Sunday, February 15, 2009

I've fallen and I can't get up!

Young guy comes to ER after playing a league soccer game. (Are these guys fanatics!.....it's 30 degrees outside!) Claims he had a head-on collision with another player and they hit knee to knee and heard a loud pop! Couldn't get up at that point and went home with help. Tried ice and advil but no help and swelled up and got worse. I see him sweaty, in a wheel chair and in pain.

The rest is easy. Essentially only four things occur that result in a knee swelling immediately after impact.

1-fracture
2-patella(knee cap) dislocation
3-meniscus(cartilage) tear
4-acl(ligament) tear

The mechanism of injury is the most important item in deciding what the problem is. I always let the resident doctors I teach know how important history taking is when deciding on a diagnosis. The physical exam the doc does backs up the working diagnosis from the history. The imaging test will back up the physical exam. I felt the heat from the knee on this soccer player, pushed a little here and there and then pulled the leg forward slightly and immediately found the problem. Every test in medicine has a fancy name to it. My name will be famous one day (The Saguil Approach) - yeah right! The anterior drawer if done properly will yield enough without going any further (other tests are a lachman and pivot shift for the acl). The best way to confirm the anterior cruciate ligament is torn is the MRI. I have had several patients seen in the past that had the perfect history, the perfect exam and I didn't have to go further and sent them straight away to the surgeon.

The anterior cruciate ligament is a primary "stabilizer" to the knee. People can live without it but the knee will move excessively and probably give out with activities of daily living. With enough episodes of giving out, other problems will eventually occur: arthritis, a meniscus tear, a fracture, a broken ankle or hip. There are other ligaments that are secondary stabilizers and one can get along without them. The big surgery to fix the acl in the 90's was to take part of the patellar tendon and use it inside the knee as a new acl, tougher than the old one! Now surgeons us cadaver, hamstring or patellar tendons.....depends on the surgeon.

Unfortunately, this young guy worked standing and walking. Also didn't have insurance. Just the xrays, crutches, knee immobilizer, meds and ER visit alone will cost him about a grand. The surgery will probably cost 7500 with the rehab. He doesn't have to get the surgery but the knee will probably give out everytime he turns. In the 80's, there were some researchers who claimed if you placed a "derotation" brace on, it will prevent the knee giving out. Naaa!

Unfortunatley, not easy to predict who will tear. Contact sports for sure, in this case, soccer is considered non contact. Happens alot with women due to a few anatomic issues. When I was team physician for Benedictine University, the womens basket ball team had about 3-4 "acls" in one season and we traced it back to the teaching techniques of the assistant coach. (Had to rule out surface, shoes, players and training) We changed techniques and next season, no problems.

I have heard some docs getting results from prolotherapy. This would be injecting stimulants to growth into the knee to speed up healing. I haven't seen enough research to say it works compared to surgery (probably not ever see a study due to funding) and havent talked to anyone that does alot of it so can't comment on success rate. Like anythin in integrative medicine, I push for alternative treatments to a certain degree, but if mechanics are altered or can be fixed with western medicine, go for it!

No comments:

Post a Comment