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“Don’t Miss” Musculoskeletal Injuries Chris G. Pappas, LTC, USA, MC Lecture adapted and revised from: LTC Fred H. Brennan, Jr., DO, FAOASM, FAAFP.

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Presentation on theme: "“Don’t Miss” Musculoskeletal Injuries Chris G. Pappas, LTC, USA, MC Lecture adapted and revised from: LTC Fred H. Brennan, Jr., DO, FAOASM, FAAFP."— Presentation transcript:

1 “Don’t Miss” Musculoskeletal Injuries Chris G. Pappas, LTC, USA, MC Lecture adapted and revised from: LTC Fred H. Brennan, Jr., DO, FAOASM, FAAFP

2 Goals Become familiar with three “don’t miss” upper extremity musculoskeletal injuries. Become familiar with three “don’t miss” upper extremity musculoskeletal injuries. Become familiar with three “don’t miss” lower extremity musculoskeletal injuries. Become familiar with three “don’t miss” lower extremity musculoskeletal injuries. Utilize this knowledge in the evaluation and treatment of patients. Utilize this knowledge in the evaluation and treatment of patients.

3 Case #1 21 year old female volleyball player dove for a low ball and fell on outstretched right hand 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 Immediate wrist pain and pain with attempts at dorsi and palmar flexion No gross deformity No gross deformity What is the possible diagnosis based on this mechanism of injury? What 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 disruption TFCC tear Carpal ligamentous injury

5 Case #1 What next? What next? Exam Exam Inspection, Range of motion, Neurovascular status, Palpation Inspection, Range of motion, Neurovascular status, Palpation Is an x-ray needed? Is an x-ray needed?

6 Wrist Xrays

7 Scapho-Lunate Dissociation Disruption of scapho-lunate ligament Disruption of scapho-lunate ligament FOOSH injury FOOSH injury Tender over scapho-lunate interval Tender over scapho-lunate interval + Watson’s clunk + Watson’s clunk Limited dorsiflexion Limited dorsiflexion > 3 mm diastasis > 3 mm diastasis Scapholunate angle > 60 degrees Scapholunate angle > 60 degrees

8 Watson’s 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

9 Treatment PRICE-M Thumb spica splint Avoid wrist pronation- supination Pain control Refer to ortho hand within 72 hours

10 Complications if Missed Chronic wrist pain Chronic wrist pain Loss of function and motion Loss of function and motion Osteoarthritis Osteoarthritis

11 Same patient

12 Scaphoid fracture

13 Scaphoid Blood supply arises distally Blood supply arises distally Fractures of middle and proximal portion prone to nonunion Fractures of middle and proximal portion prone to nonunion Get a scaphoid view if suspected Get a scaphoid view if suspected If initial film negative, but still suspected treat as a fracture and follow up with plain films or more advanced imaging If initial film negative, but still suspected treat as a fracture and follow up with plain films or more advanced imaging May be casted for up to 3 months May be casted for up to 3 months

14 Case #2 38 year old male got his right ring finger caught in a player’s shirt while playing touch football Felt pop in his finger and developed pain Now in your clinic 4 hours later What are the possibilities?

15 Case #2 Jammed finger Jammed finger Fracture Fracture DIP or PIP dislocation DIP or PIP dislocation Mallet finger Mallet finger Jersey finger Jersey finger

16 Exam --Finger held in forced extension --Tender along volar aspect of DIP --Unable to flex DIP

17 X-rays What is your diagnosis?

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

19 Complications if Missed Retraction into palm of hand Loss of flexion of tip Impaired work ability Difficult surgery

20 Mallet finger

21 Case #3 22 year old active duty male had lower leg “squished” between two military vehicles 22 year old active duty male had lower leg “squished” between two military vehicles Able to walk with a limp but pain worsening over the past 1-2 hours Able to walk with a limp but pain worsening over the past 1-2 hours

22 Case #3 Possibilities? Fractured patella Fractured fibula or tibia Tendon rupture Acute compartment syndrome Vascular disruption Contusion

23 Exam Pain is worsening after splinting Pain is worsening after splinting Lateral aspect and first web space of foot feels like “pins and needles” Lateral aspect and first web space of foot feels like “pins and needles” Leg hurts with gentle passive foot inversion and plantar flexion Leg hurts with gentle passive foot inversion and plantar flexion Leg feels weaker Leg feels weaker

24 X-ray Diagnosis?

25 Acute Compartment Syndrome Serious limb and life threatening condition Serious limb and life threatening condition Fractures, burns, crush injuries, arterial injuries Fractures, burns, crush injuries, arterial injuries Hand, forearm, arm, shoulder, back, thigh and foot Hand, forearm, arm, shoulder, back, thigh and foot

26 Acute Compartment Syndrome Increased pressure within closed compartments Compartments of lower leg Be careful with splinting and casting

27 Diagnosis High index of suspicion: pain out of proportion High index of suspicion: pain out of proportion Six P’s Six P’s Pain, Pulseless, Paresthesia, Poikilothermy, Pallor, Paralysis Pain, Pulseless, Paresthesia, Poikilothermy, Pallor, Paralysis Loss of normal sensation is a red flag Loss of normal sensation is a red flag Tight compartments Tight compartments Pressure> 30 mm Hg Pressure> 30 mm Hg

28 Treatment Surgical emergency Fasciotomy Clinical signs Elevated pressure Interrupted arterial flow for > 4 hours

29 Complications if Missed Rhabdomyolysis Acidosis Ischemic contractures Hyperkalemia DIC and sepsis Loss of limb Death

30 Case #4 26 year old sergeant playing basketball and “jammed” his left middle finger 26 year old sergeant playing basketball and “jammed” his left middle finger Pain and swelling of middle finger PIP joint (global) Pain and swelling of middle finger PIP joint (global) Pain with resisted flexion and extension Pain with resisted flexion and extension What are the possibilities? What are the possibilities?

31 Case #4 Fractured phalanx Extensor tendon rupture Volar plate injury Tear of central band of extensor tendon Mallet finger PIP dislocation

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

33 Do you want X-rays?

34 X-rays Diagnosis?

35 What is the Diagnosis? Tear of the central slip of the extensor tendon Tear of the central slip of the extensor tendon

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

37 Complications if Missed Loss of function Loss of function Persistent pain Persistent pain Boutonniere deformity Boutonniere deformity

38 Case #5 27 year old USUHS medical student playing football Loud audible pop and unable to bear weight Pain on top of mid-foot What are the possibilities?

39 Case #5 Fracture of metatarsal Fracture of metatarsal Fracture of cunieform Fracture of cunieform Extensor digitorum rupture Extensor digitorum rupture Lisfranc complex injury Lisfranc complex injury Mid-foot sprain Mid-foot sprain

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

41 Do You Need X-rays?

42 X-rays

43 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

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

45 Complications if Missed Chronic pain Arthritis Inability to run or jump Acute compartment syndrome

46 Case #6 18 year old female runner with 1 month of anterior groin/inguinal pain 18 year old female runner with 1 month of anterior groin/inguinal pain Pain worse with weight bearing Pain worse with weight bearing Over past week she has developed night pain Over past week she has developed night pain What are the possibilities? What are the possibilities?

47 Case #6 Torn adductor muscle Avulsion of adductor or sartorius muscle Pubic ramus fracture Femoral neck fracture Femoral shaft fracture SI joint subluxation Ruptured iliopsoas bursa

48 Exam Swelling noted in groin and high proximal femur Pain with all attempts at motion, especially internal rotation Distal pulses 2+ No distal sensory deficits

49 Do You Need X-rays?

50

51

52 Femoral neck stress fracture Groin pain in runner or jumper- don’t ignore Groin pain in runner or jumper- don’t ignore Female triad at increased risk as well as those with an increase in training and postmenopausal women 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) Need to know which side the stress fracture is on (compression vs tension side) Plain films often negative Plain films often negative Get MRI Get MRI

53 Treatment If stress fracture by x-ray or further imaging If stress fracture by x-ray or further imaging Compression side Compression side 12 weeks to heal +/- NWB 12 weeks to heal +/- NWB Tension side Tension side Ortho consult/surgery Ortho consult/surgery Femoral neck fracture- surgery Femoral neck fracture- surgery Cross train Cross train Proper nutrition and calories Proper nutrition and calories

54 Complications if Missed Stress to complete fracture Avascular necrosis Chronic pain End of career

55 Take Home Points Fall on outstretched hand, think: Distal forearm fx. Scaphoid fx TFCC AP, Lat, Scaphoid and clenched fist views Scapho-lunate dissociation

56 Take Home Points Grab injury with pain at distal phalynx, think jersey finger Grab injury with pain at distal phalynx, think jersey finger Crush injury or worsening pain with immobilization, think ACS Crush injury or worsening pain with immobilization, think ACS “Jammed” PIP…always test extension with resistance “Jammed” PIP…always test extension with resistance

57 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

58 Finished Thank You!


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