CLINICAL MANAGEMENT OF ACUTE ORTHOPEDIC

INJURIESKYLIE MILLER STARR, PT, DPT, ATC

LAFENE HEALTH CENTERKANSAS 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 RULESAnkle 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

• AND any of the following *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

Eiff, 1994

FOOT & ANKLE EXERCISES

• Early mobilization• Improved comfort• Earlier return to work• Active population

Visual Health information

FOOT & ANKLE EXERCISES

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

Cook, 2008

OTTAWA KNEE DECISION RULE• Criteria:

1. Age ≥ 55 years2. Tenderness at the head of the fibula3. Isolated tenderness of the patella4. Inability to flex the knee to at least 90 degrees5. 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; www.emra.org

PITTSBURGH KNEE DECISION RULE

• Criteria1. Pt hx of blunt trauma or fall2. Inability by pt to bear weight both immediately and in the ER for four

steps3. 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

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

visual health information

SHOULDER EXERCISES

BRACING

• Sling• Sling and swath

WORKS CITEDBachmann 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?