Sports Medicine Flashcards
True or False: Conditioning programs are encouraged
True
How often should conditioning programs include aerobic training?
3-4 days/week
What is the difference between weight training and power lifting?
- Weight training: Many reps with low resistance
2. Power lifting: Fewer reps with increased resistance
Which is safe for preadolescents… weight training or power lifting?
Weight training
Why is power lifting not safe for preadolescents?
Risk of apophyseal avulsion fractures
What are the 2 forms of heat illness?
- Heat exhaustion
2. Heat stroke
Is heat exhaustion or heat stroke more mild?
Heat exhaustion is more mild
Mild dehydration, core temperature <104F, headache, thirsty, nauseated, vomiting
Heat exhaustion
What is a way to distinguish between heat exhaustion versus heat stroke?
Sweating- Heat exhaustion sweats, heat stroke doesn’t
What is management for heat exhaustion?
Stop exercising
Drink fludis
Name 4 findings in heat stroke
- Temperature >105F
- Flushed, hot, dry skin (no perspiration)
- CNS depression (confusion, vertigo, syncope, lethargy
- Severe dehydration
How does heat stroke lead to end organ damage?
Release of endotoxins and cytokines
*Dehydration isn’t only cause of problems in heat stroke
True or False: Heat stroke is a medical emergency
True
What is management for heat stroke?
- Stop activity
- Get child out of heat
- Decrease core body temperature
- Rehydration via IVFs only +/- vasopressors if needed for BP
True or False: Simple evaporative cooling may be as effective as active cooling via application of ice
True
Why is oral rehydration inappropriate in heat stroke?
Due to CNS depression
Cooling a heat stroke patient below what temperature could lead to hypothermia and is inappropriate?
101-102F
What neurological findings point to heat stroke versus heat exhaustion?
Delirium, coma, seizure
Describe a grade 1 sprain
Minor stretching of the ligament
Minimal discomfort or loss of function
Initial injury often doesn’t come to medical attention
Describe a grade 2 sprain
Ligaments partially torn
Tenderness and swelling
Ecchymosis
Some loss of function
Describe a grade 3 sprain
Ligament completely torn
Significant pain, tenderness, swelling, loss of function
Usually seeks medical attention
What ligament is usually affected in an ankle injury?
Anterior talofibular ligament
*Inversion injuries involving lateral ligaments
What % of sports injuries involve lower extremities?
75%
What are the 2 most common sports injuries?
- Contusions
2. Ankle sprains
What % of ankle injuries are sprains of lateral ligaments?
85%
What are most injuries that occur in the knee and ankle due to?
Incomplete healing of a previous injury
What are 5 criteria for a child to return to sports after an ankle injury?
- Full ROM
- Full strength
- No swelling
- No pain
- No join instability
What should pain over a bone physis in a pre-adolescent child be assumed to be (even if XR is normal?)
Salter Harris I Fracture
What is the immediate treatment of an ankle sprain?
Apply ice
*Should continue for 20 minutes at a time over the first 36-48 hours
Child who recovers from an ankle injury, returns to competitive sport, then gets another more severe injury in the same ankle… most likely cause?
Re-injury: Child returned to competitive play too soon
Child whose ankle/lateral leg got stepped on during basketball. No deformity, but there is a bruise and marked swelling. Foot has strong dorsal pulse and some diminished sensation to pinprick and light touch… most appropriate next step?
Obtain compartment pressures- Bruising with marked swelling and decreased sensation point to compartment syndrome
*Presence of pulse and lack of paralysis just mean it’s in the early stages (doesn’t rule this out)
What are the 5 P’s of compartment syndrome?
- Pain
- Paresthesias
- Pallor
- Paralysis
- Pulselessness
4/5 are late findings (absence doesn’t rule it out)
When would ice and compression dressings be indicated for compartment syndrome?
Never- Ice won’t help and compression dressing will make it worse
What usually causes subluxation of the patella?
Indirect trauma
Pop after change in direction off a pivoted knee, pain over lateral aspect of patella, possible deformity over the medial aspect patella?
Subluxation of the patella
What can subluxation of the patella represent?
Patellofemoral instability
What is management of subluxation of the patella?
Developing and maintaining quadriceps and hamstring strength as well as flexibility
Anterior knee pain in adolescents involved in jumping, running, and squatting sports due to patellar maltracking?
Patellofemoral syndrome
Which gender does patellofemoral syndrome affect more frequently and why?
Females- Higher Q-angle between femur/tibia
How is patellofemoral syndrome diagnosed?
Clinically (XR isn’t helpful)
What is management of patellofemoral syndrome?
- Knee bracing
- Patellar taping
- NSAIDs
- Quad strengthening
When should you refer patellofemoral syndrome to orthopedics?
If condition doesn’t improve after 4-6 months of conservative intervention…
- Knee bracing
- Patellar taping
- NSAIDs
- Quad strengthening
Large area of swelling over thigh after blunt trauma?
Soft tissue hematoma (can be big due to blood supply to quadriceps)
*Also consider fracture or lytic lesion is clues are there
What does any athlete with a history of knee “giving way” with activities need to be evaluated for?
ACL tear
Which gender are ACL tears more common in?
Females (3-4x more common than males)
How does prepatellar bursitis present?
Anterior knee pain over patella, visible swelling
What is treatment for prepatellar bursitis?
NSAIDs, padding during sports with recurrent trauma (volleyball)
What is management for a soft tissue hematoma in the thigh?
NSAIDs, ice, rest
What complication should you be mindful of in a severe soft tissue hematoma of the thigh?
Drop in Hct- Fatigue/Dizziness
Pain over anatomical snuffbox (dorsum of hand near base of thumb)?
Scaphoid fracture
True or False: Negative XR is common in a scaphoid fracture
True
True or False: Scaphoid fractures have a poor prognosis
True
12 year old gymnast with left wrist pain, progressively worse over 3 months, no known injury. No swelling, normal ROM, no pain over wrist joint, point tenderness at distal radius. Most likely explanation/Management/XR Findings?
Distal radial epiphyseal injury
Rest and splint wrist until healed (if continues training, likely to disrupt growth plate)
Can do training that doesn’t involve wrist (doesn’t have to stop all training- for example, running)
Who and How to supracondylar humeral fractures typically occur in?
Boy age 5-8 after falling on an outstretched arm that is hyperextended at the elbow
What does a supracondylar fracture of the humerus impact?
Vasculature
*May be no external signs in presence of severe injury/trauma
If trauma to elbow is mentioned in question, what do you need to consider?
Neurovascular compromise
What are some signs of vascular damage associated with a supracondylar fracture?
Pallor/cyanosis of distal extremity
Pain on passive extension of fingers
True or False: A nondisplaced supracondylar fracture will be seen on XR
False- It might not be obvious
True or False: You should treat pain more versus less aggressively
True
Risk for respiratory depression with opiates is less than commonly believed (titrate up on dose to manage pain appropriately)
What sign may you see on XR that is a clue towards a supracondylar humeral fracture?
Posterior fat pad sign (seen on lateral elbow XR)
-Indicative of effusion associated with fracture
True or False: An anterior fat pad sign on elbow XR is suggestive of fracture
False- This is a normal finding
Patient with an elbow injury (supracondylar fracture of distal humerus). Decreased grip strength and decreased radial pulse- What is causing this?
Transient neurological deficit (not result of a direct vascular injury)
-Absent radial pulse likely due to compression of radial artery (not trauma to artery) and will resolve with reduction of fracture
What age group do you typically see dislocation of the elbow in?
11-15
What injury is likely to be seen after a fall on an outstretched arm that is supinated with the elbow partially extended (NOT hyperextended)?
Dislocation of the elbow
True or False: Elbow dislocation can be associated with neurovascular compromise
True
What injury is seen in older children due to direct impact with the arm laterally rotated on impact?
Epiphyseal Fracture
True or False: Neurovascular compromise is common in epiphyseal fractures of the elbow?
False
What position is the arm likely to be in for a lateral condyle fracture?
Supinated
True or False: Neurovascular compromise is very unlikely in a lateral condyle fracture
True
Does a nursemaid’s elbow present with elbow swelling and tenderness?
No
What is another name for Nursemaid’s Elbow?
Annular Ligament Displacement
Child falls back on a posteriorly rotated, abducted arm…injury?
Anterior humeral dislocation
Child has pain over the distal clavicle, with a prominence noted over the area of point tenderness…injury?
Acromioclavicular injury
Child sustains direct force to the posterior shoulder and has pain over the sternoclavicular joint with possible respiratory discomfort…injury?
Posterior sternoclavicular dislocation
Child with shoulder and upper arm pain in the absence of asymmetry…injury?
Proximal humeral fracture
Child with shoulder pain with elevating and lowering the arm, without any deformity. Can also present as chronic pain, most likely in absence of acute injury…Cause?
Rotator cuff injury
How is a shoulder dislocation diagnosed?
Clinically
Why do we get XR for shoulder dislocations?
For confirmation of diagnosis and assessment of other injuries like fractures
What part of the exam is important to re-evaluate after reducing a dislocation?
Neurovascular
What is done for a shoulder dislocation after it is reduced?
Immobilize it in a sling and then place a pillow/blanket between the arm and body
Teenage baseball player with a shoulder injury. Pain over distal clavicle, point tenderness over superior aspect, can’t lift arm overhead, XR negative for fracture/dislocation… most likely injury?
Acromioclavicular separation
What age are children more likely to get a fracture in the distal clavicle versus acromioclavicular separation after a shoulder injury?
<13- Fracture
>13- Acromioclavicular separation
What is the difference in pain between acromioclavicular separation and shoulder separation?
Acromioclavicular: Point
Shoulder: Diffuse
What injury is likely to result from a fall on an outstretched arm or directly on the shoulder?
Clavicular fracture
How would a kid with a clavicular fracture position the arm?
Holding it with opposite hand
True or False: Most clavicular fractures will healh without much intervention other than arm sling
True
What type of clavicular fractures require evaluation for possible displacement of trachea or mediastinal structures?
Medial clavicular fracture with anterior or posterior displacement
True or False: Clavicular fractures require ortho consult?
False- Rarely indicated
What is management for a clavicular fracture?
Immobilization
How can acromioclavicular separation be distinguished from clavicular fracture?
Acromioclavicular separation has palpable step off of the anterior shoulder joint in absence of crepitus
What is the definition of a concussion?
Alteration in level of consciousness
*NOT necessarily a loss of consciousness
What must be done immediately after sustaining an injury and developing symptoms consistent with concussion?
Must be kept out of game or practice
What are the progressive steps for the criteria for returning to play after a concussion?
- Complete rest, staying at home and relaxing
- Walking around/light activity (no weights or resistance)
- Movement consistent with their sport, minimal resistance training
- Training drills, but no contact- Followed by mental status testing
- Full-contact training
- Return to game play
If a concussion patient has symptoms recur at any step in returning to game play, what must they do?
Rest for 24 hours before returning to process
Who helps to serve as a liaison between coaching and medical staff in terms of concussions?
Trainer
True or False: Most contact sports now require assessment and documentation of neurocognitive function prior to sports participation
True- Serves as a baseline test used to compare post-traumatic results which are factored into determining when it is safe to return to play
What are the sports with the highest concussion rates?
- American football (highest risk for head injury)
- Boys’ Ice Hockey
- Boys’ Lacrosse
- Girls’ Soccer
- Wrestling
What is important with an acute injury involving the neck?
Do your ABC’s while keeping the neck in a stable position
How can you assess breathing in a football player with a neck injury?
Place a hand beneath the shoulder pads and jersey to assess chest expansion
What is done for a patient who is prone that has a neck injury?
Log roll while maintaining neck stability
When should you remove shoulder pads and/or helmets on the field?
Never
What should you do if you need to do airway management for a football player on the field?
Leave the helmet on and remove the face guard only
What is the most common sports-related cause of neck injuries?
Football (not diving)
What sport in an important mechanism to consider for C-Spine injury?
Diving
When can a patient with a neck injury return to sports?
- When there is no pain with motion or palpation of C-spine
- All neuro testing is negative
- No description of tingling sensation in extremities
*All apply even is c-spine film is negative
Which sports need a mouth guard?
- Collision sports: Football, soccer, basketball, hockey, wrestling
- Teeth Clenching: Shot put, discus throwing
- Kids with braces playing any sport
What do mouth guards do?
Significantly lower the risk of trauma to teeth (very little to reduce concussion risk)
True or False: Children with fevers cannot participate in sports
True
Kids with what four problems cannot participate in high contact sports?
- Carditis
- Hepatospleomegaly (mono)
- One functional kidney
- Repeated concussions
Which of the following sports are considered high-impact collision sports: Baseball, squash, volleyball, team handball, water polo?
Handball and water polo
True or False: Kids with any single organ cannot participate in contact sports?
False: This only applies to kidneys- Kids with a single ovary or testicle can participate in contact sports, they can wear protective equipment to safeguard other single organs.
What is the leading cause of sport-related eye injuries?
Baseball
*Mostly in kids <14, often being hit with a pitched ball
What is recommended for eye protection in kids playing baseball?
- <14, face guard when at bat
2. One functional eye (corrected vision < 20/50) protective goggles when in the field
Kid with mono, what is the best management of the patient with regards to sports clearance?
Avoiding contact sports until the splenomegaly is resolved
If a teen is suspected of using performance-enhancing substances, what is a big part of making the diagnosis?
Good intervew
What are the 3 main systems that can have side effects from anabolic steroid use?
- Renal
- Hepatic
- Psychological
If a kid is using needles to inject anabolic steroids, what are they at risk for?
- HIV
2. Hepatitis
What are 4 findings you can see in females who use anabolic steroids?
- Hirsutism
- Low voice
- Early closure of epiphyseal plates
- HTN
What are 5 findings you can see in males who use anabolic steroids?
- Severe acne
- Gynecomastia
- High pitched voice
- Hypogonadism
- HTN
If you have a tennager who is experiencing a sudden change in mood, what is one thing you should consider on the differnetial?
Withdrawal from steroids- Steroids can result in violent behavior
True or False: Arrhythmias and seizures can be due to steroid use
False
How long do oral steroids stay in the system?
Days-weeks (in the urine)
How long do IM steroids stay in the system?
6+ months
True or False: Growth hormone can enhance athletic ability and isn’t detected in current drug testing?
True (increasing in popularity)
Name 4 common lab findings you can see with steroid use
- Elevated LFTs
- Lower HDL
- Increased LDL
- Oligospermia and azoospermia
What is the appropriate first choice for hydration before, during, and after sport participation?
Water
True or False: Only kids who do exercise with vigorous intensity require replenishing carbohydrates during exercise
True- And this should be limited due to caloric load
What must coaches and sports staff remind kids to do?
Keep up with fluid intake (kids won’t do it on their own)
True or False: Fluid replacement alone is sufficient to protect against heart exhaustion
False- It is possible to produce heat quicker than it can be transmitted to the environment
What are some examples of flavored drinks that contain carbs, minerals, and electrolytes and can be appropriate for kids?
Sports drinks- All Sport, Powerade, Gatorade
What types of drinks should not be given to kids?
Energy drinks- Contain stimulants like caffeine and guarana
Kid with nephrotic syndrome in remission- What are the restrictions in sports activity and recommendations for fluid intake?
Qualifies for all sports activities
Should have full access to fluids during games and practices
Nephrotic syndrome is in remission, treat this like a normal child
What sport is it common for kids to try to lose weight to qualify for a lower weight category?
Wrestling
What is weight loss that occurs in a short period of time?
Water weight loss
What usually results from weight loss that occurs in a short period of time?
Lower muscle endurance
Name 7 things which require referral to a cardiologist prior to clearing for sports participation
- Syncope, near syncope, or chest pain on exertion
- Palpitations at rest or irregular heart rhythm
- Excessive shortness of breath or fatigue with routine activities
- FHx of Marfan, cardiomyopathy, long QT, or clinically significant arrhythmias or premature death
- Weak or delayed femoral pulses
- Fixed split second heart sound, systolic murmur >3/6, any diastolic murmur
- Turner syndrome with any chest pain
Name 11 things which are contraindications to sport participation
- Pulmonary vascular disease with cyanosis and large R-L shunt
- Severe pulmonary HTN
- Severe aortic valve stenosis or regurg
- Severe mitral valve stenosis or regurg
- Cardiomyopathies
- Vascular form of Ehlers-Danlos
- Coronary anomalies or wrong sinus origin
- Catecholaminergic polymorphic V-tach
- Acute phase of pericarditis
- Acute phase of myocarditis (at least 6 mo)
- Acute phase of Kawasaki disease (at least 8 wk)
Athletic teenager with modest LVH and bradycardia, is this normal?
Can be- Certain athletes like long distance runners can have modest LVH and low heart rates (60s)
*No sports restriction if remainder of history and exam are normal
True or False: Kids with type 1 DM may play any sport as long as proper diet, fluid, and insulin therapy are maintained
True (may extra attention in sustained activities)
What is important to remember for kids with Type 1 DM during periods of exericse?
They will need increased caloric intake or decreased insulin dose (to avoid hypoglycemia)
*Can also have delayed response to exercise hours later resulting in hypoglycemia
True or False: Vigorous exercise should be deferred in kids with Type 1 DM during episodes of poor control, especially with ketosis
True
What % of kids with Down Syndrome have atlantoaxial instability?
15 (estimated)
True or False: All kids with Down Syndrome must have plain neck XR (+ thorough neurological exam) prior to being approved to participate in competitive sports including Special Olympics
True
True or False: Kids with a well-controlled seizure disorder may participate in all sports
True
What sports considerations do kids with seizure disorders that aren’t well-controlled need to take?
Avoid contact sports
Avoid things like archery, riflery, swimming, and sports involving heights
What type of sports to kids with Marfan syndrome need to avoid?
Bodily collision
Low collision sports: Bowling, Golf, Tennis, Track
What cardiac problems are kids with Marfan at risk for?
Aortic enlargement and/or aortic dissection
What activities do kids with Marfans need to avoid?
- Muscle straining (weight lifting)
2. Contact sports
True or False: Referral to a cardiologist is appropriate for all first degree relatives of patients with hypertrophic cardiomyopathy or other known heritable cardiac conditions (like Marfan)
True
