2013 Scientific Assembly Needs Assessment Body System: Musculoskeletal Session Topic: Sprains, Strains and Dislocations Learning

Category II Interactive Needs Assessment Sprains, strains and dislocations together account for nearly 50% of all musculoskeletalrelated injuries, incurring significant economic costs due to ambulatory visits and hospitalizations. Sprains and strains accounted for nearly 16.3 million musculoskeletal injury treatment episodes in 2004 (the last year for which such estimates were available), most commonly among patients aged 18-44. Dislocations occur most frequently in the 45-64 year age range, and although theyre less common, they are more likely to be treated in physician offices.1 The National Athletic Trainers Association defines a sprain as a result of overstretching or tearing of the joint capsule or ligament, and a strain as a result from overstretching or tearing of a muscle or tendon. While they have similar signs and symptoms, they difference is in location; sprains occur along the joint and strains occur along the muscle. Sprains result from acute trauma, such as falling or twisting, and most often affect the ankle, knee or anterior cruciate ligament (ACL). Strains can be acute or chronic, either as the result of overuse/repetitive movements (chronic) or excessive muscle contraction (acute). Patients with such injuries likely present with varying degrees of severity, including pain, muscle spasms, muscle weakness, swelling and popping or cracking sounds/sensations.2 Overuse injuries are common sources of sprains and strains particularly in patients who present with conditions such as patellofemoral pain syndrome, plantar fasciitis, shin splints, runners knee or jumpers knee, Achilles tendonitis and stress fractures. As with other injuries, if not treated promptly and appropriately, patients can experience long-term complications.3,4 Dislocations, on the other hand, occur when the ends of the bones are forced from their normal position. They are usually caused by acute trauma, but they can be caused by an underlying disease like rheumatoid arthritis. They are particularly common in contact sports (e.g., football and hockey) and sports that may involve falling (e.g., downhill skiing and volleyball), and typically affect the hip, knee, ankle or toes. Once patients dislocate a joint (such as a kneecap, for instance), they are more likely to dislocate it again, especially in young, active people. In situations where the dislocation injures tissues or nerves, surgery may even be required.5 The causes of sprains, strains and dislocations are not limited to sports; many musculoskeletal injuries occur in the home or as a result of an accident. However, injuries sustained during a sports activity serve as a significant source of hospitalizations, rehabilitation and lost productivity. As many family physicians are encouraged to serve as a sports medicine physician in their community (and some may choose to be a team physician), they must be prepared to evaluate acute injuries, including sprains, cartilage and ligament tears, fractures and other traumas.6,7 When

2013 Scientific Assembly Needs Assessment patients present with acute or chronic musculoskeletal injuries, family physicians can employ a number of examination techniques to assess such factors as range of motion, stability, bone alignment and soft tissue swelling or masses. Although the type of exam depends on the injury and area affected, some of the typical clinical indications in lower extremities include: acute inflammation (indicating tendonitis/bursitis); joint effusion, locking, popping or cracking; pain or stiffness upon movement; crepitation; localized tenderness; and a palpable enlarged mass and/or warmth.8,9 In its recommended residency curriculum guidelines, the American Academy of Family Physicians advises that family physicians have skills and competence to prepare them for treatment and management of patients who require casting or splinting, joint injections or aspirations, dislocation reduction and emergency recognition and stabilization.10 However, family physicians should also be aware of the differences in treating injuries in pediatric and adult patients; because of childrens growth plates, some injuries may be more traumatic than others and thus require more careful treatment to avoid complications. As part of a musculoskeletal exam, family physicians should be prepared to stabilize and mitigate a patients pain in the event of a traumatic injury and offer appropriate treatment recommendations, such as NSAIDS, pain medication and the RICE (rest, ice, compression, elevation) strategy.11 They should also recognize when imaging studies are needed or referral to a specialist is required, in which case they should still coordinate patient care to ensure compliance with treatment and any follow-up protocols. Family physicians need to be kept up to date on current evidence-based literature for the management of patients with sprains, strains, and dislocations. Common Finger Fractures and Dislocations: Recommendations for Practice:12 Finger fractures involving greater than 30 percent of the intra-articular surface should be referred to an orthopedic or hand surgeon. Following reduction of a proximal interphalangeal dislocation, short-term splinting in flexion with early active range of motion and strengthening is preferable to prolonged immobilization. Treatment of a mallet fracture includes splinting the distal interphalangeal joint in extension; various splint types are of equal benefit. Displaced, oblique, or spiral finger fractures should be referred to a hand surgeon. Common Forearm Fractures in Adults: Recommendations for Practice:13 Nonsurgical treatment of displaced intra-articular fractures of the distal radius is associated with an increased risk of radiocarpal arthritis. Expert opinion suggests that even minimal articular incongruency is associated with increased complications Isolated ulnar shaft fractures that are not displaced by more than 50 percent of the bone diameter and that are angulated less than 10 degrees can be treated with a functional brace or short arm cast. Based on systematic review of treatment methodologies (not RCTs)

2013 Scientific Assembly Needs Assessment Early mobilization is favored in the treatment of Mason type I radial head fractures. Based on consistent findings from several RCTs There is no benefit of casting in the initial treatment of Mason type I radial head fractures.

Gaps in Knowledge, Competence and/or Performance: Family physicians need to understand the difference between sprains and strains and be able to recognize such injuries as acute or chronic in patients who present with injuries. Family physicians should be aware of the common presentations of sprains and strains that result from overuse injuries. Accordingly, they should be prepared to promptly evaluate patients and treat them appropriately in order to avoid longterm complications. Family physicians should be aware of the common anatomical sites for dislocations particularly hips, knees, elbows and toes and be prepared to treat or refer patients for specialty attention to restore the bones and joint to normal functioning. When patients present with sprains, strains or dislocations, family physicians should employ a number of examination techniques to assess such factors as range of motion, stability, bone alignment and soft tissue swelling or masses. They should also recognize typical clinical indications of an injury, which may include acute inflammation, joint effusion, locking, popping or cracking; pain or stiffness upon movement; crepitation; localized tenderness; and a palpable enlarged mass and/or warmth. In examining a patient, family physicians should not only be prepared to stabilize and mitigate his/her pain in the event of a traumatic injury, they should also offer appropriate treatment recommendations, such as NSAIDS, pain medication and the RICE strategy. o Appropriate treatment may require casting, splinting, joint injection or aspiration, dislocation reduction and emergency stabilization, and special attention may need to be paid to pediatric patients due to their growth plates.

Learning Objectives: At the end of this session, participants will be able to: 1. Compare and contrast the symptoms of sprains, strains and dislocations in patients presenting with injuries. 2. Distinguish musculoskeletal conditions that result from overuse/repetitive motion injuries, with particular attention to those that occur in pediatric patients. 3. Assess an injured patients range of motion, stability, bone alignment, soft tissue swelling, palpable warmth or mass(es), pain or tenderness and crepitation. 4. Prepare appropriate treatment plans for patients with sprains, strains or dislocations that may include NSAID or pain medication, application of the RICE strategy and/or emergency stabilization.

2013 Scientific Assembly Needs Assessment

References: 1. Musculoskeletal Injuries. The Burden of Musculoskeletal Diseases in the U.S: Prevalence, Societal and Economic Cost. U.S. Bone and Joint Decade Project. American Academy of Orthopaedic Surgeons, 2008. Available at http://www.boneandjointdisease.org/pdfs/BMUS_chpt6_injuries.pdf 2. Activity Health Tip #2: Sprains & Strains. National Athletic Trainers Association. 2003. Available at http://www.nata.org/consumer/sprainsandstrains.htm 3. Overuse Injuries. AOSSM Sports Tips. American Orthopaedic Society for Sports Medicine. 2008. Available at http://www.sportsmed.org/secure/reveal/admin/uploads/documents/ST%20Overuse%20Injuries% 2008.pdf 4. Cosca, D and Navazio, F. Common Problems in Endurance Athletes. Am Fam Physician 2007;76:237-44. Available at www.aafp.org/afp/2007/0715/p237.html 5. Dislocation. Mayo Foundation for Medical Education and Research. December 2010. Available at http://www.mayoclinic.com/health/dislocation/DS00239/DSECTION=complications 6. The Burden of Musculoskeletal Diseases in the U.S: Prevalence, Societal and Economic Cost. U.S. Bone and Joint Decade Project. American Academy of Orthopaedic Surgeons, 2008. Available at http://www.boneandjointdisease.org 7. Selected Issues in Injury and Illness Prevention and the Team Physician: A Consensus Statement. Special Communications: Team Physician Consensus Statement. American College of Sports Medicine. 2007. Available at http://www.acsm.org/AM/Template.cfm?Section=Clinicians1&Template=/CM/ContentDisplay.cfm &ContentID=9383 8. Bussieres, A; Taylor, J; Peterson, C. Diagnostic imaging practice guidelines for musculoskeletal complaints in adults an evidence-based approach. Part 1: lower extremity disorders. J Manipulative Physiol Ther 2007;30(9):684-717. Available at http://www.guideline.gov/summary/summary.aspx?doc_id=13007 9. Bussieres, A; Taylor, J; Peterson, C. Diagnostic imaging practice guidelines for musculoskeletal complaints in adults an evidence-based approach. Part 2: upper extremity disorders. J Manipulative Physiol Ther 2008;31(1):2-32. Available at http://www.guideline.gov/summary/summary.aspx?doc_id=13008 10. Recommended Curriculum Guidelines for Family Medicine Residents: Musculoskeletal and Sports Medicine. American Academy of Family Physicians. Revised April 2009. AAFP Reprint No. 265. Available at http://www.aafp.org/online/etc/medialib/aafp_org/documents/about/rap/curriculum/musculosports.Par.0001.File.tmp/Reprint265FINAL.pdf 11. (Sports Injuries. National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMSD). NIH Publication No. 09-5278. Available at http://www.niams.nih.gov/Health_Info/Sports_Injuries/default.asp 12. Borchers J. Common Finger Fractures and Dislocations. Am Fam Physician. 2012;85(5):805810. 13. Black W., Becker J. Common Forearm Fractures in Adults. Am Fam Physicians.2009;80(10):1096-1102.