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B-62 Clinical Case Slide - Urgent/Emergent Issues

Medicine & Science in Sports & Exercise: May 2013 - Volume 45 - Issue 5S - p 208–210
doi: 10.1249/01.mss.0000433600.08364.39

May 29, 2013, 3:15 PM - 5:15 PM

Room: 103

910 Chair: Robert Johnson, FACSM. University of Minnesota, Minneapolis, MN.

(No relationships reported)

911 Discussant: Chad Asplund, FACSM. Eisenhower Army Medical Center, Fort Gordon, GA.

(No relationships reported)

912 Discussant: J. Herbert Stevenson. University of Massachusetts Medical School, Fitchburg, MA.

(No relationships reported)

913 May 29, 3:15 PM - 3:35 PM

Thirteen Year Old Baseball Pitcher With Right Upper Arm Pain

Janet Howard. Kaiser Permenente Los Angeles, San Bernardino, CA.

(No relationships reported)

HISTORY: HPI: CC is a 13 year old boy who presented with a 2 week history of right shoulder pain. He had a left triceps strain 6 months previously. He is a left handed baseball pitcher who does all other tasks as right hand dominant. 2 weeks prior to visit he woke up with right upper arm pain. He iced and used anti-inflammatories without improvement.He denied any other symptoms, including fever, other joint pain,nausea, vomiting, URI symptoms. PMH: Past medical history is significant for moderate to severe eczema, mild asthma, and seasonal allergies. April of 2010- osteomyelitis of the femur, MSSA positive blood culture. September 2011-MRSA scalp lesions



BP 114/53, Pulse 81,

Temp 97.8 F, Ht 5’ 6.5”, Wt 152 lb, BMI 24.17

•Well appearing, NAD

Skin: red flaky skin of the arms, legs, trunk and face. No excoriations


•Right arm: Mild tenderness proximal lateral aspect of upper arm.

• Right shoulder with FROM including abduction, adduction, flexion, extension, internal and external rotation.

• Strength: external rotation against resistance led to a loud crack and his right arm gave way.

• Re-exam at that time showed markedly increased tenderness over proximal lateral aspect of upper arm. He could now

only abduct and flex to 90 degrees because of pain.

PHYSICAL EXAMINATION: Muscular injury, Pathological fracture, underlying bone pathology such as malignancy, stress fracture that was completed.

TEST AND RESULTS: Plain x-ray: abnormal permeative hyperlucency and periosteal irregularity of the lateral aspect of the proximal humeral diaphysis and metadiaphysis. MRI: Humeral lesion contiguous in the proximal humeral metaphysis and part of the diaphysis with surrounding mantle of periosteal enhancement in periosteal thickening.Several enlarged right axillary lymph nodes.


•CBC- White count 10.1

-Hgb 13.1

-Hct 37.3

-67.6% neutrophils

-21.6% lymphocytes

-5.0% eosinophils

•ESR 27

•CRP 3.0 (normal <7.5)

•IGG 900 (normal 603-1582)

•IGM 70 (normal 38-200)

•IGA 134 (normal 35-252)

•IGE 3304 (normal <114)


FINAL RESULT Growth of: Methicillin-Resistant

Staphylococcus aureus


osteomyelitis,Job’s Syndrome


•He was admitted for IV antibiotics, had an immunology consult and diagnosed with Job’s

914 May 29, 3:35 PM - 3:55 PM

A Rare Cause of Abdominal Pain in a Division II College Basketball Player

Zachary M. Boylan, Earl R. Stewart, James B. Robinson. University of Alabama, College of Community Health Sciences, Primary Care Sports Medicine Fellowship, TUSCALOOSA, AL.

(No relationships reported)

HISTORY: Four months after emergent abdominal surgery a 26yo male Division II college basketball player presented for his pre-participation evaluation. According to the player and hospital records, he began developing dull abdominal pain, nausea, and vomiting shortly after playing in an out-of-state recreational basketball game. He denied any trauma. On his initial visit to the tertiary care ED, after a thorough workup he was diagnosed with a “viral illness” and discharged with supportive care instructions. However, over 2 days his pain worsened to the point that “even walking hurt” and he returned to the ED.


Temp 100.6F BP 152/93 HR 120

Abdomen rigid, distended, guarding and rebound tenderness present, no bowel sounds

Rectal exam normal, no blood in stool


1. Small Bowel Obstruction

2. Appendicitis

3. Diverticulitis

4. Pancreatitis

5. Acute Mesenteric Ischemia



- WBC 18, Amylase and Lipase mildly elevated

- CMP, LFTs, and drug screen negative

CT Abd/Pelvis w contrast:

- multiple dilated loops of small bowel with air-fluid levels

- normal appendix

Surgical exploration:

- excision of necrotic-appearing bowel in the distribution of the Superior Mesenteric Artery

- thrombotic appearance of draining veins of the bowel wall and mesentery


- small bowel with extensive necrosis

- colonic mucosa with patchy necrosis


- hypercoagulability workup negative

ECG: sinus rhythm, changes consistent with athlete’s heart, no arrhythmia

Transthoracic/esophageal Echocardiograms: no thrombus, normal size, bubble study normal


Acute Mesenteric Ischemia


1. Hospitalized for 2 weeks and received heparin drip, IV antibiotics, and parenteral nutrition.

2. Prior to discharge his heparin, antibiotics, and TPN were discontinued and he was placed on lactose-free diet.

3. Warfarin therapy was recommended but he refused.

4. At his PPE, 4 months later, he had a 20kg weight loss from his previous in-season weight, a well-healed abdominal incision, and complaints of chronic diarrhea.

5. Repeat hypercoagulation and nutritional labwork were normal.

6. Nutritional consult for his Short Gut Syndrome was ordered

7. He was started on a daily aspirin, high calorie diet, and allowed to return to competition.

915 May 29, 3:55 PM - 4:15 PM

Exertional Heat Stroke in a Collegiate Cross Country Runner

Kenzie Grant1, Guy W. Leadbetter1, James Thompson2. 1Colorado Mesa University, Grand Junction, CO. 2St. Marys Hospital, Grand Junction, CO. (Sponsor: Gerald Smith, FACSM)

(No relationships reported)

HISTORY:A 22 year old female Division II varsity cross country runner was running a hilly, 6.4 mile course in 35.5° C temperatures and low humidity. Six miles into the run (50 minutes) the athlete collapsed and became unresponsive with no other warning except that she remembered she was very hot just before the collapse. Four minutes later she was stabilized for breathing purposes. Ten minutes post collapse she was covered in cold wet towels and shaded by her team members. The paramedics arrived 21 minutes post collapse and inserted an IV and began transport by helicopter within 30 minutes. She arrived at the hospital 45 minutes post collapse with a core temperature of 41° C.

PHYSICAL EXAMINATION:Oxygen saturation was 92-94% while on 40% FiO2. She was orally intubated due to coarse breath sounds bilaterally, airway protection and acute respiratory failure. Her heart rate was tachycardic, and temperature was reduced to 40° C one hour after arriving at the hospital. The patient showed erythema on the arms and legs. Ice packs, cooling blankets and fans were used for cooling. She had a seizure, lasting less than 2 minutes, which occurred approximately 1 hour after arrival at the hospital. Two additional seizures occurred within the next 2 hours. She was in a comatose state for 5 days and mental status gradually improved after those 5 days.


West Nile Encephalitis

Spinal Meningitis

TEST AND RESULTS:Blood profile within the first 3 hours revealed rhabdomyolysis, acute renal failure and liver injury. Ultrasound revealed bilateral blood clots in the arms. The clots were treated with Argatroban and Coumadin. Core temperature was measured using a Bladder Foley during the first four days. Creatine Kinase (CK) results were measured throughout the 10 -day recovery and showed extremely erratic levels during that time.


Heat Stroke

Acute renal failure


TREATMENT AND OUTCOMES:The patient was in ICU for 7 days and hospital for another 5 days, and readmitted 2 days later due to extreme Rhabdomyolysis for 3 days. Blood analysis of liver, kidneys, and CK levels were measured once a week post discharge. Rhabdomyolysis and abnormal liver markers gradually reduced and after about 3 weeks returned to normal. Fatigue and weakness remained for several weeks post discharge from the hospital.

916 May 29, 4:15 PM - 4:35 PM

Chest Trauma in a Collegiate Women’s Ice Hockey Player

Robyn C. Knutson Bueling1, Suzanne Hecht2. 1Sanford Health, Fargo, ND. 2University of Minnesota, Minneapolis, MN. (Sponsor: Rob Johnson, FACSM)

(No relationships reported)

HISTORY: A 19yo Division I collegiate women’s ice hockey player, and national team member, was struck by a shoulder in the center of her chest during game play. She felt ‘the wind knocked out’ and came off the ice. She quickly caught her breath and attempted to return but noted a mild cough and blood taste in her mouth. Because she felt more than her usual shortness of breath, she pulled herself off the ice.


In the training room, vital signs were stable with 99% oxygen saturation. She had small amounts of blood-tinged sputum and dyspnea that resolved within 1 minute of rest. She had no chest pain, no lacerations in the mouth, and equal breath sounds.

After 15 minutes, she had no dyspnea, chest pain, or hemoptysis. She attempted return to play but quickly noted increased dyspnea, return of hemoptysis and mild chest discomfort in the sternal and left sternal regions. She was pulled from the game.

Re-evaluation revealed 99% O2 sat, mild tachycardia at 90bpm, small amounts of blood-tinged sputum, and slightly diminished breath sounds in the left compared to right lung. She was taken to the ED.


1.Chest wall contusion

2.Rib fracture



5.Pulmonary contusion

6.Pleural effusion

7.Esophageal trauma



In the ED, her vital signs were stable with 100% oxygen saturation. Her hemoptysis and dyspnea had resolved. She continued to feel the need to ‘catch her breath.’ She had minimal tenderness to palpation on the sternum without bruising or deformity, breath sounds were normal, and chest x-ray taken 3 hours after initial injury was clear. After a long discussion the athlete, her parent (via telephone), the emergency physician and team physician elected to forego a CT.

She was evaluated prior to the next day’s game. She continued to complain of a bloody taste and dyspnea up one flight of stairs, therefore a CT scan of the chest was ordered.

Two days following the initial injury, CT revealed a small peripheral subpleural collection of groundglass opacity in the lateral left lower lobe and similar appearing groundglass opacity in the lingular segment.


Pulmonary Contusion


Once asymptomatic at rest, gradual return to sport was instituted and she returned to game play when dyspnea had resolved.

917 May 29, 4:35 PM - 4:55 PM

Testicular Injury - Baseball

Aaron Dawes, Philip Bosha, Peter Seidenberg. Penn State University, University Park, PA. (Sponsor: Francis G. O’Connor, FACSM)

(No relationships reported)

HISTORY: 20-year-old male catcher presented for acute evaluation of an injury to his groin during a minor league baseball game. A foul ball hit him on the right side of his groin. He complained of severe pain in his scrotum and abdomen. He was most comfortable in a supine position with his legs elevated. After rest and indirect icing he began to feel better. By the time the game was over, he was feeling much better. His scrotal pain was improving, his nausea and abdominal pain had nearly resolved, and he was able to ambulate with minimal pain. He was also able to urinate normally and denied dysuria or hematuria. After repeat evaluation, he was allowed to return home with red flag instructions. The working diagnosis was right testicular contusion.

At 0834, he presented to the ED with increasing testicular pain, rated 10/10. He denied hematuria, dysuria or difficulty with urination. He denied fever and chills. He also reported a history of contralateral testicular torsion and repair.


Initial - GU (mildly edematous scrotum, generalized tenderness to palpation of his scrotum/testicles but right-sided tenderness was greater, palpation of his scrotum/testicle caused radiating pain into the right upper abdomen, intact testicular shape and firmness, testicular artery pulses were 3+ bilaterally. No hematomas were palpable. Urethra appeared intact. No bladder tenderness. No ecchymosis or lacerations. Penis wnl, Abdomen (soft, mildly tender diffusely, no guarding, normal bowel sounds)

ED - Vitals wnl, General (obvious pain), Abdomen wnl, GU (right scrotum - edematous/ecchymotic/firm/severely tender; penis wnl)


Testicular contusion/hematoma

Scrotal hematoma

Testicular fracture

Epididymis fracture

Testicular torsion

Bladder/urethral injury


WBC 13.27, UA (no blood or bacteria)

Testicular Ultrasound - 1.6× 1.5 cm right testicular hematoma with edema of the adjacent testicular tissue and probable disruption of the adjacent tunica


Tunica albuginea tear of right testicle


1. STAT urology consult lead to right scrotal surgical exploration/repair. Findings: dark testicle from old blood and small tear in the tunica albuginea.

2. At follow up 6 days after his surgery, he was recovering well.

918 May 29, 4:55 PM - 5:15 PM

16 Year-old Male High School Football Player With Right Upper Back Pain

Leslie Michaud. Steadman Hawkins Clinic of the Carolinas, Greenville, SC. (Sponsor: Delmas Bolin, FACSM)

(No relationships reported)

HISTORY: A 16 year old male high school football player was hit in the right upper back while running back a kick return. He complained of pain in these areas and was examined by the covering physician. Immediately, the patient denied neck or shoulder pain as well as chest pain, shortness of breath, lightheadedness, or dizziness.

PHYSICAL EXAMINATION: Sideline examination revealed tenderness over the right upper back along the medial border of the scapula. Neck and shoulder examination were normal with no tenderness, full range of motion, and strength. Cardiac exam showed normal rate and rhythm. The trachea was midline. There was no crepitus or use of accessory muscles. There were clear, present, and symmetric breath sounds.

He was monitored and reassessed at half-time. There were no new findings on exam. However, the athlete complained of increasing pain. He was held from the remainder of the game and advised to report to a local urgent care for radiographs that evening. The athlete and his parents opted to be seen in clinic the following morning.

There, he was examined and chest AP, lateral, and right oblique rib views were performed. These were read as normal. He was diagnosed with a rib contusion and released to practice and play as tolerated.

Over the next two days, he complained of increasing pain exacerbated by deep breathing and activity. Pulmonary exam continued to be normal. The ATC contacted the team physician who reviewed the previous radiographs.


1. Rib contusion

2. Occult rib fracture

3. Right thoracic paraspinal muscle strain

4. Pneumothorax


Radiographs were reviewed by the team physician who noted a right pneumothorax and subcutaneous emphysema along the anterolateral chest.



TREATMENT AND OUTCOMES: He was sent to the ER where repeat chest x-rays were performed four days after the initial set and showed no expansion of the right pneumothorax. Heart rate, blood pressure, and respiratory status were stable. Oxygen saturations were 97% on room air and he was given supplementary oxygen only as a precautionary measure. A chest tube was not placed. He was admitted to the pediatrics service and maintained normal O2 sats on room air. On day 3 of admission, chest radiographs showed near-full expansion of the right lung with a small residual pneumothorax.

© 2013 American College of Sports Medicine