An elderly male with a history of bilateral total knee replacement (TKR) surgeries, who recently fell off a bike, presents with pain in his back, left side, left hand, left wrist, and both knees, what is the best course of action for his evaluation and management?

Evaluation and Management of Elderly Male with Bilateral TKR After Bike Fall

This elderly patient with bilateral total knee replacements and prosthetic hardware requires immediate radiographic imaging of all symptomatic areas without applying Ottawa or Pittsburgh clinical decision rules, as the presence of prosthetic hardware is an absolute contraindication to these rules and mandates imaging regardless of clinical findings. 1

Immediate Imaging Protocol

Obtain plain radiographs immediately for all symptomatic areas:

• Bilateral knee radiographs (AP and lateral views minimum) - The ACR guidelines explicitly state that clinical decision rules should NOT be applied in patients with prosthetic hardware, and radiographs must be obtained 1
• Left wrist radiographs (AP, lateral, and oblique views) - To evaluate for distal radius, ulnar, or carpal fractures
• Left hand radiographs (PA, lateral, and oblique views) - To assess for metacarpal or phalangeal fractures
• Thoracolumbar spine radiographs (AP and lateral) - Given back pain and the patient's age, compression fractures are a significant concern
• Consider chest radiograph - To evaluate for rib fractures given left-sided pain 1

The presence of prosthetic hardware creates an absolute indication for imaging that supersedes any clinical examination findings, as physician judgment must account for the altered biomechanics and increased fracture risk around prosthetic joints 1.

Critical Assessment for Periprosthetic Complications

Evaluate specifically for periprosthetic fractures around both knee replacements:

• Periprosthetic fractures occur more commonly in elderly patients with TKR, particularly after falls 1
• Examine for gross deformity, abnormal prosthesis positioning, or inability to perform straight leg raise 1
• Assess neurovascular status of both lower extremities, documenting pulses, sensation, and motor function 1
• If any concern for knee dislocation exists, immediately assess for vascular injury - though rare with isolated patellar issues, true knee dislocation carries 30% risk of popliteal artery injury 2

Pain Management Strategy

Implement multimodal analgesia immediately, prioritizing non-opioid approaches:

• Intravenous acetaminophen 1000mg every 6 hours as first-line treatment - This is the cornerstone of acute trauma pain management in elderly patients 1
• Consider peripheral nerve blocks if fractures are confirmed, particularly for wrist/hand injuries (regional blocks) or knee injuries (femoral nerve blocks) 1
• Add NSAIDs cautiously only for severe pain, carefully weighing cardiovascular and renal risks in this elderly patient 1
• Minimize opioid use - reserve only for breakthrough pain at lowest effective dose for shortest duration, as elderly patients have increased risk of delirium, respiratory depression, and falls 1, 3
• Apply ice packs and immobilize injured extremities as non-pharmacological adjuncts 1

Spine-Specific Evaluation

Given back pain after fall in elderly patient, assess for spinal cord injury:

• Perform detailed neurological examination including motor strength in all extremities, sensation, reflexes, and rectal tone 1
• If any neurological deficits are present, obtain MRI of the spine urgently - particularly if there are upper extremity symptoms suggesting cervical involvement 1
• Document any pre-existing neurological deficits from medical history
• Elderly patients with degenerative spinal stenosis are at higher risk for spinal cord injury even from low-energy falls 1

Additional Diagnostic Considerations

Complete laboratory workup:

• Complete blood count, basic metabolic panel, and ECG - standard for elderly trauma patients to identify anemia, electrolyte disturbances, and cardiac issues 3, 4
• Assess for underlying causes of the fall including cardiac arrhythmias, orthostatic hypotension, or medication effects 4

Evaluate fall mechanism and risk factors:

• Document exact mechanism of fall, any loss of consciousness, prodromal symptoms, or environmental hazards 4
• Assess gait and balance issues, previous falls, and time spent on ground 4
• Screen for cognitive impairment and delirium, as these affect pain assessment and treatment 1

Common Pitfalls to Avoid

Critical errors in this clinical scenario:

• Never apply Ottawa or Pittsburgh rules in patients with prosthetic hardware - this is explicitly contraindicated and will miss significant injuries 1
• Do not assume knee pain is simply prosthesis-related - periprosthetic fractures, component loosening, and infection must be excluded 1
• Avoid under-treating pain in elderly patients - 42% of patients over 70 receive inadequate analgesia even with significant fractures 1
• Do not overlook occult fractures - up to 10% of hip fractures and many wrist fractures may not be visible on initial radiographs, requiring MRI if clinical suspicion remains high 3, 4
• Recognize that multiple injuries may mask individual injury severity - systematic evaluation of each symptomatic area is mandatory 1

Disposition and Follow-up

Based on imaging results:

• If periprosthetic fractures are identified: Immediate orthopedic consultation for potential surgical intervention
• If spinal fractures are present: Spine surgery consultation and consideration for bracing or surgical stabilization
• If wrist/hand fractures require operative fixation: Orthopedic hand surgery consultation
• All elderly fall patients require fall risk assessment and prevention strategies before discharge 4