Here’s a follow-up to the case about the twisted knee (read about it here, if you want the background):
Options for treating and working up the guy’s knee included simple stuff like rest, ice and a knee immobilizer. Additionally, my fantabulous American health care system gave me the options of providing the pt with a CT or MRI, Xray and/or referral to a orthopedic specialist. I also could have mentioned that skiing and any other sport involving coordination + velocity should be bypassed from that moment forward.
I picked R-I-C-E, first and foremost. R-est, I-ce, C-ompression and E-levation tend to cover a multitude of musculoskeletal injuries. I put a knee-immobilizer on his leg, which really does little for the joint other than force it to stay still, which leads to much less pain, which leads to less involuntary muscle flexion, which might help healing but helps the pain for sure. Finally, I prescribed clinical-strength anti-inflammatories. I did not get imaging or send him to a surgeon.
It has been about a week now, and he is doing reasonably well. It will be a long time until he forgets to think about his knee when he is doing any sport. He may never have perfect use of his knee, although I still expect a full recovery at this time.
MRI is considered the gold-standard for knee (and joint) injury. But a good physical exam by a real smart doc (jury’s out on me) is statistically just as likely to identify joint pathology. When I started med school, this ohooollldd doc gave us a lecture on the physical exam. I can see why they picked this guy for the lecture because he stood up there growling for an hour about how he could diagnose pathology just as well as these “young docs who don’t know nuthin’ except for how to order more technology.”
“You can learn all you need to know just from the physical exam.” He said often, before falling asleep and asynclitically engaging his coffee cup.
His dictum is less true when it comes to detecting early cancers, etc., but he is right to some extent. We use more imaging than we need to, and it contributes in a small way to the higher cost of medical care in America. This patient is recovering as fast as can be expected (that is to say, sloooww) under the circumstances. He probably wouldn’t heal any faster with surgical intervention, either. He just needs to wait it out.
And I hope he keeps skiing.
5 responses so far ↓
medical question blog » Blog Archive » Twisted Knee - What I Did // March 4, 2008 at 6:16 am |
[...] secretwave101 wrote an post worth reading today.Here’s a quick excerpt:But a good physical exam by a real smart doc (jury’s out on me) is statistically just as likely to identify joint pathology. When I started med school, this ohooollldd doc gave us a lecture on the physical exam. … [...]
satyampatel // March 15, 2008 at 10:02 pm |
In terms of deciding what to do with the initial scenario, one needs a little more info than you have provided.
Does he localize the pain? (e.g. medial or lateral joint line, posterolateral corner, fibular head, or hamstrings)
What was his ROM? (if he has a locked knee, RICE alone is not a good idea)
And was he tender at the endpoints of ROM?
Does he have a normal neurovascular exam?
Does he have a history of previous knee injuries or surgeries? (higher likelihood of ligamentous injury & meniscal injury)
In terms of further initial assessment, Xrays are a judgement call, as there is no equivalent for the Ottawa ankle rules in the knee. His young age and low energy injury makes tibial plateau fracture unlikely, but still possible. They’re usually pretty obvious clinically though.
If there’s no red flags to the above questions, RICE + crutches +/- brace / knee immobilizer is probably the way to go initially in this kind of situation.
After the first couple weeks, I think it is very important to re-examine ROM and confirm ligamentous stability.
Down the line, any complaints that are mechanical in nature (catching, clicking, locking) should be investigated further, as should complaints about instability – especially occuring with eccentric quads loading (e.g. walking down stairs) as these may represent meniscal lesions or a PCL injury respectively.
Early surgical intervention would primarily be beneficial in the setting of meniscal tears (early being < 3 months) or posterolateral corner laxity (early is <3 weeks) as early repair has had better results than delayed in those patients.
batguano101 // June 4, 2008 at 10:24 pm |
I just read the secondary note that did not show and you addressed the opiate issue.
Now, here is the way you work in a Rural Tropical Medicine Primary care clinic.
You do a complete physical and history, no xray, no MRI, pain relief as discussed, immobilize and apply RICE, write a note, and flag down a pick up truck to move patient to a hospital with an orthopedic surgeon where ever that may be that will work on him. Where I worked in a rural clinic the pickups have benches in the back and haul passengers through the mountains, doubling as an ambulance. For less than life threatening illness that HAS to be stabilized to make the trip this works fine. For very serious emergencies the colmado (general store) owner or a church pastor will take the patient to the door of an ER.
The diagnostic workup is the physical exam. Knowing where you can get which patient seen and treated, and transportation there is the issue, not the primary care treatment.
Amazingly enough you can do pretty good quality primary care this simply on the vast majority of patients at near zero cost compared to the USA.
Carolyn // August 13, 2008 at 4:02 pm |
Interesting read. I am awaiting the results of my MRI for almost the same exact symptoms. Any twising action at the foot, to the knee causes pain that almost makes me vomit. Sometimes, it feels fine….. I really hope they don’t come back and say they can’t find anything….. I will be upset, and frustrated. I have my MRI copies, but they are like reading a foreign language to me (one I don’t know)
Wish me luck.
Carolyn
cs // December 16, 2008 at 7:55 am |
shoot – probably a menisceal tear – McMurrays isn’t just clicking, pain also positive. with rotation (I usually check this with their legs dangling sitting on exam table) If problems squatting or pivot turns after 6 wks of conservative tx, shoudl send for MRI or refer to one of me – guy that young and active will probably need a scope unless MRI neg then send to PT for stabilization exercises…