Chapter 27 Sports injuries

Case 27.1

1. Using only this information, list possible causes of Tomislav’s clinical presentation. Justify your answer.

Possible diagnosis	Justification
DDx 1: temporomandibular joint (TMJ) sprain	• Trauma to jaw • Localised pain • Provocation by yawning
DDx 2: neck-tongue (cervicolingual) syndrome	• History of possible hypermobility (self manipulation) • Tongue symptoms
DDx 3: post-concussion syndrome	• History of trauma • Headache, light-headedness
DDx 4: intracranial haemorrhage	• Direct trauma to head, fall
DDx 5: skull and/or jaw fracture	• Localised pain • Direct trauma

2. Why was Tomislav asked about:

a loss of consciousness and headache

A common occurrence in boxers who are knocked to the ground is post-concussion syndrome. A headache that increases in intensity or begins to involve other cranial signs is a red flag. Subdural haematoma is the most common intracranial haemorrhage in sport and the leading cause of death in boxers. Both concussion and haematoma may involve dizziness, nausea, loss of motor control and balance. Loss of consciousness of greater than 2 minutes constitutes a medical emergency.

b the relationship of the pain to movement

Functional pain on chewing or talking may indicate TMJ related sprain. Yawning can be inconclusive as it involves both cervical and jaw movements. Pain and tingling upon cervical movement (particularly rotation) is diagnostic of cervicolingual syndrome, although vascular and cerebral traumas cannot be ruled out.

c cardiovascular or neoplastic disease

A family history of cardiovascular disease or stroke may suggest a predisposition to malformation or disease of the vertebral or cranial arteries.

3. Describe how you would perform a cranial nerve ‘quick scan’.

I Olfactory — test smell using coffee, vanilla or other aroma.

ii Optic — visual field test, papillary light reflexes.

iii., iv., v (oculomotor, trochlear, abducens) — ptosis, eye position, tracking, accommodation reflex, nystagmus check.

vi trigeminal — facial sensation, jaw jerk reflex, corneal sensation, masticatory muscle tone.

vii Facial — facial symmetry, involuntary facial movements, taste tests either side of time.

viii Vestibulocochlear — hearing distance away from ear, Rinnes test, Webers test. Vestibular tests (eg: positional vertigo).

ix., x Glossopharyngeal and vagus — gag test, palatal articulation ‘ka’, guttural articulation ‘go’.

xi Spinal accessory — shrug shoulders, rotate neck.

xii Hypoglossal — tongue motor control, weakness, fasciculation.

4. What do you need to examine in this patient? Justify your answer.

Examination	Justification
Cranial nerve quick scan	Intracranial lesions, cranial nerve damage
Head and neck palpation	For swelling, pain, hypertonicity
Jaw and neck ROM	Restrictions, crepitus, pain, reproduction of symptoms
Test short-term memory, speech	Intracranial haemorrhage
Respiration, heart rate, temperature	Abnormalities common in intracranial traumas

5. What information can you obtain from these findings? Can you now narrow your differential diagnosis?

The most significant finding is the reproduction of tongue symptoms with rapid neck rotation. Lack of intracranial findings suggest that the most likely diagnosis is a combination of differential diagnosis 2 (cervicolingual syndrome) and differential diagnosis 1 (TMJ strain).

6. Explain the significance of the neck rotation causing tongue tingling in light of your differential diagnosis.

A typical finding in cervicolingual syndrome is a history of hypermobility of the cervical spine. The impact into the jaw might have affected his cervical spine, resulting in a cervical sprain or strain. Local inflammatory response, reactive suboccipital spasm or upper cervical joint derangement might irritate the ventral C2 ramus, which communicates with fibres of the lingual nerve.

7. Tomislav is referred to a medical practitioner. What investigations should the patient have done? Why? What would you expect, based on the physical examination findings?

Investigation	Justification	Expectations based on differential diagnosis
Cervical and cranial X-ray including functional study	To rule out fracture, atlanto-axial instability	No fracture of jaw, skull or cervical spine Possible hypermobility of upper cervical spine
CT or MRI scan if symptoms do not improve over next 1–2 weeks	To detect fractures and haemorrhages that may take longer to manifest	Possible instability at atlanto-axial joint

8. What is your final diagnosis, based on these results? Justify your answer.

Acute cervicolingual (neck-tongue) syndrome. Lack of neurological and X-ray findings coupled with the onset of tongue symptoms during rotation of neck is diagnostic. As is often the case, a patient may present with several diagnoses, all contributing to the overall clinical picture. It is entirely plausible that the patient has an accompanying jaw sprain, and is also displaying common features of post concussion syndrome.

10. Describe the ringside action plan for an unconscious boxer.

Loss of consciousness of greater than 2 minutes is treated as an emergency. Undertake the following procedure:

• check breathing — if not begin resuscitation.

• take out mouth piece.

• attach cervical collar — if patient needs to be placed on back, ensure neck safety first.

• removal of head gear remains controversial — if intracranial trauma is suspected it should be left on.

• oxygen is given.

• emergency transport to hospital.

If the patient regains consciousness within 2 minutes:

• check communication

• ask the patient to wiggle toes and fingers

• check cervical tenderness

• if the patient’s responses are rational, they have full motor control and no cervical tenderness, they are allowed to sit up on a stool — they are then checked for pupil size, reaction, balance, coherence and short-term memory

• should any of these signs continue, deteriorate, or become accompanied by vomiting, the patient should be transported to hospital

• a good policy is to go to hospital for a neurological workup for any loss of consciousness greater than 1 minute.

11. Compare and contrast some of the more common intracranial haemorrhages.

Epidural haematoma — usually due to an arterial bleed from a meningeal artery. Often due to a direct trauma. History of a loss of consciousness, followed by a lucid interval. Consciousness then decreases again as haematoma expands. Can be slow to deteriorate (several hours), eventually leading to confusion, sleepiness and vomiting. There may not be pupillary signs until midline shift has occurred. At that point a fixed, dilated pupil with contralateral hemiparesis is observed. CT usually shows a localised, rounded collection of blood over a cerebral hemisphere.

Subdural haematoma — occurs between the dura mater and arachnoid membranes, usually due to bridging veins. More common in cases of rapid deceleration (eg: boxing or car accident). Localised neurological deficits are common underlying the cerebral contusion on the side of injury. Neurological findings can vary greatly, but fixed pupillary dilation occurs with midline shift. CT shows crescent shaped haemorrhage over one hemisphere.

Cerebral contusion — brain injury can occur on the side of injury or its opposite and is usually seen in rapid deceleration accidents. Occurs most commonly at the tips of the gyri resulting in local neurological deficits. CT usually shows swelling of the gyri, and often shows widespread minor haemorrhages.

Intracerebral haemorrhage — can be delayed by hours or days. Early signs include local neurological haemorrhage. Increasing intracranial pressure will lead to decreasing level of consciousness and progressive neurological deficits. CT shows local, well-defined areas of haemorrhage, stretching adjacent tissue.

Case 27.2

1. Compile a problem list for this patient.

• Posterior left shoulder pain.

• Left shoulder weakness (arm elevation).

• Iron-deficiency anaemia.

2. Using only this information, list possible causes of Richelle’s clinical presentation. Justify your answer.

Possible diagnosis	Justification
DDx 1: post-traumatic peripheral neuropathy (eg: axillary nerve palsy, quadrilateral space syndrome)	• History of recent anterior shoulder dislocation • Muscle weakness • Nature of the pain (burning)
DDx 2: myofascial pain syndrome	• Location of the pain
DDx 3: fracture or labral lesion	• History of recent anterior shoulder dislocation
DDx 4: cervical disc and/or nerve root injury	• History of recent anterior shoulder dislocation • Muscle weakness