S4E2: Bonus - Acute Injuries and Imaging Insights with Dr Jamie Kearns - Sports
In our first bonus of the season, Leah sits down with Dr Jamie Kearns and peppers him with questions. Can he withstand the onslaught? Jamie started his career in acute medicine in Galway. He turned to general practice, shortly after and completed a masters in Sport and Exercise Medicine. He has worked with various sporting organisations including the FAI and Connacht Rugby, and now is Head of Medicine at Munster Rugby, a role that he has held since 2018.
He has completed the Sports and Exercise Medicine scheme and is now a Sports and Exercise Medicine Consultant with UPMC. He has a special interest in acute injury assessment and ultrasound guided interventions.
What is common and what is critical?
A challenge faced in the emergency department is the undifferentiated injury. Critical injuries can lead to significant disability into the future, and unfortunately a normal x-ray does not necessarily mean there is no injury. Safety-netting is crucial to avoid missing injuries that can be difficult to assess initially. At initial presentation, if the injury has recently occurred, swelling may limit exam and diagnostic confidence. In this situation, MSK or triage clinics can be helpful, as the patient can be assessed when some of the inflammation and pain has resolved, allowing for a more thorough evaluation of the injury. The key is recognising that you may not have the final diagnosis immediately, but to plan for further evaluation later.
Case example: ankle injury - normal x-ray - normal exam.
Normal x-ray does not necessarily mean the ankle is normal. Fractures of the anterior process of calcaneus (the Chopart joint) are difficult to see on x-ray. If you see a small avulsion over the talonavicular joining, consider a CT and orthopaedic input. Likewise for fore-foot and Lisfranc joint injuries. If the CT is normal but there is a lot of bruising and swelling, or the patient is still uncomfortable with weight bearing, an MRI in 2-3 weeks with GP follow up might be worthwhile. Injuries to the Chopart and Lisfranc joints can lead to significant disability; they are not that common, but they are critical.
Single leg calf raises are a good clinical exam to perform. This simple test can highlight the more severe pathology and can be a tool to differentiate between the critical and non-critical ankle injuries. Lateral ankle sprains should still be able to single leg calf raise, if not, further investigation is recommended.
Acute management
Move over RICE (rest, ice, compression, elevation), now it's all about PEACE and LOVE.
PEACE (for initial acute management)
Protect against further injury,
Elevate to reduce swelling,
Avoid anti-inflammatories,
Compression
Education
LOVE
Load
Optimisation
Vascularisation
Exercise
What critical ankle injuries are missed in Emergency Medicine?
The three ankle injuries that are often missed:
Syndesmosis injuries are difficult to spot on x-ray and CT. They can be picked up on MSK ultrasound, but this is very user dependent. If the patient is tender over the ATFL and they are 10 days post injury, consider that patient for MRI. The mechanism of injury is key; if the ankle has been forced into dorsiflexion and rotated externally, think syndesmosis injury.
Chopart joint injuries; anterior process of the calcaneus are commonly missed. If the patient comes down off a step and then rolls their ankle, think midfoot or Chopart injury.
Lisfranc injuries; tarsometatarsal fracture dislocation characterised by traumatic disruption between the articulation of the medial cuneiform and base of the second metatarsal.
Ultrasound in Sports Medicine
Ultrasound is very helpful for assessing tendon injuries. For example, acute patellar tendon tears, partial thickness tears, achilles tendon, rotator cuff tears. Remember that fat is a really poor conductor of sound waves, so if you have a patient who is very thin, athletic and muscular, the imaging will be very clear, and can even at times produce better images than MRI. Calcific tendonitis, which presents with acute onset excruciating shoulder pain with no precipitating event, shows up well on ultrasound. These patients do well with steroid injections or Barbotage.
Steroid joint injections?
Patient centred care is key.
While there is a move away from steroid injections in general, for patients who can’t exercise or can’t do rehab, steroid injections may be the best option for that patient. For example, a single mother who has young kids at home, who can’t afford the time or money for physiotherapy, recommending a course of physiotherapy for that patient may not be the most appropriate option, as she may not be able to do it, and instead could end up relying on painkillers. In this kind of situation, steroid injections may be the better choice.
Referring for follow-up with Sports and Exercise Medicine?
Undifferentiated injuries where the diagnosis is not clear may be considered for referral to Sports and Exercise Medicine. The goal is to have the person return to their previous level of activity. If the person is not doing that, then either the injury was worse than first expected, they haven’t been able to do the rehab, or they don’t have the confidence to return to that level of activity. These patients may benefit from referral to Sports and Exercise Medicine.
References:
Horan, D., Kelly, S., Hägglund, M., Blake, C., Roe, M., & Delahunt, E. (2023). Players', Head Coaches', And Medical Personnels' Knowledge, Understandings and Perceptions of Injuries and Injury Prevention in Elite-Level Women's Football in Ireland. Sports medicine - open, 9(1), 64. https://doi.org/10.1186/s40798-023-00603-6
Dubois, B., & Esculier, J. F. (2020). Soft-tissue injuries simply need PEACE and LOVE. British journal of sports medicine, 54(2), 72–73. https://doi.org/10.1136/bjsports-2019-101253
Jacobson J. A. (2002). Ultrasound in sports medicine. Radiologic clinics of North America, 40(2), 363–386. https://doi.org/10.1016/s0033-8389(02)00005-2.
