Presentation on theme: "“Don’t Miss” Musculoskeletal Injuries"— Presentation transcript:
1 “Don’t Miss” Musculoskeletal Injuries Chris G. Pappas, LTC, USA, MCLecture adapted and revised from:LTC Fred H. Brennan, Jr., DO, FAOASM, FAAFP
2 GoalsBecome familiar with three “don’t miss” upper extremity musculoskeletal injuries.Become familiar with three “don’t miss” lower extremity musculoskeletal injuries.Utilize this knowledge in the evaluation and treatment of patients.
3 Case #121 year old female volleyball player dove for a low ball and fell on outstretched right handImmediate wrist pain and pain with attempts at dorsi and palmar flexionNo gross deformityWhat is the possible diagnosis based on this mechanism of injury?
4 Case #1 Wrist sprain Scaphoid fracture Distal radius or ulna fracture Distal R-U joint disruptionTFCC tearCarpal ligamentous injury
5 Case #1 What next? Is an x-ray needed? Exam Inspection, Range of motion, Neurovascular status, PalpationIs an x-ray needed?
7 Scapho-Lunate Dissociation Disruption of scapho-lunate ligamentFOOSH injuryTender over scapho-lunate interval+ Watson’s clunkLimited dorsiflexion> 3 mm diastasisScapholunate angle > 60 degrees
8 Watson’s Test of the Wrist (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 tuberclePainful click or clunk
9 Treatment PRICE-M Thumb spica splint Avoid wrist pronation-supination Pain controlRefer to ortho hand within 72 hours
10 Complications if Missed Chronic wrist painLoss of function and motionOsteoarthritis
13 Scaphoid Blood supply arises distally Fractures of middle and proximal portion prone to nonunionGet a scaphoid view if suspectedIf initial film negative, but still suspected treat as a fracture and follow up with plain films or more advanced imagingMay be casted for up to 3 months
14 Case #238 year old male got his right ring finger caught in a player’s shirt while playing touch footballFelt pop in his finger and developed painNow in your clinic 4 hours laterWhat are the possibilities?
15 Case #2 Jammed finger Fracture DIP or PIP dislocation Mallet finger Jersey finger
16 Exam --Finger held in forced extension --Tender along volar aspect of DIP--Unable to flex DIP
25 Acute Compartment Syndrome Serious limb and life threatening conditionFractures, burns, crush injuries, arterial injuriesHand, forearm, arm, shoulder, back, thigh and foot
26 Acute Compartment Syndrome Increased pressure within closed compartmentsCompartments of lower legBe careful with splinting and casting
27 Diagnosis High index of suspicion: pain out of proportion Six P’s Pain, Pulseless, Paresthesia, Poikilothermy, Pallor, ParalysisLoss of normal sensation is a red flagTight compartmentsPressure> 30 mm Hg
29 Complications if Missed RhabdomyolysisAcidosisIschemic contracturesHyperkalemiaDIC and sepsisLoss of limbDeath
30 Case #426 year old sergeant playing basketball and “jammed” his left middle fingerPain and swelling of middle finger PIP joint (global)Pain with resisted flexion and extensionWhat are the possibilities?
31 Case #4 Fractured phalanx Extensor tendon rupture Volar plate injury Tear of central band of extensor tendonMallet fingerPIP dislocation
32 Exam Swollen PIP middle finger Tender over PIP, more so dorsally Pain with resisted extension over the PIPNo neuro compromiseFlexor tendons strength is 5/5Collaterals of PIP intactDIP intact to flexion/extension
52 Femoral neck stress fracture Groin pain in runner or jumper- don’t ignoreFemale triad at increased risk as well as those with an increase in training and postmenopausal womenNeed to know which side the stress fracture is on (compression vs tension side)Plain films often negativeGet MRI
53 Treatment If stress fracture by x-ray or further imaging Compression side12 weeks to heal +/- NWBTension sideOrtho consult/surgeryFemoral neck fracture-surgeryCross trainProper nutrition and calories
54 Complications if Missed Stress to complete fractureAvascular necrosisChronic painEnd of career
55 Take Home Points Fall on outstretched hand, think: Distal forearm fx. Scaphoid fxTFCCAP, Lat, Scaphoid and clenched fist viewsScapho-lunate dissociation
56 Take Home PointsGrab injury with pain at distal phalynx, think jersey fingerCrush injury or worsening pain with immobilization, think ACS“Jammed” PIP…always test extension with resistance
57 Take Home PointsMid-foot pain and inability to weight bear after foot axial load or twist, think Lisfranc injuryPersistent groin pain, especially in runner or jumper, rule out stress fracture of hip or pelvis