Would you insist on immobilizing this? (fibular injury)

[quietmedic]

This is a young adult who was struck in the knee.  Patient was ambulatory with very minimal antalgic gait.

As you can see in xray (zoomed in over fibular lateral condyle), noted a very faint vertical linear lucnecy in the lateral condyle, nontransverse.  Patient had concordant tenderness overlying, but no varus/valgus laxity or pain.

Given the underwhelming clinical presentation and essentially minimal nontransverse fx with no avulsion, would you enforce knee immobilizer and crutches (to avoid LCL/ fib condyle avulsion)? Or could patient do with RICE and strict instructions to avoid anything but very gentle walking?

Thanks all....

[Boatswain2PA]

I would call ortho....

[Guest UVAPAC]

I agree with consulting Ortho.

I personally think they would do fine with weight-bearing / activity as tolerated.

However I am almost certain that Ortho would recommend crutches, non-weight-bearing, and likely immobilization. 

[Guest ral]

19 hours ago, quietmedic said:

...was struck in the knee....

 

Mechanism of injury.  Although you stated no laxity, during the acute injury (pain) phase it is sometimes difficult to elicit a full satisfactory exam.  I would put him in a short knee immobilizer pending rad over-read and ortho consult.  My thought process is that nobody is going to fault you for immobilizing a joint, especially considering that an injury force strong enough to cause a small avulsion, can certainly give rise to the possibility of internal derangement.  Call me old school.

[skyblu]

It’s a fracture, patient is symptomatic, and nobody knows what “gentle walking” means in a measurable way. So immobilize, non Weight bear, f/u w/ ortho. (I’m EM/UC, obviously an ortho PA might have a different POV)


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[Guest JMPA]

i would amputate the leg and place the patient on dialysis

[d2305]

Immobilize, crutches, ibuprofen, and ortho consult. Hope they have insurance.

[GetMeOuttaThisMess]

So let's play devil's advocate here.  The exact same fracture is on the OTHER end of the fibula.  What do you do for that, and why would you treat it any differently, if at all?

[d2305]

That's more than a little avulsion Fx.

[GetMeOuttaThisMess]

I never said it was a typical avulsion fracture (OP doesn't describe it as an avulsion fracture either) from a ligament pull/inversion injury to ankle.  I asked the question as to what one would do if it were a similar fracture on the distal fibula as displayed on the x-ray?  There's a specific reason as to why I'm asking the question the way that I am.  I agree with ral/skyblu with regard to initial ED/UC treatment.  I think ortho is going to say something otherwise when seen in f/u.

[d2305]

Ortho may do nothing, or they may also stick a pin in it.

[quietmedic]

Thanks all for your thoughts!

[Guest JMPA]

what would a lawyer say when you are in court for malpractice? There is the right way and then there is the legal way. Unfortunately litigation can override common sense.

[GetMeOuttaThisMess]

I never said it was a typical avulsion fracture (OP doesn't describe it as an avulsion fracture either) from a ligament pull/inversion injury to ankle.  I asked the question as to what one would do if it were a similar fracture on the distal fibula as displayed on the x-ray?  There's a specific reason as to why I'm asking the question the way that I am.  I agree with ral/skyblu with regard to initial ED/UC treatment.  I think ortho is going to say something otherwise when seen in f/u.

The point is that you would/COULD send out the ankle avulsion fracture in a boot and with crutches since the fibula only bears 6% of the weight of the lower leg and weight bearing/ambulation is dependent on pain tolerance.  Why would this be any different treatment wise other than the boot wouldn't immobilize this fracture?  Use the knee immobilizer and put on crutches/weight bearing with crutches, and let ortho tell them that they can walk on it as tolerated.

 

[Guest ral]

On 11/15/2017 at 7:58 AM, d2305 said:

That's more than a little avulsion Fx.

 

On 11/15/2017 at 8:53 AM, GetMeOuttaThisMess said:

I never said it was a typical avulsion fracture...

Place the blame on me, if you wish.  I referred to it as an avulsion.  Right, wrong, or indifferent.  The point is, the area suggestive of a possible incomplete fracture looks like an avulsion to ME.  You don't have to agree.  The fact that it overlies the area of attachment of either the LCL or biceps femoris is what I base my assessment on.  And if it is such, then it's small, again from my experience.  My suggestion of a knee immobilizer is to provide support for the likely soft tissue/ligamentous/tendonous injury.  Honestly don't care if the patient wants to do jumping jacks; the bony injury is not what I am spotlighting.  I am not here to compare dick size with anyone.  OP asked for opinions, and I gave mine.  

[d2305]

Knee x-rays are almost always negative, and when you actually see something, a trip to ortho is warranted. Plaster at the very least is in store.

[ventana]

immobilizer crutches ortho f/u

(they can take them off when leaving the ER)

 

Or talk to ortho and see what they want (ct likely)

or get a CT and see if it is real, or not..

 

But then that all takes time and in an ER where through put seems to overrule medical care some days, splint, crutches, ortho....  in a few days it will declare it self  

[Fernwood]

I am the ortho guy this injury is sent to for consult. Proximal fibular fractures rarely require immobilization, This particular fracture does not. If symptomatic, crutches for offloading otherwise advise no running or explosive athletic activities, i.e. box jumps, for 4 weeks.

 

[Fernwood]

Here’s my issue with the knee jerk immobilizer treatment, no pun intended. The immobilizer is not doing anything to address this particular injury. Crutches will allow appropriate off-loading while allowing continued range of motion. The immobilizer falls under the same heading as a boot, they do not do anything other than increase the billing. I see this fracture routinely placed in a boot  that I promptly discontinue. This cost the system well over $500 dollars, this is just wasteful. I did emergency medicine(with a postgrad ER residency) for the first part of my career. ER volumes have continued to climb to the point that many minor injuries are treated by simple perfunctory protocol rather than through the result of thorough exam and clinical decision making. Hey, I get it. There are just too damn many people flooding ERs. We need to revisit the COBRA and EMTLA laws so that the 90+% of non emergent patients can be appropriately directed to their PCP, or even minor care clinics.

additional thoughts-

I am in Texas where “Free-standing” ERs are proliferating out of control. This is an absolute abomination. These are not true ERs. They may have a CT scanner and can diagnose that emboli stroke but they do not definitively treat. I am waiting for some intelligent individual to take a family member suffering from an MI to one of these free-standing ERs. They will diagnose the MI but will then promptly call for EMS to transfer them to a real ER for the stent. All the while the patient has sustained additional loss of cardiac muscle due to the time delay. This intelligent person is going to put it together and sue. Although I suspect that tucked away in the fine print is a boiler-plate clause that precludes a lawsuit.

look, when you have a business model that requires only 12-15 patients per day to remain profitable, there’s something hinky. Yes,  they are nicer and faster than traditional ERs but they are undermining the entire system. These facilities only take commercially insured, no Medicare, no Medicaid and no Tri-Care. They are cherry picking. This may seem great but the truth is these facilities are only adding to the increasing cost of healthcare.

if everyone continues to look for a way to scam the system the system is never going to work.