“don’t miss” musculoskeletal injuries chris g. pappas, ltc, usa, mc lecture adapted and...
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““Don’t Miss” Don’t Miss” Musculoskeletal Musculoskeletal
InjuriesInjuriesChris G. Pappas, LTC, USA, MCChris G. Pappas, LTC, USA, MC
Lecture adapted and revised from:Lecture adapted and revised from:LTC Fred H. Brennan, Jr., DO, FAOASM, FAAFPLTC Fred H. Brennan, Jr., DO, FAOASM, FAAFP
GoalsGoals
Become familiar with Become familiar with three “don’t miss” upper three “don’t miss” upper extremity extremity musculoskeletal injuries.musculoskeletal injuries.
Become familiar with Become familiar with three “don’t miss” lower three “don’t miss” lower extremity extremity musculoskeletal injuries.musculoskeletal injuries.
Utilize this knowledge in Utilize this knowledge in the evaluation and the evaluation and treatment of patients.treatment of patients.
Case #1Case #1
21 year old female 21 year old female volleyball player dove volleyball player dove for a low ball and fell on for a low ball and fell on outstretched right handoutstretched right hand
Immediate wrist pain Immediate wrist pain and pain with attempts and pain with attempts at dorsi and palmar at dorsi and palmar flexionflexion
No gross deformityNo gross deformity What is the possible What is the possible
diagnosis based on this diagnosis based on this mechanism of injury?mechanism of injury?
Case #1Case #1
Wrist sprainWrist sprain Scaphoid fractureScaphoid fracture Distal radius or Distal radius or
ulna fractureulna fracture Distal R-U joint Distal R-U joint
disruptiondisruption TFCC tearTFCC tear Carpal Carpal
ligamentous injuryligamentous injury
Case #1Case #1
What next?What next? ExamExam
Inspection, Range of motion, Neurovascular Inspection, Range of motion, Neurovascular status, Palpationstatus, Palpation
Is an x-ray needed?Is an x-ray needed?
Wrist XraysWrist Xrays
Scapho-Lunate DissociationScapho-Lunate Dissociation
Disruption of scapho-Disruption of scapho-lunate ligamentlunate ligament
FOOSH injuryFOOSH injury Tender over scapho-Tender over scapho-
lunate intervallunate interval + Watson’s clunk+ Watson’s clunk Limited dorsiflexionLimited dorsiflexion > 3 mm diastasis> 3 mm diastasis Scapholunate angle > 60 Scapholunate angle > 60
degreesdegrees
Watson’s Test of the WristWatson’s Test of the Wrist
Watson's testWatson's test(scaphoid shift test)(scaphoid shift test)
Press the scaphoid Press the scaphoid tuberosity on the palmar tuberosity on the palmar aspect while moving the aspect while moving the wrist from ulnar to wrist from ulnar to radial deviation.radial deviation.
A painful "click" or "pop" A painful "click" or "pop" identifies scaphoid identifies scaphoid instability or instability or scapholunate scapholunate separation.separation.
Scaphoid tuberclePainful click or clunk
TreatmentTreatment PRICE-MPRICE-M Thumb spica splintThumb spica splint Avoid wrist pronation-Avoid wrist pronation-
supinationsupination Pain controlPain control Refer to ortho hand Refer to ortho hand
within 72 hourswithin 72 hours
Complications if MissedComplications if Missed
Chronic wrist painChronic wrist pain Loss of function Loss of function
and motionand motion OsteoarthritisOsteoarthritis
Same patientSame patient
Scaphoid fractureScaphoid fracture
ScaphoidScaphoid
Blood supply arises distallyBlood supply arises distally Fractures of middle and proximal Fractures of middle and proximal
portion prone to nonunionportion prone to nonunion Get a scaphoid view if suspectedGet a scaphoid view if suspected If initial film negative, but still If initial film negative, but still
suspected treat as a fracture and suspected treat as a fracture and follow up with plain films or more follow up with plain films or more advanced imagingadvanced imaging
May be casted for up to 3 monthsMay be casted for up to 3 months
Case #2Case #2
38 year old male got his 38 year old male got his right ring finger caught right ring finger caught in a player’s shirt while in a player’s shirt while playing touch footballplaying touch football
Felt pop in his finger Felt pop in his finger and developed painand developed pain
Now in your clinic 4 Now in your clinic 4 hours laterhours later
What are the What are the possibilities?possibilities?
Case #2Case #2
Jammed fingerJammed finger FractureFracture DIP or PIP DIP or PIP
dislocationdislocation Mallet fingerMallet finger Jersey fingerJersey finger
ExamExam
--Finger held in forced extension--Tender along volar aspect of DIP--Unable to flex DIP
X-raysX-rays
What is your diagnosis?
Jersey FingerJersey Finger
Rupture of FDP Rupture of FDP tendontendon
Inability to flex tip Inability to flex tip of fingerof finger
Splint in positionSplint in position Repair within 7 Repair within 7
days days
Complications if MissedComplications if Missed
Retraction into Retraction into palm of handpalm of hand
Loss of flexion of tipLoss of flexion of tip Impaired work Impaired work
ability ability Difficult surgeryDifficult surgery
Mallet fingerMallet finger
Case #3Case #3
22 year old active 22 year old active duty male had lower duty male had lower leg “squished” leg “squished” between two between two military vehiclesmilitary vehicles
Able to walk with a Able to walk with a limp but pain limp but pain worsening over the worsening over the past 1-2 hourspast 1-2 hours
Case #3Case #3
Possibilities?Possibilities? Fractured patellaFractured patella Fractured fibula or tibiaFractured fibula or tibia Tendon ruptureTendon rupture Acute compartment Acute compartment
syndromesyndrome Vascular disruptionVascular disruption ContusionContusion
ExamExam
Pain is worsening Pain is worsening after splintingafter splinting
Lateral aspect and Lateral aspect and first web space of first web space of foot feels like “pins foot feels like “pins and needles”and needles”
Leg hurts with Leg hurts with gentle passive foot gentle passive foot inversion and inversion and plantar flexionplantar flexion
Leg feels weakerLeg feels weaker
X-rayX-ray
Diagnosis?
Acute Compartment Acute Compartment SyndromeSyndrome
Serious limb and Serious limb and life threatening life threatening conditioncondition
Fractures, burns, Fractures, burns, crush injuries, crush injuries, arterial injuriesarterial injuries
Hand, forearm, Hand, forearm, arm, shoulder, arm, shoulder, back, thigh and footback, thigh and foot
Acute Compartment Acute Compartment SyndromeSyndrome
Increased pressure Increased pressure within closed within closed compartmentscompartments
Compartments of Compartments of lower leglower leg
Be careful with Be careful with splinting and castingsplinting and casting
DiagnosisDiagnosis
High index of suspicion: High index of suspicion: pain out of proportionpain out of proportion
Six P’sSix P’s Pain, Pulseless, Pain, Pulseless,
Paresthesia, Paresthesia, Poikilothermy, Pallor, Poikilothermy, Pallor, ParalysisParalysis
Loss of normal sensation Loss of normal sensation is a red flagis a red flag
Tight compartmentsTight compartments Pressure> 30 mm HgPressure> 30 mm Hg
TreatmentTreatment
Surgical emergencySurgical emergency FasciotomyFasciotomy
Clinical signsClinical signs Elevated pressureElevated pressure Interrupted arterial Interrupted arterial
flow for > 4 hoursflow for > 4 hours
Complications if MissedComplications if Missed
RhabdomyolysisRhabdomyolysis AcidosisAcidosis Ischemic Ischemic
contracturescontractures HyperkalemiaHyperkalemia DIC and sepsisDIC and sepsis Loss of limbLoss of limb DeathDeath
Case #4Case #4
26 year old 26 year old sergeant playing sergeant playing basketball and basketball and “jammed” his left “jammed” his left middle fingermiddle finger
Pain and swelling Pain and swelling of middle finger of middle finger PIP joint (global)PIP joint (global)
Pain with resisted Pain with resisted flexion and flexion and extensionextension
What are the What are the possibilities?possibilities?
Case #4Case #4
Fractured Fractured phalanxphalanx
Extensor tendon Extensor tendon rupturerupture
Volar plate injuryVolar plate injury Tear of central Tear of central
band of extensor band of extensor tendon tendon
Mallet fingerMallet finger PIP dislocationPIP dislocation
ExamExam
Swollen PIP middle Swollen PIP middle fingerfinger
Tender over PIP, more Tender over PIP, more so dorsallyso dorsally
Pain with resisted Pain with resisted extension over the PIPextension over the PIP
No neuro compromiseNo neuro compromise Flexor tendons Flexor tendons
strength is 5/5strength is 5/5 Collaterals of PIP Collaterals of PIP
intactintact DIP intact to DIP intact to
flexion/extensionflexion/extension
Do you want X-rays?Do you want X-rays?
X-rays X-rays
Diagnosis?
What is the Diagnosis?What is the Diagnosis?
Tear of the central Tear of the central slip of the extensor slip of the extensor tendontendon
TreatmentTreatment
Splint in extension for 6 to 8 weeks.Splint in extension for 6 to 8 weeks. Pain reliefPain relief Watch for complicationsWatch for complications
Complications if MissedComplications if Missed
Loss of functionLoss of function Persistent painPersistent pain Boutonniere Boutonniere
deformitydeformity
Case #5Case #5
27 year old USUHS 27 year old USUHS medical student medical student playing footballplaying football
Loud audible pop Loud audible pop and unable to bear and unable to bear weightweight
Pain on top of mid-Pain on top of mid-footfoot
What are the What are the possibilities?possibilities?
Case #5Case #5
Fracture of Fracture of metatarsalmetatarsal
Fracture of Fracture of cunieformcunieform
Extensor digitorum Extensor digitorum rupturerupture
Lisfranc complex Lisfranc complex injuryinjury
Mid-foot sprainMid-foot sprain
ExamExam
Unable to weight Unable to weight bearbear
Swelling over Swelling over dorsum of footdorsum of foot
Bruising on plantar Bruising on plantar aspect of footaspect of foot
Pain with external Pain with external rotation of mid-footrotation of mid-foot
Do You Need X-rays?Do You Need X-rays?
X-raysX-rays
Lisfranc InjuryLisfranc Injury
Lisfranc injuries Lisfranc injuries may represent 1% may represent 1% of all orthopedic of all orthopedic trauma, but 20% trauma, but 20% are missed on are missed on initial presentationinitial presentation
Inability to WB, Inability to WB, mid-foot pain, mid-foot pain, weight bearing x-weight bearing x-rays are keyrays are key
TreatmentTreatment
PRICE-MPRICE-M Bulky Jones Bulky Jones
dressing or dressing or posterior splintposterior splint
NWB on NWB on crutchescrutches
Frequent Frequent neurovascular neurovascular checkschecks
Refer to OrthoRefer to Ortho
Complications if MissedComplications if Missed
Chronic painChronic pain ArthritisArthritis Inability to run Inability to run
or jumpor jump Acute Acute
compartment compartment syndromesyndrome
Case #6Case #6
18 year old female 18 year old female runner with 1 month of runner with 1 month of anterior groin/inguinal anterior groin/inguinal painpain
Pain worse with weight Pain worse with weight bearingbearing
Over past week she has Over past week she has developed night paindeveloped night pain
What are the What are the possibilities?possibilities?
Case #6Case #6
Torn adductor muscleTorn adductor muscle Avulsion of adductor Avulsion of adductor
or sartorius muscleor sartorius muscle Pubic ramus fracturePubic ramus fracture Femoral neck fractureFemoral neck fracture Femoral shaft Femoral shaft
fracturefracture SI joint subluxationSI joint subluxation Ruptured iliopsoas Ruptured iliopsoas
bursabursa
ExamExam
Swelling noted in Swelling noted in groin and high groin and high proximal femurproximal femur
Pain with all attempts Pain with all attempts at motion, especially at motion, especially internal rotationinternal rotation
Distal pulses 2+Distal pulses 2+ No distal sensory No distal sensory
deficitsdeficits
Do You Need X-rays?Do You Need X-rays?
Femoral neck stress Femoral neck stress fracturefracture
Groin pain in runner or Groin pain in runner or jumper- don’t ignorejumper- don’t ignore
Female triad at increased Female triad at increased risk as well as those with risk as well as those with an increase in training and an increase in training and postmenopausal womenpostmenopausal women
Need to know which side Need to know which side the stress fracture is on the stress fracture is on (compression vs tension (compression vs tension side)side)
Plain films often negativePlain films often negative Get MRIGet MRI
TreatmentTreatment
If stress fracture by x-If stress fracture by x-ray or further imagingray or further imaging Compression side Compression side
12 weeks to heal +/- 12 weeks to heal +/- NWB NWB
Tension sideTension side Ortho consult/surgeryOrtho consult/surgery
Femoral neck Femoral neck fracture-surgeryfracture-surgery
Cross trainCross train Proper nutrition and Proper nutrition and
calories calories
Complications if Missed Complications if Missed
Stress to complete Stress to complete fracturefracture
Avascular necrosisAvascular necrosis Chronic painChronic pain End of careerEnd of career
Take Home PointsTake Home Points
Fall on Fall on outstretched hand, outstretched hand, think:think: Distal forearm fx.Distal forearm fx. Scaphoid fxScaphoid fx TFCCTFCC AP, Lat, Scaphoid AP, Lat, Scaphoid
and clenched fist and clenched fist viewsviews
Scapho-lunate Scapho-lunate dissociationdissociation
Take Home PointsTake Home Points
Grab injury with Grab injury with pain at distal pain at distal phalynx, think jersey phalynx, think jersey fingerfinger
Crush injury or Crush injury or worsening pain with worsening pain with immobilization, immobilization, think ACSthink ACS
““Jammed” PIP…Jammed” PIP…always test always test extension with extension with resistanceresistance
Take Home PointsTake Home Points
Mid-foot pain and Mid-foot pain and inability to weight inability to weight bear after foot axial bear after foot axial load or twist, think load or twist, think Lisfranc injuryLisfranc injury
Persistent groin pain, Persistent groin pain, especially in runner especially in runner or jumper, rule out or jumper, rule out stress fracture of hip stress fracture of hip or pelvisor pelvis
FinishedFinished
Thank You!Thank You!