SYMPOSIUM Sporting Injuries. Clinical Care

8/7/2019 SYMPOSIUM Sporting Injuries. Clinical Care

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Ankle and Foot

(Field) video analysis: Post-traumatic synovitis;to assess running style/faults seen at arthrocopy

Lateral ligament reconstruction Ankle splints are needed inleaping(using the Brostrom/Gould operation) impact sports; to treat andprevent

injury

Fractured calcaneus; Fx/dislocation talus withmarkedNow standard is to ORIF displacement. URGENTORIF.

Fractured ankle;Reduce in ER, to lessenSoft tissue damage then ORIF.





Children

Children are more prone to head injuries andShould wear helmets in most sports

Avulsion tibial spine Dislocated patella, easy to reduce

( carries the ACL). but slow rehab.Re-attach ( see Fig. below).

Kohler’s disease, AVN talus Fractures of the hip= disaster inchildren;Looks dramatic, but heals high complication rate. ORIF stat.

Spontaneously.



Knee- OCD



Approach to menisectomy based on vascularity.



Mal-tracking of the patella and version of the femur.





Elbow Injuries

Osteophyte formation behind elbow jntFrom valgus extension overload

Panner’s disease- Little leaguer’s elbow- repetitive stressleads osteochondritis of separation of med. epicondylethe capitellum resulting in AVN. and possible entrapment in jnt.

Osteochondritis dissecans Large olecranon bursaof the capitellum

Ulnar nerve Rupture lower end of biceps;Dyaesthesia surgically re –attach with bony anchor



Markedly displaced Closed reduction and held with 2 k-wires.S/C Fx humerus

Elbow joints=3

Elbow ROM.





OA from valgus loads















EYE

ACID BurnExtensive facial burns and destroyed globe from ACID BURN accident toface and eye.Left eye cannot be salvaged (needs glass eye).Take great care of his remaining good ®eye.Note: Acid burns not as bad as alkali burns as the latter penetrate the eye.

ALKALI BurnAlkali burn of the eye is subtle, easily missed and devastating. Note the

scleral whitening and corneal cloudiness due to alkali infiltration into thedeeper corneal layers.OCULAR EMERGENCY

Subtle penetrating injury. Note obvious corneal abrasion (near thelimbus), with a reactive ciliary injection. Note from inspecting the pupilthat there is a small intraocular foreign body (the corneal lesion is theperforation site).

Penetrating injury of the eye. This lady brought to ER with a firm, triple-layered eye pad for eye injury suspected penetration. DO NOT PAD thisway.

Note damage done to the eye if intra-ocular pressure is increased in thepresence of ocular penetration.Never firmly pad or manipulate a suspected penetrating injury of the eye.



Heterochromia. The difference in iris colour is due to iron deposition inthe left eye, after a long standing hyphaema (Fe comes from thehaemoglobin). Pupils dilated with mydriatic.

Severe subconjunctival haemorrhage with extensive protrusion of theconjunctiva. Check-out for ocular damage such as an orbital fracture.

Severe non-penetrating blunt trauma to eye with hyphaema, oval-shaped/irregular pupil and 360° iris detachment.EMERGENCY

CT scan shows obvious Fx in Right orbit with herniation of intra-oculartissue( fat or inferior rectus muscle).

Fundoscopy shows a Fractional retinal detachment from a penetrating eyeinjury.



Blunt trauma causing iridodialysis of the superior iris(11 oclock) andTraumatic mydriasis. Easily missed.

Head and Eye trauma. SCH, lacerations on lower eyelid and obvious VIIn. palsy. Examine Face AND Eye.

Corneal FB, insect bite.



Facial Skeleton

Subcondylar Fx fixed with arch bars and guiding elastics.

CT of zygomatic Fx

Internal fixation of mandibular Fx( mini-plates).

Angle Fx, involving impacted 3 rd molar tooth.



GI/GU problems

Torsion of the testis;Occurred whilst skiingthe moguls ( twisting action)

Testicular rupture. 18 yo M,hit in scrotum, indoor cricket, ultra-soundthen urgent exploration, reveal large testicular rupture, with a viable testiswhich was debrided and repaired.

Kidney trauma. 29 yo, M, soccer player hit in left loin n by knee, IVPreveals free extra-vasation of contrast from the collecting system.

Splenic abscess. 25 yo, M, footballer, 12 days after blow to upperquadrant, pain and fevers. CT reveals splenic abscess drained bypercutaneous drainage.

Avulsed shattered both spleen



Approach to menisectomy based on vascularity









Myositis ossificans Labral detachment at arthroscopyof the quads withmature bone formed

Hamstring sprain in resited extension in rugby tackle.

Groin strain in cutting sports, side-stepping or pivoting



Hip pointer from direct blow to iliac crest

Main nerves about the hip



Air splint neck collar on the ski fields

A good air way can be obtained with a mask.

Oral air-way is good if tolerated. Air way management



Removing helmet when neck suspected injured



Shoulder Injuries(copyright 2008 worldortho)

Shoulder dislocations:Fx surgical neck post reduction;patient with PRIOR hemi-plegia,radial nerve palsy

Typical presentation of Typical posture of POSTERIOR

shoulder;ANTERIOR shoulder (left) arm locked in internal rotationdislocation

(partial)Brachial plexus palsy Patient voluntarily dislocation shoulderPost reduction ( posteriorly (Beware: these patients dopoorlyExcessive traction) with surgery)

Winging of the scapula Rotator cuff tear SLAP lesion(see Fig.below)

Following shl dislocation(damage to long. th. N)



®Acromio-clavicular ® Anterior sterno-claviculardislocation,Dislocation, rarely operate(may require surgery)

Avulsion pectoralis Rupture long head biceps (rarelyoperate)Major muscle. Withlarge haematoma

Key to A/C injuries



Only operate on Types 5 & 6 (“ ear-ticklers”)

Pitching action





Checking for anterior or posterior translation of shoulder in instability.

Posterior

Hippocratic way to reduce shoulder Y-appearance of lateralscapula



+ve impingement sign for rotator cuff pain



Yergason’s test: resisted supination with flexed elbow=bicipital

tendinitis.

Resect wedge-shaped acromial fragment in acromioplasty(better to rasp from lateral aspect)



Lift-off test for subscapularis pathology( pain/rupture)





SportHazards of the EnvironmentDrugs in Sport

(Copyright 2008 WorldOrtho)

Essential for safe scuba diving Gastric erosion at endoscopy

Death from decompression sickness. Barotrauma- telltalesign=blood in the there is gross oedema and rash. mask.

Training in a hypobaric chamber Mountaineers are prone toaltitude sickness for Everest from rapid ascent

Frostbite with gangrene Re-warming with inhalational technique



Decompression sickness, DCS

Exercise-induced asthma, EIA.Office spirometry to diagnose.FEV1 and peak flow rate-a fall of >15% post-exercise confirms EIA.



ECG: Athlete’s Heart (Sinus bradycardia, first degree AV block, tallQRSIn praecordial leads, Ts may be inverted).

Sites of possible blood loss and iron deficiency



Sports Science

Fracture healing

Basic structure of bone



Hyaline cartilage- microscopicperfiial and deep

Cartilage-superficial and deep

Muscle structure( the sarcomere is the work-horse).



Length-tension curve of muscle action

Peripheral nerves: sensory & motor



Tendon structure

Population growth- no space left



The Mature Athlete

Biking for active lifestyle

Bone density studies determine risk of fracture.

Osteoarthritis is more commonin elite athletes. EnduranceRunners and in power sports(here is a knee replacement).

Mature endurance athletes (e.g. X-country skiers) need more carbs &May dehydrate.



Injuries of the Mature Athlete





The physically challenged Athlete

16yo skier with hemiparesis

( from MVA at age 5)

Sports Wheelchair design; critical at Olympic Competition



Top Athletes

Dangerous attitudes can disrupt the safe return to sport

Leg press used early in rehab

Assessing gastroc tension

Assessing pelvic stability





Wrist and Hand

Examination of the hand and wrist

Correct/safe splint position correct buddy- strapping (onLEFT)of hand

Ring Test (flexion of FPL Finkelstein’s test is +ve in deQuervainsand index FDP) is only possible tenosynovitiswhen ant. interosseous n. is OK

Flexed finger points Mallet finger Splint for mallet finger ScaphoidImpactionto scaphoid tubercle forscaphoid injury

tenderness



Digits all pointTo scaphoid tubercle.

Large ganglion Arthroscopic view TFCC tear

Isolated volar dislocation of Rupture of both FDP & FDSthe distal R/U jnt.

Scapho-lunate Dorsi-flexed Fx hook of hamate,point dissociation with lunate inchronic tenderness, seen on CT view rotated scaphoid.scapho-lunate lig.

Surface anatomy, with ref. Subtle step in line- up lunate&triquetrum

in mid-carpal instability.



Landmarks for carpal tunnel surgery

Sites of tendinitis



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SYMPOSIUM Sporting Injuries. Clinical Care