Supe dumplings (and knee pain)
Melinda's pre-clinic conference this week addressed knee pain, a super common problem in the outpatient setting for kids but especially adults such as Mr. John Nee and Ms. Patty Ella. Love those names! The lesson covered acute (non/traumatic) and chronic knee pain. There are a lot of great physical exam videos available here. Among the many things I learned this week were:
Use the Ottawa Knee Rules to decide when to get x-rays for pediatric and adult patients (at least 2 years old) with traumatic knee pain. The OKR reduce unnecessary x-rays by 20-30%. Pro-Tip: walking with a limp still counts as "bearing weight." By comparison, use the Pittsburgh Knee Rules to decide when to get x-rays for patients at least 12 years old with knee pain due to blunt trauma. The PKR are more specific than the OKR and lead to 78% fewer x-rays.
There's something called "plica syndrome" that made me question upon what quicksand my undergraduate medical education was erected. Apparently the knee joint is formed in utero by the coalescence of bubbles of mesenchymal tissue. Around 12 weeks gestation the tissue starts to dissolve, but ~50% of cadavers still had remnants--called "plica"--on autopsy. If these bands get thick and tough (i.e. from overuse in runners), they can interfere with the mechanics of the knee joint. Symptoms include unilateral anteromedial knee pain or "popping," especially with exertion. No imaging. Treat with activity modification, ice, NSAIDs, strengthening and stretching.
Finally, treat traumatic non-fracture joint injuries with PRICE (not RICE!):
P=Pain control with anti-inflammatory medications such as NSAIDs, Tylenol, and topical anesthetics
P also = Protection with a knee immobilizer, but only for the first 24 hours
R=Range of motion (not rest!) to keep the joint from stiffening
I=Ice directly on the skin for 20 min 2-‐3 times per day)
C=Compression with a brace or compression wrap until they see Ortho
E=Elevation
Use the Ottawa Knee Rules to decide when to get x-rays for pediatric and adult patients (at least 2 years old) with traumatic knee pain. The OKR reduce unnecessary x-rays by 20-30%. Pro-Tip: walking with a limp still counts as "bearing weight." By comparison, use the Pittsburgh Knee Rules to decide when to get x-rays for patients at least 12 years old with knee pain due to blunt trauma. The PKR are more specific than the OKR and lead to 78% fewer x-rays.
There's something called "plica syndrome" that made me question upon what quicksand my undergraduate medical education was erected. Apparently the knee joint is formed in utero by the coalescence of bubbles of mesenchymal tissue. Around 12 weeks gestation the tissue starts to dissolve, but ~50% of cadavers still had remnants--called "plica"--on autopsy. If these bands get thick and tough (i.e. from overuse in runners), they can interfere with the mechanics of the knee joint. Symptoms include unilateral anteromedial knee pain or "popping," especially with exertion. No imaging. Treat with activity modification, ice, NSAIDs, strengthening and stretching.
Finally, treat traumatic non-fracture joint injuries with PRICE (not RICE!):
P=Pain control with anti-inflammatory medications such as NSAIDs, Tylenol, and topical anesthetics
P also = Protection with a knee immobilizer, but only for the first 24 hours
R=Range of motion (not rest!) to keep the joint from stiffening
I=Ice directly on the skin for 20 min 2-‐3 times per day)
C=Compression with a brace or compression wrap until they see Ortho
E=Elevation
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| "Soup dumplings," Flickr user Carlos Moreno (31 May 2017) |
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