Sports Med/MSK Flashcards
Mouthgaurd Use
- Use of mouthgaurds during sports decrease risk of all oral/tooth injuries
- Basketball is one of the highest injury sports
- Professionally fitted are not better than self fitted
Anterior knee pain in an active teenager with exam of swelling at patellar insertion site on tibia
Osgood Schlatter - treat with activity modification and a patellar strap
- Apophysitis of the tibial tuberosity
- Common in girls age 10-13 and boys age 12-15
Toddler fracture management
- Oblique fracture of distal tibia with relatively minor trauma
- Ages 1-5
- Difficult to see with just AP view CXR right after injury
- Cast and repeat imaging in 2 weeks (will often see healing fracture)
Idiopathic toe walking is normal until what age
- Age 3 - just reassurance until then, then could consider treatment but most are not effective
- If unilateral, needs workup right away
Cause of apophyseal avulsion injury
- A strong muscle contraction causes a piece of bone to pull away from the skeleton at the relatively weak apophysis (due to immature pediatric skeleton, common in hips)
- Common in young athletes when they “hear a pop”
- Tx: rest, surgery is rarely indicated
Indications for referral to a cardiologist for sports clearance
- Syncope or chest pain with exertion
- Palpitations at rest or irregular heart rhythm
- Excessive SOB or fatigue
- Family history of Marfans, carrdiomyopathy, long QT, or clinically significant arrhythmias
- Weak or delayed femoral pulses
- Cardiac exam: fixed split second heart sound, a systolic murmur graded 3/6 or greater, diastolic murmur
- Turner syndrome patient with chest pain
Contraindications to sports participation
- Pulmonary vascular disease with cyanosis and large R to L shunt
- Severe PH
- Severe aortic or mitral valve disease
- Cardiomyopathies
- Vascular form of Elhers-Danlos syndrome
- Coronary anomalies of wrong sinus origin
- Acute pericarditis or myocarditis
- Acute phase of Kawasaki (8 weeks)
Things to consider in a type 1 diabetic that is exercising
- Needs increased caloric intake and decreased insulin dose to avoid hypoglycemia
- Could be a delayed response to exercise hours later resulting in hypoglycemia
Symptoms of heat exhaustion
Mild dehydration, temperature less than 104, headache, thirsty, vomiting
Tx: stop exercising and drink fluids
Symptoms of heat stroke
- Temperature > 105
- Hot, dry skin (not sweaty)
- CNS depression/altered mental status
- Severe dehydration
- Can lead to end organ damage because of the release of endotoxins and cytokines
Treatment of heat stroke
- COOL THEM! (start in the field)
- Rehydrate with IV fluids
- Can use vasopressors to maintain BP if needed
Grade 1 sprain
Minor stretching of the ligament, minimal discomfort
Grade 2 sprain
- Ligaments are partially torn
- Tenderness, swelling, ecchymosis
Grade 3 sprain
- Ligament is completely torn with significant loss of function
Most common type of ankle injury
Anterior talofibular ligament injury (inversion injury)
Symptoms of compartment syndrome
5 P’s:
- Pain
- Paresthesias
- Pallor
- Paralysis
- Pulselessness
- -> the last two are late findings so absence of those doesn’t rule out compartment syndrome
“Pop” after a change in direction off a pivoted knee
Subluxation of the patella
- On exam have pain over the lateral aspect of the patella, can have deformity over the medial aspect
Anterior knee pain in adolescents involved in jumping, running, and squatting
Patellofemoral syndrome
- More common in females
- Tx: knee bracing, patellar taping, and NSAIDs
Anterior knee pain over the patella with visible swelling
Prepatellar bursitis
- Tx: NSAIDs
Pain over anatomical snuffbox (dorsum of the hand near the base of the thumb)
Scaphoid fracture
- May not see on xray
- Concern due to poor neurovascular supply
Distal radial epiphyseal injury
- Pain on wrist that is worsening but has no swelling and normal range of motion
- Point tenderness on distal radius
- Treat with rest and splint
Elbow fracture from fall on an outstretched arm with hyperextended elbow
- Supracondylar humeral fracture
- Commonly can impact the neurovascular components but is frequently a transient deficit (watch for pain on passive extension of the fingers)
- Posterior far pad sign on lateral elbow xray
Fall on an outstretched arm when elbow is supinated and partially extended
Dislocation of the elbow –> can have neurovascular compromise
Elbow lateral condyle fracture
Forearm is supinated, neurovascular compromise is very unlikely
Shoulder injury from patient falling back on a posteriorly rotated abducted arm
Anterior humeral dislocation
Shoulder injury with pain and prominence over the distal clavicle
Acromioclavicular injury
Shoulder injury from direct force to the posterior shoulder and pain over teh sternoclavicular joint
Posterior sternoclavicular dislocation
Shoulder injury with shoulder/upper arm pain int he absence of asymmetry
Proximal humeral fracture
Shoulder pain with elevating and lowering the arm without any deformity
Rotator cuff injury
Association with medial clavicular fracture
If anterior or posterior displacement will need an evaluation for possible displacement of the trachea or mediastinal structures
Clavicular fracture vs acromioclavicular separation
- Fracture in younger kids and will have crepitus
- AC separation will been in teenagers and have a palpable step off as well as point tenderness on the joint
Reasons that kids can’t participate in sports
- Fever
- Carditis and acute hepatosplenoemgaly (mono) can’t do contact sports
Indications that kids can’t do contact sports
- Splenomegaly
- Hepatomeglay
- One functioning kidney
- Repeated concussions
Sport with leading eye injuries
Baseball –> under age 14 should wear a facemask when batting
Timing to detecting steroid use
- Oral steroids stay in the urine for days to weeks
- IM steroids stay in the system for 6 months or more
Female complications of steroid use
- Hirsutism and low voice
- Early closure of epiphyseal plates
Male complications of steroid use
- Severe acne
- Gynecomastia
- High pitched voice
- Hypogonadism
Lab findings with steroid use
- Elevated LFTs
- Lower HDL, increased LDL
- Oligospermia and azoospermia
Symptoms in classic type Ehlers Danlos
- Hyperextensible skin
- Hyperextensible joints
- Tissue fragility/easy bruising
- Unique appearance (nose, clear skin)
- Can also have delayed wound healing
Symptoms in hypermobility type Ehlers Danlos
- Hypermobile joints
- Dislocations/chronic pain
- This is the most common type of ED (80% of cases)
Symptoms of vascular type Ehlers Danlos
- Acrogeria (old skin)
- Blood vessel ruptures
Caffey disease
Autosomal dominant - symptoms start prior to 6 months and are usually done by 24-30 months
- Mandible is involved > 95% of the time
- Cortical thickening and subperiostal new bone formation
- Leukocytosis, elevated ESR, increased alkaline phosphatase
Bone parts
- Physis: growth plate
- Metaphysis: end of the long bone
- Epiphysis: rounded end of a long bone
Varus/valgus
- Varus: distal part of the deformity points toward the midline
- Valgus: distal part of the deformity points away from the midline
Reasons why genu varus would be abnormal
- Unilateral
- Worsens after age 1
- Does not resolve after age 2 (think about Rickets or Blount’s disease)
Blount’s disease
- African Americans
- In adolescents it is due to being overweight
- Don’t need any treatment
- Abnormality with proximal tibial physis and epiphysis
Salter harris fractures
- SALTR
- Type 1: Straight through physis (casting)
- Type 2: Above physis in metaphysis (closed reduction casting)
- Type 3: Lower physis through epiphysis (open reduction)
- Type 4: Through all 3 layers (reduction in OR)
- Type 5: cRush (risk microvascular compromise with high risk of poor growth)
Fall on an outstretched hand with cortical break on one side of the bone and intact periosteum on the opposite side
Greenstick fracture
Fractures in preschool years, autosomal dominant, blue sclera
OI type 1 - most common
- Often also have hearing loss
- Normal height, normal lifespan
Born with multiple fractures, often stillborn
OI type 2 - dominant new mutation or germinal mosaicism
- Usually lethal in first week of lfie
Born with fractures and deformities are progressive
OI type 3
- Have blue/gray sclerae that lighten over time
- SGA with macrocephaly
- Wormian bones in the skull, codfish vertebrae
- Short stature, hearing is abnormal, intellect is normal
Causes of torticollis
- Muscular (positioning or trauma)
- Paroxysmal (migraine variant that can last for just a minute at a time)
- Vertebral anomalies
- Posterior fossa tumor
Symptoms of congenital torticollis
- Head tilted to one side, mass in SCM muscle, facial asymmetria
- Tx with daily stretching and PT- Can be associated with developmental dysplasia of the hip
Fusion of cervical vertebrae (short neck, low occipital hairline)
Klippel-Feil syndrome
- Can be associated with scoliosis, spina bifida, renal problems, deafness
Mimics torticollis, unilateral shorter/broader neck
Sprengel deformity
- Failure of scapula to descend to normal position in fetal development
Risk factors for DDH
- Breech
- Female
- Family history
- First born
- Oligohydraminos
- Can be associated with torticollis, metatarsus adductus, club foot
Exam findings for DDH
- Barlow (putting hip out of place), ortalani (putting it back in) - these are only reliable until 3 months of age
- After 3 months: limitations in hip abduction is the most common sign, unequal knee high, asymmetric gluteal folds
- Older child with waddling gait or leg length discrepancy
Workup for DDH/treatment
- US until 4 months of age
- AP and frog leg xray after that
- Tx is Pavlik hanress in abduction, flexion, and external rotation positioning
Symptoms/labs in viral myositis
- Weakness and tenderness, commonly in the calf
- Elevated CK
- Recent URI or influenza
Most common viruses for toxic synovitis
- Parvovirus B19
- Influenza
- Hepatitis B
- Rubella
- EBV
Symptoms/management of septic arthritis
- MC in kids < 2, won’t walk or won’t move joint, fever, elevated inflammatory markers, joint is red/swollen, won’t let you examine it, increased joint space on xray, often hematogenous spread
- Need joint aspiration and IV antibiotics - don’t delay treatment for aspiration
MC organisms for septic arthritis
Staph aureus
- Neonates: GBS, E coli
- Infants/children: strep pneumo, GAS, h. flu
- Gonorrhea in teens
Sickle cell: think Salmonella
MC organisms for osteomyelitis
Staph aureus
- Neonates: femur/tibia (hematogenous, often associated with septic joint): GBS, e coli
- GAS, Kingella, H. flu type b
- Sickle cell: Salmonella
- Step on a nail: pseudomonas
Treatment for osteomyelitis
- Staph: oxacillin, clindamycin, cephalosporin
- H. flu: ceftraixone
- Salmonella: ceftriaxone
Hip pain or limp in kids (usually boy) from age 5-7
Legg calve perthes
- Avascular necrosis of the femoral head
- Xray shows one femoral head being smaller than the other
- May actually complain of knee pain
- Need non-weight bearing, splinting, possible surgery
Obese teenager with hip or knee pain
SCFE
- Immobilization, stabilization with pins
Athletic teen with pain just below the patella
Osgood schlatter
- Due to excessive activity
- Insertion of patellar tendon at anterior tibial tubercle
- Tx rest and NSAIDs
Sever’s syndrome
- Heel pain in young athletes
- Calcaneal apophysitis
Toddler’s fracture
May not see it on xray, may just have point tenderness on exam
Simple bone cyst
Commonly found at proximal humerus or femur, not precancerous
Aneurysmal bone cyst
Common tibia or femur, can be painful, can be associated with underlying bone tumors
Symptoms of Ehlers danlos
- Stretchy skin
- Hypermobile joints
- Poor wound healing
- Easy bruising
Symptoms/workup with congenital scoliosis
- Malformation of spinal column or ribs
- Screen with renal ultrasound and an echo as well as spinal MRI
Scoliosis diagnostic criteria
- Curvature of less than 25 degrees: observation only
- If more than 2 years of growth still expected tehn do bracing for curvature between 25-40 degrees
- Surgery for greater than 40 degrees
- May need further workup if more than 1 degree per month during a growth spurt
Normal range for kyphosis
20-40 degrees
- PFTs if kyphosis is > 60 degrees
Scheuermann disease
Kyphosis, bad posture, back pain - present in teenagers, often just need NSAIDs and PT
Annular ligament displacement
Nursemaid’s elbow
- Pulled by the arm and now not using it
Inheritance of polydactyly
Autosomal dominant if isolated
- Tx is ligation until it falls off if it is simple postaxial polydactly
Treatment of club foot
Ortho referral, stretching, casting, possible surgical release later in life
Toe walking
Normal until after age 2-3
- Tx is foot dorsiflexion exercises
3 main causes of in-toeing
- Metatasus adductus in infancy
- Tibial torsion in toddlerhood
- Femoral anteversion in early childhood
