2025 – PAGE 419 – ORTHOPEDICS AND SPORTS MEDICINE

SPRAINS

Sprains refer to the tear of a LIGAMENT. These are less common than strains, and the management is more complicated.

• ANKLE SPRAINS: Most are due to inversion and resulting injury to the ANTERIOR TALOFIBULAR LIGAMENT (ATFL). Look for a mild–moderate amount of swelling, tenderness laterally, and no joint instability on exam. Prescribe Rest, Ice, Compression with a wrap, and Elevation (“RICE”). If minimally symptomatic, RICE QID for a couple of days. If there is difficulty with ambulation, prescribe RICE for 2–4 weeks (especially rest). If they are unable to ambulate, then prescribe RICE for 6–10 weeks (especially rest).
  • PEARLS: For the pediatric boards, management of sprains does NOT involve casting or orthopedic referral. Those are reserved for fractures. Prescribe “RICE.” Also, true sprains (true ligament tears) are RARE in PREpubertal children because they’re so flexible! If you are given a young child with what sounds like a sprain, get an X-ray because it’s OFTEN A FRACTURE. Lastly, if there is any sensory component, consider compartment syndrome.
  • MNEMONIC: Rename it sPrIGAMENT!

ROTATOR CUFF TEARS

Rotator cuff tears will present as a slowly progressive pain in the shoulder since it is usually due to chronic activities, such as throwing.

ANTERIOR CRUCIATE LIGAMENT TEAR (ACL TEAR)

A child with an anterior cruciate ligament tear (ACL tear) will usually present with a non-contact sport-related injury while pivoting or landing from a jump. They may have heard a “pop.” Exam will show knee swelling, a joint effusion, and an anterior drawer sign. Definitive diagnosis is by MRI. Treatment often requires surgery.

JOINT HYPERMOBILITY

A child with joint hypermobility might present with a history of “loose joints.” It sounds good, but these children are actually more prone to getting injured with sprains. Treatment includes pain management and physical therapy.

MNEMONIC/PEARL: They’ll talk about loose JOINTS, not someone being extremely flexible.

COMPARTMENT SYNDROME

Compartment syndrome occurs when trauma leads to so much swelling within a compartment of muscle that blood flow is restricted and necrosis occurs. The five classic signs are summarized by the “5 P’s” of Pain, Paresthesias, Pallor, Pulseless, and Paralysis. The key, however, is realizing that all 5 symptoms are rarely seen, and most of them are late findings (especially Pulseless and Paralysis). If presented with a case of trauma and any sensory deficit (light touch, pinprick, etc.) think COMPARTMENT SYNDROME and measure compartmental pressures.

ACROMIOCLAVICULAR JOINT SEPARATION (AC JOINT SEPARATION)

Acromioclavicular joint separation (AC joint separation) may present with point tenderness at the distal clavicle/AC joint, and pain with abduction of the arm after a fall. Treat with a sling and physical therapy. If severe, call orthopedics.