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Well,

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today, in addition to going through all of

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the information in this article, I'm just gonna

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spend some time pimping you with questions that

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came straight straight from this journal. I I

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just need more people to ask me questions

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that are just whatever pops into their head.

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That's just the best. It's okay.

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It's a safe environment. It's just you and

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me. That's that's it. It's just you and

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I having a conversation. I'm just gonna pimp

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you on some questions. You know, if you

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do terribly, we'll edit it on the back

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end. It's not like I'm gonna put the

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blooper reel in the front of this episode.

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I'm very confident that my medical students got

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to you with money, and I respect the

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fact that now they're gonna have me pimped

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on a national podcast. That's great. That's great.

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Here we go.

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Hey, everyone, and welcome back to another episode

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of Amplify. I'm one of your hosts, Sam

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Ashu. Before we dive into today's episode, I

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just wanna remind you that ebmedicine.net

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is your one stop shop for all your

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CME needs for emergency medicine and pediatric emergency

27
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medicine and even evidence based urgent care. You

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can find all three of those journals, the

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DEA MATE course, the laceration

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course, the abscess course, and so many other

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resources in in addition to the clinical pathways

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at the website

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and in the mobile app. So go there

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today, become a subscriber, and get all of

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your CME met in one stop. And now

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let's jump into today's episode.

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Ladies and gentlemen, welcome back to another episode

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of Emplify. I am one of your hosts,

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Sam Michoud. And on the other side of

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the microphone

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Back at it again, doctor t r Eckler.

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Could not be more excited to talk about

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some knees. That's right. Today, we are talking

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about the March 2025 emergency medicine practice issue

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titled emergency department management of knee pain and

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authored by three emergency physicians, one of whom

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is also a professor of sports medicine. So

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we've got doctor

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Gingard, doctor Kiel, and doctor Riveros, and my

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apologies to all three of them if I

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butchered your names. I do that very commonly.

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But they wrote,

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once again, a wonderful volume on all things

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knee pain,

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which I thought was pretty timely. Honestly, I've

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had knee pain recently. Had to go visit

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the orthopedist myself. Suffered a little Tae Kwon

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Do injury and was worried I might actually

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have a meniscal tear because the pain wasn't

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going away.

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And

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much like was listed in this article,

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there are a bunch of physical exam tests

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that can be performed

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in order to try and determine

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where the pain is,

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and there are some specialty tests. And I

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went through, I think, most of these with

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the PA who saw me and did an

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outstanding job, I might say. So this was

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very timely and hit close to home. Thankfully,

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I did not have a meniscal tear, and

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things are on the mend, but we'll talk

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more about that in a few minutes.

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TR, you ever had knee pain? Ever seen

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anybody with knee pain? I I have a

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long interesting history of injuries, but I've never

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actually done anything to either of my knees.

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I think my my sister tore her ACL

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when we were in high school, And I

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just remember that process for her and just

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the challenges of like the surgery and the

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rehab and everything. And it was probably one

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of the first points that I kind of

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thought of like the value of a career

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in medicine, because I saw how, you know,

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that you had a chance to put people

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back together. And I got to see the

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inside of that process.

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It was it was it was a cool

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thing, and she's still really athletic and more

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athletic than me. And I I respect the

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fact that those surgeons managed to, you know,

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make sure that she could still beat me

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at most things. Fair enough.

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Alright. So we're gonna start with the introduction.

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Which of the following is the most common

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etiology

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of atraumatic

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knee pain? So the most common. We've got

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gout,

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we've got osteoarthritis,

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we've got septic arthritis,

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and we've got meniscal tears.

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I think it's osteoarthritis.

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Osteoarthritis.

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Yes, sir. T r for the win on

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question number one. The major etiologies for atraumatic

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knee pain are the ones I just mentioned,

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but the most common is osteoarthritis.

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No surprise there. The, article authors mentioned there

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was six point six million knee injuries in

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The United States over a ten year period

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from '99 to 02/2008, which doesn't surprise me

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at all, honestly,

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with our extreme sports and our athleticism

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and our ice storms down here in Florida

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causing a bunch of people to slip. Knee

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injuries seem very common. Credible amount of people

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that got hurt in that snowstorm.

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But, I can't help, but highlighting the fact

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that,

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you know, the osteoarthritis

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while bad is on the rise,

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particularly linked with like the bimodal distribution where

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you have your extreme athletes, but also the

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rising obesity in America. Like that's really driving

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a lot of this. And then I, I

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really was blown away by the fact that

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31

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of orthopedic practices

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don't take Medicaid patients.

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And that really, that really rang true for

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the challenge of dealing with some of these

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is that some of these people don't have

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a follow-up option with orthopedics.

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So trying to find any other way you

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can to get them more answers or more

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treatment, I think is pretty important to not

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just assume that orthopedics is gonna be the

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answer for these people.

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Yes. Yes. And kudos to the authors for

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putting that information in there to try and

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drive home the relevance for knowing this information.

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If your practice consists of, I'm gonna get

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an X-ray, and I'm gonna send them to

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follow-up with ortho and I don't care about

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anything else, then a significant

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portion of your patients, are not able to

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get that orthopedic follow-up, and it makes a

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difference whether or not you can give them

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a definitive diagnosis

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and a treatment plan. That's really the most

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important is how are you gonna get rid

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of this knee pain so you can get

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back to work or back to your activity.

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Interestingly, you mentioned already risk factors for developing

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knee osteoarthritis.

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Obesity is on the rise as well as

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age and participation in sports and occupations. So

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you can't forget to ask about what it

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is that they do and whether or not

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they're on their knees all day. That's a

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very important differentiator.

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When it comes to

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osteoarthritis,

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which of the following is a common risk

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factor for developing osteoarthritis of the knee? Alright.

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Ready? Here we go. ACL tear. This is

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history, mind you. ACL tear, IV drug use,

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high dose steroid use,

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recent knee surgery, or rheumatoid arthritis?

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So I would tell you, I would think

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both recent knee surgery and

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use of corticosteroids

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would both increase your risk of osteoarthritis.

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You're at fifty percent, sir. That's one correct

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and one wrong.

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Okay. Well, if I had to guess but

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if I had to guess between the two

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of them, I would say it's recent knee

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surgery gives you No. Actually, you're you're

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on the right track. You're definitely on the

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right track. A history of prior injury or

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prior surgery

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is definitely a risk factor for developing knee

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osteoarthritis.

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The pitfall in this question is the recent

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knee surgery because it just hasn't been long

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enough yet to cause osteoarthritis.

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The ACL tear, the history of a prior

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ACL tear is the risk factor there, but

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you're absolutely right. Injury That's because then they

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had they usually they had surgery because their

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ACL tear. Yeah. Okay. Yeah. Or they had

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your previous trauma, and now it's healed. There's

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been some time to get the osteoarthritis.

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Here's a great step one question. That was

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just there were so many layers of traps

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in that question. I love Yes.

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Indeed. Traps indeed. IV drug use is a

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risk factor for septic arthritis. High dose corticosteroids

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gives you a vascular necrosis over time, especially

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with prolonged use. Recent knee surgery, again, if

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if you wait long enough and it's healed,

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then, yes, you get the osteoarthritis.

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And then rheumatoid arthritis causes inflammatory, not degenerative

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osteoarthritis.

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So it's a trap question, but I had

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to use it. I'm sorry. You just And

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we see so many of the the knee

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replacements to get done for osteoarthritis

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because people just have that chronic pain that's

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terrible, and then they end up getting a

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replacement and they do well. And now, you

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know, the orthopedic surgeons have invested in all

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this pickleball courts just to make sure the

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business keeps going, and I respect that. Yeah.

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I mean, pickleball is a great sport. I

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will say I have played it myself. I

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love pickleball. Not not not usually. I don't

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fit into that category of your typical pickleball

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player, but we have a new pickleball court

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here in town. And you'd be surprised how

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many college students are out there playing it.

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It's a great it's a fun sport. Alright.

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Let's talk about infectious causes. So of all

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of the different bacteria out there, this is

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gonna be a little soft ball question for

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you. What do you think is the most

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common organism to cause septic arthritis for for

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knees? Staph aureus. Yeah. All day, every day,

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baby. Exactly. There was a study, a hundred

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and five patients identified a causative agent in

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eighty one of them, and it was all

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staph. That's definitely the most common.

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When it comes to the differential diagnosis for

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atraumatic

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knee pain, there is a giant table on

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page five of the differential diagnosis that breaks

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it down very nicely based on the location

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of the symptoms. So the the number one

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question to ask them is where is your

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pain? And then you can go straight to

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this table and go, oh, your pain is

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anterior. Here's one, two, three, four different conditions

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that can cause anterior knee pain, or your

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pain is posterior or inferior. So an outstanding

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table not only tells you the differential based

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on location, but also a few extra notes

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like septic knee and

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dislocation

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should be worrisome findings for somebody with this

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kind of pain. And there is even a

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little pediatric specific section of that table. So

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something to keep in mind. I'm not gonna

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read it to you, but if you have

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access to the article, it's on page five,

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an excellent differential diagnosis.

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When it comes to prehospital care, I thought

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the authors did a pretty good job just

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driving home the fact that

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most of these patients do not need to

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go to the emergency department to begin with.

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And if you're an EMS provider and you're

266
00:09:27,659 --> 00:09:30,720
being called emergently for someone with knee pain,

267
00:09:30,940 --> 00:09:33,100
then you've got some basic assessments to do.

268
00:09:33,100 --> 00:09:36,320
Was there trauma? Is the knee obviously deformed?

269
00:09:36,875 --> 00:09:38,975
And then it can be a little difficult,

270
00:09:39,115 --> 00:09:41,774
but rarely knee dislocations can occur

271
00:09:42,154 --> 00:09:45,914
from atraumatic mechanisms, especially in the morbidly obese

272
00:09:45,914 --> 00:09:49,695
patient. And it can go unrecognized, completely unrecognized

273
00:09:50,235 --> 00:09:52,950
because of the size of that patient and

274
00:09:52,950 --> 00:09:53,450
because

275
00:09:54,149 --> 00:09:55,990
small deformities in the knee joint may go

276
00:09:55,990 --> 00:09:56,490
unrecognized.

277
00:09:56,950 --> 00:09:59,050
And if you're the EMS provider,

278
00:09:59,509 --> 00:10:01,110
sure you're gonna splint, you're gonna provide some

279
00:10:01,110 --> 00:10:03,110
pain control, and you're gonna bring them. Some

280
00:10:03,110 --> 00:10:04,870
things to note would be, do they have

281
00:10:04,870 --> 00:10:06,975
a fever? Are they attack a cardiac? Are

282
00:10:06,975 --> 00:10:10,274
they obviously septic and hypotensive? That's important information

283
00:10:10,335 --> 00:10:12,335
to know when you pass them off to

284
00:10:12,335 --> 00:10:14,975
the emergency department because it can alert us

285
00:10:14,975 --> 00:10:17,134
early that there's some kind of sepsis going

286
00:10:17,134 --> 00:10:18,735
on and that we need to address that

287
00:10:18,735 --> 00:10:19,235
quickly.

288
00:10:20,019 --> 00:10:21,620
Interestingly, and this is all the part this

289
00:10:21,620 --> 00:10:23,299
is the part I always love reading. There

290
00:10:23,299 --> 00:10:25,539
was a retrospective study, two hundred and seventy

291
00:10:25,539 --> 00:10:28,419
seven patients that demonstrated that prehospital suspicion for

292
00:10:28,419 --> 00:10:29,720
sepsis decreased

293
00:10:30,259 --> 00:10:31,480
time to treatment

294
00:10:31,940 --> 00:10:32,839
in the ED,

295
00:10:33,754 --> 00:10:36,075
but no clinical outcome benefit was studied. So,

296
00:10:36,075 --> 00:10:38,554
you know, we're very focused on time to

297
00:10:38,554 --> 00:10:41,514
antibiotic because those are always the joint commission

298
00:10:41,514 --> 00:10:43,995
metrics that we're looking at, but we're yet

299
00:10:43,995 --> 00:10:47,455
to find any strong patient data in this

300
00:10:48,029 --> 00:10:51,230
specific realm for septic knees, for example, that

301
00:10:51,230 --> 00:10:53,629
tells us that the sooner, you know, whether

302
00:10:53,629 --> 00:10:55,629
it's six hours versus two hours that you

303
00:10:55,629 --> 00:10:57,709
get the antibiotic on board, are you really

304
00:10:57,709 --> 00:11:01,230
affecting any clinical outcomes? So more data needed

305
00:11:01,230 --> 00:11:02,370
when it comes to that.

306
00:11:02,745 --> 00:11:04,264
Well, and also to your point, like, we

307
00:11:04,264 --> 00:11:06,424
have such a pressure to give antibiotics now,

308
00:11:06,424 --> 00:11:08,184
but in this case, if you really think

309
00:11:08,184 --> 00:11:09,164
it's septic arthritis,

310
00:11:09,625 --> 00:11:10,445
your clinical

311
00:11:10,825 --> 00:11:11,325
diagnostic,

312
00:11:12,024 --> 00:11:15,519
you know, specificity, sensitivity, if you if you

313
00:11:15,820 --> 00:11:18,059
do the arthrocentesis and you get a good

314
00:11:18,059 --> 00:11:19,759
sample before you give antibiotics,

315
00:11:20,139 --> 00:11:21,980
you get like, I think a positive culture,

316
00:11:21,980 --> 00:11:24,220
seventy eight percent of the time versus twenty

317
00:11:24,220 --> 00:11:25,660
five percent of the time, if you do

318
00:11:25,660 --> 00:11:28,054
it after broad spectrum antibiotics. So there really

319
00:11:28,054 --> 00:11:30,394
is a value here, not to say, wait,

320
00:11:30,534 --> 00:11:31,195
you know,

321
00:11:31,575 --> 00:11:33,335
many hours or days, but, like, if you

322
00:11:33,335 --> 00:11:34,634
can get that arthrocentesis

323
00:11:35,014 --> 00:11:36,934
done, the value you provide for the patient

324
00:11:36,934 --> 00:11:38,615
and getting them a specific answer and the

325
00:11:38,615 --> 00:11:40,779
right treatment is there. So I think to

326
00:11:40,779 --> 00:11:43,180
your point, you know, the the the value

327
00:11:43,180 --> 00:11:45,500
is in establishing the diagnosis here and getting

328
00:11:45,500 --> 00:11:47,120
the sample as opposed to,

329
00:11:47,420 --> 00:11:50,059
you know, just throwing broad spectrum antibiotics at

330
00:11:50,059 --> 00:11:50,639
it because.

331
00:11:51,180 --> 00:11:53,500
Yes. Yeah. Absolutely. Completely agree. Although we give

332
00:11:53,500 --> 00:11:55,894
antibiotics early in all forms of sepsis, if

333
00:11:55,894 --> 00:11:58,375
there is a septic joint you're entertaining in

334
00:11:58,375 --> 00:12:00,454
the differential, you gotta get a sample first

335
00:12:00,454 --> 00:12:02,154
because it definitely affects your culture.

336
00:12:02,615 --> 00:12:04,294
In the in the case for for EMS,

337
00:12:04,294 --> 00:12:05,574
I had a case the other day where

338
00:12:05,574 --> 00:12:06,615
they called me and they were like, this

339
00:12:06,615 --> 00:12:08,375
patient's in severe knee pain. We can't tell

340
00:12:08,375 --> 00:12:10,299
if it's dislocated or if it's patella. And

341
00:12:10,299 --> 00:12:11,820
I kind of tried to talk them through

342
00:12:11,820 --> 00:12:13,740
it and the field and they couldn't, they

343
00:12:13,740 --> 00:12:16,139
couldn't quite kinda, you know, they couldn't send

344
00:12:16,139 --> 00:12:17,899
me a video. Their, their connection wasn't that

345
00:12:17,899 --> 00:12:19,019
good because I was trying to just get

346
00:12:19,019 --> 00:12:20,299
a look at the knee to kind of

347
00:12:20,299 --> 00:12:22,460
see what it was. And I kinda suspected

348
00:12:22,460 --> 00:12:23,660
that it was, it was a young kid.

349
00:12:23,660 --> 00:12:24,940
I kinda thought it might just be a

350
00:12:24,940 --> 00:12:25,840
patella dislocation.

351
00:12:26,274 --> 00:12:27,554
And, I was really just waiting for him

352
00:12:27,554 --> 00:12:28,514
to get there because I was hoping I

353
00:12:28,514 --> 00:12:30,115
could just pop it back in quick and

354
00:12:30,115 --> 00:12:31,235
it was going to be the perfect end

355
00:12:31,235 --> 00:12:33,254
of my shift. And one of our partners

356
00:12:33,554 --> 00:12:35,154
just walked by as I was coming back

357
00:12:35,154 --> 00:12:36,834
from the trauma bay and saw this patient

358
00:12:36,834 --> 00:12:39,095
come in, recognized it as a patellar dislocation

359
00:12:39,235 --> 00:12:41,174
and just popped it in and walked away.

360
00:12:41,360 --> 00:12:43,700
And it just felt like just the cheapest

361
00:12:43,920 --> 00:12:46,000
robbery at the end of my shift. And

362
00:12:46,000 --> 00:12:47,360
I thought it was such a great move

363
00:12:47,360 --> 00:12:48,800
by them because it was great for the

364
00:12:48,800 --> 00:12:50,560
patient. But I just wanted to like that

365
00:12:50,560 --> 00:12:52,560
moment of being the doctor that like, oh,

366
00:12:52,560 --> 00:12:53,920
you just pop this in and it's no

367
00:12:53,920 --> 00:12:55,835
big deal. And he he stole it, and

368
00:12:55,835 --> 00:12:58,475
I just I appreciated the the the thievery

369
00:12:58,475 --> 00:12:59,995
in that that case. I just thought it

370
00:12:59,995 --> 00:13:01,754
was it was great great care by your

371
00:13:01,754 --> 00:13:03,595
partners. It's also just a good cheap shot

372
00:13:03,595 --> 00:13:05,514
at you. It is. It is it is

373
00:13:05,514 --> 00:13:07,995
a satisfying maneuver to put that patella back

374
00:13:07,995 --> 00:13:09,434
in. I mean, there is, I I think,

375
00:13:09,434 --> 00:13:11,730
very few things that satisfy me when it

376
00:13:11,730 --> 00:13:13,889
comes to orthopedic reductions, and the patella is

377
00:13:13,889 --> 00:13:15,730
definitely one of them. I think it's number

378
00:13:15,730 --> 00:13:17,410
two after, like, a nursemaid's elbow because it's

379
00:13:17,410 --> 00:13:18,450
one of those things where if you can

380
00:13:18,450 --> 00:13:19,649
really look him in the face and be

381
00:13:19,649 --> 00:13:21,490
like, I know what I'm doing. You just

382
00:13:21,490 --> 00:13:23,250
gotta count to two, and this thing is

383
00:13:23,250 --> 00:13:25,315
done. And, like, we don't need sedation with

384
00:13:25,315 --> 00:13:26,835
anything else because it's killing you right now,

385
00:13:26,835 --> 00:13:28,835
and it's gonna be good in three seconds.

386
00:13:28,835 --> 00:13:30,595
And just It is. It is one of

387
00:13:30,595 --> 00:13:32,434
those count to three we're going on two

388
00:13:32,434 --> 00:13:32,934
scenarios.

389
00:13:33,315 --> 00:13:35,014
Exactly. Not gonna tell you.

390
00:13:35,555 --> 00:13:37,889
Okay. So when it comes to history, we're

391
00:13:37,889 --> 00:13:40,450
going to ask some key things. And, again,

392
00:13:40,450 --> 00:13:42,769
an outstanding table, table two on page six

393
00:13:42,769 --> 00:13:44,850
is all about questions you need to ask

394
00:13:44,850 --> 00:13:47,730
for the physical exam. So if someone tells

395
00:13:47,730 --> 00:13:51,235
you that they had sudden onset of pain,

396
00:13:51,294 --> 00:13:53,375
you're going to be thinking about all of

397
00:13:53,375 --> 00:13:56,334
those traumatic injuries. And then your follow-up questions

398
00:13:56,334 --> 00:13:57,774
will be, did you hear a pop? Is

399
00:13:57,774 --> 00:13:59,615
there some kind of knee instability? Are you

400
00:13:59,615 --> 00:14:01,154
able to walk or weight bear?

401
00:14:01,570 --> 00:14:03,589
Were you planting your foot and twisting?

402
00:14:04,049 --> 00:14:05,809
Was there some kind of trauma involved? But

403
00:14:05,809 --> 00:14:08,230
the sudden onset puts you in that mechanical

404
00:14:08,529 --> 00:14:11,409
something has happened to your knee category, thinking

405
00:14:11,409 --> 00:14:14,309
about things like ACL tears, meniscal tears,

406
00:14:14,754 --> 00:14:19,174
quadricep tendon, patella fracture, patella ligament injuries. That's

407
00:14:19,235 --> 00:14:21,274
all of your cues that this is going

408
00:14:21,274 --> 00:14:22,534
to be an acute injury.

409
00:14:23,074 --> 00:14:25,634
If they say it was gradual in onset,

410
00:14:25,634 --> 00:14:27,074
then you've got a whole bunch of other

411
00:14:27,074 --> 00:14:29,149
questions you need to follow-up with, like what

412
00:14:29,149 --> 00:14:31,870
kind of activity makes it worse? Does going

413
00:14:31,870 --> 00:14:33,629
up or downstairs make it worse? Does weight

414
00:14:33,629 --> 00:14:34,910
bearing make it worse? Is it worse when

415
00:14:34,910 --> 00:14:36,029
you first get up in the morning, or

416
00:14:36,029 --> 00:14:37,790
does it get better throughout the day? Is

417
00:14:37,790 --> 00:14:40,350
there something that you're taking that's alleviating the

418
00:14:40,350 --> 00:14:42,029
pain? How long has it been going on,

419
00:14:42,029 --> 00:14:44,049
etcetera? And then there's always

420
00:14:44,424 --> 00:14:47,245
the important septic joint questions. Is there fever?

421
00:14:47,465 --> 00:14:49,625
Is there warmth around your knee? Do you

422
00:14:49,625 --> 00:14:51,225
have a history of IV drug abuse? Are

423
00:14:51,225 --> 00:14:51,965
you immunocompromised

424
00:14:52,424 --> 00:14:54,904
for any reason? And have you had a

425
00:14:54,904 --> 00:14:56,205
recent knee

426
00:14:56,759 --> 00:14:58,920
surgery, like, an a recent knee replacement so

427
00:14:58,920 --> 00:15:00,940
that the presence of a recent knee prosthesis

428
00:15:01,160 --> 00:15:03,000
is a risk factor for septic joint as

429
00:15:03,000 --> 00:15:04,679
well. And that's an indication to get your

430
00:15:04,679 --> 00:15:07,559
orthopedic colleagues involved very quickly. So Mhmm. Those

431
00:15:07,559 --> 00:15:10,120
are all key historical clues that you need

432
00:15:10,120 --> 00:15:12,460
to ask when it comes to your exam.

433
00:15:12,735 --> 00:15:14,495
I found this mnemonic pretty helpful. Had you

434
00:15:14,495 --> 00:15:16,335
ever heard about this IP PASS before or

435
00:15:16,335 --> 00:15:18,654
IP PASS? It's a a mnemonic that stands

436
00:15:18,654 --> 00:15:19,154
for

437
00:15:19,455 --> 00:15:19,955
inspection,

438
00:15:20,495 --> 00:15:20,995
palpation,

439
00:15:21,774 --> 00:15:24,595
passive range of motion, active range of motion,

440
00:15:25,039 --> 00:15:28,419
strength, and then special tests. So that's IPPASS

441
00:15:29,439 --> 00:15:31,139
or IP dash PSS,

442
00:15:31,519 --> 00:15:32,419
I IPPAS.

443
00:15:33,120 --> 00:15:35,039
It's a, a mnemonic that's meant to guide

444
00:15:35,039 --> 00:15:37,679
you through all of the physical exam findings

445
00:15:37,679 --> 00:15:39,634
and tests that you need to perform in

446
00:15:39,634 --> 00:15:41,875
order to try and figure out what exactly

447
00:15:41,875 --> 00:15:43,254
is going on with their knee.

448
00:15:43,715 --> 00:15:45,414
And speaking of giant tables,

449
00:15:45,794 --> 00:15:49,095
table three in this article is on pages

450
00:15:49,235 --> 00:15:51,875
seven and eight. It's the first two page

451
00:15:51,875 --> 00:15:52,855
table I've seen.

452
00:15:53,480 --> 00:15:55,800
It's it's exhaustive. And, honestly, I I wanna

453
00:15:55,800 --> 00:15:57,480
say thanks to the authors for going through

454
00:15:57,480 --> 00:15:59,240
the trouble of doing this because I think

455
00:15:59,240 --> 00:16:01,240
trying to describe this in any kind of

456
00:16:01,240 --> 00:16:04,379
textual paragraph format would have just been way,

457
00:16:04,440 --> 00:16:06,695
way too long. It's a a list of

458
00:16:06,695 --> 00:16:07,834
all of the specialized

459
00:16:08,375 --> 00:16:10,394
knee tests that you can perform,

460
00:16:10,774 --> 00:16:13,174
the description of how to perform the test,

461
00:16:13,174 --> 00:16:14,714
and then the notes regarding

462
00:16:15,174 --> 00:16:17,595
how you can make the exam more sensitive

463
00:16:17,750 --> 00:16:18,789
and some of the things to keep in

464
00:16:18,789 --> 00:16:20,709
mind. And it's all broken down by the

465
00:16:20,709 --> 00:16:23,190
type of injury that can cause that test

466
00:16:23,190 --> 00:16:25,190
to be positive. So everything from the ballotment

467
00:16:25,190 --> 00:16:27,669
test to the LACMA test to the anterior

468
00:16:27,669 --> 00:16:30,149
and posterior drawer tests, valgus and varus stress

469
00:16:30,149 --> 00:16:32,785
tests, You've got all of the tests named

470
00:16:32,785 --> 00:16:33,524
for people,

471
00:16:34,225 --> 00:16:36,245
McMurray, Apley, Thessaly.

472
00:16:36,785 --> 00:16:39,665
And you've got some iliotibial tests like the

473
00:16:39,665 --> 00:16:42,065
noble and Ober test, the hop test for

474
00:16:42,065 --> 00:16:44,789
stress fracture. There are lots of these specialized

475
00:16:44,789 --> 00:16:46,710
tests, and honestly, I can't say that I

476
00:16:46,710 --> 00:16:47,370
have done

477
00:16:47,830 --> 00:16:49,909
many of these. Some of them are pretty

478
00:16:49,909 --> 00:16:51,669
common, I think, but there are some of

479
00:16:51,669 --> 00:16:54,549
these when I'm seeing someone in triage who

480
00:16:54,549 --> 00:16:56,070
still has their pants on, I can't even

481
00:16:56,070 --> 00:16:57,654
get a look at their skin, and there's

482
00:16:57,654 --> 00:16:59,414
not a whole lot of space. I can

483
00:16:59,414 --> 00:17:02,375
definitely see that these would be helpful, but

484
00:17:02,375 --> 00:17:04,775
definitely would require a a stretcher for the

485
00:17:04,775 --> 00:17:06,474
correct positioning in order to perform.

486
00:17:07,015 --> 00:17:08,714
And I would tell you that I think

487
00:17:08,934 --> 00:17:11,019
the this is a great article to basically

488
00:17:11,019 --> 00:17:12,539
make you an expert in the care of

489
00:17:12,539 --> 00:17:14,299
knee injuries. But I thought one of my

490
00:17:14,299 --> 00:17:15,839
biggest takeaways was

491
00:17:16,140 --> 00:17:19,180
the value they saw in bringing physical therapy

492
00:17:19,180 --> 00:17:20,880
to the emergency room earlier.

493
00:17:21,180 --> 00:17:23,019
And I think this is the kind of

494
00:17:23,019 --> 00:17:25,019
thing that doing these tests on the regular

495
00:17:25,019 --> 00:17:26,964
and having done a lot of them to

496
00:17:26,964 --> 00:17:29,125
evaluate the injuries and then how to treat

497
00:17:29,125 --> 00:17:31,284
it is incredible. I had one of our

498
00:17:31,284 --> 00:17:34,325
local, physical therapists shadow me in the emergency

499
00:17:34,325 --> 00:17:36,565
room recently because she was just interested in

500
00:17:36,565 --> 00:17:38,085
learning more about kind of the ER and

501
00:17:38,085 --> 00:17:40,539
how things work and the value she immediately

502
00:17:40,539 --> 00:17:42,720
brought in, in examining these musculoskeletal

503
00:17:43,099 --> 00:17:45,019
kind of injuries. And then immediately kind of

504
00:17:45,019 --> 00:17:47,099
giving patients the first steps in treatment for

505
00:17:47,099 --> 00:17:49,579
it was so far beyond the care that

506
00:17:49,579 --> 00:17:51,835
I'm providing. I could see just the value

507
00:17:51,835 --> 00:17:54,315
we would have if we started involving physical

508
00:17:54,315 --> 00:17:56,315
therapy earlier in the emergency room, especially given

509
00:17:56,315 --> 00:17:58,954
the challenges of establishing those kind of follow-up

510
00:17:58,954 --> 00:18:00,714
things. I think that it's a huge area

511
00:18:00,714 --> 00:18:02,974
for improvement that I'm actively very interested.

512
00:18:03,690 --> 00:18:05,529
Yeah. Yeah. For sure. And even in the

513
00:18:05,529 --> 00:18:07,369
treatment section of this article, they spent a

514
00:18:07,369 --> 00:18:10,409
considerable amount of time talking about discharge instructions

515
00:18:10,409 --> 00:18:13,210
for patients. And some of the instructions that

516
00:18:13,210 --> 00:18:15,529
are available online to give your patients that

517
00:18:15,529 --> 00:18:16,029
include

518
00:18:16,424 --> 00:18:17,245
treatment exercises,

519
00:18:17,625 --> 00:18:20,525
physical therapy, maneuvers, and exercises they can perform

520
00:18:20,825 --> 00:18:22,505
just because there's going to be a delay

521
00:18:22,505 --> 00:18:24,105
in their follow-up care. I mean, nobody can

522
00:18:24,105 --> 00:18:26,265
get into an orthopedist the next day even

523
00:18:26,265 --> 00:18:27,785
if your arm is in four pieces. If

524
00:18:27,785 --> 00:18:29,465
if you need it that fast, you gotta

525
00:18:29,465 --> 00:18:31,319
be in the hospital. Otherwise, it's going to

526
00:18:31,319 --> 00:18:33,240
be a while. And during that time, you

527
00:18:33,240 --> 00:18:35,880
can get some pretty significant pain relief by

528
00:18:35,880 --> 00:18:36,940
doing these maneuvers.

529
00:18:37,480 --> 00:18:39,720
And, you know, short of the patient Googling

530
00:18:39,720 --> 00:18:42,839
it themselves, having some focused discharge instructions that

531
00:18:42,839 --> 00:18:45,339
come from you become very, very important.

532
00:18:45,684 --> 00:18:47,605
Alright. Let's talk about imaging. Everybody gets an

533
00:18:47,605 --> 00:18:48,105
X-ray.

534
00:18:48,724 --> 00:18:49,785
No. I'm just kidding.

535
00:18:50,085 --> 00:18:52,404
There is a guideline for who should get

536
00:18:52,404 --> 00:18:54,805
an X-ray. There is the Ottawa Knee Rule,

537
00:18:54,805 --> 00:18:57,384
which has been studied, prospectively validated.

538
00:18:57,845 --> 00:18:58,345
And

539
00:18:58,970 --> 00:19:00,970
when it comes to the Ottawa knee rule,

540
00:19:00,970 --> 00:19:04,269
doctor Eckler, which of the following findings warrants

541
00:19:04,330 --> 00:19:06,570
obtaining a knee X-ray? So according to the

542
00:19:06,570 --> 00:19:08,890
Ottawa knee rule, which one of these would

543
00:19:08,890 --> 00:19:10,190
warrant getting the X-ray?

544
00:19:10,730 --> 00:19:12,830
Pain with passive range of motion,

545
00:19:13,865 --> 00:19:16,125
inability to flex the knee to 90 degrees,

546
00:19:17,224 --> 00:19:18,764
pain with patellar compression,

547
00:19:20,024 --> 00:19:22,365
or presence of a mild knee effusion.

548
00:19:23,304 --> 00:19:24,684
It's not the knee effusion.

549
00:19:25,880 --> 00:19:27,240
I'm trying not to look at the table

550
00:19:27,240 --> 00:19:28,840
right now. I'm trying to just remember it

551
00:19:28,840 --> 00:19:29,500
from memory.

552
00:19:29,799 --> 00:19:31,240
Give me the first one you said one

553
00:19:31,240 --> 00:19:31,980
more time.

554
00:19:32,519 --> 00:19:35,980
Pain with passive range of motion. No. Inability

555
00:19:36,039 --> 00:19:37,740
to flex the knee to 90 degrees.

556
00:19:38,039 --> 00:19:38,539
No.

557
00:19:38,924 --> 00:19:40,705
Pain with patellar compression

558
00:19:42,285 --> 00:19:44,144
or presence of mild knee effusion?

559
00:19:44,684 --> 00:19:47,325
I think it's pain with patellar compression. Okay.

560
00:19:47,325 --> 00:19:48,945
Final answer. Yes.

561
00:19:49,245 --> 00:19:51,900
Okay. So the Ottawa Knee rule actually lists

562
00:19:52,220 --> 00:19:52,720
inability

563
00:19:53,099 --> 00:19:55,259
to flex the knee to 90 degrees as

564
00:19:55,259 --> 00:19:57,740
one of the criteria to obtain an X-ray.

565
00:19:57,740 --> 00:20:00,220
There are only five criteria at least. And

566
00:20:00,220 --> 00:20:02,619
if you have even one of these that

567
00:20:02,619 --> 00:20:03,359
is positive,

568
00:20:03,820 --> 00:20:06,294
then the Ottawa knee rule cannot be applied

569
00:20:06,294 --> 00:20:08,375
to exclude X-ray. It doesn't mean you have

570
00:20:08,375 --> 00:20:10,375
to get one. It just means it's like

571
00:20:10,375 --> 00:20:13,095
the perk rule. You cannot exclude the need

572
00:20:13,095 --> 00:20:14,775
for an X-ray based on the Ottawa knee

573
00:20:14,775 --> 00:20:17,130
rule. And those criteria are age greater than

574
00:20:17,130 --> 00:20:19,529
or equal to 55 years old. That's a

575
00:20:19,529 --> 00:20:21,049
good one. I don't think as long as

576
00:20:21,049 --> 00:20:22,349
they're cut off. Yes.

577
00:20:22,809 --> 00:20:24,809
As soon as you get there, then you

578
00:20:24,809 --> 00:20:26,190
just gonna get some x rays.

579
00:20:26,730 --> 00:20:29,529
Isolated tenderness of the patella with no other

580
00:20:29,529 --> 00:20:30,430
bony tenderness.

581
00:20:30,775 --> 00:20:32,535
You gotta give me credit for patella compression

582
00:20:32,535 --> 00:20:34,375
there. You gotta that's gotta give me Yeah.

583
00:20:34,375 --> 00:20:36,615
Yeah. That again, poorly written question. I totally

584
00:20:36,615 --> 00:20:37,115
agree.

585
00:20:37,654 --> 00:20:40,054
Tenderness I'm challenging I'm challenging that one with

586
00:20:40,054 --> 00:20:40,954
the the proctors.

587
00:20:41,414 --> 00:20:44,140
Tenderness at the fibular head is another indication.

588
00:20:44,279 --> 00:20:46,519
Inability to flex the knee to 90 degrees.

589
00:20:46,519 --> 00:20:49,819
And lastly was inability to bear weight in

590
00:20:49,880 --> 00:20:51,019
four steps

591
00:20:51,319 --> 00:20:51,819
immediately

592
00:20:52,440 --> 00:20:54,359
and in the ED. So this is kind

593
00:20:54,359 --> 00:20:56,140
of one of those nuance things.

594
00:20:56,535 --> 00:20:58,855
It's the ability to walk on your knee.

595
00:20:58,855 --> 00:21:01,414
Limping is good. Limping counts, but ability to

596
00:21:01,414 --> 00:21:03,095
put weight on your knee at the time

597
00:21:03,095 --> 00:21:05,575
of the injury and in the ED. So

598
00:21:05,575 --> 00:21:07,575
if they have even one of those criteria,

599
00:21:07,575 --> 00:21:09,880
you can't completely rule out the need for

600
00:21:09,880 --> 00:21:11,720
an x-ray. Again, it doesn't mandate an x-ray.

601
00:21:11,720 --> 00:21:12,919
You just can't rule it out based on

602
00:21:12,919 --> 00:21:13,980
the auto renew rule.

603
00:21:14,519 --> 00:21:16,759
Sam, everyone within a fusion can't bend their

604
00:21:16,759 --> 00:21:18,759
knee to 90 degrees. So, like, this is

605
00:21:18,759 --> 00:21:20,440
around the time that I start they're getting

606
00:21:20,440 --> 00:21:22,484
the eyebrow raise for me on this one.

607
00:21:22,644 --> 00:21:24,724
But I I still respect the fact that

608
00:21:24,724 --> 00:21:26,244
if you do this, you can cut down

609
00:21:26,244 --> 00:21:28,325
in x rays. Because what only six percent

610
00:21:28,325 --> 00:21:30,404
of x rays have a fracture, that's not

611
00:21:30,404 --> 00:21:32,244
a very good diagnostic yield. As much as

612
00:21:32,244 --> 00:21:34,164
I wanna defend the practice, you're right. Everyone's

613
00:21:34,164 --> 00:21:36,799
getting an x-ray, and they're all negative. Yeah.

614
00:21:36,799 --> 00:21:38,799
And if you're wondering what the sensitivity is

615
00:21:38,799 --> 00:21:40,799
for the autoimmune rule, it's 95 to a

616
00:21:40,799 --> 00:21:43,359
% for ruling out an acute fracture. Right?

617
00:21:43,359 --> 00:21:45,519
So we're getting x rays. We're looking for

618
00:21:45,519 --> 00:21:48,400
fractures, and the autoimmune rule can definitely help

619
00:21:48,400 --> 00:21:50,559
in that scenario, especially in a busy emergency

620
00:21:50,559 --> 00:21:52,615
department. You got somebody waiting for X rays.

621
00:21:52,615 --> 00:21:53,734
You can go, ah, you know, you actually

622
00:21:53,734 --> 00:21:55,095
don't need an X-ray, and let me explain

623
00:21:55,095 --> 00:21:57,095
to you why. Because the time it's gonna

624
00:21:57,095 --> 00:21:58,934
take for me to explain it to you

625
00:21:58,934 --> 00:22:00,775
is still shorter than the time it's gonna

626
00:22:00,775 --> 00:22:02,234
take for you to get an X-ray.

627
00:22:02,855 --> 00:22:04,154
Alright. Another question.

628
00:22:04,549 --> 00:22:06,169
Which imaging modality

629
00:22:06,710 --> 00:22:09,210
is the most sensitive for detecting

630
00:22:09,509 --> 00:22:11,429
an effusion in the knee? I should say

631
00:22:11,429 --> 00:22:13,910
which of these imaging modalities is the most

632
00:22:13,910 --> 00:22:15,529
sensitive. Here we go. X-ray,

633
00:22:16,230 --> 00:22:16,730
CT,

634
00:22:18,105 --> 00:22:18,924
bone scan,

635
00:22:19,464 --> 00:22:20,285
or ultrasound?

636
00:22:20,664 --> 00:22:23,065
Ultrasound. I'm an emergency doctor. I have a

637
00:22:23,065 --> 00:22:25,464
pedagogy jacket. I'm here for the stereotypes. Let's

638
00:22:25,464 --> 00:22:28,045
go ultrasound. Boom. You win, sir. Ultrasound.

639
00:22:28,505 --> 00:22:31,830
The detection limit for an ultrasound in a

640
00:22:31,830 --> 00:22:35,130
trained provider's hands is as low as four

641
00:22:35,269 --> 00:22:35,769
milliliters.

642
00:22:36,150 --> 00:22:39,590
Four milliliters. And the sensitivity and specificity in

643
00:22:39,590 --> 00:22:40,090
diagnosing

644
00:22:40,470 --> 00:22:41,529
tendon injury

645
00:22:41,910 --> 00:22:42,650
with ultrasound

646
00:22:43,029 --> 00:22:44,250
is a hundred percent.

647
00:22:44,875 --> 00:22:47,275
You can't get any better than a hundred

648
00:22:47,275 --> 00:22:49,294
percent. So that is

649
00:22:49,835 --> 00:22:52,315
great evidence for the utility of an ultrasound

650
00:22:52,315 --> 00:22:54,794
examination in a trained provider's hands, and that's

651
00:22:54,794 --> 00:22:56,974
just using a limited protocol. So the orthopedic

652
00:22:57,034 --> 00:22:59,539
surgeons will go with an expanded joint evaluation.

653
00:22:59,599 --> 00:23:00,640
You don't even have to do that. You

654
00:23:00,640 --> 00:23:02,319
can go, where does it hurt? Let me

655
00:23:02,319 --> 00:23:04,399
look at the tendons in that area, and

656
00:23:04,399 --> 00:23:06,399
then I'm gonna scan for a quick joint

657
00:23:06,399 --> 00:23:06,899
effusion.

658
00:23:07,200 --> 00:23:08,880
And you can detect as little as four

659
00:23:08,880 --> 00:23:10,815
milliliters. That's pretty darn good.

660
00:23:11,134 --> 00:23:13,534
And even more impressively, if you then use

661
00:23:13,534 --> 00:23:15,694
the ultrasound while you're there to do your

662
00:23:15,694 --> 00:23:16,194
arthrocentesis,

663
00:23:17,214 --> 00:23:19,694
your your ability to actually get fluid out

664
00:23:19,694 --> 00:23:21,875
of their knee goes up to a %

665
00:23:22,174 --> 00:23:23,934
from an that ability. I think their success

666
00:23:23,934 --> 00:23:26,190
rate was fifty five percent Fifty five. Did

667
00:23:26,190 --> 00:23:28,349
it by landmarks. So as someone that does

668
00:23:28,349 --> 00:23:29,329
a lot of landmark,

669
00:23:29,710 --> 00:23:30,769
you know, arthrocentesis

670
00:23:31,230 --> 00:23:33,150
and it feels a little you know, that's

671
00:23:33,150 --> 00:23:34,750
how we did it back in my day

672
00:23:34,750 --> 00:23:36,669
kind of about this. I think that I

673
00:23:36,669 --> 00:23:39,309
need to really revisit my ultrasound skills on

674
00:23:39,309 --> 00:23:41,365
this because as you said, to identify that

675
00:23:41,365 --> 00:23:43,365
tendon injury, make their follow-up faster because you

676
00:23:43,365 --> 00:23:44,964
can push that to ortho and say, look,

677
00:23:44,964 --> 00:23:46,884
there's clearly a tendon rupture. You're gonna need

678
00:23:46,884 --> 00:23:48,644
to fix this. And then to make sure

679
00:23:48,644 --> 00:23:50,484
you get fluid out a % of the

680
00:23:50,484 --> 00:23:53,140
time, you you can't knock that number. Yeah.

681
00:23:53,140 --> 00:23:54,900
Yeah. And that procedure is described in the

682
00:23:54,900 --> 00:23:57,700
article very nicely. There is a description of

683
00:23:57,700 --> 00:24:00,339
how you use the ultrasound to perform an

684
00:24:00,339 --> 00:24:02,680
arthrocentesis, but also how you use the ultrasound

685
00:24:02,900 --> 00:24:05,220
to just examine a knee and the tendons

686
00:24:05,220 --> 00:24:07,434
you're supposed to look at. I remember in

687
00:24:07,434 --> 00:24:10,154
the era when I trained right as ultrasound

688
00:24:10,154 --> 00:24:12,575
was starting to become popular during my residency,

689
00:24:12,634 --> 00:24:14,554
and I got accustomed to putting in, you

690
00:24:14,554 --> 00:24:17,694
know, central lines with no ultrasound guidance. So

691
00:24:17,835 --> 00:24:19,835
if if I cannot grab the ultrasound machine

692
00:24:19,835 --> 00:24:20,954
and I need to put in a central

693
00:24:20,954 --> 00:24:22,960
line, not a big deal. But arthrocentesis

694
00:24:23,259 --> 00:24:25,900
has always been one of those kinda fifty

695
00:24:25,900 --> 00:24:27,740
fifty things. You know, you've got an effusion.

696
00:24:27,740 --> 00:24:29,180
You know it's there. You just can't get

697
00:24:29,180 --> 00:24:31,660
any fluid out, and ultrasound was a huge

698
00:24:31,660 --> 00:24:34,700
help in that scenario. Huge help, because it

699
00:24:34,700 --> 00:24:36,825
also allows you to kinda need to to

700
00:24:36,825 --> 00:24:38,904
put that traction on the patella and on

701
00:24:38,904 --> 00:24:40,984
the bursa and push that fluid superiorly, and

702
00:24:40,984 --> 00:24:42,444
then you can see it with the ultrasound.

703
00:24:42,585 --> 00:24:44,184
Now in that case, you're gonna need a

704
00:24:44,184 --> 00:24:45,964
third hand, and you're gonna need an assistant

705
00:24:46,025 --> 00:24:48,605
and say, okay. You push here. I'm gonna

706
00:24:48,740 --> 00:24:50,980
use the ultrasound from here, and then we'll

707
00:24:50,980 --> 00:24:52,840
find the pocket and drain it. But

708
00:24:53,299 --> 00:24:56,119
definitely definitely going to improve your success rate.

709
00:24:56,500 --> 00:24:58,740
Alright. Let's talk about CT. CT is available

710
00:24:58,740 --> 00:25:00,500
to us in the emergency department. But in

711
00:25:00,500 --> 00:25:03,255
general, if there's no history of massive trauma

712
00:25:03,255 --> 00:25:04,615
to the joint, this is not going to

713
00:25:04,615 --> 00:25:06,775
be a helpful test. It's not gonna help

714
00:25:06,775 --> 00:25:09,034
you detect small or moderate effusions,

715
00:25:09,414 --> 00:25:11,414
and it's not going to be any better

716
00:25:11,414 --> 00:25:13,994
than X-ray at identifying tendinous injuries.

717
00:25:14,339 --> 00:25:16,019
MRI is really what you're looking for, and

718
00:25:16,019 --> 00:25:18,819
MRI is generally, we say, not available in

719
00:25:18,819 --> 00:25:20,839
the emergency department. I mean, in an emergency,

720
00:25:20,900 --> 00:25:22,579
sure, there's an MRI machine in the hospital,

721
00:25:22,579 --> 00:25:24,579
but you're not gonna use up those resources

722
00:25:24,579 --> 00:25:26,419
for a knee injury, and that's gonna be

723
00:25:26,419 --> 00:25:27,960
a huge time delay. So

724
00:25:28,454 --> 00:25:30,154
CT is there for traumatic

725
00:25:30,454 --> 00:25:32,694
knee injuries if you think you're missing something

726
00:25:32,694 --> 00:25:35,654
bony. Otherwise, it's not a good modality for

727
00:25:35,654 --> 00:25:37,275
imaging, for knee pain.

728
00:25:38,294 --> 00:25:39,654
I and I would say, I think that

729
00:25:39,654 --> 00:25:41,750
there's always the caveats to these. We had

730
00:25:41,750 --> 00:25:43,670
a patient who came in five times the

731
00:25:43,670 --> 00:25:45,269
emergency room for knee pain over the course

732
00:25:45,269 --> 00:25:47,430
of a few months on her fifth visit,

733
00:25:47,430 --> 00:25:49,590
her x-ray really looked abnormal to me. And

734
00:25:49,590 --> 00:25:51,590
I went and ran it by our, our,

735
00:25:51,590 --> 00:25:54,150
or so, you know, radiology folks. And they

736
00:25:54,150 --> 00:25:55,994
said, yeah, that, that is really suspicious. Like,

737
00:25:55,994 --> 00:25:57,194
I I think I could see why they

738
00:25:57,194 --> 00:25:59,115
read it as negative before, but it just

739
00:25:59,115 --> 00:26:01,194
really there's something there. So we admitted her

740
00:26:01,194 --> 00:26:02,875
for an MRI because she really had poor

741
00:26:02,875 --> 00:26:05,434
follow-up and and no real opportunity to to

742
00:26:05,434 --> 00:26:08,154
get an outpatient follow-up. And her MRI looked

743
00:26:08,154 --> 00:26:10,234
like an osteosarcoma, and we managed to basically

744
00:26:10,234 --> 00:26:13,119
start arranging treatment and and outpatient follow-up with,

745
00:26:13,119 --> 00:26:15,279
you know, an orthopedic cancer specialist out of

746
00:26:15,279 --> 00:26:17,039
town. And I think if that hadn't happened,

747
00:26:17,039 --> 00:26:18,799
that would have, you know, gone on for

748
00:26:18,799 --> 00:26:20,880
another couple of months before she really got

749
00:26:20,880 --> 00:26:23,359
the care. So if you're curious, keep asking

750
00:26:23,359 --> 00:26:25,279
questions about these things, and there is time

751
00:26:25,279 --> 00:26:27,554
to deploy these modalities or to to keep

752
00:26:27,554 --> 00:26:29,154
people overnight in the hospital to get things

753
00:26:29,154 --> 00:26:30,674
figured out and make sure you get the

754
00:26:30,674 --> 00:26:32,755
next step going, especially when they've had multiple

755
00:26:32,755 --> 00:26:34,835
visits and and things aren't really getting getting

756
00:26:34,835 --> 00:26:37,154
worked up. Yeah. Yeah. Great plug for the

757
00:26:37,154 --> 00:26:38,914
ops unit. That's a great ops patient right

758
00:26:38,914 --> 00:26:39,974
there. For sure.

759
00:26:40,369 --> 00:26:42,769
Alright. Let's talk about labs. So when it

760
00:26:42,769 --> 00:26:44,549
comes to trying to differentiate

761
00:26:44,850 --> 00:26:47,250
multiple things that might be going on, we

762
00:26:47,250 --> 00:26:49,670
can always get labs, and the labs

763
00:26:50,130 --> 00:26:51,190
might be helpful.

764
00:26:51,570 --> 00:26:53,970
Specifically, if you're thinking about a septic knee,

765
00:26:53,970 --> 00:26:55,714
that's that's really the only reason why you

766
00:26:55,714 --> 00:26:58,194
might get labs. So let's talk about some

767
00:26:58,194 --> 00:27:00,034
of the labs that you might get. People

768
00:27:00,034 --> 00:27:01,575
generally will get a CBC.

769
00:27:02,194 --> 00:27:05,575
They can get a erythrocyte sedimentation or ESR,

770
00:27:05,714 --> 00:27:07,394
and they can get a c reactive protein

771
00:27:07,394 --> 00:27:08,134
or CRP.

772
00:27:08,470 --> 00:27:10,789
And then blood culture, certainly, if they're febrile,

773
00:27:10,789 --> 00:27:12,230
you're gonna get blood cultures, or if you

774
00:27:12,230 --> 00:27:13,509
know they have a septic joint, you're you

775
00:27:13,509 --> 00:27:15,110
can get those as well. But when we're

776
00:27:15,190 --> 00:27:17,450
specifically, when we're talking about CRP,

777
00:27:17,990 --> 00:27:19,049
a cutoff of

778
00:27:19,350 --> 00:27:21,974
20, that's milligrams per liter, had a sensitivity

779
00:27:22,034 --> 00:27:25,335
of about ninety two percent for identifying disease.

780
00:27:25,794 --> 00:27:28,194
If you use a cutoff of 15, that

781
00:27:28,194 --> 00:27:30,674
sensitivity actually goes up to ninety eight percent,

782
00:27:30,674 --> 00:27:32,514
so even better. Now you're you're gonna get

783
00:27:32,514 --> 00:27:34,294
a lot of false positives in that scenario,

784
00:27:34,355 --> 00:27:36,839
but still, it has decent sensitivity.

785
00:27:37,299 --> 00:27:40,179
For the ESR, you get 98%

786
00:27:40,179 --> 00:27:41,859
sensitivity if you use a cutoff of 10

787
00:27:41,859 --> 00:27:43,700
millimeters per hour, or you could use a

788
00:27:43,700 --> 00:27:45,619
cutoff of 15. That sensitivity drops a little

789
00:27:45,619 --> 00:27:47,779
bit to 94%. So still, there is some

790
00:27:47,779 --> 00:27:50,694
utility for these tests if you're entertaining a

791
00:27:50,694 --> 00:27:53,575
septic joint, but the most sensitive test is

792
00:27:53,575 --> 00:27:55,494
going to be getting the fluid and sending

793
00:27:55,494 --> 00:27:56,315
it for analysis.

794
00:27:56,934 --> 00:27:59,494
And on that note, table five on page

795
00:27:59,494 --> 00:28:02,554
11 shows you the normal

796
00:28:02,980 --> 00:28:03,480
arthritic

797
00:28:03,859 --> 00:28:04,359
inflammatory

798
00:28:04,819 --> 00:28:08,019
and septic features of synovial fluid when you've

799
00:28:08,019 --> 00:28:09,079
performed that arthrocentesis.

800
00:28:09,380 --> 00:28:12,019
So that's talking about clarity, color, white blood

801
00:28:12,019 --> 00:28:12,759
cell count,

802
00:28:13,460 --> 00:28:13,960
polymorphic

803
00:28:14,500 --> 00:28:15,000
neutrophil

804
00:28:15,380 --> 00:28:17,159
percentage or PMN percentage,

805
00:28:17,625 --> 00:28:18,845
the culture results,

806
00:28:19,224 --> 00:28:22,505
and the joint lactate level. Now when's the

807
00:28:22,505 --> 00:28:24,664
last time you sent a lactate level for

808
00:28:24,664 --> 00:28:25,565
our joint fluid?

809
00:28:26,025 --> 00:28:28,664
In defense of our lab testing setup, when

810
00:28:28,664 --> 00:28:31,224
you do our ED common, you know, fluid

811
00:28:31,224 --> 00:28:33,244
orders basically for aspirating anything,

812
00:28:33,599 --> 00:28:35,679
LDH and lactic are there and I tend

813
00:28:35,679 --> 00:28:38,179
to order them fairly regularly, but only because

814
00:28:38,240 --> 00:28:40,179
I'm set up for success by a good

815
00:28:40,400 --> 00:28:42,640
lab ordering system. And I think that the

816
00:28:42,640 --> 00:28:44,720
case for this is that you should have

817
00:28:44,720 --> 00:28:46,720
that option there for you, or have it

818
00:28:46,720 --> 00:28:48,179
preselected for your arthrocentesis

819
00:28:48,815 --> 00:28:51,775
so that after you complete a complicated challenging

820
00:28:51,775 --> 00:28:53,855
procedure and you get success, you don't fumble

821
00:28:53,855 --> 00:28:55,295
the ball on the one yard line by

822
00:28:55,295 --> 00:28:57,375
not ordering the right tests because you're in

823
00:28:57,375 --> 00:28:58,914
a busy ER and you're juggling

824
00:28:59,295 --> 00:29:00,974
10 balls that are all on fire and

825
00:29:00,974 --> 00:29:02,914
trying to keep things under control.

826
00:29:03,440 --> 00:29:05,440
Yeah. Perfect. Way to plug the order sets.

827
00:29:05,440 --> 00:29:07,279
Really, that's that's something that can be prebuilt

828
00:29:07,279 --> 00:29:08,240
for you, so you don't even have to

829
00:29:08,240 --> 00:29:09,759
think about which test or which one of

830
00:29:09,759 --> 00:29:10,960
these you need to order. All of these

831
00:29:10,960 --> 00:29:13,200
should come across along with crystals and the

832
00:29:13,200 --> 00:29:13,700
LDH.

833
00:29:14,160 --> 00:29:17,105
Interestingly, the authors have a systematic review they

834
00:29:17,105 --> 00:29:18,565
quoted from 02/2011

835
00:29:18,865 --> 00:29:21,664
that looked at joint lactate levels. If you

836
00:29:21,664 --> 00:29:24,724
had a lactate level greater than 5.6

837
00:29:24,784 --> 00:29:28,859
millimoles per liter, your positive likelihood ratio was

838
00:29:29,019 --> 00:29:30,000
2.4,

839
00:29:30,140 --> 00:29:32,460
pretty significantly high. I thought it was pretty

840
00:29:32,460 --> 00:29:34,539
funny that they also said that same systematic

841
00:29:34,539 --> 00:29:36,380
reviews says if you have a lactate level

842
00:29:36,380 --> 00:29:39,599
greater than 10, your positive likelihood ratio

843
00:29:40,140 --> 00:29:41,039
was infinity.

844
00:29:42,505 --> 00:29:45,144
So pretty pretty safe that number, infinity. You're

845
00:29:45,144 --> 00:29:47,305
you're good at that point. The diagnosis is

846
00:29:47,305 --> 00:29:49,545
established. You can tell also you're sure. Time

847
00:29:49,545 --> 00:29:50,605
to give the antibiotics.

848
00:29:51,224 --> 00:29:52,924
Now now you're now you can give.

849
00:29:53,305 --> 00:29:55,865
I do think it's important to reference this

850
00:29:55,865 --> 00:29:58,160
table when you're looking at something that might

851
00:29:58,160 --> 00:30:00,960
be inflammatory versus septic because that's really always

852
00:30:00,960 --> 00:30:02,640
the question for me. It's not so much,

853
00:30:02,640 --> 00:30:04,559
you know, is this normal? Is this abnormal?

854
00:30:04,559 --> 00:30:07,200
It's is this inflammatory, or is this actually

855
00:30:07,200 --> 00:30:09,315
bacterial? And do we need to then, you

856
00:30:09,315 --> 00:30:12,034
know, get ortho involved in antibiotics and surgical

857
00:30:12,034 --> 00:30:12,534
washout?

858
00:30:12,994 --> 00:30:16,274
So the inflammatory cutoffs are anywhere from 200

859
00:30:16,274 --> 00:30:18,835
to 50,000 white blood cells, and then the

860
00:30:18,835 --> 00:30:19,815
septic cutoffs

861
00:30:20,274 --> 00:30:21,494
vary depending

862
00:30:21,875 --> 00:30:24,500
on the patient. So if they have a

863
00:30:24,500 --> 00:30:27,559
prosthetic knee joint, greater than 1,100

864
00:30:28,179 --> 00:30:31,159
is indicative of a septic joint. If they

865
00:30:31,299 --> 00:30:31,799
have

866
00:30:32,339 --> 00:30:35,220
50,000 or more, the likelihood ratio is seven.

867
00:30:35,220 --> 00:30:36,755
If they have 25,000,

868
00:30:36,755 --> 00:30:38,674
the likelihood ratio is two point nine. So

869
00:30:38,674 --> 00:30:40,855
there's this kind of overlap with the inflammatory

870
00:30:40,914 --> 00:30:43,234
white blood cell count, and that's where you

871
00:30:43,234 --> 00:30:44,994
then also need to rely on some of

872
00:30:44,994 --> 00:30:47,894
your other tests. So you've got your polymorphic

873
00:30:48,515 --> 00:30:51,089
neutrophil percentage rate or your PMN rate will

874
00:30:51,089 --> 00:30:52,549
be higher in septic arthritis.

875
00:30:52,849 --> 00:30:54,529
Both will appear yellow and cloudy, so that's

876
00:30:54,529 --> 00:30:56,210
not really gonna be much help to you.

877
00:30:56,210 --> 00:30:58,690
Sure. There's about a fifty percent positivity for

878
00:30:58,690 --> 00:31:00,769
cultures for joint fluid, but you're not gonna

879
00:31:00,769 --> 00:31:02,470
wait for that in the emergency department.

880
00:31:02,769 --> 00:31:05,605
Your LDH level will be greater than two

881
00:31:05,605 --> 00:31:08,644
fifty in a septic joint, so another benefit

882
00:31:08,644 --> 00:31:10,805
of getting that test. And then there should

883
00:31:10,805 --> 00:31:12,265
not be any crystals present.

884
00:31:12,565 --> 00:31:15,144
And so you really need all of these

885
00:31:15,859 --> 00:31:17,240
to try and differentiate

886
00:31:17,619 --> 00:31:20,660
between septic arthritis versus inflammatory unless your white

887
00:31:20,660 --> 00:31:22,119
blood cell count is super high.

888
00:31:22,420 --> 00:31:24,039
And I I think that was the takeaway,

889
00:31:24,100 --> 00:31:26,740
just that you're not gonna be sure at

890
00:31:26,740 --> 00:31:28,500
the end point where you get your cell

891
00:31:28,500 --> 00:31:30,565
counts. So there's there's a good time to

892
00:31:30,565 --> 00:31:32,644
send the culture, get all the labs, and

893
00:31:32,644 --> 00:31:34,325
then give the antibiotics and let it play

894
00:31:34,325 --> 00:31:35,605
out in a day or two as those

895
00:31:35,605 --> 00:31:36,105
cultures

896
00:31:36,484 --> 00:31:38,804
grow. Alright. Let's get into some treatment real

897
00:31:38,804 --> 00:31:39,865
quick. So

898
00:31:40,884 --> 00:31:43,605
what is the first line medication for treating

899
00:31:43,605 --> 00:31:45,890
an acute gout flare? Here we go. Ready?

900
00:31:46,109 --> 00:31:48,049
You got five options. NSAIDs,

901
00:31:48,430 --> 00:31:48,930
acetaminophen,

902
00:31:49,549 --> 00:31:50,049
allopurinol,

903
00:31:50,830 --> 00:31:51,330
colchicine,

904
00:31:52,269 --> 00:31:53,090
or methotrexate.

905
00:31:54,430 --> 00:31:57,515
Oh, nice fifth one. Yeah. You like that?

906
00:31:57,515 --> 00:31:59,434
I'm gonna go with NSAIDs, but can I

907
00:31:59,434 --> 00:32:01,534
tell you this article made me question

908
00:32:01,914 --> 00:32:03,755
whether or not I need to be giving

909
00:32:03,755 --> 00:32:05,994
more Celebrex in my practice? And I need

910
00:32:05,994 --> 00:32:07,914
to look at the cost of Celebrex because

911
00:32:07,914 --> 00:32:09,839
I think it's gone generic. And if it's

912
00:32:09,839 --> 00:32:10,339
cheaper,

913
00:32:10,640 --> 00:32:13,279
I bet it's gonna cause less GI problems

914
00:32:13,279 --> 00:32:15,519
than the Aleve that I'm regularly writing for.

915
00:32:15,519 --> 00:32:17,519
I guess I should say naproxen because we're

916
00:32:17,519 --> 00:32:20,339
using generic names here. Yeah. Yeah. Well, obviously,

917
00:32:20,400 --> 00:32:22,480
you are correct, and you're correct on both

918
00:32:22,480 --> 00:32:24,339
of those things. The Oh,

919
00:32:24,914 --> 00:32:27,475
the the treatment with NSAIDs is definitely the

920
00:32:27,475 --> 00:32:30,615
first line for inflammatory or gout arthritis.

921
00:32:30,994 --> 00:32:34,035
And and, yes, the longer acting ones are

922
00:32:34,035 --> 00:32:36,914
less GI toxic, and once a day dosing

923
00:32:36,914 --> 00:32:39,009
is certainly better. You know, you can use

924
00:32:39,009 --> 00:32:40,529
Tylenol, but it doesn't really have any anti

925
00:32:40,529 --> 00:32:42,230
inflammatory properties. Allopurinol

926
00:32:42,529 --> 00:32:44,210
is used more for chronic gout, not for

927
00:32:44,210 --> 00:32:47,890
acute flares. Colchicine is the second line agent

928
00:32:47,890 --> 00:32:50,130
because of GI side effects, and methotrexate, we

929
00:32:50,130 --> 00:32:52,690
use for rheumatoid arthritis, not gout. So not

930
00:32:52,690 --> 00:32:54,515
an ideal choice in case you're wondering.

931
00:32:55,215 --> 00:32:56,734
I also found that so often people are

932
00:32:56,734 --> 00:32:58,494
on blood thinners or have a reason they

933
00:32:58,494 --> 00:32:59,394
can't take NSAIDs,

934
00:32:59,695 --> 00:33:02,275
but I found that I've been ignoring topical

935
00:33:02,335 --> 00:33:04,994
NSAIDs for those patients. And I think that

936
00:33:05,215 --> 00:33:07,455
that's something that I need to deploy more

937
00:33:07,455 --> 00:33:08,835
in my therapy because

938
00:33:09,660 --> 00:33:11,740
you can't use them centrally. Like it can't

939
00:33:11,740 --> 00:33:13,680
work on back pain or on neck pain,

940
00:33:13,740 --> 00:33:17,920
but for elbows, wrists, knees, ankles, topical NSAIDs

941
00:33:18,140 --> 00:33:20,779
are very effective. I think should be something

942
00:33:20,779 --> 00:33:23,259
that we're looking more into giving people, especially

943
00:33:23,259 --> 00:33:24,744
when they don't have a, you know, an

944
00:33:24,744 --> 00:33:26,204
ability to take oral ones.

945
00:33:26,585 --> 00:33:28,904
Yes. Yes. Absolutely. And the authors actually mentioned

946
00:33:28,904 --> 00:33:30,904
that there are a few randomized controlled trials.

947
00:33:30,904 --> 00:33:32,904
One of them had almost five hundred adults

948
00:33:32,904 --> 00:33:34,204
with moderate knee osteoarthritis,

949
00:33:34,585 --> 00:33:37,804
and they compared diclofenac one percent topical gel,

950
00:33:37,865 --> 00:33:40,259
which did show a significant decrease in mean

951
00:33:40,259 --> 00:33:42,039
pain score. So, yes, topical

952
00:33:42,579 --> 00:33:45,720
can be effective and come with decreased systemic

953
00:33:46,019 --> 00:33:46,759
side effects,

954
00:33:47,139 --> 00:33:47,960
like the gastrointestinal

955
00:33:48,419 --> 00:33:50,980
side effects. And so definitely an option there

956
00:33:50,980 --> 00:33:51,720
for sure.

957
00:33:52,339 --> 00:33:53,559
On the treatment side,

958
00:33:53,859 --> 00:33:54,519
which treatment

959
00:33:54,914 --> 00:33:58,115
is the most effective? So most effective for

960
00:33:58,115 --> 00:34:00,215
a long term management of knee osteoarthritis.

961
00:34:00,674 --> 00:34:03,095
You ready? Here we go. Five choices, NSAIDs,

962
00:34:03,795 --> 00:34:04,295
acetaminophen,

963
00:34:05,394 --> 00:34:06,615
weight loss and exercise,

964
00:34:07,475 --> 00:34:07,975
corticosteroid

965
00:34:08,355 --> 00:34:08,855
injections,

966
00:34:09,800 --> 00:34:10,699
or opioids.

967
00:34:11,800 --> 00:34:13,400
And if you say opioids, I'm gonna slap

968
00:34:13,400 --> 00:34:17,000
you. I'm I'm gonna humbly go with choice

969
00:34:17,000 --> 00:34:19,159
c, weight loss and exercise because I'm pretty

970
00:34:19,159 --> 00:34:21,639
sure that I've picked this post everything. That's

971
00:34:21,639 --> 00:34:22,139
absolutely

972
00:34:22,840 --> 00:34:23,340
true.

973
00:34:23,704 --> 00:34:26,844
Yes. The author specifically say that a combination

974
00:34:27,144 --> 00:34:29,164
of dietary changes and exercise

975
00:34:29,465 --> 00:34:31,945
can improve physical function, lead to weight loss,

976
00:34:31,945 --> 00:34:33,724
and improve overall mobility,

977
00:34:34,264 --> 00:34:36,670
and is better than all the others if

978
00:34:36,670 --> 00:34:39,070
it can be achieved. Right? So, obviously, that's

979
00:34:39,070 --> 00:34:40,989
going to take some time. That's not an

980
00:34:40,989 --> 00:34:43,489
immediate treatment, but certainly something that should be

981
00:34:43,710 --> 00:34:44,210
discussed

982
00:34:44,510 --> 00:34:47,070
with the patient and started. So here's your

983
00:34:47,070 --> 00:34:50,429
exercise regimen. Here is your physical therapy exercises

984
00:34:50,429 --> 00:34:51,489
we want you to perform,

985
00:34:51,905 --> 00:34:54,304
and here is your prescription for a long

986
00:34:54,304 --> 00:34:57,045
acting NSAID or your topical NSAID for sure.

987
00:34:57,585 --> 00:34:59,744
Alright. Again, still on the treatment side of

988
00:34:59,744 --> 00:35:00,244
it,

989
00:35:00,545 --> 00:35:03,045
many of us are fond of giving people

990
00:35:03,184 --> 00:35:03,925
knee immobilizers.

991
00:35:04,420 --> 00:35:06,900
And I'll say many of us, myself included,

992
00:35:06,900 --> 00:35:09,000
have used these for all kinds of traumatic

993
00:35:09,139 --> 00:35:11,860
and persistent knee pain, and you're wondering, okay.

994
00:35:11,860 --> 00:35:13,219
When is it you know, I just give

995
00:35:13,219 --> 00:35:15,000
them a knee immobilizer and have them follow-up

996
00:35:15,059 --> 00:35:17,175
and give them some crutches. So the question

997
00:35:17,175 --> 00:35:18,394
is a knee immobilizer

998
00:35:18,695 --> 00:35:21,414
is most appropriately used in which of the

999
00:35:21,414 --> 00:35:22,315
following conditions?

1000
00:35:23,735 --> 00:35:24,235
Osteoarthritis,

1001
00:35:25,974 --> 00:35:26,635
the telefemoral

1002
00:35:26,934 --> 00:35:29,355
pain syndrome, that's the anterior knee pain,

1003
00:35:30,159 --> 00:35:31,940
quadriceps tendon rupture,

1004
00:35:33,440 --> 00:35:34,820
iliotibial band syndrome,

1005
00:35:35,840 --> 00:35:37,380
and prepatellar bursitis.

1006
00:35:38,640 --> 00:35:40,420
So this is a knee immobilizer.

1007
00:35:41,119 --> 00:35:43,045
Yeah. Now if you're wondering if you're listening

1008
00:35:43,045 --> 00:35:45,364
and you've never used an immobilizer before, it's

1009
00:35:45,364 --> 00:35:46,344
not that little

1010
00:35:46,644 --> 00:35:47,144
strappy

1011
00:35:47,445 --> 00:35:49,284
knee wrap that you get at a store

1012
00:35:49,284 --> 00:35:50,724
or the one that has a little opening

1013
00:35:50,724 --> 00:35:52,485
for the patella with a couple of Velcro

1014
00:35:52,485 --> 00:35:54,184
straps. It is a long device

1015
00:35:54,485 --> 00:35:55,224
that covers,

1016
00:35:55,619 --> 00:35:57,859
from about the proximal thigh down to about

1017
00:35:57,859 --> 00:36:01,059
the distal shin and has two metal bars

1018
00:36:01,059 --> 00:36:03,079
that run on the inside and the outside

1019
00:36:03,380 --> 00:36:05,779
and prevents you from being able to flex

1020
00:36:05,779 --> 00:36:07,059
your knee at all. So you can still

1021
00:36:07,059 --> 00:36:08,659
weight bear, but you kinda do that peg

1022
00:36:08,659 --> 00:36:10,655
leg walk. And in most cases, you need

1023
00:36:10,655 --> 00:36:12,094
a set of crutches as well to go

1024
00:36:12,094 --> 00:36:12,914
along with it.

1025
00:36:13,295 --> 00:36:15,074
So which are the following conditions? Osteoarthritis,

1026
00:36:15,534 --> 00:36:16,994
patellofemoral pain syndrome,

1027
00:36:17,295 --> 00:36:18,755
quadriceps tendon rupture,

1028
00:36:19,054 --> 00:36:21,875
iliotibial band syndrome, or prepatellar bursitis?

1029
00:36:22,280 --> 00:36:25,079
I'm really only using them for quadriceps tendon

1030
00:36:25,079 --> 00:36:25,579
ruptures,

1031
00:36:26,039 --> 00:36:27,179
so that's my answer.

1032
00:36:27,480 --> 00:36:29,900
Alright. And you are correct, sir. The immobilizers

1033
00:36:30,119 --> 00:36:33,099
are indicated in any kind of extensor mechanism

1034
00:36:33,320 --> 00:36:35,739
injury like a quadriceps tendon rupture.

1035
00:36:36,199 --> 00:36:37,339
Patellar fracture

1036
00:36:37,695 --> 00:36:38,195
counts.

1037
00:36:38,575 --> 00:36:41,315
A patellar tendon rupture also counts.

1038
00:36:41,695 --> 00:36:43,535
And so if they have one of those

1039
00:36:43,535 --> 00:36:47,394
mechanisms that has kinda taken away their ability

1040
00:36:47,454 --> 00:36:49,394
to extend their knee, then,

1041
00:36:49,789 --> 00:36:50,609
sure. Absolutely.

1042
00:36:51,150 --> 00:36:52,849
Displaced tibial plateau fractures?

1043
00:36:53,150 --> 00:36:56,050
Yes. You could certainly do that. And and

1044
00:36:56,269 --> 00:36:58,690
it also does say first time patellar dislocations.

1045
00:36:58,750 --> 00:37:00,109
So if this is their first one and

1046
00:37:00,109 --> 00:37:01,869
there's a lot of edema there and they

1047
00:37:01,869 --> 00:37:04,109
can't flex their knee afterwards and there's significant

1048
00:37:04,109 --> 00:37:06,695
pain, sure. This can help and provide some

1049
00:37:06,695 --> 00:37:09,275
stability to the joint and allow the,

1050
00:37:09,735 --> 00:37:11,494
edema to start to go away for a

1051
00:37:11,494 --> 00:37:12,394
couple of days.

1052
00:37:12,695 --> 00:37:14,155
But there is significant

1053
00:37:14,454 --> 00:37:16,855
morbidity associated with placing somebody in a knee

1054
00:37:16,855 --> 00:37:20,050
immobilizer, especially if they're elderly. So the reason

1055
00:37:20,050 --> 00:37:21,889
why this was even discussed in the article

1056
00:37:21,889 --> 00:37:23,670
there on page 13

1057
00:37:23,969 --> 00:37:24,469
was

1058
00:37:25,090 --> 00:37:27,110
to bring up the point that knee immobilizer

1059
00:37:27,170 --> 00:37:29,250
is not benign, and they shouldn't just be

1060
00:37:29,250 --> 00:37:31,409
handed out like candy to people who are

1061
00:37:31,409 --> 00:37:32,869
elderly who might have

1062
00:37:33,375 --> 00:37:36,175
mobility constraints to begin with because now they're

1063
00:37:36,175 --> 00:37:37,474
gonna be even more

1064
00:37:38,255 --> 00:37:40,275
apt to falling and injuring themselves.

1065
00:37:40,574 --> 00:37:41,394
And oftentimes,

1066
00:37:41,695 --> 00:37:44,655
using crutches if you're elderly is almost impossible,

1067
00:37:44,655 --> 00:37:45,934
and now we've thrown them in a knee

1068
00:37:45,934 --> 00:37:48,639
immobilizer. So just be super careful about who

1069
00:37:48,639 --> 00:37:50,719
you give this to and making sure you

1070
00:37:50,719 --> 00:37:52,739
have the right indication for it.

1071
00:37:53,119 --> 00:37:55,119
Also worth looking at a video for how

1072
00:37:55,119 --> 00:37:57,760
to actually put them on because it's challenging

1073
00:37:57,760 --> 00:37:59,679
to fit these to people, sometimes people that

1074
00:37:59,679 --> 00:38:02,025
are obese or just people that are are

1075
00:38:02,184 --> 00:38:04,264
just, you know, uncomfortable and in pain. And

1076
00:38:04,264 --> 00:38:06,184
I've seen a few orthopedic surgeons put them

1077
00:38:06,184 --> 00:38:08,184
on where they literally take them down, like

1078
00:38:08,184 --> 00:38:10,105
all the pieces apart and then wrap them

1079
00:38:10,105 --> 00:38:12,264
and then put the, like the support metal

1080
00:38:12,264 --> 00:38:13,944
rods on and then put the Velcro on.

1081
00:38:13,944 --> 00:38:16,079
And it's impressive to see it done well

1082
00:38:16,079 --> 00:38:17,619
because it reminds you that

1083
00:38:17,920 --> 00:38:20,559
doing them correctly and fitting them correctly is

1084
00:38:20,559 --> 00:38:22,159
a skill. And if you develop that, the

1085
00:38:22,159 --> 00:38:24,099
patient's gonna be more successful with it.

1086
00:38:24,639 --> 00:38:26,099
Great point. Great point.

1087
00:38:26,400 --> 00:38:29,114
There is a discussion in the article about

1088
00:38:29,114 --> 00:38:29,614
corticosteroid

1089
00:38:29,914 --> 00:38:32,014
injections and when they might be indicated.

1090
00:38:32,315 --> 00:38:35,195
That's not something I typically incorporated into my

1091
00:38:35,195 --> 00:38:36,875
emergency department practice. You ever had to get

1092
00:38:36,875 --> 00:38:37,614
one of these?

1093
00:38:37,914 --> 00:38:40,155
So when I was running a little emergency

1094
00:38:40,155 --> 00:38:42,554
room in Colorado, everyone used to request that

1095
00:38:42,554 --> 00:38:44,610
they could get their their allergy shots every

1096
00:38:44,610 --> 00:38:45,970
year. So they would come in for these

1097
00:38:45,970 --> 00:38:48,530
catalog shots. And I was always really confused

1098
00:38:48,530 --> 00:38:50,050
by, like, is this a thing? But it

1099
00:38:50,050 --> 00:38:51,570
was just local practice. Like, that was just

1100
00:38:51,570 --> 00:38:53,890
what everyone got, like, during certain allergy seasons

1101
00:38:53,890 --> 00:38:55,410
of the year. They'd get a catalog shot.

1102
00:38:55,410 --> 00:38:57,635
Their allergies wouldn't be as bad. But then

1103
00:38:57,635 --> 00:39:00,195
there was a challenge in getting orthopedic follow-up

1104
00:39:00,195 --> 00:39:01,875
in that community. And there would be older

1105
00:39:01,875 --> 00:39:03,315
people that would come in with chronic knee

1106
00:39:03,315 --> 00:39:05,474
pain that hadn't had a steroid injection in

1107
00:39:05,474 --> 00:39:07,155
six months or eight months or a year,

1108
00:39:07,155 --> 00:39:08,835
and they'd really be hurting. And I would

1109
00:39:08,835 --> 00:39:10,514
do their steroid injections. And I kind of

1110
00:39:10,514 --> 00:39:12,329
figured out how to mix, you know, some,

1111
00:39:12,329 --> 00:39:15,690
some catalog and some, some lidocaine. And it

1112
00:39:15,690 --> 00:39:17,769
was impressive how much it helped them. And

1113
00:39:17,769 --> 00:39:19,130
it was a skill that I didn't think

1114
00:39:19,130 --> 00:39:20,730
was that hard to develop. So I think

1115
00:39:20,730 --> 00:39:22,570
that if you can get them good orthopedic

1116
00:39:22,570 --> 00:39:25,005
follow-up in a reasonable time, that you should

1117
00:39:25,005 --> 00:39:26,764
leave it to the orthopedist, that's gonna manage

1118
00:39:26,764 --> 00:39:28,605
them going forward to kind of decide on

1119
00:39:28,605 --> 00:39:30,045
when they need steroids and when they don't,

1120
00:39:30,045 --> 00:39:31,484
and to kind of manage the risks and

1121
00:39:31,484 --> 00:39:33,324
benefits. But if it's been a long time,

1122
00:39:33,324 --> 00:39:35,005
six months or a year, and they don't

1123
00:39:35,005 --> 00:39:37,005
have access, and they're really someone that's gonna

1124
00:39:37,005 --> 00:39:38,764
benefit from it, I think it's worth considering

1125
00:39:38,764 --> 00:39:40,766
the ER. If you have the bandwidth and

1126
00:39:40,766 --> 00:39:42,722
if if you you feel comfortable, give it

1127
00:39:42,722 --> 00:39:44,678
a shot. Good. There were three points that

1128
00:39:44,678 --> 00:39:46,634
the authors made about these steroid injections if

1129
00:39:46,634 --> 00:39:48,590
you're going to give them in the emergency

1130
00:39:48,590 --> 00:39:50,545
department, and they didn't recommend against it, mind

1131
00:39:50,545 --> 00:39:52,501
you. So if you want to give them,

1132
00:39:52,501 --> 00:39:54,755
you certainly can. Three points they made. One

1133
00:39:54,755 --> 00:39:57,075
is make sure that your patient doesn't have

1134
00:39:57,075 --> 00:39:58,934
some kind of treatment plan with an orthopedic

1135
00:39:58,994 --> 00:40:00,375
surgeon already established.

1136
00:40:00,755 --> 00:40:03,635
Second, they can only get these shots one

1137
00:40:03,635 --> 00:40:06,410
every three months or so to avoid the

1138
00:40:06,410 --> 00:40:09,610
potential for degeneration of cartilage. And so you

1139
00:40:09,610 --> 00:40:11,369
do have to know when their last one

1140
00:40:11,369 --> 00:40:13,950
was, has it been three months. And third,

1141
00:40:14,010 --> 00:40:16,730
giving one of these shots will preclude them

1142
00:40:16,730 --> 00:40:20,010
from getting joint replacement surgery for three months.

1143
00:40:20,010 --> 00:40:22,414
And so if they know, hey. I'm seeing

1144
00:40:22,414 --> 00:40:24,414
an orthopedic surgeon and I've got you know,

1145
00:40:24,414 --> 00:40:25,695
they may tell you I've got an appointment

1146
00:40:25,695 --> 00:40:27,375
set up, but that appointment is actually to

1147
00:40:27,375 --> 00:40:28,894
have their knee replaced. And if they weren't

1148
00:40:28,894 --> 00:40:31,054
specific about that, then what you've just done

1149
00:40:31,054 --> 00:40:33,534
is reschedule their knee replacement surgery by giving

1150
00:40:33,534 --> 00:40:36,170
them a steroid injection. So be careful. Make

1151
00:40:36,170 --> 00:40:37,789
sure you get an accurate history.

1152
00:40:38,170 --> 00:40:41,150
And, otherwise, there was no other significant contraindication

1153
00:40:41,369 --> 00:40:42,969
or side effect to giving these in the

1154
00:40:42,969 --> 00:40:43,949
emergency department.

1155
00:40:44,489 --> 00:40:46,909
Okay. And that's all the treatment for osteoarthritis,

1156
00:40:47,449 --> 00:40:50,414
chronic knee pain, perhaps even acute knee injuries.

1157
00:40:50,634 --> 00:40:53,295
Let's talk about some of the treatment for

1158
00:40:53,434 --> 00:40:53,934
trauma.

1159
00:40:54,474 --> 00:40:56,795
So traumatic knee injuries, you've you've gotta be

1160
00:40:56,795 --> 00:40:57,934
careful with because

1161
00:40:58,234 --> 00:41:01,134
knees can dislocate and relocate spontaneously

1162
00:41:01,434 --> 00:41:02,414
after a trauma.

1163
00:41:02,840 --> 00:41:05,559
And it's important to have a high suspicion

1164
00:41:05,559 --> 00:41:08,760
for that because that mechanism can cause injury

1165
00:41:08,760 --> 00:41:11,659
to their popliteal artery and popliteal artery dissections.

1166
00:41:12,039 --> 00:41:14,699
The patients that come in with traumatic significant

1167
00:41:14,840 --> 00:41:15,579
knee pain,

1168
00:41:15,934 --> 00:41:17,795
swelling, effusion, discomfort,

1169
00:41:18,094 --> 00:41:20,175
you really wanna be cautious and really check

1170
00:41:20,175 --> 00:41:22,255
their pulses, you know, a couple of times

1171
00:41:22,255 --> 00:41:23,934
to really get a sense of whether or

1172
00:41:23,934 --> 00:41:25,775
not there could be vascular injury. And even

1173
00:41:25,775 --> 00:41:27,215
if they have good pulses, but you've got

1174
00:41:27,215 --> 00:41:28,989
a high suspicion, that is a good time

1175
00:41:28,989 --> 00:41:30,849
to do a CT, but a CT angiogram

1176
00:41:30,910 --> 00:41:32,989
of that leg to look at the blood

1177
00:41:32,989 --> 00:41:34,369
flow through that injured

1178
00:41:34,670 --> 00:41:37,570
leg. Because I think that that's going to

1179
00:41:37,789 --> 00:41:40,530
allow you to catch things that are challenging

1180
00:41:40,750 --> 00:41:42,664
diagnoses to make. But if you've got a

1181
00:41:42,664 --> 00:41:44,264
high suspicion for a knee injury and a

1182
00:41:44,264 --> 00:41:45,164
potential dislocation

1183
00:41:45,465 --> 00:41:47,304
and they're having pain and their pulses aren't

1184
00:41:47,304 --> 00:41:49,144
as good on the injured leg as the

1185
00:41:49,144 --> 00:41:51,784
other, don't hesitate to take that knee to

1186
00:41:51,784 --> 00:41:53,324
CT and get a CT angiogram

1187
00:41:53,625 --> 00:41:55,304
because that's gonna help you get them to

1188
00:41:55,304 --> 00:41:57,062
the vascular surgeon they need, not the orthopedic

1189
00:41:57,062 --> 00:41:57,300
surgeon.

1190
00:41:58,260 --> 00:41:59,880
Yeah. Yeah. Great advice.

1191
00:42:00,900 --> 00:42:03,059
And on that note, that is all that

1192
00:42:03,059 --> 00:42:04,820
we're going to cover today. There is more

1193
00:42:04,820 --> 00:42:07,400
in this article. It is filled with information

1194
00:42:07,619 --> 00:42:10,974
about patients with prosthetic knee joints, about tai

1195
00:42:10,974 --> 00:42:13,315
chi and physical therapy for osteoarthritis

1196
00:42:13,775 --> 00:42:16,094
and so much more. Don't forget to go

1197
00:42:16,094 --> 00:42:18,655
look at the images for ultrasound scans of

1198
00:42:18,655 --> 00:42:21,295
the knee, read through the processes for how

1199
00:42:21,295 --> 00:42:23,135
to perform ultrasounds of the knee and how

1200
00:42:23,135 --> 00:42:24,755
to do ultrasound guided arthrocentesis,

1201
00:42:25,214 --> 00:42:27,949
and, of course, don't forget tables, the multiple

1202
00:42:27,949 --> 00:42:30,030
types of physical exam maneuvers you can perform

1203
00:42:30,030 --> 00:42:32,530
to help make the diagnosis, the differential diagnosis,

1204
00:42:32,829 --> 00:42:34,989
the historical questions to ask. There's just a

1205
00:42:34,989 --> 00:42:36,750
bunch in here. I just wanna say thank

1206
00:42:36,750 --> 00:42:39,170
you to the authors for writing an outstanding

1207
00:42:39,230 --> 00:42:41,715
issue. This is the Emergency Medicine Practice March

1208
00:42:41,954 --> 00:42:44,355
'20 '20 '5 issue. And if you're a

1209
00:42:44,355 --> 00:42:46,835
subscriber, don't forget to go online, take your

1210
00:42:46,835 --> 00:42:49,974
CME test, and get your CME for completing

1211
00:42:50,355 --> 00:42:54,275
that issue. Thanks again, everyone. Until next time.

1212
00:42:54,275 --> 00:42:56,780
I'm Sam Hsu. I'm TR Eckler. Stay safe.

1213
00:42:56,780 --> 00:42:58,239
Be careful playing that pickleball.

1214
00:42:59,099 --> 00:43:00,079
Love the pickleball.

1215
00:43:00,780 --> 00:43:02,539
And that's a wrap. Thanks for joining us

1216
00:43:02,539 --> 00:43:05,179
for this episode of Amplify. I hope you

1217
00:43:05,179 --> 00:43:07,659
found it informative, and I wanna remind you

1218
00:43:07,659 --> 00:43:09,340
that evmedicine.net

1219
00:43:09,340 --> 00:43:11,494
is your one stop shop for all of

1220
00:43:11,494 --> 00:43:14,135
your CME needs, whether that be for emergency

1221
00:43:14,135 --> 00:43:16,855
medicine or urgent care medicine. There are three

1222
00:43:16,855 --> 00:43:19,894
journals. There's tons of CME. There's lots of

1223
00:43:19,894 --> 00:43:22,775
courses. There's so many clinical pathways, all this

1224
00:43:22,775 --> 00:43:24,269
information at your fingertips

1225
00:43:24,570 --> 00:43:26,590
at ebmedicine.net.

1226
00:43:26,730 --> 00:43:28,890
Until next time, everyone. I'm your host, Sam

1227
00:43:28,890 --> 00:43:30,269
Ashu. Be safe.