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Board Review 2/1/2013. We are going to do Adolescent for the next two board reviews….yay! Who likes adolescents? A. I do! They are amazing! B. A 17 yr.

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Presentation on theme: "Board Review 2/1/2013. We are going to do Adolescent for the next two board reviews….yay! Who likes adolescents? A. I do! They are amazing! B. A 17 yr."— Presentation transcript:

1 Board Review 2/1/2013

2 We are going to do Adolescent for the next two board reviews….yay! Who likes adolescents? A. I do! They are amazing! B. A 17 yr old female with abdominal pain is my worst nightmare

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4 Sports participation is increasing. The benefit of playing sports is multi-factorial Children involved in sports learn leadership and cooperative skills. Organized sports can be a source of needed physical activity. Pre-participation evaluation (PPE) Utility has been questioned, as it likely does little to prevent morbidity and mortality in screened athletes However…the AAP endorses these exams because it allows for establishment of a medical home and more effective well child care!

5 The PPE is required before practice and play by most sporting organizations Typically required every 1-2 years (for middle and high school athletes) To shield the organization from liability To ensure that the athlete can participate safely in sports Should be scheduled at least 6 weeks in advance to allow time for appropriate follow-up if warranted Various formats Office-based with the pediatrician Station-based at the school

6 Similar to typical history obtained at WCC PMH, PSH, social history, developmental history ALWAYS important to get the parents input, as there are often inconsistencies

7 Medications: Review all medications and determine if any are banned substances, which may require a therapeutic use exemption (TUE) Musculoskeletal: current injuries; any history of injury requiring evaluation, casting, bracing, surgery, or missed practice/play >90% sensitive at identifying musculoskeletal injuries Pulmonary: Baseline lung disease, exercise induced asthma, vocal cord dysfunction, etc. Neurologic: any history of concussion, stingers, cervical cord damage/symptoms

8 Dermatologic: ask about skin wounds/infections and ensure proper resolution before return to play (especially contact) Ophthalmologic: Patients may require appropriate lenses for a specific sport (ie. contacts only for wrestling, boxing, and rugby). If best corrected vision is worse than 20/40 in one eye (functionally one-eyed), must wear approved eyewear! ID: Mononucleosis precludes from sports for 3-4 weeks, HIV/hepatitis or other blood-borne illness does not preclude…universal precautions Heat illness: past diagnosis increases future risks

9 Genitourinary: Few components of the GU history will disqualify an athlete or require modified participation. Solitary or horseshoe kidney require individual assessment for contact or collision sports Protective equipment Risks v. benefit Pain in inguinal canal region suggesting hernia Female athlete triad: Disordered eating Amenorrhea Osteoporosis Psychological: Eating disorders (especially in weight restricted sports and aesthetic sports), depression/anxiety, ADHD (meds)…

10 Which of the following would NOT require referral to a cardiologist before clearing your patient for sports participation? A. Known congenital heart disease B. Marfan Syndrome C. A 2/6 systolic vibratory/musical quality murmur at the left lower sternal border D. Family history of prolonged QT syndrome E. Cardiomyopathy

11 Component of the PPE that receives the most attention The AHA recommends particular components of the cardiovascular history and exam prior to sports participation.

12 Red flags that need investigation by cardiology! Known congenital heart disease Channelopathies (long QT or Brugada Syndrome) History of myocarditis or coronary anomalies (ie. Kawasaki disease) Family history of sudden cardiac death Marfan syndrome Cardiomyopathy Must be worked up by PCP or Cardiology… Syncope, near-syncope Chest pain, palpitations, excessive SOB or fatigue with exertion

13 ALL patients with syncope should have an EKG, with further testing as indicated. Post-exertional syncope Common Benign condition that should be differentiated from exercise-associated collapse Exercise-associated collapse Occurs DURING exertion An ominous sign of hemodynamically significant cardiovascular disease or ventricular tachyarrhythmias

14 Vital Signs: often different than non-athlete…low HR, wide pulse pressure, low resting RR BP should be normal, and any elevation requires evaluation and treatment Mild-moderate HTN (>95%): encourage sports Severe HTN (>5mmHg over the 99%): disqualify from sports with high static demand, heavy weights and powerlifting HEENT: Visual acuity (special protection if not better than 20/40), auricular cartilage, nasal septum…ENT referral if damaged Neurologic: Any past history should prompt a thorough exam Musculoskeletal: the PE adds little diagnostic value to the history, cursory evaluate strength and ROM if no complaints

15 Genitourinary: not necessary in female unless complaints; for males… Bilateral testicles? If only one testicle…protective cup. Inguinal hernia exam in patients history of groin pain. Cardiovascular: Any cardiac abnormality that is not clearly benign should be FULLY evaluated by a cardiologist before sports participation. Screening echo and EKG are NOT part of the PPE.

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17 As the sports physician for the local high school football team, you are asked to lecture some coaches on safe sports participation. Which of these do you counsel them is an ABSOLUTE contraindication to playing football? A. Seizure disorder B. Diabetes mellitis C. HIV D. Febrile illness E. Sickle cell disease

18 Any condition that cannot be well-controlled and puts the athlete at risk of significant injury or death OR endangers the health of teammates or competitors requires further evaluation and disqualification from a sport. The PCPs first responsibility is to ensure the safety of the patient BUT…the physical and psychological benefits of exercise and sports participation should also factor into the decision to restrict sports participation for a patient. IF a physician disqualifies an athlete from one sport, he/she should attempt to direct them to another sport!

19 ABSOLUTE contraindication to both sports practice and competition! Puts athlete at risk Acute heat illness Reduced maximal exercise capacity Hypotension Decreased PVR Possible dehydration

20 You are seeing a 5 yo male with Down Syndrome. He is participating in the Special Olympics in a few months. Which test do you want to order before clearing him for participation? A. Echocardiogram B. EKG C. Pulmonary function tests D. MRI of the neck E. Cervical spine X-rays

21 Children with Down Syndrome often require interdisciplinary care to maximize their health outcomes and quality of life. Cervical Spine Instability Primarily atlantoaxial but also occipitoatlantal Reported in up to 30% of patients MUST get radiographic evaluation of the cervical spine before sports participation! NO collision sports, even if normal films Abnormal x-rays: disqualify from neck stressing sports (diving, butterfly stroke, gymnastics, high jump, soccer) Other medical conditions should be evaluated, too

22 Well-controlled seizures Should NOT be disqualified from sports participation. Think of return to driving laws and necessary seizure- free interval! Poorly controlled seizures Individual assessments should be made to determine suitability for contact/collision sports AVOID Archery, riflery Power lifting, weight lifting, weight training Swimming Sports involving heights (parachuting, hang-gliding)

23 Patients are allowed to participate in sports without restriction. Monitoring and treatment often becomes more complex with the varying demands of organized sports! Careful evaluation and monitoring are essential Blood glucose Check more frequently Q30 minutes during continuous exercise, 15 minutes after completion, and at bedtime Diet Insulin dose and type Hydration status

24 Which of the following patients with a known medical condition is NOT disqualified from sports participation? A. Cardiomyopathy B. Hypermobility Ehlers-Danlos syndrome C. Acute Kawasaki disease D. Severe aortic stenosis E. Severe aortic regurgitation

25 Conditions that DISQUALIFY from sports participation Pulmonary vascular disease with cyanosis or significant right- to-left shunt Severe pulmonary stenosis (untreated) Severe aortic stenosis or regurgitation (untreated) Severe Mitral stenosis or regurgitation (untreated) ANY cardiomyopathy Vascular Ehlers-Danlos syndrome Coronary anomalies (especially anomalous origin) Catecholaminergic polymorphic V-tach Acute pericarditis, myocarditis, or Kawasaki disease **ANY CV disease should be thoroughly evaluated and treated by a pediatric cardiologist to ensure safe participation in sports!

26 NO contact sports Splenomegaly Mono or mono-like illness: risk of splenic rupture Any athlete with this illness should be disqualified from sports with risk of abdominal trauma for 3-4 weeks after symptoms start Acute hepatomegaly Contagious skin lesions (until treated and resolved) Single organs Kidney (single or horseshoe) Avoid high contact sports Individual assessment required for other contact/collision sports (weigh risk v. benefit) Others Appropriate protective gear.

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28 Caused by an inability to maintain a normal body temperature Excess heat production Decreased heat transfer to the environment Normal heat transfer mechanisms are overwhelmed and central thermoregulatory control is ineffective Heat stroke = MEDICAL EMERGENCY Arises when cellular injury is caused by the excess body temperature Core temp > 105.8 (41C) for more than a short time = thermal injury Proteins denatured Injured cells undergo apoptosis or necrosis

29 Which of the following clinical findings typically distinguishes heat exhaustion from heat stroke? A. Severe neurologic dysfunction B. An elevated core temperature C. Signs of dehydration D. Nausea and vomiting E. Confusion

30 Heat stress Discomfort and physiologic strain from exposure to a hot environment Core temperature remains within the normal range Decreased exercise performance but usually no other symptoms Heat Exhaustion Elevation of core body temperature (100.4-104) after strenuous exercise OR exposure to high temperatures Mild dehydration, +/- sodium abnormalities Intense discomfort, confusion, thirst, nausea, and vomiting NO severe neurologic symptoms Heat Stroke Elevation of core body temperature >104 Neurologic dysfunction Symptoms: dry skin, dizziness, confusion, syncope

31 The incidence of heat stroke is greater during periods of unusually high temperatures. This is compounded for young children and infants because they have less tolerance to exercise than adults when air temperature is greater than body temperature! Risk factors Prolonged exertion in a warm, humid environment Dehydration Infants and young children: over-bundling or left in cars during the summer Disabled patients and elderly (cant remove themselves from environment

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33 Should be considered in any patient with significant core temperature elevation (>104) and mental status changes.

34 Multi-system illness Elevated temperature CNS dysfunction: delirium, coma, seizures Severe damage not observed until the rectal temp > 105.8 Hypotensive shock Initially due to peripheral vasodilation Later because of cardiac damage GI: swelling, hemorrhage, and hepatic damage Renal failure Prerenal azotemia with BUN:Cr ratio >20 Hematologic abnormalities: anemia, thrombocytopenia, coagulopathy

35 What is the MOST important FIRST step in treating your patient with heat illness? A. Volume resuscitation with IVF boluses B. Immersion in ice water to drop temperature C. Removal from heat and cessation of exercise D. FFP and platelets E. Immediate intubation even if the patient is breathing adequately initially

36 Phase 1: Immediate removal from the heat source, cessation of exercise, and hydration Phase 2: Cool the patient to < 104 as rapidly as possible to prevent ongoing injury Immersion in ice water may be most effective If not practical…simple evaporative cooling May be as effective as some active cooling measures Less uncomfortable for the patient Phase 3: Supportive Care

37 Shock IV rehydration for all heat stroke and MOST heat exhaustion (can use chilled IVF if temp > 104) Vaspressors Hematologic and coagulation abnormalities Monitor CBCs and coags FFP and platelets if bleeding occurs Neuro changes Anti-seizure meds: phenytoin often used Close Na control to decrease risk of cerebral edema Respiratory failure is usually central, and minimal vent support is usually required Hepatic damage typically resolves spontaneously; liver transplant is a last resort

38 What is the most likely long-term outcome that you will see in a patient who has suffered from a moderate-to-severe heat stroke? A. Chronic renal failure B. Hepatic dysfunction requiring liver transplant C. Persistent anemia and thrombocytopenia D. Death E. Behavioral changes and poor coordination

39 Mild heat stroke: generally recover uneventfully with normal neurologic function when tested several months later Moderate-to-severe heat stroke: Risk of sequelae is higher, especially if core temp > 107.6 Generally recover from hepatic and renal injury Neurologic injury is often permanent Behavior changes Impaired memory Ataxic gait, poor coordination Dysarthria, decreased visual acuity Up to 1/3 with spasticity and pan-cerebellar syndrome Mortality for severe cases = 10%

40 Risk assessment with the heat index chart Recognizing signs of heat illness…excessive fatigue, confusion, muscle cramps at onset Proper hydration during ALL practices and competition!! Significant amounts of sodium are lost in sweat, so electrolyte replacement is essential Encourage liquids containing electrolyte solutions (sports drinks) Adults: 500mL within 2h prior to exercise, 250mL q20 minutes during exercise Acclimation to warm conditions 3-4 days before competing Light colored, loose fitting clothes

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42 Some sports place an emphasis on weight and body mass…either a lean image or a more muscular appearance. Youth often resort to unhealthy, pathologic dieting and exercise practices, supplement use, and drug ingestion to reach a desired weight. Healthy weight changes Weight loss: should not exceed 1.5% of total body weight/week or 1-2 pounds/week Weight loss beyond these guidelines causes breakdown of muscle, resulting in muscle weakness Appropriate diet for most athletes = minimum of 2000 kcal/day

43 Preventative conditioning should include both aerobic conditioning and strength training. The most significant risks to athletes involve strength training, but this can be minimized High repetition with low resistance 1 st teach proper technique with no weight Add small weight increments as strength increases 20-30 minute sessions, 2-3 days per week Power lifting programs should NOT be undertaken by preadolescents (middle school) because of the risk of injury…immature skeletal system Muscle strain Epiphyseal injury to the wrist Apophyseal injury

44 Quadriceps Trauma can be associated with a significant amount of blood lost into a deep hematoma of the thigh Rarely enough to cause hypovolemia or VS changes Complications Myositis ossificans (up to 9%) Bone formation in injured muscle 3-4 weeks later Firm, nontender swelling Peripheral calcification on plain radiograph Typically resolves over months; may rarely require surgical excision Treat any hematoma with ice, compression, NSAIDs, and early mobilization!

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46 Closed head injury is a common medical problem in young athletes Yet majority of concussive episodes are not reported Incidence is unknown but roughly 300,000 cases per year in the US High and medium-contact sports carry a greater risk for head injury compared to noncontact sports

47 Which of the following is NOT characteristic of a concussion? A. Impairment of neurologic function resolves with aggressive cognitive reconditioning B. Pathophysiology involves traumatic biomechanical forces C. Neuropathologic changes are more indicative of functional derangement rather than structural injury D. Neuroimaging typically is grossly normal E. Symptoms can include confusion, amnesia, and insomnia

48 Significant head injury which causes an alteration in consciousness Confusion, amnesia, visual or hearing impairment, irritability and mood changes, difficulties with balance, headache, lethargy, insomnia, memory impairment, n/v Neurologic impairment is rapid onset, short-lived, and tends to resolve spontaneously Neuroimaging is grossly normal Multiple tools available to grade the severity

49 Which of the following statements regarding the understanding and management of a head injury is FALSE? A. A sequential progression of activity is a critical aspect of return to play criteria after a concussion B. A history of previous concussion is irrelevant to the management of a current concussion C. Postconcussive syndrome can happen even after a minor concussion D. Patients with persistent signs and symptoms of concussion should be referred for neuropsychological assessment E. Second impact syndrome is associated with a mortality rate of 70-80%

50 For patients with persistent signs and symptoms or for symptoms that recur with exertion Neuropsychological assessment Postconcussive Syndrome Residual symptoms from a concussion Can exists after ANY grade of concussion Second Impact Syndrome A second closed head injury while the patient is still symptomatic from the first injury Rapid and progressive brain injury 70-80% mortality

51 When players symptoms have resolved AND when he/she has demonstrated the ability to progress stepwise through several levels of activity without recurrence of symptoms Advancement between steps ONLY if there are NO symptoms If symptoms do recur, the athlete should rest for 24- 48hrs before trying to progress again Each regimen should be individualized to each athlete and progress monitored by those with appropriate training

52 Complete rest; mental and physical Light (low-intensity) aerobic exercise such as walking; NO resistance Activity specific to the sport such as running or skating; may add minimal resistance Training drills without contact, followed by mental status testing Full-contact training after clearance by medical personnel

53 Which of the following sports accounts for the greatest percentage of cervical spine injuries in the youth in United States? A. Synchronized diving B. Wrestling C. Soccer D. Boxing E. Football

54 C-spine injuries occur most often in medium and high-contact sports Typically occur through a head-first mechanism In the US: football poses greatest risk for injury 50% of ALL c-spine injuries **dont forget about water sports!!** Preparation: On-site emergency personnel (or ability to access EMS) Discussion with a certified athletic trainer Immobilization equipment available Understanding of the steps required to manage an acute cervical spine injury

55 Initial Management ABCs!! Remove face mask to assess airway Do NOT remove helmet or shoulder pads These help ensure neutral alignment of the c-spine If found prone, log roll to supine position One person at head; two at body Head turns at same speed as the body Improper handling of a neck injury increases the risk for neurologic deficiency**

56 In all patients with suspected c-spine injury Keep neck immobilized until bony injury can be ruled out Xrays of the c-spine: 5 views AP Lateral Flexion Extension Odontoid

57 Return to play criteria after suspected c-spine injury with NORMAL radiographic findings: No pain with motion of the cervical spine No pain with palpation of the cervical spine No report of radicular symptoms emanating from the cervical spine Results of all neurologic examinations and associated tests are normal **Must be evaluated by a physician prior to return to play**

58 First step in diagnosis: an accurate history Most common mechanism is inversion Eversion injury associated with more severe injury Most common reason for ankle injury is incomplete healing of previous injury

59 Which of the following injuries is the most likely in an athlete with open growth plates who has inverted their ankle during play? A. Fracture of the 5 th metatarsal B. Rupture of the achilles tendon C. Sprain of the posterior talofibular ligament D. Fracture of the fibular physis E. Dislocation of the ankle

60 Physical exam: Observation and inspection Watching the patient walk can help differentiate between a ligament injury or a more serious fracture Ankle exam Inversion mechanism: injury to lateral portion of foot and ankle Anterior and posterior talofibular ligaments Proximal 5 th metatarsal

61 Inverted ankle injury in a patient with OPEN growth plates Fracture of the fibular physis (growth plate)** MOST LIKELY injury in this type of patient MORE common than a sprain in this age group!! On exam: pain on palpation of lateral ankle X-rays must be obtained for any suspected bony injury Ankle: 3 views Foot: 3views if 5 th metatarsal fracture is suspected

62 Which of the following is NOT part of the management for uncomplicated ankle injury (no bone specific tenderness; normal xrays) A. Rest, Ice, Compression, and Elevation for the first 5-7 days B. A process of ankle mobilization over time that begins with range of motion movements of the ankle C. Progressive strengthening of the ankle using a device such as an elastic band D. Referral to physical therapy if the pain persists for more than 2-3 weeks E. Allowing complete healing of the ankle injury prior to returning to play

63 Management of uncomplicated ankle injury (No bone-specific tenderness) RICE (rest, ice, compression, elevation) for the first 48hrs Progressive ankle mobilization Start with ankle movement Trace alphabet with first toe Strengthening exercises Elastic band to flex against resistance 3 sets of 15 repetitions; daily for 6 weeks If ankle injury persists after a few weeks refer to physical therapy

64 Answer must be NO to all questions: Is there any limitation of normal athletic function with the injury? Is there any ongoing swelling or loss of motion in the affected joint? Has the proper preventative strategy been employed? i.e. Ankle strengthening for ankle injuries Applies to any injury to shoulder, knee, stress fracture, shin splints, as well

65 Free of pain and swelling before and after exercise Full range of motion, flexibility, and stability 95% of normal strength Recommend a stepwise return to competition Gradual increases in duration and intensity of practice

66 Pediatric and adolescent athletes who have sustained knee injuries often present initially to their primary care doctor Damage to the bone, ligaments, or cartilaginous structures may occur, depending on the mechanism of injury

67 Which of the following clinical tests would be most appropriate in diagnosing an MCL tear? A. Inspection and range of motion B. Lachman test C. Anterior drawer test D. McMurray test E. Valgus stress test

68 Age / Gender Mechanism of injury/ Sport Exam findingsImagingTreatmentRefer? Tibial tubercle fracture M>F 14-16 yrs Tubercle growth plate weak during puberty; sudden deceleration or quadriceps contraction fracture Knee held in flexion, point tenderness+/- swelling Lateral xray of knee shows fracture Immobilize, non-weight bearing; Refer to ortho Yes Osgood-Schlatter M>F 9-14yrs Chronic excessive force on tibial tubercle; rapidly growing adolescents; jumping and squatting Tenderness and swelling over tibial tubercle Lateral knee xray can show swelling and fragmentation of tibial tubercle Rest, ice, NSAIDs Self-limited Resolves once growth plates close If conservative management fails ACL tear F>MSudden deceleration and twisting of the knee (cutting and pivoting) +Lachman +anterior drawer Early: Inability to bear weight, effusion, Late: knee instability Xray: avulsion fx of lateral tibial plateau MRI Immobilizer, non-weight bearing Elective outpatient referral in 7- 10days MCL tear M=FValgus force on the knee with foot planted; often during collision or awkward fall +Valgus stress testing shows laxity of MCL Medial knee pain MRI for equivocal cases Rest, ice, NSAIDs, crutches Hinged knee- brace acutely, followed by early mobilization and PT If conservative management fails

69 Anterior drawer test Leg at 90 degrees Foot stabilized Grasp proximal tibia Pull leg forward Lachman test Flex knee to 15-30 degrees Pull tibia forward with one hand Hold femur stationary Excessive anterior tibial forward motion on either test signifies ACL injury

70 Age / Gender Mechanism of injury/ Sport Exam findingsImagingTreatmentRefer? Tibial tubercle fracture M>F 14-16 yrs Tubercle growth plate weak during puberty; sudden deceleration or quadriceps contraction fracture Knee held in flexion, point tenderness+/- swelling Lateral xray of knee shows fracture Immobilize, non-weight bearing; Refer to ortho Yes Osgood-Schlatter M>F 9-14yrs Chronic excessive force on tibial tubercle; rapidly growing adolescents; jumping and squatting Tenderness and swelling over tibial tubercle Lateral knee xray can show swelling and fragmentation of tibial tubercle Rest, ice, NSAIDs Self-limited Resolves once growth plates close If conservative management fails ACL tear F>MSudden deceleration and twisting of the knee (cutting and pivoting) +Lachman +anterior drawer Early: Inability to bear weight, effusion, Late: knee instability Xray: avulsion fx of lateral tibial plateau MRI Immobilizer, non-weight bearing Elective outpatient referral in 7- 10days MCL tear M=FValgus force on the knee with foot planted; often during collision or awkward fall +Valgus stress testing shows laxity of MCL Medial knee pain MRI for equivocal cases Rest, ice, NSAIDs, crutches Hinged knee- brace acutely, followed by early mobilization and PT If conservative management fails

71 Medial-sided knee pain Varying degree of tenderness to palpation Effusion and local ecchymosis may be present ROM is normal MCL integrity tested by valgus stress testing in full extension AND at 30 degrees of flexion text At extension: knee remains stable as long as the cruciate ligaments and posterior capsule are intact At 30 degrees: MCL is primary stabilizer

72 Which of the following is an indication to refer a patient with prepatellar bursitis to an orthopedic surgeon? A. Swelling superficial to the patella that extends outward > 1cm B. Negative findings on an xray C. Patients with significant erythema, tenderness, and swelling with a fever of 103.2 0 F D. Pain despite treatment with tylenol x 1 day E. The biggest game of the season is tomorrow and they really really want to play

73 Age / Gender Mechanism of injury/ Sport Exam findingsImagingTreatmentRefer? Discoid meniscus M=F 4-9yrs Abnormally shaped meniscus No history of trauma Symptoms exacerbated by physical activity snapping or popping of knee +McMurray test Xrays normal MRI shows bow-tie shape of meniscus Supportive; refer if pain prevents physical or daily activity Yes if pain prevents physical or daily activity Osteochondritis dissecans M>F 10-13yrs Unknown cause; Destruction of subchondral bone on undersurface of normal articular cartilage Necrosis of articular surface of joint Separation of overlying cartilage Can result in fragmentation of the affected bone Stable: Joint pain aggravated by activity; Unstable: Have feeling of joint instability but none found on exam; +/- point tenderness, +/- effusion Xrays to evaluate joint surfaces and patella MRI (test of choice) shows extent of lesion Stable lesion: activity modification, NSAIDs Unstable: refer for surgery For unstable lesions or failure of conservative management Prepatellar bursitis M>FRepeated kneeling (baseball catcher, wrestler) leads to inflammation of the prepatellar bursa Swelling, tenderness, erythema of prepatella Pain with knee flexion Not usefulRest, ice, compressive dressing Large fluid collection can be aspirated For septic bursitis or failure of conservative management

74 McMurray test Usually positive with meniscal abnormalities Hip flexed to 90 degrees and knee maximally flexed Knee extended gradually while applying valgus force and external rotation of tibia Provides axial load and rotational force to the meniscus painful

75 Age / Gender Mechanism of injury/ Sport Exam findingsImagingTreatmentRefer? Discoid meniscus M=F 4-9yrs Abnormally shaped meniscus No history of trauma Symptoms exacerbated by physical activity snapping or popping of knee +McMurray test Xrays normal MRI shows bow-tie shape of meniscus Supportive; refer if pain prevents physical or daily activity Yes if pain prevents physical or daily activity Osteochondritis dissecans M>F 10-13yrs Unknown cause; Destruction of subchondral bone on undersurface of normal articular cartilage Necrosis of articular surface of joint Separation of overlying cartilage Can result in fragmentation of the affected bone Stable: Joint pain aggravated by activity; Unstable: Have feeling of joint instability but none found on exam; +/- point tenderness, +/- effusion Xrays to evaluate joint surfaces and patella MRI (test of choice) shows extent of lesion Stable lesion: activity modification, NSAIDs Unstable: refer for surgery For unstable lesions or failure of conservative management Prepatellar bursitis M>FRepeated kneeling (baseball catcher, wrestler) leads to inflammation of the prepatellar bursa Swelling, tenderness, erythema of prepatella Pain with knee flexion Not usefulRest, ice, compressive dressing Large fluid collection can be aspirated For septic bursitis or failure of conservative management

76 Common cause of chronic anterior knee pain Athletes who engage in running, jumping, squatting** Females> males Wider pelvis higher Q angle more susceptible to PFS Q angle Angle between a line from the anterior superior iliac spine (ASIS) to the patella and a line from the patella to the tibial tubercle

77 Of the following, which is not an initial treatment for Patellofemoral Syndrome? A. Knee bracing and patellar taping B. NSAIDs C. Outpatient referral to orthopedics in 7-10 days D. Physical therapy E. Core strengthening

78 Present with vague anterior knee pain Worse with activities that require knee flexion with weight bearing Stairs, deep squatting, crawling Diagnosis/ Imaging History and physical exam Imaging only useful to exclude other conditions Treatment: Goal to improve patellar tracking Knee bracing, patellar taping PT: iliotibial band stretching, medial quad strengthening Core strengthening to improve pelvic control and minimize medial knee deviation Refer to Ortho If 4-6 months of PT do not provide relief

79 Overuse injuries Eye injuries Protective equipment Shoulder, Elbow, Wrist injuries

80 Overuse injuries are common in child athletes Characterized by repetitive microtrauma to bone and tendon Gymnasts sustain foot and hand injuries due to frequent load bearing during handstands, etc Overuse injury of the radius is common Major concern is radial epiphysitis which may result in impaired linear growth of the affected bone** Necrosis of the navicular bone is seen with fracture (usually occult) May also cause impaired growth of the wrist in children and limit movement Watch for Salter Harris fractures

81 Treatment: Rest, ice, and anti-inflammatory medications Exercise that does not aggravate the injury but preserves conditioning may be continued during recovery Can be prescribed for the athlete by the coach and trainer, often in consultation with a sports medicine specialist

82 Evaluation of an eye injury must happen before return to play** Initial evaluation: Identification of the timing, mechanism, and location of the injury Assessment of visual symptoms Change in vision? Flashing lights or floaters? Physical examination Initial management directed at preventing any increase in intraocular pressure** NO direct pressure to the eye Eye protection using an eye shield Patient positioning Recumbent positioning with the head of the bed at 45 degrees Avoid meds that increase IOP I.e. Ketamine

83 Eye examination: Inspect the face/lids for injury Lid contusions and lacerations should raise suspicion for globe or orbital injury Palpate rim of the orbit for deformities EOM Evert the lid to look for foreign material Visual acuity with a Snellen chart Evaluation of the globe: Inspection of the conjunctivae for foreign bodies and hemorrhage Cornea: assessed with a penlight and fluorescein stain/blue light for abrasions or evidence of penetration Pupils: reaction and symmetry Abnormally shaped pupil strongly suggests the presence of an open globe** Anterior chamber/iris/lens should be inspected with a penlight and, if possible, slitlamp Look for hyphema, uveitis, or lens dislocation Lastly, the fundus should be examined

84 Collection of blood in the anterior chamber of the eye between the iris and the cornea Visual disturbances, photophobia, eye pain Nausea, vomiting, lethargy Treatment Goals: Prevent rebleeding and prevent increased IOP Consult Ophtho (this is an emergency) Protective eye SHIELD (not occlusive dressing) Recumbent positioning – head at 30-45 o No medications into the eye Avoid NSAIDs for potential effects of platelet function

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87 Mouth injuries (along with other head injuries) account for the majority (48%) of youth baseball injuries Injuries generally are caused by contact with sports equipment (eg, the bat, the ball, and the base) Other injuries Leg, groin, and chest Testicular injury: less common Use of a protective cup in ALL sports is recommended to prevent testicular injury

88 Even with the use of a helmet, mouth guards protect further against injuries of teeth and oral mucosa The American Association of Orthodontists recommends that mouth guards be used for the following sports: baseball, football, soccer, basketball, wrestling, softball, ice and field hockey, volleyball, and lacrosse

89 Most are sports related Most involve anterior displacement of the humeral head Resulting from posteriorly directed force on an abducted, extended arm Arm is held slightly abducted and external rotation Humoral head may be palpated inferiorly to the mid-clavicle on the affected side Can compress the axillary nerve Numbness over the deltoid and inability to abduct or extend the shoulder Initial Management Sling immobilization with a pillow or blanket Analgesics Xrays: AP, lateral, axillary views (axillary is most sensitive) Should be reduced urgently under procedural anesthesia Sling and swathed after reduction for 2-4 weeks

90 Posterior elbow dislocation is the most common joint dislocation seen in children Fall onto outstretched hand with flexed elbow Elbow pain and olecranon prominence on exam Can cause nerve injury Most commonly affects the ulnar nerve (see in 10%) Decreased sensation over 5 th finger, loss of wrist flexion and finger abduction If seen need urgent reduction Can cause brachial artery injury Decreased radial pulse, pallor, forarm paresthesias If seen urgent reduction Acute management: Arm splinted, analgesia, referred emergently to ortho

91 Little League Elbow = elbow pain in skeletally immature athlete who participates in overhead sports (baseball, softball, swimming, gymnastics) Apophysitis of the medial epicondyle Seen most commonly in 9-12yr old athletes Swelling and tenderness on exam Xrays are typically normal Can show hypertrophy or fragmentation of the medial epicondyle or subtle apophyseal widening Treatment Rest for 4-6weeks Ice, oral analgesics Elbow brace for flexion contracture Once pain resolved completely, can slowing increase throwing activities under supervision Most athletes return to play after 12 weeks

92 Fall onto outstretched hand Tenderness over anatomical snuff box Initial xrays are often NORMAL Treatment: Thumb spica splint Ice, analgesia Follow up with ortho and repeat films in 7-10days High risk of malunion, nonunion, avascular necrosis This type of fracture has a poor prognosis

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