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Team Doc 101 Lutul D. Farrow, MD Cleveland Clinic Sports Health
Assistant Team Physician Baldwin-Wallace College
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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
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History Hundreds of thousands athletes Thousands of team docs
Adolescent High school Collegiate Professional Thousands of team docs
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Definition Licensed MD/DO responsible for treating and coordinating the medical care of athletic team members
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Principle Responsibility
Provide for the well-being of individual athletes
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How to Get There Early desire Athletic Background 4 years college
4 years medical school Allopathic (MD) Osteopathic (DO)
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How to Get There Medical Surgical Internal medicine Pediatrics
Family medicine Physical Medicine and Rehabilitation Surgical Orthopaedic Surgery Sports medicine Other subspecialties
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Case Presentation
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Case #1 D.B. 22 yo Varsity College FB player (DE)
Chief Complaint: Right ankle pain
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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
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Differential Diagnosis
Most likely diagnosis? Ankle sprain Fracture/dislocation Muscle strain Dislocated tendon Torn tendon
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ATC’s Role Alert coaching staff Initial athlete evaluation
“ATC gestalt” Triage Patch and go Versus Communicate with Doc
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Team Doc’s Role OBSERVATION! Be a trained observer! Gait Swelling
Deformity On-field performance Compare to other side
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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
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Anatomy
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Ankle Anatomy Bones Tibia Fibula Talus
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Ankle Anatomy Ligaments “ORTHO PROOF” Named by bones
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Ankle Anatomy
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High Ankle Anatomy
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Ankle Sprain Anatomy Type I Type II Type III Stretched Partially torn
Completely torn
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Ankle Exam
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Ankle Exam Observation Palpation Swelling Bruising Deformity Medial
Lateral Proximal
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Ankle Exam Special tests Anterior drawer Talar tilt
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Ankle Exam Special Tests Squeeze test External rotation test
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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”
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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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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)
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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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Not a sprain MRI showed talus fracture Nondisplaced
Also showed ligament tears
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Differential Diagnosis
Most likely diagnosis? Ankle sprain Fracture/dislocation Muscle strain Dislocated tendon Torn tendon
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10/29/2007
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9/13/2007
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Capsular Distention – Original Films
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Case #1 Treatment Foot & Ankle Specialist consulted
Non-operative management Cast x 3 weeks Aircast boot x 3 weeks Follow with serial imaging
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Case #1 Healed fracture 10 months later 10 month xrays No pain
Full motion Spring practice
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Discussion Talar neck fractures
Hi energy trauma Usually require surgery This is the first reported case in athletic competition
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Submitted for Publication
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Conclusions Take home message Keep the athlete first
Communication is key Keep an open mind Observe, observe, observe When in doubt, get more information
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Questions?
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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):
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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.
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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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