Ligamentous Injuries of the Knee Ligamentous injuries to the knee are less common than fractures of the epiphyses and physes around the knee until the growth plate closes ( Fig 111.45 ) Most injuries occur from direct trauma to the knee or from valgus or varus stress, as experienced during athletic activities The medial collateral and anterior cruciate ligaments (ACLs) are injured most frequently, with ACL injuries often associated with avulsion of the tibial spine ED management often involves exclusion of a bony injury, and then outpatient referral for repeat evaluation when the swelling has improved and examination may be more reliable Use of immobilizers is warranted for patients with significant pain with movement, but care should be taken to avoid prolonged use without repeat evaluation due to risk of quadriceps atrophy Outpatient referral to orthopedics is recommended, and MRI may be required for further evaluation of any bony and soft tissue injuries FIGURE 111.43 Transverse fracture of the patella in an 11-year-old victim of a motor vehicle collision (arrow )