Friday, 6 June 14. Wrightington Hospital, UK

Transcription

1 Mr Mike Hayton BSc (Hons) MBChB FRCS (Trauma & Orth) FFSEM (UK) Mr Mike Hayton is a Consultant Orthopaedic Hand and Wrist Surgeon at the Wrightington Hospital in Lancashire where he has a tertiary complex hand and wrist practice Over the last 10 years, Mike has developed a special interest in hand and wrist injuries that occur in elite sport. He has several publications in this area and regularly lectures on this and other subjects internationally and in North America in particular. Mike currently receives hand and wrist referrals from over 40 professional sports teams and national sporting organisations. He has treated over 20 Olympians, many of whom have gone on to achieve podium success at the highest level. Mike has been awarded the status of a Founding Fellow in the Faculty of Sports and Exercise Medicine (FFSEM UK) and he is an examiner for the Intercollegiate Board of Examinations for the FRCS (Trauma and Orthopaedics).

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3 Wrightington Hospital, UK

4 Sir John Charnley Never operate on a bone that you can swallow

5 Some things have changed

6 Some things have changed

7 Hand - Sports Medicine Mike Hayton 7

8 In US - everyone is a sport med doc! 8

9 this gastroenterologist took things too seriously 9

10 My background Rugby Finger dislocations Ankle fracture Knee ligament rupture Cauliflower ear Thumb dislocation Thumb ligament injury Knee meniscal tear

11 C6/7 bifacet fracture dislocation

12 Sometimes - just get up and do it 12

13 Sometimes - just get up and do it 13

14 Pitfalls in Sports Injury Surgery stick with what you know 14

15 15

16 Skiers thumb 16

17 Skiers Thumb UCL tear of Thumb MP joint Forced abduction Immediate pain over UCL Less pain if complete Lax 17

18 Adductor Aponeurosis UCL avulsion distally Flips outside adductor aponeurosis Will not heal 18

19 Assessment Tender over thumb MPJ UCL? Lump ( Stener lesion) Laxity - no end point 19

20 Laxity 20

21 Investigations Xray Stress xray USS MRI 21

22 Investigations Xray Stress xray USS MRI 21

23 Investigations Xray Stress xray USS MRI 21

24 22

25 Need surgery Repair Interposed adductor hood Otherwise Wont heal Weak pinch 23

26 24

27 Rehab Immediate Motion Radial blocking splint Low profile Thermoplastic 25

28 Series with accelerated rehab 15 professional thumbs 13 Athletes 11 rugby 4 soccer GK Mean FU 28 months (7-65)

29 affected thumb opposite thumb MPJ flex RD Kapandji Hand Span Lat pinch 27

30 Return play = 4.4wks (2-10) No Re-ruptures 28

31 If not treated

32 Scaphoid 30

33 Clinical Features Trauma Energy

34 History Reduced ROM (esp. EXTENSION) Pain Scaphoid - ASB - Proximal pole SL rupture - Mainly dorsal RC in the midline ( 1cm distal to Listers tubercle) 32

35 History Reduced ROM Pain Scaphoid - ASB - Proximal pole SL rupture - Mainly dorsal RC in the midline ( 1cm distal to Listers tubercle) Unable to load - Press ups / Cleans 33

36 Examination Reduced ROM (particularly extension) Swelling Pain ASB dorsal RC joint line tubercle Axial load thumb 34

37 Examination Reduced ROM (particularly extension) Swelling Pain ASB dorsal RC joint line tubercle Axial load thumb 34

38 Examination Reduced ROM (particularly extension) Swelling Pain ASB dorsal RC joint line tubercle Axial load thumb 34

39 Examination Scaphoid Tubercle

40 Examination Scaphoid Tubercle Radial deviate Flexes Prominent

41 Examination Scaphoid Tubercle Radial deviate Flexes Prominent

42 Examination Scaphoid Tubercle Ulnar deviate Extends Less Prominent

43 MRI Show fracture within a few hours Show ligament injuries oedema may show the tear abnormal inter-carpal angles 39

44 Scaphoid in Sport Same bone Do they heal any differently

45 Office Worker Rugby League Prop

46 Why dont they heal? Delay in treatment Location Blood Supply Displacement Carpal instability Instability fracture Smoking

47 Blood Supply

48 Blood Supply Obletz & Halbstein 1938

49 Investigate X-ray CT scan MRI scan (Isotope Bone Scan)

50 Wrightington classification Ramamurthy C 2007 JBJS 89B :

51 Treatment Operative or Non operative 47

52 Any suspicion Xray Wrist if normal treat as a fracture in POP and re-xray 10 days or get MRI 48

53 Does surgery diminish time to fracture union?

54 Does surgery diminish time to fracture union? 2 prospective randomized studies Bond, Shin et al JBJS A 2001 Union at 7 wks (screw) vs 12 wks in (cast) Xray/clinical eval every two weeks Adolfsson et al, J Hand Surg B 2001 Union 10 wks (screw) vs 12 wks (cast) Xray at 10 weeks, 16 weeks

55 Fixation quicker return work?

56 Fixation quicker return work? Waist Fractures Adolfsson et al: 6 wks ( screw) vs 10 wks Bond, Shin et al: 8.2 wks (screw) vs 15 wks Mixed Location Inoue & Shionoya: 5.8 wks (screw) vs10wks 5 wks earlier return to activity

57 Treatment in athletes Is there a role for non operative?

58 Treatment in athletes Is there a role for non operative? Location of fracture Time of season

59 Non Operative Cast 6-8 weeks 12 weeks proximal pole Until healed!! Muscle wasting

60 My thoughts in general public Distal pole POP 6 weeks Undisplaced Waist Mini-open Fix or POP Displaced Waist Fix Proximal pole Fix (Mini-open)

61 My thoughts in sports Distal pole Thermoplastic 4-6/52 Undisplaced Waist Mini open Fix (Dorsal) Displaced Waist Fix (Garcia-Elias approach) Proximal pole Mini open Fix (Dorsal)

62 Surgery Not without risks Screw in poor position Screw too long Screw too short Infection Tendon injury etc etc Performed by experienced user and the risks much less

63 Treatment - Volar 59

64 Treatment - Dorsal 60

65 Rehabilitation 61

66 Rehabilitation Put in under load Mobilise early if Happy with fixation

67 Return to play 63

68 Traditional views Only return when healed 15% NEVER heal therefore give up career!!! Many players play with estab non unions 64

69 Return to train / play Geissler 2010 (personal communication) Well placed screw Immediate when pain allows Slade 2009 (personal communication) 50% union and well placed screw stronger than normal scaphoid 65

70 My rehab Fracture - simple Quality of fixation Early ROM and pain free Allow return in heavily strapped wrist 4-6 weeks if xray satisfactory Early CT 66

71 Splint for scaphoid ORIF

72 Return to drive? When safe to control a vehicle What about motor sport? Huge financial rewards 68

73 Return to drive 69

74 70

75 Scapho-lunate ligament ruptures in the athlete 71

76 Scapholunate Dissocia on Most commonly recognized carpal instability Presents in a similar way to scaphoid fracture Many present late (6 12 months)

77 Acute or Chronic? 73

78 Acute < 8 weeks Assume healing potential of ligament 74

79 Chronic >12 weeks no healing potential of ligament 75

80 Fix or leave Explain the injury Show anatomical models Explain the natural Hx Treatment and rehab 76

81 Fix or leave Timing of season Timing of career Who are we to dictate? 3-4/12 rtn to sport We are there to work with the player to make the right decision for them 77

82 Direct Repair Presupposes healing potential of ligament remnants 6-8 weeks

83 Confirm diagnosis

84 80

85 81

86 Chronic Tri- ligament tendodesis Brunelli I-IV Stanelli 82

87 2.9mm drill hole

88 Half FCR passed along tunnel

89 X X X X IV

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93 Rehab Acute - wires out 6 weeks Chronic - Stanelli Splint 4 weeks Mobilise dart throw 4 weeks Return when fxn ROM pain tolerable strapping 89

94 Outcomes of Modified Brunelli Procedure in Professional Athletes with Scapholunate Instability Williams A, Ng Cy, Hayton M Br J Sports Med Nov;47(17):

95 91

96 Results Patient demographics Number of operations 16 Age Mean 30 years (range 18-42) Gender All male Dominance of hand operated on 9 dominant, 7 non dominant Level of competition before injury 9 international, 7 national Time to surgery after injury Mean 30 weeks (range 2-78) Follow up Mean 24 months (range 3-43)

97 Subjective outcome measures Mann-Whitney U test p value Instability VAS pain score at REST <0.001 VAS pain score ACTIVITY <0.001 Preoperative Postoperative VAS (Visual Analogue Score) Error bar showing SEM (standard error of mean)

98 Functional scores at final review Quick DASH 7.66 SEM 2.11 (range 0-25) Wrightington activity of daily living, assessment for wrist function 2 (8 is normal 32 most abnormal) 9.25 SEM 0.38 (range 8-13) 2 Talwalkar SC, et al. J Hand Surgery (British and European Volume) 2006; 31:

99 Modified Brunelli procedure in professional athletes generally Relieves wrist pain with (p<00.1) Appears to improve stability (not significant) Improves functional outcome scores But for other injuries 12 out of 15 (80%) returned to playing

100 TFCC 96

101 TFCC made easy

102 Triangular Fibro Cartilagenous Complex

103 Function Transmit load Stabilise the DRUJ

104 Anatomy Group of several anatomic structures Triangular fibrocartilage (articular disc) Meniscus homologue UCL ( ulnar capsule) Volar and Dorsal DRU ligaments ECU subsheath Prestyloid recess

105 TFCC 101

106 Vascular supply Supply periphery only Synovial fluid bathing Implications for repair

107 Biomechanics Ratio radius to ulnar length TFCC perforations in 73% matched or ulnar plus

108 Natural History Cadaveric study No Hx trauma <20 years no TFC perforations >60 years 50% had TFC perforations

109 Biomechanics Pronation Ulnar +

110 Biomechanics Pronation and Ulnar Deviation Increase ulnar load to 150% of neutral Pronation increases ulnar variance 1mm Gripping increases ulnar variance 4mm

111 Biomechanics of the hand-off

112 Biomechanics of the hand-off

113 Biomechanics of the hand-off

114 Symptoms Ulnar sided wrist pain Quite well localised Usually with ulnar deviation Sudden pronation activity Clicking on rotation Instability is rare

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116 Signs Pronation Ulnar deviation Axially load Rotate

117 Ulnar column stability Test the DRUJ AP stability With wrist in Neutral Radial deviation Ulnar deviation

118 Ulnar column stability

119 Unstable DRUJ

120 Investigations Plain Radiographs Ulnar variance MRI Arthrography Wrist arthroscopy

121 Investigations MRI vs arthroscopy Accuracy Arthroscopy gold standard

122 Arthroscopy - normal

123 Palmers Classification Divides TFCC lesions traumatic and degenerative TFCC injuries Further into location

124 Class 1- traumatic radial

125 Treatment Conservative and activity avoidance Steroid injection (10mg Kenolog) if DRUJ is stable Surgery DRUJ stable and failed conservative Debride arthroscopically DRUJ unstable Repair

126 Surgery Arthroscopic Repair Debridement Shavers Radiofrequency (Vapr) keep the heat down Open Repair Ulnar Shortening

127 Arthroscopic : Repair

128 Open Repair

129 Arthroscopic : Debride

130 Ulnar Shortening

131 Case 23 old RL Pronation injury Pain Clunking

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133 Unstable DRUJ

134 6 weeks post op

135 The Boxers Hand Extensor hood injuries CMCJ Instability 131

136 Boxers - MPJ Ext hood tear Make the diagnosis Flicking tendon Exposed MC head Pain on impact Ishizuki M: Traumatic and spontaneous dislocation of extensor tendon of the long finger J Hand Surg [Am] 15:969, 1990,

137 Clinical Subluxation 133

138 Imaging 134

139 Any digit - usually Index / Middle 135

140 Any digit - usually Index / Middle 135

141 Any digit - usually Index / Middle 135

142 Boxers - Ext hood tear Repair Easy Direct But do in full flexion (Deficient) use ext retinaculum

143 137

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146 Rehabilitation Back Slab 140

147 day 2 - Dorsal thermoplastic splint MPJ 80 / PIPJ free 141

148 day 10 - early active 4 weeks leave 8 weeks allow speed ball / water 12 weeks increase 16 weeks full contact 142

149 Current study 13 Knuckles in 11 elite level boxers (May 2006 Dec 2012) Many more since 7 Olympic GB squad and 4 professional Post-operative DASH score Range of flexion Time to return to sport

150 Return to sport Time to return Average 5.05 months (range 3 8) Success following surgery Olympic Gold 2 Olympic Bronze 1 Turned professional 2 Professional record Won 33, lost 2, drawn 2

151 Boxers CMCJ

152 Boxers - CMCJ instability 5000 punches / day Reactive Bossing Continued +/- injs Frank instability Occasionally spontaneous stiffen

153 Boxers - CMCJ instability

154 Boxers - CMCJ instability

155 Boxers - CMCJ instability History Hand Collapses Hand Buckles Its not my wrist doc

156 Boxers - CMCJ instability Examination Bossing obvious Isolate the CMCJ

157 151

158 Investigations

159 Dynamic - Xray or USS 153

160 Treatment Activity modification - give up Occasionally spontaneously stiffen consider waiting if possible Taping Surgery (Ligament reconstruction) CMCJ Fusion 154

161 155

162 Splinting for training 156

163 CMCJ Fusions 157

164 Which to fuse? The symptomatic and unstable on screening Usually index and middle CMCJc Very rarely the ring and little 158

165 2-5 remove back slab thermoplastic splint in neutral allow pin site cleaning (not buried in this 6 weeks Xray remove wires - usually under 8 weeks allow speed ball / water 12 weeks increase 16 weeks full contact 159

166 Results Combined joint fusion for index and middle carpometacarpal instability in elite boxers Nazarian N, Page RS, Hoy GA, Hayton MJ, Loosemore M. J Hand Surg Eur Vol May

167 Finger Fractures Most common 5 th MC Boxers fracture 161

168 Indications for fixation Shortening Rotational deformity Intra-articular Marked angulation Multiple (esp 2 nd 3 rd ) 162

169 Shortening 163

170 Rotational abnormality 164

171 165

172 Intra-articular 166

173 Anatomic reduction 167

174 Marked angulation 168

175 Multiple fractures 169

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177 Beware the fight bite 171

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179 173