Dental Avulsion in the field/sporting event
- Only replace avulsed secondary teeth
- Handle the tooth by the crown only
- Rinse tooth with cold running water gently (the root should not be wiped)
- Immediate attempt to reimplant permanent tooth into socket by 1st capable person:
* Time is tooth: Each minute tooth is out of socket reduces tooth viability by 1%
* Best chance of success if reimplant done within 5–15 min*? Poor tooth viability if avulsed for >1 hr
- If unsuccessful, place tooth in a transport solution (from most to least desirable):
- Hanks balanced salt solution (HBSS)
* Balanced pH culture media available commercially in the Save-A-Tooth kit
* Effective hours after avulsion
- Cold milk:
* Best alternative storage medium
* Place tooth in a container of milk that is then packed in ice (prevents dilution)
- Saliva:
* Store in a container of parent or child's saliva
- Never use tap water or dry transport
Concussion – Where are we now?
The Sport Concussion Assessment Tool 5th edition (SCAT 5) was released in 2017
It is a standardized tool to assist health care professionals in the evaluation of sport associated concussions
It should be used for those 13 years and older (there is a child version for younger athletes)
Print and bring to the sideline for your next coverage event!
http://bjsm.bmj.com/content/bjsports/early/2017/04/26/bjsports-2017-097506SCAT5.full.pdf
Some points to consider:
It should take at least 10 minutes to complete. Any less and you may not be performing the test correctly
The SCAT5 is the standard tool used in concussion assessment in the NCAA and NFL and other professional sports
Some symptoms of concussion appear over time. For example, an athlete may have zero or minimal symptoms immediately after yet be considerably symptomatic in 10 to 15 minutes.
-Follow up screening evaluations are essential even in those with a negative initial sideline screening test
The SCAT5 should be used immediately after injury
-Utility decreases post injury after days 3-5
-The included symptom checklist has utility in tracking recovery
-Attempt to perform in an environment free of distractions (crowd noise, bad weather)
The clinical utility of the SCAT5 can be enhanced by adding assessment of other factors such as reaction time, balance assessment, video-observable signs (if available) and oculomotor screening.
CC: 12yo boy presents with pain to base of 5th metatarsal
Osteochondrosis overuse syndromes associated with development of secondary ossification or apophyseal centers
Iselin disease – Osteochondrosis of 5th MT base
Lateral 5th foot pain with weight bearing and activity in early adolescence
Child may limp or walk on inner part of foot
Adolescents: Girls >10, Boys >12
Commonly seen in soccer, basketball, gymnastics and dance
Exam: Tenderness to palpation at proximal 5th MT at peroneal brevis insertion
Area may show edema and redness
Pain with foot inversion and resisted eversion and dorsiflexion
XR: May be normal or show enlargement or fragmentation of epiphysis
Obliquely oriented small bony fleck at 5th MT base. Parallel to long axis of 5th MT. Best seen on oblique view. Unlike fractures which tend to be horizontally oriented.
Treatment: Immobilize for comfort if severe (walking boot) or simple activity modification if mild. Ice and calf muscle stretching.
http://https://images.radiopaedia.org/images/2343487/d3478d2024c845ba0f2fffffd7d51c_big_gallery.jpg
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.
Treatment:
Medial fractures: relative rest (avoid painful activities), avoid NSAIDs, PT, gradual return to activity as dictated by symptoms
VERSUS
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:
A recent article from JAMA (link below) showed that Ibuprofen and opioids are similarly effective in the short term relief of acute extremity pain when used in combination with acetaminophen. The study looked at adults with fractures and sprains and randomized them to one of four groups.
Pain relief was similar in all groups.
With the growing increase in opioid abuse/addiction it is good to know that in our patients that are not allergic to acetaminophen and ibuprofen (or all medications except for that one that begins with a “D”) we can provide good pain relief without using opioids.
https://jamanetwork.com/journals/jama/article-abstract/2661581
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.
Quadriceps Contusion
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
http://fifamedicinediploma.com/wp-content/uploads/2015/12/myositis_ossificans_lateral-1.jpg
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)
https://upload.orthobullets.com/topic/3103/images/quad%20contusion_moved.jpg
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
http://www.eorif.com/KneeLeg/Images/OCD4w.jpg
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.
https://www.youtube.com/watch?v=e7zrKo41Pos
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
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
https://www.youtube.com/watch?v=T9ujIYIctdw
Original study
https://www.ncbi.nlm.nih.gov/m/pubmed/25536951/
Validation
https://www.ncbi.nlm.nih.gov/pubmed/26753117
Thank you to Ari Kestler for sending
Viscosupplementation
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.
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
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.
https://www.youtube.com/watch?v=rnk62Y-nDSQ
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.
http://www.kneejointsurgery.com/wp-content/uploads/2015/06/DIAL-TEST.jpg
http://www.kneejointsurgery.com/wp-content/uploads/2015/06/DIAL-TEST-90.jpg
Take Home Points:
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.
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
Women> men
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
Shin Splints
Medial tibial stress syndrome (MTSS) aka shin splints is an overuse injury of the tibia
Very common
-10 to 15% of running injuries and over 50% of leg pain syndromes
3 Characteristics
1) Pain along the posteromedial border of the tibia
2) Diffuse pain
3) Pain that is activity related
Risk Factors
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
Differential Diagnosis
Tibial stress fracture, compartment syndrome, nerve entrapment (sural), lumbar radiculopathy and popliteal artery entrapment.
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)
It is common teaching that a Segond Fracture is associated with ACL tears. A reverse Segond fracture, avulsion fracture of the knee due to avulsion of the deep fibers of the medial collateral ligament, has also been described that was initially reported as associated with PCL tears. However, a more recent study has not been able to collaborate the PCL connection, but has shown that a reverse Segond fracture is associated with multiple ligamentous injuries to the knee.
Take home point: If you note a Reverse Segond fracture on your plain flips have the patient followup with orthopedics for a possible MRI, as they probably have other ligamentous injuries that might need treatment.
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.
Lisfranc Fracture: Typically consists of a fracture of the base of the second metatarsal and dislocation, though it can also be associated with fractures of a cuboid.
Click below see image of fracture
