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Emergency Medicine News:
doi: 10.1097/01.EEM.0000398224.42953.a4
Diagnosis Deconstructed

Diagnosis Deconstructed: Back to the Drawing Board

Morchi, Ravi MD

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“My knee hurts, and I can't walk.”

Muscles and nerves o...
Muscles and nerves o...
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“Did you fall?”

“No, I don't think so.”

“When did this start?”

“Oh, I don't know. A week? My leg hurts, and I can't walk.”

“Where does it hurt exactly?”

“My whole leg.”

“Anywhere else?”

“My back.”

She was 78 years young and a bit confused. Her triage note stated mild dementia, so maybe this was her baseline. Her attention span and focus were good, and she could interact and answer basic questions, but detail was lacking. Her answers shifted in the specifics. She was generally unsure of precise events, but was consistent on one thing: She could not walk.

She had a list that included atenolol, coumadin, and aspirin, but no written record of the conditions that prompted these medications. Our patient appeared generally comfortable on exam. She was not tachypneic or in any distress. Her pulse was irregular in timing and strength. She had atrial fibrillation.

Well, that's one piece of the puzzle solved. I suppose I should have our resident contact the assisted living center for more.

Other than an irregular rhythm, her vital signs were normal. No evidence of trauma to her face or head. Her neck was nontender with full range of motion. Her chest wall and abdomen were benign. Her back was equally unimpressive: midline percussion of the vertebral column or lateral percussion over the costovertebral angles were both unrevealing. Upper extremities were littered with islands of purpura characteristic of the vascular fragility of old age, not any new trauma. She had full passive range of motion in her arms and shoulders.

Her left lower extremity was normal. Her right lower extremity was held with the hip and knee flexed. Passively her range of motion at the hip was limited, and these maneuvers seemed to cause her pain. No tenderness over the femur, patella, joint line, tibia, fibula, metatarsals, or calcaneus. Her skin exam was normal. And her muscle tone and bulk was quite good for her age. The soles of her tennis shoes sitting in her belongings bag were appropriately worn down. I had the sense that she was ambulatory, and probably quite active at baseline. Her toenails were clean and trimmed. Our patient, or someone else, was taking quite good care of them.

“CBC, chemistry, hip x-ray?” asked our senior resident. “Maybe I can add a chest x-ray and type and screen as pre-op because it looks like her hip is probably broken.”

“Sounds good,” I said.

“How do you feel about a head CT? She is slightly confused and on coumadin. We don't know her baseline.”

“I can't argue with that,” I said. I suppose she could have accumulated a subdural or two in the recent past. Although my gestalt said this was not the case, it wouldn't be the first time pixels have proven me wrong.

The problem. Her hip x-ray was negative. Joint space appeared a little narrow with some edged sclerosis over the femoral head and anterior rim of the acetabulum, but no fracture. Zooming in and tracing the trabecular lines over the monitor, I could not find evidence for a disruption.

We sat staring at the screen. “She probably still has a hip fracture. She can't walk. She has to have one,” the resident said.

“Probably,” I replied.

“Yeah. Probably nondisplaced,” he added.

“That sounds right.”

The second problem. The CT of her hip showed no fracture.

“Have it read by the attending radiologist,” I advised the resident.

“I did. She said there was no fracture.”

He was a good resident.

“She probably still has one. She can't walk. She has to have something,” he claimed.

“Yeah, probably,” I said.

“Admit to medicine? She cannot get around well at her current living situation and maybe needs a higher level of care until she heals. The inpatient team can organize this.”

The third problem. “Admit to medicine” is neither a diagnosis nor a therapy. And it will not make her walk. Time to go back to the drawing board.

When we find ourselves scratching our heads over a clinical dilemma, we are generally sitting at a computer screen, zooming in and out of pixels and meditating on a digitalization of disease. We are screening lab results, and mixing and matching our numerical database to pattern-recognize a diagnosis. We sit befuddled in our doctors' area, and strain over the Sudoku puzzle on screen before us.

But the drawing board is not at that desk or in that computer. The home of the pathology we seek, well, it's within our patient's body. The drawing board is at the bedside, and the artwork is under the skin. We should be scratching our heads there. We should be standing close to our patient, inhaling and exhaling with them, and zooming in and out of their true form, not their digitized one.

So back I am. She still lays in the same manner: right hip and knee slightly flexed and appearing overall very comfortable.

“I want something to eat. Do you have anything to eat?” she asked.

“Just a moment, ma'am.”

The hip joint. She actually had much better range of motion to external and internal rotation than she did to hip extension or flexion. Interestingly, moving her femoral head in its joint space is not limited in all directions, it is limited in particular directions. Similarly, heel strike and axial load maneuvers forcing her femoral head into the acetabulum did not cause her any pain. As much as I wanted to remain in the joint space, the pathology did not reside there.

The greater trochanter. Gluteus muscles, obturator internus, pyriformis and the gemelli all attach here. But the attachment point is nontender, and the main motion of this musculature, external rotation and abduction, was uninhibited.

The lesser trochanter. Mild tenderness here. I think I know where this is going. I am close, but need to confirm. Just one question left to ask: “Ma'am, how does it feel when I do this?” I touched the skin overlying her quadriceps. “Does it feel the same as the other side?”

“No.”

“How so?”

“It feels funny. It feels numb.”

Got it.

A powerful muscle that begins as two in the retroperitoneum and pelvic rim, its components course individually until a caudal point in the pelvis, where they merge. Between the two parts of this muscle runs the femoral nerve. It slips anteriorly over the muscle, and then under the inguinal ligament to provide motor function to the quadriceps and sensation over the anterior thigh as well as the medial anterior lower leg.

Our patient had a compressive femoral neuropathy because of pathology within this muscle. The muscle attaches at the lesser trochanter of the femur. It controls hip flexion and, when abnormal, will limit movement in this plane more so than external or internal rotation. The component of the muscle that originates in the retroperitoneum attaches to the lumbar spine laterally. In so doing, pathology along its length can cause the sensation of back pain.

Expectations. Palpating with the expectation to find iliopsoas tenderness, I notice it is there. It hurts over her lesser trochanter and superiorly over the distal body of the muscle and tendon. She has discomfort up to the lowest section of her abdomen, centimeters above her inguinal ligament and superior pubic ramus. This corresponds to the course of the iliopsoas before it dives posteriorly, deep into the pelvis and retroperitoneum. At that point, it is no longer palpable.

I review the noncontrast CT hip, whose windows are generally wide enough to include the iliacus and psoas components of the muscle. Sure enough, the distal psoas contour is deformed, enlarged, and bowing anteriorly.

I call back our attending radiology colleague, and she agrees with the diagnosis.

Spontaneous iliopsoas hematoma. Her hemoglobin was 11 and INR 4. Likely venous ooze in the strained muscle of a coagulopathic and throm-bocyto-pathic patient. Not an operative condition at this point. We started FFP, held her coumadin and aspirin, and … admitted her to medicine.

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AMA Increases ABEM Credits

The American Medical Association has approved increasing the number of AMA PRA Category 1 Credits for diplomates who have attained certification by passing the AMA's oral examination or who have renewed certification by passing the AMA's Continuous Certification Examination through the American Board of Emergency Medicine. Previously, diplomates could only apply for 25 credits, but now may apply for 60 CME credits for up to six years from the effective date on their certificates. The cost of CME credits is $30 for AMA members and $75 for non-members.

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