Sports Medicine in the Pediatric Office: A Multimedia Case-Based Text with Video

Sports Medicine in the Pediatric Office: A Multimedia Case-Based Text with Video

by Jordan D. Metzl

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Product Details

ISBN-13: 9781610021227
Publisher: American Academy of Pediatrics
Publication date: 10/01/2017
Pages: 276
Product dimensions: 8.30(w) x 10.80(h) x 0.60(d)

About the Author


Jordan D. Metzl, MD, FAAP, is a sports medicine physician at Hospital for Special Surgery in New York City, NY. With a practice of more than 20,000 patients, Dr. Metzl is widely known for his passion of sports medicine and fitness. His focus is to safely return athletes to the playing field of their choice and to keep them there. Dr. Metzl appeaers regularly on media programs including the Today Show and Good Morning America, and in print media including the New York Times, discussion the issues of fitness and health. In addition to his busy medical practice and academic interests, he practices what he preaches. He is a former collegiate soccer player, a 29-time marathon runner and 10-time Ironman finisher.

Read an Excerpt

CHAPTER 1

The Basics of Sports Injury Evaluation

Jordan D. Metzl, MD, FAAP

Taking the Patient History of a Sports-Related Injury

1. Mechanism of Injury

2. Swelling

3. Level of Disability

4. Return to Play

Keys to Physical Examination of a Sports-Related Injury

1. Inspection

2. Observation

3. Palpation

4. Active Motion (Muscle Strength)

5. Passive Motion (Joint Function)

6. Special Tests and Assessments

• Ligamentous Stability

• Neurologic Function

• Specific Function

Obtaining Specific Images, Scans, and Test Results to Evaluate a Sports-Related Injury

1. Radiographs

2. Magnetic Resonance Image

3. Computed Tomography Scan

4. Bone Scan

5. Single-Photon Emission Computed Tomography Scan

6. Dual-Energy X-ray Absorptiometry Image

7. Ultrasound Image

8. Neurocognitive Test Results

9. Complete Blood Cell Count

Referring an Athlete for Physical Therapy

Returning an Athlete to Play

1. Full Understanding of the Injury

2. Guidelines for Return to Play

3. Guidelines for Prevention

Taking the Patient History of a Sports-Related Injury

As attested by our experience teaching hundreds of pediatric residents, they do not seem as comfortable taking the history of a sports-related injury as they do dealing with a medical issue, such as an asthma exacerbation. Any difference in level of comfort felt by a pediatric health care professional, resident, or medical student between taking the history of a sports injury and the history of other medical issues would be unfortunate. Of all the issues discussed in this book, patient history is likely the most important. The way in which an injury occurs is the hallmark of the type of problem that is encountered in the office. For example, an ankle injury is often characterized by the mechanism of injury (ie, how the injury happened). The way the ankle rolls speaks volumes about the type of injury that might be anticipated when examining the patient.

Following are a few of the factors that are essential in taking the history of a sports-related injury:

1. Mechanism of Injury

The mechanism of injury is how an injury happens. This is the way in which an injury occurs, which should always be one of the first considerations in evaluating any injury in an athlete. This consideration, hopefully, should include questions such as, "How did the injury happen?" Through this knowledge, the examiner can gain a much better idea of the type of problem that might have resulted. Throughout this workbook and video, we have tried to present common injuries with common mechanisms. Sometimes, patients can essentially recreate the injury in the office, using the uninjured contralateral appendage, which is often helpful as well.

2. Swelling

Swelling is a helpful indicator that leads to the proper diagnosis of many sports-related injuries. The location and timing of the onset of swelling are important clues toward diagnosis. As is discussed in Chapter 4, Knee and Lower Leg Injuries in the Young Athlete, swelling that occurs quickly, typically within 1 hour of an injury, is likely blood related. When this bleeding occurs inside a joint, it is known as an acute hemarthrosis. Fractures, because of the readily available blood supply inside of bone, also swell quickly. As such, swelling onset is a helpful clue (ie, the quicker an injury swells, the more serious it is likely to be).

3. Level of Disability

Assessing the level of disability from an injury is helpful during evaluation of both acute traumas and overuse injuries. The rules here are simple: If an injury is limiting an athlete's ability to participate in sports, "hold the athlete out" until a clear diagnosis is reached and a treatment plan is implemented. If an athlete is having trouble participating in sports because of pain, do not clear the athlete to participate until a full understanding about the severity of the injury, as well as potential ramifications from participation, is understood. For children, when in doubt, "hold them out."

4. Return to Play

When returning an athlete to play from an injury, the same issues discussed previously are important. A clear understanding of the injury and the knowledge that the appropriate preventive or physical therapy measures have been implemented are essential; examples are a preventive strengthening program for an athlete who has sprained his or her ankle or the implementation of a diet rich in calcium and vitamin D for an athlete who is being treated for a stress fracture. In both cases, the key to a safe and healthy return to play is remedy of the existing problem. The more knowledgeable health care professionals are about return-to-play decisions, the better able they are to make informed decisions on safe and effective return to play.

Keys to Physical Examination of a Sports-Related Injury

Physical examination of the patient with a musculoskeletal concern should follow the same premise as the general physical examination. Before a health care professional examines the patient, a history (in this case, a targeted patient history) should precede the hands-on portion of the examination. However, in sports medicine, because the problems are injury- or concern-specific in most cases, the keys to proper examination are having a good concept of the mechanism and type of concern before the physical examination and possessing the skills to perform the targeted physical examination comfortably. As is the case with other skills, such as cardiac auscultation, the more times these examinations are repeated, the more effective the information-gathering skills become.

We stress that not every injury and physical examination needs to entail each of the categories discussed in the following text. However, these provide a helpful guideline from which the examiner can start to work. In general, physical examination is divided into the following portions:

1. Inspection

The inspection process starts the moment the examiner observes the patient. How is the patient moving? Is he or she using an injured extremity? Is associated swelling significant? These are all important considerations.

2. Observation

Observation pertains to watching the patient for function.

3. Palpation

Palpation is the actual (hands-on) portion of the examination. During palpation, the examiner, knowledgeable about the specific bony and soft- tissue landmarks, attempts to find pertinent areas of tenderness that can give clues to the specific diagnosis. For example, in the ankle, pain on focal palpation of the distal fibular physis is suggestive of a distal fibular physeal fracture, while pain to palpation of the anterior talofibular ligament (ATFL) is suggestive of an ATFL sprain. Palpation becomes a key issue in deciding management as well. For example, pain in the anatomical snuff-box on palpation, even in the presence of negative radiographic findings, mandates presumptive treatment for a scaphoid fracture, through the use of thumb spica splinting.

4. Active Motion (Muscle Strength)

Active motion applies to functional joint examination, during which the power of movement is performed by the patient, not the examiner. In this type of scenario, the joint or body part is actively moved by the patient and, as such, gives important clues about the integrity of the muscular attachments into bone. In young athletes, examinations primarily pertain to apophyseal attachments, such as the origin of the flexor muscle mass at the medial epicondyle of the elbow. When the elbow is flexed and the wrist is volar flexed, traction is placed on the medial elbow, which reproduces pain caused by traction.

5. Passive Motion (Joint Function)

Passive motion, the way in which a joint moves when the power is applied by the examiner, is an essential part of joint examination. Passive motion is especially important in joints, such as that of the hip, in which a limitation of passive motion during the rotational portion of the examination can indicate the presence of a structural problem in the joint, such as a slipped capital femoral epiphysis. In addition, limitation of passive flexion in the hip can be indicative of a structural problem in the anterior-inferior iliac spine, the apophyseal origin of the rectus femoris, which sits on the anterior-superior portion of the hip joint.

6. Special Tests and Assessments

Some special tests and assessments are tailored to specific parts of the body. Some of these special tests and assessments are reviewed in the following text:

Ligamentous Stability

For certain areas of the body, ligamentous examination provides important clues about the structural stability of a joint. For example, the athlete who experiences an inversion injury to the ankle generally injures the lateral ankle, and, if the athlete is skeletally mature, that often means a sprain of the ATFL. The anterior drawer test is used to assess laxity in the ATFL and is important to help grade the amount of joint laxity and the likelihood of further injury.

Neurologic Function

Neurologic assessment is also important for certain areas of the body, mainly as related to cervical or lumbar spine injury or, occasionally, with peripheral nerve injury, such as ulnar nerve subluxation in the cubital tunnel. Neurologic assessment generally includes muscle-strength testing, reflex testing, and sensory examination. These are often considered in the setting of an associated injury, such as an upper-extremity strength, reflex, and sensory loss in an athlete, such as a football player who has experienced an axial-load injury to the cervical spine. Mechanism and history of injury are important in helping assess these types of problems.

Specific Function

Finally, functional testing becomes important as athletes are ready to return to play. For example, before returning to play, the athlete who has experienced the ATFL sprain described previously will often be asked to stand for 30 seconds, with his or her eyes closed, on the injured foot or ankle. This is especially important because the ability or inability to perform this task is a good predictor of injury risk going forward.

Obtaining Specific Images, Scans, and Test Results to Evaluate a Sports-Related Injury

Knowing what image, scan, or test result to get, when to get it, and what to do with the information is tremendously important. The following text will review some of the common images, scans, and test results used in sports medicine:

1. Radiographs

Radiographs are an essential part of the evaluation of many sports-related injuries. The keys to getting proper radiographs are knowing when to get them, knowing what views to get, and developing a comfort level in evaluating musculoskeletal images. Because education regarding skeletal radiographic evaluation is minimal during many primary care residency programs, getting proper radiographs is sometimes difficult. When ordering bone radiographs, it is important to have an idea of the mechanism of injury as well as the age-appropriate findings in a particular patient. Furthermore, although not required for every injury, contralateral radiographs can aid in the comparison of injury (the injured as compared with the uninjured side). Generally, we find that repeated review of normal radiographic findings aids significantly in the ability to recognize abnormal findings.

In each section in the video, we have tried to provide the appropriate views for each body part. Although more views are needed in specific cases (and at times the opposite extremity is radiographed for comparison in evaluation of a growth plate injury), most basic information can be obtained through the radiographic screening views listed in Table 1-1. Each view is explained during the video portion of the material.

A radiograph is not only a helpful image for diagnosing bone injury but also the preferred image for diagnosing most apophyseal injuries, such as apophyseal avulsion fractures. These commonly occur in the hip, the knee, and the elbow, as discussed in the video examination.

2. Magnetic Resonance Image

Magnetic resonance imaging (MRI) has changed the face of medicine in the past 25 years. In many specialties, sports medicine included, MRI has allowed physicians to look inside the body, to avoid either delays or incorrect diagnoses. Because this is a magnetic-based study, it does not expose patients to radiation.

For the sports medicine physician, and for the primary care physician, obtaining and using an MRI is an important and helpful tool. However, please note and understand that an MRI is only as good as the context in which it is obtained. For example, an MRI can be a tremendously helpful tool in diagnosing conditions such as stress fractures (before they show on radiograph), edema in the capitellum if osteochondritis dissecans development is a concern in the lateral elbow of throwing athletes, and ligament or cartilage injuries in areas such as knees, shoulders, hips, ankles, and elbows. However, an MRI can also show information that does not necessarily pertain to the clinical picture, such as the presence of a small inter-substance meniscus tear in a patient with patellofemoral knee pain. Although the meniscus tear is present, it is not contributing to the cause of knee pain.

Therefore, the key to obtaining and using an MRI is realizing when to use MRI and what to do with the information. Magnetic resonance imaging is most helpful as a secondary study, to assess injuries that do not show on radiograph. The information from MRI, however, should be considered only in the context of an associated clinical scenario. The key to assessing if an MRI finding is significant is by assessing the patient history, physical examination, and MRI findings together. Throughout the workbook and video, we have tried to illustrate when and how MRI is helpful as a diagnostic tool.

A rule that was taught in residency applies here, as with many studies: if you are not comfortable interpreting the results of a test, it is probably best not to order that test. Many clinicians around the world have become comfortable interpreting an MRI; as such, this is a helpful image to obtain for further clarification. However, if the MRI findings are not part of your normal clinical practice, results should be interpreted with caution.

3. Computed Tomography Scan

Computed tomography (CT) scan is a helpful method for providing close-up, detailed information of bony anatomy. Like radiography, CT scan is a radiation-based study. The radiation dose is considerably higher during CT scan as compared with radiography, so these studies should always be performed with thoughtful consideration. Computed tomography scan is rarely used in the primary care setting, but, in sports medicine and all fields of orthopedic surgery, CT scan is helpful in providing further information about suspected bone injury. It is the scan of choice for evaluation of bone injuries, such as assessment of the anatomy of a spondylolysis lesion (in the spine) or the anatomical assessment and location of osteoid osteoma, a benign tumor that occurs in bone. Computed tomography scan also has the unique capability to provide 3-dimensional reconstruction views, which are especially helpful in the evaluation of trauma to bone.

4. Bone Scan

Radionuclide bone scan is a time-delayed scan that is used to screen for occult bone lesions. This scan involves injecting a radionuclide dye intravenously. A radiation-based scan is performed several hours later to screen for dye uptake. Bone scan used to be the scan of choice for diagnosing stress fracture before the age of MRI. However, if the origin of the bone-related pain is unclear, such as with suspected bone tumor, bone scan still has tremendous usefulness. In sports medicine, bone scan is a helpful screening device, but it has largely been replaced by MRI for many cases, unless the specific focus of the pain is unknown. Since the first edition of this book, bone scan use has thankfully decreased in the field of orthopedics and sports medicine and has largely been replaced by MRI.

(Continues…)



Excerpted from "Sports Medicine in the Pediatric Office"
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Copyright © 2018 American Academy of Pediatrics.
Excerpted by permission of American Academy of Pediatrics.
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Table of Contents


Foreword by Lewis R. First, MD, FAAP
Preface by Jordan D. Metzl, MD, FAAP
Introduction
Part 1: Overview and Prevention
Chapter 1: The Basics of Sports Injury Evaluation
Chapter 2: Trends in Prevention of Sports Injury in the Young Athlete
Part 2: Injuries
Chapter 3: Ankle and Foot Injuries in the Young Athlete
Chapter 4: Knee and Lower Leg Injuries in the Young Athlete
Chapter 5: Shoulder Injuries in the Young Athlete
Chapter 6: Wrist and Elbow Injuries in the Young Athlete
Chapter 7: Hip and Spine Injuries in the Young Athlete
Chapter 8: Concussions in the Young Athlete
Part 3: Sports
Chapter 9: Soccer and the Young Athlete
Chapter 10: Baseball and Softball and the Young Athlete
Chapter 11: Collision Sports and the Young Athlete: Football, Hockey, Lacrosse, and Rugby
Chapter 12: Gymnastics and the Young Athlete
Chapter 13: Running and the Young Athlete
Index
 

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