COMMON ORTHOPAEDIC

INJURIES & PROBLEMS YOU DON’T WANT TO MISS!

Bruce Hamilton Dick , MD FACSM

Director of Orthopaedic Surgery

O R T H O P A E D I C C O M P L I C A T I O N S - “ M I S U N D E R E S T I M A T E D ”

• Not Frequently seen • Difficulties• Follow up• Evolving etiologies• Other clinical interest• Dx Inaccurate

1. Low back pain - 15 mil2. Knee inj/pain - 10 mil3. Shoulder - 6 mil4. Foot and ankle - 5 mil5. Carpal tunnel - 2.5 mil

WHY ? MUSCULOSKELETAL

Musculoskeletal injuries rank # 1 in visits to physician’s offices...1 in 7 Americans has musculoskeletal impairment...

What was the most popular sport in 2014?

Skateboard

ing

Footb

all

Socce

r

Lacro

sse

Running

Cycling

0% 0% 0%0%0%0%

1. Skateboarding2. Football3. Soccer4. Lacrosse5. Running6. Cycling

0of5

10

Hottest Sports In 2014:

31%

22%

20%

20%

20%

18%

18%

15%

15%

11%

11%

11%

0% 10% 20% 30% 40%

Skateboarding

Strength

Golf

Basketball

Football

Fitness Cycling

Running

Yoga/Pilates

Soccer

Aerobic Training

Fitness Walking

Lacrosse

Source: SGMA’s Sports Research Partnership

What is the fastest growing segment of the US population?

0%0%0%0%

Ages 5 – 19 Ages 20 – 44 Ages 45 – 64 Ages 65 -

1. Ages 5 – 192. Ages 20 – 443. Ages 45 – 644. Ages 65 -

0

5

10

Population Trend By Age GroupChange In Population In Millions

61.3

61.461.8

66

104.1

105 104.4108.6

62.4

72.8

8183.7

35.1 36.840.2

54.6

0

20

40

60

80

100

120

Ages 5 - 19 Ages 20 - 44 Ages 45 - 64 Ages 65 andOlder

2000

2005

2010

2020

Source: American Sports Data/SGMA

What is the fastest growing sport in the senior US population?

20%

20%20%

20%

20%

Golf Walking Aerobics Pickle ball Tennis Diabetes

0

5

10

GolfWalking AerobicsPickle ball TennisDiabetes

SO HOW DO WE PROCEED?

CASE #1Patient is a 12 y/o lacrosse player who presents to your office with a painful forearm one day after a FOOSH injury. He is quite tender to palpation over the proximal forearm and has visible deformity. The skin is intact. Neurovascular examination is normal.Long arm splint is intact.Prior to discharge from the office for Ortho f/u in the am, the patient complains of thumb numbness. PROM fingers painful.

What is your diagnosis?

25%

25%

25%

25%1. Both bones Fx – f/u ortho a.m.

2. Both bones Fx – f/u ortho now

3. F/U ortho 1 week

4. Let’s see what the ED is up to

PAIN W/ PASSIVE STRETCH OF FINGERS MOST SENSITIVE FINDING

PARAESTHESIA AND HYPOESTHESIA

NERVE ISCHEMIA AFFECTED COMPARTMENT

PARALYSIS - LATE FINDING

PALPABLE SWELLINGPERIPHERAL PULSES ABSENT LATE FINDING

Diagnosis

Clinical AnatomyEach limb contains a number

of compartments at risk for CS.Upper arm: anterior(biceps-

brachialis) and posterior(triceps).

Forearm: volar(flexors) and dorsal(extensors)

10 compartments hand

TreatmentAcute CS is a surgical emergency.Delays over 24 hrs can result in

myoglobinuria, renal failure, metabolic acidosis, hyperkalemia, ischemic contracture.

Indications for fasciotomy:clinical signs of CStissue pressure over 30 mmHg with clinical

picture of CSinterrupted arterial circulation over 4 hours.

Take Home Message

Compartment Syndrome evolves, it is not an event

Examine “Off” the fracture

Establish direct communication with referral destination

Case #2Pt is a 18y.o. nordic skier, who presents with wrist pain. He describes a FOOSH mechanism of injury and complains of numbness in the distribution of the median nerve.

What is your diagnosis?

20%

20%

20%

20%

20% 1. Sprained wrist2. Scaphoid fracture3. Peri-Lunate dislocation4. Radius fracture5. Metacarpal fracture

Epidemiology

Wrist injuries account for 2.5% of all ED visits.

Lunate and perilunate injuries are thought to represent 10% of all carpal injuries.

Perilunate and lunate dislocations result from hyperextension injuries.

Most common mechanism of injury is a FOOSH

Clinical AnatomyThere are 8 carpal bones

comprising two carpal rows; the scaphoid bridges both rows.

With radial deviation the scaphoid and lunate palmar flex

Intrinsic and extrinsic ligaments maintain carpal stability.

PA and lateral radiographsPA view:

constant 2 mm intercarpal joint space3 arcs

Lateral view:four Cscapitolunate angle 0-15 degreesscapholunate 30-60 degrees

Stress views

Take Home MessageHistory of high energy mechanism of hyperextensionPalpable pain over the dorsum of the wristTenderness distal to Lister’s tubercle in the area of the scapholunate ligamentX-ray – identify the lunate

PT IS AN 18 Y.O. SOCCER PLAYER WHO PRESENTS WITH PERSISTENT DORSAL FOOT PAIN AFTER BEING STEPPED ON DURING A GAME OVER A WEEK AGO, AND HAS NOT IMPROVED WITH SELF-CARE.

Case #3

What is your diagnosis?

20%

20%

20%

20%

20%1. Ankle Sprain

2. Foot Sprain

3. Ankle Fracture

4. Lisfranc fracture

5. Soccer Flop

ImagingAP, lateral and oblique views

On AP and obliques the 2nd met medial border should align with the middle cuneiform

On the lateral the metatarsal shaft should not be more dorsal than the respective tarsal bone

Contralateral foot filmsWeight-bearing views

LISFRANC FRACTURE

The articulation between the tarsal and metatarsal bones in the foot is named after Jaques Lisfranc.Lisfranc injuries may represent 1% of all orthopedic trauma, but 20% are missed on initial presentation. The second metatarsal is the keystone to the Lisfranc joint.

Take Home Message

X-rayPhysical Exam

PT IS AN 18 Y/O FOOTBALL PLAYER WITH AN ANKLE SPRAIN.PT HAS CONSIDERABLE SWELLING AND DEMONSTRATES MORE TENDERNESS PROXIMAL TO THE ATFL RADIOGRAPHS ARE NEGATIVE

CASE #4

What is your diagnosis?

20%

20%

20%

20%

20%1. Ankle Sprain

2. Syndesmotic Sprain

3. Ankle Fracture

4. Foot Fracture

5. Jones Fracture

EpidemiologyAnkle sprains are the most common lower

extremity injury in sports medicine, and constitute 25% of all sports injuries.

In one series, syndesmotic injuries constituted 17 % of ankle sprains.

Syndesmotic injuries are not uncommonly associated with fractures.

Fractures of the ankle are rotational injuries and can be confused with sprains

Imaging

CASE #4

2 yo male son of parents well known to you, fell down stairs presents to your office not moving his right arm and painful cough

What would you do?

20%

20%

20%

20%

20%1. Genetic couseling

2. Refer to ortho

3. CPS

4. Splint the arm

5. More x-rays

EpidemiologyPhysical80% of deaths from head trauma in

children < 2 yr are NATFractures are 2nd most common

presentation of physical abuse (25-50%)Estimated 10% of trauma cases seen in

ED in children under 3 yr are nonaccidental

20% involve burnsTwo thirds will be seen by an MD prior to

an orthopaedist!

Risk Factors for NATYoung (age < 3 yr)First born childrenUnplanned childrenPremature infantsDisabled childrenStepchildrenSingle-parent homesUnemployed parents

Substance abuse 50-80% involve some degree of substance abuse

Families with low income < $15k were 25x more likely than > $30k

Children of parents who were abused

High Stress Environments!

Fractures in Different Stages of Healing

Present in 70% of physically abused children < 1 yr

Present in 50% of all abused children

Fractures Commonly seen in NAT - High Specificity

Femur fracture in child < 1 year old (any pattern)

Humeral shaft fracture in < 3 year old

Sternal fracturesMetaphyseal corner

(bucket-handle) fractures

Posterior rib fx'sDigit fractures in

nonambulatory children

Take Home Message

You have a legal responsibility to the child – not the parentsX-ray changesPhysical Exam

32 YO MALE SLIPPED AND FELL ON ICE AND SNOW. SEEN @ ED PLACED IN SLING. CAN’T MOVE SHOULDER. SHOULDER IS HELD IN INTERNAL ROTATION, ELBOW FLEXED.

Case #5

What is your diagnosis?

20%

20%

20%

20%

20%1. Anterior Dislocation

2. Normal shoulder

3. Posterior dislocation

4. Humerus Fracture

5. Pneumothorax

POSTERIOR SHOULDER DISLOCATIONS ARE LESS COMMON THAN ANTERIOR DISLOCATIONS, BUT MORE COMMONLY MISSED 50% OF TRAUMATIC POSTERIOR DISLOCATIONS SEEN IN THE EMERGENCY DEPARTMENT  ARE UNDIAGNOSED2% TO 5% OF ALL UNSTABLE SHOULDERS95% OF ALL SHOULDER DISLOCATIONS ARE ANTERIOR

Shoulder Dislocations

Ghana Emergency Medicine Collaborative

Advanced Emergency Trauma Course

Glenohumeral Joint DislocationsAnterior Dislocation

Inferior displaced humerus

Posterior Displacement AP = Internal Rotation of

humerus = “Light bulb sign” Y view = Humeral head

displaced

http://www.imagingpathways.health.wa.gov.au/includes/image/sh_pain/should.jpg

http://www.learningradiology.com/caseofweek/caseoftheweekpix/cow105arrows.jpg

Take Home Message

Common things happen commonly, that is why they are common…know them uncommonly well

Final ThoughtsOccupational Medicine

practice is rooted in prevention. Workers who develop occupational diseases or incur injuries in the workplace represent a failure of prevention.

Many places that have Occupational Medicine listed as a service on their signage are frequently only practicing Workers Compensation Medicine and have little to offer in the way of prevention - know your service providers.

S U M M A R Y

Hip Pathology is often seen in young active adultsGroin pain is usual presenting symptomNon operative treatment may not be effective in high demand athletes but it is indicatedHip arthroscopy offers favorable results