The summer edition of TVII is now closed. 48 providers took the quiz. 34 answered all three questions correctly and were entered in the raffle for a $150 gift card plus another gift card to be given to their site. Congrats to Dr. Laurence Jiang who won! His primary site is Memorial Medical Center Modesto. Stay tuned for a new TVII to be posted next month!
31 y/o presented to the ER with knee swelling secondary to a fall while wakeboarding. She could not describe how she fell. She reported numbness and color changes in her foot. She was unable to ambulate. Nursing assessment indicated her lower leg was red, and she was unable to bear weight. Her left foot was "mottled" with decreased sensation, there was edema from the knee to toes and a faint pedal pulse. The PA documented, "The patient had normal range of motion and CMS of the R leg, positive nvi, left knee swelling and ecchymosis, positive sensation to foot with medial numbness to the foot." The PA ordered X-rays which showed no fracture, then presented the case to the supervising physician who also evaluated the pt. The physician noted the color of her right foot appeared the same as the color in her left foot. The nurse placed the pt in a knee immobilizer and the physician re-evaluated the pt. The physician documented, "there is no evidence of compartment syndrome, septic knee, knee dislocation, or tib/fib/femur fx. There is good color to the affected foot. She has slightly decreased sensation medially along the inner calf and ankle. Exam is consistent with internal derangement of the knee, and possibly a peripheral nerve injury from her wake board straps." The pt was given crutches, dx with a knee sprain, and instructed to follow-up with her PMD for an MRI. Two days later she went to an orthopedist and had no pulses in her leg. Despite several surgeries and hyperbaric treatment in effort to save her foot and leg, she eventually had a below knee amputation.
Patient likely suffered a popliteal injury at the time of the fall while wakeboarding. The plaintiffs alleged the providers were negligent in failing to diagnose and treat this injury while in the emergency room. Expert witnesses felt the delay in diagnosis led to the resultant knee amputation. Had a vascular study been performed at the initial ED visit, it was felt a vascular surgeon could have saved her leg. This case resulted in a confidential settlement for the ED physician and PA.
Survey Question 1
A popliteal artery injury is a potentially limb-threatening complication of a knee dislocation. Diagnosis requires a high degree of suspicion on the part of the clinician. A knee can be dislocated and subsequently relocated prior to presentation, so a thorough neuro and vascular assessment of the affected extremity is paramount. If the following study had been performed in the ED on visit one, this case may have been defendable despite the unfortunate outcome
- Repeat xrays
- CT angiogram
At 18:46 a 59 y/o morbidly obese female was brought in by EMS for a knee injury sustained from a mechanical fall after she slipped on water. Med hx: R knee prosthesis 15 years prior. She c/o severe knee pain, numbness to her R lower extremity, and stated her knee was bent backwards in the fall. The PA examined the pt and noted dorsalis pedal pulses were palpable. The exam exhibited internal rotation of R lower extremity, decreased ROM of the knee, swelling, ecchymosis, deformity and tenderness.
At 20:51 x-rays showed a prosthesis with knee dislocation. CTA revealed the right common femoral artery, superficial femoral artery and deep femoral artery were patent. The PA contacted ortho who recommended they attempt closed reduction in the ER and recheck neurovascular status after reduction. The ER physician and PA performed closed reduction at 22:57.
Post reduction x-rays revealed the knee was successfully reduced, but exam was concerning for vascular compromise as there was delayed cap refill and no pulse on doppler. The ER team ordered another CTA of the lower extremity and paged the ortho and vascular surgeon. Ortho advised there was nothing more he could do if the knee was reduced. He agreed with vascular consult to r/o compartment syndrome and intimal tear. When the pt reported more pain below the knee since the reduction, the vascular surgeon came in and admitted her.
Despite surgeries for compartment syndrome and the popliteal nerve injury, the pt subsequently underwent an above knee amputation and the case resulted in a lawsuit. The PA was eventually dismissed from the case. There was a confidential settlement on behalf of the ED physician (as well as the vascular surgeon and hospital).
Survey Question 2
Physician expert witnesses explained certain types of dislocations are routinely reduced by emergency providers. It is appropriate for them to perform the reduction in the ED without involvement of the orthopedic surgeon if there is concern for vascular and neurologic compromise. What hindered the defense of this case?
- The PA and physician should not have performed the reduction. They should have waited for the orthopedist
- Appropriate studies were not ordered in the ED to correctly diagnose and treat this condition
- Plaintiffs contended the delay of 4 hours in performing the reduction caused and/or contributed to the eventual amputation
39 y/o obese (298lbs) pt was brought to the ED at 0153 for a complaint of R knee pain after he twisted his knee while walking and fell. He was unable to get up. On exam the R knee did not appear anatomically normal and was painful and swollen. He was unable to flex his knee due to pain. X-rays showed a dislocation of his right knee, soft tissue swelling and no fx. Under conscious sedation, the ER physician reduced the knee and the pt recovered well. A knee immobilizer was applied, and post-application exam revealed normal neurovascular function.
The pt was discharged at 7:30 am and instructed to f/u with an orthopedist in 2-7 days. Around 8:30 AM the ER physician performed a follow-up call to the pt and instructed him to return immediately to the ED because the pt reported reduced sensation, numbness and weakness to his toes. 3 hours later he returned. Exam at this time showed the R foot had weak dorsiflexion, diminished DP and PT pulses, somewhat cool foot, and no swelling. US was suggestive of an arterial vascular injury at the knee. Multiple unsuccessful attempts were made for a vascular surgery consult so the pt was transferred to another facility. The next facility ordered a CTA which showed probable spasm of the R proximal popliteal artery with thrombosis of the mid-and-distal segments.
Despite multiple surgeries and physical therapy, the pt has a R foot drop with loss of use of the R lower extremity. Plaintiff states he suffered ischemia of the right lower extremity and compartment syndrome. The ED physician chose to settle the case and not go to trial.
Survey Question 3
The cause of the patient’s outcome could be difficult to prove as the peroneal nerve injury could have been caused by either the trauma inducing event (the initial fall), or it could be secondary to occlusion of the popliteal artery which ultimately caused ischemia invading the peroneal nerve. Which medical decision most impacted defensibility of the care provided by the EM physician?
- The ED physician should have never performed the reduction
- Most EM physicians would perform a CTA in a patient with a knee dislocation