Lower Extremity Injuries

On the Field Management of Lower Extremity InjuriesArmando F. Vidal, M.D.Surgical Director Sports Medicine Program for Young AthletesChildrens Hospital ColoradoTeam Physician, CU & DU

OverviewHip / Thigh InjuriesContusionsHip PointersHip DislocationHamstring StrainsKneePatella DislocationKnee DislocationLigamentous InjuriesMeniscal Injury

Lower LegTibia FractureFoot / AnkleSyndesmotic Injury / Masseneuve FractureSubtalar DislocationLisFranc InjuryFoot FracturesHip PointerPainful, Direct blow to Iliac CrestFootball HockeySoccerProtective Padding is key to preventionAcuteRest, Ice, Compression, minimization of hematomaAvoid Heat, Massage, NSAIDS and Physical Activity for first 48 hr

Hip Pointer often described as a subperositeal hematomaTypically these injuries are minor and can he handled with symptomatic treatment of short duration with return to athletics as symptoms allowHowever, Radiographs are often necessary to r/o fractureHeat, massage and vigorous physcial activity and PT should be avoided in first 48 hr to avoid more bleeding

4Hip PointerXR are importantEspecially in Young AthletesConsider Injections on Game DayReturn to play as symptoms allow

Thigh ContusionsMuscle Contusion Secondary to direct blunt traumaRisk of Myositis Ossificans (9-20%)TreatmentControl Deep BleedingRICE Knee FlexionAvoid Early - PT, Heat, Massage, NSAIDSReturn to PlayPain free ROM (0-120)Near Full return of strength@ 1-2 weeks

6Some studies have identified the following risk factors for the development of myositis ossificans: 1) limited knee range of motion, 2) previous quad contusion, 3) treatment for a quad contusion that was delayed more than 72 hours, 4) knee effusion (swollen knee), and 5) injury sustained by playing football

Hip DislocationRare InjuryFootballRugbySkiing / SnowboardingPosterior Much More Common than AnteriorHip Internally rotated, flexed and shortenedReductionKnee & Hip FlexedTraction in-line with femurGentle RotationCounter-traction on pelvisRARE TO DO ON FIELD!!!

Hamstring InjuriesCross Both Hip & Knee JointsVery Characteristic & Common InjurySprintersRBPain Posteriorly +/- PopExamTendernessDefectEcchymosis

Hamstring InjuriesCross Both Hip & Knee JointsVery Characteristic & Common InjurySprintersRBPain Posteriorly +/- PopExamTendernessDefectEcchymosis

Hamstring InjuriesHigh Grade Injuries (5 Phase Tx)RICEStretch/Isometrics/EstimIsotonics / +/- IsokinecticRunning / Sport SpecificsReturn to SportsInterventions? Corticoteroid Injection? PRP

Level of pain and functional improvement dictate progression through phases

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Not SubtleDeformity obvious if presentPlanted foot, PivotingKnee DislocatedDirect ContactMany reduce spontaneouslyReductionGentle Knee ExtensionNo return to game if 1st episodeConsider return in chronic dislocator if minimal symptoms & No effusionNeed Ortho EvaluationChondral fracturesLoose bodies

Patella DislocationKnee DislocationRelatively RareEMERGENCY!!!Urgent Reduction & Transfer to EDAssessmentAlign LegSplint / Stabilize

Ligamentous Knee InjuryACL

Non-contact pivoting injuryVery CommonPop + early effusion (70% have ACL)Unable to return to playRapid Onset of EffusionLateral Knee pain is Common

Ligamentous Knee Injuries: ACLACL InjuryRight Knee

ACL InjuryLeft Knee

Ligamentous Knee Injuries: ACLACL: Physical ExamLACHMANAnterior Drawer

ACL: Physical ExamPivot Shift

ACL InjuryNon-Contact > ContactFemale : 3-5x RiskNo return in same eventSports Medicine Evaluation6 month recovery from Reconstruction

Tibial / Ankle FracturesObvious DeformityInability to bear weightImmobilize / StabilizeAir SplintDo not attempt to remove shoe unless necessaryTransport to ED

Syndesmotic InjuryCommon in Collision SportsFootballHockeyLow GradeCrutches / Boot72 hr NWBGradual returnHigh GradeORIFDistance of Symptoms up fibula Duration of SymptomsMay lose many weeks of participation

Subtalar Dislocation

Rare in AthleticsBasketballInversion injuryTypical AppearanceDo not attempt to reduce on fieldSplint / ProtectED for XR and closed ReductionRTP usually in several weeks or months after symptoms resolvedUnknown recurrence rate

LisFranc InjuryMidfoot InjuryPop or SnapPain & Ecchymosis MidfootPlantar EcchymosisArch Collapse Ability to RTP is Variable for low grade injurySports Medicine EvaluationXR - Boot or ORIF

LisFranc InjuryMay take a long time to recoverCan be devastating injuryOften NWB for 8 10 wksLow grade injuryCast / BootSteel Shank / Carbon Fiber Insert

Foot Fractures5th Metatarsal FractureMost commonInversion InjuryCan be mistaken for lateral ankle sprainStress FracturesEndurance AthleteFemale TriadMany can be treated with shoewear modification / orthotics

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