SplintER Series: One Big Bounce
Figure 1. AP and Lateral x-rays of the right knee. Case courtesy of Dr Andrew Dixon, Radiopaedia.org, rID: 16139
SplintER Series: To Immobilize or Not to Immobilize: That is the Question
A patient presents to the Emergency Department after sustaining a twisting knee injury while skiing. She felt a pop and was unable to bear weight afterward secondary to pain and a feeling of instability. Shortly after the injury, she noted increased swelling and pain. On examination, she has a moderate effusion and a positive Lachman test. An x-ray was obtained and is shown above (Image 1. Case courtesy of Mikael Häggström, M.D. – Author info – Reusing images, CC0, via Wikimedia Commons).
SplintER Series: Attack by Bat
30-year-old male presents to the ED with pain over the right shoulder after being assaulted by a bat. The right arm is held in adduction and has a limited range of motion due to pain. An x-ray of the right shoulder was obtained and is shown above (Figure 1. Case courtesy of Dr. Ian Bickle, Radiopaedia.org, rID: 74640).
SplintER Series: The Tooth of the Cervical Spine
80-year-old male patient brought in by ambulance for a witnessed fall. A cervical collar was placed by EMS because of midline neck pain. The patient is neurologically intact. A CT of the cervical spine was obtained and is shown above (Case courtesy of Dr. Talal F M Abdullah, Radiopaedia.org, rID: 58030).
SplintER Series: Open Fracture
A 65-year-old farmer presents to the ED after his ankle was run over by a piece of farm equipment in the field. His x-ray is shown above (Figure 1: Case courtesy of Dr. Oyedepo Victor Olufemi, radiopaedia.org) He also has an associated soft tissue injury overlying the area that is grossly contaminated with mud and manure. (more…)
SplintER Series: Diver’s Nightmare
A 27-year-old male presents with neck pain after diving headfirst into the shallow water of his pool. He has midline cervical spine tenderness and a normal neurological exam. CT of the cervical spine is shown below (Figure 1).
Figure 1. Case courtesy of Dr Andrew Dixon, Radiopaedia.org, rID: 9601
SplintER Series: What is Wrong With My Daughter?
A 16 year-old competitive gymnast presents to the emergency department with left ankle pain for several weeks and missed periods. The mother provides consent to treat the patient and informs you she is concerned that with the patient’s missed periods, she may be pregnant. You obtain x-rays of her ankle (Figure 1).
Figure 1. Case courtesy of Dr Hani Makky ALSALAM, Radiopaedia.org, rID: 8720
Stress fracture at the distal tibial metaphysis – note the faint sclerotic line at the tibial metaphysis (Figure 2).
Figure 2. Arrows identifying the stress fracture. Case courtesy of Dr. Hani Makky Al Salam, Radiopaedia.org, rID: 8720
When coupled with the amenorrhea, consider the female athlete triad.
- PEARL: The female athlete triad is a syndrome consisting of disordered eating, amenorrhea, and low bone mineral density (eg. osteoporosis) – Patients will have a degree of dysfunction from all 3 of the components. This is a fairly common disorder in young female athletes but the actual prevalence is hard to estimate because of the complexity of the three components [1]. Studies have shown a range from 0-16% when encompassing all three but can be as high as 4-18% when using two concurrent components and even 16-54% when only looking for one [2,3].
- PEARL: Stress fractures in competitive athletes is usually multifactorial – increased activity, poor nutrition, and possible hormone imbalance [4,5].
Plain film ankle views should be obtained. If a stress fracture is acute, sensitivity on plain films can be as low as 10% [6]. MRI can be performed outpatient with a sensitivity approaching 100% [4,5,7,8]. A pregnancy test should be performed as well given the amenorrhea. A standard workup for amenorrhea should be performed as an outpatient. Inquire about eating habits and anxiety/depression.
- PEARL: Athletes, regardless of competition level and gender, may be pushed into decreasing caloric intake for the sake of performance, appearance, or making weight. This can have serious physical and mental implications.
The three components of the female triad are on a spectrum of severity in the disruption of bone mineral density/osteoporosis, menstrual dysfunction/dysmenorrhea, and low energy with or without an eating disorder [1,9-11]. Patients will have a degree of dysfunction of all three components.
- PEARL: Risk factors for developing the female athlete triad are participation in sports that emphasize leanness or a specific weight, appearance, or are beneficial if less gravitational forces. These may include gymnastics, ice skating, wrestling, boxing, dance, and track [10,12].
Stress fracture treatment included rest and analgesics. Immobilization is not necessary, but refraining from activity which exacerbates pain is crucial. NSAIDs may be used for pain control [5,7]. Female athlete triad is multifactorial and outpatient follow up should be ensured. Referral to adolescent medicine, sports medicine, or close primary care follow up is important.
- PEARL: The patient will need education on good eating habits and nutrition, decrease in activity, and counseling [1,10,12]. The best way to treat the female athlete triad is to prevent it.
Check out ALiEM’s SplintER Series to brush up on other can’t miss diagnoses of ankle pain.
References
- Weiss Kelly AK, Hecht S; COUNCIL ON SPORTS MEDICINE AND FITNESS. The Female Athlete Triad. Pediatrics. 2016;138(2):e20160922. PMID: 27432852.
- Nichols JF, Rauh MJ, Lawson MJ, Ji M, Barkai HS. Prevalence of the female athlete triad syndrome among high school athletes. Arch Pediatr Adolesc Med. 2006;160(2):137-142. doi:10.1001/archpedi.160.2.137. PMID: 16461868.
- Hoch AZ, Pajewski NM, Moraski L, et al. Prevalence of the female athlete triad in high school athletes and sedentary students. Clin J Sport Med. 2009;19(5):421-428. doi:10.1097/JSM.0b013e3181b8c136. PMID: 19741317.
- Matcuk GR Jr, Mahanty SR, Skalski MR, Patel DB, White EA, Gottsegen CJ. Stress fractures: pathophysiology, clinical presentation, imaging features, and treatment options. Emerg Radiol. 2016;23(4):365-375. PMID: 27002328.
- Saunier J, Chapurlat R. Stress fracture in athletes. Joint Bone Spine. 2018;85(3):307-310. PMID: 28512006.
- Matheson GO, Clement DB, McKenzie DC, Taunton JE, Lloyd-Smith DR, MacIntyre JG. Stress fractures in athletes. A study of 320 cases. Am J Sports Med. 1987;15(1):46-58. doi:10.1177/036354658701500107. PMID: 3812860.
- Denay KL. Stress Fractures. Curr Sports Med Rep. 2017;16(1):7-8. PMID: 28067732.
- McInnis KC, Ramey LN. High-Risk Stress Fractures: Diagnosis and Management. PM R. 2016;8(3 Suppl):S113-S124. PMID: 26972260.
- Otis CL, Drinkwater B, Johnson M, Loucks A, Wilmore J. American College of Sports Medicine position stand. The Female Athlete Triad. Med Sci Sports Exerc. 1997;29(5):i-ix. PMID: 9140913.
- Nattiv A, Loucks AB, Manore MM, et al. American College of Sports Medicine position stand. The female athlete triad. Med Sci Sports Exerc. 2007;39(10):1867-1882. PMID: 17909417.
- Sundgot-Borgen J. Risk and trigger factors for the development of eating disorders in female elite athletes. Med Sci Sports Exerc. 1994;26(4):414-419.PMID: 8201895.
- Scofield KL, Hecht S. Bone health in endurance athletes: runners, cyclists, and swimmers. Curr Sports Med Rep. 2012;11(6):328-334. PMID: 23147022.