Jan 15, 2016
Lower Extremity Injuries
On the Field Management of Lower Extremity InjuriesArmando F. Vidal, M.D.Surgical Director Sports Medicine Program for Young AthletesChildrens Hospital ColoradoTeam Physician, CU & DU
OverviewHip / Thigh InjuriesContusionsHip PointersHip DislocationHamstring StrainsKneePatella DislocationKnee DislocationLigamentous InjuriesMeniscal Injury
Lower LegTibia FractureFoot / AnkleSyndesmotic Injury / Masseneuve FractureSubtalar DislocationLisFranc InjuryFoot FracturesHip PointerPainful, Direct blow to Iliac CrestFootball HockeySoccerProtective Padding is key to preventionAcuteRest, Ice, Compression, minimization of hematomaAvoid Heat, Massage, NSAIDS and Physical Activity for first 48 hr
Hip Pointer often described as a subperositeal hematomaTypically these injuries are minor and can he handled with symptomatic treatment of short duration with return to athletics as symptoms allowHowever, Radiographs are often necessary to r/o fractureHeat, massage and vigorous physcial activity and PT should be avoided in first 48 hr to avoid more bleeding
4Hip PointerXR are importantEspecially in Young AthletesConsider Injections on Game DayReturn to play as symptoms allow
Thigh ContusionsMuscle Contusion Secondary to direct blunt traumaRisk of Myositis Ossificans (9-20%)TreatmentControl Deep BleedingRICE Knee FlexionAvoid Early - PT, Heat, Massage, NSAIDSReturn to PlayPain free ROM (0-120)Near Full return of strength@ 1-2 weeks
6Some studies have identified the following risk factors for the development of myositis ossificans: 1) limited knee range of motion, 2) previous quad contusion, 3) treatment for a quad contusion that was delayed more than 72 hours, 4) knee effusion (swollen knee), and 5) injury sustained by playing football
Hip DislocationRare InjuryFootballRugbySkiing / SnowboardingPosterior Much More Common than AnteriorHip Internally rotated, flexed and shortenedReductionKnee & Hip FlexedTraction in-line with femurGentle RotationCounter-traction on pelvisRARE TO DO ON FIELD!!!
Hamstring InjuriesCross Both Hip & Knee JointsVery Characteristic & Common InjurySprintersRBPain Posteriorly +/- PopExamTendernessDefectEcchymosis
Hamstring InjuriesCross Both Hip & Knee JointsVery Characteristic & Common InjurySprintersRBPain Posteriorly +/- PopExamTendernessDefectEcchymosis
Hamstring InjuriesHigh Grade Injuries (5 Phase Tx)RICEStretch/Isometrics/EstimIsotonics / +/- IsokinecticRunning / Sport SpecificsReturn to SportsInterventions? Corticoteroid Injection? PRP
Level of pain and functional improvement dictate progression through phases
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Not SubtleDeformity obvious if presentPlanted foot, PivotingKnee DislocatedDirect ContactMany reduce spontaneouslyReductionGentle Knee ExtensionNo return to game if 1st episodeConsider return in chronic dislocator if minimal symptoms & No effusionNeed Ortho EvaluationChondral fracturesLoose bodies
Patella DislocationKnee DislocationRelatively RareEMERGENCY!!!Urgent Reduction & Transfer to EDAssessmentAlign LegSplint / Stabilize
Ligamentous Knee InjuryACL
Non-contact pivoting injuryVery CommonPop + early effusion (70% have ACL)Unable to return to playRapid Onset of EffusionLateral Knee pain is Common
Ligamentous Knee Injuries: ACLACL InjuryRight Knee
ACL InjuryLeft Knee
Ligamentous Knee Injuries: ACLACL: Physical ExamLACHMANAnterior Drawer
ACL: Physical ExamPivot Shift
ACL InjuryNon-Contact > ContactFemale : 3-5x RiskNo return in same eventSports Medicine Evaluation6 month recovery from Reconstruction
Tibial / Ankle FracturesObvious DeformityInability to bear weightImmobilize / StabilizeAir SplintDo not attempt to remove shoe unless necessaryTransport to ED
Syndesmotic InjuryCommon in Collision SportsFootballHockeyLow GradeCrutches / Boot72 hr NWBGradual returnHigh GradeORIFDistance of Symptoms up fibula Duration of SymptomsMay lose many weeks of participation
Subtalar Dislocation
Rare in AthleticsBasketballInversion injuryTypical AppearanceDo not attempt to reduce on fieldSplint / ProtectED for XR and closed ReductionRTP usually in several weeks or months after symptoms resolvedUnknown recurrence rate
LisFranc InjuryMidfoot InjuryPop or SnapPain & Ecchymosis MidfootPlantar EcchymosisArch Collapse Ability to RTP is Variable for low grade injurySports Medicine EvaluationXR - Boot or ORIF
LisFranc InjuryMay take a long time to recoverCan be devastating injuryOften NWB for 8 10 wksLow grade injuryCast / BootSteel Shank / Carbon Fiber Insert
Foot Fractures5th Metatarsal FractureMost commonInversion InjuryCan be mistaken for lateral ankle sprainStress FracturesEndurance AthleteFemale TriadMany can be treated with shoewear modification / orthotics
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