Crash Course Sanofi, Investigator initiated grant A n t h o n y - PowerPoint PPT Presentation

Disclosures Common Orthopaedic and Sports Medicine Problems • Founder, RunSafe™ • Founder & CEO, SportZPeak Inc. Crash Course • Sanofi, Investigator initiated grant A n t h o n y L u k e MD, MPH, CAQ (Sport Med) University of California, San Francisco FP Board Review 2015 Overview History is Key Who? • Quick approach to What? MSK problems Pain • Highlight common presentations Instability Dysfunction • Joint by joint • Discuss basics of conservative and surgical management • Numbness • Fever 1

History is Key Red Flag Symptoms When? • Severe disability • Acute vs Chronic (2 weeks? 6 weeks?) • Numbness and tingling Where? • Night pain • Think anatomy • Constitutional symptoms (fever, wt loss) • One finger test • Swelling with no injury How? • Systemic illness • Mechanism of injury • Multiple joint injury Treatment Options Intrinsic Risk Factors Extrinsic Risk Factors Surgery Conservative • Growth • Training • Reconstruction • MICE (Modified activity, • Anatomy • Technique • Repair Ice, Compression, • Muscle/Tendon • Footwear Elevation) • Re-align imbalance • Surface • Remove internal • Medications/Analgesia derangement • Illness • Occupation • Rehabilitation therapy • Nutrition • Casting/ Braces / • Conditioning • TO PREVENT Orthoses • Psychology INJURIES!! • Crutches 2

Ankle Sprains Physical Exam Mechanism LOOK Symptoms • Inversion, • Swelling/bruising • Localized pain usually plantarflexion (most laterally over the lateral aspect common injury) Anterior FEEL of the ankle talofibular • Eversion (Pronation) • Point of maximal ligament • Difficulty weight tenderness usually bearing, limping ATF Calcaneo • May feel unstable in fibular MOVE ligament the ankle • Limited motion due to swelling Special Tests Anterior Drawer Subtalar Tilt Test Test • Normal ~ 3 mm • Foot in neutral position • Foot in neutral position • Fix tibia • Fix tibia • Invert or tilt calcaneus • Draw calcaneus forward • Tests Calcaneofibular • Tests ATF ligament ligament Sens = 80% Spec = 74% No Sens / Spec PPV = 91% Data NPV = 52% van Dijk et al. J Bone Joint Surg-Br, 1996; 78B: 958-962 3

Subtalar Tilt test Grading Ankle Sprains Grade Drawer/Tilt Pathology Functional Recovery Test results in weeks 1 Drawer and Mild stretch 2 – 4 tilt negative, with no but tender instability 2 Drawer lax, ATFL torn, CFL 4 – 6 tilt with good and PTFL end point intact 3 Drawer and ATFL and CFL 6 – 12 tilt lax injured/torn Ottawa Ankle Rules Treatment of Ankle Sprains • Inability to weight bear immediately and in the Acute Physical Therapy emergency / office (4 steps) • Rest or modified • ROM activities • Strengthening • Bone tenderness at the posterior edge of the • Ice, Compression, • Stretching medial or lateral malleolus (Obtain Ankle Series) Elevation • Proprioception / • Bone tenderness over the navicular or base of • Crutches PRN Balance exercises the fifth metatarsal (Obtain Foot Series) • Bracing (Grade 2 and (i.e. Wobble Board) 3) • Sens 97%, Spec 31-63%, NPV 99%, PPV <20% • Early Motion is essential (Am J Emerg Med 1998; 16: 564-67) 4

Not Always Only a “ Sprain ” “ High Ankle ” Sprains Bone Mechanism Ligaments • Osteochondral talus • Subtalar joint sprain • Dorsiflexion, eversion injury injury • Sinus tarsi syndrome • Lateral talar process fracture • Syndesmotic sprain • Disruption of the • Posterior impingement Syndesmotic ligaments, • Deltoid sprain (os trigonum) most commonly the • Lisfranc injury • Fracture at the base of anterior tibiofibular the fifth metatarsal Tendons ligament • Jones fracture • Posterior tibial tendon • Salter fracture (fibula) • R/O Proximal fibular strain • Ankle fractures fracture • Peroneal tendon subluxation External Rotation Stress Test Squeeze test • Fix tibia • Hold leg at mid calf level • Foot in neutral • Squeeze tibia and • Dorsiflex and fibula together externally rotate ankle • Pain located over anterior tibiofibular ligament area No Sens/ Spec Data Kappa = 0.75 Alonso et al. J Orthop Sports Phys Ther, 1998; 27: 276-284 5

Ankle Sprain Prevention Treatment for Syndesmosis Injury • Ankle braces, tape and Conservative Surgery proprioceptive training help reduce the risk of • Cast or walking boot • May needs ORIF if lateral ankle sprains unstable • Protected Verhagen EALM, van Mechelen W, de Vente weightbearing with W. Clin J Sport Med, 2000 crutches must be painfree • Significant reduction in the number of ankle • PT sprains in people allocated to an external ankle support (RR 0.53, 95% CI 0.40 to 0.69). Handoll et al. Cochrane Database Rev, 2005 Maisonneuve Fracture Acute Hemarthrosis Emergencies 1) ACL (almost 50% in children, >70% in 1. Neurovascular injury adults) 2. Knee Dislocation 2) Fracture (Patella, tibial plateau, Femoral – Associated with multiple ligament injuries supracondylar, Physeal) (posterolateral) 3) Patellar dislocation – High risk of popliteal artery injury – Needs arteriogram • Unlikely meniscal lesions 3. Fractures (open, unstable) 4. Septic Arthritis 6

Anterior Cruciate Ligament (ACL) Urgent Orthopedic Referral Tear • Fracture Mechanism • “ Locked Joint ” - unable to fully extend the • Landing from a • Patellar Dislocation jump, pivoting or decelerating knee (OCD or Meniscal tear) suddenly • Tumor • Foot fixed, valgus stress Anterior Cruciate Ligament (ACL) ACL physical exam Tear LOOK • Effusion (if acute) Mechanism • Landing from a jump, FEEL pivoting or decelerating • “O’Donaghue’s Unhappy Triad” suddenly = Medial meniscus tear, MCL injury, ACL tear • Foot fixed, valgus stress • Lateral meniscus tears more Symptoms common than medial • Audible pop heard or felt • Lateral joint line tender - femoral condyle bone bruise • Pain and tense swelling in minutes after injury MOVE • Feels unstable (bones Double fist sign • Maybe limited due to effusion shifting or giving way) or other internal derangement 7

Special Tests ACL X-ray 20 ° • Lachman's test – test at • Usually non- diagnostic Sens 81.8%, Spec 96.8% 90 ° • Anterior drawer – test at • Can help rule in or Sens 22 - 41%, Spec 97%* out injuries • Pivot shift Sens 35 - 98.4%*, Spec 98%* • Segond fracture – Malanga GA, Nadler SF. avulsion over Musculoskeletal Physical Examination, Mosby, 2006 lateral tibial plateau * - denotes under anesthesia MRI MRI • Sens 94%, Spec 84% • Sens 94%, Spec 84% for ACL tear for ACL tear ACL tear signs ACL tear signs • Fibers not seen in • Lateral femoral corner continuity bone bruise on T2 • Edema on T2 films • May have meniscal tear (Lateral > medial) • PCL – kinked or Question mark sign 8

Initial Treatment ACL Tear Treatment Conservative Surgery • Referral to Orthopaedics/Sports Medicine • No reconstruction • Reconstruction • Consider bracing, crutches • Physical therapy • Depends on activity • Begin early Physical Therapy demands • Hamstring strengthening • Reconstruction allows • Analgesia usually NSAIDs • Proprioceptive training better return to sports • ACL bracing • Reduce chance of symptomatic meniscal controversial tear ADL ’ s • Patient should be • Less giving way symptoms asymptomatic with • Recovery ~ 6 months Special Tests: Meniscus Meniscus Tear Fowler PJ, Lubliner JA. Arthroscopy 1989; 5(3): 184-186. Test Sensitivity Specificity Mechanism Symptoms • Occurs after twisting • Catching Joint line tender 85.5% 29.4% injury or deep squat • Medial or lateral knee Hyperflexion 50% 68.2% • Patient may not recall pain specific injury Extension block 84.7% 43.75% • Usually posterior aspects of joint line McMurray Classic 28.75% 95.3% (Med Thud) • Swelling McMurray Classic (Lat 50% 29% pain) Appley (Comp/Dist) 16% / 5% 9

Modified McMurray Testing X-ray • Flex hip to 90 degrees • May show joint space • Flex knee narrowing and early osteoarthritis changes • Internally or externally rotate lower leg with rotation of knee • Rule out loose bodies • Fully flex the knee with rotations Courtesy of Keegan Duchicella MD MRI Meniscal Tear Treatment Conservative Surgery • Often if degenerative • MRI for specific exam • Operate if internal tear in older patient derangement • Similar treatment to symptoms • Look for fluid (linear mild knee • Meniscal repair if bright signal on T2) osteoarthritis possible into the meniscus • Analgesia • Physical therapy • General Leg Strengthening 10

Medial Collateral Ligament (MCL) Medial Collateral Ligament (MCL) Injury Injury Mechanism Symptoms Physical Exam • Valgus stress to • Pain medially • Tender medially over partially flexed knee MCL (often • May feel unstable proximally) • Blow to lateral leg with valgus “ pseudolocking ” • May lack ROM • Valgus stress test MRI MCL Treatment Conservative Surgery • X-ray non-diagnostic • Analgesia • Rarely needs surgery (rarely avulsion) • Protected motion • MRI not usually +/- hinged brace necessary +/- crutches • Rule out meniscal • Early physical therapy tear 11