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Der verletzte Meniskus: Wie sicher ist die klinische Untersuchung?

Eine Metaanalyse

Value of the clinical examination in suspected meniscal injuries

A meta-analysis

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Zusammenfassung

Hintergrund

Die klinische Untersuchung des Kniegelenks bei einer vermuteten Meniskusläsion dient zur Objektivierung der Verdachtsdiagnose. Dem Untersucher stehen neben der Inspektion und Palpation zahlreiche funktionelle Tests zur Verfügung, die durch Schmerzprovokation oder Auslösen eines Schnappphänomens den verletzten Meniskus kennzeichnen. Die diagnostische Wertigkeit dieser Tests wird unterschiedlich bewertet.

Material und Methodik

Über eine systematische Literaturrecherche in Medline und der Cochrane-Datenbank erfassten wir im Zeitraum von 1966 bis 2008 sämtliche Publikationen zur klinischen Untersuchung bei Meniskusläsion. Im Anschluss wurden diese durch 2 Reviewer unabhängig nach ihrer methodischen Qualität bewertet und einem Evidenzgrad (CEBM) zugeordnet. Für jeden Test wurden Sensitivität, Spezifität, positiver prädiktiver Wert (PPV), negativer prädiktiver Wert (NPV) sowie die positive und negative Likelihood-Ratio (LR+/LR−) berechnet, um die diagnostische Güte der klinischen Meniskustests zu beurteilen.

Ergebnisse

Die höchste Testqualität zeigte der Thessaly-Test (Sensitivität 91%, Spezifität 97%, PPV 97%, NPV 91%, LR+ 31,1, LR− 0,1). Eine eingeschränkte Aussagefähigkeit zeigten der Mc Murray-Test (Sensitivität 51%, Spezifität 78%, PPV 70%, NPV 61%, LR+ 2,3, LR− 0,6), „Druckschmerz im Gelenkspalt“ (Sensitivität 64%, Spezifität 61%, PPV 62%, NPV 63%, LR+ 1,6, LR− 0,6), der Apley-Grinding-Test (Sensitivität 38%, Spezifität 84%, PPV 71%, NPV 58%, LR+ 2,4, LR− 0,7) und der Ege-Test (Sensitivität 66%, Spezifität 86%, PPV 83%, NPV 72%, LR+ 4,7, LR− 0,4). Die Evidenz für den Steinman-Test, den Bragard-Test sowie für die Meniskuszeichen nach Böhler oder Payr konnte nicht geprüft werden.

Schlussfolgerung

Mit Hilfe verschiedener Tests kann eine Meniskusläsion diagnostiziert werden. Unter Anwendung des Thessaly-Tests kann die Wahrscheinlichkeit der richtigen Diagnosestellung erhöht werden, jedoch lässt sich dies bislang nur durch die Ergebnisse einer Studie belegen. Bei Patienten mit nicht eindeutigem klinischem Befund oder bei Verdacht auf Kombinationsverletzungen sind zur Diagnosesicherung weitere diagnostische Schritte wie z. B. die MRT indiziert. Bei klinisch sicherem Befund führt dagegen die Anfertigung zusätzlicher bildgebender Untersuchungen anderen Autoren zufolge nur in wenigen Ausnahmefällen zu einer Konsequenz für die spätere Behandlung.

Abstract

Introduction

The physical examination of the knee in cases of suspected meniscal tears serves to increase the probability of a correct diagnosis. Although there is a large variety of functional tests, the quality of each diagnostic test is controversially discussed.

Materials and methods

Through a systematic literature search in Medline and the Cochrane Database two reviewers independently screened publications, evaluated each study for methodological quality and categorized them into levels of evidence (CEBM). Sensitivity, specificity, positive and negative predicted value, as well as positive and negative likelihood ratio (LR+/LR−) values were calculated in order to render the quality threshold of the physical examination in meniscus impairment.

Results

The Thessaly test (sensitivity: 91%, specificity: 97%, PPV: 97%, NPV: 91% LR+: 31.1, LR−: 0.1) revealed the highest test quality. Limited quality was shown for the Mc Murray test (sensitivity: 51%, specificity: 78%, PPV: 70%, NPV: 61%, LR+: 2.3, LR−: 0.6), “joint line tenderness” (sensitivity: 64%, specificity: 61%, PPV: 62%, NPV: 63%, LR+: 1.6, LR−: 0.6), the Apley-Grinding test (sensitivity: 38%, specificity: 84%, PPV: 71%, NPV: 58%, LR+: 2.4, LR−: 0.7) and the Ege test (sensitivity: 66%, specificity: 86%, PPV: 83%, NPV: 72%, LR+: 4.7, LR−: 0.4). Evidence for Steinman’s test, Bragard’s test and the meniscal signs of Böhler or Payr could not be tested.

Conclusion

Meniscal injury can be detected by several functional tests. Using the Thessaly test can improve the physical examination by means of probability of the correct diagnosis, but the results are based on a single study. In patients with ambiguous findings in the physical examination or with suspected combined injury, further diagnostic procedures such as magnetic resonance imaging are necessary to confirm the diagnosis. In clinically certain cases the use of additional diagnostic imaging procedures should be avoided as other authors have shown that with few exceptions this has no influence on the therapy.

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  1. Chirurgische Klinik und Poliklinik, Klinikum der Ludwig-Maximilians-Universität, Campus Innenstadt, München, Deutschland

    B. Ockert, F. Haasters, H. Polzer, S. Grote, M.A. Kessler, W. Mutschler & K.-G. Kanz

  2. AO Research Institute Davos (ARI), AO Foundation, Clavadelerstr. 8, CH-7270, Davos, Schweiz

    B. Ockert

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  1. B. Ockert
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Ockert, B., Haasters, F., Polzer, H. et al. Der verletzte Meniskus: Wie sicher ist die klinische Untersuchung?. Unfallchirurg 113, 293–299 (2010). https://doi.org/10.1007/s00113-009-1702-2

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