CASE ONE CASE ONE. RADIAL HEAD FRACTURE Mason Classification. RADIAL HEAD FRACTURE Mechanism of Injury. RADIAL HEAD FRACTURE Imaging

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2 CASE ONE An eighteen year old female falls during a basketball game, striking her elbow on the court. She presents to your office that day with a painful, swollen elbow that she is unable to flex or extend without significant pain. Pronation and supination also produce pain, and she is tender to palpation over the radial head. CASE ONE Linear and Nondisplaced Fracture of the Radial Head with Positive Anterior Fat Pad Sign Mechanism of Injury Mason Classification Fall on an outstretched hand Force is transmitted along the radius to the radial head Radial head is compressed against the capitellum and fractures. Type I: Less than 2 mm displacement Type II: Displacement or depression of at least 2 mm Type III: Comminution of the radial head Type IV: Dislocated Imaging Treatment Comminuted fractures of the radial head are usually well seen. Subtle radial head fractures may be visualized only on a single view. Abnormal anterior or posterior fat pad signs are significant for an intra-articular fracture. Type I (nondisplaced or minimally displaced) fractures may be treated with a sling for 7-10 days for comfort followed by physical therapy. Type II, III, and IV fractures require open reduction and internal fixation or excision.

3 CASE TWO You are called to the Emergency Department to see a twenty-year old patient of yours who fell on an outstretched arm while skateboarding. He sits on the gurney cradling his right arm. His acromion process is prominent and neurovascular exam of his right upper extremity is normal. You obtain radiographs of his shoulder. CASE TWO Subcoracoid dislocation CASE THREE CASE THREE A thirty year old female fell while skiing, landing on her outstretched hand while holding on to her ski pole. Examination reveals swelling and pain on palpation of her first metacarpophalangeal (MCP) joint. Gamekeeper s Thumb with Associated Gamekeeper s Fracture Pathoanatomy Injury to the ulnar collateral ligament (UCL) of the first MCP joint Extent of injury dependent on force applied at time of injury Graded like all other ligament injuries The Ulnar Collateral Ligament The UCL is a 4-8 X mm band that originates from the metacarpal head and inserts into the medial aspect and base of the proximal phalanx of the thumb. It consists of two components: the proper collateral ligament and the accessory collateral ligament. The adductor mechanism inserts onto the extensor expansion through its aponeurosis, which lies superficial to the UCL

4 Historical Aspects The term gamekeeper's thumb originally coined by Campbell in Gamekeeper's thumb was most commonly associated with Scottish gamekeepers, especially rabbit keepers, in whom it was a work-related injury. The injury occurred as the gamekeepers sacrificed the rabbits by breaking their necks between the ground and their thumbs and index fingers. Mechanism of Injury The most common mechanism is a skier landing with his or her hand on a ski pole, causing a valgus force on the thumb. The thumb is injured as a result of valgus force on an abducted metacarpophalangeal (MCP) joint. The subsequent ulnar collateral injury results in instability accompanied by pain and weakness of the pinch grasp. Stener Lesion A Stener lesion can be present only when both the proper and accessory collateral ligaments are ruptured. In more than 80% of complete ruptures of the UCL, a Stener lesion is present, whether it is palpable or not Clinical Presentation Swelling and pain present at the ulnar aspect of the MCP joint Ecchymosis is frequently seen. A palpable mass on the ulnar aspect of the MCP joint may represent the retracted UCL stump that is proximally and dorsally displaced relative to the adductor aponeurosis. Physical Examination The thumb should be placed in 30 flexion and tested for valgus instability in this position. If the accessory collateral ligament remains intact gross instability will be absent. An isolated injury to the proper ligament usually will result in a grade I or II injury depending on the extent of the sprain. Physical Examination Stress testing with the thumb in the extended position is the best test for determining the competence of the accessory collateral portion of the UCL. Valgus laxity of more than 35 or laxity 15 more than that on the uninjured side suggests rupture of this portion of the ligament. If valgus laxity of the MCP joint is present in both the flexed and extended positions, complete UCL rupture should be suspected.

5 Treatment Nonsurgical treatment can be considered for partial tears - grade I or grade II tears - of the UCL. These tears usually involve an isolated rupture of the proper collateral ligament. These injuries may be treated by immobilizing the thumb in a thumb spica cast or splint for 4 weeks. Treatment Complete UCL tears require surgical intervention. Recent reports in the literature suggest that immobilization with a special brace designed to resist the ulnar and radial deviation of the thumb may be as beneficial as surgery in patients with these injuries. However, confirmations of these suggestions are limited. CASE FOUR A thirty-five year old long distance runner presents to your office complaining of heel pain. She relates a significant increase in her running volume over the past three weeks as she is preparing to run a marathon in three months. Her diet is normal. She is using birth control pills. CASE FOUR Physical examination reveals normal body habitus. Examination of the foot is normal except for pain on palpation of the heel. Initial radiographs of the foot are normal; you order an additional study. CASE FOUR Limited MRI of the foot STRESS FRACTURES Evaluation Imaging Radiographs May not demonstrate findings until 2-3 weeks after onset of symptoms Triple Phase Bone Scan High sensitivity, but diminished specificity Magnetic Resonance Imaging High sensitivity and specificity Computerized Tomography

6 Low Risk Stress Fractures of the Foot and Ankle High Risk Stress Fractures of the Foot and Ankle Metatarsal Shaft Calcaneus Fibula Medial Malleolus Talus Navicular Fifth Metatarsal Base of the Second Metatarsal Great Toe Sesamoids STRESS FRACTURES Management Identify and correct underlying risk factors Classify stress fracture as low or high risk Most lower extremity low-risk stress fractures successfully treated with 2 to 6 weeks of limited weightbearing progressing to full weightbearing Low impact activities are followed by a gradual resumption of sports specific activities A twenty-eight year old male presents with a complaint of knee swelling and pain after tripping while running out a ground ball while playing softball yesterday. He relates that he awoke this morning with a swollen knee despite the fact that he iced the knee last evening after the injury. Physical examination reveals a significant effusion of the left knee. An abrasion is noted over the tibial tubercle. Approximately 8 mm of apparent anterior excursion is present on performing a Lachman maneuver. When flexed to 90 degrees, the knee has the appearance shown in the following picture. The examination is otherwise unremarkable. Posterior Cruciate Ligament Strongest ligament in the knee Primary restraint to posterior translation Originates from the medial intercondylar wall, running obliquely to attach to posterior aspect of the tibia

7 PCL Rupture Mechanisms of Injury Dashboard injury Fall onto a flexed knee with the foot in plantar flexion tibial tubercle impact Pure hyperflexion injury Hyperextension injury with tibiofemoral dislocation PCL Rupture Physical Findings Effusion Limited range of motion False positive anterior drawer or Lachman signs Positive sag sign Treatment of Isolated PCL Tears Resolution of swelling Restoration of range of motion Progressive strengthening concentrate on quadriceps mechanism Functional bracing as needed for return to activity CASE SIX The mother of a 14 month old male brings him to your office for evaluation because of his inability to bear weight on his right leg without crying for the past two days. She relates that his sister indicated that he fell while stepping off of a small step into the garage and began crying. Physical examination reveals a happy toddler with no obvious deformity or swelling of the right lower extremity, ankle of foot. CASE SIX CAST Fracture Childhood Accidental Spiral Tibial Fracture Nondisplaced spiral fracture of the distal tibia Occurs most commonly in toddlers (9 months 3 years) Occurs after low energy trauma, usually with a rotational component CAST Fracture