Case 2 (Full Version)

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Dr.Wagner -> Case 2 (January 24, 2006 6:41:00 PM)

Easy, but just saw this patient from tonight.


You are working the wrestling meet of a junior high.
The heavyweight (14 year olds) are wrestling and just as one wrestler lifts up another, one of the wrestlers grabs his hip and begins to cry tearfully.
The match is stopped.

The wrestler is grabbing his hip and yelling. He says "when I bend my knee or when I sit up it hurts".

You are on the sidelines covering the meet...what do you do?



FLAOrthoPT -> Re: Case 2 (January 24, 2006 7:02:00 PM)

tell him to suck it up, wrestlers don't cry, and then point and laugh and call him names like wuss boy and sissy



FLAOrthoPT -> Re: Case 2 (January 24, 2006 7:08:00 PM)

really though, slipped capital femoral epiphyses should be suspected, growing adolescent hitting puberty...hurts in flexion, severe load placed like picking up a girlie wrestler. Have him carted off for X-rays, have him non weight bearing with crutches or WC. ortho consult and surgical consult if bad enough, first thing is to send to ER for X-ray.

Can I get a Woo Woo



Randy Dixon -> Re: Case 2 (January 24, 2006 8:49:00 PM)

I don't know FLA, I go by the scientific method of looking at the action, pretending it's me, and seeing what hurts on me. I don't see the "bending my knee hurts" with what you suggested or most other real "hip" injuries. I think it is a Petticoat Junction injury. I'm guessing a strain of the rectus femoris, up high near the hip.

Some of these kids muscles get too strong for the rest of them, ending up tearing up tendon or snapping pieces of bone.



FLAOrthoPT -> Re: Case 2 (January 25, 2006 3:38:00 AM)

not disagreeing, but bending your knee will always stress the hip, look at any total hip patients you rehab...or that you have heard about rehab, they all lose knee motion and complain of pain with knee flexion, but I wouldn't rule out your hypothesis, we'd need more info, these are both acceptable diff. diag, just that all the mechanism, age, and symptom thus far are pretty classical SCFE. Toodles-

Ben



jma -> Re: Case 2 (January 25, 2006 1:19:00 PM)

FLAOrthoPT has a good point. I also think of a rectus strain. To lift up a wrester, one has to extend the hip a bit and if it was too much, a strain may have occurred as well. Needs to be looked at further.



eam -> Re: Case 2 (January 25, 2006 4:52:00 PM)

I would order x rays and a trip to the ER. I also agree on the rectus strain theory. Another thought- What about a lower abdominal strain? I don't have any reason to support this but it is another thought.
Erica



Dr.Wagner -> Re: Case 2 (January 26, 2006 10:28:00 AM)

Do you immobilize his spine, prior to the trip?


Tell me how to post an xray and I will post a film. Otherwise I will give other hints etc.



FLAOrthoPT -> Re: Case 2 (January 26, 2006 10:43:00 AM)

no



Dr.Wagner -> Re: Case 2 (January 26, 2006 10:49:00 AM)

to clarify:

Does he need to be in a C-collar?
Does he need to go via EMS (he can't stand up)
Do you log roll him?
Does he go in a back board and strapped down?

I believe I figured out how to post pictures, so thanks for the help.

Thus far the differential is:
1. Slipped Capital Femoral Epiphysis
2. Inf. Rectus (abd) strain
3. Quad strain.



jma -> Re: Case 2 (January 26, 2006 1:21:00 PM)

I don't believe he needs to be in a c-collar since there was no mention of any loss of feeling in the UE or in the LE. Yes, he could go via EMS on a back board or perhaps a stretcher. I do believe strapping one in is standard, regardless of injury if going by EMS to a hospital. Sitting in someone's car or having someone carry him will put the knee in a flexed position, which is already aggravating to begin with



eam -> Re: Case 2 (January 26, 2006 4:18:00 PM)

I do not think he needs a cervical collar. Tough to determine given the info at hand. EMS-yes. Log roll-yes (better be safe than sorry). Any other information? How is his respiration? BP? Pulse? Is he dizzy? Confused? Which wrestler grabbbed his hip? The one lifting or the one being lifted?
Erica



FLAOrthoPT -> Re: Case 2 (January 26, 2006 4:46:00 PM)

wow you are making this complicated, stop beating yourself up. SCFE, needs to go to ER on own accord, does not need to be ambulance, trainer can give crutches, send ambulance if parents not around. Not medical emergency per se, no back boards, no collars, no bells and whistles.



Randy Dixon -> Re: Case 2 (January 26, 2006 7:40:00 PM)

I would be looking at what could be wrong in a reasonable bad case scenario. Test for sensation in the leg, look for any crazy swelling or signs of bruising. I'm not seeing anything alarming so I don't think the amublance is necessary. I think that comes down to a policy/price issue.



Dr.Wagner -> Re: Case 2 (January 27, 2006 6:51:00 AM)

Since the diagnosis is NOT known, the young man (who was being thrown by the other wrestler) is laying on the ground, will not move his leg, crying (odd in public for a 14 year old heavyweight wrestler).

He SHOULD be transported via EMS, be log rolled, and placed on back board, C collar not necessary (but may not be a bad idea), transported via EMS (he refuses to sit up due to pain and refuses to move his leg).
Seems to localize pain more in the right pelvis/hip region

He goes directly to the ED.

I remove him from a back board ...

the following xray was taken
[IMG]http://www.e-radiography.net/ibase5/1_Normal/slides/Pelvis_normal_hip_lateral.jpg[/IMG]

[IMG]http://www.e-radiography.net/ibase5/1_Normal/slides/Pelvis_normal_frogs_lateral_single.jpg[/IMG]


[IMG]http://www.e-radiography.net/ibase5/Pelvis/slides/Pelvis_frx_avulsion_asis.jpg[/IMG]

These are not my xrays, but they are very similar.



Sean Weatherston -> Re: Case 2 (January 27, 2006 8:37:00 AM)

Hmmm...young man sitting on the floor and crying after being thrown to the ground....

Wags, are you sure this isn't Peyton Manning after the Steelers game?



jma -> Re: Case 2 (January 27, 2006 1:44:00 PM)

Looks like SCFE to me (Slipped capital femoral epiphysis). Ouch!



Dr.Wagner -> Re: Case 2 (January 27, 2006 2:20:00 PM)

Nope, there are no epiphyseal plates on the xrays.



Jeffre -> Re: Case 2 (January 27, 2006 2:37:00 PM)

At first I thought either slipped cap or avulsion. Since we now know that the kid that is injured was the throwee and not the thrower, I guess it depends on how he landed. Just a wild guess, maybe a hip pointer?



jma -> Re: Case 2 (January 27, 2006 3:14:00 PM)

The transverse femoral head fracture seems clear.



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