Clinical Management of acute orthopedic injuries Kylie Miller Starr, PT, DPT, ATC Lafene Health Center Kansas State University

objectives Participants will understand and be able to correctly utilize clinical prediction rules to determine necessity of radiographs in acute knee and ankle injuries. Participants will have a basic understanding of appropriate exercises for foot/ankle, knee, and shoulder in order to facilitate earlier mobilization following injury. Participants will be comfortable selecting and applying appropriate braces for foot/ankle, knee, and shoulder injuries.

ICE or SURGERY??

Common Foot & Ankle Injuries Ankle sprains Ankle fractures Midfoot sprains 5th metatarsal fractures

FOOT & ankle injuries Estimates: 80-98% of ankle or foot injuries in the ER undergo x-rays. <15% have fractures Resources Time Healthcare costs Jenkins, 2010

Ottawa ankle rules Ankle x-ray if: Pain in anterior aspect of medial/lateral malleolus or talar dome AND any of the following *Bony tenderness over posterior aspect of medial malleolus *Bony tenderness over lateral malleolus *Inability to bear weight immediately following injury or in ER Foot x-ray if: Pain in the dorsal medial or lateral aspect of the midfoot *Bony tenderness at base of the 5th *Bony tenderness over the navicular *Inability to bear weight immediately after injury or in the ER Cook, 2008

Foot & ankle exercises Early mobilization Improved comfort Earlier return to work Active population Eiff, 1994

Foot & Ankle exercises Visual Health information

Bracing & crutches When do you use crutches? How long? Application of ankle brace, Aircast, compression wrap, Cam walker Stability Compression Function

Common KNEE Injuries ACL sprain/tear MCL sprain/tear Meniscus tear Patellar dislocation weblogs.baltimoresun.com

Ottawa Knee Decision Rule Criteria: Age ≥ 55 years Tenderness at the head of the fibula Isolated tenderness of the patella Inability to flex the knee to at least 90 degrees Inability by the patient to bear weight both immediately and in the ER for four steps Positive test: any of the five criteria ORDER X-RAYS Cook, 2008

Pittsburgh Knee Decision Rule Criteria Pt hx of blunt trauma or fall Inability by pt to bear weight both immediately and in the ER for four steps Age <12 or >50 years Positive test: blunt trauma/fall and either item 2 or 3 ORDER X-RAYS Cook, 2008; www.emra.org

Ottawa Knee Decision Rule or Pittsburgh Knee Decision Rule So... Which one do we use? Sensitivity: 85-100 vs 99-100 Specificity: 27-50 vs 60-79 LR+: 1.7-1.9 vs 2.5 LR-: .11-.30 vs .02 Our primary population Cook, 2008; www.emra.org

Knee exercises Early mobilization Improved ROM Decreased effusion Less quadriceps atrophy

KNEE exercises visual health information

Bracing & crutches Crutches Braces Immobilization vs stabilization vs compression

Common SHOULDER Injuries AC jt sprain/separation Clavicle fractures Shoulder dislocation Subluxation Rotator cuff strain Labral tear

Shoulder exercises Early mobilization Decreased pain/stiffness Improved ROM ADLs

Shoulder exercises visual health information

Bracing Sling Sling and swath

Works Cited Bachmann LM, Kolb E, Koller MT, Steurer J. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ. 2003; 326(7386): 417. Cook CE , Hegedus EJ. Orthopedic Physical Examination Tests: An Evidence-Based Approach. Upper Saddle River, New Jersey: Pearson Prentice Hall, 2008. Eiff MP, Smith AT, Smith GE. Early mobilization versus immobilization in the treatment of lateral ankle sprains. Am J Sports Med. 1994 Jan-Feb; 22(1):83-8. Jackson JL, O’Malley PG, Kroenke K. Evaluation of acute knee pain in primary care. Ann Intern Med. 2003;1 39:575-588. Jenkins M et al. Clinical usefulness of the Ottawa ankle rules for detecting fractures of the ankle and midfoot. JATA. 2010; 45(5): 480- 482. Pittsburgh Decision Rules and Ottawa Knee Rules. Emergency Medicine Residents Association. http://www.emra.org/students/advising/_to_sort/pittsburgh-decision-rules-and-ottawa-knee-rules Visual Health Information (VHI) PC-Kits. www.vhikits.com

QUESTIONS?