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Dont Miss Musculoskeletal Injuries

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... back pain at some point in their lives. 90% of low back pain resolves ... Back pain with bilateral leg neurological symptoms are concerning for what diagnosis? ... – PowerPoint PPT presentation

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Title: Dont Miss Musculoskeletal Injuries


1
Dont Miss Musculoskeletal Injuries
  • Steve Blivin, MD, FAAFP
  • Sports Medicine Department, Naval Hospital Camp
    Lejeune
  • DOS MsK Symposium Honolulu Hawaii
  • 5-6 and 9-10 FEB 09
  • Presentation modified from presentations by Chris
    G. Pappas, LTC, USA, MC Fred H. Brennan, Jr.,
    LTC, USA, MC Francis G. OConnor, Col, USA, USA

2
Objectives
  • Become familiar with three dont miss upper
    extremity musculoskeletal injuries.
  • Become familiar with three dont miss lower
    extremity musculoskeletal injuries.
  • Detail pertinent diagnostic features and clinical
    criteria for referral to an orthopedic colleague.

3
Case 1
  • 21 year old female volleyball player dove for a
    low ball and fell on outstretched right hand
  • Immediate wrist pain and pain with attempts at
    dorsi and palmar flexion
  • No gross deformity
  • What is the possible diagnosis based on this
    mechanism of injury?

4
Case 1
  • Wrist sprain
  • Scaphoid fracture
  • Distal radius or ulna fracture
  • Distal R-U joint disruption
  • TFCC tear
  • Carpal ligamentous injury

5
FOOSH Check Snuffbox TTP?
6
Scaphoid fracture
7
Treatment
  • Thumb spica splint
  • Consider early ortho surg

8
Scaphoid
  • If snuffbox tender and initial scaphoid series
    x-rays are negative, treat as a fracture and
    follow up with plain films in 10-14 if still
    tender. If films are negative then cast and get
    TPBS to r/o occult fx.
  • Blood supply arises distally
  • Fractures of middle and proximal portion prone to
    nonunion
  • May be casted long arm 1st 6weeks the short arm
    next 6 weeks.

9
Scapho-Lunate Dissociation
  • Disruption of scapho-lunate ligament
  • FOOSH injury
  • Tender over scapho-lunate interval
  • Watsons clunk
  • Limited dorsiflexion
  • gt 3 mm diastasis
  • Scapholunate angle gt 60 degrees

10
Watsons Test of the Wrist
  • Watson's test
  • (scaphoid shift test)
  • Press the scaphoid tuberosity on the palmar
    aspect while moving the wrist from ulnar to
    radial deviation.
  • A painful "click" or "pop" identifies scaphoid
    instability or scapholunate separation.

Scaphoid tubercle
Painful click or clunk
11
Treatment
  • Thumb spica splint
  • Refer to ortho
  • Acute 3 wks to 3 mo.

12
Complications if Missed
  • Chronic wrist pain
  • Loss of function and motion
  • Osteoarthritis

13
Case 2
  • 38 year old male got his right ring finger caught
    in a players shirt while playing touch football
  • Felt pop in his finger and developed pain

14
Exam
--Finger held in forced extension --Tender along
volar aspect of DIP --Unable to flex DIP
15
X-rays
What is your diagnosis?
16
Jersey Finger
  • Rupture of FDP tendon
  • Inability to flex tip of finger
  • Splint in position
  • Repair within 7 days

17
Complications if Missed
  • Retraction into palm of hand
  • Loss of flexion of tip
  • Impaired work ability
  • Difficult surgery

18
Case 3
  • 22 year old had lower leg squished between two
    military vehicles
  • Able to walk with a limp but pain worsening over
    the past 1-2 hours

19
Exam
  • Pain out of proportion to exam.
  • Lateral aspect and first web space of foot feels
    like pins and needles
  • Leg hurts with gentle passive foot inversion and
    plantar flexion
  • Leg feels weaker

20
X-ray
Diagnosis?
21
Acute Compartment Syndrome
  • Serious limb and life threatening condition
  • Fractures, burns, crush injuries, arterial
    injuries
  • Hand, forearm, arm, shoulder, back, thigh and foot

22
Acute Compartment Syndrome
  • Increased pressure within closed compartments
  • Compartments of lower leg
  • Be careful with splinting and casting

23
Diagnosis
  • High index of suspicion pain out of proportion
  • Six Ps
  • Pain, Pulseless, Paresthesia, Poikilothermy,
    Pallor, Paralysis
  • Loss of normal sensation is a red flag
  • Tight compartments
  • Pressuregt 30 mm Hg

24
Treatment
  • Surgical emergency
  • Fasciotomy
  • Clinical signs
  • Elevated pressure
  • Interrupted arterial flow for gt 4 hours

25
Complications if Missed
  • Rhabdomyolysis
  • Acidosis
  • Ischemic contractures
  • Hyperkalemia
  • DIC and sepsis
  • Loss of limb
  • Death

26
Case 4
  • 26 year old sergeant playing basketball and
    jammed his left middle finger
  • Pain and swelling of middle finger PIP joint
    (global)
  • Pain with resisted flexion and extension

27
Exam
  • Swollen PIP middle finger
  • Tender over PIP, more so dorsally
  • Pain with resisted extension over the PIP
  • No neuro compromise
  • Flexor tendons strength is 5/5
  • Collaterals of PIP intact
  • DIP intact to flexion/extension

28
X-rays
Diagnosis?
29
What is the Diagnosis?
  • Tear of the central slip of the extensor tendon

30
Treatment
  • Splint in extension for 6 to 8 weeks.
  • Pain relief
  • Watch for complications

31
Complications if Missed
  • Loss of function
  • Persistent pain
  • Boutonniere deformity

32
Case 5
  • 27 year old USUHS medical student playing
    football tackled with foot folded under during
    pile-up
  • Loud audible pop and unable to bear weight
  • Pain on top of mid-foot

33
Exam
  • Unable to weight bear
  • Swelling over dorsum of foot
  • Bruising on plantar aspect of foot
  • Pain with external rotation of mid-foot

34
X-rays
35
Lisfranc Injury
  • Lisfranc injuries may represent 1 of all
    orthopedic trauma, but 20 are missed on initial
    presentation
  • Inability to WB, mid-foot pain, weight bearing
    x-rays are key

36
Treatment
  • PRICE-M
  • Bulky Jones dressing or posterior splint
  • NWB on crutches
  • Frequent neurovascular checks
  • Refer to Ortho

37
Complications if Missed
  • Chronic pain
  • Arthritis
  • Inability to run or jump
  • Acute compartment syndrome

38
Syndesmotic Ankle Sprain
39
Clinical Presentation
  • Usually the patient cannot put weight upon the
    leg.
  • Pain is located anteriorly along the syndesmosis.
  • Active movement of external rotation of the foot
    is painful.
  • Positive Squeeze Test
  • Positive External Rotation Stress Test

40
Diagnosis
  • Clinical diagnosis
  • mechanism of injury
  • correlative physical examination
  • Radiographic imaging assists in risk stratifying

41
Imaging
  • Ottawa Ankle Rules AP, lateral and mortise views
    should be obtained
  • tenderness over the lateral and medial malleolus
  • unable to bear weight for four steps immediately
    or in the ED
  • Syndesmosis Radiographic Criterion
  • Mortise medial clear space gt 4mm
  • AP tibiofibular overlap lt 10 mm

42
Treatment
  • Ligamentous injuries without fracture or gross
    widening can be treated conservatively
  • Fractures or radiographic evidence of syndesmotic
    widening warrant orthopedic consultation for
    operative repair.

43
Case 6
  • 18 year old female runner with 1 month of
    anterior groin/inguinal pain
  • Pain progressed earlier in runs and now with
    walking.

44
Exam
  • Any examdont be comfortable with a normal
    exam or hip flexor tendon tenderness!
  • Pain with hip flexion and internal rotation
    (maybe)

45
Get X-rays!
46
(No Transcript)
47
(No Transcript)
48
Femoral neck stress fracture
  • Groin pain in runner or jumper- dont ignore
  • Female triad at increased risk as well as those
    with an increase in training and postmenopausal
    women
  • Need to know which side the stress fracture is on
    (compression vs tension side)
  • Plain films often negative
  • Get TPBS then MRI if positive TPBS
  • If cant walk pain free, keep on crutches until
    SF ruled out!

49
Treatment
  • If stress fracture by x-ray or further imaging
  • Compression side
  • 12 weeks to heal (pain free walk or crutches)
  • Tension side
  • Ortho consult/surgery
  • Femoral neck fracture-surgery
  • Cross train
  • Proper nutrition and calories

50
Complications if Missed
  • Stress to complete fracture
  • Avascular necrosis
  • Chronic pain
  • End of career

51
Cauda Equina Syndrome
52
Epidemiology
  • 80 of the population experiences back pain at
    some point in their lives.
  • 90 of low back pain resolves in 6 -12 weeks
  • Red Flag symptoms include age over 50, trauma,
    fever, incontinence, night pain, weight loss,
    progressive weakness.
  • Cauda Equina Syndrome (CES) is a rare disorder,
    representing only 0.0004 of all back pain
    patients

53
Clinical Anatomy
  • Three joint motion complex consisting of the
    facets and the intervertebral disc.
  • The spinal cord extends from the foramen magnum
    to the L1-L2 disk where the cauda equina
    continues to the coccygeal region

54
Mechanism of Injury
  • Usually secondary to extrinsic pressure from a
    massive central HNP
  • Other causes include
  • epidural abscess
  • epidural tumor
  • epidural hematoma
  • trauma

55
Clinical Presentation
  • Bilateral leg symptoms that include sciatica,
    weakness, sensory changes and gait disturbance.
  • Physical examination demonstrates bilateral
    weakness as well as decreased sensation, in
    particular in the saddle region.
  • Sphincter tone is decreased in 60 to 80 of
    patients
  • All patients who complain of urinary or fecal
    incontinence should be considered to have CES
    until proven otherwise.

56
Diagnosis
  • Clinical diagnosis
  • loss of bladder control perianal numbness pain
    and weakness involving both legs
  • Evaluation of the urinary post-void residual
    volume assists with diagnosis
  • the absence of a post-void residual volume of
    over 100ml, essentially excludes a diagnosis of
    CES, with a negative predictive value of 99.99

57
Imaging
  • Plain films
  • MRI imaging
    of the entire spine

58
Treatment
  • Neurosurgical consultation
  • High dose systemic corticosteroids
  • Emergent surgical decompression

59
ACUTE TENOSYNOVITIS
60
Mechanism of Injury
  • Trauma or puncture wound
  • often at a flexor crease
  • Hematogenous spread to the sheath (i.e.,
    Neisseria gonorrhoeae) occurs rarely but should
    be suspected if there is no puncture wound or
    history of trauma.

61
Clinical Presentation
  • Uniform, symmetric digit swelling
  • Digit is held in partial flexion at rest
  • Excessive tenderness along the entire course of
    the flexor tendon sheath
  • Pain along the tendon sheath with passive digit
    extension

62
Diagnosis (vs. subcutaneous abscess)
  • subcutaneous abscess should not have tenderness
    over the entire sheath, and passive mobility of
    the uninvolved segments should be painless
  • Elevated sheath pressures consistent with
    compartment syndrome pressures (i.e., higher than
    30 mm Hg) have been documented in flexor
    tenosynovitis.
  • Ultrasound examination may show an abnormal
    effusion or abscess in the tendon sheath with
    flexor tenosynovitis

63
Treatment
  • Early infections may respond to nonoperative
    treatment
  • Splinting
  • Elevation
  • IV antibiotics
  • Rings should be removed from the affected finger
    and other fingers of the hand as soon as
    possible.
  • Tetanus prophylaxis
  • Surgery is necessary if no improvement in 12 to
    24 hours,.

64
Take Home Points
  • Fall on outstretched hand, think
  • Scaphoid fx
  • Scapho-lunate dissociation
  • AP, Lat, Scaphoid and clenched fist views

65
Take Home Points
  • Grab injury with pain at distal phalynx, think
    jersey finger
  • Crush injury or worsening pain with
    immobilization, think ACS
  • Jammed PIPalways test extension with
    resistance

66
Take Home Points
  • Mid-foot pain and inability to weight bear after
    foot axial load or twist, think Lisfranc injury
  • Persistent groin pain, especially in runner or
    jumper, rule out stress fracture of hip or pelvis

67
Take Home Points
  • Bad ankle sprainsyndesmotic injury?
  • Bilateral leg sx or bowel / bladder sx with back
    painCauda Equina?
  • Pain along the tendon sheath with passive digit
    extension Infected finger? Think tenosynovitis.

68
Questions?
69
If FOOSH, snuffbox tenderness and normal x-ray,
you must?
  • Immediately refer for surgery
  • Place wrist in a plaster cast
  • Thumb spica splint
    and follow-up
  • All of the above

70
What must be ruled out in an athlete with groin
pain?
  • Femoral neck stress fracture
  • An STD
  • Cauda Equina Syndrome
  • OA

71
Back pain with bilateral leg neurological
symptoms are concerning for what diagnosis?
  • Prostate CA
  • Cauda Equina Syndrome
  • Sacroiliitis
  • Osteopenia

72
Post trauma pain out of proportion to exam in any
muscle group is concerning for what diagnosis?
  • Hematoma
  • Muscle tear
  • Infection
  • Compartment syndrome
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