Category: Sports Medicine

11/19/2018 0 Comments

Exertion Heat-related Illness

Results in more than 600 deaths a year in the United States!
Anticholinergic agents, beta-blockers, and sympathomimetic drugs can all interfere with heat removal and increase risk of heat-related illnesses
Patients with exertion related heat stroke are commonly young, athletes, or military personnel that present with symptoms after strenuous exercise in the heat

Heat Exhaustion

Occurs via water depletion or sodium depletion or combination
Water depletion occurs in elderly and persons working in hot environments
Salt depletion occurs when fluid losses are replaced with hypotonic solutions

Signs & Symptoms
- Known heat exposure with temperature >37 C with:
  - Tachycardia/Palpitations
  - N/V
  - Diaphoresis
  - HA/malaise/fatigue/generalized weakness
  - Lightheadedness
  - Mentation is normal* (key distinguishing factor from heat stroke)

Evaluation
- Labs may show:
  - Hemoconcentration
  - Entire spectrum of sodium derangements common electrolyte abnormality

Treatment
- *NEED to remove from heat-stressed environment
- Volume and electrolyte replacement as needed
- Oral fluids vs. IVF
- Aggressive cooling (see below)

Heat Stroke

Severe end of heat-related illness spectrum with loss of thermoregulatory mechanisms
*TRUE EMERGENCY - focus of management should be on immediate, rapid cooling (even if can be started in pre-hospital setting!)
Mortality = 21-63%; can approach 30% even with treatment
Hallmark = Elevated temperature >41°C (106°F) + MSOF; heat exhaustion CAN have temperatures >104F
Occurs when endogenous heat production in combination with absorbed ambient heat exceeds the ability of the body to dissipate heat through adaptive mechanisms (i.e. sweating, hyperventilating, peripheral vasodilation)
The extent of neurologic injury and mortality is directly related to the peak temperature and duration of the hyperthermia

Symptoms
- CNS is particularly susceptible -> AMS, coma, ataxia, confusion, seizures, hallucinations
- Anhidrosis is frequently present; however, sweating found in up to 50% of patients
- Shunting of perfusion to less vital organs (e.g. liver, gut) -> GI bleeds, ischemic hepatopathy
- Compartment syndrome
- *Hepatic injury is so common (↑AST/ALT) that if not present, consider an alternative diagnosis
Workup
- ECG
- Continuous core temp monitoring
- Blood glucose, CBC, CMP (including liver enzymes)
- VBG (with lactic acid)
- DIC labs – fibrinogen, D-dimer, PT/INR
- CK (Rhabdomyolysis – 5x ULN) and UA (myoglobinuria)
- Chest x-ray
- CT brain (± LP), if indicated – BE SURE THIS IS NOT MENINGITIS
Management
- As always in emergency medicine -> ABCs
- Remove from environment
- IVF (for renal protection and avoiding rhabdomyolysis)
  1. Goal UOP 3 mL/kg/hr
  2. Accumulation of intracellular cytoplasmic calcium which leads to myocyte cell membrane damage and ATP depletion -> Hyperphosphatemia and hypocalcemia
  3. Precise guidelines do not exist, but the goal CK should be a level less than 1000 U/L
  4. No target value for creatinine level, however may see ATN
- Rapid cooling is mainstay of treatment
  1. Reduces morbidity/mortality, needs to be started in prehospital setting
    - Weak evidence available for target temperature; theoretical concern of overshoot hypothermia
  2. No role for antipyretics!
- Techniques:
  1. ***Cool water immersion
    - Immersion of body to level of torso or neck in cool or ice-water
    - May not be immediately available, so consider other techniques (listed below)
    - As you can imagine, not well-tolerated
    - You will have to take them out of the water in the unfortunate event a patient has a cardiac arrest subsequently
  2. Diffuse application of ice or cold packs to entire body
    - Benefit may be similar to ice-water immersion
  3. Evaporative/Convective Cooling
    - Set-up large fans and spray tepid water on patient’s body
    - Can perform this while getting ice bath drawn
    - Slightly higher morbidity and mortality compared to immersion
  4. Invasive
    - V V-ECMO, cold water rectal/bladder/NG lavage; bilateral chest tubes with pleural lavage… Weak data, so perform only if needed with caution
Consider giving antibiotics in addition to IVF hydration as it is difficult to rule out infection as a predisposing factor to the development of heatstrok

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10/25/2018 0 Comments

Patellar Dislocation

Background

Typically occurs with trauma to an extended knee with externally rotated foot (quick pivoting in basketball, football and soccer)
Acute dislocation occurs with traumatic injury, M=F, may see hemarthrosis
Chronic dislocation or patholaxity seen more commonly in women
- Ehlers-Danlos syndrome
- Typically, little or no swelling; painless
- Recurrent subluxation episodes with each flexion movement
May occur from a direct blow (ex. helmet to knee collision in football; knee-knee collision in basketball)
- Usually on noncontact twisting injury with the knee extended and foot externally rotated
- Patient will usually reflexively contract quadriceps thereby reducing the patella
Common associated fractures
- Medial patella facet
- Lateral femoral condyle

Clinical Features

Patella is usually displaced laterally
Knee is held in flexion
Acute dislocation usually associated with a large hemarthrosis
- Absence of swelling supports ligamentous laxity and chronic dislocation mechanism

Evaluation

Clinical diagnosis
May consider pre-reduction x-ray if concern for fracture (not required)

Management

Reduction = Relocation with lateral pressure on dislocated patella
Do NOT need x-rays prior to reduction
- Consider XR following reduction to rule out fracture or loose body
Rarely need any sedation (sub-dissociative dose ketamine ?)
Option #1:
- Mild flexion of hip (20-30 degrees by raising head of bed, not by propping the leg up off the bed) to relax quadriceps
- Slowly extend and slightly hyperextend the knee and slide patella back into place.
Option #2
- One provider applies slow downward pressure over the quads. This stretches out the muscle and slowly straightens the leg
- At the same time, second provider pulls gentle traction of the patella outward while rotating the patella back over from lateral to anterior

Disposition

Obtain ortho consult if unable to reduce or fracture/loose bodies seen on post-reduction x-ray
Otherwise may be discharged with ortho follow-up in 1-2 weeks
Non-Operative:
- NSAIDS, activity modification, and physical therapy
- Knee immobilizer for comfort (short-term)
- Quad strengthening exercises
- Core and hip strengthening to improve limb positioning and balance (hip abductors, gluteals, and abdominals)
Consider knee aspiration for tense effusion
- Positive fat globules indicates fracture

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9/21/2018 0 Comments

Knee Dislocations

Introduction

Usually from a high-impact injury (tackle while leg planted);
Outside of sports medicine, we typically see in trauma setting with dashboard injuries
Nearly 75% of ligaments will be disrupted
Associated Injuries:
- Vascular
  - 5-15% in all dislocation with nearly have occurring in A/P dislocations
- Nerve
  - Common peroneal nerve injury in 25% of cases!
    - S: Decreased sensation over dorsum of foot sparing the lateral most portion
    - M: loss of dorsiflexion/eversion of the ankle; Loss of EHL -> Foot drop
- Fractures presenting 60% of cases with femur and tibia being most common

Signs & Symptoms

Symptoms = Knee pain/instability (brought to knees)
PE:
- No deformity!
  - 50% of knee dislocations will spontaneously reduce prior to arrival; very deceptive
- Swelling, effusion, abrasions
- Obvious deformity
  - Reduce immediately!!!
Make sure you assess all ligaments (ACL, PCL, MCL, LCL)
Vascular exam is key!
- Number one priority
- Need to do both BEFORE and AFTER reduction
- DP/PT pulses
  - If pulses present/normal àDoes NOT rule-out arterial injury; collateral circulation can mask complete popliteal artery occlusion
  - ABI time!
    - >0.9 = serial examinations
    - <0.9 = CT angiography; consult vascular surgery if needed
  - Diminished/Absent Pulses:
    - Make sure knee is reduced!
    - Time = Muscle
    - IMMEDIATE surgical consult if pulses are still absent following reduction or hard signs of vascular compromise (expanding hematoma, distal ischemia, thrill)
    - Ischemia >8 hours has amputation rate ~85%
- Pulses present after reduction àABIs àObservation vs angiography

Classification

Kennedy classification for direction of displacement of tibia on femur; Schenck for ligaments
Anterior
- Most common (30-50%)
- Hyperextension injury and usually requires PCL to tear
Posterior
- 2ndmost common (25%)
- Due to axial load on a flex knee
- *Highest rate of vascular injury, i.e. complete popliteal artery tear
Lateral and Medical
- Due to varus/valgus force
- Lateral dislocation has highest change of peroneal nerve injury

Diagnostics:

XR ànormal if spontaneous reduction
Look for other fractures (Segond)
Non-emergent MRI
CT angiography as above

Treatment:

Reduce and re-exam!

This is an ORTHOPEDIC/SPORTS EMERGENCY
There is one situation where reduction of the knee should not take place. The “dimple sign” represents buttonholing of the medial femoral condyle through the anterior medial joint capsule. The sign indicates an irreducible dislocation and closed reduction is contraindicated for the risk of skin necrosis.
Posterior:
- Someone holds distal femur, provider pulls longitudinally then anteriorly
- Be careful; too much force can cause popliteal injury
Anterior:
- Counter-traction on proximal tibia
Once reduced, splint in 20-30 (deg) flexion and re-shoot films
Most cases require surgical stabilization, consult your orthopedic surgeons
If ABI >0.9 with strong pulses and normal doppler -> Admit for observation
ABI <0.9 with asymmetric pulses or abnormal doppler -> consult vascular surgery, obtain CTA

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9/14/2018 0 Comments

Clavicle Fracture

Background

Secondary to shoulder trauma (not as much direct clavicle trauma)
- Tackled to ground
- FOOSH
- Direct impact to lateral shoulder
Majority of fractures involves the middle third (75-80%); Distal third (15%); Medial third (5%)
Distal third associated with AC joint injury and/or coracoclavicular ligament rupture
Medial fracture àintrathoracic injuries

Clinical Features

Swelling, deformity, tenderness, pain over anterior shoulder
Patient may be supporting affected arm with the contralateral arm
Displaced fractures
- Medial fragment displaced posteriorly and superiorly (SCM pulls)
- Lateral fragment displaced inferiorly and medically (Pectoralis and weight of arm pulls)
- Open fractures usually result from medial fragment buttonholing through platysma

Evaluation

Assess distal pulses, motor, and sensation
XR (CXR, SXR, Dedicated clavicle films)
- Associated injuries are rare, but can see rib fractures, PTX, neurovascular injuries
- Additional XR view = ZANCA view (15-degree cephalic tilt)
  - Determines superior/inferior displacement
  - Have patient hold 5-10 lbs weight in affected hand
Consider CT for further eval and possible vascular injury

Classification

Neer, Allman, Craig, Robinson

AO Classification:
- Type A, B, C (A = Simple; B = Wedge; C = Complex)

Management

Non-operative
- Sling or figure-of-eight immobilization with early ROM exercises at 2-4 weeks; start strength training at 6-10 weeks
- Best for minimally displaced, <2 cm shortening, no neuro deficits
- Nonunion rate = 1-5 %
  - Most often in elderly and females
Operative
- ORIF
  - Open fractures
  - Displaced fracture with skin tenting
  - Neurovascular injury
  - Risk of need for future procedures, implant removal or debridement for infection
Pain control
- Chang AK, Bijur PE, Esses D, et al. Effect of a Single Dose of Oral Opioid and Nonopioid Analgesics on Acute Extremity Pain in the Emergency Department: A Randomized Clinical Trial. JAMA2017;318:1661-7

Disposition

Discharge with ortho/sports follow-up
Possible surgical intervention for comminuted fractures, significant displacement or >2 cm of shortening
Consult orthopedics in the ED if patient has an open fracture, Neurovascular compromise or skin tenting

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9/14/2018 0 Comments

BiCeps Tendon Rupture

Incidence

Rare
Distal biceps tendon rupture represents about 10% of biceps ruptures, with majority being proximal
Ruptures tend to occur in the dominant elbow (86%) of men (93%) in their 40s

Risk factors

Your muscle builders with their anabolic steroids
Smoking has 7.5x greater risk than nonsmokers
Typically, patients will report a snap or pop as the elbow is eccentrically loaded from flexion to extension

Weakness and pain, primarily in supination, are hallmarks of this injury
May produce mid-arm "ball", also be referred to as the reverse “Popeye’s sign” = change in contour of the muscle
Motor exam often shows loss of supination and flexion, with mostly loss of supination
Distal swelling and tenderness over antecubital fossa
- For most complete tears, there will be an Inability to palpate distal biceps tendon in antecubital fossa
- However, there is a great provocative test you can perform called the Hook test. This was a technique first described in 2007 in an article published in the AJSM (Dr. Shawn O’Driscoll), which was found to be ~100% sensitive and specific
  - Performed by asking the patient to actively flex the elbow to 90° and to fully supinate the forearm. Using you index finger, attempt to hook the lateral edge of the biceps tendon.
  - With an intact / partially torn tendon, finger can be inserted 1 cm beneath the tendon
- Follow-up study using the Hook test has shown once again near 100& specificity, however lower sensitivity at 82%, but overall a great physical exam maneuver if you have high suspicion!
The biggest challenge is going to be distinguishing between complete tear and partial tears
Biceps tendon is absent in complete rupture and palpable in partial rupture (otherwise they have a very similar clinical picture)

Evaluation

Obtain radiographs to rule-out avulsion fracture (Usually normal)
- However, occasionally shows a small fleck or avulsion of bone from the radial tuberosity
Ultrasound can help with diagnosis--> Use linear probe (high frequency probe) to assess for tendon defects
Ideally, outpatient MRI will often be used to distinguish between complete tear vs. partial tear or muscle substance vs. tendon tear

Management

Proximal rupture
- Sling, ice, NSAIDS, physical therapy, referral to ortho
Distal
- Nonoperative
  - Supportive treatment followed by physical therapy
  - Older, low-demand or sedentary patients who are willing to sacrifice function. Most becoming asymptomatic at 4-6 weeks
- Operative
  - Surgical repair of by fixation of tendon to tuberosity
  - Indications
    - Young healthy patients who do not want to sacrifice function
    - Partial tears that do not respond to nonoperative management
    - Surgical treatment should occur within a few weeks from the date of injury
    - Further delay may preclude a straightforward, primary repair

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9/7/2018 0 Comments

Achilles Tendon Injury

Background:

Associated with fluoroquinolone use
Sudden, severe pain typically with rapid acceleration or pivoting. Sports like football, track and field (sprinting), basketball, soccer
May hear a "pop"
Inability to run, stand on toes, or climb stairs
Most frequently ruptures 2-6cm above calcaneus (where blood supply is weakest)

Dx:

Clinical diagnosis
Ultrasound can be used in equivocal cases:
- Use linear probe (high frequency probe)
- Place probe in longitudinal plane over suspect tendon:
- Achilles 2-6cm above calcaneus
- Fan and slide side to side to optimize your view
- Slide distal to proximal to find defect
- Turn probe 90° to assess for tendon body defects
- Positive Findings
  - Discontinuity in longitudinal view of ligament
  - Collection of fluid in longitudinal or transverse view suggests injury
- Look at other limb for "normal" anatomy
- Have patient range attempt plantar/dorsi-flexion and view in real time
- Be aware of partial tears!
Comparing to normal ankle can reveal smaller defects or tears
- Kankle
Thompson test (SN 96% and SP 93%)
- Lay patient prone with knee bent at 90°
- In normal patient, squeezing calf results in plantar-flexion; Patient’s with tendon rupture will likely have lack of plantar flexion with calf squeeze
Palpable defect in Achilles tendon 2-6 cm proximal to calcaneus, however the data on this finding isn’t very strong and wouldn’t base your diagnosis solely on this fact

Tx:

Short leg posterior splint in plantarflexion
~25% of ruptures will have some amount of active plantar flexion or be able to walk
Even if partial tear, splint! Can evolve into a complete tear
Outpatient orthopedic referral

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From the J. Lee Garvey Innovation Studio in the
Department of Emergency Medicine
Carolinas Medical Center
Charlotte, NC

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Exertion Heat-related Illness

Patellar Dislocation

Knee Dislocations

Clavicle Fracture

BiCeps Tendon Rupture

Achilles Tendon Injury

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