Dr. Orthochick: Knee Pain

We had a consult at 3AM from the ER for a patient who had gotten run over by a car and was now having knee pain. They had done an x-ray at some outside hospital that showed a possible avulsion fracture, but they had repeated the x-ray here and it didn't show said possible avulsion fracture. Oh, and the patient was demented and only spoke Spanish. The worst thing I can think of happening with a possible avulsion fracture is some sort of ligament tear and half the time we don't do anything for that even if it exists so we're really not going to do anything for it after 1AM.

I got down there and the guy was looking pretty good for a 90 year old who got run over by a car, so I'm not sure about the mechanism of injury here. They already had an interpreter and there were a whole pile of family members, so at least I had that going for me.

Me: Where does it hurt?
Interpreter: He says in his knees
Me: Where in the knees?
Interpreter: He says in his knees
Me: In the front? The sides? The back?
Interpreter He says in his knees
Me: Is it a sharp pain? dull? shooting pain?
Interpreter He says the pain is in his knees.

I attempted to do a physical exam, except since half of a knee exam involves doing something and asking if it hurts, it's a little hard to do. That being said, I'm a pretty firm believer that if the patient has to tell you it hurts, it means it doesn't hurt enough to consider it a positive test (it's not too hard to figure out when you're really hurting someone. If you don't believe me, do Yergasson's test on my dad.) so that one at least crosses the language barrier. On physical exam, the only thing I could get was medial pain with valgus stress testing on the right knee, so I decided he probably had a partial MCL tear. I couldn't actually confirm it with an MRI since the guy had a pacemaker in, but I figured we were going to treat it the same way regardless of whether or not it existed, so I told the ER doc to stick the guy in a knee immobilizer until he felt better and just let him weightbear as tolerated.

Me: There's nothing broken in your knees and we don't need to do surgery.
Interpreter: He says his knees are broken
Me: They're not. There's a tear in the ligament. That's what holds the bones together.
Interpreter: He says his knees are broken
Me: I'm sure they're hurting, but the bones are OK
Interpreter: He says his knees are broken
Me: The thing that holds the knee bones together is torn
Interpreter: He says his knees are broken.