Sports Med - UE Flashcards
Define concussion
Current definition: a complex pathophysiological process affecting the brain induced by biochemical forces.
Is concussion a structural injury?
NO!
it may result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance NOT a structural injury.
Concussion typically results in…
the rapid onset of short-lived impairment of neurologic function that resolves spontaneously
Concussion epidemiology
-8.9% of all reported high school athletic injuries
-F > M in similar sports
? F weaker neck muscles and smaller head mass?
? M more reluctant to report injury?
Common sports for concussion
Football, F Soccer, M Lacrosse, M Soccer, F Basketball, Wrestling, F Lacrosse, Softball, M Basketball, M & F Volleyball, Baseball
**cycling is #1 for traumatic brain injuries
Concussion symptoms
- HA
- dizziness
- double vision
- nausea
- light/sound sensitivity
- feeling foggy
- LOC
- amnesia
- behavioral changes
- cognitive impairment
- sleep disturbance
- depression
Classification of concussions
- grading system was abandoned
- the majority resolve in short (7-10 day period)
- children take longer than adolescents to recover
On-field evaluation
-initial action: primary survey/LOC
- determine level of consciousness:
- “Can you hear me?”
- Response to painful stimulus - Determine ABCs:
- Clear the airway and assess breathing
- Remove mouthpiece
- Check Circulation - Inspect ears and nose:
- do you see CSF? - Secondary Survey:
- Signs of trauma (fracture, dislocations, bleeding)
On-field evaluation
-Management of Unconscious Athlete
Airway:
- Permanent brain damage – within 4 minutes after oxygen deprivation
- Assess airway:
- -Look, listen, feel for breathing
- Emergency Roll:
- -No pulse / not breathing and not in supine position (maintain in-line stabilization)
- -Expose chest
- -Remove facemask
- -Jaw thrust to open airway (2 quick breaths)
Circulation:
- Carotid pulse
- Not breathing with pulse – Rescue breathing
- No pulse – CPR
On-field evaluation
-Facemask removal
Most helmets have four fasteners
-Can cut all four or cut the bottom two and retract the mask
Common tools for helmet removal:
- Hand held screwdriver
- Anvil Pruner
- Trainer’s Angels
- FM Extractor
On-field evaluation
-Modified jaw thrust
-Grasp each side of the mandible at the angle and pull upwards
-Must be careful not to disturb the c-spine
-May not always open the airway
Should be done by a professional rescuer or athletic trainer
-Essentially dislocating the jaw
On-field evaluation
-Management of unconscious but breathing athlete
Cervical spine evaluation:
-Palpate for gross bony deformity
Blood pressure:
- Palpation of pulse and minimum Systolic BP:
- -Carotid artery – 60 mmHg
- -Femoral artery – 70 mmHg
- -Radial artery – 90 mmHg
Pupil responsiveness:
- Open athlete’s eyelids:
- Open eyelids – pupil constriction (absence – brain not receiving oxygen / brain damage)
**Continue monitoring every 5 minutes
On-field evaluation
-Management of conscious athlete (history)
Loss of consciousness:
-Does athlete describe “blacking out” or “seeing stars”
Mechanism of injury
Symptoms:
- Pain in cervical spine
- Numbness, tingling, burning pain radiating through upper or lower extremities
- Sensation of weakness in cervical spine, upper and/or lower extremities
- Burning or aching in the chest secondary to cardiac inhibition
On-field evaluation
-Management of conscious athlete (inspection/palpation)
Inspection:
- Cervical vertebrae:
- Alignment
- Cervical musculature:
- Presence of spasm
Palpation:
- Cervical spine:
- -Spinous and transverse processes:
- -Alignment, crepitus, tenderness
- -Cervical musculature:
- -Spasm in upper trapezius, levator scapulae, SCM
On-field evaluation
-Management of conscious athlete (neuro evaluation)
Neurological Testing:
- Sensory testing
- Motor Testing
- Active motion:
- -Wiggle toes and fingers
- -Movement of ankles, wrists, knees, elbows, hips, and shoulders
Removing the athlete from the field
Walking athlete off the field:
Lying → standing: ↓ BP (risk of fainting / unsteadiness)
Allow athlete to adjust to position changes
Removing the athlete from the field
-Using a spine board (supine athlete)
- Place the extremities in axial alignment (arm on side toward which athlete rolled abducted to 90 degrees - if not wearing shoulder pads)
- Place the spine board close to the side of the patient
- Other responders position along the side of the athlete, according to the captain’s (person at the head) directions
- Ideal to have 4 or 5 additional helpers, depending on the size of the patient
- Each person is responsible for one body segment: trunk, hips, thighs, lower legs
Removing the athlete from the field
-Using a spine board (prone athlete)
- one person takes charge and immobilizes the head
- hands should be placed so that the head and neck can maintain their position as the body moves
- assistants kneel and reach across patient’s body
- each person is in charge of a different part, such as the trunk, hips, and legs
- their arms should cross each other for stability and synchronization
- limbs are placed at athlete’s sides
- on the captain’s call, the body is turned in unison onto the board
Concussion management
- physical and cognitive REST until symptom resolution
- do NOT need to awaken throughout the night, observe for normal breathing pattern
- “Cocoon Therapy” AKA a whole list of what you CANNOT do vs. do what you can tolerate/does not worsen symptoms
- encourage pt to eat/drink normally
- wear sunglasses if photophobia
- sleep in a dark room as much as possible 2 – 3 days, then try to resume normal sleep/wake hours and nap 15 – 20 minutes
- limit exposure to telephone, texting, music, TV
New concussion recommendations regarding exercise
- new recommendations include starting very light, easy, early exercise after 48 hours
- activity should be below symptom-exacerbation thresholds
Management via medications
- avoid and let symptoms be your guide
- extreme headache , ok to take Tylenol but NO NSAIDs…
- -avoid over use
- -masking symptoms
- -rebound headaches
- melatonin for sleep & headaches
School considerations
- Attendance
- Visual Stimulus
- Workload
- Physical Exertion
- Breaks
- Audible Stimuli
- Testing
Return to play (RTP)
- symptom free & off medication (exception: antidepressants
- neurocognitive Testing
- -objectively evaluate condition, track recovery
- -measures symptoms, verbal & visual memory, processing speed, reaction time
What is gradual RTP protocol?
- proceed 1 level at a time if asymptomatic at current level
- 24 hrs per level = 1 week to proceed through full rehabilitation protocol
- any symptoms = drop down to asymptomatic level x 24hrs before proceeding
- may stretch out RTP if < 13 years old
Rehab stage 1
- functional exercise
- objectives
- no activity
- complete physical and cognitive rest (no school, if indicated)
- recovery of cognitive function
Rehab stage 2
- functional exercise
- objectives
- light aerobic exercise
- walking, swimming, or stationary bike; no resistance training
- increase heart rate
Rehab stage 3
- functional exercise
- objectives
- sports-specific exercise
- running drills; no head impact activity
- add movement
Rehab stage 4
- functional exercise
- objectives
- non-contact training drills
- progression to more complex training drills; start progressive resistance training
- exercise, coordination, cognitive load
Rehab stage 5
- functional exercise
- objectives
- full contact practice
- after medical clearance only; normal activity
- restores confidence and assess functional skills
Rehab stage 6
- functional exercise
- objectives
- return to play
- normal game/ competition
- prevent next injury
Do helmets prevent concussions?
NO!
Helmets/headgear info
- get a new bike helmet following impact
- football helmets reduce impact force to head, but not concussion incidence
- soccer head gear unclear utility, heading can be performed safe? and avoidance does not prevent concussion
Define second-impact syndrome
Sustain an initial head injury then second injury before symptom free from first head injury
Cerebral vascular congestion → diffuse cerebral swelling → death
Who is at higher risk for second-impact syndrome?
- peds and adolescents at higher risk
- all reported cases are of athletes < 20 y.o.
- catastrophic football head injuries 3x more likely in high school than in college athletes
Long term effects
-CTE
Chronic Traumatic Encephalopathy
- seen in 18-year old multisport athlete with a history of concussions from football upon autopsy
- new football, soccer
Long term effects
-3 or more concussions
increased LOC, post-amnesia, confusion
Athletes with 2 or more concussions…
- athletes with 2 or more concussions who are concussion free x 6 months performed similarly on NP testing as athletes with 1st concussion in last week
- 2 or more concussions lower GPA
List common shoulder injuries
- Clavicle fracture
- AC sprain
- SC sprain
- Shoulder Dislocation
- Little Leaguer Shoulder
- Shoulder Impingement
- Rotator Cuff Sprain/Tear
Treatment of clavicle fractures
- MC is sling or figure 8
- figure 8 is to try to move the bone back in place so it doesn’t require surgery
SC sprain
- between sternum and clavicle
- rare injury
SC sprain mechanism of injury
- indirect force transmitted through the humerus, the shoulder joint and the clavicle
- direct impact to clavicle
S/sx of SC sprain
-may have deformity at sternal end
Swelling
-pain
-inability to abduct shoulder through full ROM
What are the degrees of separation for SC sprain?
1st degree: no deformity, pain w/ palpation & motion, mild stretching of SC ligament
2nd degree: subluxation of the proximal end of clavicle
3rd degree: complete rupture of SC and CC ligaments, with dislocation of the proximal end of clavicle
Tx for SC sprain
- RICE
- immobilization
- NSAIDS
Grade 1 seperation – RTP in 1-2 weeks
Grade 2 seperation – RTP in 3-4 weeks
Grade 3 seperation – Surgery
What is an emergency in SC sprain??
Any posterior subluxation or dislocation is an emergency d/t potential cardiovascular compromise
Define little leaguer’s shoulder
- proximal humerus (Salter Harris Type I fracture)
- secondary to overuse
What do you see on xray for little leaguer’s shoulder?
widening of proximal humeral physis
Tx of little leaguer’s shoulder
rest and activity modification
List the elbow injuries
- Radial Head Fracture
- Supracondylar Fracture
- Little Leaguer’s Elbow
- UCL injury
- Medial Epicondylitis
- Lateral Epicondylitis
- Elbow Dislocation
- Olecranon Bursitis
Radial head fx etiology
- MC adult elbow fracture
- mechanism - FOOSH
PE of radial head fx
- Pain/Effusion Elbow
- Commonly associated with wrist pain
- Pain with forearm rotation
- Check for mechanical click
Xray findings of radial head fx
- fat pad or boat sail sign
- can be subtle
Mason classification of radial head fx
I - nondisplaced
II - < 30% head and > 2mm displacement
III - comminuted
Nonoperative tx of radial head fx (grade I)
- Sling/posterior splint for comfort
- ROM 7 days
- Possible Aspiration Hematoma
- Repeat XR 2-3 wks
- Complication
- Extension/Supination Loss
Tx of grade II
- debatable
- Ortho Referral
- No Mechanical Sx
- -Conservative
- -Early ROM
- -Close XR F/U
- Mechanical Sx
- -Possible SURGERY
- -ORIF
Tx of grade III
Ortho Referral
Surgery
- ORIF
- radial head replacement
What is the MC fracture of the elbow in children?
Supracondylar humerus fx
Supracondylar humerus fx
-etiology
- 95% are extension type injuries
- Produces posterior angulation/displacement of the distal fragment
- Occurs from a fall on an outstretched hand
- Ligamentous laxity and hyperextension of the elbow are important mechanical factors
- May be associated with a distal radius or forearm fractures
Supracondylar humerus fx
-types
Type 1: Non-displaced
Type 2: Angulated/displaced fracture with intact posterior cortex
Type 3: Complete displacement, with no contact between fragments
Supracondylar humerus fx type I tx
- in most cases, these can be treated with immobilization for approximately 3 weeks, at 90 degrees of flexion
- if there is significant swelling, do not flex to 90 degrees until the swelling subsides
Supracondylar humerus fx type II tx
- if minimally displaced (anterior humeral line hits part of capitulum)
- immobilization for 3 weeks.
- close follow-up is necessary to monitor for loss of reduction
Displaced (anterior humeral line misses capitulum):
- reduction
- the degree of posterior angulation that requires reduction is controversial
- probable surgical fixation
- if varus/valgus malalignment exists, reduction and surgical fixation
Supracondylar humerus fx type III tx
Surgery!
Define little leaguer’s elbow
- with repetitive throwing, ligaments and tendons put tension on the end of the bone → causes inflammation of growth plate and ultimately stress fracture
- activity-related pain, tenderness to palpation, decreased pitching effectiveness
Tx of little leaguer’s elbow
Rest for several weeks until sx resolve
Ulnar collateral ligament injuries
- chronic valgus stress places ligament at risk for laxity or tearing
- pitchers at highest risk
UCL injuries
-evaluation
- medial pain during late cocking, acceleration or deceleration is hallmark
- pain with valgus testing more reliable than laxity
- laxity on valgus testing at 30° minimal unless tear is complete
What do you see on MRI for UCL injury?
fluid leakage outside of joint represents complete tear
UCL injury tx
- rest
- physical therapy
- NSAIDs
- return to throwing when pain-free
- surgery → autologous tendon secured in tunnels in humerus and ulna in figure-of-eight fashion, ulnar nerve transposed
Lateral epicondylitis
“tennis elbow”
- result of poor mechanics and continual use over a long period of time
- wrist extensor tendons at lateral epicondyle of the humerus become chronically inflamed
Lateral epicondylitis
- PE
- tx
- pain over lateral epicondyle and minimal swelling
- TX: RICE, Counterforce brace, wrist brace, limiting activity, mild stretching and strengthening, NSAIDS, Tenex, PRP, Surgery is rare
Medial epicondylitis
“golfer’s elbow”
- inflammation of wrist flexor tendons
- result of repetitive throwing
Medial epicondylitis
- PE
- tx
- pain over medial epicondyle
- TX: Same as lateral epicondylitis and decrease throwing
*monitor ulnar nerve- watch for numbness, tingling, or excessive pain
Elbow dislocation mechanism of injury
- third most frequent joint dislocation
- fall on extended elbow with outstretched hand
- majority posterior/posterolateral (90-95%)
S/sx of elbow dislocation
- Ulna and/or radius displaced posteriorly, w/ olecranon process sitting posteriorly
- Severe swelling/bleeding
- Extreme pain
Classification of elbow dislocation
Simple: no fracturepurely ligamentous
Complex: associated with fracture
-Radial head is MC fx
Tx of elbow dislocation
- Immobilize in position you find it
- Send to ER
- Radiographs
Tx of simple elbow dislocation
- closed reduction
- long arm splint/cast x 2 weeks
- progressive ROM
- protect terminal extension x 6wks
*Major Complication = Extension Loss
Tx of complex elbow dislocation
- Splint in situ - no reduction
- Exception: NV compromise
*Ortho referral for surgery
Olecranon bursitis
-etiology
- aseptic
- direct blow or fall - hemarthrosis
- gout
- septic
- insect bite
- cut/abrasion
- hematogenous
S/sx of olecranon bursitis
- pain
- swelling
- erythema/febrile = septic
Tx of olecranon bursitis
- Ice
- Compression
- Aspirate
- If serous/bloody: inject 40mg steroid +compressive dressing+elbow extension x 3 days
- If puss, requires I+D (Ortho Consult)
-Recurrent aseptic bursitis = surgery
Scaphoid fx
- MC fractured bone in the wrist
- Peanut shaped bone that spans both row of carpal bones
- Does not require excessive force and often not extremely painful so can be delayed presentation
Scaphoid fx pathoanatomy
- Blood supplied from distal pole
- In children, 87% involve distal pole
- In adults, 80% involve waist
- Treatment depends on location of fracture
Imaging for scaphoid fx
- AP, lateral, oblique, and scaphoid view
- Radiographs can be delayed for up to 4 weeks
- ?MRI, bone scan, or treat and repeat film
Scaphoid fx tx
- cast 6-12 weeks
- short arm vs. long arm
- follow patient every 2 weeks with x-ray
- CT and clinical evaluation to determine healing
- consider screwing early
Scaphoid fx non-operative tx disadvantages
- nonunion rate 5-55%
- delayed union
- malunion
- “cast disease”- joint stiffness
- prolonged immobilization- sometimes >12 weeks
- loss of time from employment and avocations
Scaphoid fx referral
- Angulated or displaced (1mm)
- Non-union or AVN
- Proximal fractures
- Late presentation
- Early return to play desired
Triangular Fibrocartilage Complex (TFCC) Tear etiology
- “wrist sprain”
- Fall on dorsiflexed and ulnar deviated wrist
- Axial load with forearm in hyperpronation
- Positive ulnar variance predisposes to injury
TFCC Tear Diagnosis
Exam:
- Ulnar sided wrist pain
- Often experience a click
Imaging:
- Radiographs
- MR arthrogram
TFCC Tear Treatment
- Splinting
- Time
- Injection
Surgical treatment:
- Debridement
- Repair
- Open vs. arthroscopic
- Ulnar shortening osteotomy
DeQuervain’s Tenosynovitis Etiology
- pain d/t inflammation of the short extensor and abductor tendons of the thumb
- repetitive or unaccustomed griping and grasping causes friction over the distal radial styloid
DeQuervain’s Tenosynovitis: Diagnosis
- swelling and pain over 1st dorsal compartment
- (+) Finkelstein’s test
DeQuervain’s Tenosynovitis: Treatment
- Splint
- Injection- 1st line
- -up to 90% are pain free if injected within 6 months
- Ice
- NSAIDS
- Rehab exercises
DeQuervain’s tenosynovitis recurrence
Recurrence despite repeated injections
Mallet finger etiology
- Injury to the extensor tendon at the DIP joint
- MC closed tendon injury of the finger
Mallet finger mechanism
- Mechanism: object striking finger, creating forced flexion
- Tendon may be stretched, partially torn, or completely separated by a distal phalanx avulsion fracture
Mallet Finger Presentation
- Pain at dorsal DIP joint
- Inability to actively extend the joint
- Characteristic flexion deformity
- On exam, very important to isolate the DIP joint to ensure extension from DIP and not the central slip
- If can’t passively extend consider bony entrapment
**all of these need x-rays
Mallet Finger Treatment
- Splint DIP in neutral or slight hyperextension for 6 weeks
- Cochrane review- all splints same results
- Surgical wiring does not improve outcome
- Office visit every 2 weeks
- If not extension lag at 6 weeks, splint at night and for activity for 6 weeks.
- Conservative treatment effective up to 3 months delayed presentation
Mallet Finger Referral
- Bony avulsion >30% of joint space
- Inability to achieve passive extension
- Despite proper treatment permanent flexion of the fingertip is possible
- No fracture reduction in the splint
Flexor Digitorum Profundus Tendon Injury (jersey finger)
-etiology
- Athlete’s finger catches another player’s clothing
- Forced extension of the DIP joint during active flexion
- 75% occur in the ring finger
- Force can be concentrated at the middle or distal phalanx
Jersey Finger Presentation
- Pain and swelling at the volar aspect of DIP joint
- Can often feel fullness proximally if tendon retracted
- Need to isolate the DIP to properly test
Jersey Finger Treatment/ Referral
***All need to be referred for surgery immediately
Collateral Ligament Injuries
-etiology
- Forced ulnar or radial deviation
- Can cause partial or complete tear
- PIP is usually involved
- Present with pain at the affected ligament
- Evaluate with involved joint at 30 degrees of flexion and MCP at 90 degrees of flexion
Collateral Ligament Injuries
-treatment
-If joint stable and no large fracture- can buddy tape
-Never leave the pinky alone
?Physical Therapy- if joint stiff
Metacarpal Fractures
-etiology
- MC hand fracture
- Usually involves the neck
- Fight or fall common mechanism
- 4th and 5th fingers are most common fractures
Metacarpal Fractures Diagnosis
- Present with edema over the dorsum of the hand
- Point tender
- Ecchymosis
- The distal fragment usually displaces volarly due to the interosseous muscles
- Radiographs: AP, lateral, oblique
Metacarpal Fracture Treatment
- Angulation up to 40+ degrees can be tolerated
- Attempt reduction?
- Different cast types
Metacarpal Fracture
-complications
- Malrotation
- Common with spiral or oblique fractures
- Greater than 10% malrotation leads to scissoring effect of the fingers
- Metacarpal head
- Loss of knuckle
Metacarpal Fracture Referral
- Rotation
- Angulation > 70 degrees
- Preference
Proximal PIP dorsal dislocation (Coach’s Finger)
- MC dislocated joint in the body
- can injure the volar plate or cause an avulsion fracture of the middle phalanx
Proximal PIP dorsal dislocation
-relocation
- reduce via gentle longitudinal traction
- If initially unsuccessful should hyperextend the distal portion to unlock
- If not done <1 hour consider a digital block
Post Reduction Care of proximal PIP dorsal dislocation
- Radiographs should be obtained to ensure joint congruity
- Examine collaterals
- PIP should be splinted in less than 30 degrees
Proximal PIP Dorsal Dislocation
-referral
- Avulsion fracture > 1/3 of joint space
- Irreducible fracture
- Instability post-reduction
Volar Plate Injury
-etiology
- Hyperextension, such as dorsal dislocation
- PIP is usually affected
- Collateral damage is often present
- The loss of joint stability can cause hyperextension deformity
Volar Plate Injury
-diagnosis
- Maximal tenderness at volar aspect of affected joint
- Bruising, swelling
- Full extension and flexion possible if joint stable
- Collaterals should be tested
- Radiographs may show an avulsion fracture at the base of involved phalanx
Volar Plate Injury
-treatment
- Progressive splinting starting at 30 degrees flexion
- Followed by buddy taping
- If less severe, can buddy tape immediately
- Can play sports if splinted
Ulnar Collateral Ligament Injury of the Thumb (GameKeeper’s/Skier’s Thumb)
-etiology
- Caused by forced abduction of the 1st MCP joint
- Left untreated the joint will be unstable with weak grip strength
Skier’s Thumb
-diagnosis
- Difficulty opposing pinky to thumb
- Swelling and black and blue over thenar eminence
- Can’t hold an OK sign
- Consider digital block and to facilitate ligament testing
Skier’s Thumb Grading/Treatment
-grade 1
- Pain without instability with stress
- Splinting 1-2 weeks
Skier’s Thumb Grading/Treatment
-grade 2
- Pain with mild instability: gapping <20 degrees
- Casting 3-6 weeks
Skier’s Thumb Grading/Treatment
-grade 3
- Stenner’s Lesion
- Instability: gapping > 20 degrees or > 35 degrees compared to unaffect thumb
- Early surgical intervention within 2-3 weeks
Skier’s Thumb Referral
- Fracture
- Unstable joint
- Stener lesion
Stener lesion
fibers of the adductor pollicis tendon (intrinsic hand muscle) with fibers of the extensor aponeurosis
-aponeurosis has flipped up and gotten in the way of the UCL
