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Team Doc 101 Lutul D. Farrow, MD Cleveland Clinic Sports Health

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Presentation on theme: "Team Doc 101 Lutul D. Farrow, MD Cleveland Clinic Sports Health"— Presentation transcript:

1 Team Doc 101 Lutul D. Farrow, MD Cleveland Clinic Sports Health
Assistant Team Physician Baldwin-Wallace College

2 History 19th century Almost banned 1905 Rule/equipment changes
1st Physicians on sidelines Almost banned 1905 Serious injuries Deaths Rule/equipment changes Formation of NCAA Greatly reduced injuries

3 History Hundreds of thousands athletes Thousands of team docs
Adolescent High school Collegiate Professional Thousands of team docs

4 Definition Licensed MD/DO responsible for treating and coordinating the medical care of athletic team members

5 Principle Responsibility
Provide for the well-being of individual athletes

6

7 How to Get There Early desire Athletic Background 4 years college
4 years medical school Allopathic (MD) Osteopathic (DO)

8 How to Get There Medical Surgical Internal medicine Pediatrics
Family medicine Physical Medicine and Rehabilitation Surgical Orthopaedic Surgery Sports medicine Other subspecialties

9 Case Presentation

10 Case #1 D.B. 22 yo Varsity College FB player (DE)
Chief Complaint: Right ankle pain

11 Case #1 History “Coming off of a block and rolled my right ankle”
Inversion injury Felt a ‘pop’ in the ankle Able to walk off the field Not able to return to play

12 Differential Diagnosis
Most likely diagnosis? Ankle sprain Fracture/dislocation Muscle strain Dislocated tendon Torn tendon

13 ATC’s Role Alert coaching staff Initial athlete evaluation
“ATC gestalt” Triage Patch and go Versus Communicate with Doc

14 Team Doc’s Role OBSERVATION! Be a trained observer! Gait Swelling
Deformity On-field performance Compare to other side

15 Team Doc’s Role Communicate with ATC Help coordinate care
Timely athlete evaluation In gear Versus Gear off Sideline vs Locker room SAFELY get patient back into competition

16 Anatomy

17 Ankle Anatomy Bones Tibia Fibula Talus

18 Ankle Anatomy Ligaments “ORTHO PROOF” Named by bones

19 Ankle Anatomy

20 High Ankle Anatomy

21 Ankle Sprain Anatomy Type I Type II Type III Stretched Partially torn
Completely torn

22 Ankle Exam

23 Ankle Exam Observation Palpation Swelling Bruising Deformity Medial
Lateral Proximal

24 Ankle Exam Special tests Anterior drawer Talar tilt

25 Ankle Exam Special Tests Squeeze test External rotation test

26 Case #1 Exam on sideline Antalgic gait (visible limp) +Swelling
No deformity No ecchymosis (bruising) Significant TTP (pain to touch) No bony TTP Stable No “Syndesmosis pain” “NV intact”

27 Case #1 On field Similar exam in injury clinic next day
Ankle taped Standard tape job + ‘spats’ Unable to perform sport-specific drills Placed in walking boot/crutches Similar exam in injury clinic next day Sent for xrays on Post-injury day (PID) #2

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30 Case #1 Interval history PID #7 PID #7 – 21 Weaned out of boot
Attempt to ramp up activity No go Back into boot PID #7 – 21 Continued ankle rehab Step-wise improvement (objective/subjective)

31 Case #1 Returned to play 3 weeks after injury
Played in 2 Varsity Games Still mildly hobbled by injury Ankle not at 100% No interval injury MRI obtained at 5 ½ weeks post injury Continued pain

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35 Not a sprain MRI showed talus fracture Nondisplaced
Also showed ligament tears

36 Differential Diagnosis
Most likely diagnosis? Ankle sprain Fracture/dislocation Muscle strain Dislocated tendon Torn tendon

37 10/29/2007

38 9/13/2007

39

40 Capsular Distention – Original Films

41 Case #1 Treatment Foot & Ankle Specialist consulted
Non-operative management Cast x 3 weeks Aircast boot x 3 weeks Follow with serial imaging

42 Case #1 Healed fracture 10 months later 10 month xrays No pain
Full motion Spring practice

43 Discussion Talar neck fractures
Hi energy trauma Usually require surgery This is the first reported case in athletic competition

44 Submitted for Publication

45 Conclusions Take home message Keep the athlete first
Communication is key Keep an open mind Observe, observe, observe When in doubt, get more information

46 Questions?

47 Prospective plain film evaluation
Detection of radiographically occult ankle fractures following acute trauma: positive predictive value of an ankle effusion. Clark et al Am J Roentgen 1995 Prospective plain film evaluation 1,153 ankles w/acute trauma All with negative x-rays 33 patients with capsular distention on x-ray 11/33 with fracture on tomography Clark TW, Janzen DL, Ho K, Grunfeld A, Connell DG. Detection of radiographically occult ankle fractures following acute trauma: positive predictive value of an ankle effusion. Am J Roentgen ;164(5):

48 Vascular supply Inokuchi S, Ogawa K, Usami N: Classification of fractures of the talus: Clear differentiation between neck and body fractures. Foot Ankle Intl 17: , 1996.

49 Clark et al (cont) Cumulative measurement of anterior/posterior fat pads Predictive for fracture Composite measure > 13mm 82% sensitive 91% specific Retrospective analysis of our athlete 16mm composite measure Highly suggestive of occult fracture Clark TW, Janzen DL, Ho K, Grunfeld A, Connell DG. Detection of radiographically occult ankle fractures following acute trauma: positive predictive value of an ankle effusion. Am J Roentgen ;164(5):


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