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” lower extremity musculoskeletal injuries.
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
Immediate wrist pain and pain with attempts at dorsi and palmar flexion
No gross deformity
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? Is an x-ray needed? Exam
Inspection, Range of motion, Neurovascular status, Palpation
Is an x-ray needed?

6. Wrist Xrays

7. Scapho-Lunate Dissociation
Disruption of scapho-lunate ligament
FOOSH injury
Tender over scapho-lunate interval
+ Watson’s clunk
Limited dorsiflexion
> 3 mm diastasis
Scapholunate 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 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
Loss of function and motion
Osteoarthritis

11. Same patient

12. Scaphoid fracture

13. Scaphoid Blood supply arises distally
Fractures of middle and proximal portion prone to nonunion
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
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 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

17. X-rays
What is your diagnosis?

18. Jersey Finger Rupture of FDP tendon Inability to flex tip of finger
Splint in position
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
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
Lateral aspect and first web space of foot feels like “pins and needles”
Leg hurts with gentle passive foot inversion and plantar flexion
Leg feels weaker

24. X-ray
Diagnosis?

25. Acute Compartment Syndrome
Serious limb and life threatening condition
Fractures, burns, crush injuries, arterial injuries
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 Six P’s
Pain, Pulseless, Paresthesia, Poikilothermy, Pallor, Paralysis
Loss of normal sensation is a red flag
Tight compartments
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
Pain and swelling of middle finger PIP joint (global)
Pain with resisted flexion and extension
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 Tender over PIP, more so dorsally
Pain with resisted extension over the PIP
No neuro compromise
Flexor tendons strength is 5/5
Collaterals of PIP intact
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

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

37. Complications if Missed
Loss of function
Persistent pain
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 cunieform
Extensor digitorum rupture
Lisfranc complex injury
Mid-foot sprain

40. Exam Unable to weight bear Swelling over dorsum of foot
Bruising on plantar aspect of 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 Bulky Jones dressing or posterior splint
NWB on crutches
Frequent neurovascular checks
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
Pain worse with weight bearing
Over past week she has developed night pain
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?

52. Femoral neck stress fracture
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
Need to know which side the stress fracture is on (compression vs tension side)
Plain films often negative
Get MRI

53. Treatment If stress fracture by x-ray or further imaging
Compression side
12 weeks to heal +/- NWB
Tension side
Ortho consult/surgery
Femoral neck fracture-surgery
Cross train
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
Crush injury or worsening pain with immobilization, think ACS
“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!