Dont Miss Musculoskeletal Injuries

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Dont Miss Musculoskeletal Injuries

• Steve Blivin, MD, FAAFP
• Sports Medicine Department, Naval Hospital Camp
  Lejeune
• DOS MsK Symposium Honolulu Hawaii
• 5-6 and 9-10 FEB 09
• Presentation modified from presentations by Chris
  G. Pappas, LTC, USA, MC Fred H. Brennan, Jr.,
  LTC, USA, MC Francis G. OConnor, Col, USA, USA

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Objectives

• Become familiar with three dont miss upper
  extremity musculoskeletal injuries.
• Become familiar with three dont miss lower
  extremity musculoskeletal injuries.
• Detail pertinent diagnostic features and clinical
  criteria for referral to an orthopedic colleague.

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Case 1

• 21 year old female volleyball player dove for a
  low ball and fell on outstretched right hand
• Immediate wrist pain and pain with attempts at
  dorsi and palmar flexion
• No gross deformity
• What is the possible diagnosis based on this
  mechanism of injury?

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Case 1

• Wrist sprain
• Scaphoid fracture
• Distal radius or ulna fracture
• Distal R-U joint disruption
• TFCC tear
• Carpal ligamentous injury

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FOOSH Check Snuffbox TTP?
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Scaphoid fracture
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Treatment

• Thumb spica splint
• Consider early ortho surg

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Scaphoid

• If snuffbox tender and initial scaphoid series
  x-rays are negative, treat as a fracture and
  follow up with plain films in 10-14 if still
  tender. If films are negative then cast and get
  TPBS to r/o occult fx.
• Blood supply arises distally
• Fractures of middle and proximal portion prone to
  nonunion
• May be casted long arm 1st 6weeks the short arm
  next 6 weeks.

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Scapho-Lunate Dissociation

• Disruption of scapho-lunate ligament
• FOOSH injury
• Tender over scapho-lunate interval
• Watsons clunk
• Limited dorsiflexion
• gt 3 mm diastasis
• Scapholunate angle gt 60 degrees

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Watsons Test of the Wrist

• Watson's test
• (scaphoid shift test)
• Press the scaphoid tuberosity on the palmar
  aspect while moving the wrist from ulnar to
  radial deviation.
• A painful "click" or "pop" identifies scaphoid
  instability or scapholunate separation.

Scaphoid tubercle
Painful click or clunk
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Treatment

• Thumb spica splint
• Refer to ortho
• Acute 3 wks to 3 mo.

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Complications if Missed

• Chronic wrist pain
• Loss of function and motion
• Osteoarthritis

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Case 2

• 38 year old male got his right ring finger caught
  in a players shirt while playing touch football
• Felt pop in his finger and developed pain

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Exam
--Finger held in forced extension --Tender along
volar aspect of DIP --Unable to flex DIP
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X-rays
What is your diagnosis?
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Jersey Finger

• Rupture of FDP tendon
• Inability to flex tip of finger
• Splint in position
• Repair within 7 days

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Complications if Missed

• Retraction into palm of hand
• Loss of flexion of tip
• Impaired work ability
• Difficult surgery

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Case 3

• 22 year old had lower leg squished between two
  military vehicles
• Able to walk with a limp but pain worsening over
  the past 1-2 hours

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Exam

• Pain out of proportion to exam.
• Lateral aspect and first web space of foot feels
  like pins and needles
• Leg hurts with gentle passive foot inversion and
  plantar flexion
• Leg feels weaker

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X-ray
Diagnosis?
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Acute Compartment Syndrome

• Serious limb and life threatening condition
• Fractures, burns, crush injuries, arterial
  injuries
• Hand, forearm, arm, shoulder, back, thigh and foot

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Acute Compartment Syndrome

• Increased pressure within closed compartments
• Compartments of lower leg
• Be careful with splinting and casting

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Diagnosis

• High index of suspicion pain out of proportion
• Six Ps
• Pain, Pulseless, Paresthesia, Poikilothermy,
  Pallor, Paralysis
• Loss of normal sensation is a red flag
• Tight compartments
• Pressuregt 30 mm Hg

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Treatment

• Surgical emergency
• Fasciotomy
• Clinical signs
• Elevated pressure
• Interrupted arterial flow for gt 4 hours

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Complications if Missed

• Rhabdomyolysis
• Acidosis
• Ischemic contractures
• Hyperkalemia
• DIC and sepsis
• Loss of limb
• Death

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Case 4

• 26 year old sergeant playing basketball and
  jammed his left middle finger
• Pain and swelling of middle finger PIP joint
  (global)
• Pain with resisted flexion and extension

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Exam

• Swollen PIP middle finger
• Tender over PIP, more so dorsally
• Pain with resisted extension over the PIP
• No neuro compromise
• Flexor tendons strength is 5/5
• Collaterals of PIP intact
• DIP intact to flexion/extension

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X-rays
Diagnosis?
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What is the Diagnosis?

• Tear of the central slip of the extensor tendon

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Treatment

• Splint in extension for 6 to 8 weeks.
• Pain relief
• Watch for complications

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Complications if Missed

• Loss of function
• Persistent pain
• Boutonniere deformity

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Case 5

• 27 year old USUHS medical student playing
  football tackled with foot folded under during
  pile-up
• Loud audible pop and unable to bear weight
• Pain on top of mid-foot

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Exam

• Unable to weight bear
• Swelling over dorsum of foot
• Bruising on plantar aspect of foot
• Pain with external rotation of mid-foot

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X-rays
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Lisfranc Injury

• Lisfranc injuries may represent 1 of all
  orthopedic trauma, but 20 are missed on initial
  presentation
• Inability to WB, mid-foot pain, weight bearing
  x-rays are key

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Treatment

• PRICE-M
• Bulky Jones dressing or posterior splint
• NWB on crutches
• Frequent neurovascular checks
• Refer to Ortho

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Complications if Missed

• Chronic pain
• Arthritis
• Inability to run or jump
• Acute compartment syndrome

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Syndesmotic Ankle Sprain
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Clinical Presentation

• Usually the patient cannot put weight upon the
  leg.
• Pain is located anteriorly along the syndesmosis.
• Active movement of external rotation of the foot
  is painful.
• Positive Squeeze Test
• Positive External Rotation Stress Test

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Diagnosis

• Clinical diagnosis
• mechanism of injury
• correlative physical examination
• Radiographic imaging assists in risk stratifying

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Imaging

• Ottawa Ankle Rules AP, lateral and mortise views
  should be obtained
• tenderness over the lateral and medial malleolus
• unable to bear weight for four steps immediately
  or in the ED
• Syndesmosis Radiographic Criterion
• Mortise medial clear space gt 4mm
• AP tibiofibular overlap lt 10 mm

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Treatment

• Ligamentous injuries without fracture or gross
  widening can be treated conservatively
• Fractures or radiographic evidence of syndesmotic
  widening warrant orthopedic consultation for
  operative repair.

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Case 6

• 18 year old female runner with 1 month of
  anterior groin/inguinal pain
• Pain progressed earlier in runs and now with
  walking.

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Exam

• Any examdont be comfortable with a normal
  exam or hip flexor tendon tenderness!
• Pain with hip flexion and internal rotation
  (maybe)

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Get X-rays!
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Femoral neck stress fracture

• Groin pain in runner or jumper- dont ignore
• Female triad at increased risk as well as those
  with an increase in training and postmenopausal
  women
• Need to know which side the stress fracture is on
  (compression vs tension side)
• Plain films often negative
• Get TPBS then MRI if positive TPBS
• If cant walk pain free, keep on crutches until
  SF ruled out!

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Treatment

• If stress fracture by x-ray or further imaging
• Compression side
• 12 weeks to heal (pain free walk or crutches)
• Tension side
• Ortho consult/surgery
• Femoral neck fracture-surgery
• Cross train
• Proper nutrition and calories

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Complications if Missed

• Stress to complete fracture
• Avascular necrosis
• Chronic pain
• End of career

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Cauda Equina Syndrome
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Epidemiology

• 80 of the population experiences back pain at
  some point in their lives.
• 90 of low back pain resolves in 6 -12 weeks
• Red Flag symptoms include age over 50, trauma,
  fever, incontinence, night pain, weight loss,
  progressive weakness.
• Cauda Equina Syndrome (CES) is a rare disorder,
  representing only 0.0004 of all back pain
  patients

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Clinical Anatomy

• Three joint motion complex consisting of the
  facets and the intervertebral disc.
• The spinal cord extends from the foramen magnum
  to the L1-L2 disk where the cauda equina
  continues to the coccygeal region

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Mechanism of Injury

• Usually secondary to extrinsic pressure from a
  massive central HNP
• Other causes include
• epidural abscess
• epidural tumor
• epidural hematoma
• trauma

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Clinical Presentation

• Bilateral leg symptoms that include sciatica,
  weakness, sensory changes and gait disturbance.
• Physical examination demonstrates bilateral
  weakness as well as decreased sensation, in
  particular in the saddle region.
• Sphincter tone is decreased in 60 to 80 of
  patients
• All patients who complain of urinary or fecal
  incontinence should be considered to have CES
  until proven otherwise.

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Diagnosis

• Clinical diagnosis
• loss of bladder control perianal numbness pain
  and weakness involving both legs
• Evaluation of the urinary post-void residual
  volume assists with diagnosis
• the absence of a post-void residual volume of
  over 100ml, essentially excludes a diagnosis of
  CES, with a negative predictive value of 99.99

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Imaging

• Plain films
• MRI imaging
  of the entire spine

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Treatment

• Neurosurgical consultation
• High dose systemic corticosteroids
• Emergent surgical decompression

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ACUTE TENOSYNOVITIS
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Mechanism of Injury

• Trauma or puncture wound
• often at a flexor crease
• Hematogenous spread to the sheath (i.e.,
  Neisseria gonorrhoeae) occurs rarely but should
  be suspected if there is no puncture wound or
  history of trauma.

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Clinical Presentation

• Uniform, symmetric digit swelling
• Digit is held in partial flexion at rest
• Excessive tenderness along the entire course of
  the flexor tendon sheath
• Pain along the tendon sheath with passive digit
  extension

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Diagnosis (vs. subcutaneous abscess)

• subcutaneous abscess should not have tenderness
  over the entire sheath, and passive mobility of
  the uninvolved segments should be painless
• Elevated sheath pressures consistent with
  compartment syndrome pressures (i.e., higher than
  30 mm Hg) have been documented in flexor
  tenosynovitis.
• Ultrasound examination may show an abnormal
  effusion or abscess in the tendon sheath with
  flexor tenosynovitis

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Treatment

• Early infections may respond to nonoperative
  treatment
• Splinting
• Elevation
• IV antibiotics
• Rings should be removed from the affected finger
  and other fingers of the hand as soon as
  possible.
• Tetanus prophylaxis
• Surgery is necessary if no improvement in 12 to
  24 hours,.

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Take Home Points

• Fall on outstretched hand, think
• Scaphoid fx
• Scapho-lunate dissociation
• AP, Lat, Scaphoid and clenched fist views

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Take Home Points

• Grab injury with pain at distal phalynx, think
  jersey finger
• Crush injury or worsening pain with
  immobilization, think ACS
• Jammed PIPalways test extension with
  resistance

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Take Home Points

• Mid-foot pain and inability to weight bear after
  foot axial load or twist, think Lisfranc injury
• Persistent groin pain, especially in runner or
  jumper, rule out stress fracture of hip or pelvis

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Take Home Points

• Bad ankle sprainsyndesmotic injury?
• Bilateral leg sx or bowel / bladder sx with back
  painCauda Equina?
• Pain along the tendon sheath with passive digit
  extension Infected finger? Think tenosynovitis.

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Questions?
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If FOOSH, snuffbox tenderness and normal x-ray,
you must?

• Immediately refer for surgery
• Place wrist in a plaster cast
• Thumb spica splint
  and follow-up
• All of the above

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What must be ruled out in an athlete with groin
pain?

• Femoral neck stress fracture
• An STD
• Cauda Equina Syndrome
• OA

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Back pain with bilateral leg neurological
symptoms are concerning for what diagnosis?

• Prostate CA
• Cauda Equina Syndrome
• Sacroiliitis
• Osteopenia

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Post trauma pain out of proportion to exam in any
muscle group is concerning for what diagnosis?

• Hematoma
• Muscle tear
• Infection
• Compartment syndrome