fibula or the patella, inability to bear weight for 4 steps, or inability to flex the knee to 90 degrees) have the strongest supporting evidence. When the history suggests a potential meniscal or ligamentous injury, the physical examination is moderately sensitive (meniscus, 87%; anterior cruciate ligament, 74%; and posterior cruciate ligament, 81%) and specific (meniscus, 92%; anterior cruciate ligament, 95%; and posterior cruciate ligament, 95%). The Lachman test is more sensitive and specific for ligamentous tears than is the drawer sign. For meniscal tears, joint line tenderness is sensitive (75%) but not specific (27%), while the McMurray test is specific (97%) but not sensitive (52%). Compared with the physical examination, MRI is more sensitive for ligamentous and meniscal damage but less specific. When the differential diagnosis for acute knee pain includes an exacerbation of osteoarthritis, clinical features (age >50 years, morning stiffness <30 minutes, crepitus, or bony enlargement) are 89% sensitive and 88% specific for underlying chronic arthritis. Adding plain films improves sensitivity slightly but not specificity. Plain films for pseudogout are not sensitive or specific, according to limited-quality studies.
We recommend the Ottawa knee rules to decide when to obtain plain films for suspected knee fracture. A careful physical examination should be sufficient to decide whether to refer patients with potential meniscal and ligament injuries, and we prefer clinical criteria rather than plain films for evaluating osteoarthritis. We do not recommend using plain films to diagnose pseudogout.
急性膝关节疼痛的评估通常包括膝关节X线检查。
综合文献以确定放射学检查在评估急性膝关节疼痛常见病因（骨折、半月板或韧带损伤、骨关节炎和假性痛风）中的作用。
1966年至2002年10月的MEDLINE检索。
我们纳入了所有已发表的、经同行评审的骨折决策规则研究。我们纳入了以关节镜检查作为衡量体格检查准确性的金标准以及以磁共振成像（MRI）作为评估膝关节半月板和韧带损伤的研究。我们纳入了所有关于X线片在假性痛风中应用的研究。
我们对所有数据进行了双人提取，并将体格检查和MRI结果汇总到2×2表格中。
在5条关于何时对膝关节骨折使用平片的决策规则中，渥太华膝关节规则（因外伤导致且年龄>55岁、腓骨头或髌骨压痛、无法负重行走4步或无法将膝关节屈曲至90度）有最强的支持证据。当病史提示可能存在半月板或韧带损伤时，体格检查具有中等敏感性（半月板损伤，87%；前交叉韧带损伤，74%；后交叉韧带损伤，81%）和特异性（半月板损伤，92%；前交叉韧带损伤，95%；后交叉韧带损伤，95%）。Lachman试验对于韧带撕裂比抽屉试验更敏感和特异。对于半月板撕裂，关节线压痛敏感（75%）但不特异（27%），而McMurray试验特异（97%）但不敏感（52%）。与体格检查相比，MRI对韧带和半月板损伤更敏感但特异性较低。当急性膝关节疼痛的鉴别诊断包括骨关节炎加重时，临床特征（年龄>50岁、晨僵<30分钟、摩擦音或骨肿大）对潜在慢性关节炎的敏感性为89%，特异性为88%。增加平片检查可略微提高敏感性但不提高特异性。根据质量有限的研究，用于假性痛风的平片检查既不敏感也不特异。
我们推荐使用渥太华膝关节规则来决定何时对疑似膝关节骨折进行平片检查。仔细的体格检查应足以决定是否转诊可能存在半月板和韧带损伤的患者，并且我们更倾向于使用临床标准而非平片来评估骨关节炎。我们不建议使用平片来诊断假性痛风。
