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

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

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 - 2.5 mil Musculoskeletal injuries rank # 1 in visits to physician’s offices... 1 in 7 Americans has musculoskeletal impairment...

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

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

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

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

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

So How do we proceed?

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.

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

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

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

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.

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

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.

What is your diagnosis? Sprained wrist Scaphoid fracture Peri-Lunate dislocation Radius fracture Metacarpal fracture

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

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.

PA and lateral radiographs PA view: constant 2 mm intercarpal joint space 3 arcs Lateral view: four Cs capitolunate angle 0-15 degrees scapholunate 30-60 degrees Stress views

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

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.

What is your diagnosis? Ankle Sprain Foot Sprain Ankle Fracture Lisfranc fracture Soccer Flop

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

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.

Take Home Message X-ray Physical Exam

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

What is your diagnosis? Ankle Sprain Syndesmotic Sprain Ankle Fracture Foot Fracture Jones Fracture

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

Imaging

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

What would you do? Genetic couseling Refer to ortho CPS Splint the arm More x-rays

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!

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!

Fractures in Different Stages of Healing Present in 70% of physically abused children < 1 yr Present in 50% of all abused children

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

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

Case #5 32 yo male slipped and fell on ice and snow. Seen @ ed placed in sling. Can’t move shoulder. Shoulder is held in internal rotation, elbow flexed.

What is your diagnosis? Anterior Dislocation Normal shoulder Posterior dislocation Humerus Fracture Pneumothorax

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

Glenohumeral Joint Dislocations Posterior Displacement AP = Internal Rotation of humerus = “Light bulb sign” Y view = Humeral head displaced Anterior Dislocation Inferior displaced humerus http://www.learningradiology.com/caseofweek/caseoftheweekpix/cow105arrows.jpg http://www.imagingpathways.health.wa.gov.au/includes/image/sh_pain/should.jpg Ghana Emergency Medicine Collaborative Advanced Emergency Trauma Course

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

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.

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