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Darryl B. Thomas, MD. Chief, Orthopaedic Sports Medicine Service Scott & White University Medical Campus Round Rock, TX Assistant Professor of Surgery Texas A&M Health Science Center College of Medicine Temple, TX February 6,2010 - AAOS/AAPA Sports Medicine.

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Chief orthopaedic sports medicine service scott white university medical campus round rock tx

Darryl B. Thomas, MD

Chief, Orthopaedic Sports Medicine Service

Scott & White University Medical Campus

Round Rock, TX

Assistant Professor of Surgery

Texas A&M Health Science Center College of Medicine

Temple, TX

February 6,2010 - AAOS/AAPA

Sports Medicine


Darryl b thomas md education

Darryl B. Thomas, MD - Education

  • 1991 Princeton University (Army ROTC)

  • 1995 Johns Hopkins School of Medicine

  • 2000 Johns Hopkins Orthopaedic Residency

  • 2001 Sports Medicine Fellowship

    • US Military Academy, West Point, NY

    • Hospital for Special Surgery, New York, NY

    • Steadman Hawkins Clinic, Vail, CO

  • 2003 Chief Sports Medicine, BAMC

  • 2005 Orthopaedic Surgeon, Baghdad, Iraq

  • 2006 Private practice, Austin/Round Rock, TX


Overview

OVERVIEW

  • Sports Medicine Specialty

  • Pre-participation Physical Exam (PPE)

  • The Collapsed Athlete

  • Sideline Medical Treatment for Common Conditions

  • Appropriate Referrals to Physicians


Sports medicine

SPORTS MEDICINE

The study and practice of medical principles related to the science of sports, athletic performance, and exercise-related activity

  • Sports injury prevention

  • Sports injury diagnosis and treatment

  • Sports training and athletic performance

    • Exercise and workouts

    • Sports nutrition

    • Sports psychology


Team doc

TEAM DOC

SPORTS MEDICINE PHYSICIAN

  • No residency in sports medicine

  • Typically complete a 1-yr fellowship after residency

    • Orthopaedic surgery

    • Primary Care

      • Family medicine

      • Pediatrics

  • At hospital or clinic associated with high school, collegiate, semi-pro, or professional teams


Team doc1

TEAM DOC

SPORTS MEDICINE PHYSICIAN

  • Physician is ultimately responsible for the decisions regarding care for the athlete

  • Institution must vest the physician with the authority to make medical judgements relating to athletic participation

  • Important to be readily accessible

  • Keep in direct contact with the athletic trainer and / or coaches


Chief orthopaedic sports medicine service scott white university medical campus round rock tx

PPE

PRE-PARTICIPATION PHYSICAL EXAM

  • Musculoskeletal Injuries

  • Cardiovascular disease

  • Neurologic conditions

    • convulsive / SZ disorders

  • Medical conditions

    • Exertional hyperthermia

    • Exertional rhabdomyolysis

    • Status asthmaticus - ∅ response to normal Tx

  • Leading causes of nontraumatic, non-cardiac sports death


Musculoskeletal

MUSCULOSKELETAL

Orthopaedic Conditions

  • Most common disqualification from sports !

  • Knee injury > Ankle injury

    • stable ligamentous exam

    • no effusion, pain

    • 80-90% normal strength

  • Shoulder injury

    • No recent dislocation / subluxation

    • Resolved stingers / burners

  • Neck Injury

    • Free of neck or radicular pain, Full ROM

ACL Recon


C spine disqualifications

C-SPINE DISQUALIFICATIONS

No athletic participation

  • Congenital Conditions

    • Odontoid agenesis, hypoplasia

    • Atlanto-occipital fusion; Klippel-Feil

  • Developmental Conditions

    • Stenosis of the cervical spinal canal

      • neuropraxia, lig instability, + MRI

    • Spear Tackler’s Spine

      • stenosis, ∅ nl lordosis, post-traumatic X-ray ∆’s

  • Traumatic Conditions

    • Lig laxity, acute fx’s, certain healed fx’s (displ.)

Torg (Canal / Body) Ratio ≤ 0.8


Chief orthopaedic sports medicine service scott white university medical campus round rock tx

HCM

Hypertrophic Cardiomyopathy

  • Heart muscle thickens making it more

    difficult for blood to leave the heart ➔ heart

    must work harder to pump blood

  • Estmated to affect 1/500 people in the US

  • Leading cause of sudden

    cardiac death in the young

    athlete, 12-32 yo

  • H.S. and college age

    • 1:200,000 - 1:300,000 / yr

    • AHA: 36% athletes who suffered SCD


Chief orthopaedic sports medicine service scott white university medical campus round rock tx

HCM

History

  • HCM = heterogeneous group of disorders,

    AD, incomplete penetration

  • Sx ➔➔ early adulthood

  • Hx reveals 64-78% of conditions

  • affecting participation in sports

  • More sensitive tool than PE !!!

  • Other conditions - Fam Hx:

    • Marfan syndrome ➔ aortic rupture

    • Premature atherosclerosis

    • Unexplained sudden death


Chief orthopaedic sports medicine service scott white university medical campus round rock tx

HCM

Symptoms

  • Standard PPE’s not always able to detect

  • Often succum to SCD despite clearance !!!

  • Most athletes have prodromal Sx

    • Fainting / syncope during exercise

    • Lightheadedness after activity

    • Chest pain, palpitations, SOB

  • First Sx among many is sudden collapse

    and possible death ➔ arrhythmias


Chief orthopaedic sports medicine service scott white university medical campus round rock tx

HCM

Physical Exam

  • Systolic murmur on dynamic ascultation

    • ↑ w/ standing, or straining phase of Valsalva maneuver

      • ↓ preload

      • ↓ end diastolic

      • volume of LV

    • ↓ w/ squatting

      • ↑ preload


Chief orthopaedic sports medicine service scott white university medical campus round rock tx

HCM

Physical Exam

  • Routine ECG screening not recommended

    for routine PPE

    • too many false positives & negatives

    • not cost-effective on large-scale

  • Resting ECG rate is abnl

    in 80-90% of pts w/ HCM

    • ST-segment ↑ in lateral leads

    • biphasic T-waves in V1 to V3

  • Order w/ Hx, Fam Hx, PE


Cardiac disqualifications

CARDIAC DISQUALIFICATIONS

No athletic participation

  • HCM, Marfan syndrome

  • Rhythm and conduction abnl

  • Systemic hypertension

  • Valvular heart disease

  • Require cardiology clearance !!!


Medical disqualifications

MEDICAL DISQUALIFICATIONS

  • Sickle Cell Disease

    • No contact or collision sports

    • SC Trait ➔ OK, but ↑ risk rhabdo

  • Solitary Organs

    • One paired organ ➔ controversial

      • No sports if diseased single organ

      • single eye ➔ only w/ protective eyewear

        • swimming, T&F, gymnastics

        • no boxing, wrestling, martial arts

      • single testicle ➔ protective cup


Collapsed athlete

COLLAPSED ATHLETE

  • PRIMARY SURVEY

    • ABCDE

    • Sudden Cardiac Death

    • Arrythmias

    • Environmental Injury

  • SECONDARY SURVEY

    • Head / neck Injury

    • Electrolyte Imbalance

    • Anaphylactic reaction


Primary survey

PRIMARY SURVEY

  • AIRWAY

    • Laryngeal fracture / edema

    • Foreign body

    • Oral trauma

  • BREATHING

    • Pneumo / hemothorax

    • Flail chest

    • Excercised induced asthma

    • Acute asthma exacerbation


Primary survey1

PRIMARY SURVEY

  • CIRCULATION

    • Pulselessness:

      • VF until proven otherwise

    • Hypoxia

    • Shock (hypovolemic)

  • DEFIBRILLATE / DISABILITY

    • Dysrythmia

    • Head Injury (GCS, AVPU)

    • C-spine / Neck Injury - Neuro exam


Primary survey2

PRIMARY SURVEY

  • EXPOSURE / ENVIRONMENT

    • Undress to expose all injuries

    • Remove from environment

      • Hyperthermia

      • Hypothermia

      • Lightning

  • Primary survey takes place on the field or immediate sideline - no time for training rm

  • Game is interrupted; Offical clock stopped


Collapsed athlete1

COLLAPSED ATHLETE

  • CARDIAC CAUSES

    • Congenital cardiac anomalies

      • Hypertrophic cardiomyopathy

      • coronary artery anomalies

        • left main off right sinus

    • Myocarditis

    • Aortic rupture / dissection

    • Idiopathic left ventricular hypertrophy


Collapsed athlete2

COLLAPSED ATHLETE

  • CARDIAC CAUSES (Cont’d)

    • Lethal arrythmias

      • arrythmogenic RV dysplasia

    • Aortic stenosis

    • Premature coronary artery disease

      • Ischemia

      • Myocardial Infaction

    • Commotio cordis

    • Recreational drug use


Collapsed athlete3

COLLAPSED ATHLETE

  • METABOLIC EMERGENCIES

    • Symptomatic hyponatremia

    • Hypoglycemia

  • NEUROLOGIC CONDITIONS

    • CVA - stroke

    • Subarachnoid bleeding

    • Seizure


Sudden cardiac death

SUDDEN CARDIAC DEATH

  • Sudden cessation of cardiac activity

    • Victim becomes unresponsive

    • Abnormal / absent breathing

    • No signs of circulation

  • Victim must receive immediate

    CPR or they will die

  • Relatively uncommon

    • death rate in male athletes < 35 yrs of age

      • 0.75 per 100,000 participants per yr

    • H.S. cardiac arrest rate = 25-50 per yr


Chief orthopaedic sports medicine service scott white university medical campus round rock tx

AED

Automatic External Defibrillator

  • Ventricular Fibrillation (V Fib)

  • ➔ Immediate CPR and defibrillation

    • Adhesive pads easy to attach

    • Anaylzes the rhythm

    • Determines if shock is needed

    • Charges to the appropriate

    • dose - voltage

    • Gives command to deliver

    • the shock


Chief orthopaedic sports medicine service scott white university medical campus round rock tx

AED

Automatic External Defibrillator

  • Designed for use by anyone - lay people

  • Can be used on anyone > 1 yr old

  • Cost $1500 - $2500

  • Most schools and public facilities are now

    equipped with AED’s

  • Victim’s survival chances drop by 10% for

    every minute that passes

  • AED’s have been shown to increase

    survival chances in SDA from 5 - 75%


Commotio cordis

COMMOTIO CORDIS

  • Sudden disturbance of heart rhythm

  • Latin term for “commotion of the heart”

  • Refers to a functional effect of mechanical stimulation in the absence of structural damage - as opposed to mycardial contusion

  • Occurs as the result of a blunt,

  • non-penetrating impact to the

  • precordial region➔ impact of

  • ball, bat, or other projectile

  • Usually in boys or young men

  • George Boiardi, died 2004


Commotio cordis1

COMMOTIO CORDIS

  • USA National Commotio Cordis Registry

    • 188 cases ‘96-’07, 1/2 during organized sports

    • 96% in males, mean age 14.7, < 1 in 5 survived

  • Timing of impact in relation to cardiac cycle

    • ascending phase of T-wave; repolariziation

      • 10-30 millisec portion

      • asystole to diastole

  • Causes an arrythmia

    • ectopic beat

    • ventricular tachycardia

    • ventricular fibrillation


Commotio cordis2

COMMOTIO CORDIS

TREATMENT

  • Unfortunately, death is the most

  • common outcome → CPR and

  • AED must be initiated immediately

    • AED use w/ in 2 min ↑ survival rate 98%

    • delayed > 6 min ↓ survival rate to < 25%

  • Leading cause of fatalities in youth baseball

    • 2-3 deaths per year in the U.S.

  • AED’s recommended at all schools - on field


Environmental injuries

ENVIRONMENTAL INJURIES

HYPERTHERMIA

  • 3rd most common cause of death in athletes

  • If temperature > 108º F (42º C)

  • ➔ mortality rate approaches 80%

  • Worse outcome with

  • delayed treatment

  • Spectrum of disease

    • heat cramps ➔ heat syncope

    • heat exhaustion ➔ heat stroke

    • ➔ death


Hyperthermia

HYPERTHERMIA

HEAT CRAMPS

  • Can occur at any temperature

  • Loss of electrolytes, mainly salt

    HEAT SYNCOPE

  • Core temp is normal or mildly elevated

  • Dehydration ➔ can lead to abrupt LOC

  • Occurs near end of exercise due to reduced

    cardiac return and postural hypotension

  • Often happens at the beginning of the summer

    season before the body acclimates


Hyperthermia1

HYPERTHERMIA

HEAT EXHAUSTION

  • Unable to continue exercise in heat since the

    CV system fails to respond to ↑ workload

  • Core temp 100.4º - 104º F (38º - 40º C)

  • Sx: muscle cramps, mild confusion, HA,

    dizziness, nausea, often collapse

  • Treatment

    • As long as VSS, cool by removing

    • excess clothing and rest in shady place

    • Ice pack wrapped in towel → to neck, axilla, or groin


Heat stroke

HEAT STROKE

  • Thermoregulatory failure with central nervous system (CNS) dysfunction

  • Usually core temp >104º F (40º C)

  • Absence of sweating can be present

  • Results is rhabdomyolysis,

  • renal failure, DIC, liver

  • failure and brain injury

  • Sx: tachycardia,

  • tachypneia, hypotension


Heat stroke1

HEAT STROKE

TREATMENT

  • Immerse in tub of ice water as soon as

    possible ➔ about 5-10 min, until core (rectal)

    temp < 100.4º F (38º C) or pt starts to shiver

  • Or spray with cool water and place near fan,

    include ice packs to neck, axilla, and groin

  • Hydrate with IVF and oral sports drinks

  • Avoid antipyretic agents for heat injuries

  • Benzodiazepines reserved for athletes who

    have severe shivering or are having seizures


Hypothermia

HYPOTHERMIA

Core temp ≤ 97º F (36.1º C)

  • CNS normal

  • Pt walks with or without assistance

    Core temp ≤ 95º F (35º C)

  • CNS normal

  • Unable to walk or several muscle spasm

    Core temp ≤ 90º F (32.2º C)

  • CNS changes ➔ profound hypothermia

  • Mild confusion and intense shivering


Hypothermia1

HYPOTHERMIA

TREATMENT

  • Move indoors or to protected environment

  • Removing wet clothing

  • Passive warming with blankets, oral liquids

    Core temp ≤ 80º F (30º C)

  • Critical hypothermia

  • Handle gently or can go into V Fib

  • May not respond to defibrillation


Environmental injuries1

ENVIRONMENTAL INJURIES

TRANSFER TO HOSPITAL

  • Unstable vital signs

  • Core (rectal) temp < 90º F or > 104º F

  • Hyper- or hypothermia persisting > 30 min

  • Prolonged unconsciousness

  • Development of chest pain or arrythmias


Electrolyte imbalances

ELECTROLYTE IMBALANCES

HYPONATREMIA

  • Endurance athletes at greater risk

  • 2003 Boston marathon, up to 13%

  • of runners experienced Sx hyponatremia

  • As athletes ingest excessive water ➔ serum

    sodium levels fall ➔ confusion, nausea,

    vomiting, ataxia, coma and potentially death

  • Consider IV access if signs of dehydration:

    sunken eyes, parched lips, poor skin turgor

  • Hemodynamic instability, arrythmia ➔ IV !!!


Rehydration iv fluid

REHYDRATION IV FLUID

CONTROVERSIAL !!!

  • ACSM - no official recommendation

  • Most commonly used: 5% dextrose in either

    0.45% or 0.9% normal saline

    • Ironman Triathlon World Championship, HI

    • Marine Corps Marathon, DC

  • If athlete requires more than 2 L of IV fluid

    without clinical improvement and/or

    hemodynamic stabilization, transfer

    to medical facility


Hypoglycemia

HYPOGLYCEMIA

  • Relatively uncommon

  • Sx: body tremors, weakness, anxiety, sweating, slurred speech ➔ eventually coma

  • Treatment

    • administration of glucose

    • sports drinks, juice, candy,

    • or glucose tablets

    • unconscious / unresponsive

      • D50 IV or glucagon (IM)

      • Send to ER if no

      • improvement after 15-30 min


Head injury

HEAD INJURY

DIFFUSE

  • Concussion

  • Second Impact Syndrome

    FOCAL

  • Intracranial hemorrhage

    • Subdural hematoma (SDH)

    • Epidural hematoma

    • Subarachnoid hemorrhage (SAH)

  • Leading cause of death from athletic head injury


Concussion

CONCUSSION

MILD BRAIN INJURY

MILD TRAUMATIC BRAIN INJURY (MTBI)

MINOR HEAD INJURY (MHI)

  • Most common head injury in sports

  • Trauma induced alteration in mental status

  • Transient loss in

  • brain function

  • Incidence as high as

  • 6 in 1000 people / yr

  • 300,000 athletes / yr


Concussion1

CONCUSSION

  • ETIOLOGY

    • Blow to the head

    • Acceleration forces

    • without direct impact

  • MECHANISM

    • CSF not able to absorb forces associated with rapid acceleration

    • Angular and rotational forces affect midbrain disrupting nl cellular activity

    • impaired neurotransmission, deploarization

    • reduced cerebral blood flow → LOC


Concussion sx

CONCUSSION - SX

  • PROBLEMS IN BRAIN FUNCTION

  • confused state, dazed look, vacant stare

  • memory loss (score, period, day)

  • HA, nausea, vomiting, blurred vision

  • SPEED OF BRAIN FUNCTION

  • slow response, reaction time, slurred speech

  • UNUSUALY BEHAVIOR

  • combative, aggressive, silly, restless, irritable

  • BALANCE & COORDINATION PROBLEMS

  • dizzy, clumsy, “drunk”, can’t walk straight


Second impact syndrome

SECOND-IMPACT SYNDROME

  • An athlete sustains a head injury and then sustains a second head injury before the symptoms assoc w/ the first have cleared

  • Second blow can be remarkably minor

  • Within 2-5 minutes, athlete can die

    • → collapse, dilating pupils, ↓ eye mvt, respiratory failure

    • loss of autoregulation

    • → vascular engorgement, ↑ ICP, ➔ brian herniation


Second impact syndrome1

SECOND-IMPACT SYNDROME

  • Mortality rate approaches 50%

    • kills 4 - 6 people < age 18 / yr

  • Morbidity rate near 100%

  • 35 cases reported b/w 1980 - 1992

  • 17 cases reported b/w 1992 - 1995 (CDC)

    • majority involved adolescent athletes or young adults (age 16 - 24)

  • Sports at most risk:

    • football, boxing, soccer, rugby, baseball


Concussion grading

CONCUSSION - GRADING

  • GRADE I - MILD

  • No LOC

  • post-traumatic amnesia (PTA) < 30 min

  • post-concussive sx (PCSS) < 24 hrs

  • GRADE II - MODERATE

  • LOC < 1 min

  • PTA ≥ 30 min, but < 24 hrs

  • or PCSS ≥ 24 hrs, but < 7days

  • GRADE III - SEVERE

  • LOC ≥ 1 min or PTA ≥ 24 hrs

  • or PCSS > 7 days

  • Cantu grading system


Concussion evaluation

CONCUSSION - EVALUATION

  • BLS; ? LOC occurred

  • Careful observation by MD, ATC

  • Question teammates, coaches

  • Neuro, mini-mental exam (MME)

    • CN’s, coordination, motor fcn

    • short- and long-term memory

      • 3-word memory (baseline exam)

      • coach asks specifics of plays

  • Sideline exertional testing before RTP

  • If no RTP, stick to decision

    • keep athlete’s essential equip: helmet, shoe


Concussion mgmt

CONCUSSION - MGMT

  • GRADE I - MILD

  • #1 - may return to play (RTP) if ASx for 1 wk

  • #2 - may RTP in 2 wks if ASx for 1 wk

  • #3 - terminate season, but RTP following season if ASx

  • GRADE II - MODERATE

  • #1 - may RTP if ASx for 1 wk

  • #2 - 1 mo off sports, RTP if ASx but ? termination

  • #3 - terminate season, but RTP following season if ASx

  • GRADE III - SEVERE

  • #1 - 1 mo off sports, RTP if ASx but ? termination

  • #2 - terminate season, but RTP following season if ASx

  • #3 - no return to sports


C spine injury

C-SPINE INJURY

  • PPE - Identify those with h/o previous injury

  • Rules prohibiting “spearing” have eliminated the head as the initial contact point

    • significantly reduced incidence of injury

  • Note differences in helmets

  • and hardware needed to

  • remove the faceguard

  • Helmet and shoulder pads considered one unit

    • removing one takes airway out of neutral

    • if must remove for eval, put on collar


Stinger burner

STINGER / BURNER

  • Transient weakness of the shoulder musculature and paresthesias into the upper extremity

  • Named for the “stinging or burning” pain that spreads from the shoulder into the hand

  • Neuropraxia or axonotmesis of a cervical nerve root or element of the brachial plexus

  • Mechanism unclear

    • traction

    • compression

    • extension compression


Stinger burner1

STINGER / BURNER

  • Common injuries in contact sports

    • Football tackling or blocking

    • Fall onto head during wrestling takedown

  • Up to 70% of all college football players report having experienced a burner or stinger during their 4-yr careers

  • Recurrent injuries

    • 87% evid. of disc disease

    • 53% “developmentally”

    • narrow spinal canal

    • Levitz, Pelly, and Torg AJSM ‘97


Stinger classification

STINGER CLASSIFICATION

  • NEUROPRAXIA

  • Transient dysesthesias & weakness

    • Mild: resolution in seconds - minutes

    • Moderate: resolution minutes - hours

    • Severe: Unresolved at 12 hours

  • NEUROPRAXIA / AXONOTMESIS

  • Motor, +/- sensory deficit > 2 wks

  • full recovery in 12-18 months

  • NEUROTOMESIS

  • No clinical improvement in 12-18 mo


Stinger diagnosis

STINGER DIAGNOSIS

  • Establish Dx with accurate exam

  • Know brachial plexus anatomy

  • Differentiate from C-spine and nerve root injury

    • consider X-rays

    • MRI

    • bone scan

    • EMG’s


Stinger mgmt

STINGER MGMT

TREATMENT

  • Sling if necessary

  • ROM exercises

  • Elect muscle stim

    RTP ➔ COMPLETE RESOLUTION OF SX

  • Strength normal by manual muscle testing

  • Cybex isokinetic muscle testing

  • Go by exam ➔ little correlation b/w EMG and

    clinical exam (normal EMG not criteria to RTP)


Summary

SUMMARY

  • PPE: important screeing tool for athletic participation; don’t reveal all pre-existing conditions that may lead to sideline injury

  • Orthopaedic and CV conditions are the most common for sports disqualifcation

  • On-the-field injury mgmt begins with ABC’s

  • AED’s critical for collapsed athletes

  • Concussions & Stingers require full resolution of symptoms prior to return to play


References

REFERENCES

  • Head, Spine, and Plexus: Screening and Return to Play, John A Bergfeld, MD, AOSSM Annual Meeting 2008, IC 202.

  • The Preparticipation Athletic Evaluation, Kurt Kurowski, MD and Sangili CHandran, MD, AAFP Web Archive, May 1, 2000.

  • Killer Athlete Killers - SIdeline Management of the Collapsed Athlete, Neha P Raukar, MD, MS et al, AOSSM Annual Meeting 2008, IC 306.

  • UIL (University Interscholastic League) Extracurricular Activity Safety Training Program 2008-2009.


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