Editor’s Note: These cases stories indicate that clinical skills, attention to detail and good judgement remain key to quality patient care. The lessons delineated here are priceless and timeless!
Case number one: “The chief of a local Indian tribe came to me for a second opinion about a knee problem.” He was 4-5 months out from treatment at the prominent all male orthopaedic group in my new city of practice. The patient was initially told he had a medial meniscal tear which showed on an MRI report. That orthopaedic surgeon had to leave town and handed him off to a partner who did knee arthroscopy. He performed an arthroscopic partial medial meniscectomy.
Unfortunately, the patient developed a draining medial portal site. Initially, irrigation and debridement were performed in the office and the patient was placed on oral antibiotics. The wound did not heal so he was sent back to the initial partner for treatment. The first surgeon took the patient to the operating room for more extensive open irrigation and debridement of the soft tissues only and him placed on IV antibiotics. Despite these efforts, a 3cm wound continued to drain despite wound care.
As was my custom, x-rays were performed as part of my examination. A proximal tibial tumor was clearly visible on the films and sadly, had extended through the tibial cortex. Yes, this was in the 90”s when x-rays were still developed on film, and we were able to put them up on lighted view boxes in the patient’s room.
As the patient was then 4-5 months out from initial treatment, I encouraged him to go pick up his MRI at the other practice so I could view it. Being the new kid in town, I did not want to be involved in the transfer. Although smaller in size, the lesion was visible on the scan but was still contained within the tibia. The MRI report was read as: 1. Medial meniscus tear
- Lesion in the tibia, recommend further study. In reviewing the scan the lesion was enclosed in the proximal medial tibia but was cut off because it was a knee scan. Also no plain xrays were obtained by the original surgeons.
I performed a work-up and biopsied the area through the open wound. Not surprisingly it came back showing osteosarcoma. I transferred him to an orthopaedic surgical oncologist at Mayo clinic where he underwent an above knee amputation. I followed him post op until he was ambulating with a prosthesis. He did live for several more years and later died of a brain tumor. He also sued the original surgeons and got a multimillion-dollar settlement.
The lessons here:
- ALWAYS do a detailed history, physical examination and take appropriate radiographs as part of your initial examination especially if you plan surgery.
- ALWAYS look at the actual MRI images or tests you order as well as the reports. That way at least two physicians have reviewed it. In practice I have occasionally missed something and sometimes I have found what the radiologist missed.
- Identify a radiologist in your area who has had extra training in orthopaedics and specializes in reading MRI, CT etc. Befriend them so you can consult if you have any questions about a scan.
Case number two: “A 43-year-old formerly active tennis player came to my office in a wheelchair which she had been using for one year.” Her history began with right knee pain. Doctor #1 got a MRI and told her she had a meniscus tear. She underwent an arthroscopy with no improvement. Her pain grew progressively worse and spread to both hips and knees.
She sought several other orthopaedic opinions. They felt the pain was coming from her hips but radiographs were normal. She then saw a Rheumatologist and had an extensive workup. He placed her on medication for possible rheumatoid arthritis and ordered physical therapy.
By that time, she could no longer walk and was in a wheelchair.
Thankfully, she had a physical therapist who noted a bilateral abnormal hip examination and referred her on to me. I examined the patient supine on the exam table and found she had severely limited hip range of motion bilaterally and there was pain at end range. Her radiographs were normal. It appeared to me that she had adhesive capsulitis of the hips just as we might see in the shoulder.
I called a colleague who was a pioneer in doing hip arthroscopies. He agreed to see her and said that she should bring an overnight bag with her. He agreed with my diagnosis and said he had only seen a couple of bilateral cases. He examined her and went on to scope her hips the next day. Two weeks later she walked into my office and was overjoyed. Her range of motion seemed normal and her pain was gone. She eventually returned to playing tennis. Subsequently, my colleague reported this case in a journal.
Lessons:
- Use your clinical skills and respect your intuitions when a patient presents with what appears to be an atypical diagnosis. Unusual diagnoses are not always joint-specific.
- Confer with an expert specialized in diagnosing and treating disorders of the anatomical body part and make appropriate referrals.
- Follow the patient’s progress from presentation through to recovery. This adds to your armamentarium of clinical knowledge.