An obese 60-year-old male presents with knee pain after a fall. He reports that 2 days ago he slipped on some ice and fell forcefully onto his left knee. He is able to walk but does have a noticeable limp. On examination he is able to flex his knee past 90° and has no point tenderness. Which one of the following would be most appropriate at this time?

A. Anti-inflammatory medication
B. A corticosteroid injection
C. A knee brace
D. A radiograph
E. MRI

ANSWER: D

The Ottawa knee rule is a validated tool that decreases unnecessary radiography in patients with a knee injury. According to the Ottawa knee rule, a radiograph should be obtained if any of the following are present:

• age 55+ years
• isolated tenderness of the patella
• tenderness of the head of the fibula
• inability to flex the knee to 90°
• or the inability to bear weight for four steps both immediately after the injury and at the time of the examination

A radiograph would be indicated for this patient based on his age. Anti-inflammatory medication may be an appropriate strategy for acute pain treatment, but this patient meets the criteria for a radiograph, which should be done first to rule out a fracture. A corticosteroid injection may be a consideration for treatment of chronic knee pain, generally in the setting of osteoarthritis, but would not be recommended in the setting of acute, undifferentiated pain. Knee braces can be useful with certain causes of knee pain, such as medial unloading knee braces for medial knee osteoarthritis, but the use of a knee brace in this situation without a diagnosis would not be warranted. MRI could be appropriate later in the workup, but the first step should be a radiograph.

Ref: Bunt CW, Jonas CE, Chang JG: Knee pain in adults and adolescents: The initial evaluation. Am Fam Physician 2018;98(9):576-585. 2) Sprouse RA, McLaughlin AM, Harris GD: Braces and splints for common musculoskeletal conditions. Am Fam Physician 2018;98(10):570-576.

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