Emergencymedicinepracti

EMERGENCY MEDICINE PRACTICE EMPRACTICE.NET AN EVIDENCE-BASED APPROACH TO EMERGENCY MEDICINE April 2003 Orthopedic Sports Injuries: Volume 5, Number 4 Off The Sidelines And Into Authors Lisa Freeman, MD, FACEP Assistant Residency Director, Department of Emergency The Emergency Department Medicine, University of Texas Medical School at Houston, Houston, TX. 8:50 p.m., Friday night: Paramedics radio ahead—they are bringing in a local high Adam Corley, MD school football player who was tackled during a game. He can’t feel or move anything Department of Emergency Medicine, University of Texas Medical School at Houston, Houston, TX. below his legs. The news media are already at the hospital asking questions. The paramedics want to know whether they should start steroids. The on-call neurosurgeon Peer Reviewers is not answering his pages. Mohamud Daya, MD, MS, FACEP, FACMT, DTM&H Associate Professor of Emergency Medicine, Oregon PORTS injuries present unique challenges to the emergency physician. Health & Science University, Portland, OR. From the little-leaguer to the cardiac rehabilitation patient, millions of S David Della-Giustina, MD, FACEP Americans participate in sports or fitness activities. While an athletic injury LTC, U.S. Army; Emergency Medicine Consultant to the rarely requires a life- or limb-saving intervention in the ED, the personal impact Surgeon General of the Army; Chairman and Program on the player can be monumental. Emergency physicians must be expert in the Director, Madigan Army Medical Center—University of diagnosis and initial treatment of sports-related injuries. Washington Emergency Medicine Residency; Clinical Assistant Professor of Medicine, University of Each year in the United States, an estimated 150 million adults participate Washington; Adjunct Assistant Professor of Military and in some type of non-work-related physical activity, and approximately 30 Emergency Medicine, Uniformed Services University, million children and adolescents participate in organized sports.1 From July Tacoma, WA. 2000 through June 2001, an estimated 4.3 million sports- and recreation-related injuries were treated in U.S. EDs, comprising 16% of all unintentional injury- CME Objectives related ED visits.1 The percentage was highest for those 10-14 years old and Upon completing this article, you should be able to: lowest for those over 45. Among all ages, rates were higher for males than for 1. list conditions or circumstances that require females.1 Males are most often injured during playground activities, cycling, orthopedic or surgical consultation or referral in patients with sports injuries; football, and basketball. In girls, most injuries are caused by playground 2. describe the appropriate treatment and disposition 1 activities, basketball, cycling, and general exercise. for common orthopedic sports injuries; The most frequent diagnoses include strains/sprains (29.1%), fractures 3. describe clinical decision rules such as the Ottawa (20.5%), contusions/abrasions (20.1%), and lacerations (13.8%). The body parts knee rules that are used to determine the need for most frequently involved are the ankles (12.1%), fingers (9.5%), face (9.2%), radiography; and 4. discuss different techniques for shoulder reduction. head (8.2%), and knees (8.1%). Overall, 2.3% of people with sports- and recreation-related injuries were hospitalized.1 (See Table 1 on page 2.) Date of original release: April 1, 2003. This issue of Emergency Medicine Practice describes management strategies Date of most recent review: March 7, 2003. for common orthopedic sports injuries. Prior issues of Emergency Medicine See “Physician CME Information” on back page. Editor-in-Chief New Mexico Health Sciences Vice-Chairman, Department of Francis P. Kohrs, MD, MSPH, Associate Medical Service, Orlando, FL. Center School of Medicine, Emergency Medicine, Morristown Professor and Chief of the Division Alfred Sacchetti, MD, FACEP, Stephen A. Colucciello, MD, FACEP, Albuquerque, NM. Memorial Hospital. of Family Medicine, Mount Sinai Research Director, Our Lady of Assistant Chair, Department of School of Medicine, New York, NY. W. Richard Bukata, MD, Clinical Lourdes Medical Center, Camden, Emergency Medicine, Carolinas Michael A. Gibbs, MD, FACEP, Chief, Professor, Emergency Medicine, NJ; Assistant Clinical Professor Medical Center, Charlotte, NC; Department of Emergency John A. Marx, MD, Chair and Chief, Los Angeles County/USC Medical of Emergency Medicine, Associate Clinical Professor, Medicine, Maine Medical Center, Department of Emergency Center, Los Angeles, CA; Medical Thomas Jefferson University, Department of Emergency Portland, ME. Medicine, Carolinas Medical Director, Emergency Department, Center, Charlotte, NC; Clinical Philadelphia, PA. Medicine, University of North Gregory L. Henry, MD, FACEP, San Gabriel Valley Medical Professor, Department of Corey M. Slovis, MD, FACP, FACEP, Carolina at Chapel Hill, Chapel CEO, Medical Practice Risk Center, San Gabriel, CA. Emergency Medicine, University Professor of Emergency Medicine Hill, NC. Assessment, Inc., Ann Arbor, of North Carolina at Chapel Hill, and Chairman, Department of Francis M. Fesmire, MD, FACEP, MI; Clinical Professor, Department Chapel Hill, NC. Emergency Medicine, Vanderbilt Associate Editor Director, Heart-Stroke Center, of Emergency Medicine, University Medical Center; Erlanger Medical Center; University of Michigan Medical Michael S. Radeos, MD, MPH, Andy Jagoda, MD, FACEP, Vice- Medical Director, Metro Nashville Assistant Professor of Medicine, School, Ann Arbor, MI; President, Attending Physician, Department Chair of Academic Affairs, EMS, Nashville, TN. UT College of Medicine, American Physicians Assurance of Emergency Medicine, Lincoln Department of Emergency Chattanooga, TN. Medicine; Residency Program Society, Ltd., Bridgetown, Medical and Mental Health Center, Mark Smith, MD, Chairman, Director; Director, International Valerio Gai, MD, Professor and Chair, Barbados, West Indies; Past Bronx, NY; Assistant Professor in Department of Emergency Studies Program, Mount Sinai Department of Emergency President, ACEP. Emergency Medicine, Weill College Medicine, Washington Hospital School of Medicine, New York, NY. Medicine, University of Turin, Italy. of Medicine, Cornell University, Center, Washington, DC. Jerome R. Hoffman, MA, MD, FACEP, New York, NY. Michael J. Gerardi, MD, FACEP, Professor of Medicine/Emergency Charles Stewart, MD, FACEP, Editorial Board Clinical Assistant Professor, Medicine, UCLA School of Steven G. Rothrock, MD, FACEP, FAAP, Colorado Springs, CO. Medicine, University of Medicine Medicine; Attending Physician, Associate Professor Thomas E. Terndrup, MD, Professor Judith C. Brillman, MD, Residency and Dentistry of New Jersey; UCLA Emergency Medicine Center; of Emergency Medicine, University and Chair, Department of Director, Associate Professor, Director, Pediatric Emergency Co-Director, The Doctoring of Florida; Orlando Regional Emergency Medicine, University Department of Emergency Medicine, Children’s Medical Program, UCLA School of Medicine, Medical Center; Medical Director of of Alabama at Birmingham, Medicine, The University of Center, Atlantic Health System; Los Angeles, CA. Orange County Emergency Birmingham, AL. Practice, such as the January 2000 issue on mild head cular status in injured extremities prior to and after splint- trauma, the February 2000 issue on back pain, the October ing. Helmets should be stabilized rather than removed in 2001 issue on cervical spine injuries, the November 2001 the field unless the helmet prevents control of a bleeding site issue on wrist injuries, and the May 2002 issue on ankle or airway management. injuries, also provide pertinent information. Emergency Department Evaluation: “When I played pro football, I never set out to hurt anybody Shoulder Injuries deliberately, unless it was, you know, important, like a league game or something.”—Dick Butkus The shoulder is composed of three joints—the glenohumeral (GH), the acromioclavicular (AC), and the sternoclavicu- Critical Appraisal Of The Literature lar—and one articulation (the scapulothoracic). The GH and AC joints are the most relevant in the practice of sports Sports medicine, which has long been more of an art, is medicine. The AC joint has a limited range of motion and is slowly becoming more of a science. However, few large, stabilized by several ligaments and muscle attachments. randomized, controlled trials provide evidence for many of (See Figure 1.) the treatments used for sports injuries. A recent study Unlike the AC joint, the GH joint is designed for attempted to examine the evidence base of sports medicine research. In evaluating four major journals that present core Figure 1. Shoulder anatomy. research in sport and exercise medicine, it was noted that randomized, controlled trials comprised 10% or less of all original research articles. Observational/descriptive studies were the most commonly published study design. When good quality research methods (randomized, controlled trials as well as case-control and cohort studies) were categorized together, the difference between sports journals and other medical journals was not significant (P = 0.09). This seems to indicate that the quality of sports medicine research is comparable to that in other specialities.2 Well-designed clinical decision rules such as the Ottawa knee and ankle rules are excellent examples of evidence- based medicine. Such rules begin with a derivation set (in these cases, indications for

Load more