Sports Medicine
Orthopaedics
Common Adult Orthopaedic Injuries
General Rules about Fractures
1- When you suspect a fracture, order 2 views at 90° to one another and always include the joints
above and below the broken bone.
2- Always x-ray other sites “in the line of force” (e.g., lumbar spine for someone who falls and lands
on the feet, hips in a patient who has been in a motor vehicle accident with force of knees against the
dashboard).
3- Closed reduction is the answer for fractures that are not badly displaced or angulated.
4- Open reduction and internal fixation is the answer when the fracture is severely displaced or
angulated or cannot be aligned.
5- Open fractures (the broken bone sticking out through a wound) require cleaning in the OR and
reduction within 6 hours from the time of the injury.
6- Always perform cervical spine films in any patient with facial injuries.
7- Always worry about gas gangrene in any deep penetrating or dirty wounds. Three days later, the
patient will be septic with a tender, swollen injury site with gas crepitus. Treatment is large doses of
IV penicillin and hyperbaric oxygen.
Fractures
There are 5 main types of fractures, all of which present with pain, swelling, and deformity.
1. Comminuted fractures: a fracture in which the bone gets broken into multiple pieces
• Most commonly caused by crush injuries
2. Stress fractures: a complete fracture from repetitive insults to the bone.
• Most common stress fracture is of the metatarsals.
• describe an athlete with persistent pain.
• X-ray does not show evidence, so a CT or MRI must be conducted in order for diagnosis.
• Treatment is with rehabilitation, reduced physical activity, and casting.
If persistent, surgery is indicated.
3. Compression fractures: a specific fracture of the vertebra in the setting of osteoporosis
• Approximately one-third of osteoporotic vertebral injuries are lumbar, one-third are thoracolumbar,
and one-third are thoracic in origin.
4. Pathologic fracture: a fracture that occurs from minimal trauma to bone that is weakened by disease
• Metastatic carcinoma (e.g., breast or colon), multiple myeloma, and Paget disease are a few
examples of diseases that cause brittle bones.
• An older person fractures a rib from coughing.
• Treatment is surgical realignment of the bone and treatment of the underlying disease.
5. Open fracture: a fracture when injury causes a broken bone to pierce the skin
• An open fracture is associated with high rates of bacterial infection to the surrounding tissue
• Surgery is always the right answer
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Upper Extremity: Shoulder, Elbow, Forearm, and Hand
Shoulder
Injury Etiology Signs/symptoms Diagnosis Treatment
DJD of Uncommon; caused by Anterior shoulder Limited AROM Conservative
glenohumeral trauma or repetitive use. pain with and PROM Arthroplasty
joint abduction and X-ray (replacement)
external rotation
Limited PROM
Subacromial Overhead activities Lateral shoulder Neer Conservative
impingement/ (swimming, throwing). pain with Hawkins Corticosteroid
bursitis Lidocaine injection: pain, abduction and Painful arc injection
resolved (impingment) external rotation MRI
unresolved (tear). Normal PROM
Rotator cuff tear Trauma fall on outstretched Lateral shoulder Jobe (empty can) Surgery for full
hand (FOOSH) and/or pain + Weakness Drop arm thickness
chronic impingement. with abduction MRI Tear or failed
Most commonly torn is external rotation conservative
supraspinatus (first 15° of Normal PROM treatment
abduction) → Drop arm Limited AROM
Adhesive Chronic inflammation, Lateral shoulder MRI Physical therapy
capsulitis fibrosis, and contracture of pain + Stiffness ROM exercises
(frozen joint capsule. Risk factors: with abduction Manipulation
shoulder) prior trauma, DM, CVA, external rotation Under anesthesia
hypothyroidism, female, age Limited AROM OMT (Spencer
>40 years. and PROM technique)
+/− corticosteroid
injection if failed
physical therapy
Biceps tendinitis Associated with other Anterior shoulder Speed Tendinitis:
and rupture shoulder pathology pain, audible Yergason conservative
(labral tear, rotator cuff snap, ecchymosis, Ultrasound (US) +/− corticosteroid
tear) in elderly. visible bulge or MRI can injection with
Overuse injury from (Popeye sign) help confirm impingement.
overhead activities or sports Rupture: surgical
in adults >40 years reattachment
Most common: proximal in young patients
long head of biceps in
bicipital groove.
Labral or SLAP Overuse injury from Similar to O’Brien Physical therapy
(superior labrum overhead sports. Associated shoulder Load and shift For strengthening
Ant to Post) tear with biceps tendon rupture. instability (pain, MRI Arthroscopic
locking, clicking). surgery for
numbness, and refractory cases
paresthesias
AC separation Massive force on adducted Anterior shoulder Cross-arm Types 1–2
arm, usually a fall onto the pain with adductor (no clavicular
tip of the shoulder (football palpation over X-ray displacement):
conservative + sling
Elsebey notes 2
tackle, wrestling throw, ice- AC joint and Types 3–6:
hockey) adduction of arm. surgical ORIF
Clavicular Trauma (FOOSH) Pain over clavicle X-ray Middle third: Simple
fracture Angiogram for vascular on Palpation arm sling, rest and ice.
injury if neurovascular Distal third: ORIF
compromise is suspected
(subclavian artery and
Brachial plexus)
Surgical neck May cause axillary nerve Bony tenderness, X ray
humerus injury with paralysis of swelling,
dracture deltoid and teres minor and ecchymosis, or
sensory loss in the lateral crepitus over the
upper arm fracture
Anterior GH Most common (>90%); Arm held in Observation Reduction followed
dislocation Commonly caused by abduction with Apprehension with a sling
FOOSH. involves risk of external rotation. test (relocation and
axillary nerve damage. X-ray (initial) immobilization)
MRI (most
accurate) Surgery for repeated
occurrences
Posterior GH Uncommon (<10%); result of Arm held in X-ray (initial) Closed reduction
dislocation seizure or electrocution. adduction with MRI (most
internal rotation. accurate) Surgery if pulses or
sensation are
diminished
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Elbow
Lateral Epicondylitis Medial Epicondylitis
Risk factors Tennis elbow, carpenters, plumbers Golfer’s, little leaguer’s, pitcher’s
Cause Results from microtrauma to the Results from microtrauma to the
common extensor origin, or common flexor tendon
extensor carpi radialis brevis (ECRB)
caused by noninflmmatory
angiofibroblastic tendinosis
Symptom Pain over lateral epicondyle that Pain over medial epicondyle that
increases with repetitive supination or increases with repetitive pronation or
forearm extension. wrist flexion
Pain with passive wrist flexion Pain with passive wrist extension
Often causes weakness in grip strength
Sign Pain with resisted supination and Pain with resisted pronation and wrist
forearm extension (SEX) flexion
Treatment • Modified activity & ergonomics
• Inelastic counterforce brace
• NSAID
• Stretching & resistence excersice
• Physical Therapy
Radial tunnel syndrome (similar to lateral epicondylitis)
Tenderness tends to overlie extensor muscle wad and pain elicited on examination by flexing the
long finger while fingers and wrist extended.
Panner disease (osteochondrosis)
It affects capitellum esp in adolescent patient engaged in sports involving in throwing. Chronic dull
pain, crepitation, loss of pronation and supination.
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Hand
Etiology Sign/symptoms Diagnosis Treatment
Scaphoid Fall on Pain, tenderness over Best initial test: plain Immobilize the wrist in
Fracture outstretched the anatomic snuffbox. x-rays. If fracture is thumb spica cast for 7–14
hand (FOOSH) Reduced hand grip not seen on imaging days and then repeat X-
This injury involves the but is suspected, ray to confirm fracture.
risk of avascular MRI or CT can make Nondisplaced fracture:
necrosis (AVN) of the immediate thumb spica cast for 6+
scaphoid and non-union diagnosis. CT is best weeks
test for patients that Displaced fracture (>2
are still symptomatic mm): ORIF
after 4–6 weeks of
treatment.
De Quervain overuse injury Pain and tenderness Finkelstein test Acute management
Tenosynovitis caused by over radial side of the (+ve in both OA Activity modification
(Mommy repeated thumb wrist. The pain results Carpometacarpal thumb spica splint,
Thumb) abduction and from inflammation of joint & De Quervain) NSAIDs.
extension. Look the tendons of the X- ray Persistent pain:
for a new mother extensor pollicis brevis De Quervain: N corticosteroid injection
constantly (EPB) and abductor OA: abnormal Failed 2 injection within
holding her baby. pollicis longus (APL) Local nerve block → 1year:
Bowling and De Quervain: relief Surgery
texting pain
OA: No response
Flexor carpi Pain with radial flexion
radialis of the wrist and point
tenosynovitis tenderness over
trapezium
Dupuytren There is a genetic This is the hyperplasia Triamcinolone, lidocaine,
Contracture predisposition of the palmar fascia or collagenase injection
Association with leading to nodule may help. Surgical release
alcoholism and formation and is performed when
cirrhosis. contracture of the function is impaired.
fourth and fifth fingers
Patients lose the ability
to extend their fingers
Trigger Woman who Pain over the palmar Steroid injection is the
thumb awakens at night aspect of the 1st MCP best initial therapy. If
with an acutely joint and locking of the steroids fail, surgery to
flexed finger that thumb in flexion cut the sheath that is
“snaps” when restricting the tendon is
forcibly extended the definitive treatment.
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Distal radius (Colles’) fracture
Smith’s fracture
Direct blow to the ulna (Monteggia fracture) or radius (Galeazzi fracture) results in a combination
of diaphyseal fracture and displaced dislocation of the nearby joint. Open reduction and internal
fixation is needed for the diaphyseal fracture, and closed reduction for the dislocated joint.
Hutchinson fracture
Metacarpal fractures
Hamate fracture
Elsebey notes 7
Supracondylar fracture
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Carpal Tunnel Syndrome
Causes
• Pregnancy (accumulation of fluid, estrogen- mediated depolymerization of ground substance)
• Diabetes (Anatomic compression)
• Rheumatoid arthritis (inflammation of tendon and sheath)
• Acromegaly (synovial edema, tendon hyperplasia)
• Amyloidosis (accumulation of amyloid, B2 micoglobulin in renal failure)
• Hypothyroidism (deposition of mucopolysaccharide protein complexes with the perineurium and
endoneurium of the median nerve.
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Complex Regional Pain Syndrome (Reflex Sympathetic Dystrophy)
Treat like peripheral neuropathy: NSAIDs, TCAs, gabapentin, pregabalin.
Sudeck's atrophy is a radiographic term for spotty rarefaction seen with reflex sympathetic dystrophy.
DD
Complex regional pain syndrome likely involves a reflex arc along the sympathetic nervous system
leading to vasomotor symptoms (e_g_, sweating, abnormal hair growth, tissue swelling, and
coldness) VS cervical radiculopathy (no vasomotor symptoms)
Elsebey notes 10
Compartment Syndrome (Soft tissue swelling)
Diagnosis/treatment
Prognostic factor
Prognosis
Volkmann's ischemic contracture is the final sequel of compartment syndrome in which the dead
muscle has been replaced with fibrous tissue
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Amputated body part
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Lower Extremity: The Hip, Knee, and Foot
Hip
Disease Etiology Signs/symptoms Diagnosis Treatment
Avascular steroid use, sickle This is an insidious onset of MRI total hip
Necrosis of cell disease, hip and groin pain that is X-rays are arthroplasty
the Femoral alcohol abuse, worsened by activity (stairs, normal in
Head osteomyelitis, or incline) and weight-bearing first few
SLE, or previous but relieved by rest. A months of
fracture, Look for a younger patient pathology
dislocation, or (<40 years old) with the Normal
surgical fixation. Age and risk factors are main ESR, CRP,
clues to differentiate AVN WBC
from OA of the hip.
Osteoarthritis overuse, trauma, progressive hip and groin pain X-ray Conservative
of the Hip and chronic that is worse with movement until pain is
degeneration of in patients > 50 years old. Pain intolerable,
articular cartilage. at rest usually correlates to then total hip
clinically significant x-ray arthroplasty
findings
FABER/Patrick test +ve
Elsebey notes 15
Osteoarthritis
Treatment
Conservative until pain is intolerable, then total hip arthroplasty
Hip fracture
Elsebey notes 16
Meralgia paresthetica
Elsebey notes 17
Knee
Etiology Signs/symptoms Diagnosis Treatment
Anterior Forceful Rapid onset of pain and large MRI RICE (Rest, Ice,
cruciate hyperextension effusion dt hemoarthrosis) Compression,
ligament injury to knee or a Lachman's test, anterior Elevation)
noncontact drawer test and pivot shift Arthroscopic
torsional injury repair
Posterior Dashboard injury Pain MRI Arthroscopic
cruciate posterior drawer, reverse repair
ligament pivot shift and posterior sag
Medial Abduction/ lateral Medial knee Pain, tenderness MRI RICE (Rest, Ice,
collateral injury to the knee valgus stress Compression,
ligament or knee twisting No acute effusion Elevation)
Lateral Adduction/ medial Lateral knee Pain, tenderness MRI Surgical repair
collateral injury to the knee varus stress
ligament No acute effusion
Iliotibial band Lateral knee pain at the Clinical Conservative
syndrome ITBS lateral femoral condyle, Physical therapy
where the Iliotibial band (ITB)
inserts radiating to the thigh
with flexion and extension.
Ober test +ve
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Anterior knee pain
Etiology Signs/symptoms Diagnosis Treatment
Patellar tendon Fluoroquinolones, pivot, Anterior knee pain with Clinical Immediate
tear landing superior displacement of surgical repair
patella. Delayed
Popping sensation, pain, treatment lead
swelling and difficulty to contracture,
bearing weight limited knee
Inability to maintain ROM
passive and active Quadriceps
extension atrophy
Patellofemoral Overuse, trauma Anterior knee pain under Clinical Conservative
Syndrome Malalignment patella. NSAID, activity
(runner’s knee) (weakness of hip Pain increased with modification
abductors, angular squatting, running, Physical therapy
deformities) prolonged sitting and (Quadriceps
Poor biomechanics using upstairs strengthening
(bowlegged). Patellar grind test +ve exercises)
(extension of knee while
compressing the patella)
Patellar tendinitis Overuse injury caused by Inferior patellar knee Clinical Conservative
(jumper’s knee) repetitive overload of pain. Physical therapy
quadriceps on patellar Episodic pain commonly
tendon occurs in athletes in
jumping sports
(basketball, volleyball).
Osgood-Schlatter Overuse injury by Anterior knee pain Clinical NSAIDs, activity
disease repetitive stress from the Tenderness over over X-ray as tolerated and
Tibial Tuberosity quadriceps tendon pulling tibial tuberosities. Sports shows patellar strap
Avulsion- Traction on the tibial tuberosities with jumping, running, separation
Apophysitis) during rapid growth squatting and kneeling of tibial
spurts make it worse. tubercle.
Rest improves symptoms.
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Anserine bursitis
It presents with point tenderness along the medial inner knee and a negative valgus stress
maneuver. Acute therapy includes activity restriction, a pillow between knees at night, ice and
possibly NSAIDs. Patients refractory to conservative measures with persistent symptoms may
receive a steroid joint injection.
Prepatellar bursitis
Elsebey notes 23
Treatment Most cases (> 80%) of septic bursitis Nonsteroidal anti-inflammatory agents
are due to staphylococcal infections, (NSAIDS) are more effective in treating
and initial antibiotic treatment should symptoms of non-septic bursitis.
include coverage for methicillin- Corticosteroid injections are superior to
resistant Staphylococcus aureus (e_g, NSAIDs for faster recovery and prevention
trimethoprim-sulfamethoxazole). In of future non-septic olecranon bursitis
some cases, repeated aspiration of the
bursa may be required. Surgery is
reserved for patients with inadequate
drainage by needle aspiration or
catheter placement, foreign body, or
adjacent skin or soft tissue infection
requiring debridement
Elsebey notes 24
Posterior knee pain
Popliteal cyst
Elsebey notes 25
Foot
Injury Eitiology Symptoms/signs Diagnosis Treatment
Stress Caused by dramatic Pain in midfoot Clinical 2nd metatarsal
fracture increase in activity (2nd metatarsal most X-rays are Conservative
(Military, athletes). common) normal for 3– with rest and
Female athlete triad: low 6 weeks wide, hardsoled
calorie, low bone density, MRI/CT/bone footwear
amenorrhea low vit D, scans are 5th metatarsal
calcium more sensitive CAM boot
Jones Common fracture with 5th metatarsal fracture X-rays Non-displaced:
fracture ankle sprains and caused at junction of metaphysis 6–8 weeks in
when heel is off the and diaphysis. cast and non–
ground but forefoot is weight bearing
planted.
Plantar Heel pain focal to the Clinical: point Best initial
fasciitis rear foot. Pain is greatest tenderness Conservative
with first steps in the distal to heel With stretching
morning and then of plantar fascia
improves. Prolonged X-rays are not Resolves over
daily activity often Useful. rays time in 12–18
causes a return of the may show a months.
pain at night bony spur Refractory cases
Steroid injection
Tarsal tunnel Caused by entrapment of Pain, tingling, and Best initial Best initial
syndrome tibial nerve under flexor burning on medial side +ve Tinel sign NSAIDs,
retinaculum by of the distal planter Steroid injection
Tenosynovitis of tibialis surface of the foot at Most accurate
posterior, flexor digitorum rest and activity EMG Tunnel release
longus, and flexor hallucis for progressive
longus. nerve damage
Morton Caused by an interdigital Numbness and burning Best initial Best initial
neuroma neuroma. Worsened by pain between 3rd and Mulder sign Conservative,
walking on hard surfaces 4th digits. (squeezing metatarsal
and wearing tight or high metatarsal support pads
heeled shoes joints causes or wide,
pain and hard-soled
crepitus at footwear
3rd/4th digits)
Refractory cases
Most accurate Steroid injection
US or MRI and surgery
Hallux valgus Deformity causing pain Pain with walking and Clinical Orthotics and
(bunion) over the great toe at the blisters can occur. Don’t X-ray surgery
metatarsophalangeal confuse with gout, which
(MTP) joint. has similar location
Achilies Burning pain and
tendinopathy stiffness 2-6 cm above
the posterior calcaneus
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Stress fracture
Tibial stress injury
Elsebey notes 28
Achilles tendinopathy
Fat embolism
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