10 sports injuries not to miss - Bone & Joint Center · •15 yo M football lineman presents with...
Transcript of 10 sports injuries not to miss - Bone & Joint Center · •15 yo M football lineman presents with...
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10 Sports Injuries Not to Miss
Jessica Juntunen, MDPrimary Care Sports Medicine
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I have no financial interests or relationships to disclose in regards to this
presentation
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• 12 yo RHD male baseball pitcher presents with R elbow pain for one month. Began after pitching back-to-back games at a tournament. Doesn’t recall feeling a pop or any visible bruising. Localized medially. Greatest pain with late cocking phase of pitch. Seems to improve with rest, but returns every time he tries to return to pitching.
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Little league elbow
• apophysitis of the medial epicondyle growth plate
• due to repeated valgus stress, most commonly associated with overhead throwing
• associated with increase # pitches and decrease in rest period between seasons
• 9-12 yo
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• adults tend to injure UCL, while greatest force is localized to UCL attachment in adolescents
• most will have normal XR
• COMPARISON VIEWS
• MRI may help to confirm diagnosis or evaluate for any ligamentous injury
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• treatment = REST for 3 months*
• USA Baseball Medical and Safety Advisory Committee
• pitch counts
• 8-10 yo: 50
• 11-14 yo: 75
• 15-16 yo: 90
• 17-18 yo: 105
• for pitchers, 3mo rest from all overhead throwing
• physical therapy
• eventual, gradual return to throwing with interval throwing program
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• 14yo M RHD pitcher presents with R shoulder pain x 6 wk. Pain with pitching - worst in cocking and deceleration phases. Tender lateral shoulder/proximal humerus. Improves with rest.
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Little League shoulder
• Apophysitis/epiphysiolysis of proximal humerus
• Adolescent males > females
• Pain in both late cocking (rotational torque) and deceleration (distraction) phase of pitch
• Pitch # greatest risk factor
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• May report decreased pitch velocity
• On exam, may have:
• Tenderness at level of physis
• Pain in ER
• GIRD
• XR to evaluate for widening
• MRI may be useful to confirm dx and r/o other pathology
• Treatment: 3mo rest, PT, gradual throwing program
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• 22 yo F college basketball player presents with R wrist pain following FOOSH injury onto R hand. Pain along radial side of hand and wrist. Some swelling of thenar eminence.
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Scaphoid Fracture• Most commonly fractured carpal bone
• Usually due to fall with wrist extended and axial load (FOOSH injury)
• Snuffbox tenderness on exam
• major blood supply is dorsal carpal brach of radial artery and 80% of scaphoid is supplied via retrograde flow
• risk of AVN and non-union
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• Initial imaging with XR
• If negative XR, but high clinical suspicion, may treat empirically with spica cast/brace and f/u for repeat XR or proceed with advance imaging
• MRI first-line advanced imaging
• CT or bone scan are other options
• Proximal and displaced fractures higher risk of non-union
• surgical referral usually if displaced >1mm
• When treated conservatively, 3-6 mo for healing
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• 20 yo M soccer player presents with L ankle pain. Foot was caught up under another player during a tackle. Felt like ankle was twisted. Immediately unable to bear weight. Worst pain is anterior and lateral. Significant edema and ecchymosis of ankle.
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High Ankle Sprain(syndesmosis injury)
• Syndesmosis maintains integrity between tibial and fibula
• Can be a/w fractures of distal fibula, 5th metatarsal, talus
• Important to recognize, as missed diagnosis may lead to significant, early DJD of ankle
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• Presents like severe sprain - swelling, bruising
• Anterolateral pain
• tenderness proximally, over syndesmosis
• Unable to weight bear
• Provocative tests:
• squeeze test
• external rotation
• fibular drawer
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• Initial XR to include AP, lateral, mortise views
• consider WB, external rotation stress, XR of proximal fibula, and contralateral views if suspicious
• XR may show
• decreased tibiofibular overlap
• increased medial clear space
• increased tibiofibular clear space
• MRI, CT
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• Conservative treatment, NWB in tall boot followed by progression to WB in boot and PT
• variable recovery/healing time; much longer than normal ankle sprain
• only if no diastasis or instability
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• 33yo M flag football player presents with R foot pain. Injury occurred during a tackle when another player fell onto heel of his plantar flexed foot. He cannot bear weight and reports diffuse pain through fore foot. There is medial plantar ecchymosis noted.
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Lis Franc Injuries• Lis franc ligament spans articulation from the medial
cuneiform to base of 2nd metatarsal
• lis franc complex consists of TMT, inter metatarsal, and inter tarsal articulations
• spectrum of injury: sprains —> fracture-dislocation of TMT joint
• Axial load through hyper plantar flexed foot
• Missed injury = chronic pain, deformity
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• presentation: pain and tenderness TMT joint, NWB, swelling, medial plantar bruising
• pain with pronation and abduction*
• +instability test (if +, plantar ligaments are torn, and surgery may be indicated)
• If unstable, XR may show
• widened interval between 1st and 2nd ray
• medial base of 2nd MT does not line up with medial side of middle cuneiform
• dorsal displacement of 1st or 2nd MT
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• Advanced imaging: MRI or CT*
• non-op/stable - cast/boot immobilization 8+ weeks
• unstable - operative - ORIF, arthrodesis
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• 17 yo F runner presents with L hip pain. Gradual worsening over last 3-4 months. No injury. Runs 20-40 miles per week. Pain begins earlier and earlier into run and now has some discomfort walking.
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Femoral neck stress fracture
• Rare*, but may be catastrophic if missed
• average diagnostic delay of 14 weeks
• insidious onset of groin/hip pain
• with impact and sometimes at extremes of ROM
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• Compression v tension side
• compression more common and more stable
• XR is usually normal
• MRI is imaging of choice
• Treatment
• non-op: NWB, crutches
• compression side, fatigue line <50% neck width
• operative: ORIF w/percutaneous screw
• tension side or compression side >50%
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• 32 yo M sprinter presents with bilateral lower leg pain. R began 2 months ago and L began over last 2 weeks. Worsening and occurring sooner into practice. No neurovascular symptoms. No pain with strength or ROM testing at knee and ankle. Pain bilaterally when tuning fork is placed to anterior tibia.
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Tibial shaft stress fracture
• runners, military recruits
• insidious onset
• pain usually well localized to stress reaction/fracture site
• XR first; MRI most sensitive
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• Treatment:
• activity restriction and protected WB
• avoid NSAIDs
• bone stim?
• Other locations to consider stress injuries: distal fibula, metatarsals (specifically 5th MT), femoral shaft
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• 15 yo M football lineman presents with low back pain, worsening over the last 6mo. No specific injury. Hurts with extension. No radicular symptoms.
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Spondylolysis• Stress injury of pars
• Due to repeated low back hyperextension
• Gymnasts, cheerleaders, dancers, swimmers/divers, weight lifting, football linemen
• On exam, pain with back extension
• Begin with XR
• may visualize sclerosis or defect on lateral or oblique views (“scotty dog”)
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• If suspect spondy, move on to advanced imaging
• MRI
• Treatment is rest, eventually followed by PT and gradual RTP
• opinions differ on time and bracing
• 3-6 months
• If left untreated, may cause continued pain and progress to bilateral defect and spondylolithesis
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• 16 yo F soccer player collides with another player during a hard tackle. Impact isn’t seen, but she stumbles a bit getting to her feet. When she comes to sideline, she complains of mild vertigo, but says she is otherwise fine and wants to continue to play.
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Concussion• > 50% are not reported
• A prior history of concussion(s) negatively impacts an athletes likeliness to report symptoms
• Important to do a quick assessment if any suspicion
• A concussed athlete should not return to play same game
• Many assessment tools (e.g. SCAT, Impact)…key is consistency
• Importance of physical and mental rest
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• 15 yo male football player present with R groin pain. Began suddenly, following a “pop” while running sprints at practice. Pain in anterior groin. Unable to continue practice. Cannot perform straight leg raise. Tenderness over iliopsoas.
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Lesser trochanter avulsion
• Avulsion of distal iliopsoas tendon
• Usually feel a “pop” and cannot perform SLR
• Look for avulsed fragment off lesser trochanter on XR
• Treatment (unless significant displacement): activity restriction, protected WB, no progression until visible healing on XR
• Also consider AIIS avulsion (rectus femurs)
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• Benjamin HJ, Briner WW. Little League Elbow. Clin J Sport Med 2005; 15:37-40.
• Brooks S, Cicuttini FM, Lim S, et al. Cost effectiveness of adding magnetic resonance imaging to the usual management of suspected scaphoid fractures. British Journal of Sports Medicine 2005; 39:75-79.
• Clough TM. Femoral neck stress fracture: the importance of clinical suspicion and early review. British Journal of Sports Medicine 2002;36:308-309.
• Masci PL, Malara F, et al. Use of the one-legged hyperextension test and magnetic resonance imaging in the diagnosis or active spondylolysis. British Journal of Sports Medicine 2006; 40:940-946.
• Pediatric Spondylolithesis and Spondylolysis. Orthobullets (online). Updated 6/26/17.
• Register-Mihalik JK, et al. Relationship Between Concussion History and Concussion Knowledge, Attitudes, and Disclosure Behavior in High School Athletes. Clin J Sport Med 2017; 27:321-324.
• Scaphoid Fracture. Orthobullets (online). Updated 9/18/18.
• Selhorst M, Fischer A, MacDonald J. Prevalence or Spondylolysis in Symptomatic Adolescent Athletes. Clin Journal of Sports Med 2017; volume publish ahead of print.
• Sman AD, Hiller CE, Rae K, et al. Diagnostic accuracy of clinical tests for ankle syndesmosis injury. Br J Sports Med 2015;49:323-329.