Keywords: Stress fracture, runner, non union (PubMed Search)
Tibial shaft stress fractures
An overuse injury where the tibia is subjected to repetitive stress resulting in progressive microfractures
Commonly seen in runners and military recruits
Location of injury is very important for prognosis and treatment
1) Medial tibia (compression side) – Most common stress fracture site in athletes (runners)
2) Anterior tibia (tension side) – Seen in repetitive jumping athletes
History: Change in routine (volume or surface), Insidious onset of pain, worse with activity better with rest
Exam: Focal tenderness to palpation (versus larger diffuse area with shin splints)
Radiology: Plain film often normal in first 2 to 3 weeks
Lateral X-ray may show the “dreaded black line” on the anterior tibia
MRI has replaced bone scan as most sensitive for early diagnosis. Fracture line surrounded by edema.
Medial fractures: relative rest (avoid painful activities), avoid NSAIDs, PT, gradual return to activity as dictated by symptoms
Anterior stress fractures: Very high risk injury pattern (delayed union and non union). Non weight bearing splint/cast. Intramedullary nail often used for failure of conservative treatment or earlier return to sport in competitive athletes.
Dreaded black line picture:
Keywords: Shoulder pain, neuritis (PubMed Search)
Parsonage Turner syndrome aka Neuralgic amyotrophy
30 cases per 100,000
Under recognized and often missed
Unknown cause, perhaps post viral. Also reported post stress (surgery, pregnancy)
Can be B/L in 10 to 30%
CC: sudden onset of severe pain in the shoulder.
Can last for hours to weeks.
Radiates to upper arm.
As pain begins to subside, muscle weakness and sensory loss follows.
Can preferentially involve the suprascapular and axillary nerve.
Outpatient workup may include MRI and EMG
Treatment: Supportive. Consider a trial of oral steroids. Provide good pain control.
Majority of patients improve within 3 months. Though up to a third have persistent pain/functional deficit.
Keywords: Muscle injury, splinting (PubMed Search)
Mechanism: Blunt trauma to the anterior thigh (frequently football helmet or opponents knee)
Usually involves the anterior quadriceps (rectus femoris and vastus intermedius)
Pain on passive stretch and active contraction
Can develop large hematomas
Loss of knee flexion is a poor prognosticator
Complication: Myositis Ossificans (MO) (5-17%)
Increased risk with delay in treatment > 3 days
Radiographs can lag. Ultrasound in more sensitive
Painful firm area in region of contusion occurring 2 to 3 weeks post injury
Prompt treatment….key to good outcome and earlier return to sports
Large hematoma can be aspirated. NSAIDs may reduce edema and risk of MO. Splinting
Place quadriceps in 120 degrees of flexion for 24 hours following injury (keep muscle lengthened)
Keywords: Knee pain (PubMed Search)
Complete or incomplete separation of the articular cartilage and subchondral bone
-70% occur at the lateral aspect of the medial femoral condyle
-Also seen in the talar dome and capitellum
Repetitive overloading leads to fragmentation and separation from surrounding bone
Prognosis better in kids than in adults
CC: Vague difficult to localize activity related pain and swelling. Mechanical symptoms only if loose body is present
PE: Wilson’s test
Internal tibial rotation and knee extension impinges the tibia on the OCD lesion causing pain. Pain abates with external rotation and flexion.
Plan of care: Limit activity and trial period of non-weight bearing for 6 weeks.
50% resolve in 10 to 18 months with conservative care.
Detached, loose or unstable fragments or failure of non-operative care will need surgery
Keywords: ACL tear (PubMed Search)
Lever Sign/Lelli’s test
A new test for diagnosing ACL tears
Higher sensitivity (94 - 100%) than the Lachman test (highest sensitivity test to date)
With time and more study, this may become our new gold standard physical examination test
Very easy to learn and apply to bedside care
Can help with diagnosing partial tears
Area of manipulation is the femur and not the tibia (as in other tests)
Consider incorporating into your standard knee examination
Thank you to Ari Kestler for sending
Keywords: Knee OA, injection (PubMed Search)
Hyaluronic acid (HA) is a high-molecular weight polysaccharide
A major component of synovial fluid and of cartilage
Major role of HA is as a lubricant, shock absorption, antinociceptive effect
Used in veterinary medicine for decades
Multiple brands exist with differences based on the molecular weight and how they are produced
Use supported by the Cochrane database (2007, 2014) for knee OA
Post injection strength gains are due to pain relief
May have a role for those who cannot receive steroid injections
Inject in similar manner to intra articular steroids
Caution in those with known allergy to poultry /eggs
Risks: Local reaction (likely from preservative), injection site pain, infection, bleeding.
Keywords: Concussion recovery (PubMed Search)
There is tremendous interest in identifying factors that may influence outcome from sports related concussion.
The strongest predictor of slower recovery is the severity of symptoms in the 1-2 days post injury
-Fewer Sx's in this time period predict a quicker recovery
Pre injury history of mental health problems, depression or migraine headaches predict a longer recovery course
Teenagers might be more vulnerable to having persistent symptoms with greater risk for girls than boys
Having a prior concussion is a risk for having a future concussion
The large majority of injured athletes recover from a clinical perspective within the first month of injury many within the first 10 days
McCrory P et al. Br J Sports Med 2017;51:838-847.
Keywords: Knee instability (PubMed Search)
PCL injuries can sometimes have involvement of the posterolateral corner (PLC)
The dial test can be used to diagnose posterior lateral instability and help differentiate it from isolated PCL injuries
The dial test involves comparing the amount of external rotation of the lower leg at the knee while the knees are in 30° and in 90° of knee flexion.
An isolated injury to the posterolateral corner will result in more than 10° of external rotation in the injured knee that is present at 30° but not at 90° of knee flexion.
Keywords: Hip, pediatrics, arthritis (PubMed Search)
Idiopathic osteonecrosis of the femoral head
Children as young as 2 or as old as 12 but generally 4 to 8 (worse in older children)
Fare better than adults with osteonecrosis of femoral head
1 in 10,000
4-5x more common in males, much less common ini African Americans
Unilateral femoral head involvement 90% of the time (Bilateral 10% of the time)
Long term consequences are deformity and arthritis
Typical presentation: Subacute limping for weeks (Painless)
As activity worsens limp, it is maximal at the end of the day (Intermittent)
As in adults with hip pathology, IF pain is reported, it is located at the upper anterior thigh and groin
On examination, look for restriction in range of motion of the hip (compare with contralateral side)
May only present with mild to moderate decreased range of motion of the hip
30 versus 60 degrees for example
ABduct both legs with pelvis in neutral OR Place one hand on contralateral pelvis and ABduct affected leg with other hand.
Keywords: Adhesive Capsulitis (PubMed Search)
Adhesive Capsulitis aka Frozen Shoulder
Spontaneous gradual onset stiffness and pain of the Glenohumeral joint
Shoulder capsule becomes thickened and contracted
Often affects patients between 40 and 60 years old
Left> Right shoulder
Association with diabetes and thyroid disease
3 clinical stages
1) Pain – gradual onset, diffuse, severe, disabling, often worse at night
2) Stiffness – decreased ROM, affects ADLs, improved pain
3) Thawing – gradual return of motion
Physical examination: Painful and decreased ROM. Evaluate active and passive movement, external rotation and ABduction of the shoulder most affected
Surgical or post traumatic shoulder stiffness usually resolves within 12 months.
Adhesive capsulitis is generally self-limiting lasting an average of 18-36 months.
DDX: Chronic locked posterior shoulder dislocation (VERY IMPORTANT), tumor.
Treatment: NSAIDs, Physical therapy, Intra articular steroids
If this fails, manipulation under anesthesia and/or arthroscopic surgical release
Keywords: Runner, injury (PubMed Search)
Medial tibial stress syndrome (MTSS) aka shin splints is an overuse injury of the tibia
-10 to 15% of running injuries and over 50% of leg pain syndromes
1) Pain along the posteromedial border of the tibia
2) Diffuse pain
3) Pain that is activity related
Female sex, increased weight, previous running injury, and
Higher navicular drop (amount of foot pronation) and
Greater hip external rotation with the hip in flexion
Tibial stress fracture, compartment syndrome, nerve entrapment (sural), lumbar radiculopathy and popliteal artery entrapment.
Keywords: Wrist fracture, splinting (PubMed Search)
High energy mechanism in younger patients
Falls more common in older patients
Higher incidence in older women due to osteoporosis
May indicate overall poor bone health
Avoid splinting in positions of flexion (palmer) and ulnar deviation
Palmer flexed positions may have a higher rate of displacement
Extra-articular fx, less than 5mm shortening of radius, Less than 5 degrees of dorsal angulation.
Consider fractures than are only stable in extreme positions to be unstable
If fx involves the ulnar styloid or DRUG (distal radial ulnar joint) place in long area posterior splint with arm in mid supination (anatomic position of forearm)
Keywords: Lateral knee pain (PubMed Search)
Iliotibial band tendonitis
IT band is the continuation of the tensor fascia lata and inserts on the tibia at Gerdy's tubercle
Common cause of lateral knee pain seen in Primary care/Sports med clinics
Mechanism: May be due to excessive friction between the IT band and the lateral femoral condyle
Second most common overuse injury of the knee (PF syndrome). Not an acute event.
Affects up to15% of active individuals
Impingement zone is at 30 degrees of knee flexion
Most common in runners and cyclists
Pain localized over the lateral femoral condyle. Better w/ rest. Often occurs at a predictable distance into the run and not at onset.
Exacerbated with changes to mileage or running terrain.
Additional risks include poor shoes (best to change every 300 to 500 miles), excessive foot pronation (pes planus), quad versus hamstring strength asymmetry, weak hip ABductors, leg length discrepancy, tight IT band.
Keywords: Hip, pediatrics, arthritis (PubMed Search)
Septic Arthritis in Children
Classic presentation: Pain, fever (may not always be present)
Limited range of motion of joint or refusal to bear weight,
Joint swelling (difficult to visualize in hip or shoulder),
Limb held in position that allows greatest capsular volume (elbow held in 30° flexion for example)
Diagnostic testing may include diagnostic markers (ESR, CRP) or imaging (US/MRI)
Most common organisms: Staph and Strep, Neisseria (adolescents), HACEK organisms, consider gram negatives in immunocompromised children
DDX: Transient synovitis, osteonercrosis or osteomyelitis, Psoas abscess, acute leukemia, Lyme disease
A common ED presentation is the child with the painful limp
35% of all cases of septic arthritis
>50% of cases occur in children younger than 2yo
Hip held in flexion, Abduction, external rotation
Fever and inflammatory markers are more sensitive than WBC count and refusal to bear weight
1) Refusal to weight bear on affected side
2) Sed rate greater than 40mm/hr
3) Fever (>38.5°C
4) WBC count of >12,000 mm3
- 4/4 criteria are met, there is a 99.6% chance of septic arthritis;
- when 3/4 criteria are met, there is a 93% chance of septic arthritis;
- when 2/4 criteria are met, there is a 40% chance of septic arthritis;
- when 1/4 criteria are met, there is a 3% chance of septic arthritis;
CRP can also be incorporated into a diagnostic algorithm
CRP>2.0 (mg/dl) in a child who refuses to bear weight yields a 74% probability of septic arthritis
Keywords: EKG, athletes (PubMed Search)
Most of our knowledge of the athlete’s EKG is based on white athletes.
African/Afro-Caribbean athletes are more likely to have an abnormal EKG than white athletes in multiple studies.
Different selective criteria have been developed to minimize classification of benign normal patterns as abnormal.
The 2010 ESC criteria classified 40.4% of black athletes as abnormal versus the Refined criteria which resulted in 11.5% of EKGs classified as abnormal.
This reduction was aided by the recognition that isolated anterior TWI in asymptomatic black athletes is considered a benign finding.
Note this does NOT apply if the TWI extend to the lateral leads
For example, T-wave inversion (TWI) was present in 23% of African/Afro-Caribbean athletes vs. 3.7% of white athletes (usually in contiguous anterior leads).
Other changes included a higher prevalence of early repolarization, RV hypertrophy, and LA/RA enlargement.
1) Jacob et al., 2016. Ethnic and Gender Specific Differences Among Athletes Participating in ECG Screening.
2 )WIlson et al., 2012. Significance of deep T-wave inversions in asymptomatic athletes with normal cardiovascular examinations: practical solutions for managing the diagnostic conundrum.
3) Brown et al., 2017. THe Complex Phentype of the Athlete's Heart: Implications for the Preparticipation Screening.
Keywords: team doctor, sports medicine (PubMed Search)
Physicians are often called upon to serve as a team physician for a local high school in an official or unofficial capacity.
To aid in preparedness for sport-related emergencies, multiple national organizations have defined institutional best practices.
Knowledge of the following 3 best practice recommendations is important before taking on the role of “Doc covering the game”
1)The written Emergency Action Plan (EAP) – details the standard of emergency care at the particular venue.
2)The availability of life saving equipment: AED – where is it, charged and working?
3)Are the coaches trained in use of the AED and CPR. You can’t be everywhere and often multiple sporting events occur on campus simultaneously. It’s imperative that your first responder (coach or athletic trainer) can perform these tasks until you are able to respond
Please investigate these best practice recommendations before agreeing to serve as the physician for the local high school.
Keywords: stress fracture, runner (PubMed Search)
22yo college track athlete presents with 3 weeks of gradual onset groin and thigh pain, worse with running, better with rest.
Stress fractures are a common cause of groin pain in athletes, particularly in long distance runners
Fractures occur in the pubic rami and femoral neck
Ask about a sudden change in training regimens
PE: check for tenderness to deep palpation over the pubic ramus. Ask athlete to stand and support full weight on affected leg or perform one legged hop on affected side. Pain out of proportion to physical examination findings.
Imaging: XR usually negative. Bone scans can be positive as early as 4 to 8 days after symptom onset. MRI used to diagnose and rule out other causes of groin pain.
Treatment: Rest for 4 to 6 weeks. Consider making patient non weight bearing if walking causes pain especially with femoral neck fractures on the superior side. Inferior side neck fractures may benefit from prophylactic fixation.
Groin Injuries (Athletic Pubalgia) and return to play. Elattar et al., Sports Health Aug 2016.
Keywords: forearm trauma (PubMed Search)
The Essex-Lopresti injury pattern is the lesser known of the triad of forearm injuries (Monteggia & Galeazzi).
It follows the “rule of the ring” aka the life saver candy rule: You can’t break a life saver in just one place.
These injury patterns are frequently missed because our eyes are drawn to the fracture and miss the associated dislocation.
The Essex-Lopresti fracture pattern involves a fracture of the radial head with concomitant dislocation of the distal radio-ulnar joint (DRUG)
-With associated interosseous membrane disruption
Think of it as the Maisonneuve fracture of the forearm.
Mechanism: fall from height/high energy forearm trauma.
PE: Suspect if patient has significant tenderness at the DRUG with a radial head fx.
Patients have worse outcomes if injury is missed on initial presentation due to radial migration and instability.
Take home point: Remember the rule of the ring. Remember to exam the elbow with wrist injuries and the wrist with all elbow injuries
Category: Airway Management
Keywords: Elbow, fracture, trauma (PubMed Search)
Is that a fracture or a growth plate?
Pediatric elbow x-rays are complicated to interpret due to the large number of ossification centers.
Elbow trauma is common in pediatrics.
Ossification centers of the elbow appear in a reliable chronologic pattern which aids in distinguising fractures from growth plates.
Note the age ranges are an estimate with great variability. For example, girls can develop these up to 2 years earlier than boys.
The numbers 1/3/5/7/9/11 correspond to the average age of development of each ossification center
Years of fusion shown below in ()
Radial head (14-16yo)
Medial epicondyle (16-18yo)
Lateral epicondyle (12-14yo)
Pneumonic: "Can't Resist My Team Of Lawyers"
Consider ordering films of both elbows to compare if in doubt.
How is this useful? If the trochlear center is present, but there is no medial epicondyle then you are most likely looking at a fx where the ossification center has been avulsed and displaced.
Keywords: nerve, entrapment (PubMed Search)
During a busy ED shift, your 40yo charge nurse asked you to look at his hand. He is known avid mountain biker. He has pain in his right 4th and 5th digits. . He feels a lack of coordination and a feeling of “clumsiness” of the hand. Where is his possible nerve compression and what do you expect to find on exam?
Ulnar nerve entrapment is sometimes called “handlebar palsy.”
Compression location is Guyon’s canal.
The ulnar nerve supplies the intrinsic muscles of the hand AND the extrinsic muscles for flexion of the 4th and 5th digits. This is what aids in a “power grip” and why he may have diminished grip strength on exam.
Also innervates the ADDuctor pollicis and 1st dorsal interosseous muscles (pinch)
Note the ulnar nerve also passes through the radial tunnel at the elbow. Entrapment here is called Radial tunnel syndrome or Cubital tunnel syndrome and causes forearm pain and paresthesias in the 4th and 5th digits with grossly normal motor and sensory function.