ACOFP 55th Annual Convention & Scientific Seminars

8

New Physicians and Residents: Sports Medicine - Fractures and Sprains

Priscilla Tu, DO

3/14/2018

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Sports Medicine

Fractures and Sprains

Priscilla Tu, DO, FAOASM, FAAFP

ACOFP New Physicians & Residents

March 23, 2018

Disclosures

• I have no financial

disclosures…unfortunately!

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Objectives

• Recognize common sprains seen in family

medicine

• Discuss common fractures seen in family

medicine

• Determine when to splint v brace v cast

and referrals for above

Splint, Brace, or Cast

• Immobilize a joint

• Help minimize pain

• Improve progression of chronic

injury

• Stabilize an acute injury

• With large amount of swelling

• Unload a joint

• Definitive fracture management

(all)

• All

• All

• Brace

• Splint/Brace

• Splint

• Brace

• Cast

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Goals of Immobilization

• Decrease pain

• Provide stability – limit ROM

• Maintain alignment

• Promote healing

• Protect injury

• Help compensate for surrounding

muscular weakness

Bracing – When to Use

• Chronic injury

• Unload joint

• Must have accurate

diagnosis

• Worsening of injury

• Injury prevention

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Bracing – Fitting Brace

• BRACE MUST FIT

WELL

• Patient should know

how to put on brace

properly

• Watch them in clinic

before you let them

leave

Splint v Cast

• Stage and severity of injury

• Potential for instability

• Risk of complications

• Patient's functional requirements

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Splint versus Cast

• Fast and easy

• Can be static or

dynamic

• Allow for swelling

• Removed more easily

• Less risk

complications

• Soft tissue injuries

• Circumferential

• Superior

immobilization

• Complex fractures

• Definitive fracture

management

• Harder to remove

Case 1

• A 19yo F Longhorns volleyball player presents to clinic with ankle pain, swelling, and bruising after landing poorly during a game. She has a positive drawer sign and talar tilt. Xrays are negative, but patient is still having difficulty bearing weight.

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Ankle Sprain

Ankle Sprain

• Most common injury

in sports

• Lateral more common

than medial (85-90%)

• Usually <35yo

• Usually ligament

sprain or tear

• Occ fractures

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Ankle Sprain

• Medial Ankle

Ligament = Deltoid

Ligament

• Largest ankle ligament

• Broad, fan-like

• Prevents abduction /

eversion of ankle and

subtalar joint

Ankle Sprain – Treatment

• PRICE

• Control swelling

• Early ROM

• Stretching

• Proprioception / Balance

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Case 2• A 29yo F falls after a 3 hour brewery tour and

hands on her outstretched hand. There was

immediate swelling, no ecchymosis, 6/10 pain,

and difficulty moving her wrist. She denies

previous injuries or parasthesias.

Case 2

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Wrist Sprain / Soft Tissue Injury

• PRICE

• Control swelling

• Early ROM

• Stretching

Case 3

• A 32yo M rodeo clown

presents with medial

knee pain after

distracting a bull the

night before. No pops.

Pain made worse

turning in bed and

getting out of car.

Positive Valgus stress

test and tenderness

medially.

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Medial Collateral Ligament

Sprain• Grade I, II, III

• Treatment

• PRICE

• Control swelling

• Early ROM

• Physical therapy

• RTP – depends on

grade

• Surgery – rare

• Same for LCL

Lateral Collateral Ligament

Sprain

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Fractures

Fractures – Most Common

• Phalanges (Fingers)

• Metacarpals

• Radius (Distal)

• Phalanges (Toes)

• Fibula

• Metatarsal

• Clavicle

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Fracture Classification /

Description• Open v closed

• Anatomic location

• Distal, mid, proximal

• Diaphysis,

epiphysis,

metaphysis

• Intra-articular

• Fracture line pattern

• Relationship of

fragments

• Angulated

• Displaced

• Rotated

• Dislocation

• Neurovascular

status

Fracture Classification

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Fracture Classification – Parts

of Bone

Fracture Classification

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Fracture Classification

Fracture Classification -

Pediatrics

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Fracture Assessment

History

• MOI

• Other injuries

• Previous injuries

• PMH

• Medications

• Menstrual cycle for

women

• Nutrition

• Allergies

Physical Exam

• On field

• ABCs

• Neurovascular, skin breaks

• Palpate entire bone

• Joint above and below

• Radiographs

• At least 2 differing by 90

degrees

• Put in order what you are

concerned about

Fracture Treatment

• Factors affecting healing

• Age

• Hormone balance / nutrition

• Medications – NSAIDS, corticosteroids, Abx

• Smoking / ETOH

• Diabetes

• Weight bearing

• Patient non-compliance

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Fracture Healing

• Most fractures heal in?

• 8 weeks

• How long before swelling resolve / patient

feel normal?

• A year or more

• If surgery needed, when?

• Within 2 weeks if possible

Fracture Treatment – Refer?

• Open or comminuted fractures• Tenting of skin concern for open fracture

• Arterial or nerve injury

• Intra-articular fractures

• Fracture dislocations

• Specifics for different body parts

• Compartment Syndrome• Elevated pressures in rigid fascial muscle

compartments

• 5 Ps – pain, pallor, paresthesias, pulselessness, paralysis

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Fracture Treatment – Refer?

• Calcaneus

• Talus

• Tibia shaft

• Femoral shaft

• Hip

• Humerus

• Ankle

Case 4

• A 19yo male Texas

Longhorn basketball

player noted a pop

and pain in his finger

after going for a loose

ball. Since then, the

distal end of his finger

cannot straighten.

You obtain an xray.

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Case 4

Mallet fracture

• Finger Splint (6-8 weeks)

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Case 5

• 45 yo male professional wrestler presents

to urgent care after a match, noting hand

pain after punching his opponent.

Case 5

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Boxer’s Fracture

• Most common hand fracture

• Check for rotation / angulation / dislocation refer

• Check for teeth marks• Abx if needed

• Ulnar Gutter Splint

• Heal Time: 4-6 wks

Case 6

• A 33yo M presents with

wrist pain with swelling

and ecchymosis. He

was riding a

mechanical bull and

was thrown off, landing

on his outstretched

hand. He has snuff box

tenderness on the

affected hand.

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Case 6

Scaphoid Fracture

• Thumb spica splint 8-12 weeks

• Refer to ortho

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Scaphoid Fracture?

• If initial xrays negative but snuffbox tender,

splint and re-xray in 10-14 days

• If still negative and pain, consider CT/MRI

• Refer to ortho

• Healing: 6-24 wks

• Complications

• Nonunion

• Avascular necrosis

Other Finger FracturesDiagnosis Exam Treatment Referral

PIP Dislocation

(Volar =

boutonniere)

Attempt reduction,

check NV status,

postreduction xray

Dorsal: splint; ROM

Volar: splint

extension if central

slip extensor tendon

disrupted

>30% intra-articular

surface; cannot

reduce; no full

extension after

reduction

MCP Dislocation

(esp thumb)

See above Splint; early ROM Open or hard

reductions

DIP Dislocation See above Splint; early ROM Complicated

Distal Phalanx

(Tuft Fracture)

Assess tenderness;

xray

Splint 2-4 weeks

then ROM

Rare

Mallet Fracture If unable to extend at

DIP, xray

Splint DIP in

extension 8 weeks

If large displaced

fragment; large

volar subluxation

FDP Avulsion

Fracture (Jersey)

If unable to flex at

DIP, xray

Refer for possible

FDP retraction

All

Middle/Proximal

Phalanx Fracture

Assess tenderness,

rotation, xray

Buddy tape, early

ROM

Displaced, oblique,

spiral fx

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Case 1

• A 19yo F Longhorns

volleyball player

presents to clinic with

ankle pain, swelling,

and bruising after

landing poorly during

a game. She has a

positive drawer sign

and talar tilt. Xrays…

Avulsion Fracture 5th MT

• Most common

fracture LE

• Peroneal brevis

tendon

• Firmed sole shoes for

4-8 weeks

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Case 1

• A 19yo F Longhorns volleyball player presents to clinic with ankle pain, swelling, and bruising after landing poorly during a game. She has a positive drawer sign and talar tilt. She also has tenderness lateral leg.

Maisonneuve Fracture

• Lateral ankle sprain

proximal fibula

fracture

• Non-weightbearing

bone

• Walking boot w

crutches

• Heal 6-8 weeks

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Case 7

• A 28 yo male Austin

Huns rugby player

presents with ankle

and foot pain with

inability to bear

weight after an injury

during a match. He

has pain and swelling

in lateral ankle and

foot.

Case 7

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Jones Fracture

• Cast for at least 6

weeks, up to 12

weeks

• Refer to ortho

• Poor blood supply

• If does not heal well

surgery needed

• May perform surgery

earlier if athlete or

concern for non-

healing

Other Foot FracturesFracture Type Treatment Radiographs Referral

First MT shaft Posterior splint;

NWB; f/u 3-5

days; short leg

walking cast or

boot; f/u q2-4 wks;

heal 6 wks

3-view foot;

repeat 1 wk and

4-6 wks

Open, fx-

dislocations; intra-

articular;

displacement or

angulation

Lesser MT shaft Posterior splint;

NWB; f/u 3-5

days; short leg

walking boot/cast

6wks; f/u q2-4

wks; heal 6 wks

3-view foot;

repeat 1 wk and

4-8 wks

Open,

fx/dislocations;

multiple; >3mm

displaced; >10deg

angulation

5th MT tuberosity Compressive

dressing; WBAT;

f/u 4-7 days

3-view foot attn

oblique; repeat 6-

8 wks

>3mm displaced;

>1mm stepoff;

fragment 60%

MT-cuboid joint

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Other Foot Fractures

Fracture Type Treatment Radiographs Referral

Prox 5th MT

(Jones)

Posterior splint;

NWB; f/u 3-5 days

3-view foot attn

oblique; repeat 1

wk and 4-6 wks

(10-12 wks if no

healing)

>2mm displaced;

nonunion after 12

wks; athletes

Great toe Short leg walking

boot; WBAT; f/u 4-

7 days

3-view foot or

phalanx; repeat 1

wk if IA or

reduced

Fx/dislocations;

intra-articular

displaced or

>25% joint; physis

Lesser toes Buddy tape, rigid

toe shoe; WBAT;

f/u 1-2 weeks

Same as great toe Displaced IA;

>20deg angled;

>20deg rotation;

>25% joint; physis

Case 8

• A 21yo male football

player presents to

urgent care with his arm

adducted close to body,

holding it up with the

other arm. MOI was

falling during a game

onto his shoulder. He

has shoulder pain and

swelling and bruising

noted.

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Case 8

Clavicle Fractures

• Nondisplaced midshaft

• Most common

• Immobilize with sling or

figure of eight dressing until

pain resolved; then

pendulum for ROM

• Displaced midshaft –

higher rate nonunion if

>15% displaced refer

• Medial 1/3 = nonoperative

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Clavicle Fractures – Distal

• 12-15% clavicle fx but

50% of nonunions

• Type 1:

coracoclavicular

ligaments intact;

minimal to no

displacement

nonoperative

Clavicle Fractures – Distal

• Type II

• Level of

coracoclavicular

ligament

• IIA – conoid and

trapezoid ligaments

intact; fracture medial

to ligaments

• IIB – disruption conoid

ligament

• Surgery recommended

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Clavicle Fractures – Distal

• Type III

• Distal to

coracoclavicular

ligaments and involve

AC joint

• Minimally or

nondisplaced usually

• Nonoperative

treatment

Questions?

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References

• Bica D, Sprouse RA, Armen J. Diagnosis and management of common foot fractures. AFP 2016; 93(3): 183-191.

• Borchers JR & Best TM. Common finger fractures and dislocations. AFP 2012; 85(8): 805-810.

• Boyd AS, Benjamin HJ, Asplund C. Principles of casting and splinting. AFP 2009; 79(1): 16-22.

• Boyd AS, Benjamin HJ, Asplund C. Splints and casts: Indications and methods. AFP 2009; 80(5): 491-499.

• Pecci M & Kreher JB. Clavicle fractures. AFP 2008; 77(1): 65-70.