The Physician and the Athlete: 12 Sports Injuries We Cant Afford to Miss

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The Physician and the Athlete12 Sports
Injuries We Cant Afford to Miss

• James S. Distefano, D.O., FAAEM
• Sports Medicine/Emergency Medicine
• Oklahoma State University

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• Emergency Medicine Physicians are trained to
  consider worst case scenario.
• This is what we MUST think in the ED.
• If we dont, things get missed and people die!

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• 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.

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• 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.

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• Here are 12 athletic injuries it behooves us as
  physicians not to miss
• Remember to Think bad thoughts.

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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.

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Scaphoid(Contd)

• 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.

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Scaphoid fracture/Carpal dislocation

• If resources are limited, immobilize athletes
  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.

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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.

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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.

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Player down on the fieldCervical 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.

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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 ABCs (Airway,
  Breathing, and Circulation)
• Do a focused neurological exam.
• Always assume a neck injury in players with head
  injuries!!

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C-Spine(Contd)

• 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 athletes airway!

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C-spine injury (contd.)

• 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.

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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 patients airway or the helmet is
  not maintaining c-spine immobility.

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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.

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Sudden Cardiac Death(contd)

• 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.

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Sudden Cardiac Death(contd)

• 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.

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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.

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Spleen or intestinal rupture(Contd.)

• Referred pain to the RIGHT shoulder(Kerrs 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)
• Dont hesitate to transport to ED if in doubt.
• US in ED or CT scan of abdomen for stable
  patients are methods of evaluation.

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Spleen or intestinal rupture(Contd)

• 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.

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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.

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Concussion(Contd)

• 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.

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Concussion(Contd)

• 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.

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Heat StrokeThe 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.

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Heat Stoke(Contd)

• 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!!

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Heat Stroke(Contd)

• 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.

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Heat Stroke(Contd)

• 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 societys recommend COLD
  water immersion,but data is still inconclusive.

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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.

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SCFE(Contd)

• 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.

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Compartment SyndromePainful 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.

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Compartment Syndrome(Contd)

• 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.

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Compartment syndrome(Contd)

• Remember the 5 Ps of Compartment Syndrome
• 1. Pain
• 2. Parasthesias
• 3. Pallor
• 4. Pulselessness
• 5. Paralysis

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Compartment Syndrome(Contd)

• 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.

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Tarsal Navicular Stress FractureTop 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.

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Tarsal Navicular Stress Fracture(Contd)

• 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.

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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.

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Spondylolysis(Contd)

• 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.

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Femoral Neck Stress FractureMy 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.

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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.

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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