Sports Medicine Review
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Transcript Sports Medicine Review
Kristine Campagna, DO
Latham Medical Group
September 8, 2012
Objectives
Review frequently missed orthopedic diagnoses
Review criteria for ordering imaging in acute back
pain, knee injury and ankle sprain
Epidemiology
Data on incidence is scant
1.2 per 100,000 patients per year (Miyamoto et al)
Dominant arm of male patients between 30-60 y/o
Smokers 7.5 times greater risk of injury than
nonsmokers
Distal Biceps Rupture
Etiology
Hypovascular
Lack of blood supply to the distal biceps predisposed to
rupture
Mechanical
The pronated forearm decreases the available space for
the tendon between the lateral border of the ulna and
the radial tuberosity causing impingement
Distal Biceps Rupture
Anatomy
Supination and flexion of forearm
Innervated by Musculocutaneous Nerve
Long head tendon originates intra-articularly at
superior gleniod tubercle
Short head tendon originates at coracoid process
Two heads merge at level of deltoid tubercle and insert
onto the radial tuberosity
Bicipital aponeurosis merges with the fascia and
inserts onto the ulna
Distal Biceps Rupture
Anatomy
Distal Biceps Rupture
Mechanism of Injury
Usually during a specific traumatic event
Unexpected extension force applied to flexed elbow
Eccentric contraction
Tearing sensation in antecubital fossa
Distal Biceps Rupture
Physical Exam
Loss of normal biceps contour
Obvious deformity may be present
Weakness with elbow flexion marked weakness with
forearm supination
Rupture may be missed if aponeurosis intact
Distal Biceps Rupture
Special Tests
Hook Test
Insert finger under the lateral edge of biceps tendon in
antecubital fossa when elbow flexed at 90°
Biceps Squeeze Test
Similar to Thompson test
Squeeze biceps to elict forearm supination
Distal Biceps Rupture
Imaging
MRI can help delineate if partial tear or severe
tendinopathy
Distal Biceps Rupture
Treatment
Referral to Orthopedics for surgical intervention
Unrepaired distal biceps tendon rupture (Miyamoto et
al)
Mean supination and flexion strength 74% and 88%,
respectively, compared to contralateral arm
Supination strength worse if the dominant arm is injured
Biceps Injury
Epidemiology
Most commonly fractured carpal bone
1o% of hand fractures
60%-70% of all carpal fractures
1.21/1000 person years
Males and whites have a higher relative risk
20 to 24 year olds highest incidence
Scaphoid Fracture
Anatomy
Only carpal bone that
bridges proximal and
distal rows
80% of the surface is
covered by cartilage,
which limits
ligamentous
attachments and
vascular supply
Scaphoid Fracture
Anatomy
Palmar carpal branch of radial artery supplies blood
distally and then proceeds proximally
Scaphoid Fracture
Classification of Fractures
Distal third (distal pole)-10%
Central third (waist)-65%
Proximal third (proximal pole)-15%
8% at tuberosity (protuberance at distal palmar
aspect)
Scapoid Fracture
Mechanism of Injury
Direct axial compression
Hyperextension of the wrist with a fall on outstretched
hand (FOOSH)
Scaphoid Fracture
Physical Exam
Pain in radial aspect of wrist, often just proximal to 1st
metacarpal
+/- swelling
Focal tenderness
Volar prominence distal wrist crease for distal pole
fractures
Anatomic snuffbox for waist fractures
Just distal to Lister’s Tubercle
Scaphoid Fracture
Plain Radiographs
PA
Scaphoid Fracture
Plain Radiograph
True Lateral
Scaphoid Fracture
Plain Radiograph
Scaphoid view
Scaphoid Fracture
Management of Suspected
Fracture
Immobilization in a short-arm thumb spica splint or
cast for 7-10 days followed by reimaging with x-rays
May result in 75-90% of patients being immobilized for
a week or more with only a soft tissue injury
Repeat imaging at 3-5 days using Bone Scan, CT or
MRI
MRI after x-rays
Scaphoid Fracture
Indications for Surgical
Referral
Displacement >1mm
Fracture associated with an increased tilt of lunate
Carpal instability or dislocation
Nonunion during follow-up
Osteonecrois
Possible scapholunate dissociation
Biceps Injury
Physeal Anatomy
Growth plate or physis represents a major anatomical
difference between adult and pediatric bone
Growing long bones composition
Diaphysis (shaft)
Metaphysis (where the bone flares)
Physis (growth plate)
Epiphysis (secondary ossification center)
Biceps Injury
Physeal Anatomy
Physeal Injuries
Physis Anatomy
Represent a weak point in pediatric bone
Third zone (zone of hypertrophic cartilage)
In infancy and early childhood, physis is thick and
epiphysis is mostly cartilaginous
Shock is absorbed and transmitted to the metaphysis
During adolescence, the epiphysis begins to ossify and
forces are less absorbed
Shock is transmitted to the physis
Physeal Injuries
Fracture Pattern
Tensile strength of pediatric bone is less than that of
the ligaments
Physis separates or fractures before disruption or
“spraining” of an adjacent ligament
Physeal Injuries
Fracture Pattern
Most commonly involve distal growth plates of radius
and ulna
Girls-between ages 9-12
Boys-between ages 12-15
Growth arrest, permanent decreased range of motion
and angular deformity
30% cause a growth disturbance (premature closure
and unilateral long bone shortening)
Physeal Injuries
Fracture Classification
Salter-Harris Classification
S (“Straight across”)- Type I low risk for injury
A (“Above”)- Type II
L (“Lower” or “BeLow”)- Type III
T (“Through”) – Type IV
E (“End”) or ER (Erasure of the growth plate”) – Type V
(high risk for growth plate injury)
R
Biceps Injury
SCFE
Epidemiology
10.8 cases per 100,000 children
More common in boys and African-Americans and
Pacific Islanders
Average age of diagnosis 13.5 for boys and 12 for girls
Bilateral presentation 18%-50% of patients
Some patients present sequentially (hips affected
within 18 mos of each other)
SCFE
Etiology
Obesity- 63% have a weight 90th percentile or higher
Growth surges
Endocrine disorders-hypothyroidism, growth
hormone supplementation, hypogonadism and
panhypopituitarism
Consider in unusual presentations-younger than 8, older
than 15, underweight
SCFE
History and Examination
Hip, groin, thigh or knee pain and walks with a limp
Pain with internal rotation of the hip with decreased
range of motion
May be pain with hip abduction and flexion
SCPE
Radiographs
Lateral Frog leg view
AP
SCFE
Treatment
Urgent referral to an Orthopedic Surgeon for pinning
to prevent progression of the slip
SCFE
Epidemiology
Back pain accounts for 2.5% of medical visits resulting
in 15 million office visits
Cost of LBP in the US exceeds $100 billion per year
75% of the total cost is attributable to fewer than 5% of
patients with LBP
LBP
Epidemiology
Many cases are self-limited and resolve with little
intervention
31% of patients with LBP will not fully recover within 6
months
Recurrent back pain occurs in 25-62% of patients
within 1-2 years
33% moderate pain
15% severe pain
LBP
Risk Factors
Smoking
Worker’s Compensation
Obesity
insurance
Job dissatisfaction
Psychological factors
Older age
Female gender
Physically strenuous
Somatization disorder
work
Sedentary work
Low educational
attainment
Anxiety
LBP
depression
Differential Diagnosis
Compression fracture
Herniated nucleus
pulposus
Lumbar strain/sprain
Spinal stenosis
Spondylolisthesis
Spondylolysis
Spondylosis
(degenerative disc or
facet joint arthropathy)
LBP
Connective tissue
disease
Inflammatory
spondyloarthropathy
Malignancy
Vertebral
discitis/osteomyelitis
Differential Diagnosis
Abdominal aortic aneurysm
Gastrointestinal conditions
Pancreatitis, peptic ulcer disease, cholecystitis
Herpes aozter
Pelvic conditions
Ednometriosis, pelvic inflammatory disease, prostatitis
Retroperitoneal conditions
Renal colic, pyelonephritis
LBP
History
Is there evidence of systemic disease?
Is there evidence of neurologic compromise?
Is there social of psychological distress that may
contribute to chronic, disabling pain?
LBP
Red Flags
History of cancer, especially cancer metastatic to bone
Recent significant trauma, or milder trauma age > 50
Unexplained weight loss
Unexplained fever
Immunosuppression
Intravenous drug use
Osteoporosis, prolonged use of corticosteroids
Age >70
Focal neurologic deficit progressive or disabling symptoms
Duration greater than 6 weeks
LBP
Physical Examination
Straight leg raise
Positive for L4-S1 nerve root if radiated pain below the
knee
Crossed straight leg raise
Positive when lifting unaffected leg reproduces pain
Seated straight leg raise
Reverse straight leg raise (extending hip and flexing
knee in prone position)
Positive for L3 nerve root pain if pain into anterior thigh
LBP
Disc Herniation
Affected
Nerve
Root
Motor
Deficit
Sensory
Deficit
Reflex
Central Para
central
Lateral
L3
Hip
Flexion
Anterior/
medial
thigh
Patella
Above
L2-L3
L2-L3
L3-L4
L4
Knee
Anterior
extension leg/medial
foot
Patella
Above
L3-L4
L3-L4
L4-L5
L5
DF/great
toe
Lateral
leg/dorsal
foot
Medial
Above
hamstring L4-L5
L4-L5
L5-S1
S1
PF
Posterior
leg/lateral
foot
Achilles
tendon
L5-S1
None
Above
L5-S1
Radiographs
Imaging is not warranted for most patients with acute
low back pain
Reserve imaging for patients with severe or progressive
neurologic deficits or when serious underlying
conditions are suspected
If clinical improvement has not occurred after 4-6
weeks, AP and lateral radiographs may be useful
LBP
MRI
Indicated for progressive neurologic deficits
High suspicion of cancer or infection
Persistent back pain more than 12 weeks
LBP
Indications for Referral
Cauda equina sydrome
Blowel and bladder dysfunction (urinary retention,)
saddle anesthesia and B/L leg weakness and numbness
Suspected spinal cord compression
Progressive or severe neurologic deficit
LBP
Ottawa Knee Rules
Age 55 years or older
Tenderness at head of fibula
Isolated tenderness of patella
Inability to flex knee to 90°
Inability to walk 4 weight-bearing steps immediately
after the injury and in the emergency room
Knee Injury
Ottawa Knee Rules
Retrospective chart review
Sensitivity 92% and specificity 57% for knee fracture
Prospective validation of rules published in 1996
100% sensitive for identifying knee fractures
If decision rules were negative, probability of a knee
fracture was 0%
Knee Injury
Ottawa Ankle and Foot Rules
Tenderness at posterior edge or tip or either malleolus
Tenderness in mid foot zone and at base of 5th
metatarsal or navicular
Inability to weight bear (4 steps) immediately after
injury and in the ER or physician’s office
Ankle Injury
Ottawa Ankle and Foot Rules
Ankle Injury
Ottawa Ankle and Foot Rules
Nearly 100% sensitive for detecting fractures in adults
and children as young as 5 years
Negative findings eliminate need for x-rays
Specificity 30%-50%
Ankle Injury