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)
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
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
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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
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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