Sports Medicine Flashcards
(42 cards)
What is transient tenosynovitis?
“transient (toxic) synovitis (aka transient tenosynovitis), a condition most commonly presenting in the 2-6-year age range and more commonly seen in boys (male:female ratio of 2-3:1). It often is preceded by a viral respiratory infection, although numerous studies have failed to demonstrate a specific viral or bacterial agent. Physical exam reveals a limp or refusal to walk and complaint of pain over the groin and/or proximal thigh. There is pain with ROM testing, especially during abduction. Most children will be afebrile with a temperature of <38°C.”
A patient sprains their ankle. Which med is best, an NSAID, ASPIRIN OR acetaminophen?
“Most acute injuries are not inflammatory and acetaminophen is a lot safer without gastropathy or platelet inhibition”
What should the workup of transient tenosynovitis include?
“Patients with mild symptoms may be observed without further investigation. However, if the pain is significant, if ROM is significantly impaired, or if the temperature is >37.5°C, further diagnostic workup is indicated. Laboratory findings consistent with transient synovitis include clear joint fluid aspirate, normal CBC, and a mildly increased ESR. Blood cultures, ASO titer, bone scan, and MRI may also be of benefit to rule out other possibilities (e.g., septic arthritis, rheumatic fever, and SCFE). It is of extreme importance to differentiate transient synovitis from septic arthritis. Unfortunately, there is no combination of physical findings and laboratory tests short of joint fluid that will tell you absolutely that this is transient synovitis. It requires clinical judgment; decide which patients you are worried enough about that you want to commit them to hip joint aspiration”
What is the treatment for transient tenosynovitis?
“Conservative treatment is warranted: the appropriate initial treatment is rest and observation. Transient synovitis generally responds well to oral NSAIDs. Home care is acceptable; however, admission is indicated if the diagnosis is equivocal or if significant pain management is required.
Osteonecrosis of the femoral head in a 6 year old is associated with which disease?
“LCPD (Legg-Calfe-Perthes Disease). The correct answer is “D.” LCPD is idiopathic osteonecrosis of the femoral head. It is unilateral in 90% of cases, and the typical age range is 4-8 years, but patients may be as young as 2 years and as old as 12 years.”
How does age impact legg-calve-perthes disease?
“Compared to older children, younger children generally have a longer time for remodeling to occur via molding of the femoral head within the acetabulum; and therefore, younger children have less flattening of the femoral head”
What is the treatment of leg-calf-perthes disease?
“The initial treatment for a patient with LCPD typically includes rest, traction, and the use of an abduction brace. The objectives are to increase ROM in the hip and to reduce the risk of significant deformity.”
“LCPD is difficult to treat largely because of the long duration of treatment and activity restrictions required. Periods of rest with traction, casting or bracing, and surgical intervention may be indicated over 1-2 years of treatment and observation. Even with the best of care, prognosis is fair with need for total hip replacement reaching approximately 50% by middle age due to severe degenerative arthritis”
What is a common overuse syndrome seen more frequently in runners and female athletes that involves knee pain?
Patellofemoral pain syndrome “may involve lateral subluxation or mal-tracking within the femoral groove due to vastus medialis weakness. Mal-tracking may be observed clinically and subluxation may be seen on plain films using a Merchant view”
What is the treatment for patellofemoral pain syndrome?
“Quadriceps strengthening is usually initiated by resisted straight leg raises (SLRs) to minimize patellofemoral compressive forces. NSAIDs and cross-training may also be of benefit. Consider physical therapy referral for exercise instruction and trials of therapeutic modalities such as orthotics. Recalcitrant cases and patients with recurrent dislocation/subluxation should be referred to orthopedics for consideration of surgical intervention”
What is plica syndrome and how does it present?
It presents as pain is exacerbated by knee flexion with popping and snapping when standing from sitting. Physical exam shows tenderness about 1 cm medial to the patella with palpable fullness in the area”
“The plica should be palpable. A medial/inferior plica is the most common (between the patella and the medial joint line). It can also occur laterally and either above or below the mid-pole of the patella.”
“The plica is a synovial remnant that did not resorb properly during development. It can be irritated, usually chronically or subacutely, especially in sports that require repeated flexion of the knee (rowing, cycling, running).
What is the treatment for Plica syndrome?
Treatment includes rest, ice, quadriceps strengthening, and NSAIDs. If conservative management fails, steroid injection or arthroscopy may alleviate the symptoms”
What is internal tibial torsion?
“Internal tibial torsion is characterized by a flexible, normal foot, with the patellae in a neutral position. The condition can be diagnosed by examining the child on his knees. Normally, there should be approximately 30 degrees of external rotation of the feet in this position. With internal tibial torsion, the toes will be pointing inward. Additionally, when the child is sitting with legs dangling over a table, the lateral malleolus will be anterior to the medial malleolus, which is the opposite of what is normally observed. Finally, the hips must be normal in order to confirm this diagnosis”
What is the treatment of choice for internal tibial torsion in a child?
“Spontaneous resolution is the norm for most intoeing and outtoeing deformities. Most will spontaneously correct by age 7 or 8. Children continuing to have difficulty with persistent trips and falls or grossly unsightly gait beyond this time may benefit from a rotational osteotomy. Children with neuromotor disorders and cerebral palsy are more likely to require surgical intervention”
What are the signs of femoral torsion in a child presenting with in-toeing
“Spontaneous resolution is the norm for most intoeing and outtoeing deformities. Most will spontaneously correct by age 7 or 8. Children continuing to have difficulty with persistent trips and falls or grossly unsightly gait beyond this time may benefit from a rotational osteotomy. Children with neuromotor disorders and cerebral palsy are more likely to require surgical intervention”
What is slipped capital femoral epiphysis and how does it present?
“difficulty walking with hip pain getting worse over a weeks time. It has forced him to stop playing sports. No specific trauma. On examination, it may be accompanied by obesity and no distress at rest. There is loss of internal rotation at the hip joint. When his hip is flexed to 90 degrees, this loss of ROM is more pronounced”
It commonly occurs in active, overweight, adolescent males. Shear forces across the relatively weak physis causes displacement. Slippage is generally gradual, but may occur acutely. Mean age at presentation is 12 for females (range 10-14) and 13 for males (range 11-16). Endocrinopathies should be considered in those presenting atypically or outside the typical age range. Watch for development of a similar process in the contralateral hip over time”
How does one diagnose slipped capital femoral epiphysis?
“Radiographs of the hip should demonstrate displacement of the femoral head, which can then be classified as mild, moderate, or severe”
What is slipped capital femoral epiphysis?
“The goals of treatment are to prevent further slippage, promote closure of the physis, and to minimize the risk of osteonecrosis or chondrolysis. These aims are best accomplished through referral to an orthopedic surgeon and, ultimately, surgical fixation”
What is metatarsus ad ductus?
“In the normal foot, a line bisecting the heel would pass between the second and third toes. In those with metatarsus adductus, it passes through the fourth toe. In addition to the heels remaining in a neutral position—indicating that the problem is isolated to the shape of the foot and not to an internal rotation of the tibia—the forefoot is flexible and easily straightened into normal position. This is as opposed to metatarsus varus in which the forefoot is rigid”
How is metatarsus adductus treated?
“In the normal foot, a line bisecting the heel would pass between the second and third toes. In those with metatarsus adductus, it passes through the fourth toe. In addition to the heels remaining in a neutral position—indicating that the problem is isolated to the shape of the foot and not to an internal rotation of the tibia—the forefoot is flexible and easily straightened into normal position. This is as opposed to metatarsus varus in which the forefoot is rigid”
A 5-yo female with a swollen, erythematous thigh presents after a chicken pox infection. What is the diagnosis and what is the most likely causative agent?
Osteomyelitis and staph aureus. “The acute nature of the symptoms, presence of fever, and minimal involvement of the joint makes osteomyelitis the most likely diagnosis. Additionally, osteomyelitis is associated with chicken pox in children.”
Pseudomonas is most often associated with plantar puncture through a tennis shoe.
What is the most likely causative agent of osteomyelitis in a patient with sickle cell disease?
“Salmonella species are responsible for up to 85% of bone and joint infections in patients with a history of sickle cell disease. Staphylococcus, which is responsible for the majority of bone infections in the general population, is responsible for <25% of infections in patients with sickle cell disease”
How does one identity the causative agent in osteomyelitis?
“A blood culture will reveal the offending organism in 40-50% of cases. Joint aspiration is not typically indicated unless there is strong evidence of joint involvement. After 7-10 days, osseous changes may be seen on plain film radiographs, MRI, and bone scan. If changes are identified and a neoplastic process is ruled out, aspiration at the site of periosteal elevation and bony destruction should be considered if a pathogen has not yet been identified by blood culture”
Joint fluid analysis of a patient with a new knee effusion reveal both high WBC and calcium pyruvate crystals. What is the next step?
IV antibiotics and emergent ortho referral. “Various cutoffs for synovial WBC counts have been proposed, ranging from >25,000/μL to >100,000/μL with sensitivities ranging from 13% to 88%. A synovial WBC count of 51,000/μL does not rule out septic arthritis in this patient. When the percentage of polymorphonuclear cells is >90%, this significantly increases the likelihood of septic arthritis. Don’t let the fact that the crystal analysis showed calcium pyrophosphate crystals dissuade you from suspecting septic arthritis as both gout and pseudogout can coexist with septic arthritis”
How good is the Lachman’s test?
“In the hands of an experienced clinician, the Lachman test is the most sensitive test for ACL insufficiency (80-95%). The anterior drawer sign is negative in about 50% of acute ACL tears, and often is negative subacutely”
