A case of Knee bucklingdisc extrusion L3 – L4

Vinod NaneriaGirish Yeotikar

Arjun WadhwaniChoithram Hospital & Research Centre,

Indore India

Case summary

• A 40 years old male C/o acute pain in the right knee associated with frequent fall since last 7 days.

• No history of trauma.• He was scared to walk with out support. • Patient was limping and had insecurity while

walking.• Now pain was gradually reducing.

Clinical examination

• Right knee was cold, (no inflammation)• no deformity, • no effusion, • no tenderness,• no laxity and had full range of movements. • Patello-femoral joint was normal.

Clinical examination

• Examination of hip:• full range free movements.• Spine full flexion, • SLRT - negative. • Ankle normal with palpable DP, & PT vessels.• EHL gr 5 power, • ankle jerks are normal on both sides.• Unable to walk on toes and heels.

Clinical examination

• There was no wasting of any muscle. • The history was only 7 days. • Active quadriceps was ok but not against

resistance (could be attributed due to pain). • Quadriceps weakness gr 3 ?• Left knee jerk was present.• Right knee jerk was absent.

Clinical examination

• Testing of knee reflex and comparing with deep reflexes of other limb, click the possibility of neurological involvement.

• Hence I asked for MRI. My patient had doubt in mind. His pain/discomfort was in/around knee and I am asking for MRI of spine!

Treatment

• Conservative– Pain was getting less.– Mono-radiculopathy.– Minimal neurological deficit.– Least possibility of progression/or deterioration of neurology.

comments

• L3 –L4 extruded disc can be missed.• Knee pain can come from spine and hip.• High degree of suspicion.• Through neurological examination.• Comparison on two sides.

comments

• When Patient’s narration of symptoms does not match with the clinical examination, it is better to over investigate the patient.

• When differentiating between an L3 radiculopathy versus a femoral neuropathy, weakness in the hip adductors in addition to the quadriceps group would indicate an L3 radiculopathy.

DISCLAIMER • Information contained and transmitted by this presentation is based

on personal experience and collection of cases at Choithram Hospital & Research centre, Indore, India.

• It is intended for use only by the students of orthopaedic surgery. • Views and opinion expressed in this presentation are personal. • Depending upon the x-rays and clinical presentations viewers can

make their own opinion. • For any confusion please contact the sole author for clarification.• Every body is allowed to copy or download and use the material best

suited to him. • We not responsible for any controversies arise out of this

presentation. For any correction or suggestion please contact naneria@yahoo.com