10th annual sports medicine continuing education conference · 2018-09-05 · 10th annual sports...
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10th Annual Sports Medicine Continuing Education Conference
Presented on: June 18, 2016
Presented by: Northwestern Medicine Orthopaedics
Northwestern MedicineHealth System Overview
Northwestern Medicine
• Shared strategic vision of Northwestern Memorial HealthCare and Northwestern University Feinberg School
• 7 Hospitals (Four have earned Magnet status, and are U.S. News & World Report ranked)
• Northwestern Memorial Hospital
• Northwestern Medicine Central DuPage Hospital
• Northwestern Medicine Delnor Hospital
• Northwestern Medicine Lake Forest Hospital
• Northwestern Medicine Kishwaukee Hospital
• Northwestern Medicine Valley West Hospital
• Marianjoy Rehabilitation Hospital
• More than 100 Locations throughout the Chicagoland area
Northwestern Medicine Regional Medical Group• More than 300 physicians in 36 locations throughout the western suburbs
• 26,500 clinical and administrative staff, medical and science faculty and medical students
• Contributed more than $615 million in community benefit in 2014
Northwestern MedicineLocations
Evaluation of Upper Extremity Vascular and Nerve Conditions
David H. Watt, MD
Orthopaedic Surgery, Sports Medicine
Northwestern Medicine
• Consultant for FH Orthopaedics
Disclosure
Objectives
• Recognize and Identify upper extremity vascular and nerve conditions, including differential diagnosis, for appropriate management and referral
Outline
• Stingers
– Cause, differential diagnosis, return to play considerations, when to refer (length of episode, number of episodes), shoulder pathology considerations (i.e. playing with labral damage, chronic instability)
• Paget-Schroetter (Effort Thrombosis)
– What to look for, treatment, return to play following an episode
• Suprascapular Nerve Impingement
• Other nerve injuries about the shoulder
Stingers/Burners
• Transient sensation of burning, pain, numbness or tingling in a unilateral upper extremity, which may be accompanied by motor weakness.
• Estimated that more than 50% of collegiate football players sustain a stinger each year.
Mechanism of Injury
Older, stronger Younger, weaker
Direct Blow Compression Traction
Pathology
• Traction injuries commonly involve the C5 root and upper trunk, resulting in deltoid and biceps weakness (C5 myotome).
• Most symptoms resolve within minutes, with full sensorimotor symptoms resolution within 1 to 2 days.
Presentation
• Comes off the field holding arm in sling-like position, similar to shoulder dislocation
• Bilateral symptoms should be evaluated for spinal cord injury
• Cervical range of motion and compression should be evaluated
Return to Play
• Return of strength
• Cervical ROM and compression without symptoms
• 3 occurrences in one season, consider ending season and work-up
Referral
• Persistence or recurrence of symptoms, an abnormal physical examination, or symptoms concerning for a more central process preclude a player from returning to the game and require further imaging such as cervical spine MRI.
• Frequent recurrences, often with extension-compression mechanism, suggests cervical canal stenosis or foramina stenosis.
• Symptoms that continue longer than 2-3 weeks should be evaluated with EMG
Prevention
Paget-Schroetter SyndromeEffort Thrombosis
• A rare subset of thoracic outlet syndrome in which deep venous thrombosis of the upper extremity occurs as the result of repetitive overhead motion
• May lead to pulmonary embolism (20-30%)
• Early intervention can be lifesaving
Bushnell, et al, Sports Health. 2009;1(6):493-9
Mall, NA, et al, Sports Health. 2013;5(4):353-6
Paget-Schroetter SyndromeEffort Thrombosis
• Thoracic Outlet Syndrome (TOS)
– Neurogenic
– Venous
– Arterial
• Paget-Schroetter Syndrome (PSS) is a subset of the venous subgroup
• Described by Paget in 1875 and von Schroetter in 1884
• Effort Thrombosis coined by Adams and DeWeese in 1971
PSS
• Incidence of 1-2 cases per 100,000 individuals per year
• Deep venous thrombosis of the subclavian vein due to repetitive activity of the shoulder, typically hyperabduction and external rotation
• Young, healthy, athletic men in overhead athletic or occupational activities, most commonly baseball
• Also softball, wrestling, swimming, hockey, martial arts, backpacking, racquet sports, pass blocking, repetitive lifting, chopping wood and billiards
PSS: Causes of Upper Extremity ThrombosisI Intimal injury
a Penetrating trauma i Intravenous catheter placementii Stab woundiii Vascular surgery procedure
b Blunt trauma i Sudden blow to shoulder/armii Sustained pressure from positioning during surgery or while otherwise unconscious
c Extrinsic compression i Thoracic outlet syndrome
1 Cervical rib2 Clavicular exostosis3 Anterior scalene hypertrophy4 Musculofascial banding5 Sternoclavicular joint arthrosis
ii Clavicle fracturesiii Local compressive neoplasm or massiv Repetitive overhead activity
1 Normal motion with anatomic predisposition2 Physiologic extreme motion with either normal or abnormal anatomy
d Caustic internal injury i Intravenous medicationsii Radiographic dyeiii Illegal drugsII Venous stasis
a Congestive heart failureb Radical mastectomy or other procedures altering venous flowc Local compression of venous system by neoplasm or massd Congenital malformations
III Hypercoagulability a Hematologic disordersb Cancer or other systemic diseasesc Oral contraceptivesd High altitude
PSS: Anatomy
• Subclavian vein passes through the triangular space bordered by the first rib inferiorly, the scalenus anterior posteriorly, and the subclavius muscle and tendon medially just posterior to the intersection of the first rib and clavicle
PSS: Pathoanatomy
• Hyperabduction and external rotation at the shoulder is the most common position
• Axillary vein may be compressed by the pectoralis minor and head of the humerus
• Subclavian vein compression occurs at the intersection of the clavicle and the first rib.
– Normal anatomy with extremes of motion and power
– Or anatomic predisposition
– Or hypercoagulability
PSS: Presentation
• Pain, swelling, weakness, color or temperature differences, or a sense of “heaviness” or “dead arm”
• Venous engorgement, dilated superficial veins, swelling, discoloration, palpable axillary cords, and abnormal Adson or Wright maneuvers
I Symptoms: affected areas include the neck, shoulder, and axillary region a Heaviness or dead armb Achingc Easy fatigued Discoloratione Swellingf Tinglingg Numbness
II Signs: affected areas include the neck, shoulder, and axillary region a Edema with or without pittingb Erythemac Mottling or bluish/purple coloringd Dilated superficial veinse Palpable axillary cordingf Low-grade feverg Positive Adson maneuver: palpation of radial pulse with rotation of the head to
the ipsilateral direction with simultaneous inspiration reveals a dramatic decrease in or disappearance of the pulse or the onset of paresthesias.
h Positive Wright maneuver: palpation of the radial pulse with hyperabduction and external rotation of the shoulder reveals progressive decrease in or disappearance of the pulse or the onset of paresthesias.
PSS: Common Symptoms and Signs
PSS: Testing
• Duplex ultrasound 71-100% accurate
• Contrast venography is the gold standard
PSS: Differential Diagnosis
• Neurologic thoracic outlet syndrome
• Arterial thoracic outlet syndrome
• Malignant tumors of the head, neck or arm
• Pan coast tumor
• Complex regional pain syndrome
• Brachial neuritis
• Cervical nerve root compression
• Quadrilateral space syndrome
• Peripheral nerve compression
PSS: Treatment
• Multimodal (Outcomes are poor with anticoagulation as single therapy)
• Initial thrombolysis - best within 10-14 days
• Oral and/or low-molecular-weight heparin anticoagulation for 3-6 months
• Evaluation for thoracic outlet syndrome and vessel integrity
PSS: Treatment
• If due to thoracic outlet syndrome, may involve first rib resection, scalenectomyand venolysis
• If venous integrity is compromised (venous stenosis), care may include angioplasty, vein reconstruction, and/or formation of a temporary arteriovenous fistula
• Multimodal treatment success:
– 87% symptom relief
– 80% total venous recannulization
• Mean return to sport 3.5-4.4 months
Suprascapular Nerve
• Suprascapular nerve at the suprascapular or spinoglenoid notch - mimic rotator cuff disease
• Suprascapular notch entrapment - supraspinatus and infraspinatus
• Spinoglenoid notch compression - infraspinatus
• Posterior/superior labral tear with paralabral cyst
Anatomy
Presentation
• Vague posterolateral shoulder pain, muscle fatigue with overhead activities
• Weakness of external rotation and/or abduction
• Atrophy of the infraspinatus and/or supraspinatus
Differential Diagnosis
• Rotator cuff tear
• Central neurologic discorders
– cervical spinal disc protrusion
– cervical spin instability
– spinal cord contusion
• Transient brachial plexopathy
Spinoglenoid Notch Cyst
16 year old FB, WR, T&F thrower
Spinoglenoid Notch CystPosterior Labral Tear
Infraspinatus Muscle Atrophy
• Common finding in high-performing tennis players, and if asymptomatic, does not appear to significantly compromise performance.
• 52% of professional female tennis players had infraspinatus atrophy in their dominant shoulder
• Also noted in dominant shoulders of volleyball and baseball players (4-34%)
Young, SW, et al, Am J Sports Med. 2015;43(8):1989-93
Parsonage-Turner Syndrome
• Brachial neuritis, brachial plexus neuropath, brachial plexitis
• Rare (1.64/100,00), idiopathic, autoimmune inflammation
• Typically involves the suprascapular nerve, and variably involves the axillary and subscapular nerves.
PTS: Presentation
• Acute, sudden-onset pain radiating from the shoulder to the upper arm and/or paralysis of the supraspinatus, infraspinatus and sometimes deltoid
PTS: Prognosis
• Wasting and long-lasting
• Most cases resolve themselves and recovery is usually good in 18-24 months
Other NV Injuries
• Quadrilateral space syndrome
– compression of the axillary nerve by teres minor superiorly, teres major inferiorly, long head of triceps medially and proximal humerus laterally
• Thoracic outlet syndrome
– anomalous bands of pectoralis minor, and anomalous first rib or extremes of arm positioning
– heaviness, fatigue, cold intolerance, paresthesias, coolness and numbness -Wright test
Bibliography
Kibler, Orthopaedic Knowledge Update: Sports Medicine, AAOS, 2009
Miller, Orthopaedic Knowledge Update: Sports Medicine, AAOS, 2016
Physeal Injuries in Youth Sports
Aimee Brasher, MD
Pediatric Orthopaedic Surgery
Ann & Robert H. Lurie Children’s Hospital of Chicago at Northwestern Medicine Central DuPage Hospital and Northwestern Medicine Delnor Hospital
• Describe anatomy and physiology of physis
• Discuss acute physeal injuries
• Discuss chronic physeal injuries
• Propose reasons for concern
• Propose injury countermeasures
Objectives
Background
• Widespread participation in sports
• Year round training
• Early specialization
• Risk injury to young athlete
Background: Concern
• Mechanical stress on physis
Football
Hockey
Lacrosse
• Repetitive stress on physis
Baseball
Gymnastic
Cross country
Background: Concern
• Physeal growth disturbance
Limb length discrepancy
Angular deformity
Altered joint mechanics
• Long term disability
Anatomy and Physiology
Anatomy and Physiology
• Children are NOT little adults!!!
• Unique A+P
Fracture patterns
Treatment protocols
Healing potential
• Understand differences
• Treat accordingly
Anatomy and Physiology
• Children are NOT little adults!!!
• Growing bone
Epiphysis
Physis
Metaphysis
Diaphysis
• Periosteum – thicker
Reduction
Healing
• Remodeling potential
Anatomy and Physiology
Germinal/Resting zone
• Attached to epiphysis
• Small cells
• Surrounded by thick matrix
• Germinal stem cells
Crucial to longitudinal growth
• Fractures -> long term consequences for growth
Proliferative zone
• Thin cells
• Surrounded by thick matrix
Hypertrophic zone
• Cells enlarge
• Less room for ECM
Weakest layer
Most common location of fractures
Provisional calcification
• Metaphyseal vascular invasion
• Mineralization
• Remodel
• Removed
• Replaced by mature bone
strongest
Secondary ossification centers
Closure of physis
Susceptibility to Injury
• Physeal cartilage - weak
Tendons
Ligaments
Articular cartilage
• Adults – sprain/tear ligaments
Dislocate joints
• Children – physeal fractures
Sprains very rare!!!
Susceptibility to Injury
• Periods of rapid growth
Pubescent growth spurt
• Structural changes
Thicker, more fragile physis
• Bone mineralization slower than linear growth
More porous
Acute Physeal Injuries
Salter Harris Classification
SALTRI: Straight across II: Above III: LowerIV: ThroughV: Rammed
SH - I
• Xrays
No fx line
Soft tissue swelling
• Low risk growth arrest
Physeal separation through zone of hypertrophy
SH-II
• Metaphyseal fragment on compression side
• Periosteum intact
Reduction – stable
• Low risk of growth arrest
Physeal separation w metaphyseal spike
SH-III
• Begin in epiphysis
• Extend vertically
• Through physis
• INTRAARTICULAR
Anatomic reduction
• Involves germinal and proliferative zones
Increased risk of growth arrest
Physeal separation w extension across the epiphysis
SH-IV
• Begins in epiphysis
• Through physis
• Metaphyseal spike
• INTRAARTICULAR
Anatomic reduction
• Prevent cross union b/w epiphysis and metaphysis
Growth arrest
Epiphyseal fx through physis and into metaphysis
SH-V
• Compression
• Difficult to diagnose
• Xrays
SH-I fx
• Late physeal arrest
Acute Physeal Fractures: Epidemiology
• 30% children’s long bone fx
• M:F = 2:1
• Boys: 12-15yo
• Girls: 9-12yo
• Most common
Phalanges
Distal radius
Distal tibia
Acute physeal fractures
• Competitive sports – 34%
Football
• Recreational activities –22%
Bicycles
Skateboards
Playgrounds
• MVA
• ATVs
Treatment Goals
• Obtain and maintain acceptable reduction
• Prevent further injury to physis
• Return to sports!
Factors affecting treatment
• Age – growth remaining
• Severity of injury
• Anatomic location
• Degree of residual deformity
• Time elapsed from injury
>7 days
SH I-II fx
Do not attempt reduction
• Preinjury level of activity
Longitudinal Growth %
Average growth per year
Location Ave Growth(mm/yr)proximal humerus 7distal humerus 2proximal radius 1.75distal radius 5.25proximal ulna 5.5distal ulna 1.5proximal femur 3.5distal femur 9proximal tibia 6distal tibia 5proximal fibula 6.5distal fibula 4.5
Why important?
• Remodeling potential
• Younger patient
• Proximity to physis
• In plane of motion
• 13 yo boy
• Presented 4wks post-injury
• 6months later
• 4yo boy
• Acute injury
• 3 wks postinjury
• 12 wks postinjury
Treatment Principles
• ABC’s trauma protocol
• Life threatening injuries
• Neurovascular injuries
• Open injuries
• Reduce/stabilize fracture
General Principals
• Respect physis
One attempt at reduction
• Min/no displacement
Immobilize 3 wks SH I,II
Immobilize 4-6 wks SH III, IV
• Displaced SH I or II – reduce
Immobilize for 3 weeks
• Displaced SH III or IV – ORIF
Fixation: parallel to physis
Chronic Physeal Injuries
Chronic Physeal Injuries
• Repetitive loading
• Disrupts metaphyseal blood supply
• Interferes w mineralization of cartilage
• Widened zone of hypertrophy
Necrosis
Deformity
Long term disability
Chronic Physeal Injuries
• Overhead athletes
Baseball pitchers
• Little leaguer’s shoulder
• Little leaguer’s elbow
Little leaguer’s shoulder
Widening of proximal humeral physis Normal contralateral proximal humeral physis
Little Leaguer’s elbow
• Gymnasts – distal radius
• Widened physis
• Cystic changes/irreguarlity of metaphysis
Chronic Physeal Injuries
Chronic Physeal Injuries
• 14 yo female gymnast
• R wrist pain
Normal left wrist – physis open Right wrist – premature physealclosure distal radius
Treatment
• Rest until pain free
+/- immobilization
• Advanced PT/OT
• No return to sports until cleared by PT
• Altered training schedule
Reasons for Concern
Potential Complications
• Growth disturbance
Arrest - LLD
Angular deformities
• Nonunion
• Malunion
• Infection
• Neurovascular injuries
• Osteonecrosis
Growth Disturbance
• Which physis
• Location within physis
• Duration of injury
• Skeletal maturity
Growth Arrest
• Complete
• Partial
Peripheral
Central
Combined
Growth Arrest
• Medial malleolus
Growth arrest - Overagressive treatment of physealfracture distal radius
Treatment
• PREVENTION
• Careful evaluation
• Radiographs
• MRI
• Predict growth remaining
• Growth modulation
LLE Genu valgum
Bony bar
Injury Prevention
Prevention
• Proper training and equipment
• Individualized training – rapid growth
Decrease loads
Delay specialization
• Avoid excessive repetitive movements
• Diet and nutrition
• Equalize competition
• Periodic physical exam
• Adequate rest
• Widespread sports participation
• More competitive
• Earlier specialization
• Risk of physeal injury
• Understand pediatric anatomy
Susceptibility – fracture NOT sprain
• Understand unique aspect of healing
Faster time to union – early treatment
Remarkable remodeling potential
Conclusions
Questions?Thank you.
Hand Fractures In Athletes
Thomas W. Kiesler, MD
Hand Microsurgery, Orthopaedic Surgery
Northwestern Medicine
Hand Fractures
• Importance is often downplayed
many injuries heal well with minimal attention
• Significant injuries dismissed as “sprain”
suboptimal healing at best
long-term disability at worst
• Questions:
When do you treat?
Can the athlete still play?
Can treatment wait till season over?
If treat now, how long will they be out?
Does this injury end their season/limit career/career advancement?
Hand Fractures
• Must weigh risks/rewards of potential treatment scenarios
• Player/parents must be informed
accept risks of treatment
accept consequences of treatment
• Be ready to alter original plan if condition changes
• Have next option in mind if change occurs
• Have salvage plan
• NO cookbook answer for all athletes
• Most recommendations based on small case series
• Treatment dependent on
Sport
Position
Time in season
Tolerance for risk / What’s at stake
Hand Fractures
• Philosophy
Treat athlete as person, FIRST• Consider:
• Short term goals: this season
• Mid term goals: career
• Long-term goals: the players life after the career
• ALL decisions must be optimized to honor all three
Sideline Management
• Focused History
age, hand dominance
current complaints
mechanism of injury
position of hand at time of injury
previous injuries
player’s position and expected needs
Sideline Management
• Physical Exam
tenderness
stability
range of motion
tendon integrity
sensation
vascularity
* follow-up initial sideline exam after the game
Sideline Management
• Immobilize: Return to Play
• Restrict from return to play:
deep lacerations, open wounds
swelling
gross deformity
limited range of motion
pain or weakness
neurovascular compromise
Return to Play
• Criteria
no deformity
full range of motion/strength without significant pain
Able to play position• Safely
• Well enough to help team/self
Referral
• Location
Emergency Department
Urgent Care
Doctor’s Office
• Reasons
swelling
deformity
stiffness
Pain
wounds
X-rays
»Every patient with a significant musculoskeletal complaint resulting from a sports-related injury requires radiographic evaluation!!!
X-rays
• YOU DON’T HAVE XRAY VISION
• Xray:
“Cheap”
“Quick”
Now you know, no more guessing
Move on to:• Referral
• “Return to play”
Swollen Finger: NO XR = Missed Injury
6/17/2016 110
Finger Injuries
• Mechanism
* “I jammed it!”
axial load
hyperextension
hyperflexion
Deviation
• Sideline Management:
Coban
Splint where it lies
Deformed• Longitudinal traction / splint
Wound• Sterile saline irrigation
• Sterile guaze
• Coban: edema control
• Splint
• referral
Common Acute Finger Fractures
• DIP joint
mallet finger
jersey finger
• Distal phalanx
• PIP joint
sprains
Fracture –dislocations
Middle phalanx
● MP joint
– Fractures
– Proximal Phalanx
– Metacarpal fractures
DIP Joint Injuries
• Distal phalanx fractures:
• Non displaced Jersey finger
FDP insertion
• Mallet Finger
Terminal extensor insertion
Jersey Finger
• Etiology
avulsion of flexor digitorum profundus(FDP) tendon
with or without fracture
• Mechanism
forceful extension of flexed DIP joint
Grabbing a jersey-jersey going the other way!
Commonly missed injury!!
• PE:
Absence of isolated DIP joint flexion
Block DIP joint, assess FDP
• Diagnosis:
Need MRI to determine if tendon attached to fragment
Jersey Finger: Fractures• Treatment SURGERY-within 5-7 days• If tendon avulsed from fragment
SURGERY-within 3 weeks • Tendon attached to fragment• Fragment at DIP
repair of distal phalanx base and FDP tendon • As unit• separately
timing can be critical depending on level of retraction of FDP tendon stump
Rehabilition/Return to play: Flexor tendon:• Attached to fragment: 6-8 weeks• Avulsed from fragment: 3 months
Alternative• Return to play immediately• Excision of FDP in offseason• ***Permanent loss DIP flexion***
Mallet Finger
• Etiology
disruption of the extensor mechanism of DIP joint
with or without fracture
• Mechanism
forceful flexion of extended DIP joint
• Exam:
DIP joint flexed
PIP hyperextended
Tenderness DIP joint dorsally
• Complications:
Nonunion: Pain/stiffness
Swan Neck Deformity-Imbalance
Mallet Finger
• Treatment
Splinting-full time • 4 weeks nondisplaced
• 6-8 weeks displaced
surgery (rare)• Required if joint not congruent
• subluxation of fragments
• Wide displacement
Mallet Finger
• Return to sport
Can be immediate—in splint/protected
When threat of displacement in splint is minimal
Too early return: risk re-injury
• Displacement
• Surgery
• Prolonged absence
PIP Joint Injuries
PIP Injuries
• Sprains
• Fractures
• Dislocations
* All can look the same!!!
* Need X-rays!!!
PIP Sprain/Fracture
• Collateral Ligament
proper (PCL)
accessory (ACL)
• Volar Plate
• Volar Plate Avulsion Fracture
bony equivalent
PIP Sprain/Fracture
• Natural History
Stiffness
FLEXION CONTRACTURE
not instability!
• Treatment
aggressive protected mobilization
Edema control
buddy taping
IF VOLAR INJURY IS PREDOMINANT• Dorsal blocking splint
• Prevent hyperextension/instability
• ROM in splint for 3-4 weeks
• Transition to extension splint
PIP Sprain/Fracture
• Return to Sport
as soon as pain and swelling subside and motion is restored
protective buddy taping for 3 months post-injury
PIP Sprain/Fracture
• Complications
volar plate contracture
• “pseudoboutonniere deformity”
• flexion contracture
volar plate laxity
• chronic PIP hyperextension
• swan neck deformity
• Difficulty initiating flexion at Pip
• Lateral band dorsal subluxation
may require further splint treatment or surgery if finger function significantly affected
PIP Fracture-Dislocations
• Palmar lip fractures of middle phalanx base
dorsal subluxation of middle phalanx on proximal phalanx
PIP Fracture-Dislocations
• Palmar lip fractures of middle phalanx base
dorsal subluxation of middle phalanx on proximal phalanx
fractures involving > 40% of articular surface
• Treatment Goals:• Congruent joint
• Healed fracture
• Regain ROM/function
• Treatment
urgent closed reduction
adequate anesthesia
assess joint congruency and stability after reduction
• x-rays
• exam
PIP Dislocations
• Extension Block Splinting
PIP congruency able to be maintained with joint flexion
simple fracture dislocations
P2 palmar lip fractures involving < 40% of articular surface
PIP Fracture Dislocations
• Surgery
displaced fractures
impaction of articular surface of middle phalanx base
PIP joint unable to held reduced by splinting in flexion
open dislocations
PIP Fracture Dislocations
• Surgery
impaction of articular surface of middle phalanx base
joint subluxation
ORIF: screws/plate
Hemi-hamate arthroplasty
PIP Fracture Dislocations
• Surgery: immediate
open dislocations
PIP Fracture Dislocations
• Return to sport
4-8 weeks post-injury for contact/impact/ball sports
protective buddy taping until 3 months post-injury
• Sequelae
stiffness
post-traumatic arthritis
MP Joint Injuries
• Periarticular fractures
Fracture + possibility of instability
Impact grip / pinch strength
Require treatment to restore stability
Thumb MP Joint
• Skier’s Thumb Fracture
UCL injury: UCL avulsion fracture
Ligament incompetent
results in instability of thumb MPJ
Skier’s Thumb Fracture
• Evaluation
Tenderness/swelling/bruising• Ulnar MP joint
X-rays first:• Determine if fractured
stress testing of UCL integrity
• 0° extension (PCL)
• 30° flexion (ACL)
compare to uninjured thumb!
Thumb UCL Avulsion Fracture
• Nondisplaced
• Conservative Treatment
thumb spica splint or cast
4-6 weeks
rehabilitation
• Displaced
• Surgery
UCL avulsion fragment repair
protect repair with splint for 4-6 weeks
rehabilitation
Phalangeal Fractures
• Distal Phalanx
Nondisplaced • Splint 3-4 weeks
• Return to play?
• Depends on sport/position
Displaced fractures• Closed reduction/pinning
• Out of sport for 4 weeks
• Splint additional 2 weeks
Watch for occult open fractures • Open growth plate
• Clues:
• Nailplate avulsion/bleeding
Proximal Nail Plate AvulsionsBEWARE!!!!
• Flexion/crush injury
• Nail plate avulsed from proximal nail fold
Compresses proximal nail fold beneath it
• Be aware of occult physeal fracture at distal phalanx base —Pediatric: Seymour fracture
• If bleeding, at base of nail it is can be an open fracture
Higher chance of infection
Higher chance growth arrest
Higher chance nail deformity
• Nailbed could be trapped in fracture
• Skin at risk for necrosis
• Treatment:
Immediate HAND Consult
Formal I&D, pinning of Fx and nailbed repair
137
Proximal Nail avulsionsSeymour Fracture:
138
Proximal Nail avulsions/Seymour Fracture: Complication
6/17/2016 139
Phalangeal Fractures
• Middle /Proximal Phalanx
Nondisplaced• Orthoplast splint
• Playing cast?
• Immobilize 4 weeks
• Protect for 2-3 weeks
Displaced/unstable/open• Surgery
• Pinning vs plating
Return to play• 4-8 weeks
• Can’t play till pins out/sutures out
• Skilled vs non skilled positions
• Club?
Metacarpal fractures
• Nondisplaced
Splint/cast 4-6 weeks
• Return to play:
Able to play with splint?
Pain tolerable to play?
Risks displacement / surgery? • Displaced
Transverse (length stable)• Attempt closed reduction casting
• Anatomic
• Treat as nondisplaced
• Nonanatomic
• Interposed muscle
• Treat surgically
Spiral/short oblique: Not length stable• Usually rotated
• Not acceptable
• Surgery ORIF
• Early mobilization/OT
Metacarpal fractures
Playing splint at
4 weeks
Conclusions
• Hand/Finger injuries
Just as important as the knee!!
If any doubt, get an Xray
ALWAYS GET AN XRAY
Treatment dependent on a host of factors
Balance return to sport with• Adherence to fracture healing principles
• Avoiding complications
• Position/point in season/handedness/future
Patient/parents make decision WITH you
Full Disclosure current risks / future risks
BACK TO SPORT!!
Upper Extremity Peripheral Neuropathies in Sports Medicine
Steven E. Mayer, MD
Physiatry, Physical Medicine and Rehabilitation, Sports Medicine
Northwestern Medicine
Anatomy
Anatomy
Anatomy
Nerve Injury
Nerve Injury
Peripheral Neuropathies
• Median Neuropathy
• Ulnar Neuropathy
• Radial Neuropathy
Median Neuropathy
• Most common UE neuropathy
• Typically affected at the carpal tunnel
• Rarely, at the pronator teres muscle
Carpal Tunnel Syndrome
• Mostly, not related to sports, in general population
• Racquet sports, hand ball, etc….
• Can be post traumatic (Colles Fracture)
Carpal Tunnel Syndrome
• Numbess and/or pain
• Weakness
• Vague symptoms in the hand
Carpal Tunnel Syndrome
• Symptoms primarily with flexed wrist position
• Night symptoms very common
Carpal Tunnel Syndrome
• Exam
• Decreased sensation and 2 point discrimination
• Tinel’s Sign
• Phalen’s Maneuver
• Thumb abduction and opposition
Carpal Tunnel Syndrome
• Treatment
• Avoiding aggravating activities
• Splint
• Injection
• Surgery
Proximal Median Neuropathy
Anterior Interosseous Nerve Syndrome
• Branch to FPL, FDP (2,3), and PQ
• Weakness distal phalanx
• OK Sign
Ulnar Neuropathy
• C8/T1
• Elbow, most common
• Wrist
Ulnar Nerve
• Medial elbow, ulnar groove
• Under FCU
• Proximal to wrist - Dorsal Ulnar Cutaneous
• Enters Guyon’s Canal at wrist
• Usually chronic compression or stretch injury
• Motor and/or sensory symptoms
• Typically will not see weakness or clawing in athletes unless after trauma
Wartenberg’s Sign
Weak pinch - adductor and flexor pollicis
Flexor pollicis and Flexor digitorum profundus compensate
Ulnar Neuropathy at the Wrist
Radial Neuropathy
Descends around the spiral groove then to the elbow
Divides distal to lateral epicondyle into:
• Superficial Radial Sensory Nerve
• Posterior Interosseous Nerve
• Most common
• Compression
• Saturday Night Palsy
• Fractures
• Wrist/Finger drop with spared elbow extension
• Radial Neuropathy - Axilla
• Rare
• Compression - crutches
• Weak triceps present
• Normal deltoid and lat strength
• Posterior Interosseous Nerve
• Similar to spiral groove findings
• Spares brachioradialis and long head ECR
• No sensory deficit
• Superficial Radial Sensory Neuropathy
• Subq along radius distal to elbow
• Compression - bands, watches, bracelets, handcuffs
EMG/NCS
Thank You!
Medial Elbow Pain in Athletes
Richard Makowiec, MD
Hand Microsurgery, Orthopaedic Surgery
Northwestern Medicine
Overview
• Demographics and trends
• Anatomy
• Biomechanics
• Ulnar collateral ligament
• Valgus extension overload
• Medial epicondylitis
• Ulnar nerve
Medial elbow sports injuries
Baseball players are most commonly affected
97% of elbow complaints in pitchers
Football, volleyball, javelin
Pitching BiomechanicsKinetic chain that derives energy from the lower extremity, transfers that energy through pelvis and trunk rotation & releases it through the upper extremity
Pitching Biomechanics
Energy
Funneled into the sequentially smaller segments of the upper extremity
Elbow joint experiences tremendous biomechanical stress
65 Nm of valgus torque or 300 N of medial shear force at the elbow
Biomechanics of Throwing
5 Stages of Overhead Throwing
Stage I: Windup
Elbow is flexed / forearm pronated
Stage II: Early cocking
ball leaves gloved hand ends with forward foot contacting the ground
5 Stages of Overhead Throwing
Stage III: Late cocking
Shoulder abduction and maximal external rotation & elbow flexion and increasing forearm pronation
Stage IV: Acceleration
Internal rotation & adduction coupled with rapid elbow extension
Terminates with ball release
5 Stages of Overhead Throwing
Stage v: Follow through
Dissipation of kinetic energy
Deceleration of 500,000 deg/sec2 in 50 msec
Ends when motion is complete
Injury Trends: Major league baseball
• Epidemiology
Similar rates & types of injuries in collegiate and minor league levels
400 Mucl repairs in mlb players from 1974-2015
• Increasing incidence with 1/3rd done in last 5 years
• 90% pitchers
• Offsets decreasing shoulder injuries
Mean return time to competition 17.1 months
Dines et al. (2016). Injury Trends in Major league Baseball Over 18 Seasons: 1998-2015. Am. J. Orthopaedics 45(3): 2016
Injury Trends: Major league baseball
• Dramatic increase in number of MUCL reconstructions
1/3rd of all MUCL reconstructions done in last 5 years
• 25% of all major league pitchers and 15% of all minor league pitchers
• Overall, pitchers have the most injuries
Of these, ½ are elbow injuries
Similar rates reported at collegiate and minor league levels
MUCL injuries represent the most costly of all injuries
Dines et al. (2016). Injury Trends in Major league Baseball Over 18 Seasons: 1998-2015. Am. J. Orthopaedics 45(3): 2016
Elbow Injuries in throwing athletes
• Increasing in frequency
Associated with maximum pitch velocity
Typically occur during late cocking/early acceleration phase
• Valgus torque reaches 65 nM with angular velocity of 5000 /̊sec
• 3 Major forces on elbow
• Tensile stress on UCL
• Compression force on radiocapitellar joint
• Shearing stress posteriorly on the medial tip of olecranon and olecranon fossa
Medial Elbow Bone Anatomy
• Gynglymus hinge
• Medial
Ulna
Medial epicondyle
Ulnotrochlear joint
• Lateral
Radiocapitellar joint
Lateral epicondule
Medial elbow ligaments
• Medial ulnar collateral ligament
3 Distinct bands (ligament complex)
• Transverse band contributes little
• Anterior band is the primary stabilizer with the elbow flexed
Medial elbow muscles
• Common flexor pronator muscles
FCR
FDS
FDP
FCU
PL
Medial elbow examination
• Medial epicondyle
Medial epicondylitis
• Mcl
Ligament instability
• Ulnar nerve
Ulnar neuritis or subluxation
• Medial triceps
Snapping triceps
Ulnar collateral ligament
3 Bands- anterior, posterior and oblique bundles
• Anterior bundle provides stability against valgus loads
• Throughout range of motion
• Posterior bundle
• Flexion beyond 90˚
• Oblique band doesn’t cross the elbow joint
Ulnar collateral ligament
• Patient history
Occasional “pop” while throwing
Vague pain / decreased velocity
• Late cocking / early acceleration
• Physical exam
Tenderness posterior and inferior to flexor pronator origin
Valgus stress test
Milking maneuver
Moving valgus stress test
Ulnar collateral ligament
• Imaging
Xrays
Mri
• Modality of choice
• Mri arthrogram
ultrasound
Ulnar collateral ligament
• Biomechanics
Valgus forces of 64 nM during late cocking and early acceleration
• Approaches maximal tolerable stress with every pitch
• Prevention
Challenging due to year round competitive play
Injury prevention in youth pitching is a public health concern
• Education of coaches and parents
Ulnar collateral ligament
• Treatment
Nonsurgical
• Partial tears
• No throwing x 6 weeks
• Rehabilitation
• Focus on mechanics
• Interval throwing program
• Platelet rich plasma
Surgical Treatment of UCL Injuries
Indications
Competitive athletes with acute ruptures
Chronic symptoms not responsive to conservative treatment
Goal: restore stability & maximize function
Ulnar collateral ligament
• Surgical treatment
Graft of choice is ipsilateral palmaris longus
Ulnar nerve can be transposed
Muscle splitting approach
Docking
Ulnar collateral ligament
• Surgical treatment
Postoperative management
• 3 months of guided therapy focusing on motion and strength
• Interval throwing program starts 4 months after surgery
• Competitive throwing at 12 months
Ulnar collateral ligament
• Results
80-90% of patients return to their prior level of competition
Surgical Treatment of UCL Injuries
Postoperative Regimen
Immobilization: 7-10 days
Week 2-4: AROM to shoulder, elbow and wrist
Week 4-6: Progressive strengthening of wrist and forearm but no valgus stress x 4 mos.
Month 3-4: Light toss / throwing program
Month 6-7: 50% maximum velocity
Functional performance is usually maximized at 12-18 months from surgery
Valgus extension overload
• Throwing pushes the olecranon in to the olecranon fossa
• Shear stress on the medial olecranon tip leads to osteophytes
• Valgus extension overload
Constellation of injuries
Ucl insufficiency, radiocapitellarcompression, posterior medial osteophytes
Valgus extension overload
• History
Repetitive throwing or overhead activity (tennis, lacrosse, gymnastics, javelin)
Pain @ posterior/medial elbow at terminal extension
Limited extension
Locking & catching
Valgus extension overload
• Crepitus & tenderness over posteromedial olecranon
• Loss of extension
Extension impingement test
Arm bar test
• Valgus laxity
• Moving valgus stress test
• Imaging
Radiographs show posteromedial osteophytes
Mri shows bone edema, loose bodies, stress fractures and ucl injury
Valgus extension overload
• Nonoperative is first line treatment
Modify activities and rest from throwing
Nsaids
Corticosteroid injections
Pitching mechanics
Valgus extension overload
• Operative treatment
Posterior compartment decompression
• Arthroscopic debridement
• Limited incision arthrotomy
• Ucl reconstruction if needed
• Post op progressive throwing program
Medial epicondylitis“golfers elbow”
• Common flexor/pronator tendon origin
Degeneration and microtrauma
• Repetitive eccentric loading of muscle
• Eccentric contracture with valgus load
4th-6th decade of life
Equal incidence in men and women
Medial epicondylitis“golfers elbow”
• History
Medial elbow pain
Insidious onset
Overhead throwing, golf, tennis
Late cocking & early acceleration
Occupational repetitive forceful gripping
• Physical exam
Tenderness over anterior medial epicondyle
Diminished grip
Pain with resisted wrist flexion and pronation
Elbow contracture
Medial epicondylitis“golfers elbow”
• Nonsurgical treatment
Ice
Nsaids
Counterforce bracing
Corticosteroid injection
Prp
Physical therapy
Medial epicondylitis“golfers elbow”
• Surgical treatment
Mini open debridement
• Remove pathologic tissue
• Start strengthening @ Week 6-8
• Return to sport at 3-6 months
Ulnar nerve injuries
• Ulnar neuritis
Ulnar nerve is stretched repeatedly in throwing athletes
“electrical shock” sensation radiating down arm
Painful snapping
Paresthesias and/or pain in ulnar nerve distribution
Can persist even after throwing stops
Functional Anatomy: Ulnar nerve
Susceptible to injury during overhead athletic acitivities
Floor of cubital tunnel is the UCL
Sensory fibers are more peripheral and anteromedial
Prone to injury
Return to throwing program
• Interval based throwing program
Kinetic chain concept
• Stride
• pelvis rotation
• upper torso rotation
• elbow extension
• shoulder internal rotation
• wrist flexion
• Principles
Each level must be completed pain free
Adequate warm up
mechanics
Chang et al. (2016). Interval Throwing and Hitting Programs in Baseball: Biomechanics and Rehabilitation. Am. J. Orthopaedics 45(3): 2016
Return to throwing program
• Phase 1
Proper mechanics
Flat ground 45, 60, 90, 120, 150, 180 ft
Pitchers stop at 120 ft
• Then move to 60’6”
All about mechanics
• Phase 2
Throwing off mound
50%, 75%, 100% velocity
Increase volume and effort gradually
Return to throwing program
Summary
Throwing injuries to the elbow are becoming more common
Mechanisms of injury is consistent
Injury pattern differs based on age
Understand the biomechanics
When does it hurt?
Summary
Injury prevention begins with avoiding overuse and proper conditioning
Nonsurgical treatment works well if treatment is instituted at an early stage
Early recognition is key
Injury prevention begins with avoiding overuse
Summary
Advancements in rehab protocols and surgical treatment have improved restoration of function in throwing athletes
The End“Frank Jobe's fix is one of few things that truly changed the game of baseball, and should be
remembered alongside the advent of night games, the live ball, and maybe even Jackie Robinson.”
Thank You
Medical Issues in Sports Medicine:When can the athlete be cleared?
Matthew D. Gimre, MD
Sports Medicine
Northwestern Medicine
Medical Issues in Sports Medicine
• Understand the basic clinical characteristics of select medical issues in sports medicine, specifically: infectious mononucleosis, febrile illness, and exercise-induced bronchoconstriction.
• Understand the relevant considerations regarding safe return to play.
• No speaker disclosures.
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Objectives
Infectious Mononucleosis (IM)
• Epstein-Barr virus.
• Eventually infects 90% of people by adulthood.
• Clinical course is different in children (typical viral illness) and adults.
• Peak incidence is in adolescents and young adults, with an annual incidence of 1% to 3% for developing IM.
• Humans are the only host.
• Transmission mainly through oral secretions (including sneezing or sharing food and drinks).
General characteristics
Infectious Mononucleosis (IM)
• Incubation period of 30-50 days, making the source of infection difficult to determine.
• Possible prodrome of malaise and headache before fulminant illness.
• Fever. Chills, fatigue.
• Cervical lymphadenopathy, including posterior chain (possibly painful and tender).
• Pharyngitis (at least 80%), including tonsillar enlargement. Co-existing strep throat in up to 30% of cases!
• Splenomegaly (50-100%).
• Palatal petechiae (25%).
• Rash on trunk and upper arms (10-40%). Rash much more likely with inadvertent use of antibiotics for diagnosis of strep throat (ampicillin or amoxicillin).
• Periorbital edema.
• Jaundice, central nervous complications, myocarditis (rare).
Clinical manifestations
Infectious Mononucleosis (IM)General characteristics
Infectious Mononucleosis (IM)Lymphadenopathy
Infectious Mononucleosis (IM)Exudative pharyngitis. Palatal petechiae.
Infectious Mononucleosis (IM)
• Typically is needed to confirm diagnosis.
• Elevated lymphocytes on complete blood count (CBC), including more than 10% atypical lymphocytes.
• Positive Monospot test (heterophile antibody test).
Sensitivity 87% (range 79% - 95%). False negative more likely early in illness, Repeat if clinically indicated.
Specificity 91% (range 82% - 99%). False positives considered rare. False positives possibly with lymphoma, hepatitis, autoimmune disease (lupus, e.g.).
• Possible specific antibody tests, if needed.
Laboratory diagnosis
Infectious Mononucleosis (IM)
• Mild to severe range of severity.
• Generally requires rest and supportive care.
• Typical resolution in 4-8 weeks, though occasionally it can take up to 3 months.
• Complications (up to 5% of cases):
Aplastic anemia, Guillain-Barré syndrome, meningitis, encephalitis, neuritis, lymphoma, hemolytic-uremic syndrome, disseminated intravascular coagulation (DIC).
Severe clinical course if patient is immunocompromised.
Chronic fatigue syndrome? (possible connection)
Airway compromise.
Splenic rupture.
Clinical course
Infectious Mononucleosis (IM)
• Can occur with significant tonsillar enlargement.
• Shortness of breath and increased respiratory effort, especially supine.
• Also, possible difficulty swallowing, with resultant dehydration.
• Prompt medical referral.
• Evaluation should also include test for strep throat.
• Oral corticosteroid (prednisone) treatment can be effective.
• Please note, oral corticosteroids generally are only indicated in this situation (or possibly in other severe complications), as they have not been shown to otherwise modify or shorten the clinical course of uncomplicated IM.
Airway compromise
Infectious Mononucleosis (IM)
• Significant concern in athletes, and therefore for ATCs and sports physicians.
• Enlarged spleen is nearly universal in IM, but rupture is rare. Clinical determination of splenomegaly is difficult.
• Incidence of splenic rupture is low, approximately 0.1% to 0.2% of cases.
• Can occur spontaneously! Can also occur with increased abdominal pressure, and with trauma.
• Spleen is most vulnerable in the first 3-4 weeks after illness onset -documented rupture after this timeframe is rare.
• Sign/symptoms of splenic rupture in general:
Abdominal pain and tenderness, particularly left upper quadrant.
Left shoulder pain.
Signs of vascular compromise from internal bleeding: decreased BP, increased HR, lightheadedness, decreased alertness, syncope, etc. This is a medical emergency!
Splenic rupture
Infectious Mononucleosis (IM)Splenic rupture
Infectious Mononucleosis (IM)
• Splenic ultrasound is controversial!
• Wide range of normal. Varies with height and weight, and with gender.
• Splenic rupture has been known to occur in the absence of splenomegaly!
• Would be helpful if somehow a baseline test were available, but of course this is not normally the case.
• Generally not recommended! In some cases, it an actually make management and return-to-play decisions harder.
Splenic ultrasound?
Infectious Mononucleosis (IM)
• No well-designed studies exist.
• Expert opinion.
• Risk of returning to soon can range from severe (splenic rupture) to mild (prolonged recovery).
• General guidelines:
Afebrile, symptom-free, well-rested, well-hydrated. No obvious splenic enlargement.
Light, non-contact exercise at 3 weeks. Some studies (military) suggest that light exercise could commence earlier, if the patient is afebrile and symptom-free prior to 3 weeks. This activity should not include exercises with significantly increased intra-abdominal pressure (weight-lifting or rowing, for example).
Return to contact is more controversial. The vast majority of splenic ruptures occur before 3 weeks, but it has been described out as long as 7 weeks. Risk is never zero.
A good rule of thumb is 3-4 weeks minimum, and light non-contact activity needs to be well-tolerated first.
Should be physician clearance.
I would recommend abdominal protection, if possible, based on the sport.
Return to Play Guidelines!
Febrile illness (not IM)
• Fever is any elevation above normal set-point, but generally > 38°C or 100.5°F.
• Conditioned athletes generally are more resistant to infection, though evidence exists that risk of infection increases with very high-intensity training.
• Fever affects the body’s ability to regulate body temperature, and leads to increased insensible fluid losses.
• Fever puts an athlete at increased risk of heat illness and dehydration.
• Febrile illnesses have detrimental effects on the musculoskeletal system, and has been shown to decrease muscle strength and endurance, reduce exercise tolerance, increase fatigue, and reduced speed and coordination.
• Febrile illness has been shown to decrease cardiac output (resulting in compensatory elevation of heart rate).
• The benefits of vigorous exercise (training) during a fever are questionable at best.
General considerations
Febrile illness (not IM)
• No evidence-based guidelines, only expert opinion-based guidelines.
• No guidelines support RTP before resolution of fever.
• If URI without fever, without dehydration, and no lower respiratory symptoms, athlete can be cleared if they can tolerate light-to-medium exercise without symptom worsening.
• If there is a fever, the athlete should sit out.
• If there is slight elevation of temperature (0.5-1°C above normal), with symptoms and elevation of heart rate 10 bpm above normal, the athlete should sit out.
• Consensus recommendation would be that if the fever and any associated dehydration have resolved, and the majority of other symptoms have resolved, then return to play can begin.
• Some guidelines suggest waiting 7 – 14 days after symptom resolution. (?)
• All guidelines suggest that athletic activity should be resumed gradually.
• Physician clearance is recommended.
Return to Play Guidelines
Exercise-induced Bronchoconstriction (EIB)
• Temporary airway narrowing during or soon after exercise.
• Slightly different than exercise-induced asthma (EIA), which occurs in athletes that already carry the diagnosis of asthma. Asthma has a significant component of airway inflammation, while pure EIB does not.
• EIB commonly has symptoms after exercise, while EIA is more likely to cause symptoms during exercise.
• Most patients with asthma with have some component of EIA.
• IF EIB is present, underlying asthma (and EIA) should be considered.
• Symptoms include cough, chest tightness or pressure, wheezing, shortness of breath, dizziness, or fatigue. Other diagnoses can also be considered if symptoms are new.
• Symptoms typically aggravated by cooler inspired air.
• Peak flow (PEF, peak expiratory flow rate) reduction of 15% during exercise (at least 80% maximal exertion) compared to baseline. Other tests available.
General considerations
EIB/EIA
• Rashidi Wheeler, a Northwestern football player, died in 2001 from and acute EIA attack. (There is some controversy regarding the circumstances, but EIA clearly played a role.)
Can be serious, and even life-threatening!
EIB/EIA
• If EIA, make sure asthma is well-controlled in general, including use of inhaled corticosteroids, and control of allergies. Ongoing daily maintenance is important. If not well-controlled, then trying to control it only on game-day will be difficult.
• A short warm-up (80% intensity) 15-20 minutes prior to exercise can be beneficial.
• An inhaled β₂-agonist such as albuterol 2 puffs 15 minutes before exercise is recommended. Other similar medications can be used.
Treatment
EIB/EIA
• Written action plan recommended.
• Any athlete showing signs/symptoms of airway hyper-reactivity should be removed from competition.
• Evaluation by ATC, and sideline MD, if available.
• Often symptoms can resolve simply with brief rest, or with administration of 2 puffs of the inhaled β₂-agonist (albuterol).
• If available, peak flow measurement can be helpful. A reduction from baseline of 15-20% or more would be consistent with an episode that requires observation and rest from play. A peak flow that returns to baseline after rest and inhaler treatment would be reassuring.
• If still symptomatic after 5 minutes, a second dose of 2 puffs from the inhaler can be administered.
• If symptoms persist or worsen, or if there are signs of respiratory distress, then medical referral or activation of emergency services should be considered, as appropriate.
Return to Play Guidelines and Considerations
Thank You!