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161-180 of 475 results with category "Orthopedics"
Bottom Line:
Less than 1/2 of patients presenting to EDs and being diagnosed with concussion receive mild traumatic brain injury educational materials, and less than 1/2 of patients have seen a clinician for follow up by 3 months after injury.
In order to improve long term outcomes in patients with concusions please remember to provide the patient with approriate discharge instrucitons and strict instructions to follow up on their injury.
Full details of the article in JAMA can be found at https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2681571
Syndesmotic sprain aka a “high ankle sprain”
Ankle injuries make up almost 30% of the injuries in professional football
High ankle injuries make up between 16 and 25% of these injuries in the NFL (lateral most common)
10% in general population
In comparison to lateral ankle sprains, high ankle sprains result in significantly more missed games, missed practices and required a longer duration of treatment
Anatomy: The syndesmosis comprises several ligaments and the interosseous membrane
Mechanism: External foot rotation with simultaneous rotation of the tibia and fibula.
Can lead to a Maisonneuve fracture
Injuries 4x more likely in game setting than practice
A positive proximal squeeze test significantly predicts missed games and practices compared to those without.
https://www.youtube.com/watch?v=ThiW_9m7cFM
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Exertional rhabdomyolysis (ER)
The warm weather is here and with it comes an increased risk of ER
Risks include the intensity, duration and types of exercises performed
One of the biggest risks is the exercise experience of the participants, both in those with little to no experience and in those experienced athletes less trained than their counterparts.
Multiple case reports find that intense novel exercises early in the preseason before getting acclimatized and “in shape” carry great risk to the participant. These can be summarized as “too much, too soon, too fast.”
Coaches need to be educated about this and be prepared to detect and effectively handle ER through an emergency action plan.
-Conditioning workouts need to be phased in rather than start at maximum intensity on day one.
Eccentric exercises appear worse than concentric exercises.
Has been seen in almost all sports, ranging from swimming to golf.
It’s not just preseason football!
High humidity and high temperature environments increase the likelihood of ER
Males are more vulnerable to ER than females
Increased risk with sickle cell trait and glycogen storage diseases
Multiple drugs may increase individual risk including alcohol, cocaine, amphetamines, MDMA and caffeine.
Implicated medicines include, salicylates, neuroleptics, quinine, corticosteroids, statins, theophylline, cyclic antidepressants and SSRIs
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Does mild traumatic brain injury increase risk of dementia?
Background: Most studies of moderate to severe TBI have found an association with increased risk of dementia and earlier onset of Alzheimer’s. There is growing concern that repeated TBIs, even if more mild, can lead to neurodegenerative conditions such as chronic traumatic encephalopathy (CTE). However, the link between mild TBI and dementia risk has not fully been elucidated, especially in the case of mild TBI without loss of consciousness (LOC).
Recent Data: A recent JAMA study evaluated the association between TBI severity, LOC, and dementia diagnosis in 350,000 veterans between 2001-2013. After adjusting for demographics as well as medical and psych comorbidities, veterans with even mild TBI without LOC had more than a 2-fold increase in risk of dementia diagnosis than those with no TBI. The risk increased only slightly if there was LOC (from a hazard ratio of 2.4 to 2.5). Risk was >3-fold for those with moderate-severe TBI.
Take home: TBI of any severity, even without LOC, appears to be associated with long term neurodegenerative consequences. Avoidance of TBI is of the utmost importance, and if TBI occurs, close neurocognitive follow up should occur.
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Exercise talking points for the pregnant patient
(from ACSM 2017 Consesnsus statement)
Exercise throughout pregnancy is generally safe but should be monitored
No evidence of higher rates of preterm or prolonged labor, or deliveries that require induction or episiotomy
No evidence of negative effect on APGAR scores
Other benefits:
Avoidance of excessive weight gain, improved balance, and decreased back pain
Improved well-being, energy levels, and sleep patterns
Improved labor symptoms and facilitation of post-partum recovery
Lower risk of C-section
Reduced risk of having a large for gestational age (LGA) or small for gestational age (SGA) infant
Risks include environmental exposure, dehydration, hypoxia, and uterine trauma:
High impact or high-strain physical activity during the fetal implantation phase may lead to slightly higher risk of miscarriage
Sports with high risk of trauma last in pregnancy could result in placental abruption
Scuba diving is contraindicated because the fetus is not protected from decompression problems
Limit use of sauna or hot tub to fewer than ten minutes or omit altogether
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Female Athlete Triad
- Low energy availability
- With or without eating disorders
- Menstrual dysfunction
- Low bone mineral density (BMD)
Energy availability considers the amount of remaining energy for metabolic processes based on calories takin in with eating and calories burned through exercise or both.
Menstrual dysfunction occurs as a result of low energy availability causing decreased GnRH inhibition and ovarian suppression and decreased estrogen.
Low bone mineral density occurs due to amenorrhea and decreased energy availability. Estrogen limits bone resorption (stimulates calcitonin and renal calcium retention).
This is very important for young girls as by age 12 they have 83% of their total BMD & 95% two years after menarche.
If you see an athlete in the ED with one component of the triad, inquire about the other two. A 15yo athlete with a stress fracture may not realize that her disordered eating, excessive exercise or amenorrhea may by contributing factors and may benefit from follow up with PCP, dietitian, Gyn, etc.
Boutonniere Deformity
aka buttonhole deformity
Misdiagnosed as a “jammed” or “sprained” finger
- Deformity occurs at the PIP joint
- Trauma to the PIP joint can cause the joint capsule to tear, the head of the phalanx can buttonhole thru the defect and the lateral bands of the extensor tendons fall laterally & contract
- The lateral bands then function as PIP flexors and not extensors
- DIP hyperextension due to excessive pull of the displaced lateral bands
- As a result, the pateint WILL be able to flex the DIP joint, but WILL NOT be able to extend the PIP joint
- OCCURS 1 - 3 weeks post injury
- May not present with classic textbook deformity
- The Elson test is the best way to detect the injury pattern before the deformity is evident
- https://www.youtube.com/watch?v=G9HY0qXWUvE
Pectoralis Major Rupture
Most commonly seen in male weightlifters
Usually occurs as a tendon avulsion
Incidence is increasing
Hx: Sudden, sharp, tearing sensation with pain and weakness with arm movement
PE: Palpable defect and deformity of anterior axillary fold. Bruising and swelling.
Deformity may not be obvious with arm by side and relaxed
Testing: Weakness with ADDuction and internal rotation
Treatment: Operative treatment has better outcomes but depends on patient subgroups
Nonoperative treatment generally indicated for partial ruptures and tears in the body of the pec and muscle tendon junction
Sling, ice and pain control.
Operative treatment generally for high demand patients (athletes) and bony avulsion injuries
The search for an objective reliable test for mild traumatic brain injury found an early promising result last week.
May be arriving in your hospital in the near future.
A handheld sideline version is sure to follow
The FDA approved the first blood test for concussion/mild TBI
Called the Banyan BTI (Brain Trauma Indicator)
This test measures 2 neural protein biomarkers released into the blood following mild TBI
The FDA approved this test within 6 months after reviewing data on just under 2,000 blood samples.
They concluded the Banyan BTI can predict the absence of cranial CT lesions with an accuracy greater than 99% and may reduce imaging in up to a 1/3rd
Be optimistic but consider the small sample size and remember that this test looks for biomarkers and may miss subtle cases where proteins didn’t leak. This test is NOT ready to be used for return to play decisions. It takes 3 to 4 hours to result and costs about $150. Other biomarkers are being investigated and may prove to be better
https://www.fda.gov/newsevents/newsroom/pressannouncements/ucm596531.htm
Femoral neck stress fractures
Adults>kids
Represents 5% of all stress fractures
Usually due to repetitive abductor muscle contraction
As with all stress fractures can occur in 2 types
1) Insufficiency type (normal physiologic stress on abnormal bone)
2) Fatigue type (abnormal/excessive physiologic stress on normal bone)
2 locations on interest:
1) Compression side (inferior femoral neck)
2) Tension side (superior femoral neck)
History: Insidious onset of groin or lateral hip pain associated with weight bearing
Exam: Antalgic gait, pain with hip log roll and with FABER (hip flexion, Abduction and external rotation test)
Treatment:
Compression side: reduced weight bearing and activity modification
Tension side: Non weight bearing (due to high risk of progression to displacement with limited weight bearing) AND surgical consultation for elective pinning to prevent displacement. If displaced, will require ORIF
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Dental Avulsion in the field/sporting event
- Only replace avulsed secondary teeth
- Handle the tooth by the crown only
- Rinse tooth with cold running water gently (the root should not be wiped)
- Immediate attempt to reimplant permanent tooth into socket by 1st capable person:
* Time is tooth: Each minute tooth is out of socket reduces tooth viability by 1%
* Best chance of success if reimplant done within 5–15 min*? Poor tooth viability if avulsed for >1 hr
- If unsuccessful, place tooth in a transport solution (from most to least desirable):
- Hanks balanced salt solution (HBSS)
* Balanced pH culture media available commercially in the Save-A-Tooth kit
* Effective hours after avulsion
- Cold milk:
* Best alternative storage medium
* Place tooth in a container of milk that is then packed in ice (prevents dilution)
- Saliva:
* Store in a container of parent or child's saliva
- Never use tap water or dry transport
Concussion – Where are we now?
The Sport Concussion Assessment Tool 5th edition (SCAT 5) was released in 2017
It is a standardized tool to assist health care professionals in the evaluation of sport associated concussions
It should be used for those 13 years and older (there is a child version for younger athletes)
Print and bring to the sideline for your next coverage event!
http://bjsm.bmj.com/content/bjsports/early/2017/04/26/bjsports-2017-097506SCAT5.full.pdf
Some points to consider:
It should take at least 10 minutes to complete. Any less and you may not be performing the test correctly
The SCAT5 is the standard tool used in concussion assessment in the NCAA and NFL and other professional sports
Some symptoms of concussion appear over time. For example, an athlete may have zero or minimal symptoms immediately after yet be considerably symptomatic in 10 to 15 minutes.
-Follow up screening evaluations are essential even in those with a negative initial sideline screening test
The SCAT5 should be used immediately after injury
-Utility decreases post injury after days 3-5
-The included symptom checklist has utility in tracking recovery
-Attempt to perform in an environment free of distractions (crowd noise, bad weather)
The clinical utility of the SCAT5 can be enhanced by adding assessment of other factors such as reaction time, balance assessment, video-observable signs (if available) and oculomotor screening.
CC: 12yo boy presents with pain to base of 5th metatarsal
Osteochondrosis overuse syndromes associated with development of secondary ossification or apophyseal centers
Iselin disease – Osteochondrosis of 5th MT base
Lateral 5th foot pain with weight bearing and activity in early adolescence
Child may limp or walk on inner part of foot
Adolescents: Girls >10, Boys >12
Commonly seen in soccer, basketball, gymnastics and dance
Exam: Tenderness to palpation at proximal 5th MT at peroneal brevis insertion
Area may show edema and redness
Pain with foot inversion and resisted eversion and dorsiflexion
XR: May be normal or show enlargement or fragmentation of epiphysis
Obliquely oriented small bony fleck at 5th MT base. Parallel to long axis of 5th MT. Best seen on oblique view. Unlike fractures which tend to be horizontally oriented.
Treatment: Immobilize for comfort if severe (walking boot) or simple activity modification if mild. Ice and calf muscle stretching.
http://https://images.radiopaedia.org/images/2343487/d3478d2024c845ba0f2fffffd7d51c_big_gallery.jpg
Tibial shaft stress fractures
An overuse injury where the tibia is subjected to repetitive stress resulting in progressive microfractures
Commonly seen in runners and military recruits
Location of injury is very important for prognosis and treatment
1) Medial tibia (compression side) – Most common stress fracture site in athletes (runners)
2) Anterior tibia (tension side) – Seen in repetitive jumping athletes
History: Change in routine (volume or surface), Insidious onset of pain, worse with activity better with rest
Exam: Focal tenderness to palpation (versus larger diffuse area with shin splints)
Radiology: Plain film often normal in first 2 to 3 weeks
Lateral X-ray may show the “dreaded black line” on the anterior tibia
MRI has replaced bone scan as most sensitive for early diagnosis. Fracture line surrounded by edema.
Treatment:
Medial fractures: relative rest (avoid painful activities), avoid NSAIDs, PT, gradual return to activity as dictated by symptoms
VERSUS
Anterior stress fractures: Very high risk injury pattern (delayed union and non union). Non weight bearing splint/cast. Intramedullary nail often used for failure of conservative treatment or earlier return to sport in competitive athletes.
Dreaded black line picture:
A recent article from JAMA (link below) showed that Ibuprofen and opioids are similarly effective in the short term relief of acute extremity pain when used in combination with acetaminophen. The study looked at adults with fractures and sprains and randomized them to one of four groups.
- 400mg Ibuprofen and 1000mg acetaminophen
- 5mg Oxycodone and 325mg acetaminophen
- 5mg Hydrocodone and 300mg acetaminophen
- 30mg Codeine and 300mg acetaminophen
Pain relief was similar in all groups.
With the growing increase in opioid abuse/addiction it is good to know that in our patients that are not allergic to acetaminophen and ibuprofen (or all medications except for that one that begins with a “D”) we can provide good pain relief without using opioids.
https://jamanetwork.com/journals/jama/article-abstract/2661581
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Parsonage Turner syndrome aka Neuralgic amyotrophy
30 cases per 100,000
Under recognized and often missed
Unknown cause, perhaps post viral. Also reported post stress (surgery, pregnancy)
Can be B/L in 10 to 30%
CC: sudden onset of severe pain in the shoulder.
Can last for hours to weeks.
Radiates to upper arm.
As pain begins to subside, muscle weakness and sensory loss follows.
Can preferentially involve the suprascapular and axillary nerve.
Outpatient workup may include MRI and EMG
Treatment: Supportive. Consider a trial of oral steroids. Provide good pain control.
Majority of patients improve within 3 months. Though up to a third have persistent pain/functional deficit.
Question
Quadriceps Contusion
Mechanism: Blunt trauma to the anterior thigh (frequently football helmet or opponents knee)
Usually involves the anterior quadriceps (rectus femoris and vastus intermedius)
Pain on passive stretch and active contraction
Can develop large hematomas
Loss of knee flexion is a poor prognosticator
Complication: Myositis Ossificans (MO) (5-17%)
Increased risk with delay in treatment > 3 days
Radiographs can lag. Ultrasound in more sensitive
Painful firm area in region of contusion occurring 2 to 3 weeks post injury
http://fifamedicinediploma.com/wp-content/uploads/2015/12/myositis_ossificans_lateral-1.jpg
Prompt treatment….key to good outcome and earlier return to sports
Large hematoma can be aspirated. NSAIDs may reduce edema and risk of MO. Splinting
Place quadriceps in 120 degrees of flexion for 24 hours following injury (keep muscle lengthened)
https://upload.orthobullets.com/topic/3103/images/quad%20contusion_moved.jpg
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Complete or incomplete separation of the articular cartilage and subchondral bone
-70% occur at the lateral aspect of the medial femoral condyle
-Also seen in the talar dome and capitellum
Repetitive overloading leads to fragmentation and separation from surrounding bone
Prognosis better in kids than in adults
http://www.eorif.com/KneeLeg/Images/OCD4w.jpg
CC: Vague difficult to localize activity related pain and swelling. Mechanical symptoms only if loose body is present
PE: Wilson’s test
Internal tibial rotation and knee extension impinges the tibia on the OCD lesion causing pain. Pain abates with external rotation and flexion.
https://www.youtube.com/watch?v=e7zrKo41Pos
Plan of care: Limit activity and trial period of non-weight bearing for 6 weeks.
50% resolve in 10 to 18 months with conservative care.
Detached, loose or unstable fragments or failure of non-operative care will need surgery