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David L. Mann, MD, CCFP J. Preston Wiley, MD, CCFPD. Gregory Powell, MD, CCFP(EM), FRCP(C)

Sports Injuries in the Emergency Department:Controversies and Management GuidelinesSUMMARYSport-related injury is a common problemseen in the emergency department ofCanadian hospitals. The mechanism of injuryis essential information in making an accuratediagnosis. The motivation of the athlete is animportant factor in arranging appropriatefollow-up and counselling for return toactivity. This article addresses diagnostic andmanagement considerations for shoulderinjury, acute knee injury, concussion,compartment syndrome, and stress fracture.(Can Fam Physician 1988; 34:133-137.)

RESUMELes belssures sportives constitutent l'un des problemesfrequents rencontres dans les salles d'urgence des h6pitauxcanadiens. Pour en pr&ciser le diagnostic, il est essentiel des'informer du mecanisme de la blessure. La motivation del'athlIte est un facteur important pour determiner la relanceet les conseils favorisant la reprise des activites. Le presentarticle considere certains aspects diagnostiques ettherapeutiques des blessures a l'paule, au genou, traite descontusions, du syndrome du compartiment et des fracturesde stress.

Key words: sports injury, emergency department

Drs. Mann and Wiley are staffmembers in the Department ofFamily Medicine at the Universityof Calgary, Foothills Hospital, andthe McMahon and SaddledomeSport Medicine Clinics. Dr. Powellis an associate professor at theUniversity of Calgary, and Chief ofthe Division of Emergency Medicineat the Foothills Hospital. Requestsfor reprints to: Dr. D.G. Powell,Chief, Division of EmergencyMedicine, Foothills Hospital,1403-29th Street N.W., Calgary,Alta. T2N 2T9

ATHLETIC INJURY has alwaysbeen a major component of pa-

tient volume in the emergency depart-ment of Canadian hospitals. Whetherthey are the weekend warriors or eliteathletes, identification of sports parti-cipants is important for two reasons.First, the sports participant will pres-ent with a different spectrum of injurythan will the sedentary person, al-though they may share many commoninjuries. Secondly, their motivation tocontinue will sometimes blind them to

common sense, so that they often par-ticipate before an injury has healedsufficiently to make such activitymedically safe.

It is these two aspects of the emer-gency-department patient who is ac-tive in sport that may frustrate thephysician as well as the patient. There-fore, the physician must:* recognize the athlete's motivationand pattern of injury;* implement immediate manage-ment strategies;* provide guidelines for return to ac-tivity or appropriate referral for fol-low-up; and* recognize common pitfalls insport-injury management.This article will relate accomplishmentof these goals to five sport injuries.The topics to be discussed are stressfracture, compartment syndrome, theacute knee, concussion, and theshoulder.

Stress FractureRepetitive trauma, as occurs in run-

ning or Jumping, may produce an

overuse injury. We shall deal with twosuch injuries; the compartment syn-drome and the stress fracture.

Stress or fatigue fracture has beenreported in most bones of the body. 1, 2Initially, the patient will complain ofaching at the end of and after activity.This discomfort will progress withcontinued activity to night and morn-ing aching. If activity is further contin-ued, pain will become more intenseand will occur earlier in the activity.Eventually the pain may cause cessa-tion of the activity. If this call to stopis ignored, the stress fracture will pro-gress to a more clearly defined frac-ture.

Examination of the involved bonemay reveal swelling. Tenderness topalpation is usually present if the frac-ture is superficial: femoral neck stressfractures, for example, are impossibleto palpate. If the bone is in the lowerextremity, patients will usually have apositive "hop test", that is, he or sheis usually unwilling to hop on one legon the involved side, or if they do hop,the pain will be reproduced.2 Less than

CAN. FAM. PHYSICIAN Vol. 34: JANUARY 1988

0

133

40% of the time X-rays are helpful indiagnosing stress fractures, and there-fore a high index of suspicion is im-portant. Bone scans are often neededto confirm these fractures.3Common sites of stress fractures in

runners include the metatarsals, thetibia, and the fibula. Stress fractures ofthe femoral neck, pelvis, and tarsalbones are less common.2 The impor-tance of their recognition is that con-

tinued activity or minor trauma maycause complete fracture and its asso-

ciated complications. Frank femoralneck fracture in a young athlete is a ca-

tastrophe and has long-term complica-tions of osteoarthritis.4 Frank fractureof the tarsal navicular bone may re-

quire bone grafting and pinning, andprolonged immobilization.,Once a stress fracture is suspected,

the athlete should be told to avoidweight-bearing activity, although nor-

mal walking is acceptable. A patientwith a femoral neck stress fractureshould use crutches until the pain startsto subside. Casting is rarely required,except for pain relief; it may be indi-cated for tarsal navicular stress frac-tures. The physician with a high indexof suspicion can provide sound adviceabout participation and follow-up toavoid major problems.

Compartment SyndromeCompartment syndrome appears in

the emergency department in twoforms. Most physicians are aware ofthe acute compartment syndrome(ACS) that if left untreated, results inVolkmann's ischemic contracture.'iThese contractures are commonly seen

in crush or prolonged compression in-juries of the forearm, or in fractures ofthe tibia and fibula, commonly seen indownhill skiing injuries.

The physician may be less familiarwith chronic compartment syndrome(ccs). This is a relatively recentlyrecognized injury, described andtreated only in the last 21 years.7 Itoccurs only in people who participatein repetitive activity, such as runningor aerobics. Any muscle compartmentin the body may be affected, but thesyndrome is most commonly seen inthe four compartments of the leg. Thepathology is similar to that of acutecompartment syndrome in that ele-vated pressure in the compartmentcauses the symptoms.

Clinically, the patient will complainof crampy pain or tightness in the in-volved compartment during and justafter repetitive exercise. The sensationis characteristically brought on by thesame amount of activity each day, al-though a tough work-out one day willcause discomfort to occur earlier thefollowing day (the "second-day phe-nomenon"). Rest will invariably alle-viate the symptoms.8

Physical examination is usually nothelpful. By the time the patient gets tothe emergency department, he or shewill have rested long enough to causethe pressure in the compartment to de-crease and the discomfort to dissipate.Occasionally muscle hernias may beseen in the distal anterolateral aspectof the leg, but they are not diagnosticof ccs.9

Compartment syndrome is not alimb-threatening problem, and the ath-lete may be reassured that no immedi-ate action need be taken. The patientwho is referred to a sports medicinephysician (primary-care physician, or-thopedic surgeon, or vascular surgeon)will have exercising compartment-pressure measurements taken to docu-ment ccs. Once documented, a double

Table 1Comparison of Presentation and Treatmentof Acute and Chronic Compartment Syndrome

Acute Chronic

Significant injury Present NonePain Present Exercise onlyPhysical findings Present Usually noneCompartment pressure >30 mm Hg Elevated in exercise onlyTreatment Immediate open Elective fasciotomy

FasciotomyFailure of recognition Volkmann's Exercise pain

IschemicContracture

134

skin-incision technique fasciotomywill be performed if the patient sowishes."' The surgery gives excellentresults, and only minor complicationsare reported in the literature. The phy-sician presented with an athlete com-plaining ot pain must be alert to thispossibility and generate proper follow-up. A comparison of presentation andmanagement of ACS and CCS is pre-sented in Table 1.

Acute Knee InjuriesOne of the most common problems

associated with sports injuries thatfaces the physician is the assessmentof the acute knee. Patients with thistype of injury usually present withpain, swelling, instability and/or lock-ing. It is imperative that the physicianrule out significant internal derange-ment. The major pitfall discussed hereis missed anterior cruciate ligament(ACL) injuries.The history of the injury will usually

include varus or valgus stress with theapplication of some form of rotationalforce. Often the athlete has heard orfelt a "pop" from within the knee.The hallmark of significant internalderangement is early swelling (in lessthan 3-4 hours), which is indicativeof an acute hemarthorsis. This symp-tom carries a 90% probability of sig-nificant internal derangement and 72%of patients will have an ACL injury. 'The player often complains of extremepain and distrust of knee stability.On examination, the physician

usually finds marked and sometimestense swelling. This condition oftenrestricts range of motion, which mayalso be reduced because of internalblockage. Palpation may show mild tomoderate joint-line tenderness. In theacute situation, joint-line tenderness isthe most reliable sign for meniscus in-juries. ' 2

Clinical examination is critical. Col-lateral stability is tested in both full ex-tension and 300 of flexion. Any insta-bility in extension is indicative ofmajor ligament disruption. At 300 offlexion, the degree of collateral insta-bility can be graded mild (Grade I),moderate (Grade II), or severe (GradeIII). Grade III disruption, as indicatedby finding no end-point, is associatedwith a high probability of further dam-age. The anterior cruciate ligament istested primarily by the Lachman test,the most reliable ACL test.'3 The An-terior Drawer test is quite unreliable:

CAN. FAM. PHYSICIAN Vol. 34: JANUARY 1988

even under anesthesia it is only 50%accurate.'4 In skilled hands, the pivotshift manoeuvre is highly specific, butit is technically difficult in the patientwith a painful knee.

Posterior cruciate injuries are as-sessed by a posterior lag of the tibia in900 of flexion. Posterior cruciatedisruption also produces a false-posi-tive Lachman test.The differential diagnosis for major

acute internal derangement of the kneemust take into account cruciate injury,collateral ligament injury, meniscustears, osteochondral injuries, and pa-tellar subluxations or dislocations. Thephysician must always look for epi-physeal injuries among skeletally im-mature athletes. A femoral epiphysisinjury will cause an acute he-marthrosis.

Complete radiographic investigationis mandatory. The examining physi-cian must observe the X-rays closelyfor chip fractures of the femoral troch-lea and patella, and avulsion fracturesat the tibial ACL insertion and collateralligament insertions. Stress radiographsshould be considered if epiphyseal in-juries are suspected.

Arthrocentesis is useful to identifyan acute hemarthrosis and to assess thepossibility of osteochondial injury,(which is indicated by the presence offat globules in the withdrawn blood).Absolute sterile technique must be ob-served. Removal of the fluid may alsomake the knee more amenable to clini-cal examination.

Arthroscopy has become an ex-tremely valuable technique in sportsmedicine for the diagnosis and man-agement of knee injuries. The high in-cidence of major disruption associatedwith hemarthrosis, coupled with thelimited reliability of some of the exam-inations in the acute situation (espe-cially in meniscus injuries), makearthroscopy an attractive choice. Theperi-operative risks must, of course,be considered. If a major internal de-rangement is suspected in a seriousathlete, arthroscopy should beseriously considered. Open arthrotomyis of limited use in these situations, asthe entire joint cannot be observed,and lesions-too often a torn ACL-aremissed.Management of the injury depends

on accurate diagnosis. Major internalknee derangements should be referredfor orthopedic consultation concerningacute reconstruction, where indicated.

The most commonly missed injuryis the acute anterior cruciate ligamentdisruption. The natural history of anACL-deficient knee is one of significantinstability and progressive degenera-tive arthritis.15 If an acute injury ofthis type cannot be ruled out, appro-priate follow-up must be ensured.

Cerebral ConcussionsCerebral concussions account for

over 70% of all head and neck injuriessustained in contact sports.1' The an-nual rate of concussive events amonghigh school football players approxi-mates 20% .17 The management ofconcussions is currently quite contro-versial, especially with respect to cri-teria for return to play. 17, 18A concussion implies an impairment

of consciousness (IOc) that requiresderangement in arousal and/or cogni-tion. Arousal is easily assessed and iscommonly described as the patient'slevel of consciousness (LOC). Moresubtle abnormalities resulting from in-jury are impaired cerebral cognition,which is measured by performance ofhigher functions such as memory, con-centration, calculation, informationassimilation, and more general symp-toms such as irritability, sensorychanges, and headaches (Table 2). Ac-tual loss of consciousness is not re-quired to support the diagnosis of cere-bral concussion, as LOC is frequentlyabsent.

Table 2Signs and Symptoms ofConcussion

AmnesiaRetrograde amnesia (RGA)-amnesia

prior to time of impactPost-traumatic amnesia(PTA)-amnesia from time of impact

Impairment of consciousness (IOC)Impaired memoryPoor concentrationImpaired information assimilationIrritabilityGait unsteadinessNauseaChanged vision or hearingPost-concussive symptoms (PCS)Headache Mental fatiguabilityDizziness Poor concentrationUnsteadiness Changed vision or

hearingIrritability Any IOC or PCS

aggravated byexertion

Insomnia

CAN. FAM. PHYSICIAN Vol. 34: JANUARY 1988

Subtle impairment of cognitivefunctions resulting from a concussiveevent are potentially dangerous to theathlete. Contact sports requiresplit-second reactions, not only to exe-cute the proper play, but also to avoidbeing "caught with your head down".The consequence of the latter is anopen invitation to further injury thatmay be limb- or even life-threatening.Every year, approximately one dozenfootball players either die or sufferpermanent spinal cord damage in theirsport.19 The contact-sport player, inparticular, must not be allowed backinto play until full recovery has oc-curred.The concussion, a transient and re-

versible disruption of neurologicalfunction, usually occurs when the ath-lete sustains a blow to or about thehead. This type of injury can also re-sult from a situation likely to causewhiplash. There is often relatively im-mediate headache, light-headedness,unsteadiness, sensory changes, andnausea. In such an instance the diag-nosis is straightforward, and only theseverity of the injury needs to be deter-mined. If the symptoms do not occur,the diagnosis may be missed. Not in-frequently, the player will suffer onlya slight dazed sensation accompaniedby either retrograde and/or post-traumatic amnesia. He or she may stillbe able to function at a sub-optimallevel, choosing to ignore the injury.For the reasons mentioned above, thisis a potentially dangerous situation.

Having ruled out other significantmusculoskeletal injury to the head andspinal cord, the physician should ad-dress the possibility of concussion.Any evidence of actual loss of con-sciousness for more than a few sec-onds requires appropriate neurologicalassessment and/or referral as indi-cated. Grading the concussion requiresexperience, but the presence of signifi-cant LOC is helpful (Table 3). Differen-tiation between mild and moderate in-juries is based on the degree ofcognitive impairment and the severityof the somatic symptoms. The physi-cian should keep in mind that cogni-tive impairment is just as significant asare other symptoms and should pre-clude further play.

Most concussions involve impair-ment of consciousness and the reduc-tion of the more subtle functions, asmentioned above. The physician mustcomplete a careful and detailed mental

135

status examination, addressing theareas of memory, concentration, cal-culation, information assimilation, andmental fatiguability. Any somaticsymptom such as headache, dizziness,unsteadiness, or nausea, is considereda positive finding.Many post-concussive symptoms

may be aggravated by strenuous exer-cise. This is a good indicator ofwhether the athlete is ready to return toactivity. Re-examination should be ab-solutely negative, and no symptomsshould recur following vigorous activ-ity. The athlete who meets these cri-teria is allowed to return to contactsports following the prescribed periodof rest, but should be referred to theappropriate specialist if he or she sus-tains any subsequent concussions. Sig-nificant warning signs and symptomsinclude profound cognitive dysfunc-tion, any focal neurological signs, sei-zure activity, worsening of symptoms,or lack of improvement. Any of theseconditions requires urgent neurologi-cal and/or neurosurgical assessment.Table 3 summarizes our managementof first-time cerebral concussions inathletes.

Shoulder InjuriesDislocations

Shoulder dislocations are a commonresult of athletic activity. The usual di-rection of dislocation is anterior, andthe displacement is easily diagnosedby a combination of physical signs andX-ray. Occasionally, it is tempting toreduce, or attempt to reduce, these in-juries without the benefit of X-ray. Atthe time of the injury, particularly ifthe problem is recurrent on the ski hillor playing field, it may be appropriateto restore gently the integrity of theglenohumeral joint. However, when

the patient presents to emergency oneor two hours later, there is usually sig-nificant muscle spasm, and an X-rayshould be done both pre- and post-reduction."' This routine should befollowed in order to identify subtlefractures, to support medical/legalconsiderations if there are complica-tions, and to make appropriate deci-sions about time off required to protectprofessional athletes. If the directionof dislocation is anterior and inferior,there may be considerably more dam-age and considerably more difficultyin reducing the injury.Once the shoulder is reduced, the

period of convalescence can be di-vided into two parts. There should be aperiod of immobilization that is rea-sonably absolute, lasting about 21days.'21 Three additional weeks of lessrigorous immobilization in a sling,while the athlete is commencing exer-cises, are appropriate. It is definitelynecessary to keep the athlete off theplaying surface for eight weeks.Strength measurements, when avail-able, which compare the injured to thenon-injured shoulder are a useful guidefor permitting recommencement ofcontact sports.

Posterior dislocations

An athlete may present with a greatdeal of swelling that makes the physi-cal signs of dislocation difficult to dis-cern. In this circumstance, it is veryimportant for the physician to obtainan axillary lateral X-ray to documentthe direction of the dislocation. Poste-rior glenohumeral dislocations areoften missed, for instance, because ofdifficulty in assessing the shoulder.Limitation of external rotation and ab-duction should alert the physician toposterior dislocations. Posterior dislo-

cations may also be seen in muscle-contraction problems, such as seizuresand electrical shock. They should becarefully searched for in all cases ofmajor shoulder trauma.

A-C joint separationAn A-C joint separation is a clini-

cal, rather than a radiological, diag-nosis. There is no need to send the pa-tient to have an X-ray with weights inorder to document the injury, and ingeneral these injuries do not need to befixed. Cosmesis will be a reason to fixcertain injuries, but unless the proxi-mal clavicle is button-holed throughthe deltoid or soft tissue structures,surgical repair is usually unnecessary.A period of rest with early mobiliza-tion is standard therapy, and in fact, itis controversial whether third degreeA-C joint injuries in an athlete shouldbe fixed. There is some evidence tosuggest there is greater dysfunction, interms of useful joint function, whenthese injuries are pinned than whenthey are not.22 Referral to an orthope-dist is appropriate in cases of majordisruption. An arm sling or shoulderimmobilizer, analgesia, and physio-therapy are standard therapies in theless serious instances.

ConclusionsThis discussion of sport-related in-

jury is intended to inform the physi-cian in the emergency departmentabout some of the current controver-sies and management techniques.Sports medicine is a rapidly expandingfield, and the physician must be awareof its many pitfalls and controversies.It is important for management guide-lines to be concrete and commonly un-derstood by athletes and physicians.*

Table 3Management and Criteria for Return to Playfollowing First-Time Cerebral ConcussionGrade Signs/Symptoms Management Return to PlayMild lOC <30 min. may >30 min. outfor

return same day 5- 7 daysModerate IOC Out of game Out for 7 daysSevere LOC > few seconds Out of game Asymptomatic

Severe IOC Emergency-room for 7-10 daysSevere somatic assessmentcomplaints

Note: Recurrent cerebral concussions should be assessed by theappropriate specialist to determine appropriate time for return to play.

References1. Devas MB. Stress fractures. Edinburgh:Churchill Livingstone, 1975.2. Matheson GO, Clement DB, McKenzieDC, et al. Stress fractures in athletes: astudy of 320 cases. Am J Sports Med 1987;15(l):46-58.3. Rupani HD, Holder LE, Espinola DA,et al. Three-phase radionuclide bone imag-ing in sports medicine. Radiol 1985;156:187-96.4. D'Ambrosia R, Drez Jr. D. Preventionand treatment of running injuries. Thoro-fare, N.J.: Charles B. Slack Inc., 1982.5. Torg JS, Pavlor V, Cooley LH, et al.Stress fractures of the tarsal navicular. JBone Joint Surg 1982; 64A:700- 12.

136 CAN. FAM. PHYSICIAN Vol. 34: JANUARY 1988

6. Mubarak SJ, Hargens AR. Compart--ment syndrome and Volkmann's contrac-ture. Philadelphia: W.B. Saunders Co.,1981.7. Mavor GE. The anterior tibial syn-drome. J Bone Joint Sutrg 1956;38B:513-7.8. Wiley JP, Clement DB, Doyle DL, et al.A primary care perspective of chronic com-partment syndrome of the leg. PhysSportsmed 1987; 15(3):110-20.9. Detmer DE, Sharpe K, Sufit RL, et al.Chronic compartment syndrome: diag-nosis, management and outcomes. Am JSports Med 1985; 13:162-70.10. Rorabeck CH, Bourne RB, Fowler PJ.Surgical treatment of exertional compart-ment syndrome in athletes. J Bone JointSiurg 1985; 65A:1245-51.11. deHaven KE. Diagnosis of acute kneeinjuries with hemarthrosis. Am J SportsMed 1980; 8(1):9- 14.12. Zarins B, Nemeth VA. Acute knee in-juries in athletes. Clin Sports Med 1983;2(1):149-66.13. Fowler PJ. Classification and earlydiagnosis of knee joint instability. ClinOrthop 1980; 147:15-21.14. Larson RL. Combined instabilities ofthe knee. Clin Orthop 1980; 147:68- 72.

15. Fetto JF, Marshall JL. The natural his-tory and diagnosis of anterior cruciate liga-ment insufficiency. Clin Orthop 1980;147:29-38.

16. Buckley WE. Concussion injury in col-lege football: an eight-year overview. Ath-/etic Training 1986; 21(3):207-1 1.

17. Cantu RC. Guidelines for return tocontact sports after a cerebral concussion.Phys Sportsmed 1986; 14(10):75-83.18. Torg JS. Athletic iniuries to the head,neck and face. Philadelphia: Lea and Fe-biger, 1982.19. Mueller FO, Blyth CS. An update onfootball deaths and catastrophic injuries.Phys Sportsmed 1986; 14(10): 139-42.20. Cofield RH, Simonet WT. Theshoulder in sports. Mayo Clin Proc 1984;59(Symposium on sports medicine, partII): 157-64.21. Grana WA, Holder S, Schelberg-Karnes E. How I manage acute anteriorshoulder dislocations. Phys Sportsmed1987; 15(4):88-93.22. Neer CS, Welsh RP. The shoulder insports. Orth Clin N Am 1977;8(3):583- 91.

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CAN. FAM. PHYSICIAN Vol. 34: JANUARY 1988