10th annual sports medicine continuing education conference · 2018-09-05 · 10th annual sports...

10th Annual Sports Medicine Continuing Education Conference

Presented on: June 18, 2016

Presented by: Northwestern Medicine Orthopaedics

Northwestern MedicineHealth System Overview

Northwestern Medicine

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• Northwestern Memorial Hospital

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• Northwestern Medicine Valley West Hospital

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• 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

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Northwestern MedicineLocations

Evaluation of Upper Extremity Vascular and Nerve Conditions

David H. Watt, MD

Orthopaedic Surgery, Sports 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

• 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

Thank You

rmg.nm.com

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

• Children are NOT little adults!!!

• Unique A+P

Fracture patterns

Treatment protocols

Healing potential

• Understand differences

• Treat accordingly

• Children are NOT little adults!!!

• Growing bone

Epiphysis

Physis

Metaphysis

Diaphysis

• Periosteum – thicker

Reduction

Healing

• Remodeling potential

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

• 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

• 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

• 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

• Repetitive loading

• Disrupts metaphyseal blood supply

• Interferes w mineralization of cartilage

• Widened zone of hypertrophy

Necrosis

Deformity

Long term disability

• 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

• 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

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

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

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

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Finger Injuries

• Mechanism

* “I jammed it!”

axial load

hyperextension

hyperflexion

Deviation

• Sideline Management:

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

• Surgery

impaction of articular surface of middle phalanx base

joint subluxation

ORIF: screws/plate

Hemi-hamate arthroplasty

• Surgery: immediate

open 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

Proximal Nail avulsionsSeymour Fracture:

Proximal Nail avulsions/Seymour Fracture: Complication

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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

Anatomy

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)

• Numbess and/or pain

• Weakness

• Vague symptoms in the hand

• Symptoms primarily with flexed wrist position

• Night symptoms very common

• Exam

• Decreased sensation and 2 point discrimination

• Tinel’s Sign

• Phalen’s Maneuver

• Thumb abduction and opposition

• 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

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

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

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

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

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

• 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

• Imaging

• Modality of choice

• Mri arthrogram

ultrasound

• 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

• 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

• Surgical treatment

Graft of choice is ipsilateral palmaris longus

Ulnar nerve can be transposed

Muscle splitting approach

Docking

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

• 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

• History

Repetitive throwing or overhead activity (tennis, lacrosse, gymnastics, javelin)

Pain @ posterior/medial elbow at terminal extension

Limited extension

Locking & catching

• 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

• Nonoperative is first line treatment

Modify activities and rest from throwing

Nsaids

Corticosteroid injections

Pitching mechanics

• 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

• 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

• Nonsurgical treatment

Nsaids

Counterforce bracing

Corticosteroid injection

Physical therapy

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

• 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

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

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.

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

• 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.

• 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

• 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

• 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

• 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

• 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?

• 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!

10th annual sports medicine continuing education conference · 2018-09-05 · 10th annual sports...

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