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my 16 year old with hard case that I learned more from

Exit forum ID Forum Discussion my 16 year old with hard case that I learned more from

This topic contains 3 replies, has 2 voices, and was last updated by   Eric Lambert, DC November 6, 2018 at 5:23 pm.

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  • #4796

    Eric Lambert, DC
    Participant

      I debated posting this on the forum.  However, this is real life and sometimes as providers we forget how much we help people get to the real diagnosis.  I was reminded of that this week and the fact that I’m better than I give myself credit to be.  Sorry for the length of the story and case, but I lived it as a father, so it means that much more.

      The past couple weeks are weeks as a provider and a father I will always remember.   My son was the patient this time and although his case looked like something in my wheelhouse, thanks to the principles I have learned from ID and years of experience I knew there was something much more happening as the case unfolding.   Below is the case, tests and result findings within a 2 week period.   I wanted to share the case as it gives a viewpoint of something we see daily, but much more as it progresses past what is in our wheelhouse and the reason it’s good to have other providers you can work with.   And as a father, it’s really difficult to watch as your child goes through this.   I’m very thankful to have great doctors who know what their job is in my city.   I’m also incredibly grateful to have a good name with several medical doctors in town including the sports orthopedic doctor that took care of my son who now wants to meet with me in December to discuss building our working relationship more.

      My son is 16 years old, I noticing he was limping one night.   He came downstairs the next morning with inability to fully straighten his left knee and pain in his posterior knee.  I performed an immediate ID exam at home.

      Location: left posterior knee and medial proximal calf area

      Palliative: nothing at the time of initial symptoms, since then ice, rest, compression of area

      Provocative: everything at first, now only dancing, standing for prolonged periods

      Quality: mild pain in proximal left medial calf with knee extension and inability to extend left knee to full extension

      Severity: 4/10

      Second Order:   Started dancing for school musical at beginning of September.  Worked in a greenhouse carrying out heavy planters for shoppers.   Never an athlete.  Normal daily activities are mild. No trauma, no images, initially

      Initial Exam:

      PKF:  mild to moderate pain in posterior knee at 115 degrees

      PKE: mild to moderate pain in the posterior knee and proximal medial calf

      Did no check Rectus Femoris due to PKF range

      Apley’s Compression test: mildly painful in the posterior knee

      Moderate edema in the entire knee joint

      Adhesions were palpated in the following structures:

      Unable to palpate knee joint capsule due to edema.

      Rectus Femoris: 1

      Given this set of data, lack of ability to palpate and edema my top diagnosis at that time was a left knee strain with a possible meniscus tear.  Likely due to the new exercise of dancing that irritated his left knee. Eventually he exceeded the capacity of the tissue which has created inflammation and pain and a possible tear.

      Unfortunately due to the swelling, it was hard to tell exactly what was the most accurate diagnosis here at that time.

      Due to the swelling I instructed the him to ice and rest, including limited his load by not dancing for at least a week.

      The evening of the initial exam day, he came home from school with his left lower leg swollen twice the size of his other lower leg with discoloration and heat coming from the back of the calf.    I took him to the ER immediately where an ultrasound was performed to rule out DVT.   They found a large hematoma in his deep calf and small superficial thrombosis in the superficial veins.   We were told that he was to not do anything strenuous and see an ortho and his pediatrician within a few days for evaluation due to all the swelling.

      Visit with orthopedic doctor, happened the following Monday.   Examination the ortho doc agreed with my initial diagnosis of knee area with his own exam, which was very similar to an ID knee exam, minus specific measurements, it was all eyeball numbers.  An in office ultrasound was performed and found that the fluid in the calf was coming from the back of the knee.   Had an in office x-ray and immediately ordered an MRI of the left knee

      MRI was done on Wednesday morning, Orthopedic doc called me back the same day and requested an appointment to go over results on Thursday morning.  MRI was clean, nothing torn, all tissues normal except for inflammation and fluid behind the knee joint.

      Report results:

      Technique:
      Routine knee MRI protocol.

      Date:
      10/31/2018

      Comparison:
      X-ray left knee October 29, 2018. Ultrasound DVT study dated 10/24/2018

      History:
      Left knee pain and swelling, no known injury.

      Findings:

      Cruciate Ligaments:
      The ACL appears intact.
      The PCL appears intact.

      Extensor Mechanism:
      The distal quadriceps tendon and patellar tendon appear intact.

      Lateral Ligamentous Complex:
      The components of the LCL appear intact.

      Lateral Compartment:
      The lateral meniscus appears morphologically intact.
      No significant signal abnormality is seen within the meniscus.
      No measurable articular cartilage defects are seen.

      Medial Ligamentous Complex:
      Intermediate signal and thickening of the meniscal femoral deep MCL could be reactive. Superficial MCL is intact.

      Medial Compartment:
      The medial meniscus appears morphologically intact.
      No significant signal abnormality is seen within the meniscus.

      Bone marrow edema pattern within the medial central breast posterior aspect of the medial tibial condyle. There is suggestion of some cartilage thinning posteriorly although no overt chondral defect. Focal concavity at the marginal medial tibia beneath the meniscal body although with well-defined cortex on the coronal nonfat suppressed sequence is not felt to relate to an erosion.

      Patellofemoral Joint:
      Motion artifact on the axial sequence although no overt chondral defect. Medial retinaculum appears intact.

      Additional Findings:
      There is a large joint effusion with diffuse synovial thickening. A moderate-sized popliteal cyst is present. Layering along the medial gastrocnemius is a partially imaged large complex collection with mass effect on the muscle. The popliteal cyst is just superior to this collection and appears more simple with no overt communication although there is extensive edema within the surrounding fascial planes at the posterior knee. There is also mild amount of soft tissue edema predominantly posterior to the knee. Mildly prominent lymph nodes are seen posterior.

      Impression:

      1. Large joint effusion with diffuse synovial thickening. Bone marrow edema pattern at the medial tibial condyle with suggestion of chondral thinning posteriorly at the tibial plateau although no aggressive erosion seen. Leading differential considerations include inflammatory or infectious arthritis to include septic arthritis or Lyme arthritis.

      2. Partially imaged large complex fluid collection with mass effect upon the medial gastrocnemius and extensive surrounding fascial edema or fasciitis could be an extension of the above inflammatory/infectious process within the knee joint although is more complex than fluid seen within the popliteal cyst with no direct communication seen. An isolated hematoma is felt to be less likely. Note that the inferior extent of this process is not visualized on this study.

      Diagnosis gets more worrisome when MRI comes back clean and we can’t explain the swelling. This is something as a provider I’m normally ok with, but not with my son.

      We have more tests ordered Thursday morning, including aspirating the left knee fluid for testing as well.

      Tests Ordered:

      1)     Lyme disease serology

      2)     Body fluid cell count with differential

      3)     C-reactive protein

      4)     Sedimentation rate

      5)     Anti nuclear antibody HEP 2 IFA w/reflex titer/pattern

      6)     Rheumatoid antibody level

      7)     Cyclic citrullinated peptite AB level

      8)     Complete blood count (CBC) with differential

      9)     Comprehensive metabolic panel

      10) Manual differential BFL

      Saturday morning the orthopedic doctor called me and stated that all tests came back normal except inflammation testing was higher than normal, but within limits for the inflammation found.  He recommended a steroid to help with inflammation and load management.

      Final diagnosis via the ortho:

      1. Transient synovitis of unknown origin – I believe however at least part of it was from the impacts from jumping and dancing for the school musical the past month and a half.

      I plan to work on his knee flexion once his edema is gone in another week or two.  We are 70% there as of today.  PKF is now 125 degrees and about ½ inch difference in leg circumference due to swelling.   I’m very grateful this was all it was.   Working through some of the more serious diagnoses with all the blood/fluid testing was not a pleasant thought process for me and my wife.   This was the second case this year of a kid having something that was out of the ordinary for our normal musculoskeletal wheelhouse.  So these 1%er’s, as I’m now calling them, do happen in practice and I believe it’s good to know what to look for.  I’m very grateful for everything I’ve learned with ID and look forward to continuing to get even better as the years go on.  I’m definitely a better doctor than I was even 5 years ago thanks to ID and all the clinical excellence than we train for now.

      #4798

      William Brady, DC
      Participant

        Thanks for sharing this case. Lots of good lessons here. I hope your son does well.

        #4799

        Brandon Cohen DC, CSCS
        Participant

          Eric, Thanks for sharing. My children and family produce some of the most difficult cases due to the difficulty in removing emotion from my assessment.

          You said its been over about two weeks if I saw that correctly. Did he have any sx before you saw him limping that day? The onset and course are interesting to me…

          #4800

          Eric Lambert, DC
          Participant

            Thanks Bill and Brandon.

            Yes, Brandon I forgot to put into, with all the other details that he had some discomfort, not pain, for about 3 weeks prior on and off he told us. But he never told me or my wife anything about it until the day that he couldn’t move his knee. We never knew anything was different until the night prior to all of it occurring. In Michigan we’ve been wearing pants due to colder weather for at least a month now.

            Thus far swelling continues to decrease and he’s had no more pain this week. So things are looking up. Makes me happy because I can attend the seminar this weekend without having to worry about it now.

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