Evaluating and Treating Sports Injuries in Young Athletes

EVALUATING & TREATING
SPORTS INJURIES IN YOUNG
ATHLETES: SHOULDER,
ELBOW, HAND & WRIST
Rachel A. Coel, MD, PhD
Co-Medical Director
Sports Medicine for Young Athletes
Children’s Hospital Colorado
DISCLOSURES
No financial conflicts or disclosures today
I Grew Up in Hawaii…
…and graduated
from Punahou
School like
President Obama.
OBJECTIVES
• Describe techniques for diagnosing upper
•
•
extremity injuries in youth.
Describe common treatment options for upper
extremity injuries.
Recognize need for appropriate referral to
orthopedic specialist.
INTENSITY
INTENSITY
INTENSITY
“DiME”
Pediatric Bone vs. Adult
• Higher H20 content, lower mineral content per unit
•
•
•
volume.
More elastic and higher strain : failure ratio
Growth plate – usually weaker than bone and prone
to injury in and around it. Also very vascular which
hastens repair. (Salter Harris fx’s)
Thick periosteum adds protection to bone like bark on
a green tree limb, also hastens healing. (Torus fx,
plastic deformity/greenstick fx, spiral fx)
• Ligaments stronger than bone – mechanism
producing sprain in adult will typically cause
fracture in child
Physeal (Growth Plate) Fractures - General
• “Weak link” of pediatric bone (cartilage)
• Adults - sprains & dislocations; children •
•
•
•
physeal injuries
Rapid healing (1/2 time of shaft fractures)
Tenderness over physis: suspect a SH I
fracture, even with normal radiographs!
Risk of premature growth arrest leading to limb
length discrepancy or angular deformity
Risk of articular complications (SH type 3-5)
Examples
Chronic Injury
• Joint overload
• ie: Patellofemoral
•
•
•
•
•
Stress Fracture
Apophysitis (ie: Sever’s)
Epiphysitis (ie: Little Leaguer’s elbow)
Tendonitis
Burnout / Overtraining
Physical Exam
• Inspection
• Palpation (bony
•
•
•
•
structures, joints, soft
tissue)
Active & passive ROM
Strength testing
Neurovascular
Special tests
Musculoskeletal Physical Exam
1) Inspection: swelling, bruising, angulation,
2)
3)
4)
5)
6)
deformity, shortening, or rotation
Gentle Palpation: with focus on bony vs. soft tissue
structures; crepitus; step-off’s; bony mass; growth
plates ($1,000,000 exam tool: one finger to localize tenderness)
ROM: flexion, extension, abduction, adduction,
Neurovascular: motor function, vascular function,
strength, and sensory perception
Special maneuvers: ligaments, tendons, laxity
Beware of bony tenderness in the absence of any
trauma history!
BASIC PRINCIPLES:
“PRICEMM”
P = Protect
R = Rest
I = Ice
C = Compression
E = Elevation
M = Medications
M = Modalities
BE SURE TO ALWAYS CHECK
NEUROVASCULAR STATUS!
•Pulse
•Capillary refill
•Warmth & Color
•Sensation
•Motor function
•Strength
SHOULDER
12 year old female swimmer
• Right shoulder pain x 1 month
• No known injury or trauma
• Radiates to upper arm, shoulder blade
Causes of Shoulder Pain in Pediatrics
• Injuries
- AC joint sprain, Clavicle fx, Humerus fx
• Shoulder instability / Multi-Directional Instability (MDI)
- Subluxation
- Dislocation
• Rotator Cuff Syndrome, Impingement Syndrome
- Overhead athletes
• Little League Shoulder
• Tumor
Could it be a fracture?
Little Leaguer’s Shoulder
Abnormal
Normal
Little Leaguer’s Shoulder
Proximal Humeral Epiphysitis
• Stress fracture: proximal humeral physis
• High level pitchers 11-16 yrs of age
• Exam may be normal
• X-ray may be negative early
• Looks like growth plate fx
• Check comparison xray
Little Leaguer’s Shoulder Treatment
•
•
•
•
•
NO THROWING x 3-6 mo
P.T. – Throwing program / Biomechanics
SLOW return, consider switching position
Pitch counts
Choose pitcher or catcher
Little Leaguer’s Shoulder
HUMERUS FRACTURES
- PROXIMAL
- SHAFT
•REFER to Ortho
•Arm sling x 6 weeks
•RTP at 10-12 weeks
•REFER to Ortho
•Sling x 4 weeks
•RTP at 6-8 weeks
8 weeks
CLAVICLE FRACTURE
An Example of Pediatric
Healing Potential
Does she have a rotator cuff injury?
Rotator Cuff Tendinitis / Tear
• Partial thickness tear
• Full (Complete) thickness
tear
• May be due to:
•
•
•
•
Impingement
Degeneration
Overuse
Trauma
• Partial tears
• Conservative
• Complete tears
• Surgery
• Supraspinatus
- Abduction
• “Empty can" test
• a.k.a. Jobe’s Test
• Arms abducted 90° and
• Arms at 30° (in scapular
plane)
• Elbows locked straight
• Thumbs down
• Attempts to elevate arms
against resistance
• Infraspinatus, Teres Minor
• Externally rotates shoulder
• Arms at the sides
- Elbows flexed to 90 degrees
• Externally rotates arms
against resistance
• Subscapularis
- Internally rotates shoulder
- Arms at the sides
- Elbows flexed to 90°
- Internally rotate arms
against resistance
- Subscapularis Lift-Off Test
Does she have impingement?
Impingement Signs
Neer’s Sign
– Arm fully pronated and
placed in forced flexion
– Trying to impinge
subacromial structures
with humeral head
– Pain is positive test
Impingement Signs
Hawkin’s Sign
– Arm is forward flexed
to 90°, then forcibly
internally rotated
– Trying to impinge
subacromial structures
with humeral head
– Pain is positive test
Biceps Tendinitis: Speed’s Test
• Shoulder forward flexed
to 90°
• Arm in full supination
• Apply downward force to
distal arm
• Pain is positive test
• Weakness without pain:
muscle weakness or
rupture
Shoulder Instability / MDI
Failure to keep humeral
head centered in glenoid
Dislocation
– Complete disruption of joint
congruity or alignment
Subluxation
– Partial or incomplete
dislocation
Laxity
– Looseness in joint
– May be normal or abnormal
•Dislocation: REFER for
Xrays, MRI, sling x 2
weeks, P.T.,
– MANAGE with P.T., activity
modification
Instability / MDI: Sulcus Sign
• Inferior instability
• Arm relaxed in neutral
position
• Arm pulled downward
• Positive test is a visible
sulcus at infra-acromial
area
• Compare to
contralateral side
Instability: Apprehension Test
• Anterior instability
• Shoulder abducted 90°,
externally rotated
• Stress to humeral head
directed in anterior direction
• Positive test is apprehension
due to feeling of instability or
impending dislocation
Instability: Relocation Test
• Anterior instability
• After a positive
apprehension, apply
posteriorly directed force
over externally rotated
humeral head
• Positive test is relief of
apprehension
Shoulder
Dislocation:
Check over
deltoid
Does she have an AC joint sprain?
Acromio-clavicular (AC) Joint Sprain
– Typically due to fall
onto tip of shoulder
(acromion)
– Arm tucked into
side
– Treatment depends
on type
– MANAGE Types 1 & 2
– Sling, P.T.
– REFER Types 3-6
AC Joint: Cross-Arm Adduction Test
• Arm forward flexed to 90°
and adducted 45°
• Hyperadduct shoulder
• Resist abduction of elbow
• Positive test is pain in AC
joint
Could she have any joint damage?
Glenoid Labral Tear
Usually due to instability
Acute vs. Chronic
– Fall on outstretched hand or
shoulder
– Rotator cuff tendinosis or
tears
– Anterior shoulder dislocation /
subluxation
– REFER to Ortho
O’Brien’s Active Compression Test
• Labral, AC, or biceps pathology
• Arm forward flexed 90°
and adducted ~15°
• Resist downward force with
hand fully pronated
• Positive test if pain
• Beware location of pain
• AC
• Biceps
• Internal +/- click
Elbow
13 year old male “righty” baseball pitcher
• Right elbow pain x 2 days
• Sudden onset without a “pop”
• 6 hours later: swelling
• Plays on two teams (club & school)
• Plays year-round
• Alternate position: catcher
Pediatric Elbow
1 – Capitellum
2 – Radial head
3 – Medial Epicondyle
4 – Trochlea
5 – Lateral Epicondyle
Physical Exam
• Inspect
• Palpate



- Medial structures (medial epicondyle, flexor/pronators)
- Lateral structures (lateral epicondyle, radiocapitellar
joint, extensor muscles)
- Posterior structures (olecranon process, bursa)
Range of Motion
Elbow stability (varus / valgus stress)
Strength testing
NERVE TESTING
• Dorsiflex wrist: Radial
nerve weakness
• Abduct ulnar half of
fingers:
Ulnar nerve weakness
• Appose thumb and index
finger tips (O sign):
Median nerve weakness
Loss of
full range
of
motion…
**Must
MRI**
Medial Epicondyle Apophysitis:
“Little League Elbow”
• Traction apophysitis of
•
•
•
•
medial epicondyle
Etiology: repetitive overuse
Valgus overload
Typical age: 10-15 yrs
Medial elbow pain worse
with throwing activity
Little Leaguer’s Elbow
Abnormal
Normal
Little League Elbow
• Exam
- tenderness over
medial epicondyle
- pain with resisted
flexion and pronation,
valgus stress
• MANAGE with Rest, Ice,
P.T. (interval throwing
program), pitch counts/types
If there was trauma and the elbow
is swollen, do NOT push on it or
passively test range of motion.
* THINK “FRACTURE” *
Elbow: Supracondylar Fractures
• Most common elbow fx; 10% of pediatric fx’s
• Mechanism = FOOSA
• Can be occult: suspect if + fat pad, or
•
•
•
displacement of AH line
Cannot tolerate > 5 degrees angulation (can
result in a varus “gunstock” deformity)
Tx if not displaced or angulated: posterior 90o
splint or long arm cast for 3-6 weeks
1 week follow-up
Type I and Type II SC Fx’s
Type III SC Fx
Flexion-type
SC Fx
PATHOLOGIC FAT PADS
Anterior Humeral Line
Radiocapitellar Line
ELBOW FRACTURE
• Posterior long arm splint
WRIST
14 year old male swimmer
Slipped on pool deck.
FOOSH (Fall Onto Outstretched Hand).
Tender over snuffbox, no swelling.
SWELLING
DEFORMITY
Scaphoid Fracture
Wrist: Scaphoid Fracture
• Always rule out if have snuffbox tenderness
• Blood supply from distal 1/3 of bone
• Any displacement has high nonunion rate;
•
•
proximal Fx lead to avascular necrosis
X-ray: include scaphoid views
If X-rays normal, but pain persists: thumb spica
cast and repeat X-rays in 2 wks (may need
MRI)
Avascular Necrosis of
Scaphoid
Scaphoid Fracture
• Thumb spica wrist splint
Scaphoid Fracture
• Rx: Casting x 8-10 wks total
• Thumb Spica LAC x 2-4 wks;
•
•
•
TS SAC x 4-6 wks
Repeat XR’s
Wrist brace for sports x 1 mo.
+/- F/u MRI for healing vs.
non-union vs. osteonecrosis
at 10 wks from DOI
Nonunion
Buckle (Torus) Fracture
3 weeks later
Sclerosis
Callus
WRIST FRACTURE
• Volar splint
• Sugartong splint
Treatment
• Buckle Fx = short arm cast for 3-4 weeks,
brace at f/u if fx site still tender; can play
• Transverse Fx = LAC 2-3 weeks with f/u xrays
then SAC x 2-4 wks.
• Consider f/u wrist brace for sports activity x 1
mo.
4 wks
later
Callus
Formation
HAND & FINGERS
ANATOMY
MUSCULATURE
Dorsal =
Extensors
&
Supinators
MUSCULATURE
Volar =
Flexors &
Pronators
Obama has intact nerves.
OTHER FAMOUS INTACT NERVES
(Post. Interosseous Nerve/Radial N.)
WHAT IS THIS INJURY?
17 yo male football player injured left 4th
finger while tackling an opposing player…
Jersey Finger: aka “Football Finger”
• CAUSE: Forced
extension of distal
phalanx while actively
flexing DIP… rupture/tear
of flexor digitorum
profundus tendon (FDP)
• SX: Pain, swelling at DIP
• “Pop!” felt
• SI: Unable to flex specific
DIP
• TTP over volar aspect
• Test the FDP by
holding PIP straight
and having athlete flex
DIP
FDP
JERSEY FINGER
• CONCERNS: Grade III
(complete) tear of flexor
digitorum profundus
(FDP) tendon
• Bony avulsion Fx
• Compromised palmar
digital artery blood
supply
• Poor healing & loss of
function if delayed
care
• Must be recognized
early
JERSEY FINGER
• Most commonly ring
finger
• X-Rays
• Splint in comfortable
position
• Refer for surgery ASAP
• RTP: 6-12 wks s/p
surgery
WHAT IS THIS INJURY?
15 yo female basketball player injured her
finger while catching the ball…
Mallet Finger: (aka Baseball Finger)
• CAUSE: Axial load
against an actively
extending finger;
“Jammed finger”
• Extensor digitorum
rupture
• SX: Pain at dorsal DIP
joint
• SI: Unable to extend
specific DIP
• TTP over dorsal
aspect of distal
phalanx
Mallet Finger
• CONCERNS: Dorsal bony
avulsion Fx
• Grade III complete tear
of extensor digitorum
tendon
• If left untreated,
permanent DIP
extensor lag
• XR: bone avulsion from
dorsal proximal aspect of
distal phalanx (20-30% of
cases)
Mallet Finger
• If no Fx, splint DIP fully
extended x 6-8 wks plus
addtl 6-8 wks if active.
• If Fx >30% jt space, refer
to ortho for ORIF.
• RTP: ASAP with adequate
splinting
WHAT IS THIS INJURY?
Skier’s Thumb
(aka Gamekeeper’s Thumb)
• CAUSE: Hyperabduction
of thumb MCP joint
• Rupture of UCL (ulnar
collateral ligament)
• SX: Pain over UCL; weak
pinch; painful pinch
• SI: XR first to r/o avulsion
fx!
• Pain w/ testing; TTP,
swelling over ulnar
aspect of thumb MCP
EXAMINATION
Skier’s Thumb
• CONCERN: Ulnar
collateral ligament
sprain +/- unstable Fx
• XRAY: if avulsion fx
displaced >2mm or
rotated, unstable.
Skier’s Thumb
• Tx: thumb spica cast x 4 wks.
•
ORIF if displaced Fx or
unstable joint or torn ends of
UCL / Stener’s
• RTP: Cast x 4 wks; RTP
thereafter w/ 2-4 mo of
splinting
FINGER FRACTURES
WHAT INJURY IS THIS?
• 17 yo male wrestler sustains twisting injury
•
to his left pointer finger during a match…
Later develops pain, swelling, bruising over
the finger.
Middle Phalangeal Fx
Middle Phalangeal Fx
• CAUSE: Direct trauma or twisting
• SX: Pain, swelling
• SI: TTP and swelling over middle phalanx +/•
deformity (check for rotation)
XR: usually transverse Fx but can be avulsion,
base Fx, or Salter-Harris; check for angulation or
displacement
Middle Phalangeal Fx
• TX:
• if stable, buddy-tape
and splint for sports
• if angulated, splint
MCP flexed 70 deg, PIP
flexed 45 deg, DIP free,
then buddy-tape x 3-4
wks
• if unstable or intraarticular, refer to Ortho
WHAT INJURY IS THIS?
• 13 yo girl is mad at her parents and
•
punches a wall…
Later she develops pain, swelling, and
bruising over her palm.
Metacarpal Fx, Boxer’s Fx
• CAUSE: axial load or
compressive force
• Poor punching
technique
• SX: Pain, swelling
• SI: angular or rotational
deformity
• XR: confirm angulation,
displacement
• Boxer’s Fx = 4th or 5th
MC
ROTATIONAL DEFORMITY
NORMAL
ABNORMAL
Metacarpal/Boxer’s Fx
• Ulnar gutter splint
Metacarpal/Boxer’s Fx
• Tx: Boxer’s cast
• Flex MCP 90
deg
• Cast x 4 wks,
then early ROM
• Splint for RTP x
3-4 wks
WHAT INJURY IS THIS?
• 16 yo female rugby player snags her finger on
another player’s jersey…
Dorsal PIP/DIP Dislocations
Dorsal PIP/DIP Dislocations
• CAUSE:
•
•
Hyperextension
with axial load
SX: Pain, swelling
SI: Deformity,
swelling, unable to
move joint
Dorsal PIP/DIP Dislocations
• If no Fx, splint in 30
deg flexion x 10-12
days (DIP) or 3 wks
(PIP)
• Buddy-taping for
sport x 4-6 wks.
• ROM exercises ASAP
DIP/PIP REDUCTION
REDUCTION
SUMMARY
• Always check neurovascular status.
• “PRICEMM”
• Deformed, angulated, or rotated injuries need
•
immediate referral!
Do not range or stress a suspected fracture.
REFERENCES
• Griffin, LY. Essentials of Musculoskeletal Care, 3rd ed. Rosemont, IL.
•
•
•
•
American Academy of Orthopaedic Surgeons, 2005.
Howard, TM & Butcher, JD. Blackwell’s Primary Care Essentials:
Sports Medicine. Malden, MA. Blackwell Science, Inc., 2001.
McKeag, DB & Moeller, JL. ACSM’s Primary Care Sports Medicine,
2nd ed. Philadephia, PA. Lippincott Williams & Wilkins, 2007.
Moore, KL & Dalley, AF. Clinically oriented anatomy, 5th ed.
Philadelphia, PA. Lippincott Williams & Wilkins, 2006.
http://www.wheelessonline.com/
Any questions?
•Rachel.Coel@childrenscolorado.org
•www.childrenshospitalcolorado.org/sports
•Sports Medicine Scheduling (720) 777-6600