“Don’t Miss” Musculoskeletal Injuries Chris G. Pappas, LTC, USA, MC Lecture adapted and...

““Don’t Miss” Don’t Miss” Musculoskeletal Musculoskeletal

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

ulna fractureulna fracture Distal R-U joint Distal R-U joint

disruptiondisruption TFCC tearTFCC tear Carpal Carpal

ligamentous injuryligamentous injury

Case #1Case #1

What next?What next? ExamExam

Inspection, Range of motion, Neurovascular Inspection, Range of motion, Neurovascular status, Palpationstatus, Palpation

Is an x-ray needed?Is an x-ray needed?

Wrist XraysWrist Xrays

Scapho-Lunate DissociationScapho-Lunate Dissociation

Disruption of scapho-Disruption of scapho-lunate ligamentlunate ligament

FOOSH injuryFOOSH injury Tender over scapho-Tender over scapho-

lunate intervallunate interval + Watson’s clunk+ Watson’s clunk Limited dorsiflexionLimited dorsiflexion > 3 mm diastasis> 3 mm diastasis Scapholunate angle > 60 Scapholunate angle > 60

degreesdegrees

Watson’s Test of the WristWatson’s Test of the Wrist

Watson's testWatson's test(scaphoid shift test)(scaphoid shift test)

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.

Scaphoid tuberclePainful click or clunk

TreatmentTreatment PRICE-MPRICE-M Thumb spica splintThumb spica splint Avoid wrist pronation-Avoid wrist pronation-

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


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

syndromesyndrome Vascular disruptionVascular disruption ContusionContusion

ExamExam

Pain is worsening Pain is worsening after splintingafter splinting

Lateral aspect and Lateral aspect and first web space of first web space of foot feels like “pins foot feels like “pins and needles”and needles”

Leg hurts with Leg hurts with gentle passive foot gentle passive foot inversion and inversion and plantar flexionplantar flexion

Leg feels weakerLeg feels weaker

X-rayX-ray

Diagnosis?

Acute Compartment Acute Compartment SyndromeSyndrome

Serious limb and Serious limb and life threatening life threatening conditioncondition

Fractures, burns, Fractures, burns, crush injuries, crush injuries, arterial injuriesarterial injuries

Hand, forearm, Hand, forearm, arm, shoulder, arm, shoulder, back, thigh and footback, thigh and foot

Acute Compartment Acute Compartment SyndromeSyndrome

Increased pressure Increased pressure within closed within closed compartmentscompartments

Compartments of Compartments of lower leglower leg

Be careful with Be careful with splinting and castingsplinting and casting

DiagnosisDiagnosis

High index of suspicion: High index of suspicion: pain out of proportionpain out of proportion

Six P’sSix P’s Pain, Pulseless, Pain, Pulseless,

Paresthesia, Paresthesia, Poikilothermy, Pallor, Poikilothermy, Pallor, ParalysisParalysis

Loss of normal sensation Loss of normal sensation is a red flagis a red flag

Tight compartmentsTight compartments Pressure> 30 mm HgPressure> 30 mm Hg

TreatmentTreatment

Surgical emergencySurgical emergency FasciotomyFasciotomy

Clinical signsClinical signs Elevated pressureElevated pressure Interrupted arterial Interrupted arterial

flow for > 4 hoursflow for > 4 hours


RhabdomyolysisRhabdomyolysis AcidosisAcidosis Ischemic Ischemic

contracturescontractures HyperkalemiaHyperkalemia DIC and sepsisDIC and sepsis Loss of limbLoss of limb DeathDeath

Case #4Case #4

26 year old 26 year old sergeant playing sergeant playing basketball and basketball and “jammed” his left “jammed” his left middle fingermiddle finger

Pain and swelling Pain and swelling of middle finger of middle finger PIP joint (global)PIP joint (global)

Pain with resisted Pain with resisted flexion and flexion and extensionextension


Case #4Case #4

Fractured Fractured phalanxphalanx

Extensor tendon Extensor tendon rupturerupture

Volar plate injuryVolar plate injury Tear of central Tear of central

band of extensor band of extensor tendon tendon

Mallet fingerMallet finger PIP dislocationPIP dislocation

ExamExam

Swollen PIP middle Swollen PIP middle fingerfinger

Tender over PIP, more Tender over PIP, more so dorsallyso dorsally

Pain with resisted Pain with resisted extension over the PIPextension over the PIP

No neuro compromiseNo neuro compromise Flexor tendons Flexor tendons

strength is 5/5strength is 5/5 Collaterals of PIP Collaterals of PIP

intactintact DIP intact to DIP intact to

flexion/extensionflexion/extension

Do you want X-rays?Do you want X-rays?

X-rays X-rays

Diagnosis?

What is the Diagnosis?What is the Diagnosis?

Tear of the central Tear of the central slip of the extensor slip of the extensor tendontendon

TreatmentTreatment

Splint in extension for 6 to 8 weeks.Splint in extension for 6 to 8 weeks. Pain reliefPain relief Watch for complicationsWatch for complications


Loss of functionLoss of function Persistent painPersistent pain Boutonniere Boutonniere

deformitydeformity

Case #5Case #5

27 year old USUHS 27 year old USUHS medical student medical student playing footballplaying football

Loud audible pop Loud audible pop and unable to bear and unable to bear weightweight

Pain on top of mid-Pain on top of mid-footfoot


Case #5Case #5

Fracture of Fracture of metatarsalmetatarsal

Fracture of Fracture of cunieformcunieform

Extensor digitorum Extensor digitorum rupturerupture

Lisfranc complex Lisfranc complex injuryinjury

Mid-foot sprainMid-foot sprain

ExamExam

Unable to weight Unable to weight bearbear

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

NWB on NWB on crutchescrutches

Frequent Frequent neurovascular neurovascular checkschecks

Refer to OrthoRefer to Ortho


Chronic painChronic pain ArthritisArthritis Inability to run Inability to run

or jumpor jump Acute Acute

compartment compartment syndromesyndrome

Case #6Case #6

18 year old female 18 year old female runner with 1 month of runner with 1 month of anterior groin/inguinal anterior groin/inguinal painpain

Pain worse with weight Pain worse with weight bearingbearing

Over past week she has Over past week she has developed night paindeveloped night pain


Case #6Case #6

Torn adductor muscleTorn adductor muscle Avulsion of adductor Avulsion of adductor

or sartorius muscleor sartorius muscle Pubic ramus fracturePubic ramus fracture Femoral neck fractureFemoral neck fracture Femoral shaft Femoral shaft

fracturefracture SI joint subluxationSI joint subluxation Ruptured iliopsoas Ruptured iliopsoas

bursabursa

ExamExam

Swelling noted in Swelling noted in groin and high groin and high proximal femurproximal femur

Pain with all attempts Pain with all attempts at motion, especially at motion, especially internal rotationinternal rotation

Distal pulses 2+Distal pulses 2+ No distal sensory No distal sensory

deficitsdeficits

Do You Need X-rays?Do You Need X-rays?

Femoral neck stress Femoral neck stress fracturefracture

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

Femoral neck Femoral neck fracture-surgeryfracture-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

and clenched fist and clenched fist viewsviews

Scapho-lunate Scapho-lunate dissociationdissociation


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


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

FinishedFinished

Thank You!Thank You!

“Don’t Miss” Musculoskeletal Injuries Chris G. Pappas, LTC, USA, MC Lecture adapted and...

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