Download PDF by David Drez, Bernard Bach, Charles Nofsinger: Sports Medicine

By David Drez, Bernard Bach, Charles Nofsinger

ISBN-10: 051141577X

ISBN-13: 9780511415777

ISBN-10: 0521735262

ISBN-13: 9780521735261

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ACUTE NAVICULAR FRACTURE MAYO A. NOERDLINGER, MD history ■ History of trauma ■ Midfoot pain and swelling physical exam ■ Swelling and exquisite pain on dorsomedial aspect of midfoot ■ Dorsal lip avulsion – two ligaments insert on dorsum of navicular ➣ Dorsal talonavicular r Stressed with inversion and plantarflexion ➣ Anterior aspect of deltoid ligament r Stressed with eversion 17 18 Acute Navicular Fracture ■ Tuberosity fractures ➣ Result of acute valgus or eversion injury increases stress on posterior tibialis tendon studies ■ AP, oblique, and lateral radiographs ➣ Examine closely for midtarsal joint (Lisfranc) injuries ■ Bone scans, CT scan, MRI for occult fractures ■ Differentiate acute tuberosity fracture from accessory navicular ➣ Accessory navicular is smooth and regular differential diagnosis ■ Cuneiform and cuboid fractures ■ Navicular stress fracture ➣ Running or jumping athletes ■ Navicular avulsion fracture treatment ■ Dorsal lip avulsion ➣ Conservative r Weight-bearing cast for 4–6 weeks ➣ Open reduction and internal fixation if fragment is >25% of navicular ■ Displaced acute fractures treated with anatomic and stable internal fixation ➣ Anatomic reduction of talonavicular joint more critical r Mobility of this joint is important for function ➣ Anatomic reduction of anterior and distal navicular not critical r Naviculocuneiform joints have little motion disposition N/A prognosis ■ Navicular is largely covered with articular cartilage ➣ Not much room for nutrient vessels to enter ➣ Makes the tarsal navicular subject to osteonecrosis caveats and pearls ■ Located in the uppermost part of the arch, the navicular is the key- stone for vertical stress on the arch ■ Anatomic reduction essential to restore talonavicular motion 19 Anterior Cruciate Ligament Injury ANTERIOR CRUCIATE LIGAMENT INJURY BERNARD R.

AN, MD, PhD history ■ Differentiate between acute vs. chronic herniated nucleus pulposus (HNP) ■ Acute ➣ May recollect specific traumatic onset r Lifting r Movement of neck r Direct contact injury to head ➣ Pain, usually severe ➣ Acute HNP with myelopathy rare ➣ Radiculopathy symptoms affected by neck position ➣ Neck pain may precede radicular symptoms ■ Chronic ➣ May have slow insidious onset ➣ Usually cannot recollect specific injury/time of onset ➣ Pain may fluctuate ➣ Radiculopathy may not be affected by neck position ➣ May have numbness without pain ➣ Cervical spine rotation may give vertebral artery occlusion symptoms ➣ Anterior osteophytes may give visceral pressure symptoms (pharyngeal symptoms) ■ Similar symptoms between acute and chronic ➣ Painful stiff neck ➣ Usually mid/upper neck ➣ Radiation to suboccipital region ➣ Referred pain to upper shoulders/trapezius region ➣ Pain provoked by motion ➣ May be precipitated by postural position during sleep ➣ Suboccipital headache (upper cervical disease) ➣ May have torticollis posturing ■ Radicular pain ➣ Depends on disk involved ➣ Burning, radiating, electrical, knife-like description ➣ Often related to neck position r Extension Cervical Disk Disease r r r r ➣ Ipsilateral side bending Contralateral side bending Rotation Flexion May note that hands seem clumsy physical exam ■ Assess cervical ROM ➣ Extension, flexion, side bending, rotation – correlate with pain, restriction, referred pain ➣ Extension and rotation toward the painful side reproduces pain down the arm – positive Spurling’s maneuver Palpation of cervical spine for tenderness May have specific motor atrophy with chronic denervation Motor testing upper and lower extremity Assess for hyporeflexia, hyperreflexia ➣ Hyperreflexia may be sign of upper motor neuron, cord compression, myelopathy ■ Assess, sensation – light touch, vibratory, positional, temperature ■ Myelopathy findings ■ ■ ■ ■ studies ■ Radiographs ➣ AP – joints of Luschka, coronal alignment ➣ Lateral – loss of cervical lordosis, narrowing of intradiskal spaces, osteophytes, narrowing of AP canal ➣ Obliques – foraminal stenosis/spondylosis ➣ Open mouth – C1-2, dens assessment ➣ Instability r Flexion/extension views ■ MRI ➣ ➣ ➣ ➣ Most sensitive for HNP Caveat: disk bulge is common Acute indication – weakness Usually defer 6 weeks; may be forced in athlete to obtain earlier ➣ Can rule out intrinsic cord process ■ EMG/nerve conduction study ➣ Helpful to assess for peripheral entrapment ■ MRI + gadolinium ➣ Helpful with previous surgery 47 48 Cervical Disk Disease ■ Myelography or CT myelography ➣ Excellent assessment for neural compression due to osteophytes ■ Thin CT sections with 45-degree oblique sagittal reconstruction are helpful to assess foraminal stenosis.

Chronic herniated nucleus pulposus (HNP) ■ Acute ➣ May recollect specific traumatic onset r Lifting r Movement of neck r Direct contact injury to head ➣ Pain, usually severe ➣ Acute HNP with myelopathy rare ➣ Radiculopathy symptoms affected by neck position ➣ Neck pain may precede radicular symptoms ■ Chronic ➣ May have slow insidious onset ➣ Usually cannot recollect specific injury/time of onset ➣ Pain may fluctuate ➣ Radiculopathy may not be affected by neck position ➣ May have numbness without pain ➣ Cervical spine rotation may give vertebral artery occlusion symptoms ➣ Anterior osteophytes may give visceral pressure symptoms (pharyngeal symptoms) ■ Similar symptoms between acute and chronic ➣ Painful stiff neck ➣ Usually mid/upper neck ➣ Radiation to suboccipital region ➣ Referred pain to upper shoulders/trapezius region ➣ Pain provoked by motion ➣ May be precipitated by postural position during sleep ➣ Suboccipital headache (upper cervical disease) ➣ May have torticollis posturing ■ Radicular pain ➣ Depends on disk involved ➣ Burning, radiating, electrical, knife-like description ➣ Often related to neck position r Extension Cervical Disk Disease r r r r ➣ Ipsilateral side bending Contralateral side bending Rotation Flexion May note that hands seem clumsy physical exam ■ Assess cervical ROM ➣ Extension, flexion, side bending, rotation – correlate with pain, restriction, referred pain ➣ Extension and rotation toward the painful side reproduces pain down the arm – positive Spurling’s maneuver Palpation of cervical spine for tenderness May have specific motor atrophy with chronic denervation Motor testing upper and lower extremity Assess for hyporeflexia, hyperreflexia ➣ Hyperreflexia may be sign of upper motor neuron, cord compression, myelopathy ■ Assess, sensation – light touch, vibratory, positional, temperature ■ Myelopathy findings ■ ■ ■ ■ studies ■ Radiographs ➣ AP – joints of Luschka, coronal alignment ➣ Lateral – loss of cervical lordosis, narrowing of intradiskal spaces, osteophytes, narrowing of AP canal ➣ Obliques – foraminal stenosis/spondylosis ➣ Open mouth – C1-2, dens assessment ➣ Instability r Flexion/extension views ■ MRI ➣ ➣ ➣ ➣ Most sensitive for HNP Caveat: disk bulge is common Acute indication – weakness Usually defer 6 weeks; may be forced in athlete to obtain earlier ➣ Can rule out intrinsic cord process ■ EMG/nerve conduction study ➣ Helpful to assess for peripheral entrapment ■ MRI + gadolinium ➣ Helpful with previous surgery 47 48 Cervical Disk Disease ■ Myelography or CT myelography ➣ Excellent assessment for neural compression due to osteophytes ■ Thin CT sections with 45-degree oblique sagittal reconstruction are helpful to assess foraminal stenosis.

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Sports Medicine by David Drez, Bernard Bach, Charles Nofsinger


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