3/11/07njm

**Knee pain prior to the championship game**

M + M Primary Care Discussion

Case

A 12 year old with no significant past medical history presents to the
outpatient clinic at a rural hospital. The patient is accompanied by his
father, who indicates that he hurt his knee while playing on the junior
high football team 2 days ago. Today, he told his dad that it was still
hurting. His father brought him into clinic to be evaluated.

He denies any fever, chills, additional injuries, illness at home,
vomiting, diarrhea or other systemic symptoms. His physical exam is
remarkable for pain with flexion and extension; there is no effusion and
there is no evidence of ligament instability or laxity. You order a knee
X-Ray, which you read as normal.  Radiological studies are sent to a
radiologist 3 times week, and the result will be available in one week.
Abnormal results are usually called to the facility once they are noted.

At this point, the patient is sent home with an anti-inflammatory, and
instructed to not engage in any strenuous activity for a week. A
follow-up appointment is scheduled for 10 days from this initial visit.
The patient imperceptively scowls.

Other Comments:

It is a busy day in a busy clinic; it is 4:30 and there are still
several patients to be seen. Your clinic has not empanelled patients
yet, so most patients do not have an identified primary care provider.
Ortho and adolescents are NOT your strong point.

As the father and son rise to leave you inquire: Do you have any other
concerns?  The patient's father dejectedly states the big junior high
football game of the year is this upcoming Friday night. The various
high school scouting staff are expected to be there in force.

Questions:

What is next for this pt?

Would you have done anything differently at your facility?

What is the impact of the lack of on-site radiology reading
availability?

What constitutes quality care in the I/T/U setting?

**Jarvis, James N. (HSC) \[James-Jarvis@ouhsc.edu\]**

**Mon 2/5/2007 1:50 PM**

It's interesting how frequently the \*history\* is omitted in evaluating
patients with trauma. Knowing exactly what happened in the game/practice
can assist in determining the level of concern to have re: aggravating
an existing injury by having him play Friday night.  Your biggest
concern is that he may have a partial tear of ligament.  If the history
suggests he hyper-extended the knee or had torsional stress, then that's
a legitimate concern.  If the history says he took someone's helmet into
the tibial plateau (e.g., laterally, where the knee pad is less
protected), then your reading of the x-ray may be all you need.  A bone
bruise hurts, but may heal quickly. 

Why not have him on a therapeutic dose of naproxen (375 mg bid) and
re-evaluate him on the day of the game? 

Jim Jarvis, M.D.

Professor of Pediatrics and

Section Chief: Pediatric Rheumatology

University of Oklahoma College of Medicine

**mary ellen shields \[meshields47@GMAIL.COM\]**

**Mon 2/5/2007 2:12 PM**

My thoughts and questions:

What day of the week is this and do you have time to get this boy in to
a doc who is familiar with orthopedics/sports medicine before Friday
night? If so, would be helpful to do so. I feel accommodating his social
needs as well as physical needs is very important. He is likely to play
anyway with the current plan, and if the injury is a significant one, he
might injure the knee further. If he is taken seriously, and can see
another doc, he is more likely to follow instructions not to play or to
play as indicated.

I work in a small clinic where I am the part time pediatrician. There is
a part time internist and three family doctors. One family doc is quite
good at women\'s health issues and she has an interest in sports
medicine. We often curb side each other if we are there the same day, or
squeeze in a look within a day or two if the situation warrants. Do you
have that option? We try in the clinic to guide patients to a primary
care person, but it doesn\'t always work. It does lend continuity even
so\--and builds better relationship so patients are more likely to speak
up.

I like that you asked if there were any more concerns as it clearly
opened the door for them to say what was on their minds\--and may change
the way you plan the follow-up.

How about telemetry for quicker radiological opinions? This would be
helpful in lots of instances. Though with the knee, probably a good
Ortho exam is even more important. Backup is very important in a rural
setting. Often one can call the appropriate tertiary center and speak
with a specialist who can gives tips about how to proceed with the exam,
or ideas about what lab to order, or which views to get in an x-ray. In
some cases video telemetry is useful. Waiting a week for an x-ray result
does not seem appropriate in this day and age and at times could pose a
serious problem, depending on how capable a doc is at reading films. All
of us are more competent at some films than others.

**Simpson, Loren (IHS/PHX) \[Loren.Simpson@ihs.gov\]**

**Mon 2/5/2007 3:53 PM**

Hx? Although the patient mentions that it "hurts" is he practicing? Many
athletes as you know will play through pain with little impact on their
"game". If this athlete has a stable knee, can or has been practicing
full speed and a solid Lachmans with no large effusion as described then
I want to be darn sure that the x-ray indeed was negative. I think of
all sorts of bad things to rule out when looking at a knee x-ray in
addition if there is a question about Salter Harris involvement then he
is out until cleared by Ortho.  I would hold him out of practice and ask
the athletic trainer to evaluate him as well on the field. We are
fortunate to be able to work with PT and AT folks in rehabbing our
athlete's injuries. If this young man can not go 100%, limps- then he
does not play until perhaps he is full strength on follow up, is imaged
or seeks that Ortho opinion.

Question if a "partial" ACL tear exists-I hear mixed opinions from Ortho
on this one.  Ultimately I would do what is best in the patient's best
interest. His/her future athletic career should not hinge on one game at
the junior high level.

Loren P Simpson MD

Clinical Director

Washoe Tribal Health Center

**Wegehaupt, Dr. Paul \[pwegeha@SHSMH.ORG\]**

**Tue 2/6/2007 6:59 AM**

This response below is from Dr. David Bernhardt, pediatrician, team
physician, and head of sports medicine at University of Wisconsin
Hospitals in Madison Wisconsin.  I am forwarding his comments to the
group with his permission.  His contact information is listed as well,
and David has always been prompt with responses to questions by email in
my experience.

Paul Wegehaupt

Rhinelander, WI

 

\-\-\-\--Original Message\-\-\-\--\
From: David T. Bernhardt \[mailto:dtbernhardt@pediatrics.wisc.edu\]\
Sent: Tuesday, February 06, 2007 9:38 AM\
To: Wegehaupt, Dr. Paul\
Subject: RE: Knee pain in a 12 year old

Paul

 

Feel free to share my comments.  Sounds like an interesting case. 

 

The key in evaluating this patient is an adequate history.  Although a
12 year-old may not articulate the exact mechanism of injury, hopefully
a parent, teammate or coach can give a better history related to how he
actually got hurt.  Common injury mechanisms include:

1.  Hyperextension when trying to plant or pivot which would be
consistent with a possible ACL tear

2.  Valgus force when tackled from the outside which would be consistent
with a possible MCL tear or the triad of MCL, ACL or meniscus

3.  Twisting - meniscus or ACL

 

Another key point is any swelling associated with injury.  Acute
swelling in the first 24 hours is likely a hemarthrosis associated with
fracture, ACL injury or patellar dislocation.

 

PE with pain at extremes of flexion and extension is rather
non-specific.  Ligament exam assuming the practitioner is skilled in
this area is very re-assuring.  Focal tenderness over the medial or
lateral joint line would be worrisome for a meniscus tear.

 

X-rays are likely to be normal.  Osteochondritis dessicans would
possibly only be seen on a Tunnel or notch view so make sure appropriate
x-rays are ordered.  We usually obtain standard AP, lateral, merchant or
sunrise and tunnel views on all patients.

 

Playability based on the information given is based on the function.  Is
he able to jog, sprint, sprint and cut and perform football related
activities without pain, limping or favoring leg in any manner?  Keep in
mind this is a 12 yo athlete and although playoffs maybe important,
there is a long football career ahead for most youngsters.  Conveying
this information to the parents is often more difficult than to the
child/adolescent.

 

No problem with lack of radiologist on site for most of these injuries
as x-rays often have low yield.  MRI may be helpful in our situation but
usually based on exam findings which are non-specific.  Importance will
be clinical follow-up.

David

 

David T. Bernhardt, M.D.

Department of Pediatrics/Ortho & Rehab

Division of Sports Medicine

2870 University Avenue

Madison, WI 53705

**Tobe Propst \[TobePropst@SEMTRIBE.COM\]**

**Tue 2/6/2007 8:19 AM**

I agree with the other responses regarding concern for a subtle fracture
or partial tear.  Could also be a meniscal tear, although that will
often produce an effusion.  Areas of concern with this case so far:

1\. The provider feels weak in the areas of Ortho/teens.  I didn't get
much detailed knowledge out of the year-long sleepwalk they call
"Internship", but I did come out of it with some important gestalts --
one is it gave me a fairly good sense of that line between forging ahead
on your own as much as you can to try to figure out something you're
unfamiliar with; and when it's time to ask for help.  The provider needs
help to appropriately triage this boy.  Try to get someone qualified to
make the call or advise him to stay off it until they can.  Later, when
time allows, s/he can try to learn more Ortho.

2.  The case history and exam gives some important info, but some more
details would help, such as:\
HX:  Firstly, we don't even know how the pain started yet.  For all we
know this could be PFPS or IT band syndrome (basically "overuse"
injuries) or bursitis or patellar tendonitis or even a Baker's cyst or
Osgood-Schlatter that was exacerbated and brought to light by the
activity.  We should ask whether he can point to the pain precisely, the
mechanism of injury as best the boy can recall (was it twisting?; was
there a "pop"?; did he fall straight onto the patella?; was it a sharp
deceleration/turn (ACL)?; was it a direct blow to the front of the knee
(PCL/patellar sublux/fx)?), is it catching/locking/clicking/giving way?
(meniscus); whether he was able to bear weight immediately after the
injury (Ottawa knee rules...originally studied adults, but an Annals Em
Med article found that it worked in kids \<5yo as well).

PE:  Sounds like we did Lachman's and varus/valgus testing, and maybe a
posterior drawer, but realize that if it's only a partial ACL tear, it
probably won't show laxity on exam.  We also need to do a meniscal exam
of the knee, and check the hip and ankle joints as well (and assure
NVI!).  Other PE tests as indicated by the history.

 

Depending on these answers, you might ask for some specific views of the
knee on x-ray...for example AP & LAT & sunrise ("merchant") views if
there's isolated patellar TTP.  The inexperienced provider can readily
tell whether there's an obvious fracture or dislocation, but there are
many subtler yet serious injuries to be considered in a football
injury.  And, of course, an x-ray's not going to catch most soft tissue
injuries (which you wouldn't want to exacerbate by continuing play).

Dr. Propst

**Holve, Steve (TCRHCC) \[steve.holve@TCIMC.IHS.GOV\]**

**Tue 2/6/2007 3:18 PM**

The exam portion is unclear. Does this patient have pain on extension
and flexion of his knee joint? Did he have his hip joint examined?

Steve Holve, MD

**Erdrich, Angela ame (IHS/ABR) \[Angela.Erdrich@IHS.GOV\]**

**Wed 2/7/2007 2:22 PM**

In my 10 years in the Indian Health Service I have been working in a
"Priority One" situation about 50% of the time. On Priority One, the
places I have worked have not covered a referral to an orthopedic
surgeon for a non-fracture or an MRI of the knee. In fact my husband and
I would keep lists of these kids and bring them forward for the fine day
when we were off Priority One (assuming there were no Medicaid, CHIPS or
Private Insurance Options for the kids). We sometimes waited a year for
the Shriner's Ortho people to come in the summer (bless their be-fezzed
heads). Even with Ortho consults available on site, we would not cover
their requested MRIs unless the situation was life or limb threatening.

I have found this very frustrating, because young athletes are the
healthiest people in our system and they are so very deserving of
medical care to keep them in the game. This has also been the case with
working adults who suffer orthopedic injuries that affect their
livelihood. Yet we ration their healthcare and pay for the "life
threatening emergencies" which are often preventable. I am tempted to
say, truthfully, "we can not pay for your child's knee because we are
busy paying for the people who don't wear seat belts!" The reservation
is a microcosm in which there are very direct effects on the bottom line
when people do not practice preventive healthcare -- the costs are borne
by the whole tribe. Yet this is not discussed directly very often
locally. The same thing is happening nationally --a s the great
healthcare debate rages on and more money is needed to cover booming
healthcare costs, the politicians fail to mention that maybe people
should start taking care of themselves now, because there won't be
enough money to cover all the diabetes of the future!

Are there service units that analyze their contract healthcare costs to
assess each case as a preventable injury, a preventable health problem"
etc.? Some problems are hard to categorize.

I am happily on Priority Two at present, but I still would wait to refer
most minor acute knee injuries, unless I am dealing with a high school
athlete who is very serious about his/her sport and I think he is in
need of a more definitive opinion. I would tend to refer the patients in
worse pain or the patients who continue to hurt or feel a deficit for 2+
weeks? Often in the acute setting for a more serious injury, it is
difficult to get a good exam due to pain, so the history is important
(see previous comments) and immobilization/rest is needed.

Is there a case in which rest/immobilization for the knee and wait until
there is no limp/pain/swelling to resume sports is a bad idea? The
physical exam is helpful for the primary doc in a rural area because we
are trying to decide how serious the problem is, but truthfully, it
seems the Ortho doctors often base their definitive diagnosis on the MRI
results.

Angie Erdrich, MD

**Kaur, Judith S. M.D. \[kaur.judith@MAYO.EDU\]**

**Thu 2/8/2007 8:37 AM**

Angie,\
The whole issue of rationed care is so distressing to all of us.  I
wonder if someone from our Ortho department here has anything on
guidelines that might help contract health care decipher how to deal
with these issues.

Judith

**Boyd, David (IHS/HQE) \[David.Boyd@ihs.gov\]**

**Thu 2/8/2007 10:11 AM**

My Dear Colleagues,

I believe every IHS MD and Clinical Provider has a take on the "Ortho
Problem" at their facility and in their experiences.  My own personal
experience in this dilemma was when I was the General Surgeon and later
Clinical Director at the Blackfeet IHS Community Hospital, Browning, MT
(1992-2006).  Our gut wrenching Contract Care Meetings were without
resolve, as the available funds were already utilized by numbers of
trauma and other critical emergencies.  Last year I came to the IHS HQ,
OCPS and am currently the EMS Coordinator in the Office of Emergency
Services.   I do not have quick fix for the "Ortho Problem", but here in
part is what we are doing in this problem area.

> 1\) The IHS-Tribal Alcohol Screening and Brief intervention (ASBI)
> Program is aimed at reducing injury recurrence by 50%. This will save
> Trauma Limbs, Lives and Dollars.
>
> 2)  We are developing a visiting orthopedics' volunteer program in
> conjunction with the American Academy of Orthopedic Surgeons (AAOS).

3)  We are currently working to upgrade our Emergency Medical Services
    Systems both in the field and in our hospitals/ service units.

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3)  We will soon be Re-Regionalizing our Trauma and Critical Care
    systems.

These efforts, I believe will have direct and indirect impact on our
injured patients and the associated costs.  These  efforts  will  get
our SU's in better communication with surgeons and others who can assist
us in   professional education and training, case evaluation, on-site
surgery and  rehabilitation for orthopedic and other injuries.

Stay tuned. I will need your help in all of this.

Thank you, DRB

David R. Boyd MDCM, FACS

EMS Coordinator

Emergency Service

Indian Health Service

801 Thompson Ave Suite 320

Rockville, MD  20852

<David.Boyd@ihs.gov>

**North, Charles (IHS/ALB) \[Charles.North@IHS.GOV\]**

**Thu 2/8/2007 9:59 AM**

I have been impressed with the level of knowledge about adolescent knee
problems in the discussion to date.  Dr. Erdrich raises the issues of
"limited access to services and consultants" raised by Dr. Cullen
initially.  At the Albuquerque Service Unit we found the numbered
priority system to be less than useful. We abandoned it many years ago.
 

Instead we use the following guidelines to decide on contract care
payments:

-No experimental or cosmetic procedures are covered.

-If Medicare covers the service, it is not experimental or cosmetic. 

-If the IHS doctor recommends a consult, we find a way to support the
medical decision

since the "doctor knows best" and we want to show our support by
providing

recommended care. Both the medical side of the IHS and the
administrative side are

saying the same thing. 

-Nothing undercuts patient care more than conflict, i.e. the doctor
recommends a consult

and the nasty IHS administration doesn't support the doctor's decision.

-Consults are cheap, lawsuits, ED visits; hospitalization, loss of
function; chronic disease

and deaths are expensive.

-If you want to find ways to reduce CHS expenditures, find alternate
resources for

hospitalized patients, better contract rates and consultants who will
hold clinics on site for

low fees.

-If push comes to shove, it is better to delay or halt payments on care
provided beyond

your control in the ED and hospitalizations where patients have already
received care

than restricting consults by your medical staff. 

-All patients in the USA have access to emergency care and
hospitalization.  If the

hospitals complain about the government (CHS) not paying them, they have
recourse by

contacting elected officials who can increase the CHS budget.  This
actually happens, but

not enough.

If you follow the above principles you will have happy patients,
doctors, consultants and communities.  The alignment of interests in CHS
with the interest of patients and their physician advocates is the moral
position of preference.  No one should settle for less.

I have worked in IHS just 5 months short of 30 years and find that the
issue frustrating Dr. Erdrich has been frustrating our physicians and
patients my entire career.  Don't our patients, families and communities
deserve better?  Who will advocate for a sane CHS policy if we don't?

**Esposito, Douglas (FDIH) \[Douglas.Esposito@IHS.GOV\]**

**Thu 2/8/2007 2:48 PM**

Angie:

Thanks for your comments.  I will uncharacteristically say relatively
little, but would like to turn everyone's attention to a little
commentary and an article I came across last night in the most recent
American Journal of Public Health (link below) I imagine many of you not
at federal sites will not be able to bring this article up unless you
are members of the APHA.  For those that can, they are interesting and
relevant documents for those of us serving Native American kids.  For
those that can't. Sorry.  I don't want to go to jail for illegal
distribution of a couple of fantastic articles!

A major portion of the problem is governmental/societal imposed
disparities in access to healthcare for Native Americans.  If there were
sufficient contract health dollars allocated by Congress, the problems
you are facing would cease and we could deliver the needed care to our
constituents.  Additionally, if we were to have sufficient funds to
distribute currently available medical and preventive technologies,
measurable health disparities would surely be reduced dramatically
(that's the gist of the above articles).  It's embarrassing that the
problems our AI/AN patients endure are so similar to those experienced
in the developing world; we are, after all, the richest nation on the
planet!  But, it's not that surprising given the similar root of our
shared difficulties: colonization, domination, and exploitation.  As
described in the above articles, effective distribution of currently
available technologies is lacking, yet we spend BILLIONS developing new
technologies that only address the health needs of a small percentage of
our (and the world's) population.  Go figure!  That's not the most
rational or equitable road to take, in my humble opinion.

I'd also like to take a second to recommend a book.  It really sheds
light on the legal limbo that helps keep Native American societies from
moving forward.  Despite the author being a lawyer, he's a "good guy." 
Having read this, I now feel like I have a better understanding of what
those of us seeking societal change are up against.  Much of the health
disparities we combat are rooted in the legal status of Indians and
Tribes.

Other than my typical rants about the systematic injustice exacted upon
Native Americans by our society, I really haven't anything else to add
to the discussion of the case itself.  Thanks for listening, though!

Doug

Links from above

[[http://www.ajph.org/cgi/reprint/97/2/203]{.underline}](http://www.ajph.org/cgi/reprint/97/2/203)

[[http://www.ajph.org/cgi/reprint/97/2/219]{.underline}](http://www.ajph.org/cgi/reprint/97/2/219)

Book recommendation: Here's how to get a copy

[[http://www.amazon.com/Rights-Indians-Tribes-Authoritative-Liberties/dp/0814767184/sr=8-1/qid=1170972341/ref=sr_1_1/105-5740649-7758824?ie=UTF8&s=books]{.underline}](http://www.amazon.com/Rights-Indians-Tribes-Authoritative-Liberties/dp/0814767184/sr=8-1/qid=1170972341/ref=sr_1_1/105-5740649-7758824?ie=UTF8&s=books)

Douglas H. Esposito, MD, MPH, FAAP

Director, Division of Community Health

Navajo Area Indian Health Service

Fort Defiance Service Unit

**Toedt, Michael mt (IHS/NAS) \[Michael.Toedt@IHS.GOV\]**

**Thu 2/8/2007 5:40 PM**

I certainly sympathize with the comments about health disparities for
Native Americans. There are also health disparities for those in poverty
of any race, for illegal aliens, for migrant workers, for African
Americans, for \"medi-gap\" population, and many other groups. The fact
is that healthcare in the United States is broken for far more than the
1.5% or so of the population that is Native.

I spent a few years working in the National Health Service Corps in
rural West Virginia, where I saw many people of different races that
don\'t have access to any such services like we have in IHS. We had no
health care dollars for referrals or studies, and specialists were often
simply unavailable because they had been driven out of the state by
prohibitive malpractice costs. Pharmaceutical company indigent care
programs or samples were all too often inadequate and/or inappropriate.
Even if you spend your entire career in the IHS, you get a sense of what
it\'s like for those without the IHS \"safety net\" when you see a
patient that is not eligible for medications and CHS services.

Of course we should not ignore the health disparities of the population
we are directly serving, and we should remain our patients\' staunchest
advocates. At times it seems that all we can do is fight for a bigger
piece of the budget. But we also should consider the broader need for
national health care reform. Meaningful reform is needed for tort
claims, malpractice, drug pricing control, access to quality care, etc.
We should make sure our representation knows that brothers and sisters
of all races and creeds are suffering and dying under the weight of a
broken health care system.

Michael Toedt, MD

**Jarvis, James N. (HSC) \[James-Jarvis@OUHSC.EDU\]**

**Fri 2/9/2007 4:52 AM**

It's actually worse than Doug describes.  We spend BILLIONS of dollars
in this country to PREVENT people from having access to health care.
 How sick is THAT?????

Jim Jarvis, M.D.

**Morphet-Brown, Mary (IHS/POR) \[Mary.Morphet-Brown@IHS.GOV\]**

**Fri 2/9/2007 9:31 AM**

There are a few programs that are demonstrated to improve access (and
outcomes).  One is the Nurse-Family Partnership (David Olds). The data
are impressive, but despite more than 20 years of solid science behind
it, they seem to be still in pilot programs.  We're fortunate to have
one of their pilot programs here in Yakima. The down side is, of course,
that they're under funded and max out their caseloads very quickly.
 Again, it may just be a band aid, but it's a band aid with empirically
demonstrated outcomes.

 Mary Morphet-Brown, MSN, ARNP

Yakama Indian Health Center

Public Health Nursing

**Esposito, Douglas (FDIH) \[Douglas.Esposito@IHS.GOV\]**

**Fri 2/9/2007 6:28 AM**

True. I too have direct experience working with indigent populations
both here and abroad; including eastern and western-stream migrant farm
workers and their continued fight against indentured servitude (it seems
that yet another case has surfaced in Maine, this time involving legal
Guatemalan exchange-worker program participants). Nevertheless, what
differs for all other minority groups and underserved populations in the
US is that our country and our government entered into treaties with the
original inhabitants of this land. In my estimation, by all the rights
and tenets of honor and decency, this should guarantee some level of
protection for Native Americans. No other minority group in this country
is similarly \"protected.\" This makes the plight of Native Americans
all the more abhorrent, in my opinion.

Doug

Director, Division of Community Health

Fort Defiance Service Unit

**Cullen, Theresa (IHS/HQE)**

**\
Sunday, February 11, 2007 11:00 PM**

The next update on this case:

Remember, a 12 year old with knee pain presenting to the busy outpatient
clinic. Initial exam was remarkable for some pain, and a normal
radiograph per the primary care provider. Patient was sent home with
anti-inflammatories and instructed to not engage in strenuous activity
for a week.

He returns 10 days later, as instructed. However, the provider that he
originally saw is not in clinic this day, so he (and his dad) sees
another physician.

The physician comes into the exam room; the patient is already sitting
up on the exam table. The provider talks to the father about his son.
The dad reveals that the son DID play in the football game because he
felt better on the medication. However, the next day, he noticed that
his son was limping and still complained of knee pain. His son has not
played in practice for the last 2 days; he is now starting to feel
better and wants to practice again.

The official knee X ray result is finally found in medical records\--and
is noted to be \'within normal limits\'. The patients knee exam is still
painful on full flexion and extension, but \'not as bad\' per the
patient.

Luckily, the monthly consultant Ortho clinic is scheduled for the next
day, and you are able to squeeze this patient into that clinic. The
orthopedic surgeon believes that the knee is stable though the patient
is still complaining of pain; he diagnoses overuse syndrome, and
indicates that the patient should limit strenuous activity and continue
on NSAID\'s. The patient is given a follow up appointment in 3 weeks
into general pediatric clinic.

 

Questions:

1.      Would you have done anything differently at your facility?

2.      Would you have questioned and/ or examined the patient without
the father in the room?

3.      The patient has now seen a specialist who seems to agree with
your diagnosis.

What level of reassurance does this give you as a provider?

4.      Additional comments?

**Wegehaupt, Dr. Paul \[pwegeha@SHSMH.ORG\]**

**Tue 2/13/2007 5:00 AM**

I remember several questions about details of the knee X-rays, but do
not recall if it was mentioned which films were obtained and read as
\"within normal limits.\"  Until a \"sunset\" or \"tunnel\" view is
specifically mentioned and found to be normal, I would continue to
wonder about osteochondritis dessicans.

 PKW

Rhinelander, WI

**Kandel, Joan (TCRHCC) \[joan.kandel@TCIMC.IHS.GOV\]**

**Wed 2/14/2007 1:10 PM**

What about his hip exam and x-ray?  Is this a slipped capital femoral
epiphysis?

Joan Kandel, DO

Family Physician

Tuba City

**Cullen, Theresa (IHS/HQE) \[Theresa.Cullen@IHS.GOV\]**

**Tue 2/13/2007 5:47 PM**

The knee films were all read as within normal limits, including the
sunset view.

By the way

There was no hip exam documented, and there was no hip X-ray taken.

**Cullen, Theresa (IHS/HQE) \[Theresa.Cullen@IHS.GOV\]**

**Fri 2/16/2007 7:16 AM**

New Update:

Over the next 3 months, the patient was seen intermittently by multiple
providers for pain and prescribed NSAID\'s. He continued to indicate
that he felt better on NSAID\'s, and continued to be active. His
physical exam was intermittently positive for knee pain with active ROM.
His diagnosis continued to be overuse syndrome; many providers
referenced the previous Ortho consultation that seemed to confirm that
diagnosis.

He is now in walk in clinic again (5 months after his initial
presentation) complaining of increased pain

What should you do? 

**Kandel, Joan (TCRHCC) \[joan.kandel@TCIMC.IHS.GOV\]**

**Fri 2/16/2007 7:28 AM**

There is a very good chance that he has a slipped capital femoral
epiphysis.  Get some hip x-rays and examine his hips.

Joan Kandel, DO

Family Physician

Tuba City, AZ

**Begay, Rosaline (Tsaile) \[rosaline.begay@IHS.GOV\]**

**Fri 2/16/2007 8:50 AM**

I would also consider checking an RA profile

Rosaline Begay, M.D.

Internal Medicine

**Jarvis, James N. (HSC) \[James-Jarvis@OUHSC.EDU\]**

**Fri 2/16/2007 1:49 PM**

Pediatricians aren't kidding when they say, "Children are not just small
adults."  Diagnostic approaches developed for evaluating adults with
musculoskeletal complaints are poorly suited to use in children.  Thus,
"RA profiles" as used in adult medicine aren't very helpful in children.

\*I\* would not consider chronic inflammatory arthritis in this child,
for several reasons:

1.  JRA almost never presents with pain as a chief complaint (see McGhee
    et al, Pediatrics, 2002; Dr. McGhee, by the way, is a very talented
    Native American physician who is completing her residency in
    pediatrics at St. Louis Children's Hospital in 2008).  If a child is
    complaining of pain, take JRA and move it down the list. If the pain
    is SEVERE and waking the child up at night, take leukemia and move
    it UP the list.

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1.  No one has described in this patient the sine qua non of chronic
    arthritis: warmth and proliferative synovium.  This is an easy thing
    to detect on physical exam.

I would avoid drawing laboratory tests you would regret drawing on this
young man.  For example:

> \- You've got a 40% chance that an ANA test will be positive, so all
> you're going to do with THAT test is worry the family when it comes
> back 1:160 (see Malleson et al, Arch Dis Childhood). BECAUSE ANA tests
> are so commonly positive in children, AND because titers in healthy
> children completely overlap those of children with rheumatoid disease,
> spondyloarthopathy, and even dermatomyositis, we recommend that ANA
> testing in children be used to answer one \*and only one\* question in
> pediatrics: Does this child have lupus?  In SLE, titers of 1:1,080 and
> higher are common, and titers of that magnitude fairly infrequent (but
> occasionally seen) in healthy children.  Obviously, isolated knee pain
> in a 9 y.o. BOY would NOT be a common presentation for SLE. Once
> again, the data to support this recommendation were generated by Dr.
> Julie McGhee and colleagues.
>
> \- Rheumatoid factor tests have the opposite problem: extraordinarily
> low sensitivity and specificity.  Most children with rheumatoid
> disease don't have a positive test, and most children with a positive
> test don't have the disease (see Eichenfield et al Pediatrics 1986). 
> For that reason, we say, \*there is no reason at any time to EVER
> order a rheumatoid factor test on a child for diagnostic purposes.\*
>     Children with RF+ RA have such prominent morning stiffness and
> proliferative synovitis on exam that the diagnosis is readily apparent
> from the history and physical.

I'm attaching the relevant literature.  The ANA paper is one of THE most
highly accessed papers on the Biomed Central web site and is the work of
2 extraordinarily talented Native American women.  Dr. McGhee wants to
do her IHS pay-back in the southwest.  Sorry Billings and Aberdeen; she
has \*really\* bad Raynaud's phenomenon, and as much as I'd like to see
her with a really talented pediatrician like Lori Byron, I think Navajo
will get first crack at her.

(**Editorial Note**: References at the bottom of this document)

Pardon my being long-winded.

Jim Jarvis, M.D.

Professor of Pediatrics and

Section Chief: Pediatric Rheumatology

University of Oklahoma College of Medicine

**Cullen, Theresa (IHS/HQE) \[Theresa.Cullen@IHS.GOV\]**

**Tue 2/20/2007 5:14 PM**

Last we left:

12 year old male is now in walk in clinic again (5 months after his
initial presentation) complaining of increased pain.

Recommendations have included examining the hips as well as other
evaluations.

What happened:

1.  CBC, ESR, BMP are done---all within normal limits

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1.  It is unclear if the patients hips are examined at this visit or
    not---the note is not clear

2.  Patient is sent home with pain medication and similar advice to the
    last 5 months of visits; however, the primary care provider ( the
    6^th^ different provider to see this patient) is concerned about the
    ongoing nature of the problem, and wants to get another orthopedic
    opinion

3.  Referral is placed for a pediatric orthopedics consultation 60 miles
    away; the family has to apply for state Medicaid prior to their
    visit being scheduled ( they will subsequently be denied)

2 weeks later:

The medical director receives a call from a distraught referral clerk,
who is trying to schedule the orthopedics visit. The father has called,
and indicated that he took his child to the emergency room over the
weekend---where he was told that he had to see pediatric orthopedics
'immediately' on Monday.. He has told the referral clerk that his son is
now unable to walk. He knows that his son had X-rays done (hip and knee)
and that they were not normal. The father is unclear about a diagnosis
but he is calling to try to schedule the visit ASAP. The father was not
given any paperwork to bring back to the IHS facility.  The clerk is
attempting to schedule the visit, but is not able to get an appointment
for 3 weeks. 

What would you do?

**Holve, Steve (TCRHCC) \[steve.holve@tcimc.ihs.gov\]**

**Fri 3/2/2007 7:09 AM**

This is a disturbing, but unfortunately not uncommon case history.

 

I suspect that at the ED visit hip x-rays were done which showed a
slipped capital femoral epiphysis (SCFE). This is an orthopedic urgency,
if not emergency.

 

Knee pain can originate in the knee but can also be referred pain from
the hip joint. Any pediatric patient presenting with knee or thigh pain
needs to have an examination of the hip joint. If the hip joint is
involved there will be pain on flexion of the hip \>90 degrees and there
is often severe pain on internal rotation of the hip joint. These
findings are not consistent with the knee as a source of the discomfort
and should prompt radiographs of the hip joint and consultation with an
orthopedist if there are any concerns. The differential can include
toxic synovitis, avascular necrosis and SCFE.  Toxic synovitis will
resolve within 3- 5 days. Avascular necrosis and SCFE will feel better
if the joint is rested but will not resolve. If hip radiographs are
normal the patient needs to be seen back in a week to make sure the pain
is gone and hip mobility is completely normal. If not, the patient needs
further work-up including possible a CT or MRI of the hip which can
defect changes in avascular necrosis or SCFE before they may be visible
on plain films.

 

SCFE is the most common single orthopedic malpractice claim of children
for pediatricians. This likely reflects the practitioner focusing on the
site of pain and failing to consider hip involvement. SCFE, if treated
early with pinning, can prevent further slippage and the long term
outcome can be excellent. If the diagnosis is delayed, the slip will
progress. The slipped proximal femoral head cannot be reduced to its
original position because of the tenuous blood supply via the femoral
artery; the slip can only be pinned and stabilized in the location it is
found. A slipped proximal femoral head will heal but will no longer be
anatomically correct in position in the acetabulum. These patients begin
to have chronic hip pain in their 20s and often need hip replacements by
the time they are 30.

 Steve Holve, MD

**Heath, Stephen W. (IHS/ALB) \[Stephen.Heath@IHS.GOV\]**

**Fri 3/2/2007 7:25 AM**

I can confirm that the IHS does indeed have tort claims filed against
the Agency with some regularity alleging failure to timely diagnose and
treat SCFE in children.  Almost always the issue is that SCFE was not in
the differential diagnosis.  These cases are rarely defensible.....

Steve Heath

IHS Risk Management Program

**Wall, Angela D (IHS/TUC) \[Angela.Wall@IHS.GOV\]**

**Fri 3/2/2007 8:31 AM**

Images can be seen at the following website

[[http://www.emedicine.com/radio/topic641.htm]{.underline}](http://www.emedicine.com/radio/topic641.htm)

Angela Wall, DO

**Cullen, Theresa (IHS/HQE) \[Theresa.Cullen@IHS.GOV\]**

**Fri 3/2/2007 10:59 AM**

Thanks for the great comments.

Update to this case

The patient was able to get into pediatric orthopedics through a phone
conversation. The patient was diagnosed with a SCFE, and eventually
underwent surgery to stabilize his hip slippage, which was significant
by this time. However, due to complications, he required additional
surgery approximately 3 months after the first one.

The parents were appropriately concerned about the patients care, and
had a few conversations with the medical director at this facility.

Potential areas of concern were addressed by the medical staff:

1.  lack of continuity of care

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1.  lack of more frequent follow up

2.  failure to consider additional diagnoses at the initial time of
    presentation and at subsequent visits

3.  failure to consider additional diagnoses due to 'the patient already
    had an Ortho consult'

4.  lack of communication with the family

Any other comments on what could have been done differently? SCFE may be
on of those---once you see it, you never forget it. But, if you never
saw it, it may not enter into your differential thinking. Dr. Heath and
Holve remind us of the need to consider this diagnosis as an appropriate
differential in a case like this.

Please let us know your thoughts.

**William Green \[greenfamil@YAHOO.COM\]**

**Thu 3/8/2007 4:37 PM**

For whatever it is worth (not much in the arena of tort liability) a few
years ago I had a 15 year old Down syndrome patient c/o knee pain and
refusal to walk. After several consultant visits the mother was
eventually labeled as \"over seeking of medical attention\" for this
persistent complaint by consultant pediatric orthopedists. The films
including the hip were available to the pediatric orthopedic consultants
but apparently not interpreted properly or furnished to radiology dept
for review (the missing films syndrome). Eventually the dx was
clear\--SCFE.

The advent of digital imaging available to all providers has improved
quality of radiological interpretation and communication at this
particular \"large New Mexico referral facility\". Digital transmission
of images and timely interpretation by qualified radiologists is
difficult, perhaps expensive to set up, but just a few tort claims
prevented can certainly justify the expense. Of course the diagnosis
would have to be considered, as has been discussed extensively.

**Resources quoted in message above:**

Victora. Addressing International Child Health Priorities *Am J Public
Health.*2007; 97: 203

[[http://www.ajph.org/cgi/reprint/97/2/203]{.underline}](http://www.ajph.org/cgi/reprint/97/2/203)

Leroy et al. Current Priorities in Health Research Funding and Lack of
Impact on the Number of\...\
*Am J Public Health.*2007; 97: 219-223

[[http://www.ajph.org/cgi/reprint/97/2/219]{.underline}](http://www.ajph.org/cgi/reprint/97/2/219)

The Rights of Indians and Tribes: The Authoritative ACLU Guide to Indian
and Tribal Rights, Third Edition (American Civil Liberties Union
Handbook) by [Stephen L.
Pevar](http://www.amazon.com/exec/obidos/search-handle-url/002-9373753-1775251?_encoding=UTF8&search-type=ss&index=books&field-author=Stephen L. Pevar)
(Author)

[[http://www.amazon.com/Rights-Indians-Tribes-Authoritative-Liberties/dp/0814767184/sr=8-1/qid=1170972341/ref=sr_1_1/105-5740649-7758824?ie=UTF8&s=books]{.underline}](http://www.amazon.com/Rights-Indians-Tribes-Authoritative-Liberties/dp/0814767184/sr=8-1/qid=1170972341/ref=sr_1_1/105-5740649-7758824?ie=UTF8&s=books)

CONCLUSIONS: Musculoskeletal pain was the most common reason for
referral to our pediatric rheumatology clinic. However, isolated
musculoskeletal pain, in the absence of other signs or symptoms, is
almost never a presenting complaint of children with chronic forms of
arthritis. Children with arthritis more commonly present with complaints
of joint swelling and/or gait disturbance. Neither ANA nor rheumatoid
factor evaluations were useful in evaluating children with
musculoskeletal complaints.

[McGhee
JL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="McGhee+JL"%5BAuthor%5D),
et al Identifying children with chronic arthritis based on chief
complaints: absence of predictive value for musculoskeletal pain as an
indicator of rheumatic disease in children.
[Pediatrics.](javascript:AL_get(this, 'jour', 'Pediatrics.');) 2002
Aug;110(2 Pt 1):354-9

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=12165590>

CONCLUSION: Age and ANA titer assist in discriminating children with SLE
from children with other conditions. ANA tests are of no diagnostic
utility in either making or excluding the diagnosis of JRA.

[McGhee
JL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="McGhee+JL"%5BAuthor%5D),
et al Clinical utility of antinuclear antibody tests in children. [BMC
Pediatr.](javascript:AL_get(this, 'jour', 'BMC Pediatr.');) 2004 Jul
9;4:13

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=15245579>

[Jarvis
JN](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Jarvis+JN"%5BAuthor%5D).
The unique clinical presentation of children with chronic arthritis:
putting the pediatrics in pediatric rheumatology. [Curr Probl Pediatr
Adolesc Health
Care.](javascript:AL_get(this, 'jour', 'Curr Probl Pediatr Adolesc Health Care.');)
2006 Mar;36(3):80-2

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16473283>

Slipped Capital Femoral Epiphysis

[[http://www.emedicine.com/radio/topic641.htm]{.underline}](http://www.emedicine.com/radio/topic641.htm)