Case Study:
In the middle of a rather chaotic shift in the ED, you pick up a chart that notes a chief complaint of knee injury in a 14-year-old male. The adolescent and his family have emigrated from Nigeria and speak broken English, but they are able to explain he was playing basketball when this injury oc¬curred. You wonder if any further history is helpful or if you should just send him for radiographs. With a little more investigating you discover he was “faking” a shot when this injury occurred and there was no contact with another player. His physical exami¬nation reveals tenderness surrounding the patella and proximal tibia, but his pain appears out of proportion to the degree of acute swelling you notice. You explain to the family that pain control is going to be started with hydro¬codone, and radiographs will follow.
Is this adolescent more likely to have a fracture or a ligamentous injury based on his age, history, and physical examination? Do the clinical decision rules regarding knee injuries apply to the pediatric patient? Do the injury pat¬terns in this adolescent differ from those in an 8-year-old or a 17-year-old? If his knee radiographs are inconclusive, what should you do? What are the latest trends in treating pediatric anterior cruciate ligament (ACL) injuries?
Case Study Conclusion:
The 14-year-old Nigerian basketball player who presented to the ED with knee pain after playing basketball came back from radiology without an obvious finding on his radiograph. Further questioning revealed after “pump-faking” a shot, he had intense anterior knee pain and has been unable to ambulate since. He had previously been healthy without any chronic symptoms. His degree of ten¬derness with palpation around the patella and proximal tibia were still concerning. He was sent back for compari¬son views of the uninjured knee. Upon closer comparison, a slightly higher riding patella was noted in the injured knee, and there appeared to be a small “fleck” of bone where the inferior patella normally resides. With his pain now under better control, he was still unable to extend the knee which confirmed the diagnosis. This young athlete had a patellar “sleeve” fracture after a forceful contraction of his quadriceps. After consultation with orthopedics, he was discharged home in extension with a knee immobi¬lizer and instructions for no weight-bearing. Follow-up the next day confirmed the diagnosis and surgical repair was arranged.
Risk Management Pitfalls:
1. “I found a large, traumatic effusion of the knee in my patient who was involved in a motor vehicle accident, but I could not find any evi¬dence of a fracture.” Knee dislocations of the femur and tibia may spontaneously reduce before arriving to the ED. A high degree of suspicion should be main¬tained for this dislocation because of the risk of neurovascular injuries which may necessitate amputation. If a dislocation is suspected, ortho-pedic consultation and admission with frequent neurovascular checks are essential.
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