Musculoskeletal Case study
Part 1: Presentation
Patient admission
A 22-year-old female was admitted to the emergency department after being involved in a motorcycle accident. On presentation she was unable to weight bear and there was slight knee effusion without ecchymosis or deformity. On physical examination, she was keeping her knee in slight flexion and knee range of motion was painful and grossly restricted. Further detailed physical examination could not be performed due to intentional guarding, pain and muscle spasm. X-rays and computed tomography (CT) scans were performed. Note: At this time you only have access to the X-rays.
Patient presentation (Task 1)
The elbow dislocation and the hand fractures are obvious to observe, however you are not sure about the knee. You ask the attending physician to help clarify it for you. The elbow dislocation and the hand fractures are obvious to observe, however you are not sure about the knee. You ask the attending physician to help clarify it for you.
(Click here for the interactive version of the marked up x-rays that the physician made for you. Once you have done that return to this page) You return to the physician a couple of minutes later, after having studied the X-ray over a cup of coffee.
You are ready you say, and you feel confident identify the landmarks. Give you a big smile the physician wipes the pen marks off and asks you a question. (This has been recorded and saved below for as long as the internet survives).
Physician: So you are feeling confident are you. Let’s test you out then. Can you point to the lateral condyle, the medial condyle, and the intercondyle eminance? (Click here for an interactive version of the X-ray so you can point out the correct features for the physician. Once you have done that return to this page)
Patient presentation (Task 2)
The physician seeing that you have correctly identify the appropriate landmarks on the normal knee bones holds up the two X-rays and gets you to compare them (below).
Fig. 1. Knee radiographs of the patient before and after the accident. Left image is an X-ray from a previous admission (courtesy of Mr Andrew Murphy, Radiopaedia.org), where no issues were observed.
Right image is an X-ray of the knee at the time of admission following the accident (courtesy of Gerry Gardney, Radiopaedia.org) As part of your “training” with the physician you are asked to answer the following three questions. Which bone of the knee do you think was fractured in the motorcycle accident? How would you describe the location of the fracture (Hint: Use directional terms). Do you think there might be other structures within the knee joint that could have been affected by the accident and if so, why?
Part 2: Family arrives
Questions from the family The immediate family of the patient have arrived and the consulting surgeon has explained the injury to them, however he was brief and used a lot of medical terminology. (It has been recorded below for clarity)
Surgeon: Your daughter has suffered a lateral tibial plateau fracture. This will require surgery and most likely some screws. She has also sustained an elbow joint dislocation, and multiple fractures to her phalanges. The patient and the family all node and say “right, ok, cool”. And before the surgeon can explain what it all means he is called away to consult on a critical patient who just arrived by helicopter. As he leaves the patients keeps repeating the word cool. (e.g “Cool cool
cool cool cool cooooool.”) Once the surgeon has left the patients mother turns to you and states: Mother: I have no idea what that doctor said. I don’t know what a lateral blah blah blah is. Can you please explain what has happened to my
daughter’s leg?
Practical Assessment Task – Part 1
Write a script for how you would explain the injury to the patient and the mother.
Remember to use terms that they would understand, but also make sure you explain the medical terms the doctor used.
Rehabilitation
Following surgery the patient has been transferred to the ward where she will continue to receive treatment relating to her motorcycle accident. Due to the significant damage that was sustained by her left knee she has been informed that it will take time to recover the majority of her range of movement, and that it may not fully return. She is also told that while her knee is recovering, she will not be able to move her leg or foot much, and that when she starts physiotherapy she
may experience tightness and a severe limit to her range of motion. Time passes. The patient is to be released from hospital today and will be going home to continue her rehabilitation. You help her pack her things ready to leave, then are called away by the nurse unit manager. You are brought into a meeting and notice one very important person whom you have only met on a handful of occasions (usually staff end of year celebrations), the chief nursing officer. They indicate for you
to take a seat and then introduce you to two other people behind the table. The chief medical officer and the executive director operations. They inform you that they would like you to become part of a new team of health staff that will assist with
intensive home-care for physiotherapy patients. More is discussed during the meeting, but as you leave they make sure to impress the importance of what you need to do next.
Chief nursing officer: Remember, before you start with the first patient next week you need to make sure you understand their situation. This will require you to familiarize yourself with the case. The chief physiotherapist has asked that
you present to him a short summary of the muscles you believe would be affected and the reasoning for your decisions before the end of this week . You nod, and thank them for choosing you.
Chief nursing officer: Also remember that this is a new appointment and the first time this type of team has been put together and we want it to work. You have been identified by your nursing unit manager as the prime candidate for this position, don’t let them down.
Practical Assessment Task – Part 2
Based on the case you will need to create a document that outlines the muscles you believe would be affected directly by the damage to the knee and also provide your reasoning as to why they are affected. (You may use diagrams or
drawings to help you explain your reasoning).
Hint: Looking at the muscles that attach to the affected area would be a good place to start.
Part 4 – Rehabilitation
The patient has been undertaking physical therapy for a period of time, however her progression has plateaued. The physical therapist reports to the health team that the patient is able to walk, but requires a cane in order to walk any
significant distance. In fact, one of the tests used to assess the patient’s walking ability was the 6-minute walk test. The results from the test showed the patient was only able to walk 45m. Further tests are discussed at the meeting and the therapist
concludes her report:
Physical Therapist: The patient experiences dorsiflexion weakness in her left foot, a result of atrophy of the tibialis anterior muscles that occurred during the post-operative period. I suggest that we trial the use of functional electrical stimulation to strengthen the muscle. This should aid in helping the patient move past the progression plateau. The team agrees that this is a good direction for the patient’s rehabilitation. At the meeting it is also determined that at
her next visit the PT will discuss the option with the patient. It is also decided that you will have training relating to transcutaneous electrical nerve stimulation, and the functional electrical stimulation protocol. You spend a day with other nurses learning about the basics of the TENS units, and experimenting with different settings. You particularly find it fascinating that you were able to induce a tetanic contraction in your lab partner’s hand by increasing the frequency of stimulation continuously higher.
Part 5 – Questions from the patient
The patient has been undergoing the FES trial for a couple of weeks now and is able to now apply the electrodes herself, and also program the unit to deliver the appropriate treatment protocol. While you are visiting she asks you a couple of
questions.
Patient: Ummm… I feel silly asking this but I just want to double check that I understand what this machine is doing and how it is supposed to be helping me.
You look at the patient and smile.
You: Don’t feel silly. Please ask any questions you have.
Patient: Well if I understand correctly the electrodes stimulate electrical sensors in my muscle, where I place the electrodes… the tibia muscle… or something. But, the electricity is detected by sensors in my muscle and then my muscle sends a signal to my brain that tells my brain to send a signal back down to my muscle telling it to contract. Is that right?
But before you can answer the patient continues.
Patient: Then because my muscle contracts it means that it learns how to contract again, you know, because it didn’t know how to contract before. So it learns and once it has learnt how to contract again, then I will be able to walk properly
because at the moment every time I try to walk my foot just droops.
She takes a deep breath and continues quickly on.
Patient: So what I’m saying is the machine electrocutes my leg, which causes my brain to tell my muscle how to contract and then it will get better walking and I’ll be able to walk.
It is your turn to speak.
Your task is to write a script explaining to the patient what is actually happening between the machine and her muscles.
You should also make sure to kindly explain where she is incorrect about how the machine works. You should also explain which muscle is affected, and why it is important in walking. (Hint: remember what the PT said in her report about the patient. It would also be good to explain what dorsiflexion weakness is and why it is a problem for walking).
Criteria: Exemplary, Mastering, Developing, Emerging, Not attempted
Knowledge (Scientific)
- The patient’s situation has been clearly, appropriately, and systematically described.
- The differences between normal and abnormal skeletal structures have been methodically comprehensively contrasted.
- A comprehensive description of the patient’s condition is evident, with differences between normal and abnormal skeletal structures being sufficiently discussed.
- Has demonstrated sound understanding of the underlying scientific knowledge relating to the case.
- An appropriate description of the patient’s condition has been provided, but is limited in information.
- The differences between normal and abnormal skeletal structures have been adequately described.
- The patient’s situation has been awkwardly and/or poorly explained.
- Discussion on the differences between normal and abnormal skeletal structures in this case study is vague and limited.
- Not attempted or no clear demonstration of the criteria
Knowledge (Terminology)
- All anatomical and medical terminology has been comprehensively, accurately, and appropriately explained in part 1, and applied in part 2 & 3.
- Accurate, appropriate, and clear explanations have been provided for the majority of terms in part 1, and has been applied accurately and appropriately in the majority of parts 2 and 3
- There is a clear attempt to provide suitable explanations of the specialized terminology used in part 1 and explanations are mainly limited in describing or defining the terms.
- There is a clear attempt to apply terminology correctly in parts 2 & 3.
- There is an attempt to explain some terms, however very few terms have been explained to a satisfactory standard.
- Explanations are confusing and/or ineffective in describing the terms.
- There is little appropriate use of terminology in parts 2 & 3.
- Not attempted or no clear demonstration of the criteria
Communication
- The assessment demonstrates a clear, effective, and comprehensive approach to presenting the information.
- There is a logical and professional approach that demonstrates a skilful approach in patient interaction, scientific communication, and the assessment shows clear examples of a professional approach to the situation, and clearly demonstrates an appropriate plan for delivering the information.
- Information is presented in a systematic, logical order. Information is presented in a clear, consistent manner.
- There is an obvious logical approach to the order in which information is presented.
- Some information is not effectively presented.
- The assessment lacks effective, clear, and appropriate communication throughout.
- There is no clear indication of a logical approach to delivering the information.
- Not attempted or no clear demonstration of the criteria
