12 Case #1Patient is a 12 y/o lacrosse player who presents to your office with a painful forearm one day after a FOOSH injury. He is quite tender to palpation over the proximal forearm and has visible deformity. The skin is intact. Neurovascular examination is normal.Long arm splint is intact.Prior to discharge from the office for Ortho f/u in the am, the patient complains of thumb numbness. PROM fingers painful.
14 What is your diagnosis? Both bones Fx – f/u ortho a.m. Both bones Fx – f/u ortho nowF/U ortho 1 weekLet’s see what the ED is up to
15 Diagnosispain w/ passive stretch of fingers most sensitive finding paraesthesia and hypoesthesia nerve ischemia affected compartment paralysis - late finding palpable swelling peripheral pulses absent late finding
16 Clinical AnatomyEach limb contains a number of compartments at risk for CS.Upper arm: anterior(biceps- brachialis) and posterior(triceps).Forearm: volar(flexors) and dorsal(extensors)10 compartments hand
17 Treatment Acute CS is a surgical emergency. Delays over 24 hrs can result in myoglobinuria, renal failure, metabolic acidosis, hyperkalemia, ischemic contracture.Indications for fasciotomy:clinical signs of CStissue pressure over 30 mmHg with clinical picture of CSinterrupted arterial circulation over 4 hours.
18 Take Home Message Compartment Syndrome evolves, it is not an event Examine “Off” the fractureEstablish direct communication with referral destination
19 Case #2Pt is a 18y.o. nordic skier, who presents with wrist pain. He describes a FOOSH mechanism of injury and complains of numbness in the distribution of the median nerve.
20 What is your diagnosis? Sprained wrist Scaphoid fracture Peri-Lunate dislocationRadius fractureMetacarpal fracture
21 Epidemiology Wrist injuries account for 2.5% of all ED visits. Lunate and perilunate injuries are thought to represent 10% of all carpal injuries.Perilunate and lunate dislocations result from hyperextension injuries.Most common mechanism of injury is a FOOSH
22 Clinical AnatomyThere are 8 carpal bones comprising two carpal rows; the scaphoid bridges both rows.With radial deviation the scaphoid and lunate palmar flexIntrinsic and extrinsic ligaments maintain carpal stability.
23 PA and lateral radiographs PA view:constant 2 mm intercarpal joint space3 arcsLateral view:four Cscapitolunate angle 0-15 degreesscapholunate degreesStress views
24 Take Home Message History of high energy mechanism of hyperextension Palpable pain over the dorsum of the wristTenderness distal to Lister’s tubercle in the area of the scapholunate ligamentX-ray – identify the lunate
25 Case #3Pt is an 18 y.o. soccer player who presents with persistent dorsal foot pain after being stepped on during a game over a week ago, and has not improved with self-care.
27 What is your diagnosis? Ankle Sprain Foot Sprain Ankle Fracture Lisfranc fractureSoccer Flop
28 Imaging AP, lateral and oblique views Contralateral foot films On AP and obliques the 2nd met medial border should align with the middle cuneiformOn the lateral the metatarsal shaft should not be more dorsal than the respective tarsal boneContralateral foot filmsWeight-bearing views
29 Lisfranc FractureThe articulation between the tarsal and metatarsal bones in the foot is named after Jaques Lisfranc.Lisfranc injuries may represent 1% of all orthopedic trauma, but 20% are missed on initial presentation.The second metatarsal is the keystone to the Lisfranc joint.
31 Case #4Pt is an 18 y/o football player with an ankle sprain. Pt has considerable swelling and demonstrates more tenderness proximal to the ATFL Radiographs are negative
32 What is your diagnosis? Ankle Sprain Syndesmotic Sprain Ankle Fracture Foot FractureJones Fracture
33 EpidemiologyAnkle sprains are the most common lower extremity injury in sports medicine, and constitute 25% of all sports injuries.In one series, syndesmotic injuries constituted 17 % of ankle sprains.Syndesmotic injuries are not uncommonly associated with fractures.Fractures of the ankle are rotational injuries and can be confused with sprains
36 Case #42 yo male son of parents well known to you, fell down stairs presents to your office not moving his right arm and painful cough
37 What would you do? Genetic couseling Refer to ortho CPS Splint the arm More x-rays
38 Epidemiology Physical 80% of deaths from head trauma in children < 2 yr are NATFractures are 2nd most common presentation of physical abuse (25-50%)Estimated 10% of trauma cases seen in ED in children under 3 yr are nonaccidental20% involve burnsTwo thirds will be seen by an MD prior to an orthopaedist!
39 High Stress Environments! Risk Factors for NATYoung (age < 3 yr)First born childrenUnplanned childrenPremature infantsDisabled childrenStepchildrenSingle-parent homesUnemployed parentsSubstance abuse50-80% involve some degree of substance abuseFamilies with low income< $15k were 25x more likely than > $30kChildren of parents who were abusedHigh Stress Environments!
40 Fractures in Different Stages of Healing Present in 70% of physically abused children < 1 yrPresent in 50% of all abused children
41 Fractures Commonly seen in NAT - High Specificity Femur fracture in child < 1 year old (any pattern)Humeral shaft fracture in < 3 year oldSternal fracturesMetaphyseal corner (bucket-handle) fracturesPosterior rib fx'sDigit fractures in nonambulatory children
42 Take Home MessageYou have a legal responsibility to the child – not the parentsX-ray changesPhysical Exam
43 Case #532 yo male slipped and fell on ice and snow. ed placed in sling. Can’t move shoulder. Shoulder is held in internal rotation, elbow flexed.
44 What is your diagnosis? Anterior Dislocation Normal shoulder Posterior dislocationHumerus FracturePneumothorax
45 Shoulder Dislocations Posterior shoulder dislocations are less common than anterior dislocations, but more commonly missed 50% of traumatic posterior dislocations seen in the emergency department are undiagnosed 2% to 5% of all unstable shoulders 95% of all shoulder dislocations are anterior
46 Glenohumeral Joint Dislocations Posterior DisplacementAP = Internal Rotation of humerus = “Light bulb sign”Y view = Humeral head displacedAnterior DislocationInferior displaced humerusGhana Emergency Medicine CollaborativeAdvanced Emergency Trauma Course
47 Take Home MessageCommon things happen commonly, that is why they are common…know them uncommonly well
50 Final ThoughtsOccupational Medicine practice is rooted in prevention. Workers who develop occupational diseases or incur injuries in the workplace represent a failure of prevention.Many places that have Occupational Medicine listed as a service on their signage are frequently only practicing Workers Compensation Medicine and have little to offer in the way of prevention - know your service providers.
51 SUMMARY Hip Pathology is often seen in young active adults Groin pain is usual presenting symptomNon operative treatment may not be effective in high demand athletes but it is indicatedHip arthroscopy offers favorable results