Sport Injuries

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Sport Injuries

  1. 1. 28 October 2013 Sport Injuries Mohammad Alsofyani Teaching Assistant – Orthopedic Department 6th MBBS - Surgery Module 1
  2. 2. 2 Syllabus Sport Injuries Upper Limb Lower Limb Impingement Syndrome Frozen Shoulder PCL Injury Tennis Elbow Meniscal Injury Golfer’s Elbow 6th MBBS - Surgery Module ACL Injury Ankle Sprain 28 October 2013
  3. 3. 3 Upper Limb 1. 2. 3. 4. 6th MBBS - Surgery Module Impingement Syndrome. Frozen Shoulder. Tennis Elbow Golfer‟s Elbow. 28 October 2013
  4. 4. 4 1. Impingement Syndrome  Anatomy:  The shoulder consists of three bones (humerus, scapula and clavicle).  2 joints (glenohumeral, acromioclavicular ).  2 articulations (scapulothoracic, acromiohumer al) that are joined by several interconnecting ligaments and layers of muscles. 6th MBBS - Surgery Module 28 October 2013
  5. 5. 5 1. Impingement Syndrome  Anatomy:  Rotator cuff is a group of muscles and their tendons that act to stabilize the shoulder. 6th MBBS - Surgery Module 28 October 2013
  6. 6. 6 1. Impingement Syndrome Muscle Origin Insertion Action Nerve Supply Supraspinatus Supraspinous fossa of scapula Greater tubercle of humerus Abduct the arm Suprascapular nerve Infraspinatus Infracspinous fossa of scapula Greater tubercle of humerus External rotation Suprascapular nerve Teres Minor Lateral border of scapula Greater tubercle of humerus External rotation Axillary nerve Subscapularis Subscapular fossa Lesser tubercle Internal rotation Upper and lower subscapular nerves 6th MBBS - Surgery Module 28 October 2013
  7. 7. 7 1. Impingement Syndrome  Definition: Is a painful disorder which is thought to arise from repetitive compression or rubbing of the rotator cuff. 6th MBBS - Surgery Module 28 October 2013
  8. 8. 8 1. Impingement Syndrome  Pathophysiology: Degeneration Trauma 6th MBBS - Surgery Module Vascular Reaction Swelling Impingement Rotator Cuff Disruption 28 October 2013
  9. 9. 9 1. Impingement Syndrome  Grades: Grade Age Cause Mechanism Grade I 18 – 30 years Supraspinatus tendinitis – subacromial bursitis overuse Grade II 40 – 45 years Supraspinatus tendinitis – subacromial bursitis – partial tear - fibrosis Overuse – degeneration (Osteoarthritis) Grade III Over 45 years Supraspinatus tendinitis – subacromial bursitis – progressive fibrosis – disruption of the cuff Overuse – Fall – atrophic degeneration in the cuff 6th MBBS - Surgery Module 28 October 2013
  10. 10. 10 1. Impingement Syndrome  Clinical Features:  Pain.  Swelling.  Limitation of shoulder movement.  Muscle atrophy.  Tenderness over greater tuberosity. 6th MBBS - Surgery Module 28 October 2013
  11. 11. 11 1. Impingement Syndrome  Diagnosis: Arthroscopy Radiological Examinations Clinical Examinations 6th MBBS - Surgery Module 28 October 2013
  12. 12. 12 1. Impingement Syndrome  Diagnosis:  Clinical tests: 1. The painful arc: on active abduction, the pain is aggravated as the arm transverses an arc between 60° and 120°. 2. The impingement sign: The scapula is stabilized with one hand while the other raises the affected arm in flexion, abduction and internal rotation. The test is positive when the pain is elicited. 6th MBBS - Surgery Module 28 October 2013
  13. 13. 13 1. Impingement Syndrome  Diagnosis:  Non-invasive: 1. X-ray. 2. MRI. 6th MBBS - Surgery Module 28 October 2013
  14. 14. 14 1. Impingement Syndrome  Diagnosis:  Invasive: 1. Arthrography: Dye is injected into the glenohumeral joint and postinjection radiographs are filmed to assess the integrity of the glenohumeral joint. If dye escapes out of the joint and into the subacromial space, it is diagnostic of a full-thickness rotator cuff tear. 6th MBBS - Surgery Module 28 October 2013
  15. 15. 15 1. Impingement Syndrome  Diagnosis:  Invasive: 1. Arthroscopy: Minimally invasive visual surgical procedure to assess shoulder pathology. 6th MBBS - Surgery Module 28 October 2013
  16. 16. 16 1. Impingement Syndrome  Management:  Conservative: 1. It consists of rest, heat, massage, NSAIDs, local infiltration of hydrocortisone. 2. Exercises both active and passive. 3. Temporary immobilization. 6th MBBS - Surgery Module 28 October 2013
  17. 17. 17 1. Impingement Syndrome  Management:  Operative: 1. Failure of conservative treatment for three months. 2. Patients are young and active. 3. Increase loss of shoulder function.  Methods: 1. Excision of calcium deposits. 2. Repair of incomplete tear. 3. Acromioplasty. 6th MBBS - Surgery Module 28 October 2013
  18. 18. 18 2. Frozen Shoulder (Adhesive Capsulitis)  Definition: it is a disorder characterized by progressive pain and stiffness of the shoulder which usually resolves spontaneously after about 18 months. 6th MBBS - Surgery Module 28 October 2013
  19. 19. 19 2. Frozen Shoulder (Adhesive Capsulitis)  Etiology: Idiopathic  Risk Factors:  Diabetes.  Dupuytren‟s disease.  Hyperlipidemia.  Hyperthyroidism.  Cardiac disease.  Hemiplegia.  After recovery from neurosurgery. 6th MBBS - Surgery Module 28 October 2013
  20. 20. 20 2. Frozen Shoulder (Adhesive Capsulitis)  Clinical Features:  Age 40 – 60 years.  70% of patients are women.  Pain gradually increases in severity and often prevents sleeping on the affected side.  After several months it begins to subside.  Stiffness becomes an increasing problem, continuing for another 6-12 months after pain has disappeared. 6th MBBS - Surgery Module 28 October 2013
  21. 21. 21 2. Frozen Shoulder (Adhesive Capsulitis) 6th MBBS - Surgery Module •Duration 9-15 months. •Minimal pain except at end of ROM. •Significant limitation of ROM with rigid end feel. Stage 3 (Thawing or Recovery) •Duration 1-9 months. •Pain with active and passive ROM. •Significant limitation with flexion, abductio n, external and internal rotation. Stage 2 (Frozen) Stage 1 (Freezing)  Stages: •Duration 15-24 months. •Minimal pain. •Progressive improvement in ROM 28 October 2013
  22. 22. 22 2. Frozen Shoulder (Adhesive Capsulitis)  Diagnosis: “Not every stiff or painful shoulder is a frozen shoulder. And indeed there is some controversy over the criteria for diagnosing frozen shoulder” (Zuckerman et al., 1994) 6th MBBS - Surgery Module 28 October 2013
  23. 23. 23 2. Frozen Shoulder (Adhesive Capsulitis)  Diagnosis:  The diagnosis of frozen shoulder is clinical resting on two characteristic features: 1. Painful restriction of the movement in the presence of normal x-rays. 2. A natural progression through three successive stages. 6th MBBS - Surgery Module 28 October 2013
  24. 24. 24 2. Frozen Shoulder (Adhesive Capsulitis)  Management:  Conservative: 1. To relieve pain and prevent further stiffness. 2. Analgesics and anti-inflammatory drugs. 3. Reassure the patient that recovery is certain. 4. Pendulum exercises are encouraged. 5. Once the acute pain has subsided, manipulation under general anesthesia may improve the range of movement. 6th MBBS - Surgery Module 28 October 2013
  25. 25. 25 2. Frozen Shoulder (Adhesive Capsulitis)  Management:  Operative: 1. Surgery doesn‟t have a well-defined role. 2. The main indication is prolonged and disabling restriction of movement which fails to respond to conservative treatment. 3. The rotator interval and coracohumeral ligament are released and the coracoacromial ligament is excised. 6th MBBS - Surgery Module 28 October 2013
  26. 26. 26 3. Tennis Elbow (Lateral Epicondylitis)  Definition: Pain and tenderness over the lateral epicondyle of the elbow (The bony insertion of the common extensor tendons). 6th MBBS - Surgery Module 28 October 2013
  27. 27. 27 3. Tennis Elbow (Lateral Epicondylitis)  Mechanisms: Forceful repetitive wrist extension. 6th MBBS - Surgery Module 28 October 2013
  28. 28. 28 3. Tennis Elbow (Lateral Epicondylitis)  Clinical Features:  Active individual of 30 or 40 years.  Gradual pain and localized to the lateral epicondyle.  The elbow looks normal, and flexion and extension are full and painless.  Pain can be elicited by: 1. Extending the elbow. 2. Pronating the forearm. 3. Passively flexing the wrist. 6th MBBS - Surgery Module 28 October 2013
  29. 29. 29 3. Tennis Elbow (Lateral Epicondylitis)  Management:  Conservative: 1. Rest and physiotherapy. 2. Injection of the tender area with corticosteroid and local anesthetic relieves pain. 3. Using a brace centered over the back of your forearm may also help relieve symptoms of tennis elbow. 6th MBBS - Surgery Module 28 October 2013
  30. 30. 30 3. Tennis Elbow (Lateral Epicondylitis)  Management:  Operative: 1. Persistent of symptoms for 6 to 12 months. 2. A few cases are sufficiently persistent or recurrent. 3. Release of lateral epicondylar muscles. 6th MBBS - Surgery Module 28 October 2013
  31. 31. 31 4. Golfer‟s Elbow (Medial Epicondylitis)  Definition: Is very similar to Tennis Elbow but occurs on the medial side of the elbow where the flexor origins are effected. 6th MBBS - Surgery Module 28 October 2013
  32. 32. 32 4. Golfer‟s Elbow (Medial Epicondylitis)  Mechanisms: overuse flingers flexion. 6th MBBS - Surgery Module 28 October 2013
  33. 33. 33 4. Golfer‟s Elbow (Medial Epicondylitis)  Clinical Features:  Resisted wrist and finger flexion in pronation will provoke the pain 6th MBBS - Surgery Module 28 October 2013
  34. 34. 34 Lower Limb 1. 2. 3. 4. 6th MBBS - Surgery Module ACL Injury. PCL Injury. Meniscal Injury. Ankle Sprain. 28 October 2013
  35. 35. 35 1. ACL Injury  Anatomy:  Origin: 1. Medial and anterior aspect of the tibial plateau.  Insertion: 1. Lateral femoral condyle.  Function: 1. provide approximately 85% of total restraining force of anterior translation. 2. Prevents excessive tibial medial and lateral rotation. 6th MBBS - Surgery Module 28 October 2013
  36. 36. 36 1. ACL Injury  Definition: One of the most common knee injuries is an anterior cruciate ligament sprain or tear.  Mechanisms:  Hyperextension force.  Twisting force on a semiflexed knee. 6th MBBS - Surgery Module 28 October 2013
  37. 37. 37 1. ACL Injury  Mechanisms:  Hyperextension force. 6th MBBS - Surgery Module 28 October 2013
  38. 38. 38 1. ACL Injury  Mechanisms:  Twisting force on a semiflexed knee. 6th MBBS - Surgery Module 28 October 2013
  39. 39. 39 1. ACL Injury  Clinical Features:  Immediately collapse and is painful.  Popping sensation felt or heard.  Swelling.  Giving away. 6th MBBS - Surgery Module 28 October 2013
  40. 40. 40 1. ACL Injury  Classification:  Ligaments sprain are classified in three degrees: 1. 1st Degree: Tear of only a few fibers of the ligament. Minimal swelling, localized tenderness but little functional disability. 2. 2nd Degree: Almost all the fibers of a ligament are disrupted. Pain, swelling and inability to use the limb. Joint movements are normal. 3. 3rd Degree: complete tear of the ligament 6th MBBS - Surgery Module 28 October 2013
  41. 41. 41 1. ACL Injury  Diagnosis: Arthroscopy Radiological Examinations Clinical Examinations 6th MBBS - Surgery Module 28 October 2013
  42. 42. 42 1. ACL Injury  Diagnosis:  Clinical Examinations: 1. Lachman‟s test. 2. Anterior drawer test. 3. Pivot shift test. 6th MBBS - Surgery Module 28 October 2013
  43. 43. 43 1. ACL Injury  Diagnosis:  Radiological Examinations: 1. Plain X-ray: to demonstrate bone avulsed or associated fracture. 2. MRI 6th MBBS - Surgery Module 28 October 2013
  44. 44. 44 1. ACL Injury  Diagnosis:  Arthroscopy: 1. May be needed in cases where doubt persists. 6th MBBS - Surgery Module 28 October 2013
  45. 45. 45 1. ACL Injury  Management:  Conservative: 1. Most cases of grades I and II. 2. The hematoma is aspirated and the knee is immobilized in a commercially available knee immobilizer. 3. After a few weeks, the adequate strength can be regained by physiotherapy. 6th MBBS - Surgery Module 28 October 2013
  46. 46. 46 1. ACL Injury  Management:  Operative: 1. Indicated in multiple ligaments injured knee, especially in young athletes. 2. Performed 2-3 weeks after injury after acute phase subsided. 3. Methods: a) Repair of the ligament: performed for fresh. Additional reinforcement is provided by a fascial or tendon graft (Tendon of Hamstring). b) Reconstruction: in cases of ligament injuries presenting late. 6th MBBS - Surgery Module 28 October 2013
  47. 47. 47 2. PCL Injury  Anatomy:  Origin: 1. The posterior intercondylar area of the tibia.  Insertion: 1. Medial condyle of the femur.  Function: 1. keeps the tibia from moving backwards too far. 6th MBBS - Surgery Module 28 October 2013
  48. 48. 48 2. PCL Injury  Definition: It is less common than ACL tears.  Mechanisms:  Backward force on tibia. 6th MBBS - Surgery Module 28 October 2013
  49. 49. 49 2. PCL Injury  Clinical Features:  Pain with swelling that occurs steadily and quickly after the injury.  Swelling that makes the knee stiff and may cause a limp.  Difficulty walking.  The knee feels unstable, like it may "give out”. 6th MBBS - Surgery Module 28 October 2013
  50. 50. 50 3. Meniscal Injury  Anatomy:  The semilunar cartilages are two crescentshaped plates of fibrocartilage placed on condylar surface of the tibia  Functions: 1. Increase the stability of the knee. 2. Controlling the complex rolling and gliding actions of the joint. 3. Distributing load during movement. 6th MBBS - Surgery Module 28 October 2013
  51. 51. 51 3. Meniscal Injury  Definition: Medial meniscus is more commonly injured than the lateral and is usually associated with other ligament injuries of the knee.  Mechanisms:  Medial meniscal: 1. In young: twisting force with the knee bent and taking weight. 2. In middle age: fibrosis has decreased the mobility of meniscus and hence tear occurs with less force. 6th MBBS - Surgery Module 28 October 2013
  52. 52. 52 3. Meniscal Injury  Mechanisms: 6th MBBS - Surgery Module 28 October 2013
  53. 53. 53 3. Meniscal Injury  Classifications 6th MBBS - Surgery Module 28 October 2013
  54. 54. 54 3. Meniscal Injury  Clinical Features:  Usually a young person.  Pain (usually on the medial side).  Knee is „locked‟ in partial flexion.  Sometimes the knee gives way spontaneously. 6th MBBS - Surgery Module 28 October 2013
  55. 55. 55 3. Meniscal Injury  Diagnosis:  Clinical Examinations: 1. McMurray‟s Test. 2. Apley Compression Test. 6th MBBS - Surgery Module 28 October 2013
  56. 56. 56 3. Meniscal Injury  Diagnosis:  Radiological Examinations: 1. Plain X-ray 2. MRI 6th MBBS - Surgery Module 28 October 2013
  57. 57. 57 3. Meniscal Injury  Diagnosis:  Arthroscopy: 1. May be needed in cases where doubt persists. 6th MBBS - Surgery Module 28 October 2013
  58. 58. 58 3. Meniscal Injury  Management:  Conservative: 1. Indicated in patients soon after injury with no locking. 2. If knee is locked, it is manipulated under general anesthesia. 3. The is immobilized for 2-3 weeks followed by physiotherapy. 6th MBBS - Surgery Module 28 October 2013
  59. 59. 59 3. Meniscal Injury  Management:  Operative: 1. Indicated if the joint can‟t be unlocked and if symptoms are recurrent. 2. Closed partial meniscectomy via an arthroscope is better than total removal of the menisci by open surgery. 6th MBBS - Surgery Module 28 October 2013
  60. 60. 60 4. Ankle Sprain  Anatomy:  Ligaments of the ankle: 1. Anterior talofibular ligament. 2. Calcaneofibular ligament. 3. Posterior talofibular ligament. 6th MBBS - Surgery Module 28 October 2013
  61. 61. 61 4. Ankle Sprain  Definition: Common injury in sport. If improperly treated it may result in chronic laxity, pain or delayed recovery.  Mechanisms:  Inversion of supinated planter flexed foot. 6th MBBS - Surgery Module 28 October 2013
  62. 62. 62 4. Ankle Sprain  Clinical Features:  Anterior talofibular ligament commonly injured followed by Calcaneofibular ligament.  The posterior talofibular ligament is rarely sprained.  Pain, swelling and tenderness over the affected ligament. 6th MBBS - Surgery Module 28 October 2013
  63. 63. 63 4. Ankle Sprain  Diagnosis:  Clinical: 1. Anterior Drawer Test: If the displacement of talus is more than 8 mm anterior, it suggests laxity of the anterior talofibular ligament. 6th MBBS - Surgery Module 28 October 2013
  64. 64. 64 4. Ankle Sprain  Diagnosis:  Radiological Examinations: 1. X-ray : AP of the ankle to assess talar tilt. 2. Talar tilt test:  Examiner stabilizes the leg with one hand while inverting plantar flexed heel with the other hand.  Alternatively, place the patient's leg in the lateral position, hanging off the table.  A strap is applied around the ankle which courses around the lateral side of the ankle.  A 4 kg wt is then applied which forces the ankle into inversion and plantar flexion. 6th MBBS - Surgery Module 28 October 2013
  65. 65. 65 4. Ankle Sprain  Diagnosis:  Radiological Examinations: 1. Talar tilt test: If the tilt is more than 5°, it suggests laxity of anterior talofibular and calcaneofibular ligaments 6th MBBS - Surgery Module 28 October 2013
  66. 66. 66 4. Ankle Sprain  Management:  Grade I: 1. Ice therapy, compression bandage, foot elevation, NSAIDs, are the recommended treatment.  Grade II: 1. Long leg cast, range of motion exercises, strengthening exercises are helpful.  Grade III: 1. Same lines as mentioned above and sometimes may require surgical repair. 6th MBBS - Surgery Module 28 October 2013
  67. 67. 67 Case Study 6th MBBS - Surgery Module 28 October 2013
  68. 68. 68 History A 25-year-old man was playing football for his local team. While going in for a tackle he sustained a twisting injury to his knee. There was no immediate swelling. He continued to play for about ten minutes to the end of the game but then complained of some pain in the medial aspect of his knee. He awoke the next day with a painful swelling in the knee and so consults his general practitioner. 6th MBBS - Surgery Module 28 October 2013
  69. 69. 69 Examination This young man has some mild swelling, associated with marked tenderness to palpation over the medial joint line. He has normal varus/valgus stability of the knee and a negative anterior draw and Lachman‟s test. The range of motion is full. A plain x ray shows good preservation of the joint space, and MRI film is shown. 6th MBBS - Surgery Module 28 October 2013
  70. 70. 70 Questions  What is the diagnosis?  What are the common clinical features of this injury?  How would you manage this injury? 6th MBBS - Surgery Module 28 October 2013
  71. 71. 71 References Textbook of Orthopedics (John Ebnezar). Aply‟s System of Orthopedics and Fractures. Essential of Orthopedics (RM Shenoy). Essential Orthopedics (J.Maheshwari). Field Guide to Fracture Management (Richard B. Birrer).  Current Diagnosis and Treatment of Orthopedic (Harry B. Skinner).  Essential Orthopedic and Trauma (David J. Dandy)  Pocket of Orthopedics and Fractures. (Ronald McRae).      6th MBBS - Surgery Module 28 October 2013

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