International Emergency Nursing 24 (2016) 71–73
Contents lists available at ScienceDirect
International Emergency Nursing j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / a a e n
CASE STUDY
An unusual cause of limp James Bethel RN, MSc, BSc (Hons), PGCE, NP (Senior Lecturer, Advanced Practitioner) a,b,* a b
Emergency Care, Faculty of Education Health and Wellbeing, University of Wolverhampton, UK Emergency Directorate, Sandwell and West Birmingham Hospitals NHS Trust, UK
A R T I C L E
I N F O
Article history: Received 20 May 2014 Received in revised form 10 March 2015 Accepted 12 April 2015
1. Patient presentation A 38-year-old male re-presented to the ED five days after being discharged with a diagnosis of soft tissue injury to the left knee. Re-attendance was prompted by increased inability to weightbear and loss of joint function. The patient limped into the department and was asked to lie supine for examination. Even a cursory visual examination revealed marked infra-patellar swelling with a loss of contour and definition to this aspect of the joint. Pain was not a significant part of the presentation being scored at 2/10 at worst. The patient was an otherwise active adult who had become frustrated by his inability to indulge in any sort of sporting activity since discharge. After visiting the gym that morning he had been advised by one of the staff to re-attend as there was a possibility that he may have a more significant injury than previously diagnosed.
2. History Five days previously, the patient had been playing football and had been involved in what he described as a hyperflexion mechanism of injury involving the left knee; he stated that his knee had become flexed with significant force and that he had perceived an immediate ‘popping’ sensation in the joint. He had attempted to continue his activities but had been unable to properly weight-bear on a joint that he described as feeling unstable. That evening’s ED visit included plain x-ray investigation of the left knee, which revealed no bony abnormality. The patient was subsequently discharged with a diagnosis of soft tissue injury and advised to attend his primary care provider for any follow up care.
* Emergency Care, Faculty of Education Health and Wellbeing, University of Wolverhampton, Room WP123, Boundary House, Gorway Road, Walsall, West Midlands, WS1 3BD, UK. Tel.: 07789 693431. E-mail addresses: [email protected]; [email protected]. http://dx.doi.org/10.1016/j.ienj.2015.04.002 1755-599X/© 2015 Elsevier Ltd. All rights reserved.
Over the last 12 months the patient had shed almost 30 kg secondary to a change in diet and increase in physical activity. This activity comprised of gym-based sessions including working with weights and regular amateur level football. Prior to this weight loss, he disclosed a long history of being overweight and having a sedentary lifestyle. He worked in the banking sector, was otherwise healthy, with no regular medications. 3. Examination and diagnostic findings The patient had walked into the department with great difficulty stating that he felt as if he had to ‘drag’ the affected limb. There was obvious loss of contour to the inferior aspect of the left knee. He could actively flex the knee to approximately 45° when lying supine, though this manoeuvre was achieved with some difficulty, and markedly exaggerated the swelling and deformity in the infrapatella pouch. He could not actively perform a straight leg raise with the affected limb, though this was achieved with ease in the unaffected limb. He said that attempts at this manoeuvre did not cause any significant pain; he simply felt physically incapable of complying. Anterior and posterior drawer tests were performed without causing undue distress and yielded little marked laxity; lateral and medial stress testing revealed similarly unremarkable findings. The oedematous part of the joint was not particularly tender on palpation; there was no isolated patella tenderness, no tenderness in the superior, medial or lateral aspects of the joint, and no tenderness at the head or neck of the fibula. The typical ridge comprising the length of the patella tendon, apart from not being visually evident, was not physically palpable. Examination of the ipsilateral hip, ankle and foot revealed no significant findings. Review of the initial plain x-ray yielded more information in that the radiological report had identified a very subtle avulsion fracture of the distal pole of the patella with an effusion adjacent to this (Fig. 1). Based upon this and the history and examination findings, and despite the fact that there did not appear to be any discernible superior displacement of the affected patella, or radiological report of what is termed patella alta following plain x-ray
72
J. Bethel/International Emergency Nursing 24 (2016) 71–73
Table 1 Risk factors for traumatic patella tendon rupture. Patient demographics
Mechanism of injury
Contributing medical conditions
Contributing treatments
Males
Contents lists available at ScienceDirect
International Emergency Nursing j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / a a e n
CASE STUDY
An unusual cause of limp James Bethel RN, MSc, BSc (Hons), PGCE, NP (Senior Lecturer, Advanced Practitioner) a,b,* a b
Emergency Care, Faculty of Education Health and Wellbeing, University of Wolverhampton, UK Emergency Directorate, Sandwell and West Birmingham Hospitals NHS Trust, UK
A R T I C L E
I N F O
Article history: Received 20 May 2014 Received in revised form 10 March 2015 Accepted 12 April 2015
1. Patient presentation A 38-year-old male re-presented to the ED five days after being discharged with a diagnosis of soft tissue injury to the left knee. Re-attendance was prompted by increased inability to weightbear and loss of joint function. The patient limped into the department and was asked to lie supine for examination. Even a cursory visual examination revealed marked infra-patellar swelling with a loss of contour and definition to this aspect of the joint. Pain was not a significant part of the presentation being scored at 2/10 at worst. The patient was an otherwise active adult who had become frustrated by his inability to indulge in any sort of sporting activity since discharge. After visiting the gym that morning he had been advised by one of the staff to re-attend as there was a possibility that he may have a more significant injury than previously diagnosed.
2. History Five days previously, the patient had been playing football and had been involved in what he described as a hyperflexion mechanism of injury involving the left knee; he stated that his knee had become flexed with significant force and that he had perceived an immediate ‘popping’ sensation in the joint. He had attempted to continue his activities but had been unable to properly weight-bear on a joint that he described as feeling unstable. That evening’s ED visit included plain x-ray investigation of the left knee, which revealed no bony abnormality. The patient was subsequently discharged with a diagnosis of soft tissue injury and advised to attend his primary care provider for any follow up care.
* Emergency Care, Faculty of Education Health and Wellbeing, University of Wolverhampton, Room WP123, Boundary House, Gorway Road, Walsall, West Midlands, WS1 3BD, UK. Tel.: 07789 693431. E-mail addresses: [email protected]; [email protected]. http://dx.doi.org/10.1016/j.ienj.2015.04.002 1755-599X/© 2015 Elsevier Ltd. All rights reserved.
Over the last 12 months the patient had shed almost 30 kg secondary to a change in diet and increase in physical activity. This activity comprised of gym-based sessions including working with weights and regular amateur level football. Prior to this weight loss, he disclosed a long history of being overweight and having a sedentary lifestyle. He worked in the banking sector, was otherwise healthy, with no regular medications. 3. Examination and diagnostic findings The patient had walked into the department with great difficulty stating that he felt as if he had to ‘drag’ the affected limb. There was obvious loss of contour to the inferior aspect of the left knee. He could actively flex the knee to approximately 45° when lying supine, though this manoeuvre was achieved with some difficulty, and markedly exaggerated the swelling and deformity in the infrapatella pouch. He could not actively perform a straight leg raise with the affected limb, though this was achieved with ease in the unaffected limb. He said that attempts at this manoeuvre did not cause any significant pain; he simply felt physically incapable of complying. Anterior and posterior drawer tests were performed without causing undue distress and yielded little marked laxity; lateral and medial stress testing revealed similarly unremarkable findings. The oedematous part of the joint was not particularly tender on palpation; there was no isolated patella tenderness, no tenderness in the superior, medial or lateral aspects of the joint, and no tenderness at the head or neck of the fibula. The typical ridge comprising the length of the patella tendon, apart from not being visually evident, was not physically palpable. Examination of the ipsilateral hip, ankle and foot revealed no significant findings. Review of the initial plain x-ray yielded more information in that the radiological report had identified a very subtle avulsion fracture of the distal pole of the patella with an effusion adjacent to this (Fig. 1). Based upon this and the history and examination findings, and despite the fact that there did not appear to be any discernible superior displacement of the affected patella, or radiological report of what is termed patella alta following plain x-ray
72
J. Bethel/International Emergency Nursing 24 (2016) 71–73
Table 1 Risk factors for traumatic patella tendon rupture. Patient demographics
Mechanism of injury
Contributing medical conditions
Contributing treatments
Males
