Sports Medicine RoundsApril 2012

Tom Green

Outline & Objectives

• Thanks to those with requests

• Optimum management of suspected scaphoid fractures.

• Ankle sprains: review and rehab advice

• ACL tears: Emerg management

• My Sports Medicine Clinic

• What we do

• Who and How to Refer

• Requests for future topics

Question 1What is the best approach to suspected scaphoid

fractures?A.Follow-up with primary care, no imaging

B.Return for repeat x-rays (emergency or GP)

C.Further, more advanced imaging

D.Follow-up with hand surgeon

A. Circumferential thumb spica cast

B. Thumb spica splint (non circumferential)

C. Splint only for comfort as needed

D. Nothing

What form of immobilization should be applied?

• Physical examination:

• Excellent Sensitivity but low specificity (75%)

• Snuffbox tenderness.

• Palpation of the scaphoid tuberosity volarly

• axial compression of the thumb metacarpal

• Pain with resisted supination, limited thumb range of motion and pain at the end of arc of motion, especially with flexion and radial deviation

Scaphoid Fractures

• Immobilization and follow-up are a problem

• Unreliable patient

• Unreliable doctor

• Splint / Cast immobilization

• Can advanced imaging help us?

• ie: can CT or MRI prevent prolonged casting

Scaphoid Fractures

Diagnostic accuracy of multidetector computed tomography for patients with suspected scaphoid fractures and negative

radiographic examinationsAhmet Turan Ilica · Selahattin Ozyurek Ozkan Kose · Murat

Durusu

Jpn J Radiol (2011) 29:98–103

• Prospective study of occult scaphoid

• MRI as gold standard (this is not ideal)

• CT had NO False positives

• CT had THREE false negatives

• Summary: negative CT is not good enough if you believe MRI is a good gold standard

Comparison of CT and MRI for Diagnosis of Suspected Scaphoid Fractures

Wouter Mallee, MSc, Job N. Doornberg, MD, PhD, David Ring, MD, PhD, C. Niek van Dijk, MD, PhD, Mario Maas, MD, PhD, and J. Carel Goslings, MD, PhD

J Bone Joint Surg Am. 2011;93:20-8

• Patients: within 24hrs of clinically suspected scaphoid, and normal plain radiographs.

• CT and MRI within 10 days

• Gold Standard was radiograph 6 weeks after injury.

• Summary: Both CT and MRI had false positives and false negatives. they are pretty good, but not perfect, and therefore may not add anything to clinical follow-up

• Stick to the old school approach

• Visible on initial x-ray• Splint in removable spica• CT may actually be useful for surgical planning, but can be arranged on

F/U.

• Clinically suspected• ie: if # then non displaced• Splint in removable spica splint

• Can be removed to shower etc....• Can be removed to allow clinical exam and better x-rays

• Follow-up in 10 days for repeat x-ray and clinical exam.• GP, Ortho, EP

• There is no value in CT, MRI, Bone scan, U/S............. for us.

Scaphoid FracturesOur Consultants ApproachDiscussed with Dr. Perey

Ankle SprainPhysical Exam

• Palpate joint line

• Grading

• Weight bearing, degree swelling

• Stability

• Also difficult on day 1

• Syndesmosis

• Squeeze Test / External Rotation

• Impossible on day 1 of injury

Audience PollFor a suspected high grade ankle sprain

Who gives

•Tensor

•Soft Brace

•Hard Brace

•Walker boot

•Cast

•Physio referral or suggestion

Grading Lateral Ankle Sprains

• Largely athletic college population (age 30)

• Patients with first ligament injury were stratified by the severity of the sprain (grades I, II, or III) and then randomized to undergo functional treatment with different types of external supports.

• Completed daily logs until they returned to normal function

• Followed up at 6 months.

• Grade 1 or 2: Elastic wrap, aircast or combination

• Grade 3: Aircast or Walking Cast

• Outcomes combination of functional and stability tests

A Prospective, Randomized Clinical Investigation of the Treatment of First-Time Ankle Sprains

Bruce D. Beynnon,PhD, Per A. Renström, MD, PhD, Larry Haugh, PhD, Benjamin S. Uh, MD, and Howard Barker, MDThe American Journal of Sports Medicine, Vol. 34, No. 9, 2006

• Grade I and II sprains

• Stirrup brace combined with elastic wrap provided earlier return to pre-injury function compared with Stirrup alone, elastic wrap, or walking cast.

• Grade III sprains

• Stirrup brace returned to pre-injury function in the same time as walking cast for 10 days followed by the use of an elastic wrap.

• After 6 months, all treatments produced comparable outcomes in terms of clinical testing, activity level, functional status, and patient satisfaction.

A Prospective, Randomized Clinical Investigation of the Treatment of First-Time Ankle Sprains

Bruce D. Beynnon,PhD, Per A. Renström, MD, PhD, Larry Haugh, PhD, Benjamin S. Uh, MD, and Howard Barker, MDThe American Journal of Sports Medicine, Vol. 34, No. 9, 2006

Cochrane ReviewsImmobilisation and functional treatment for acute lateral ankle ligament injuries in adults

Functional treatment with early mobilisation appears to provide improved outcomes for patients compared with immobilisation.

Different functional treatment strategies for acute lateral ankle ligament injuries in adults

The use of an elastic bandage seems preferable to the use of tape.

The use of a semi-rigid ankle support seems preferable to the use of an elastic bandage.

No definite conclusions about optimal functional treatment strategy can be drawn.

• Adult pts with grade 2-3 ankle sprains seen within 3 days of ED visit

• Randomized to 10 days of:

• tubular compression, stirrup aircast, walker boot, below knee cast.

• Outcomes: symptom self report, lifestyle, stability, health service usage,

• Adverse effects:

• 3 DVT: aircast, tubular, cast

• 2 PE: tubular, aircast

• 2 Cellulitis: aircast, walker boot

Mechanical supports for acute, severe ankle sprain:a pragmatic, multicentre, randomised controlled trial

S E Lamb, J L Marsh, J L Hutton, R Nakash, M W Cooke, on behalf of The Collaborative Ankle Support Trial (CAST Group)*

Lancet 2009; 373: 575–81

Conclusion

•A short period of immobilisation in a below-knee cast or Aircast brace resulted in faster recovery than if the patient is only given tubular compression bandage.

•Self reported severity of symptoms as 1 and 3 months.

•Walker boot was less effective that both brace and cast???

•Limited differences over 9 months

•Tensor was consistently the worst.

Mechanical supports for acute, severe ankle sprain:a pragmatic, multicentre, randomised controlled trial

S E Lamb, J L Marsh, J L Hutton, R Nakash, M W Cooke, on behalf of The Collaborative Ankle Support Trial (CAST Group)*

Lancet 2009; 373: 575–81

Ankle Sprains in Athletic PatientsMy Suggested Approach

• Depends on patient and on $$$

• PRICE with tensor early and weightbearing as tolerated

• Brace: can expect to use for many months if active.

• Low grade sprain: soft brace.

• High grade sprain: stirrup followed by soft brace.

• Physiotherapy for all except minor sprains

• Protected range of motion early

• Inversion / Eversion strength training

• Proprioception training (balance progressing from flat to uneven surfaces)

Ankle Sprains in Athletic Patients

My Ideal Approach

• Follow up with GP (or someone)

• Ongoing pain in 10-14 days (repeat x-rays)

• Mechanical symptoms (locking, clicking, catching)

• Recurrent unexplained swelling

• When its not getting better:

• Inadequate Rehab / Stiff joint

• Osteochondral defects

• Tendinopathy / Tendon tears / Subluxing

• Syndesmosis injuries (high ankle sprain)

• Synovitis

• Sinus tarsi syndrome

Ankle Sprains: Bracing OptionsThe two choices I think are good for emerg

referal

ASO EVO: soft brace with strapping optionsProvides comfortable long term stability

Indicated for all moderate sprains to allow return

to activity. Expect to wear for 6 to 18 months depending on severity of sprain and activity.

Aircast Air-Stirrup: Provides excellent lateral stability while allowing dorsi/plantar flexion.

Should be suggested for significant sprains as will allow much faster return to daily activity.

Can be worn longterm, but probably not as comfortable as ASO-EVO for sports.

ACL Physical Exam

• History is key!!!!• Particularly in chronic

• Range of motion• Effusion• Tender joint line• Tender femoral condyles

• Stability• MCL / LCL• Anterior Drawer• Lachman• Pivot Shift

QuickTime™ and a decompressor

are needed to see this picture.

QuickTime™ and a decompressor

are needed to see this picture.

ACL Reconstruction

• Should everyone get repair

• Early Surgery:

• Faster return to normal function / sport.

• Less risk of further articular damage resulting from episodic instability

• Less muscle atrophy

• Delayed Surgery:

• Improved range of motion pre-op

• Recovery of surrounding tissue / injury

• Less arthofibrosis

• Young (25yr), active subjects with acute ACL tear

• Randomized to rehab plus and early (<2.5 months) vs. optional delayed reconstruction.

• No difference in functional outcome.

• 50% of delayed group went on to have reconstruction at average of 10 months.

• Supported by systematic review

• Many varied outcome measures: stability, pain, arthritis

A Randomized Trial of Treatment for Acute Anterior Cruciate Ligament TearsRichard B. Frobell, Ph.D., Ewa M. Roos, P.T., Ph.D., Harald P. Roos, M.D., Ph.D., Jonas Ranstam, Ph.D.,

and L. Stefan Lohmander, M.D., Ph.D.

N Engl J Med 2010;363:331-42.

Important Discharging the Suspected Ligamentous Knee Injury

• Bony edema / meniscus injury hurts.• Weight bearing guided by pain.• Immobilizer only to ambulate (Must not use when at home no

weightbearing)• MOBILIZE joint at home (Essential to decrease swelling)• PRICE

• Follow-up for re-exam.• effusion should be decreased• Range should be improved

• Locking in extension• get off it• seek care

• Definite tear: refer to ortho directly• Possible tear: sports med in 1-2 weeks