knee dislocation disaster

Tuesday, August 30, 2016

While most injuries require some sort of significant trauma, bad luck may be the most ominous cause of disaster. Bad luck has befallen Vikings quarterback Teddy Bridgewater, who dislocated his knee without being touched. Normally, this injury requires high velocity and high impact because the knee joint is held stable by four ligaments in addition to the quadriceps and hamstring muscles.

knee dislocation anterior knee dislocation

Anterior Dislocation                              Posterior Dislocation

Knee dislocations are a big deal and should not be confused with kneecap (patella) dislocations, which are relatively common, affect women more than men because of anatomic and muscle attachment differences and are easily taken care of in the field or the ER. Knee dislocations, though, not only tear ligaments but also potentially tear the popliteal artery that supplies blood to the lower leg.

It is drilled into emergency doctors that a knee dislocation is an injury that can be missed, because the knee can relocate spontaneously before medical care happens. That can lull doctors into a false sense of security but that may lead to disaster. A missed diagnosis may lead to leg amputation if there is a damaged popliteal artery. For that reason, in addition to the orthopedic surgeon, a vascular surgeon usually gets involved in the evaluation and treatment of this injury.

Once the dislocation diagnosis is made, the next step is to evaluate the artery. There are different diagnosis options, whether it is repeatedly measuring blood pressures in the arms and legs (ankle-brachial index) or performing CT angiograms, the index of suspicion for artery injury needs to be very high. And that suspicion needs to be maintained for a few days, just in case there is delayed clotting in the artery.

Not every dislocation is the same. The four ligaments that hold the knee stable can be torn in different combinations depending upon the forces placed on the knee and the direction it dislocates. Regardless, the surgery to repair the ligament damage needs to happen within a few days of injury

This is not an injury that always gets better, even with the best of care. The prognosis for a “normal” knee, one which is stable and without pain happens about 60-70% of the time, 20% will have reasonable function and the last 20% will have a chronically painful, unstable knee.

Knee dislocation is the same injury that derailed the career of Robert Edwards in 1998. He was playing in an NFL flag football game as part of that year’s Pro Bowl events when he was injured. It took four years for him to rehab and return to play one season in the NFL and four more in the CFL.

It seems though that the only good news for Mr. Bridgewater comes from the Minnesota Vikings press release: “Fortunately, there appears to be no nerve or arterial damage”.

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narcotics role is changing

Monday, August 29, 2016

Football is a violent sport and with it comes injury and that begets pain. Some injuries are self-evident, like the tibia and fibula fracture sustained by Chicago Bears quarterback, Connor Shaw. His leg was splinted and he was carted off the field in obvious pain. Other injuries take some time to sort out, like the Cowboys’ Tony Romo, who failed to talk his way into playing in the same game and was later found to have a compression fracture of his lumbar spine. Both injuries hurt and both players will likely be prescribed narcotic pain medication in the first few days of recovery. NFL players have been known to take a variety of legal and illicit medications to allow them to play through the pain each weekend, but that mindset does not translate well into the real world off the playing field.

The Fifth Vital Sign

Not too long ago, pain was added to the medical mind frame as the fifth vital sign. It followed blood pressure, pulse respiratory rate and temperature. Regardless of the reason for the doctor’s visit, patients were often asked whether they were having pain and their assessment, often on a scale of zero to ten. Kids had the smiley/ frowny face pain scale option. Pain is not normal and medicine is all about keeping vital signs in their normal range. Patients didn’t want to hurt and it was easy for a doctor to write a prescription for narcotics.

Doctors like to make their patients feel better but there was another benefit to writing the prescription. Patient satisfaction scores for doctor performance might have been tied to giving patients what they want. Who knew that excessive narcotic prescribing habits might lead to an increase in drug dependence, addiction and become a gateway to the increase abuse of heroin and other illegal street drugs.

The pendulum is beginning to swing back and patients might take a while to understand that a pain-free life may not be available through the use of narcotics. They may not like the doctor who says no to their request and those negative feelings are being expressed by examples of falling patient satisfaction scores.

Wisconsin Prescribing Guidelines

The Wisconsin Medical Examining Board, the governing agency that licenses doctors in the state) has published guidelines about prescribing narcotics, including when to use them what drug to prescribe, how many pills and the expectation to look for patients who exhibit drug seeking behavior. Doctors in the state need to listen and act according. Without a medical license, their career has effectively ended. Just a few of the highlights:

  • It is difficult to know how much a patient hurts. Find out why there is pain and treat the underlying cause. Use non-opioid (non-narcotic) medicines like acetaminophen, ibuprofen or naproxen.
  • If prescribing narcotics, use the lowest dose and fewest number of pills. Most patients will need less than three days of treatment and rarely more than five.
  • There is little evidence that narcotics should be used to treat chronic pain.
  • “Physicians should avoid using intravenous or intramuscular opioid injections for patients with exacerbations of chronic non-cancer pain in the emergency department or urgent care setting.
  • Physicians are encouraged to check Wisconsin Prescription Drug Monitoring Program website to see whether the patient is already receiving narcotics from other doctors. This becomes law in April, 2017 before prescribing any controlled substance for greater than a three-day supply.
  • “The use of oxycodone is discouraged.”

Patient Satisfaction

Patients may not be satisfied with the result of their doctor visit if expectations for pain control are not met. This might be especially true for chronic pain patients who have come to rely on narcotics for their symptom control. It may take time to consider treatment alternatives and still meet the needs and demands of the patient.

The New York Times reported on the experience at Marion (Indiana) General Hospital. Over the course of 18 months, emergency physicians decreased their narcotic prescribing by 50%. Patients weren’t happy and ER satisfaction scores fell from the 58th percentile (of 1100 similar hospitals) to the 14th. Does that mean that the doctors practiced bad medicine or did it mean that there was a disconnect between what the patient wanted and what they received. The words of Mick Jagger and Keith Richards might have been ahead of their time describing this phenomenon.

You can’t always get what you want…you get what you need.

 

 

 

 

 

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