Chapter 24. Orthopedics and Sports Medicine

Introduction

• Goal of section: The reader will understand common causes of acute ankle, knee, shoulder, back injuries, and chronic back pathology injuries, their diagnoses and management.
• 1%–19% of musculoskeletal injuries evaluated in the ED receive proper discharge instructions for optimal management and rehabilitation.
  • The mnemonic PRICEMMMS (see treatment section) includes the necessary components for proper care of acute musculoskeletal pain and swelling.

Definitions

• Sprain: Stretch or tear of a ligament that connects two or more bones (localized tenderness, swelling, ± joint instability over injured ligament)
• Strain: Inflammation and injury to a muscle or tendon
• Acute: Pain less than 3 mo
• Chronic: Pain greater than 3 mo
• Valgus: A force or alignment that results in the joint opening medially
• Varus: A force or alignment that results in the joint opening laterally (opposite of valgus)
• Apophysitis: Inflammation of growth plate (epiphysis under tension at site of tendon insertion)
• Spondylolysis: Stress injury or fracture of pars interarticularis
• Spondylolisthesis: Anterior movement of one vertebrae in relation to adjacent vertebrae

Evaluation

• History: (1) mechanism of injury; (2) degree of functional impairment immediately after injury; (3) a “pop”, snap, or tear (→ fracture or ligament tear); (4) painful locking or catching sensation (→ cartilage tear, loose body, Osteochondritis dissecans (OCD); (5) feeling of instability (→ dislocation or ligament injury); (6) onset and timing of swelling; (7) pain assessment (where, pain scale 0–10, what makes it worse, what makes it better)
• Physical exam
  • Inspection: Surface anatomy (alignment, swelling, ecchymoses, or deformity)
  • Neurovascular: Document pulses, and determine sensation
  • Palpation: Provoke complaint by pressing with fingertips to elicit tenderness
  • Range of motion: Active, passive (flexibility), resisted (strength)
  • Provocative tests: Special maneuvers or manipulation techniques unique to each body segment (see Tables 1–6; a video demonstration of each exam is available at http://www.sportsmedkids.com)
  • Function: Assess patient's ability to bear weight, stand, walk, toe raise, hop, broad jump, throw
• Red flags: Fever; sweating; age <5 yo; local tenderness/warmth/redness; no history of injury; night pain; weight loss; migratory joint pain (SLE, rheumatic fever, HSP, subacute endocarditis, Lyme disease, gonococcal arthritis, viral or Mycoplasma infection, sepsis); elevated WBC, ESR, or CRP (evaluate for septic arthritis or osteomyelitis).
• Radiographic studies
  • Two views minimum of entire bone. Add oblique view for foot, ankle, and elbow injuries (foot injuries require weight-bearing views so that a Lisfranc injury is not missed).
  • Normal X-ray does not rule out fracture: Consider other views if exam strongly suggests fracture (if in doubt, splint and order follow-up radiographs in 5–10 d).