key: cord-281796-sutgyaep
authors: Bluman, Eric M.; Fury, Matthew S.; Ready, John E.; Hornick, Jason L.; Weaver, Michael J.
title: Orthopedic telemedicine encounter during the COVID-19 pandemic: A cautionary tale
date: 2020-06-27
journal: Trauma Case Rep
DOI: 10.1016/j.tcr.2020.100323
sha: 
doc_id: 281796
cord_uid: sutgyaep

The COVID-19 pandemic has necessitated increased use of telemedicine for diagnosis and management of musculoskeletal disorders. We describe the initial virtual/telemedicine encounter and management of a patient with knee pain initially diagnosed as gonarthrosis but that actually resulted from an impending pathologic fracture of the femur. Definitive diagnosis and treatment occurred only after completion of the impending fracture. The multiple factors making telemedicine encounters challenging which contributed to this outcome are highlighted. Orthopedists need awareness of these challenges and must take steps to mitigate the risk of complications possible with continued increased utilization of telemedicine during this pandemic and beyond.

J o u r n a l P r e -p r o o f Summary The COVID-19 pandemic has necessitated increased use of telemedicine for diagnosis and management of musculoskeletal disorders. We describe the initial virtual/telemedicine encounter and management of a patient with knee pain initially diagnosed as gonarthrosis but that actually resulted from an impending pathologic fracture of the femur. Definitive diagnosis and treatment occurred only after completion of the impending fracture. The multiple factors making telemedicine encounters challenging which contributed to this outcome are highlighted.

Orthopedists need awareness of these challenges and must take steps to mitigate the risk of complications possible with continued increased utilization of telemedicine during this pandemic and beyond.

Keywords: coronavirus, telemedicine, orthopedic surgery, delayed diagnosis, impending fracture

Telemedicine or virtual visits (VVs) refers to the treatment of various medical conditions without seeing the patient in person. Encounters conducted over the phone without video imaging to J o u r n a l P r e -p r o o f No physical examination was possible because of the virtual nature of the encounter. Three nonweight bearing radiographs of her right knee were evaluated as part of the encounter (Figure 1 ).

These demonstrated mild arthritic changes of the patellofemoral joint. No appreciable deformity was noted. A diagnosis of mild right knee arthritis was made. Non-operative management including weight loss, NSAIDs and physical therapy to include a home exercise program was decided upon.

On 13 Apr 2020, the patient twisted her body while at home with a resultant fall, pain in her right thigh, and inability to stand. She was transported to our hospital by emergency services. In the emergency department, her right lower extremity was shortened and her thigh was tender to palpation but her integument and neurovascular exam were intact. Radiographs of her right femur revealed a displaced, oblique subtrochanteric fracture through a lytic lesion ( Figure 2 ).

Further history revealed that her prior thyroid cancer had metastasized to a rib that required resection. Standard lab testing for patients with known skeletal metastases was initiated. She was admitted and a bone scan and skeletal survey was performed to ensure there were no other sites of impending fracture and to identify possible targets for radiation therapy.

The patient underwent reduction and placement of a cephalomedullary device for fixation of the right femur ( Figure 3 ). The surgery was un-eventful, and she tolerated it well. During the procedure, a biopsy of the contents of the lytic lesion within the right femur was performed and sent to surgical pathology for gross and microscopic histologic evaluation. This analysis confirmed the diagnosis of metastatic thyroid carcinoma (Figure 4 ).

Radiation oncology was consulted to provide post-operative radiation therapy and medical oncology was consulted for consideration of postoperative chemotherapy. She was mobilized with physical therapy, and was able to walk with the aid of a walker at the time of discharge.

In this case report, we illustrate numerous factors associated with a telemedicine visit that resulted in the delayed diagnosis of a skeletal metastasis. This case highlights many of the pitfalls possible with orthopeadic surgeons' use of this type of encounter.

One obvious drawback to using telemedicine visits is the limitation placed in conducting a physical examination. Telephonic-only visits are the most limited. These types of visits can detect certain components of the examination (e.g. affect) the patient's verbal communication. In some unusual circumstances, the physician may be able to evaluate audible findings (e.g. tendon crepitus).

Physical examinations through the video component of eVisits are also limited, albeit less so than with telephonic encounters. eVisits with orthopeadic encounters can certainly provide greater information but still prevent adequate examination of tissue character, temperature, sensory function, motor strength, differentiation of pain intensity and certain types of coordination.

With both isolated telephonic encounters and eVisits, there is a very limited ability to obtain synchronous supplemental imaging. For these visits, patients ideally obtain imaging just before the visit itself (e.g. one or a few days before) to allow accurate radiographic diagnosis. When patients are seen in-person in the orthopeadic clinic, they are easily sent back to radiology for repeat imaging for those studies that were inadequate or for supplementary studies to show expanded fields of view or non-standard views. In most cases, this option is not available for telephonic or eVisits. Some locales have services that provide mobile imaging at the home of the patient. [3] [4] [5] Where available, these services can help improve the quality of the care.

However, the imaging equipment such companies are able to bring to the patient's home is limited; specialized studies are not able to be performed. This limits the improvement in diagnostic capabilities.

All patients are not able to use eVisit technology. While smart phones are extremely common, the expertise to conduct a eVisit is not universal. We have found that many geriatric patients have difficulty with eVisit technology. In our case, had an eVisit been possible, it may have tipped-off the treating surgeon to the true nature of the problem. In the hospital, when describing her "knee pain," she grabbed her thigh. This observation during an eVisit may have led to further questioning or radiographs. 

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