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Patient who comes to you instead of A&E

Case

history

John Cockbain, 26, presents to you on a Monday morning with a knee injury sustained while playing for his local pub team on Saturday. He tells you he would rather see you than have gone to A&E over the weekend. How do you manage his problem?

Why did he wait till Monday?

The reasons for him seeing you need to be explored. Perhaps he knew he would have to wait a while in A&E and would rather miss time from work to see you. It could be that he feels the injury is not too serious, but that must not lull you into a false sense of security and lead to a missed diagnosis or poor management in the surgery.

Another possibility is that the injury is more serious but John has a high pain threshold and is playing down his symptoms. Does he know how experienced or interested you are with regard to sports injuries?

What difficulties in management could arise because of the delay?

Although John has avoided spending time in A&E, he has not got into the system. It could be difficult to send him to A&E after seeing him, particularly if the local hospital has a

48-hour rule.

If you want him to have an X-ray the local department may not be able to see him that day, and there would also be a delay in the result reaching you.

Follow-up A&E clinics are notoriously fully booked. The wait for physiotherapy may be longer if arranged by you compared with an A&E-generated referral.

Are there advantages to the delay?

There are a number. The injury will have progressed since the initial incident. If there was a haemarthrosis this would have developed within a few hours, and an effusion from a meniscal injury would have taken more like

48 hours to develop.

Ask John how he managed the injury (did he rest and apply ice and elevate?) as this would help you understand how competent and motivated he is. Bruising may have come out, and also John would be able to give an idea of how restricted in everyday activities he has been over the weekend.

What else is important from the history?

The actual mechanism of injury is vital. A twisting injury in contact may indicate a meniscal injury, whereas rotating on a flexed knee and hearing a pop is suggestive of anterior cruciate ligament (ACL) rupture. Did John continue the match or was he substituted?

What findings are important on examination?

Is there an effusion? If so did it come soon after injury ­ this suggests a haemarthrosis and therefore serious pathology such as ACL rupture.

If this is the case I would arrange for an urgent orthopaedic assessment, probably that day. ACL ruptures may be missed because the diagnosis is not considered.

If the effusion came later then I would look for signs of meniscal injury, such as joint line tenderness, a locked knee, or positive McMurray's-type tests. In this situation a referral is indicated for MRI scanning or arthroscopy, but is probably not as urgent as for a haemarthrosis.

Keep in mind the commonest injury is a medial collateral ligament (MCL) sprain. This causes a restriction in knee flexion and, to a lesser degree, knee extension as the MCL joins the knee capsule, as well as pain on stretching the ligament.

When examining John remember that a MCL injury could be a rupture ­ indicated by less pain and more instability than a MCL sprain ­ and also that there could be associated meniscal or ACL injury.

At any stage if you are unsure about management refer to hospital, even if John is keen to avoid such action.

What advice should you give him?

Assuming his injury did not need referral, it would probably be sensible to refer soft tissue injuries for physiotherapy.

With the inevitable delays, you may find giving patients some advice sheets on general management of soft tissue injuries as well as some detailed exercise leaflets helpful.

These measures help improve patient compliance and give them an idea of the timescale involved in their injury resolving.

Make it clear you would be happy to see John again if he does not progress as hoped.

What was the outcome in this case?

John had a history of twisting in a tackle, and delayed swelling. He continued the match but was limping. On examination he had an effusion, joint line tenderness and pain on stretching the MCL.

I gave him some exercises to maintain his quadriceps muscle tone, referred him urgently, and he had a partial arthroscopic menisectomy later that week. He was playing football six weeks later after some physiotherapy.

Steve Brown is a GP trainer and partner in Beaconsfield, Buckinghamshire ­ he completed

the VTS in 1991

Key points

 · Avoiding A&E and seeing GP instead could lead to longer waits for X-ray and physio

 · Delay in seeking treatment means injury would have progressed, making it easier for you to assess its nature and severity

 · Find the mechanism of injury ­ is there an effusion? When did it occur? If soon after injury, suggesting a haemarthrosis, arrange for urgent orthopaedic assessment

 · Advice sheets and exercise leaflets are useful for patients awaiting physio

References

·The Sports Medicine Adviser by P Rouzier ISBN 0-9671831-0-3

·The Oxford Textbook of Sports Medicine

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