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!

The back pain that became a pain in the … back!

Mechanism. Never forget mechanism of injury when assessing a patient with any sort of trauma. We tend to get distracted by other people’s assessments, or their version of events, or their assessment of injuries – do NOT fall into that trap. Always start from scratch, when you are the one responsible ultimately. And always, ALWAYS take mechanism of injury into consideration, however minimal the injuries may seem to be.

Quite a while ago now, I had a patient in ED, middle-aged female who had a background of hypertension and had previously had some chronic respiratory illness, and a heart rhythm abnormality called atrial fibrillation, for which she was on warfarin – an anticoagulant. She had come in with the history of traumatic back pain. As the story went, she had been lifting some sort of semi-heavy load outside her house, and had turned around (or intended to turn around) and fallen over backwards on 2 very low steps, in the process also managing to hit her head against a brick wall. She did not lose consciousness, and her husband heard her scream, and came out of the house at once to help her. She was unable to get up on her own, but with help got to her feet and felt fine. Due to her hitting her head, her husband felt they should get a check up, so they came into the ED. Enter yours truly – their saviour in shining armour. Or not.

I assessed the patient, took a detailed history, and fully examined her. I had in the back of my mind right from the outset that she needed a scan of the head due to her head injury while being on warfarin. She denied any neck pain, and had no palpable tenderness of the bony bits in her c-spine, or neck. She also complained of mid to lower back pain, but not in the midline, rather on the right side. I specifically feltĀ all the palpable bony aspects of her vertebral column from top to (literal) bottom, and it did not elicit any pain. There was no bruising (surprising, since she was on an anticoagulant, and had literally landed on her back on the stairs). She had full range of motion of her majors joints, and had walked in to the department to be assessed. For all intents and purposes, her major injury was the head wound, and for that I requested a CT scan of the head. It came back as normal. I found no reason to investigate anything else. Her back pain wasn’t too severe, but I still advised her to take regular analgesia, and to seek medical help if it was worsening, or not improving after a few days, or if she had any other concerns (a typical statement for me when I discharge any patient). I sent her home with some head injury advice, instructing her husband on the red flag signs to look out for, and if any concerns to come back to us. I documented the whole encounter, and went on to see my next patient.

I found out later that the patient had returned 2-3 days later, because her back pain had not improved, rather it had become much worse, and she found it difficult to mobilise out of bed. One of my other colleagues very kindly examined her this time, there was still no bony tenderness in her back, and her pain seemed to be localised to the right side of her lower back, and my colleague agreed that it seemed very much like a soft tissue injury. However, because this was the patient’s second visit to ED with the same complaint – and the situation had worsened to the point that her activities of daily living were being hampered (like getting out of bed!) – he requested an x-ray of her thoracolumbar spine, which revealed to my extreme embarrassment and shock a wedge fracture of one of the vertebral bodies. She was admitted under orthopaedics, and I crawled into a hole and died. No I didn’t.

I read up on traumatic back pain, and I gathered as much information as I could about it. I also gave a presentation to my other colleagues in the department, as a learning point. Here is what I learnt, and I utilise this information everyday: Whenever assessing traumatic back pain, the method that I have been taught and always employed was the one I have described. What is now advised, is to not just palpate the bony prominences of the vertebrae, but to place one hand on the bony prominence of the spine at any level – with the palm resting on the back; then make a fist out of your other hand, and lightly tap the fist onto the back of the hand that is flat on the back – if it elicits any pain anywhere on the back, investigate further (do x-rays) – and assess the whole vertebral column integrity in this fashion.

I have also learnt after discussing this at length with many of my colleagues of varying seniority and specialty, that even though clinically an x-ray may not have been warranted at the first presentation, yet purely based on mechanism if you looked at it, along with her age group (women middle-aged and above are more likely to begin to have osteoporotic fractures with moderate trauma), an x-ray would not have been completely out of the question.

To this day, I am terrified when I see ‘back pain – fall’ as my next patient’s presenting complaint. But I am more, much more cautious now, and I am sharing this experience to highlight how easy it is to miss something even if you are looking for it at the right place and at the right time, and I hope this post will serve to help/guide someone to not make the same mistake I did. Cheerio!