2. Common Orthopaedic Injuries & problems You Don’t Want to Miss!
Bruce Hamilton Dick , MD FACSM
Director of Orthopaedic Surgery

3. Orthopaedic complications- “misunderestimated”
Not Frequently seen
Difficulties
Follow up
Evolving etiologies
Other clinical interest
Dx Inaccurate

4. Why ? musculoskeletal 1. Low back pain - 15 mil
2. Knee inj/pain - 10 mil
3. Shoulder - 6 mil
4. Foot and ankle - 5 mil
5. Carpal tunnel mil
Musculoskeletal injuries rank # 1 in visits to physician’s offices...
1 in 7 Americans has musculoskeletal impairment...

5. What was the most popular sport in 2014?10
Skateboarding
Football
Soccer
Lacrosse
Running
Cycling of 5

6. Hottest Sports In 2014:
Source: SGMA’s Sports Research Partnership

7. What is the fastest growing segment of the US population?5
Ages 5 – 19
Ages 20 – 44
Ages 45 – 64
Ages 65 - 10

8. Population Trend By Age Group Change In Population In Millions
Source: American Sports Data/SGMA

9. What is the fastest growing sport in the senior US population?5
Golf
Walking Aerobics
Pickle ball
Tennis
Diabetes 10

11. So How do we proceed?

12. Case #1
Patient 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 now
F/U ortho 1 week
Let’s see what the ED is up to

15. Diagnosis
pain 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 Anatomy
Each 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 CS
tissue pressure over 30 mmHg with clinical picture of CS
interrupted arterial circulation over 4 hours.

18. Take Home Message Compartment Syndrome evolves, it is not an event
Examine “Off” the fracture
Establish direct communication with referral destination

19. Case #2
Pt 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 dislocation
Radius fracture
Metacarpal 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 Anatomy
There are 8 carpal bones comprising two carpal rows; the scaphoid bridges both rows.
With radial deviation the scaphoid and lunate palmar flex
Intrinsic and extrinsic ligaments maintain carpal stability.

23. PA and lateral radiographs
PA view:
constant 2 mm intercarpal joint space
3 arcs
Lateral view:
four Cs
capitolunate angle 0-15 degrees
scapholunate degrees
Stress views

24. Take Home Message History of high energy mechanism of hyperextension
Palpable pain over the dorsum of the wrist
Tenderness distal to Lister’s tubercle in the area of the scapholunate ligament
X-ray – identify the lunate

25. Case #3
Pt 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 fracture
Soccer 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 cuneiform
On the lateral the metatarsal shaft should not be more dorsal than the respective tarsal bone
Contralateral foot films
Weight-bearing views

29. Lisfranc Fracture
The 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.

30. Take Home Message
X-ray
Physical Exam

31. Case #4
Pt 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 Fracture
Jones Fracture

33. Epidemiology
Ankle 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

34. Imaging

36. Case #4
2 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 NAT
Fractures are 2nd most common presentation of physical abuse (25-50%)
Estimated 10% of trauma cases seen in ED in children under 3 yr are nonaccidental
20% involve burns
Two thirds will be seen by an MD prior to an orthopaedist!

39. High Stress Environments!
Risk Factors for NAT
Young (age < 3 yr)
First born children
Unplanned children
Premature infants
Disabled children
Stepchildren
Single-parent homes
Unemployed parents
Substance abuse
50-80% involve some degree of substance abuse
Families with low income
< $15k were 25x more likely than > $30k
Children of parents who were abused
High Stress Environments!

40. Fractures in Different Stages of Healing
Present in 70% of physically abused children < 1 yr
Present 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 old
Sternal fractures
Metaphyseal corner (bucket-handle) fractures
Posterior rib fx's
Digit fractures in nonambulatory children

42. Take Home Message
You have a legal responsibility to the child – not the parents
X-ray changes
Physical Exam

43. Case #5
32 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 dislocation
Humerus Fracture
Pneumothorax

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 Displacement
AP = Internal Rotation of humerus = “Light bulb sign”
Y view = Humeral head displaced
Anterior Dislocation
Inferior displaced humerus
Ghana Emergency Medicine Collaborative
Advanced Emergency Trauma Course

47. Take Home Message
Common things happen commonly, that is why they are common…know them uncommonly well

50. Final Thoughts
Occupational 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 symptom
Non operative treatment may not be effective in high demand athletes but it is indicated
Hip arthroscopy offers favorable results