Compartment Syndrome Craig Young MD

 Case 1

 35 yo runner

 Foot drop and tingling in 1st web space  Only when running pace < 5 mim/mile Do you think this person has exertional compartment syndrome? If yes, which compartment?

 Basic physiology

 Average capillary pressure ~ 25 mm Hg  Normal interstitial pressure 4-6 mm Hg  Capillaries collapse in ~30 mm Hg  Hypoxic injury causes cells to release vasoactive substances (e.g. histamine, serotonin  Increase endothelial permeability.  Increases fluid leakage, which increases tissue pressure and advances injury Exertional compartment pressure measurements Measurement Pressure (mm Hg) Resting Normal < 12 Suspicious > 15 1 min post-exercise Normal < 20 Suspicious 20 - 30 Diagnostic > 30 5 min post-exercise Normal < 12 Suspicious 12 - 20 Diagnostic > 20 Common locations

 Anterior compartment of calf (40-50%)  Extensor muscles (Tib Ant, EDL)  Ant tibial a & v  Deep peroneal n (Dorsal 1st web space)  Deep posterior compartment (30-40%)  Deep flexor muscles (FDL, Tib Post, FHL)  Post tib a& v; Peroneal a & v  Tibial nerve (plantar foot) Other locations

 Lateral compartment of calf (20%)  Peroneus longus & brevis  Superficial peroneal n  lateral lower leg  dorsum of foot (check between 3rd & 4th metatarsals) Rare locations

 Superficial posterior compartment of calf  Gastrocnemius, plantaris & soleus  Sural nerve – Provides sensation to the lateral aspect of the foot and distal calf  Forearm  Volar - rare  Dorsal - extremely rare  Mobile wad of Henry (brachioradialis, ECRB & L)  Hand Case 1 results

 PE - wnl

 Anterior compartment measurements  Resting - 8 mm Hg  1 min p exercise - 32 mm Hg  5 min p exercise - 22 mm Hg What treatments would you consider for this patient?

 Non-surgical treatment

 Removal of constricting equipment or clothing

 Relative rest

 Shorting stride

 Forefoot/midfoot strike

 Better cushioned shoes

 Zero drop/Barefoot shoes

 Stretching and massage Surgical treatment

 Gold standard

 Fascial release

 Fasciotomy

Image from eMedicine Case 1 treatment

 In middle of workup his wife became pregnant  Decreased mileage and racing  Asymptomatic

 8 years later started racing again  Symptoms returned with racing

 Surgery  Asymptomatic Case 2

 43 year old referred for compartment testing from a surgeon up North

 Complains of pain from knee to mid shin

 Pain is usually present

 Denies any numbness or weakness Do you think this person has compartment syndrome?

 3 categories

 I think you have ECS

 I don’t think you have ECS

 You might have ECS Epidemiology

 Usually younger athletes

 Usually endurance athletes

 Often bilateral Presentation

 Localized aching pain

 Feeling of fullness

 Onset with specific effort

 Rapid resolution with rest (within 20 min)

 Associated weakness and numbness Examination

 Usually normal at rest

 After exercise  Increased firmness of compartment  Pain with passive motion or stretching of compartment Bob Dimeff ’s clinical pearl

 Ask subject to rate pain (1-10) of slowly injected Marcaine into test sites  if high rating ≥ 7  Almost always negative (i.e. less likely to be exertional compartment syndrome)  ≤ 3 all have been positive Slit catheter system

18 gauge needle Case #2 Results of Case

 Normal pressures Case #3

 Professional soccer player

 Took a kick to lateral ankle in practice the day before

 Now c/o pain and swelling over the lateral ankle

 Difficulty walking

 Numbness on dorsum of foot

Do you think this person has exertional compartment syndrome?

 Acute compartment syndrome

 Signs & symptoms  Poikilothermia - cool extremity often earliest sign of impending compartment syndrome  Pain  To passive motion  Out of proportion to exam  Painful, tight/tense compartment to palpation/squeeze  Paresthesias  Pulselessness & pallor - rare  Surgical emergency Acute compartment pressure measurements Pressure 0-10 mm Hg Normal 10-30 Elevated 30-40 Potentially dangerous 40-60 Usually dangerous 60+ Consistently dangerous Case 3 Results

 Elevated lateral compartment pressure

 Taken to surgery

 Clot found occupying a large portion of the lateral compartment

 Back to playing soccer with no residual symptoms Summary

 Acute compartment is surgical emergency

 If it doesn’t seem classic think twice before sticking

 Leg pain of unknown etiology may represent chronic compartment syndrome  Should involve whole compartment  Unless variant anatomy In Season Management of PF Injuries

Elizabeth A. Arendt Professor & Vice Chair University of Minnesota Department of Orthopaedic Surgery

SPORTS MEDICINE

I have no conflicts of interest with this talk. In Season Management of PF issues

• PF instability – Primary ( first time) – Recurrent – With cartilage damage by MR

• PF Cartilage Damage w/out Instability – Patella – Central groove defect Partnership Approach Weighing the Options

Risks Benefits Working together to find the best solution For all cases

• Eliminate swelling (ideal) before return to practice – (Minimum) no increase in swelling w/ training

• Symmetric Strength & LSI on functional tests

• Confident in Sport Movement – Observed – Self reported ( Mental outcome scores) PF Instability Primary Dislocation : •Risk of second dislocation – 17 % (Fithian – Kaiser data) – 33 % ( U of M data)

Recurrent Dislocation: •Risk of additional dislocation: – 49% (Fithian – Kaiser data) – 70% + in some studies Primary LPD – no cartilage damage

• Favor more restrictive RTP scenario to guard against second patella dislocation. • Aggressive attention to faulty movement mechanics • MPFL repair : no in my surgical algorithym • If RTP in season would protect with knee sleeve and / or taping • Favor McConnell over Kinesio Recurrent LPD – No Cartilage Injury

• Favor RTP using standard criteria

• If RTP in season would protect with knee sleeve and / or taping • Favor McConnell over Kinesio

•Consider MPFL reconstruction @ season end • If needs bony surgery to stabilize (distal TTT): • RTP might take > 9 mo. (? Next season?) Recurrent LPD: Established Cartilage Wear • Try to distinguish between – Acute chondral injury • Usually uni-polar • No sclerosis • (Usually) recent injury – Chronic injury • History of ‘problems’, often ignored • History of current &/or remote injury • MRI: sclerosis &/or cysts Treat Chondrosis and Arthrosis Differently?? • Chondrosis: – Softening of the cartilage – Usually uni-polar, focal – Etiology varied • Arthrosis: – cartilage wear – Usually bi-polar, diffuse – Etiology varied Case History #1 • Junior IC tennis player • H/o LPD age 14, reduced in ER • Cont’d to play tennis at high level • ‘Some’ problems, no more LPD • 2nd LPD spring / 2nd year not reported to MD • Want to play pro after college

Complaints: • Swelling w / confidence • No pain • No further dislocations.

• Trochlear Dysplasia Type D

• Good engagement between patella and trochlea cartilage

MR PF Risk Factor Measurments

• TT-TG 21mm (20mm) • Tilt 22 ° (20º) • C/D 1.3 (1.2) • PTI 0.3 (.I2)

Patella cartilage wear 25mm x 15 mm Bipolar disease (patella and groove) Case History #1

• Needed bony procedure to optimize PF joint function • Chondral wear on – going and (formerly) well tolerated • Major surgery w/ +/- cartilage restoration not likely compatible with professional career • Advise on future prognosis • Revise / modify training regiment • Give athlete time to accept her knee function and be honest with herself Case History #1

• Allowed play using swelling as guide

• Optimized body mechanics

• More realistic about # games played in tournaments

• Injected with Synvisc, no chronic NSAIDS

• Is re-evaluating her future ( 4-6 mo. Journey) No History of LPD: (+) Cartilage Wear Case # 2 • Junior IC W Gymnast • All-rounder, lead point scorer • No h/o PF instability • C/o swelling & ‘instability’ w/ 6 wks. left to season • MRI obtained Case History #2 Imaging Case # 2

In Season Management • Cortisone x 1 with 5 days rest • Severely restrict practice to those activities that do not cause swelling • Use of oral toradol on game day • Use of knee sleeve • Scope at season end • Scoped at end of season

• Debridement with ACL biopsy

Post Op Discussion • One year left, does not plan on remaining in competitive Gymnastics post college career.

• Wants to finish Senior year as all rounder (ideally)

• Agreed to reduce training year long & possibly give up vault if needed (most symptomatic event) Case # 2 – Finale • Managed last season as all rounder w/ multiple PB and awards • Used knee sleeve and NSAIDS in season

• End of season discussion: – No knee swelling 1 mo. post season – Continues with “Zumba” like exercise routines • Does not want further surgery at this time, is satisfied w/ knee function Case #3 • Freshman F VB player – defensive specialist • First LPD 6th grade. • Scoped 2006 (11th grade): Grade 4 changes noted on LFC and lateral patella facet • Dislocated (?) pre-season as a Freshman (2008) • MRI ordered. Case # 3

• Tilt 22 degrees • Imagine the MRI • TT-TG 17 mm Case # 3

Normal Patella Height.

Mild Trochlear Dysplasia

No “knee’ arthritis or malalignment Case #3 • Treated symptomatically with NSAIDs/ knee sleeve / relative rest / CORE • Persistent swelling remained • No further “dislocations”

• Played thru her symptoms with us monitoring her knee, rarely complained. • Scoped at end of Freshman year Case #3

Surgical procedure 12/2008 • Patella debridement • Lateral femoral condyle microfracture • Partial lateral facetectomy • Lateral retinacular lengthening w/ medial imbrication. Case # 3 – scope

Grade 3-4 lateral patella facet

Grade 3-4 lateral femoral condyle

Case #3 – OR report

• 2008 • Patella debridement • Lateral femoral condyle microfracture • Partial lateral facetectomy • Lateral retinacular lengthening • Medial imbrication. Case # 3 – Finale • Added Synvisc year # 3 • Played Libero (starter) year # 3 and # 4 • No further dislocations

• End of career discussion : did not want further surgery or potential cartilage restoration. • Cont’d (against advice) to run for recreation (my acquired) Level V Evidence

• Help the athlete come to their own decision about the short and long term health of their knee (injury)

• The value of cartilage restoration and a competitive sports career is questionable at this time. University of Minnesota / Big Ten Conference

Thank you LEFT FLANK PAIN IN A HIGH SCHOOL FOOTBALL ATHLETE

Tracy Ray, MD History of Present Illness

 Patient- 14 YO H.S. football running back  Setting-hospital emergency room  Chief Complaint-”my side hurts”  Onset-early in the fourth quarter after being tackled while carrying the football

HPI Continued

 Feet knocked from under him with landing on left side onto ball  Initial symptoms-felt as if he had the “wind knocked out” of him  Initial work-up-sideline evaluation by the team trainer-went back into the game after sitting out for two plays

HPI Continued

 Played the remainder of the game as a running back with only mild, persistent left flank and chest wall soreness  Received multiple hits

HPI Continued

 After the game, he noted increased left flank, chest wall and hip pain  On the team bus, developed nausea with vomiting with no noted blood in the emesis  Evaluated by the team physician and referred to the emergency room where he arrived approximately 1 hour and 45 minutes after the initial injury Past Medical History

 Illnesses-Asthma  Current Meds-Albuterol MDI prn  NKDA  Past Surgical History-None  Social History-Freshman in high school. No alcohol, no tobacco, no illicit drugs.  Family History-Non-contributory Review of Systems

 Patient complains of nausea with two episodes of vomiting and a non-productive cough. He denies any light-headedness, current SOB, lower extremity edema. He had not urinated or had a bowel movement since the injury. He denies any other complaints. Physical Examination

 Vitals-T- 97.8 P-92 BP-136/76 R-24 No orthostasis.  General-Well developed, agitated, restless  HEENT-Negative. No blood in mouth/nose/TM  Neck-No JVD or hepatojugular reflux  Lungs-Shallow, clear. Normal percussion  CV-RRR with no murmur, rub, or gallop  Thorax-Diffuse tenderness on the left, worse at the postero-lateral T5-T12 ribs. Positive left CVA tenderness. Physical Examination Continued

 Abdomen-Voluntary guarding. BS decreased, but positive. Soft and diffusely tender, but worse over the left quadrants to the anterior groin. No appreciable organomegaly.  Extremities-No noted edema. Peripheral pulses are normal.  Skin-No noted ecchymosis, abrasions, lacerations.  Musculoskeletal-Pain with passive ROM of the left hip.  Neurologic-Oriented. Restless. Non-focal. Questions and Comments

 Questions or comments  Suggestions for Differential Diagnosis Differential Diagnosis

 Splenic Rupture/Injury  Rib Fracture  Soft Tissue Contusion  Renal Contusion/Laceration  Hepatic Contusion/Laceration  Bladder/Ureteral injury  GI/Intestinal Rupture  Pancreatic Trauma  Testicular Trauma/Torsion  Hip/Pelvis Fracture Laboratory Evaluation

 Electrolytes-normal/ BUN 15 (7-18)/ Creatinine-1.4 (0.5-1.3)/ Alk Phos-322 (50- 136)/ Amylase-93 (25-115)/ Lipase-300 (114- 286)/  Hgb-13.4 (13.5-17.5)/ Hct.-39.1 (42-52)/ WBC-24.07 (4.0-11.0)/ Neut.-85%  UA-Gross hematuria “loaded” with RBC’s. Radiologic Evaluation

 CXR, KUB, Hip and Pelvis plain films-negative  Chest/Abdominal/Pelvic CT with IV contrast- ”Extensive left upper pole renal contusion extending inferiorly into a left renal laceration with associated retroperitoneal hematoma extending inferiorly down along the psoas muscle. No noted splenic injury.” Chest CT negative.  IVP-Suggestive of extravasation of contrast from the left renal upper pole caliceal system.

Hospital Course

 Admitted to ICU on Urology service  Strict bedrest, IVF, NPO  Serial Hct’s with nadir of 25 on Day #4  Creatinine normalized by Day #3  BP-100’s to 130’s/40’s to 60’s  Fever-cultures negative, prophylactic antibiotics  Difficult pain control-Morphine PCA  Ileus  Floor on Day #7, and home on Day #8-Hct-27.5. Follow-up

 Urology followed the patient-strict bedrest for a total of 2 weeks and limited all activity for a total of 8 weeks from date of injury  BP elevated to 128/100 two weeks after discharge but then slowly trended to normal by 2 months post-discharge  Repeat CT scan with IV contrast at 2 months- ”decreased attenuation of the upper pole of the left kidney. No extravasation of contrast is noted.”

RTP?

 Would you allow RTP to contact/collision sports?  What “milestones” need to be met for RTP? Or is it all a matter of timing?  Any further studies prior to RTP? Return-to-Play

 The patient was last seen by Urology at his 5-month follow-up from the date of injury and was released to full activity.  6 months later, the patient was contacted, and he denied any current complaints or symptoms. He had been doing light weight-lifting and running but no sporting activities. He later returned to baseball and football. He was recommended to wear a rib guard while playing contact sports in the future, and was informed of the risks of contact sports. Any help from the Literature?

 4.4 million athlete-exposures from 95 – 97 – Only 18 kidney injuries • None catastrophic  6 renal injuries in rugby athletes “Individually based RTP” Take Home Points

 High index of suspicion and serial exams  Know clinical symptoms/signs  Appropriate work-up and treatment-team approach  Salvage kidney if hemodynamically stable  Slow return to sports  Note potential secondary complications and appropriate follow-up studies  Player education regarding RTP Questions or Comments? THANK YOU MRSA CASE

ATPC December 2016 16 yo HS wrestler reports to ATC at training room that he might have been bitten by a spider Exam reveals a large “boil” on the anterior, right thigh

CASE PRESENTATION General hygiene recommendations for the team? Nasal swab the team for carriers? Participation? Cleaning for the mats, locker room, weight room and training room?

QUESTIONS FOR CONSIDERATION Readily available products; review product label for use against MRSA Disinfectants- application, contact time, need for rinsing, surface tolerance of product, safety precautions There is a lack of evidence that large-scale use (e.g., spraying or fogging rooms or surfaces) of disinfectants will prevent MRSA infections more effectively than a more targeted approach of cleaning frequently- touched surfaces

CLEANING http://www.cdc.gov/mrsa/community/environment/index.html http://www.cdc.gov/mrsa/community/environment/athletic-facilities.html Laundry Routine laundry procedures, detergents, and laundry additives will all help to make clothes, towels, and linens safe to wear or touch. If items have been contaminated by infectious material, these may be laundered separately, but this is not absolutely necessary http://www.cdc.gov/mrsa/community/environment/ index.html LAUNDRY •Make sure supplies are available to comply with prevention measures (e.g., soap in shower and at sinks, bandages for covering wounds, hand hygiene such as alcohol-based hand rubs). •Make sure athletes: •keep wounds covered and contained •shower immediately after participation •shower before using whirlpools •wash and dry uniforms after each use •Do not share equipment, toiletries, clothing, etc. •report possible infections to coach, athletic trainer, school nurse, other healthcare providers, or parents. •If MRSA is suspected, consider excluding the athlete from participation until evaluated by a healthcare provider. HYGEINE HTTP://WWW.CDC.GOV/MRSA/COMMUNITY/TEAM-HC-PROVIDERS/INDEX.HTML Role of decolonization  Regimens intended to eliminate MRSA colonization should not be used in patients with active infections. Decolonization regimens may have a role in preventing recurrent infections, but more data are needed to establish their efficacy and to identify optimal regimens for use in community settings.  After treating active infections and reinforcing hygiene and appropriate wound care, consider consultation with an infectious disease specialist regarding use of decolonization when there are recurrent infections in an individual patient or members of a household. http://www.cdc.gov/mrsa/community/clinicians/index.html

MOST CURRENT RECOMMENDATIONS Excluding Athletes with MRSA Infections from Participation  If sport-specific rules do not exist, in general, athletes should be excluded if wounds cannot be properly covered during participation.  The term "properly covered" means that the skin infection is covered by a securely attached bandage or dressing that will contain all drainage and will remain intact throughout the activity. If wounds can be properly covered, good hygiene measures should be stressed to the athlete such as performing hand hygiene before and after changing bandages and throwing used bandages in the trash.  A healthcare provider might exclude an athlete if the activity poses a risk to the health of the infected athlete (such as injury to the infected area), even though the infection can be properly covered.  Athletes with active infections or open wounds should not use whirlpools or therapy pools not cleaned between athletes and other common-use water facilities like swimming pools until infections and wounds are healed.

PARTICIPATION HTTP://WWW.CDC.GOV/MRSA/COMMUNITY/TEAM-HC-PROVIDERS/INDEX.HTML ATTITUDE AT ALTITUDE

JONATHAN S HALPERIN MD

MEDICAL CARE OF THE ELITE ALPINE SK

JONATHAN S.HALPERIN MD Fellow ABPMR DipSportMed CASEM CAQ Sports Medicine ( ABPMR)

CHIEF PHYSICAL MEDICINE AND REHABILIATION SHARP REES STEALY MEDICAL GROUP SAN DIEGO CA

I HAVE NO RELEVANT FINANCIAL DISCLOSURES

THANKS FOR YOUR ATTENTION!!!

Scenario one:

Athlete takes big air off “ coaches corner and windmills in the air and then goes off five foot vertical drop and falls on right side

Responders: Course worker, ski patrol, team doctor

Injuries: # right hip; Epidural hematoma

Presentation: Initially confused and witnessed LOC. Becomes Uncooperative/combative ( after primary survery completed)

Key interventions: ? Airway intervention ? Control bleeding ?Medications to consider ? Transfer options Discussion: Medications used and route of administration Helmet: on or off? Lateral trauma position Destination protocols Scenario two

Athlete catches outside edge in “ Gun Barrel” and then cartwheels and ski is caught in B netting. Patient screaming with obvious angulated tib/fib Deformity

Responders: Ski patrol, course worker, team physician, coach

Injuries: Angulated just below knee/ open tib/fib # with bleeding

Initial presentation: Awkward position in netting, screaming about lower leg Pain; Cooperative but focused on pain; Boot and ski caught in netting

Key interventions: ?Pain control ?Primary survery ( other relevant injuries )

Discussion: ? Med use and Route ? How to splint leg ? Destination protocols Scenario three

Scenario: Skier hits little kicker off “ Claire’s corner” and lands unexpectedly hard onto Left side and ski pole coming up into abdominal area upon impact and bends the pole

Responders: Ski patrol, team doc, course worker, coach from another country

Injuries: Left wrist fracture; Splenic laceration, Left rib fracture

Presentation: Uncomfortable but cooperative; Pain in left wrist; No abdominal pain Until palpated. Pain with deep inspiration. No tenderness in Pelvis

Key Interventions: Identify abdominal injury and possible internal bleeding ? Need for wrist splint or sling ? Analgesia

Discussion: ? Med use and route ? Stabilize pelvis ( Pelvic binder) ?Destination protocols ( is patient hemodynamically stable) ? TXA ( Tranexamic Acid) Scenario four

Athlete catches big air, then loses control lands to far forward, strikes chin on knee As he lands then falls onto left side as he skids to a stop

Responders: Course worker, Team doc, ski patrol

Injuries: huge tongue laceration, three upper teeth missing, mildly confused

Presentation: Sitting up with blood pouring out of the month Mildly confused No other injuries on primary survey

Key interventions: ? Airway management ?Bleeding control ? Management of possible head injury ? Position for transportation

Discussion: ?Bleeding control options ? Transportation of potential choking patient MEDICATIONS WE CARRY ON HILL

Ketamine ( Ketalar) ( 50mg/ml) 6cc bottle= 300mg 1.5 mg/kg IV 4-5mg/kg IM

Midazolam ( Versed) ( 5mg/ml) 2cc =10mg 5-10 mg IM or IV

Fentanyl (50mcg/ml) 2cc=100mcg 50-100mcg IV ( ? Interosseous)

Ondansetron ( Zofran) 2mg/ml ( 2ml=8mg) 4mg IV