Knee Pain After a Fall

The Eyes See What the Mind Let’s It

Thomas V Gocke, MS, ATC, PA-C, DFAAPA President & Founder Orthopaedic Educational Services, Inc. Boone, NC [email protected] www.orthoedu.com

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• Clinical Case review for Shoulder related injuries/conditions

• Clinical Case review for Wrist and Hand related injuries/conditions

• Clinical Case review for knee related injuries/conditions

• Clinical Case review for Foot related injuries/conditions

• Clinical Case review for Pediatric related injuries/conditions

Orthopaedic Educational Services, Inc. © 2013 Orthopaedic Educational Services, Inc. all rights reserved. Shoulder Pain • Chief Complaint: intractable RTC/Shoulder pain • History: – 56 yo male with 3+month hx worsening shoulder pain – Progressively getting worse - constant – Now unable to lift arm without assistance – No hx of trauma – No sports or strength training activity – No moving/yard work/home improvements/child care/automotive/factory • Presenting Symptoms: – Severe, constant pain – Deltoid pain – Sleep pain – Nite pain – Limited ROM Orthopaedic Educational Services, Inc. © 2013 Orthopaedic Educational Services, Inc. all rights reserved. Shoulder Pain • Allergies: none (Drugs-Food-Latex) • Medications: OTC NSAIDS, Verapamil, Atorvastatin • PMH: HTN, Hypercholesterolemia • SocialHx: occasional cigar & etoh, negative drugs • FMH: Throat/Lung CA • Physical Exam: – General: AAO, normal appearance, no acute distress – Skin-no abnormalities – Palpate: tender AC jt, Coracoid, Deltoid/Proximal humerus – ROM: limited shoulder/painful, normal cervical ROM – Neuro/sensory intact – Ortho Tests: unable to perform 2nd to pain Orthopaedic Educational Services, Inc. © 2013 Orthopaedic Educational Services, Inc. all rights reserved. Radiographs PCP office 3+ moths ago

What is your Diagnosis • RTC Impingement • Rupture RTC Tendon • Shoulder Arthritis • Proximal Humerus fx • Cervical

PCP office 3+ moths ago ER Visit

Radioluce nt tumor

Radiolucent Tumor Orthopaedic Educational Services, Inc. © 2013 Orthopaedic Educational Services, Inc. all rights reserved. Treatment • Diagnosed with Renal Cell Carcinoma – Originates lining proximal convoluted tubules kidney – Most common kidney cancer in adults (80%) – Frequently presents: back/groin pain, Abd mass, weight loss, hematuria – Metastasis to bone (pelvis most common) – Responds poorly to Radiation and Chemotherapies – Favorable response to Immunotherapy – 5 year survival for patients with metastatic renal cell carcinoma is between 5 and 15%

Orthopaedic Educational Services, Inc. © 2013 Orthopaedic Educational Services, Inc. all rights reserved. Treatment • Diagnosed with Renal Cell Carcinoma – Originates lining proximal convoluted tubules kidney – Most common kidney cancer in adults (80%) – Frequently presents: back/groin pain, Abd mass, weight loss, hematuria – Metastasis to bone (pelvis most common) – Responds poorly to Radiation and Chemotherapies – Favorable response to Immunotherapy – 5 year survival for patients with metastatic renal cell carcinoma is between 5 and 15%

• Unusual diagnosis for RTC type symptoms • Variety conditions can cause shoulder pain – RTC tendonitis – Biceps Tendonitis – Impingement Syndrome – Cervical Radiculopathy – Gleno-Humeral (GH)joint arthritis – Zebras • Recognize failures to respond to conservative care • Recognize other conditions & physical exam • Proficient skeletal x-ray review

Orthopaedic Educational Services, Inc. © 2013 Orthopaedic Educational Services, Inc. all rights reserved. Knee Pain after a Fall • CC: knee pain • HPI: – 78 yo female tripped and fell on a flexed knee – Acute onset of pain and unable to walk – Pt taken to local ER by EMS 2nd to pain & unable to walk • PE: (ED) – Vital signs stable – Difficulty with weight bearing – improved after pain management

Orthopaedic Educational Services, Inc. © 2013 Orthopaedic Educational Services, Inc. all rights reserved. Knee Pain after a Fall • PE: (ED) cont. – Radiographs • KNEE AP & Lateral : negative – Diagnosis: • Contusion Knee – Treatment: • NSAIDS • Ice • Knee immobilizer/walker/TDWB-WBAT • Follow-up appt 1 week on-call orthopaedist Orthopaedic Educational Services, Inc. © 2013 Orthopaedic Educational Services, Inc. all rights reserved. Knee Pain after a Fall 2nd opinion Orthopaedic Follow-up • Allergies: NKDA • Meds: Lisinipril, HCTZ, OCP, Naprosyn, Hydrocodone • PMH: HTN, GERD, Kidney stones, carpal tunnel • SurgicalHx: Shoulder arthroscopy • SOCHx: + etoh; - tobacco/drugs • FAMHx: HTN, DM, GERD, Asthma/COPD • ROS: + knee pain, all other systems negative • Vital Signs: BP- 186/101, P- 90 reg, R-20,

Orthopaedic Educational Services, Inc. © 2013 Orthopaedic Educational Services, Inc. all rights reserved. Knee Pain after a Fall On-call Orthopaedic Follow-up • HPI – Seen 3 times by on-call ortho MD (day 3, day 10 & day 18) – Pain escalating & constant – Difficulty sleeping, sitting, standing – Initially able to ambulate – now unable to walk • Complains foot is turning out and catching foot on furniture – Refill pain meds twice w/ no relief – Told to improve home treatment & D/C walker • Heating pad on knee for pain • Increase walking Orthopaedic• Home Exercise program prescribed Educational Services, Inc. © 2013 Orthopaedic Educational Services, Inc. all rights reserved. Knee Pain after a Fall

Orthopaedic Follow-up • Physical examination: R knee – Gen: WNWD, NAD – MSK: • No knee effusion, no skin lesion or bursing, no deformities • Unable to wt bear • ROM- -5 -0-90 degrees (painful) • No tenderness knee or thigh • No ligament laxity • Noticeable leg length difference • External rotated right foot • NV, NS intact Orthopaedic Educational Services, Inc. © 2013 Orthopaedic Educational Services, Inc. all rights reserved. Knee Pain after a Fall

2nd opinion Orthopaedic Follow-up • HPI – presented 3 weeks after initial injury occurred to our clinic – Pain uncontrollable with narcotic analgesics – Difficulty sleeping, sitting, standing – Wheelchair or bed bound – Pt states on-call ortho x-rayed knee twice with neg. – Home treatment making pain worse

Orthopaedic Follow-up • X-ray examination – AP, LAT & Skyline

What is your diagnosis? a. Lateral Femoral Condyle fracture b. Patella fracture c. Tibial Plateau fracture d. Femoral neck fracture

Orthopaedic Educational Services, Inc. © 2013 Orthopaedic Educational Services, Inc. all rights reserved. Diagnosis: Femoral Neck Fx Basicervical Femoral Neck Fx. • Cause – 2nd falls or trauma – Osteoporosis – Tumor • Symptoms – Age – Fall – Pain – Inability to wt-bear – Leg length inequality – Rotation deformities Photo courtesy TGocke, PA-C

Orthopaedic Educational Services, Inc. © 2013 Orthopaedic Educational Services, Inc. all rights reserved. Take Home Points • Hip Injuries provide referred pain to the knee • Key points over looked – 2 negative knee x-rays – Unable to wt- bear – Escalating symptoms – Foot turning out • Consider – Lumbar/Pelvic fx – Hip Fx – Knee fx (Tibial plateau) Proficient Physical Exam & Skeletal x-ray review

Orthopaedic Educational Services, Inc. © 2013 Orthopaedic Educational Services, Inc. all rights reserved. “Bilateral Knee pain” HPI: • 34 YO African-American involved 4 wheeler accident 10 days ago • Ejected from 4 wheeler & reports striking left knee against the ground. • He was unable to walk or bend his knee 2nd to pain. • Seen the following day in a local ER for exam and x-rays. • Reports x-ray was neg for fx and was told he had a bad contusion • Placed in a knee immobilizer, given Rx for narcotics and told to follow up if he was not better in a week • He was instructed on crutch ambulation but chose not to use the crutches. Orthopaedic Educational Services, Inc. © 2013 Orthopaedic Educational Services, Inc. all rights reserved. “Bilateral Knee pain”

HPI - continued • 3 days after ER visit pt stumbled off a street curb & reported a sudden popping sensation with pain right knee • Seen ER for exam and x-ray. Again had a neg. x-ray and told he strained a tendon in his right knee. • Place in a knee immobilizer and told to follow up if he was not better in a week. Narcotic Rx was refilled and also given Rx for Ibuprofen.

Current History • Pt presented to clinic 10-12 days post injury • Complained of decreased ability to walk and pain in both knees. • Reported knee immobilizers fit poorly and he was tired of using the crutches. • Described intense pain w/flex/ext either knee. • Reports swelling in both knees that has not gone away • Denies F/C/S, radicular symptoms and is able to stand & walk with the immobilizers

Orthopaedic Educational Services, Inc. © 2013 Orthopaedic Educational Services, Inc. all rights reserved. “Bilateral Knee pain” • Allergies: NKDA • PMH: ESRD, Home hemodialysis, IDDM, HTN • SHx: hemodialysis shunt LUE • Meds: Insulin, HTN meds, narcotics • SocHx: + tobacco, ETOH, - drugs • Exam: – 2+ effusion R & L knees – Skin: no lesions – ROM: 0 to 10 degrees, pain with flex ROM passively – Neurovascular: 2+ pulses – Ortho: no laxity, poor quad strength, unable to SLR or terminal extend • X-rays – AP, Lateral and Sunrise Orthopaedic Educational Services, Inc. © 2013 Orthopaedic Educational Services, Inc. all rights reserved. Radiographs Left Knee Right Knee

What is your Diagnosis? Traumatic Patellar Tendonitis Quad Contusion Quad Tendon Rupture Calcific Patellar Tendonitis Dislocated Patella Patellar Tendon Rupture Traumatic Quad Tendonitis

ANSWER

Quad Tendon Rupture – Right Knee Patellar Tendon Rupture – Left Knee

Left Knee • Radiographs – Large joint effusion – Traction patella – Inferior pole patella avulsion fx (irregular border) – Bone Fragment patellar tendon (distal) – OCD patella

Right Knee • Radiographs – Large joint effusion – Splayed patella – Patella tethered (inferior) – Swollen thigh (distal)

Orthopaedic Photo courtesy TGocke, PA-C Educational Services, Inc. © 2013 Orthopaedic Educational Services, Inc. all rights reserved. Take Home Points • Mechanism of injury – 4 wheeler accident & pop stepping off curb. • PMH: ESRD, Home hemodialysis, IDDM • SocHx: tobacco • Described intense pain w/flex/ext either knee. • Inability to perform SLR against gravity • Inability to perform terminal knee extension • Reports x-ray was neg for fx • Obvious x-ray findings: • Joint effusion • Changes to patella alignment • Changes patellar tendon Orthopaedic Educational Services, Inc. © 2013 Orthopaedic Educational Services, Inc. all rights reserved. Sprained Knee

Orthopaedic Educational Services, Inc. © 2013 Orthopaedic Educational Services, Inc. all rights reserved. Sprained Knee HPI: • 34 YO male injured the right knee when he tripped over a tree root in the sidewalk • Unable to recall events of injury 2nd to admitting to ETOH. • He was unable to walk or bend his knee 2nd to pain. • Seen the following day in the ER for exam and x-rays. • Reports x-ray was neg for fx and was told he had a bad sprain • Admitted to the Medicine services 2nd to intoxication lab abnormalities and inability to wt bear.

Orthopaedic Educational Services, Inc. © 2013 Orthopaedic Educational Services, Inc. all rights reserved. Sprained Knee • Allergies: NKDA • PMH: IDDM, HTN • Meds: Insulin, HTN meds, • SocHx: ETOH, - drugs • Exam: – 3+ effusion R knees – Skin: no lesions – ROM: 0 to 10 degrees, pain with any knee motion – Neurovascular: faint pulses, drop foot, L5 sensory changes – Ortho: Poor exam 2nd to body size, pain with any motion • X-rays – AP, & Cross-table Lateral

What is your Diagnosis?

Traumatic Patellar dislocation Quad Tendon Rupture Patellar Tendon Rupture ACL Rupture LCL Rupture Knee Dislocation

Medial meniscus tear ACL, PCL, LCL, Deep MCL ruptures Iliotibial band rupture Biceps Femoris Tendon rupture Popliteus Tendon rupture Posterior lateral corner Capsule tear Common Peroneal nerve rupture

Orthopaedic Educational Services, Inc. © 2013 Orthopaedic Educational Services, Inc. all rights reserved. Take Home Points • Mechanism of injury – – Vague hx • Physical Exam changes: – Unable to move knee – Drop Foot – Dorsal foot sensory changes – Asymmetric pulse assessments • PMH: ETOH • Reports x-ray was neg for fx • Joint effusion • Lateral joint swelling • Avulsion fx Fibular head • Varus knee alignment Orthopaedic Educational Services, Inc. © 2013 Orthopaedic Educational Services, Inc. all rights reserved. Ankle/Foot Pain

Orthopaedic Educational Services, Inc. © 2013 Orthopaedic Educational Services, Inc. all rights reserved. Foot Pain • CC: Foot & ankle pain • HPI: – 11yo female fell climbing stairs of a “bouncy-house – Got foot and ankle caught under her as she fell – ? Inversion mechanism – Complained of ankle and foot pain – Painful wt bearing and significant ankle swelling – See in ER day of injury: x- Picture courtesy TGocke, PA-C ray ankle and foot shows 5th MT avulsion fx

Orthopaedic Educational Services, Inc. © 2013 Orthopaedic Educational Services, Inc. all rights reserved. Foot Pain Follow up same day Ortho PE: • Unable to wt bear • Limited ROM Ankle 2nd pain • Tender base 5th MT and Lisfranc • Tender Medial & Lateral malleolus Review of original X-ray

Picture courtesy TGocke, PA-C What is your Diagnosis?

Picture courtesy TGocke, PA-C Diagnosis? Picture courtesy TGocke, PA-C • 5th MT avulsion fx • Triplane Injury – Medial Tibial physis injury – Salter- Harris III tibia

Orthopaedic Educational Services, Inc. © 2013 Orthopaedic Educational Services, Inc. all rights reserved. Ankle/Foot Pain Diagnosis: 5th MT avulsion fx Triplane Fx Tibia* • Fx unrecognized original x-ray by Picture courtesy TGocke, PA-C initial provider • Salter-Harris III (IV) fx pattern – Epiphysis fx sagittal plane – Physis separated axial plane – Metaphysis fx coronal plane (lateral) • External rotation mechanism • 5th MT avulsion fx 2nd to Peroneus Brevis

Andrew J. Rosenbaum, MD; John A. DiPreta, MD; Richard L. Uhl, MD: Review of Distal Tibial Epiphyseal Transitional Fractures, Orthopedics, December 2012 - Volume 35 · Issue 12: 1046-1049 th RockwoodOrthopaedic & Wilkins: Fractures in Children, 7 edition 2009, WoltersKluwer Educational Services, Inc. © 2013 Orthopaedic Educational Services, Inc. all rights reserved. Take Home Points • High suspicion for growth plate injuries in pediatric injuries • Key points over looked – Provider did not know what to look for on x-ray – Not suspicious this injury pt. age range • Characteristics – Tibial growth plate fusion • Occurs between 12-15 yrs age • Transitional Fx rare before 10 yrs and after 16.5 yrs age • Closes over 18month time frame – Central – Medial - -Posteromedial –Lateral

• 68 yo male involved motor cycle accident vs. Semi- truck • Ejected 300 ft. • EMS to Community Hospital • Evaluated extremity injuries & D/C • Transported home by EMS • PMH – HTN – NIDDM – Sleep apnea – Asthma

• Allergies: NKDA • Meds: Lisinipril, HCTZ, OCP, Naproxen, Hydrocodone, cyclobenzaprine • PMH: HTN, GERD, Kidney stones, carpal tunnel, DM, COPD • SurgicalHx: GSW military service left ankle • SOCHx: +etoh; -tobacco, - drugs • FAMHx: HTN, GERD, Asthma/COPD • ROS: bilateral foot pain, abdominal pain, weak and dizzy • Vital Signs: BP- 114/64, P- 90 reg, R-16 non-labored

Orthopaedic Educational Services, Inc. © 2013 Orthopaedic Educational Services, Inc. all rights reserved. Foot Pain Physical Exam: Inspection: – Left foot/ankle: abrasions, fracture blisters, fusiform swelling, plantar bruising foot Palpation: tender Abdomen left ankle, right & left feet ROM: limited left ankle & foot motion, right ankle NL Strength: 3+/5 DF left foot Neuro/Vascular: CN II-XII intact, equal reflexes, pulses +1 Ortho: + Neck + Lumbar + Abdomen + Bilateral feet Orthopaedic Educational Services, Inc. © 2013 Orthopaedic Educational Services, Inc. all rights reserved.

Foot X-Ray

Photo courtesy TGocke, PA courtesy Photo Photo courtesy TGocke, PA courtesy Photo Orthopaedic Educational Services, Inc. © 2013 Orthopaedic Educational Services, Inc. all rights reserved. Foot Pain What should you have seen?

• High energy injury mechanism – Suspicious Lisfranc injury • Plantar Bruising- Lisfranc injury • Fracture Blisters - • Missed findings: – Wide Medial & Middle

cuneiform

C - – Suspect Tarso-Metatarsal

• High suspicion for Mid-Foot Injuries – Falls from height vs. High Energy Injury Mechanism – Hyper-plantar-flexed foot position – Significant swelling/Fx. blisters – Plantar foot bruising • Key points over looked – Level 1 trauma pt. – C-T-L spine, chest, pelvis, abdomen • encapsulated liver hematoma

Burroughs KE, Reimer CD, Fields KB: Lisfranc Injury of the Foot: A Commonly Missed Diagnosis, Am Fam Physician. 1998 Jul 1;58(1):118-124 Orthopaedic Educational Services, Inc. © 2013 Orthopaedic Educational Services, Inc. all rights reserved. Take Home Points

Characteristics • Medial / Middle / Lateral Cuneiforms & 1-2-3 MT base align • Cuboid & 4/5 MT base align

• Fleck sign- avulsion fx

C - Proficient Physical Exam & Skeletal x-ray review

Burroughs KE, Reimer CD, Fields KB: Lisfranc Injury of the

Foot: A Commonly Missed Diagnosis, Am Fam TGocke, PA courtesy Photo Physician. 1998 Jul 1;58(1):118-124 Orthopaedic Educational Services, Inc. © 2013 Orthopaedic Educational Services, Inc. all rights reserved. CONCLUSION

Learn more about MSK X-rays @ www.orthoedu.com

Blue Ridge Parkway, Ashe county, NC Orthopaedic Picture courtesy TGocke, PA-C Educational Services, Inc. © 2013 Orthopaedic Educational Services, Inc. all rights reserved. Conclusion • Understand potential injury mechanisms • PMHx, SocHx. Medications tell a story • Become Familiar w/ Common MSK Injury Diagnosis • Become proficient in MSK x-ray review • MRI is NOT your first diagnostic study • CT Scan better for bone/joint assessment • MRI better soft tissue (good for stress fracture) • Establish Orthopaedic/Radiology resource to review films • Don’t assume ER/Urgent Care visit addressed ALL injuries • Pediatric ortho injuries can present diagnostic challenges • Conventional Injuries respond to Conventional Treatment