Musculoskeletal Case study

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 markedup
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 familiarise
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 office: 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.
Have a good weekend.
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 specialised
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
A marking rubric has been provided to assist you in creating your assessment.
written
communication.

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