Sports Injuries Not Goals To improve the learner’s To Misdiagnose awareness of five sportssports-- related injuries To learn how to avoid a misdiaggynosis or delayed diagnosis of these five sportssports--relatedrelated injuries To improve the learner’s clinical acumen on these potentially catastrophic LtCol Fred H. Brennan, Jr., DO, FAOASM, FAAFP, FACSM injuries Head Team Physician, University of New Hampshire Deputy Commander, 157th Medical Group, Pease ANGB Case #1 Case #1 21 year old female volleyball Scaphoid fracture player dove for a low ball and Distal radius or ulna fell on outstretched right hand fracture Immediate wrist pain and TFCC tear pain with attempts at dorsi Distal R-R-UU joint and palmar flexion disruption No gross deformity Carpal ligamentous What is the possible diagnosis based on this injury mechanism of injury? Do You Want An X-X-ray?ray? Wrist XX--raysrays Lateral Wrist A-P Wrist Name them…. Clenched Fist A-P > 60 degrees What is your diagnosis? 1 ScaphoScapho--LunateLunate Dissociation Watson’s Test of the Wrist Disruption of scaphoscapho--lunatelunate Watson's test ligament (scaphoid shift test) FOOSH injury Tender over scaphoscapho--lunatelunate interval Press the scaphoid tuberosity on the pppalmar aspect while +W+ Wa tson’ s cl u nk moving the wrist from ulnar Limited dorsiflexion to radial deviation. > 3 mm diastasis > 3mm diastasis A painful "click" or "pop" (“Madonna sign”) identifies scaphoid instability or scapholunate separation. Scaphoid tubercle Painful click or clunk Treatment Complications if Missed Thumb spica splint PRICEPRICE--MM Chronic wrist pain Refer to ortho hand within 1 Loss of function, week for ORIF Avoid wrist pronation-pronation- motion, and strength supination Osteoarthritis Pain control Don’t Miss This! Case #2 38 year old male got his FOOSH mechanism left ring finger caught in a Dorsal wrist pain with player’s shirt while playing limited dorsi-dorsi-flexionflexion touch football Pa in over snuffb ox Fl“Felt “pop” ”i in hi hifis finger and now has pain Get AP and AP clenched fist view Now in your clinic 2 days later MR arthrogram What are the possibilities? 2 Case #2 Exam Fracture DIP or PIP dislocation Extensor tendon injury Flexor tendon injury Collateral ligament tear XX--raysrays Jersey Finger Rupture of FDP tendon Inability or weakness flexing finger tip Splint in position Repair within 7 days What is your diagnosis? Complications if Missed Don’t Miss This! Retraction into palm of hand History Loss of flexion of tip Feel pop in finger Impaired work ability Isolate the Flexor Difficult surgery Dig itorum PfProfund us Weak or unable to flex tip of finger 3 “New Jersey” Finger Case #3 12 year old wrestler complaining of mild groin and knee pain for 2 months Occasional limp after wrestling Otherwise feels fine Improved with tylenol and gentle adductor stretching What are the possibilities? Case #3 Exam Adductor strain Normal gait NonNon--tendertender knee exam Pelvic apophysitis without effusion OCD lesion of femur Mild groin pain with PtllfPatellofemoral paiiin palilpation an dllld leg roll Slipped capital femoral No adenopathy epiphysis No hernia appreciated Septic joint ESR and CBC normal Tumor Groin pain with “duck walk” XX--rayray Requested Returned to Sport Physical therapy Ice/heat/Ice/heat/tylenoltylenol Pain in groin to knee Limping after match 2 months later, returned to family physician Exam unchanged 4 Repeat xx--raysrays Diagnosis Slipped Capital Femoral Epiphysis Treatment Complications if Missed Crutches with toe touch Avascular necrosis weight bearing Hip dysplasia Orthopedic consult Early osteoarthritis within 24 hours Leg length difference Percutaneous fixation Chronic pain/limp Don’t Miss This! Case #4 21 year old football player Loud audible pop and unable to bear weight Pain on top of midmid-- - Knee pain in adolescent-check hip foot - Overweight boys What are the - AP Pelvis - Lateral frog leg view possibilities? - If unclear, check MRI. 5 Case #4 Exam Unable to weight bear Fracture of metatarsal Swelling over dorsum Fracture of cunieform of foot Extensor digitorum Bruising on plantar rupture aspect of foot Pain with external Lisfranc complex injury rotation of midmid--footfoot MidMid--footfoot sprain Do You Need XX--rays?rays? XX--raysrays Anything special….? Treatment What is the Diagnosis? Told to ice, elevated, Lisfranc fracture- fracture- and gradually return dislocation Lisfranc injuries may to running represent 1% of all Limped x 2 months orthopedic trauma , but and returned to 20% are missed on initial presentation provider Inability to WB, midmid--footfoot “I can’t run on it” pain, weight bearing xx-- rays are key 6 Treatment Complications if Missed Acute compartment PRICEPRICE--MM syndrome NWB on crutches Chronic pain Bulky Jones dressing Arthritis or poste rio r sp lint Collapsed arch Inability to run or jump Refer to Ortho Frequent neurovascular checks Don’t Miss This! Case #5 18 year old high school runner with one month MidMid--footfoot pain and swelling “pulled groin” Inability to bear weight Winning races then limp ing Check weight bearing xx-- rays with comparison view State championship “snap” in groin on the CT scan or MRI if in final 50 yards; unable to question WB! What are the possibilities? Case #5 Exam Torn adductor muscle Avulsion of adductor or 2 ½ days after injury sartorius muscle NWB on crutches Pubic ramus fracture Swelling noted in groin Femoralkfl neck fracture and high proximal femur Femoral shaft fracture Pain with all attempts at motion SI joint subluxation Distal pulses 2+ Ruptured iliopsoas bursa No distal sensory deficits 7 Do You Need XX--rays?rays? XX--rayray Diagnosis? What is the Diagnosis? Treatment If stress fracture by xx--rayray or Femoral neck stress fracture further imaging – complete Compression side Groin pain in runner or 12 weeks to heal +/+/--NWBNWB jjpumper or soldier- soldier- don’t Tension side Ortho consult/surgery ignore Femoral neck fracturefracture-- Need to know which side the surgery stress fracture is on Cross train (compression vs tension side) Proper nutrition and Plain films often negative calories (LMP, DEXA, Vitamin D) Complications if Missed Take Home Points Stress to complete Fall on outstretched fracture hand, think: Avascular necrosis Distal forearm fx..fx Chronic pain Scaphoid fx End of career ScaphoScapho--lunatelunate dissociation or other carpal lig disruption TFCC AP, Lat, Scaphoidand clenched fist views 8 Take Home Points Take Home Points MidMid--footfoot pain and Grab injury with pain at inability to weight bear distal phalynxphalynx,, think after foot axial load or jjygersey finger twist, think Adolescent with knee Lisfranc injury pain…ask about hip/groin pain and Persistent groin pain, check. Think SCFE rule out stress fracture of hip or pelvis 9.