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Football and netball seasonA review of the apophysis and the acute shoulder:
assessment
Simon Locke
Sport and Exercise Physician
Apophyseal injuries; How to
diagnose and manage?
Goals for tonight
• Recognise
– Skeletal maturity assessment
• Assess
• Investigate
• Manage
ApophysisThe apophysis is a normal bony outgrowth
that arises from a secondary ossification centre
and fuses with the bone in course of time.
Apophysis a site of tendon or ligament
attachment
Pelvic apophyses appearance/closing
Site Appearance (yrs) Fusing complete (yrs)
Iliac crest 13-15 15-17
ASIS 14 16
Ischium 15-17 19-25
Rossi et al (2001) Average age avulsion fractures 13.8 years
Schuett et (2015) Average age avulsion fractures 14.5 years
Maturity Risser staging
Mechanism apophyseal injuries
• Timing
• Peak Height Velocity (12 girls, 14 boys)– Bone density weakest
– Bone grow before MT unit – increasing stress at apophysis
• Acute
• Avulsion fractures
• Sprinting, kicking, jumping sports
• Overuse
• Long distance running
• Baseball pitching – elbow
• Gymnastics
*Rossi et al 2001
Case History• Patient
– Male, 14yrs
• Event
– Footy training
– Sprinting or sprinting to kick
• Symptoms
– Sudden onset pain, limp or cannot continue
• Local tenderness
• Function loss – ROM, strength
Injury site and prevalence
IT 11%
Males 82%
ASIS 30%
Males 75%
AIIS 49%
Males 82%
Relative Percentages of Pelvic
Avulsion Fracture Locations
• Ischial tuberosity – 54%
• AIIS – 22%
• ASIS – 19%
• Pubic Symphysis – 3%
• Iliac Crest – 1%
http://crashingpatient.com
Rossi F, Dragoni S. Acute Avulsion Fractures of
the Pelvis in Adolescent Competitive Athletes.
Skeletal Radiol. 2001;30(3):127-31.
Fracture type
• Associations
• Increasing age / maturity– Risser stage 0 - AIIS avulsion – 85% of all avulsion
injuries
– Risser 4 – ASIS, Iliac Crest – 84%
• Sex (males)– 76% of all avulsion fractures
Schuett et al 2015
Fracture displacement
• 69% of all fractures displaced <10mm
• 24% of all fractures displace 10-20mm
• 7% displaced >20mm
Schuett et al 2015
Prognosis
• Multiple fractures (14%)
• Bilateral avulsion injuries (6%)
• 98% conservative success
• Pain > 3 mos 14% (? Recurrence – 7%)
• AIIS most likely 4.47 times
– Postulates – sub spinal impingement, labral injury
• Non union (2%)
• Ischial tuberosity
• >20 mm displacement
Schuett et al 2015
Assessment• Age 14 yr male
• Sport
• Mechanism - sudden
• Examination• Local tenderness,
• ROM, weakness)
• Plain Xray (AP pelvis, frog leg lateral)• Fracture site, displacement
• Skeletal Maturity – Risser
• Triradiate physis status
Management
• Conservative
• 98% heal
• NWB crutches – 4-6 weeks
• Rehabilitation
• ROM, strength
• Gradual return to sport (fitness)
• Return to sport (10-12 weeks)
Surgical indications
• Risk appears 2%
• Displacement >20mm
• Persistent pain and disability >3 mos
Schuett et al 2015
ASIS Avulsion Fracture
Ischial Avulsion Fracture
11 yr male sprinting
Shoulder Injuries:
Acute dislocating
Instability
Clinical Problem
• 22 yo footballer
• Occupation – electrician subcontractor/ own business
• 1st Dislocated – last weekend
• Relocated in ER
• Current management IR
• When can I return to footy?• Definitive management
• Recurrence risk
• Impact on occupation
• Football importance
Why Bother?
• Are shoulder and upper limb injuries common?
• Dislocation
• Instability
• How do they happen?
• Approach to investigations – Xr, MR
• Treatment
Shoulder injuries are common in
athletes!!
QAS Screening injury Prevalence
Figure 4: Proportion of QAS athletes with current injuries by anatomical site
28.7%
23.8%
47.5%
Head, neck and spine
Shoulder girdle andupper limb
Pelvis, hip and lower limb
Shoulder Injuries in elite College Football (NFL)
Shoulder Injury Injury (%) Surgery (%,Y)
AC separation 41 12
Anterior Instability 21 76
RC tendon 10 13
Clavicle # 4 0
Posterior
Instability4 78
SLAP 2 40
RC tear 2 100
SC separation 2 0
MD Instability 2 50
Kaplan AJSM 2005
Injury Risk
Previous shoulder injury
Reported
Observed
Increasing player experience
Athletes have multiple injuries
1.3 per injured player*
*Kaplan AJSM 2005
Shoulder Anatomy
ClavicleACJointAcromion
Coracoid
Shoulder
Joint
Ligaments
SubscapularisTendon
BicepsTendon
Anterior Dislocation mechanism
• Arm forced into extension, abduction and
external rotation (ABER)
• Ant. capsule stretched torn
• Humeral head slips anteriorly
• Acute Injury - Intense pain / Paraesthesia
• Chronic Injury - Recurrent dislocation
• Subluxation
Anterior Dislocation
• Sharp contour of shoulder joint
• Prominent acromion
Anterior Dislocation
Anterior displacement of humerus
Defect of humeral head (HS lesion)
Chip fracture of inferior rim of
glenoid (Bankart)
Glenoid Labrum tear on MRI
Natural History Anterior Dislocation
Recurrence
85-90% recurrence young adults
Age
90% <20
65% 20-25 (Hovelius)
30% >30 (Simonet and Coldfield)
Sport
High risk
Robinson, C. M. et al. J BJS 2006
Recurrence after initial dislocation
Anterior Dislocation
Treatment
Reduction
Analgesia
ice, analgesics
Immobilization ER
Surgery
Rehabilitation
Immobilisation In ER
Basic Science – Cadaver study, MR“Coaptation zone” adduction +IR to 30º ER
MR Bankart lesion and glenoid closer in ER
Clinical Study Recurrence**Immobilisation 3/52
Follow-Up 15.9 mthsAll (40 yrs) IR (30%), ER (0%)
Young (<29 yrs) IR (45%), ER (0%)
Apprehension Sign +ve IR (14%), ER (5%)
*Itoi JBJS 1999,2001
**Itoi Am Acad OS 2003
Acute Dislocation Treatment Decisions
• Reduction – anterior
• Immobilisation (Recurrence rate)
Yes (90%) versus No
IR (45%) versus ER (0%)*
• Surgery, Risk Factors
• Age, Sport
*McCarty Clin Sports Med23,2004
Treatment Options
Conservative
Surgical – anterior instability
Open versus arthroscopy
Quality of life post treatment (work, family)
Prospective studies of Recurrence rates
Surgery recurrence 4-15%
Non Operation recurrence (age related) 30-80%
Instability - Clinical problem
22yo footballer – electrician (subcontractor/owner)
Tackled opponent with arm outside
Felt shoulder move
Pain on front of shoulder
Questions:
When can I play again?
What treatment do I need?
Shoulder Instability Injuries
• Anterior
• Inferior
• Posterior
• Multidirectional
Instability (MDI)
Recurrence following self report of
instability
• Self reported PH of instability:
• Dislocation HR 5.5(2.5-12.1)
• Instability HR 3.6 (1.8-7.4)
• Most common in 1st 2 years after initial event
Cameron et al JBJS 2013
Return To Play No Surgery*
• Is a safe return possible?
• Is there a difference between dislocation and subluxation injury?
• Is there a risk of further injury?
• Can the athlete protect themselves?
• Do they meet return to play criteria?• No Pain
• Normal ROM
• Normal Strength, Function, Sports, Skills
*McCarty Clin Sports Med23,2004
Final scenario
• Footballer 30 yrs age (final season)
• Married 2 children (2,4yrs)
• Own business
• What is your management?
• How do I get the best outcome for my patient?