Transcript The Emergency Physician and the AthleticTrainer

The Physician and the Athlete:
12 Sports Injuries We Can’t
Afford to Miss
James S. Distefano, D.O., FAAEM
Sports Medicine/Emergency
Medicine
Oklahoma State University
Emergency Medicine Physicians are
trained to consider worst case
scenario.
This is what we MUST think in the
ED.
If we don’t, things get missed and
people die!
The same holds true for Sports
Medicine Physicians.
We must consider the worst
possibilities when evaluating the ill or
injured athlete, on the field, in the
training room, in the clinic, or in the
ED.
Less than 5% of EM physicians are
trained in Sports Medicine, so your
knowledge can be vital in assisting
the EM and clinics staff with the care
of athletes.
Here are 12 athletic injuries it
behooves us as physicians not to
miss:
Remember to “Think bad thoughts”.
Scaphoid (Navicular)
Fracture/Carpal Dislocation
The most common fracture of the
carpal bones.
Classic mechanism is a fall on the
outstretched hand (So called FOOSH
injury).
Blood supply to scaphoid runs
DISTAL to PROXIMAL, making
avascular necrosis a common
complication.
Scaphoid(Cont’d)
Initial X-rays may be negative, but
scaphoid tenderness (in the anatomical
snuff box or via axial load of the thumb) is
an indication for immobilization.
Scaphoid fractures can be ruled out with
bone scan, MRI or CT scan.
Also, excessive movement of the carpal
bones on exam could be ligamentous
injury or dislocation.
Dislocation of carpal bones requires
prompt reduction by the Emergency
Physician or an orthopedic surgeon.
Scaphoid fracture/Carpal
dislocation
If resources are limited, immobilize athlete’s wrist
and retake x-ray in 10-14 days.
Scaphoid fracture can be ruled out with Bone
Scan, MRI or CT if needed sooner.
Watch for widening between Scaphoid and Lunate
on AP films(Scapholunate dislocation).
Watch for disruption of the “teacup” alignment of
lunate relative to capitate on lateral x-ray(Lunate
dislocation).
Lunate dislocations require prompt reduction.
Knee Dislocation ( Knee
Hyperextended)
True knee dislocation is rare in athletics
compared to lesser injury to major
ligaments, meniscus or patella.
Mechanics include hyperextension
(anterior dislocation) or a direct blow to
the tibia with the knee flexed (posterior
dislocation).
These may reduce spontaneously, so
maintain a high index of suspicion.
Knee dislocation, cont.
Injury to the popliteal artery is seen in up
to 33% of dislocations.
Peroneal nerve injury may result in
parasthesias and foot drop.
Careful Neurovascular exam is essential!!!
Dislocation must be reduced as soon as
possible and athlete should be admitted to
the hospital for full neurovascular
monitoring.
Consider US or arteriogram to assess
vascular status.
“Player down on the field”
Cervical Spine Injury
If you are the physician on the
sidelines of an event you must
WATCH THE GAME!
This gives you the chance of
witnessing the mechanism of injury
and can help you with your
assessment.
“Player down on the field”
Cervical Spine Injury
Evaluating a player on the field differs
from one in the ED in full spinal
immobilization.
Players collapse to the ground for any
number of reasons: c-spine injury,
dysrhythmia, ankle injury, or just
frustration from a bad play.
On the field, evaluate your ABC’s (Airway,
Breathing, and Circulation)
Do a focused neurological exam.
Always assume a neck injury in players
with head injuries!!
C-Spine(Cont’d)
If mechanism and/or exam are suspicious
for c-spine injury, activate EMS,
immobilize and transport.
In the ED, explain to the staff and
physician on duty the mechanism of injury
if possible.
Offer your assistance with equipment
removal.
NEVER remove equipment in the field
unless there is no other way to access
athlete’s airway!
C-spine injury (cont’d.)
In the ED, difficulty in obtaining
radiographs is no excuse for missing
a c-spine fracture.
Difficult areas include C1-2(obscured
by helmet) and C6-T1(obscured by
shoulder pads.)
Consider CT scan or at least CT scout
film to get a good lateral view.
C-spine injury(cont.d)
If the helmet and shoulder pads MUST
come off, remember they must be
removed as a unit.
Very difficult and takes a number of
personnel to do properly.
Remember: NEVER take off the helmet or
shoulder pads on the field unless there is
no other way to access the patient’s
airway or the helmet is not maintaining cspine immobility.
Sudden Cardiac Death
(Chest Pain or Blacking out)
Any athlete who complains of chest pain
or syncope (fainting spells) should be
worked up.
Many athletes will either have risk factors,
or will have had previous episode of
symptomatology.
Below age 30, a congenital structural
problem (hypertrophic cardiomyopathy,
anomalous coronary artery) or rhythm
problem (prolonged QT syndrome) is the
most likely cause of sudden death.
Sudden Cardiac Death(cont’d)
Ask the athlete about family history of
sudden death, heart murmur or other
episodes of chest pain or syncope.
These athletes should get an ECG(looking
for rhythm disturbances and LVH) and a
chest X-ray(looking for cardiomegaly.)
Withhold these athletes from participation
and ask for a cardiology consultation.
Sudden Cardiac Death(cont’d)
Athletes older than 30 are at risk of
sudden death as a complication of
coronary artery disease.
Treatment and work-up should be the
same.
Inquire as to risk factors and symptoms.
Get an ECG and enzymes if indicated.
Admit any high risk patients for
monitoring and work-up.
Spleen or Intestinal Rupture
(“My stomach hurts”)
Spleen is the most commonly injured
organ in blunt abdominal trauma.
Contact sports have highest rates of
splenic injury (football and ice
hockey.)
High velocity sports (skiing and
motorsports) are next highest.
Sideline exam may reveal LUQ pain
and tenderness.
Spleen or intestinal rupture(Cont’d.)
Referred pain to the RIGHT
shoulder(Kerr’s sign) may be present
Overlying rib fracture is also a risk factor
Be vigilant for signs of rupture (low blood
pressure, tachycardia, or mental status
changes)
Don’t hesitate to transport to ED if in
doubt.
US in ED or CT scan of abdomen for stable
patients are methods of evaluation.
Spleen or intestinal rupture(Cont’d)
Unfortunately, in milder injury your initial
sideline exam may be normal; frequently
reassess the athlete.
If pain worsens or vital signs change
transport to the ED.
If the athlete is sent home from the
sideline or the ED (benign exam, normal
vital signs, and low risk mechanism for
injury), make sure someone will be with
them at all times.
Worsening pain or weakness warrants
immediate re-evaluation.
Concussion
(In-game collision)
Missing a concussion on the sideline or in
the ED places the head-injured athlete at
risk (a 3-4 fold risk of sustaining another
concussion)
Cognitive and physical impairment
increase risk of another injury.
Rarely, a second impact syndrome may
result in the concussed athlete developing
rapid cerebral vasodilation, brain edema,
and death.
Concussion(Cont’d)
Majority of athletes do NOT present with
loss of consciousness
Athlete may report “ding” or “getting my
bell rung” or may not report any head
injury at all
Common symptoms include nausea,
dizziness, headache and inability to
concentrate.
Focal neurologic deficits point to a
structural lesion and require rapid
evaluation by the CT scan.
Concussion(Cont’d)
If you are covering games on the
sidelines,familiarize yourself with a
concussion assessment tool such as the
SAC (Standardized Assessment of
Concussion)-in back of handout.
Each school should have a policy
regarding return to play protocol, but a
good rule of thumb is one week following
the resolution of symptoms.
Make sure the athlete completes his
functional rehabilitation before being
allowed to return to play.
Heat Stroke
The “sweaty, disoriented athlete”
Note the difference between classic and
exertional heat stroke.
Classic- elderly people who spend
prolonged time exposed to high
temperatures (uncooled apartment during
a heat wave).
This person presents with elevated core
temperature, altered mental status, dry
skin and electrolyte disturbance.
Heat Stoke(Cont’d)
Exertional (our athletes)- this occurs
when the athlete pushes him or
herself or is pushed too hard in the
heat.
Inadequate hydration and poor
conditioning puts them at risk.
They present with elevated core
temperature, altered mental status
and often are profusely SWEATING!!
Heat Stroke(Cont’d)
The old axiom of dry skin differentiating
between heat exhaustion and heat stroke
does not hold in exertional heat illness.
Any athlete with an elevated core
temperature and altered mental status
has heat stroke until proven otherwise!!!
Treatment remains rapid cooling, ideally
with convection fans and TEPID water
misting. Place athlete in a cool
surrounding immediately.
Team doctors should keep a rectal
thermometer in your kit.
Heat Stroke(Cont’d)
Groin and axillary ice packs can be applied
in the field and in the ED (the ED also
should have a cooling blanket.)
Cool water immersion has many
problems: monitoring and resuscitation
can be difficult, and peripheral
vasoconstriction can interfere with heat
elimination.
Some Sports Medicine society’s
recommend COLD water immersion,but
data is still inconclusive.
Slipped Capital Femoral Epiphysis
(Medial thigh or knee pain)
SCFE occurs when the femoral head
displaces through the physis, usually
posterior and medial.
Most common age is 13 for males and 12
for females.
Risk factors include male sex, obesity and
sports activities.
Young athlete complains of pain with
activity or with a limp.
Bilateral involvement in up to 50% of
patients.
SCFE(Cont’d)
Referred pain is common (medial thigh or
knee.)
ALWAYS examine the hip!! Look for loss
of internal rotation of the hip (highly
sensitive finding.)
X-ray shows medial displacement of the
physis.
Long term morbidity of a missed SCFE
includes arthritis, osteonecrosis, and
chronic disability.
Compartment Syndrome
“Painful long bone injury”
Usually follows acute trauma to the
extremities, such as a long bone fracture
or significant muscle contusion.
Anterior compartment of the lower leg and
volar aspect of the forearm are most
commonly affected.
Always suspect compartment syndrome
when pain is out of proportion to the
injury.
Compartment Syndrome(Cont’d)
Parasthesias distal to the affected
compartment may be present.
Decreased arterial pulses are a LATE
finding (normal pulses do not rule out the
diagnosis.)
ED physician or orthopedist should
measure intercompartmental pressures
(usually greater than 35-40mmHg.)
Treatment is fasciotomy.
Compartment syndrome(Cont’d)
Remember the 5 P’s of Compartment
Syndrome:
1. Pain
2. Parasthesias
3. Pallor
4. Pulselessness
5. Paralysis
Compartment Syndrome(Cont’d)
Exertional compartment syndrome occurs
with distance runners and military recruits
when there is sudden increase in activity
Pain will occur with activity, resolving with
rest.
Suspected exertional compartment
syndrome athletes should be referred for
outpatient compartment testing (done pre
and post activity).
Suspected compartment syndrome
warrants quick evaluation.
Tarsal Navicular Stress Fracture
“Top of My Foot Hurts”
This is a very difficult one to
diagnose in the training room, in the
clinic, or the ED.
Symptoms are usually very vague
with an unrewarding physical exam.
Soft tissue swelling may/may not be
present.
X-rays can be normal for several
weeks.
Tarsal Navicular Stress
Fracture(Cont’d)
It is adequate to have the athlete reduce
or cease the instigating activity, and
follow-up with sports medicine physician
for reassessment.
Bone scan or MRI can be used to confirm
the diagnosis.
If stress fracture is suspected, make
athlete non-weight bearing.
Navicular stress fractures that go onto
completion have high rates of non-union.
Spondyloysis
(Low-back Pain)
Spondylolysis is a stress fracture of
the pars interarticularis.
Most often occurs during the rapid
growth phase.
Low back pain with extension is
highly suspicious for the injury.
The key is prevention of the fracture
going to completion with activity
modification and bracing, if needed.
Spondylolysis(Cont’d)
Bilateral pars fracture can lead to
spondylolisthesis (anterior slippage
of one vertebral body to another)
and chronic pain.
X-rays are warranted.
Athlete with suspected injury should
be withdrawn from play and referred
promptly.
Femoral Neck Stress Fracture
“My groin hurts”
Most common in endurance athletes.
Present with groin pain with activity
that eventually becomes present
with daily activity.
Fractures can often become complete
with a risk of Avascular Necrosis if
not diagnosed promptly.
Femoral Neck Stress Fracture
X-ray should be obtained; also Bone
Scan or MRI if needed.
Look for radiographic changes of
periosteal elevation or sclerosis.
Make athlete non-weight bearing
with crutches.
Tension-sided stress fractures may
require internal fixation surgery.
Conclusion
Treating athletes in the field, the clinic, or
the ED can be a rewarding experience.
Missing any of these conditions can be
disasterous for the athlete and our
careers.
Remember: Think bad thoughts.
Questions?
Thank you