Geriatrics

The Great Plateau

Authors: Drs. Paul Cohen and Shihab Ali

Case 1:

A healthy 21-year-old female presents to the ED following a motor vehicle crash. She was the restrained passenger in a head-on collision at approximately 30 mph. Her only complaint is left knee pain. On exam, her left knee is tender over the anterior aspect with moderate swelling and ecchymosis. Her ligamentous exam is limited by pain, but there is no gross laxity.  Neurovascular exam is normal, and the remainder of her trauma survey is unremarkable. Plain films are obtained:  

What are the pertinent radiographic findings? 

Figure        SEQ Figure \* ARABIC     1: Illustrative image courtesy of Dr. Mark Holland. (Radiopaedia.org, rID: 19162)

Figure 1: Illustrative image courtesy of Dr. Mark Holland. (Radiopaedia.org, rID: 19162)

Answer:

Lipohemarthrosis is a layering of fat and blood that is indicative of an intra-articular fracture.  Blood and fat from bone marrow escape into the joint space and layer on a horizontal cross-table view because they are different densities. Close inspection also reveals a subtle depression of the lateral tibial condyle consistent with a tibial plateau fracture.    

Figure        SEQ Figure \* ARABIC     2: Radiographs demonstrating lipohemarthrosis (lateral view) and depressed lateral tibial plateau fracture (AP view).

Figure 2: Radiographs demonstrating lipohemarthrosis (lateral view) and depressed lateral tibial plateau fracture (AP view).

Case Outcome:

The diagnosis of a minimally depressed lateral tibial plateau fracture (type III) was made. The patient was evaluated by orthopedics in the ED and discharged home in a knee immobilizer with orthopedic follow-up in 2 days.

Case 2:

An active, independent 72-year-old female presents with left leg pain after a mechanical fall at home. She fell down multiple stairs onto a wooden floor. Her exam is notable for swelling and tenderness of the left knee with a normal neurovascular exam. An AP radiograph of the knee is shown below.

Figure 3. Illustrative image (Gentili A, Tibial Plateau Fracture Imaging, Emedicine)

Figure 3. Illustrative image (Gentili A, Tibial Plateau Fracture Imaging, Emedicine)

What is the diagnosis? How should this injury be managed?

Answer:

A minimally displaced lateral split tibial plateau fracture is depicted on radiographs. This injury is classified as a Schatzker type I fracture and is amenable to nonoperative treatment.

Case Outcome:

Orthopedic surgery was consulted. The patient was placed in a knee immobilizer and admitted. Given the minimal displacement of the fracture, she was managed nonoperatively. No weight-bearing was recommended and she was discharged to a skilled nursing facility with orthopedic follow-up in one week.

Overview of Tibial Plateau Fractures:

Epidemiology:

  • Most common mechanism = axial loading
  • Bimodal distribution:

o   Young adults → high-energy trauma (MVC, fall from height)

o   Elderly → low-energy compression force to osteoporotic bone

  • Majority involve lateral tibial plateau

Associated Injuries:

  • Popliteal artery injury (artery is tethered both proximally and distally at the knee) → any intra-articular disruption can cause vascular injury
  • Displacement of the lateral tibial condyle can cause peroneal nerve injury → assess for foot drop!
  • Concomitant soft tissue injuries are common (e.g., ligaments, meniscus)

o   Ligamentous injury occurs in up to 66% of patients → accurate exam limited on initial presentation due to pain, so follow-up examinations are essential

  • High risk for compartment syndrome!

Diagnostic Imaging:

  • AP and lateral radiographs for initial imaging

o   Lipohemarthrosis suggests occult fracture in the appropriate clinical setting

  • CT is useful for:

o   Diagnosing occult fracture not evident on plain radiographs

o   Improved characterization of fractures

o   Identification of articular depression which may alter management in up to 25% of cases

o   Operative planning

  • MRI shows concomitant soft tissue injury but is rarely indicated in the ED

Classification:

Figure 4: Schatzker Classification of Tibial Plateau Fractures. (Image from Zeltser et al, Classifications in Brief: Schatzker classification of tibial plateau fractures, Clinical Orthopedics and Related Research, 2013 Feb)

Figure 4: Schatzker Classification of Tibial Plateau Fractures. (Image from Zeltser et al, Classifications in Brief: Schatzker classification of tibial plateau fractures, Clinical Orthopedics and Related Research, 2013 Feb)

Management Considerations:

  • Ice and elevate!
  • Schatzker IV injuries are associated with high risk of popliteal injury → consider ABIs and/or vascular imaging (i.e. CTA)
  • Nonoperative management with a hinged knee brace and protected weight bearing is indicated for:

o   Minimally displaced split or depressed fractures

o   Nonambulatory patients

  • Surgical management is common for tibial plateau fractures, especially:

o   Segment depression > 5mm

o   Condylar widening > 6mm

o   Schatzker type ≥ IV

  • Orthopedic consultation is recommended
Figure 5: Algorithm for ED management and disposition. (Karadesh M, Tibial Plateau Fractures, Orthobullets)

Figure 5: Algorithm for ED management and disposition. (Karadesh M, Tibial Plateau Fractures, Orthobullets)

Take Home Points:

  • Tibial plateau fractures are often complex injuries with associated ligament and meniscal disruption
  • Clinical suspicion for occult tibial plateau fracture (i.e., mechanism, age, effusion) warrants CT imaging in the ED
  • Maintain vigilance for neurovascular injury and recognize risk for compartment syndrome
  • Patients with minimally displaced split or depressed fractures can often be discharged in a knee immobilizer as long with close orthopedic follow up assuming adherence to strict non-weight-bearing and adequate pain control
  • More complex fractures often require admission for operative management
  • Consult orthopedics

Faculty Reviewer: Jeffrey P. Feden, M.D.

References:

1. Chan PS, et al. Impact of CT scan on treatment plan and fracture classification of tibial plateau fractures. J Orthop Trauma 1997;11:484–489.

2. Egol KA, Tejwani NC, Capla EL, Wolinsky PL, Koval KJ. Staged management of high-energy proximal tibia fractures (OTA types 41): the results of a prospective, standardized protocol. J Orthop Trauma 2005;19:448–455.

3. Schatzker J, McBroom R, Bruce D. The tibial plateau fracture: the Toronto experience 1968-1975. Clinical Orthop Relat Res 1979;138:84-104.

4. Gentili, Amilcare. Tibial Plateau Fracture Imaging. Emedicine [Internet]. Available from: http://emedicine.medscape.com/article/396920-overview. Accessed 23 March 2017.

5. Karadsheh M.  Tibial Plateau Fractures.  Orthobullets [Internet].  Available from: http://www.orthobullets.com/trauma/1044/tibial-plateau-fractures.  Accessed 20 April 2017.

6. Pallin, Daniel J.  Tibial Plateau Fractures, Knee and Lower Leg, Chapter 57.  Rosen’s Emergency Medicine, 8th ed.  Philadelphia: Elsevier, 2014.  698-722 p.

7. Thomas Ch, Athanasiov A, Wullschleger M, Schuetz M. Current concepts in tibial plateau fractures. Acta Chir Orthop Traumatol Cech. 2009;76(5):363-73.

8. Tscherne H, Lobenhoffer P. Tibial plateau fractures. Management and expected results. Clin Orthop Relat Res 1993;292:87-100.

 

Clinical Image 21: A Sparkle in the Eye

WELCOME BACK TO ANOTHER CLINICAL IMAGE FROM THE CASE FILES OF THE BROWN EM RESIDENCY!

Case:

HPI/ROS: 49-year-old female with a history of hypothyroidism and asthma  presents to the ED with right eye swelling and pain. She reports that four days ago she initially developed a severe right-sided headache, which progressed to right eye swelling, redness and pain with movement. She was seen at an urgent care center and diagnosed with conjunctivitis and treated with topical antibiotics[am1] . Today, she awoke with a new rash on her scalp as well as chills, nausea, and watery discharge from the eye. She denies visual changes or fevers.  

Vital Signs: T: 98.6, HR: 91, BP: 123/73, R: 16, SpO2: 99% on room air

Visual Acuity: R 20/25 L 20/25

Physical Examination: The patient is alert and oriented. Normocephalic, atraumatic head. Tympanic membranes are clear. Oropharnyx clear and moist. Cranial nerves II-XII are intact. Pupils are 4 mm and reactive bilaterally. Extra-ocular movements are intact. Peripheral vision is intact. Patient accommodates appropriately. Neck is supple. Lungs are clear to auscultation. Heart is regular rate and rhythm without murmurs, rubs, or gallops. Abdomen is soft, non-tender, non-distended. A rash is appreciated above the right eye with some associated mild peri-orbital swelling (see image 1). There is conjunctival injection. Slit lamp examination is performed as well (see image 2). No other pertinent exam findings.

Image 1: Rash appreciated above the right eye.

Image 1: Rash appreciated above the right eye.

Image 2: Slit lamp examination findings

Image 2: Slit lamp examination findings

What’s the diagnosis?

Herpetic Zoster Ophthalmicus (HZO)

Here are some quick facts:

  • Herpetic Zoster Ophthalmicus (HZO) is a vision threatening condition secondary to Varicella Zoster Virus (VZV) reactivation, “shingles”, within the trigeminal ganglion, specifically the first division (V1).
  • Up to one-half of all patients with VZV V1 reactivation experience direct ocular involvement.
  • Typical prodromal symptoms include headache, malaise, fever, pain and photophobia in the affected eye and surrounding dermatome.
  • Upon eruption of vesicular lesions within the trigeminal dermatome, patients will likely experience hyperemic conjunctivitis, blurred vision, and/or lid droop. The rash typically does not cross the midline.
  • Two thirds of patients will develop corneal involvement (keratitis), which can either manifest as punctate (our patient) or dendritic lesions on slit lamp examination.
  • The anterior chamber can show cells and flare if deeper structures are affected (iritis).
  • Lesions on the nose are fairly specific for HZO due to involvement of the nasociliary branch of the trigmeninal nerve, which also innervates the eye.  
  • Early diagnosis is critical and management involves oral anti-retrovirals and adjunctive topical steroid drops to reduce the inflammatory response. Associated conjunctivitis can be treated with topical erythromycin ointment. Pain reduction can be achieved with topical cycloplegic agents.
  • If the patient is immunocompromised or systemically ill, consider admission with IV acyclovir.
  • Prompt ophthalmological follow up is warranted as well.

Case Conclusion:

This patient was discharged home on oral acyclovir and topical steroid drops. She had follow up with ophthalmology the following day.

Faculty Reviewer:

Dr. Alyson McGregor

References:

Albrecht, Mary. Clinical Manifestations of Varicella-Zoster Virus Infection: Herpes Zoster. UptoDate. 2017.

Tintinalli, et. al. Emergency Medicine. 8th Edition. 2016. 1061-1062.   

The contents of this case were deliberately altered to protect the identity of the patient. All content in this report are for educational purposes only. The patient consented to the use of these images.

 

Asynchrony EM: Dementia and Delirium in the ED

New to Asynchrony EM? It's an asynchronous learning course in its third year at Brown EM. Digital resources and #FOAMed are curated and packaged by topic, following Brown EM's curricular calendar. In the spirit of #FOAMed, we've started putting it out there for the EM community at large. Check out the theme song, the 'extras', and the discussion questions -- and leave us your thoughts in the comments section.

Note: Brown EM residents must complete the modules (including discussion/quiz) in Canvas to obtain credit hours.

You see them every shift. Could you be taking better care of them?

You see them every shift. Could you be taking better care of them?

This week, we start our Neurology block. There are lots of 'sexy' neuro topics we could be starting off with, but we're starting with care of elderly patients with dementia and delirium in the emergency department. We'll look at how to differentiate between the two diagnoses (which can co-exist), talk about best practices for caring for these patients in the ED, about the burden on caregivers, and some of the more 'humanistic' aspects of dementia. 

No theme song this week; a theme movie trailer instead.  Julianne Moore won the Oscar for her portrayal of 'Alice' in 'Still Alice' (the book is worth a read but I haven't seen the movie.)  

 

Now, before I forget, let's hit it. 

1)From EM Docs, Sept 2016. "Dementia in the Emergency Department: Can You Do Anything About It?" 

 

2)  In 2013, Geriatric ED Guidelines were jointly approved by ACEP, SAEM, the American Geriatric Society, and the Emergency Nurses Association.  But why would these guidelines not apply to the treatment of the elderly in any ED when possible?

Please read starting on page 26 the section entitled "Delirium and Dementia in the Geriatric Emergency Department". Also read the brief Palliative Care section immediately following.  (It's somewhat telling that the Palliative Care section is so short. See our discussion section.)

 

3) Did looking at all those screening tools make you crazy?  Think you can pick up delirium on your own without a screening tool? Well, maybe you can, Superdoc, but most of your colleagues can't: check out this Annals of EM 4 minute podcast about the May 2014 article, "Screening for Delirium in the Emergency Department." The podcast is assigned; reading the article is OPTIONAL.  The take-home point from both is that we stink at identifying delirium, and it's a dangerous thing to miss.

 

4) Now we're going to get a little more...humanistic.

It is difficult sometimes to imagine an elderly, frail, confused patient as the person they might have been once upon a time. We see these patients as a snapshot, without the benefit of knowing them "before,"and without the inherent compassion that comes with that knowing. When the snapshot is a screeching, drooling, vacant, shrunken being, it's easy to restrain or oversedate or ignore. But maybe, the next time (which will of course, be tomorrow) that you see this patient, imagine them as Pam (in this mini-documentary) or Alice, or someone you may have known in your own life that you have watched fall slowly into the abyss. You will find that it does wonders for your patience. 

Not a medical video, but worth watching. An eight minute, beautiful Op-Doc video called "A Marriage to Remember," from the New York Times. This very short film was made by a son documenting his mother's dementia and his father's efforts to care for her over a four year period.

"A Marriage to Remember"


 

5)  As the video above highlights, patients who are cared for at home create a heavy burden on families, even on families with means (as the family in the op-doc appears to have). Caregiver fatigue and burnout is increasingly recognized, and you will see and treat patients with depression and stress-related illness that stems directly from caregiver burnout.  And when caregivers burn out, where do the patients with dementia wind up?

With the silver tsunami gathering strength, it's time for us to learn to 'help the helpers', because they are the ones who will determine how much of an overall burden patients with dementia present to emergency departments.

True story: a few years ago, I treated a man with advanced dementia whose wife called 911 after she knowingly gave him an overdose of his pain medication. She then could not go through with her plan, which was to kill him, and then kill herself. (Both of them became my patients--she was admitted to psychiatry.)  The wife had no previous history of mental illness or depression; her symptoms stemmed entirely from caregiver burnout, and the stress of the promise she had made to her husband to 'never put him in a home.' 

This is an area that is only beginning to be addressed, and is ripe for research. In September 2016, the National Academies of Sciences, Engineering, and Medicine (NASEM, formerly known as the Institute of Medicine) released a very long report on "Families Caring for an Aging America." For our purposes, read this Geri Tech Blog Post. 

 

6) Because it's more prevalent among cognitively impaired patients: Elder Abuse, a quick reminder from LITFL.

 

7) Three quick news blurbs: lots of mainstream news attention on dementia and anti-psychotics/benzo use.  The immediate implications are for long term prescriptions, but you will find that (as in the Geriatric ED guidelines) there is counsel to avoid them even in the ED if non-pharmacologic methods can curb behaviors instead. You should also consider this when sending dementia patients back from whence they came after they are sedated for behaviors in the ED. 

a) From a March 5th, 2015 NPR post:  'Behavioral Therapy Helps More than Drugs' in dementia

b) From the March 1, 2015 NY Times: "Investigators are recommending that Medicare officials take immediate action to reduce unnecessary prescriptions to older Americans with dementia."  This is mostly about anti-psychotic drugs.

c) Couple those with the February 2015 JAMA Psychiatry article "Benzodiazepine Use in the US" (abstract/scroll through is enough) -- and you will find there is a lot of pressure to de-prescribe the elderly, maybe with good reason. 

 

The OPTIONAL (but really worth the time) blurbs:

a) Nursing homes that eschew the use of antipsychotics: from NPR.

b) A recent series from NPR, "Inside Alzheimer's" -- perspective from caregivers and afflicted. 

c) Speaking of non-pharmacologic methods, do you have a working iPod you don't use?  Music and Memory NEEDS IT. Check them out: awesome stuff.

d) If you didn't see the documentary Alive Inside (featuring the work Music and Memory does: won the Audience award at the 2014 Sundance film festival), this stuff is pure genius, and so, so simple.  (I'd love to see a trial of using music to calm and comfort  patients with dementia.)

 

 e) Finally, because the Music and Memory videos above feature the wonderful Dr. Oliver Sacks, who died in 2015, I'm throwing this in: very much worth the short time it takes to read. Not dementia related, but we're in the Neuro block, and he was the world's sweetheart neurologist/writer. If I haven't gotten you teared up yet, keep reading.  "My Own Life: Oliver Sacks on Learning He Has Terminal Cancer."  "Above allI have been a sentient being, a thinking animal, on this beautiful planet, and that in itself has been an enormous privilege and adventure."

That's all for this week. Share any thoughts or other #FOAMed resources you'd like us to know about in the comments.