“ “ Don’t Miss” Don’t Miss” Musculoskeletal Musculoskeletal Injuries Injuries Chris G. Pappas, LTC, USA, MC Chris G. Pappas, LTC, USA, MC Lecture adapted and revised from: Lecture adapted and revised from: LTC Fred H. Brennan, Jr., DO, FAOASM, FAAFP LTC Fred H. Brennan, Jr., DO, FAOASM, FAAFP
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“Don’t Miss” Musculoskeletal Injuries Chris G. Pappas, LTC, USA, MC Lecture adapted and revised from: LTC Fred H. Brennan, Jr., DO, FAOASM, FAAFP.
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InjuriesInjuriesChris G. Pappas, LTC, USA, MCChris G. Pappas, LTC, USA, MC
Lecture adapted and revised from:Lecture adapted and revised from:LTC Fred H. Brennan, Jr., DO, FAOASM, FAAFPLTC Fred H. Brennan, Jr., DO, FAOASM, FAAFP
GoalsGoals
Become familiar with Become familiar with three “don’t miss” upper three “don’t miss” upper extremity extremity musculoskeletal injuries.musculoskeletal injuries.
Become familiar with Become familiar with three “don’t miss” lower three “don’t miss” lower extremity extremity musculoskeletal injuries.musculoskeletal injuries.
Utilize this knowledge in Utilize this knowledge in the evaluation and the evaluation and treatment of patients.treatment of patients.
Case #1Case #1
21 year old female 21 year old female volleyball player dove volleyball player dove for a low ball and fell on for a low ball and fell on outstretched right handoutstretched right hand
Immediate wrist pain Immediate wrist pain and pain with attempts and pain with attempts at dorsi and palmar at dorsi and palmar flexionflexion
No gross deformityNo gross deformity What is the possible What is the possible
diagnosis based on this diagnosis based on this mechanism of injury?mechanism of injury?
Case #1Case #1
Wrist sprainWrist sprain Scaphoid fractureScaphoid fracture Distal radius or Distal radius or
Press the scaphoid Press the scaphoid tuberosity on the palmar tuberosity on the palmar aspect while moving the aspect while moving the wrist from ulnar to wrist from ulnar to radial deviation.radial deviation.
A painful "click" or "pop" A painful "click" or "pop" identifies scaphoid identifies scaphoid instability or instability or scapholunate scapholunate separation.separation.
supinationsupination Pain controlPain control Refer to ortho hand Refer to ortho hand
within 72 hourswithin 72 hours
Complications if MissedComplications if Missed
Chronic wrist painChronic wrist pain Loss of function Loss of function
and motionand motion OsteoarthritisOsteoarthritis
Same patientSame patient
Scaphoid fractureScaphoid fracture
ScaphoidScaphoid
Blood supply arises distallyBlood supply arises distally Fractures of middle and proximal Fractures of middle and proximal
portion prone to nonunionportion prone to nonunion Get a scaphoid view if suspectedGet a scaphoid view if suspected If initial film negative, but still If initial film negative, but still
suspected treat as a fracture and suspected treat as a fracture and follow up with plain films or more follow up with plain films or more advanced imagingadvanced imaging
May be casted for up to 3 monthsMay be casted for up to 3 months
Case #2Case #2
38 year old male got his 38 year old male got his right ring finger caught right ring finger caught in a player’s shirt while in a player’s shirt while playing touch footballplaying touch football
Felt pop in his finger Felt pop in his finger and developed painand developed pain
Now in your clinic 4 Now in your clinic 4 hours laterhours later
What are the What are the possibilities?possibilities?
Case #2Case #2
Jammed fingerJammed finger FractureFracture DIP or PIP DIP or PIP
dislocationdislocation Mallet fingerMallet finger Jersey fingerJersey finger
ExamExam
--Finger held in forced extension--Tender along volar aspect of DIP--Unable to flex DIP
X-raysX-rays
What is your diagnosis?
Jersey FingerJersey Finger
Rupture of FDP Rupture of FDP tendontendon
Inability to flex tip Inability to flex tip of fingerof finger
Splint in positionSplint in position Repair within 7 Repair within 7
days days
Complications if MissedComplications if Missed
Retraction into Retraction into palm of handpalm of hand
Loss of flexion of tipLoss of flexion of tip Impaired work Impaired work
ability ability Difficult surgeryDifficult surgery
Mallet fingerMallet finger
Case #3Case #3
22 year old active 22 year old active duty male had lower duty male had lower leg “squished” leg “squished” between two between two military vehiclesmilitary vehicles
Able to walk with a Able to walk with a limp but pain limp but pain worsening over the worsening over the past 1-2 hourspast 1-2 hours
Case #3Case #3
Possibilities?Possibilities? Fractured patellaFractured patella Fractured fibula or tibiaFractured fibula or tibia Tendon ruptureTendon rupture Acute compartment Acute compartment
Swelling over Swelling over dorsum of footdorsum of foot
Bruising on plantar Bruising on plantar aspect of footaspect of foot
Pain with external Pain with external rotation of mid-footrotation of mid-foot
Do You Need X-rays?Do You Need X-rays?
X-raysX-rays
Lisfranc InjuryLisfranc Injury
Lisfranc injuries Lisfranc injuries may represent 1% may represent 1% of all orthopedic of all orthopedic trauma, but 20% trauma, but 20% are missed on are missed on initial presentationinitial presentation
Inability to WB, Inability to WB, mid-foot pain, mid-foot pain, weight bearing x-weight bearing x-rays are keyrays are key
TreatmentTreatment
PRICE-MPRICE-M Bulky Jones Bulky Jones
dressing or dressing or posterior splintposterior splint
Groin pain in runner or Groin pain in runner or jumper- don’t ignorejumper- don’t ignore
Female triad at increased Female triad at increased risk as well as those with risk as well as those with an increase in training and an increase in training and postmenopausal womenpostmenopausal women
Need to know which side Need to know which side the stress fracture is on the stress fracture is on (compression vs tension (compression vs tension side)side)
Plain films often negativePlain films often negative Get MRIGet MRI
TreatmentTreatment
If stress fracture by x-If stress fracture by x-ray or further imagingray or further imaging Compression side Compression side
12 weeks to heal +/- 12 weeks to heal +/- NWB NWB
Tension sideTension side Ortho consult/surgeryOrtho consult/surgery
Cross trainCross train Proper nutrition and Proper nutrition and
calories calories
Complications if Missed Complications if Missed
Stress to complete Stress to complete fracturefracture
Avascular necrosisAvascular necrosis Chronic painChronic pain End of careerEnd of career
Take Home PointsTake Home Points
Fall on Fall on outstretched hand, outstretched hand, think:think: Distal forearm fx.Distal forearm fx. Scaphoid fxScaphoid fx TFCCTFCC AP, Lat, Scaphoid AP, Lat, Scaphoid
Grab injury with Grab injury with pain at distal pain at distal phalynx, think jersey phalynx, think jersey fingerfinger
Crush injury or Crush injury or worsening pain with worsening pain with immobilization, immobilization, think ACSthink ACS
““Jammed” PIP…Jammed” PIP…always test always test extension with extension with resistanceresistance
Take Home PointsTake Home Points
Mid-foot pain and Mid-foot pain and inability to weight inability to weight bear after foot axial bear after foot axial load or twist, think load or twist, think Lisfranc injuryLisfranc injury
Persistent groin pain, Persistent groin pain, especially in runner especially in runner or jumper, rule out or jumper, rule out stress fracture of hip stress fracture of hip or pelvisor pelvis