Football and netball season A review of the apophysis and the acute shoulder: assessment. Simon Locke Sport and Exercise Physician

Transcription

1 Football and netball season A review of the apophysis and the acute shoulder: assessment Simon Locke Sport and Exercise Physician

2 Apophyseal injuries; How to diagnose and manage?

3 Goals for tonight Recognise Skeletal maturity assessment Assess Investigate Manage

4 Apophysis The 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

5 Pelvic apophyses appearance/closing Site Appearance (yrs) Fusing complete (yrs) Iliac crest ASIS Ischium Rossi et al (2001) Average age avulsion fractures 13.8 years Schuett et (2015) Average age avulsion fractures 14.5 years

6 Maturity Risser staging

7 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

8 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

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10 Injury site and prevalence ASIS 30% Males 75% AIIS 49% Males 82% IT 11% Males 82%

11 Relative Percentages of Pelvic Avulsion Fracture Locations Ischial tuberosity 54% AIIS 22% ASIS 19% Pubic Symphysis 3% Iliac Crest 1% Rossi F, Dragoni S. Acute Avulsion Fractures of the Pelvis in Adolescent Competitive Athletes. Skeletal Radiol. 2001;30(3):

12 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

13 Fracture displacement 69% of all fractures displaced <10mm 24% of all fractures displace 10-20mm 7% displaced >20mm Schuett et al 2015

14 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

15 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

16 Management Conservative 98% heal NWB crutches 4-6 weeks Rehabilitation ROM, strength Gradual return to sport (fitness) Return to sport (10-12 weeks)

17 Surgical indications Risk appears 2% Displacement >20mm Persistent pain and disability >3 mos Schuett et al 2015

18 ASIS Avulsion Fracture

19 Ischial Avulsion Fracture 11 yr male sprinting

20 Shoulder Injuries: Acute dislocating Instability

21 Clinical Problem 22 yo footballer Occupation electrician subcontractor/ own business 1 st Dislocated last weekend Relocated in ER Current management IR When can I return to footy? Definitive management Recurrence risk Impact on occupation Football importance

22 Why Bother? Are shoulder and upper limb injuries common? Dislocation Instability How do they happen? Approach to investigations Xr, MR Treatment

23 Shoulder injuries are common in athletes!!

24 QAS Screening injury Prevalence Figure 4: Proportion of QAS athletes with current injuries by anatomical site 47.5% 28.7% 23.8% Head, neck and spine Shoulder girdle and upper limb Pelvis, hip and lower limb

25 Shoulder Injuries in elite College Football (NFL) Shoulder Injury Injury (%) Surgery (%,Y) AC separation Anterior Instability RC tendon Clavicle # 4 0 Posterior Instability 4 78 SLAP 2 40 RC tear SC separation 2 0 MD Instability 2 50 Kaplan AJSM 2005

26 Injury Risk Previous shoulder injury Reported Observed Increasing player experience Athletes have multiple injuries 1.3 per injured player* *Kaplan AJSM 2005

27 Shoulder Anatomy Acromion AC Joint Clavicle Ligaments Subscapularis Tendon Biceps Tendon Coracoid Shoulder Joint

28 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

29 Anterior Dislocation Sharp contour of shoulder joint Prominent acromion

30 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

31 Natural History Anterior Dislocation Recurrence Age 85-90% recurrence young adults 90% <20 65% (Hovelius) 30% >30 (Simonet and Coldfield) Sport High risk

32 Recurrence after initial dislocation Robinson, C. M. et al. J BJS 2006

33 Anterior Dislocation Treatment Reduction Analgesia ice, analgesics Immobilization ER Surgery Rehabilitation

34 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 mths All (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

35 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

36 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%

37 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?

38 Shoulder Instability Injuries Anterior Inferior Posterior Multidirectional Instability (MDI)

39 Recurrence following self report of instability Self reported PH of instability: Dislocation HR 5.5( ) Instability HR 3.6 ( ) Most common in 1 st 2 years after initial event Cameron et al JBJS 2013

40 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

41 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?