ortho/knee injury/major boo-boo

So some of you may recall in one of my previous blog posts, I saw a patient who had come in with a patellar fracture – avulsion fracture that happened when the ligament/muscle contracted and pulled off a small bit of the patella bone (also known as the kneecap). I got called to the consultant’s office recently because of this case – and I wanted to share a key element that I missed in my diagnosis/management that I wouldn’t want someone else to repeat.

So to recap (in case i am flattering myself and no one has actually read the afore-mentioned blog post :p) This was a 40 something year old male, with a football injury. Now when I say football injury, it wasn’t your usual contact trauma. No. He hadn’t played in a while, and without warming up very well, he began playing. He went in to kick the stationary ball, and as he pivoted on his left leg, and used his right leg to go in for the kick, he heard (felt?) a crack in his left leg which was basically his weight-bearing leg as he went in for the kick and he stopped there without being able to kick the ball. He was able to stay standing, but felt his knee go a bit wobbly and unsteady – ‘as if I couldn’t trust to put my weight on my knee, Doc’ – and so he laid himself down on the ground. He didn’t think it was extremely painful, but certain movements did make him prone to the occasional twinge of pain. He was able to hobble on the left leg, but unable to walk properly due to the unsteadiness of his knee joint. By the time he got to the ED and was seen by myself, it had been nearly 3 hours since the injury and his knee had become quite swollen. Not red or inflamed looking but definitely quite significant soft tissue swelling, with particular tenderness overs knee cap or patella bone. On examination, there seemed to be quite a doughy consistency swelling all around the joint, and even though he was able to flex the knee, he was unable to extend the knee fully without help (I assumed due to pain).

Even though there was no direct trauma to it (in that he hadn’t knocked the knee directly onto anything) and he could put his weight on it and walk (hobble?) on his own without support, made me question whether or not I should x-ray the injury. I did end up x-raying his knee, and to my surprise (I was surprised at how surprised I was!) found him to have had an avulsion fracture of his patella. I asked the ENP what needed to be done in this case, and she advised a cricket pad splint, with a fracture clinic referral for the next possible date. This was the last day of the week and so since this wasn’t apparently a clinical emergency, he was given an appointment for the fracture clinic for the following monday (3 days after the injury) and sent home with a cricket pad splint and crutches. He felt quite comfortable with this plan.

Fast forward to a few weeks later when as I mentioned the consultant asked me to see them in their office. Needless to say, I was scared I had made the ultimate boo-boo, and went though my mind every scenario of every patient I had seen recently that had seemed like it might lead to a conversation with the consultants (I am slightly embarrassed to admit many such cases came to mind) but when the consultant mentioned this case, I was surprised, I thought I had done good management there – assessed the patient, investigated and found a fracture, dealt with it and had also safety-netted him with a fracture clinic appointment. Where did I go wrong?

To be fair, the consultant quickly reassured me that there wasn’t any major issues ongoing. I hadn’t missed anything, on the contrary I had actually picked up something. The two things that needed to be learning experiences for me from this case were:

A) it was not just a patellar avulsion, the whole of the quadriceps tendon had become ruptured – the orthopaedic team had therefore complained that while they appreciated me picking up the injury, they would have liked to deal with it sooner than the 3-days-later non-urgent clinic appointment. I should have called the orthopaedic team on call at the time and gotten this patient seen by them and they would probably have admitted him overnight and done a surgical correction the next day (which was the management of this kind of injury) and while they appreciated my very detailed examination notes from the knee exam (even my own consultant was more than slightly happy at the knee exam!), I had failed to check – or document that I had checked! – the fact that the patient could not perform extension at the knee joint, which should have raised the possibility of patellar tendon rupture

B) Never, ever, EVER use cricket pad splints for…anything in the ED! I am supposed to be reading up on the use (or discouraged use!) of these in the ED and while I haven’t yet had the chance to read up on them, I have been advised to not use these for any injuries unless expressly advised by an orthopaedic or emergency medicine consultant. Check this space again later and I will update this blog post with the WHY of this.

A third aspect of the written complaint was highlighted by my consultant, I had apparently been promoted without being aware of it (this was said in slight jest by my consultant), as the orthopedic consultant felt that it was unforgivable for ‘an ST4 EM trainee (registrar level) to have missed such a crucial management point’ – I am only a lowly year 1 trainee currently!

Anyway, the take home messages from this incident need to be addressed and learnt, and while the patient did not suffer any adverse effects and got his surgery done, and there was no harm done, it is best to be aware of all protocols and nuances of management – and when in doubt, ASK!

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