Musculo-skeletal Musculo-skeletal sport injurysport injury

Kriangkamol Benjawongsathien, MDKriangkamol Benjawongsathien, MD

Orthopaedic departmentOrthopaedic department

Buddhachinnaraj HospitalBuddhachinnaraj Hospital

Sport injurySport injury

Stage of injuryStage of injury

1.Inflammatory phase1.Inflammatory phase 2.Reparative phase2.Reparative phase 3.Remodeling phase3.Remodeling phase

1.Inflammatory phase1.Inflammatory phase

24-72 hr24-72 hr hematoma clot formationhematoma clot formation Chemical mediator-vasodilate Chemical mediator-vasodilate

(prostaglandin( PG))(prostaglandin( PG)) Pain,warm,swellingPain,warm,swelling

2.Reparative phase2.Reparative phase 1- 6 week1- 6 week Fibroblast – collagen Fibroblast – collagen

filling defectfilling defect OsteoblastOsteoblast FibroblastFibroblast

3.Remodeling phase3.Remodeling phase

Maturation ,tensile strengthMaturation ,tensile strength balancebalance Month-yearMonth-year Bone ( 1- 2 year)Bone ( 1- 2 year) Ligament ( 6- 12 month)Ligament ( 6- 12 month)

Bone healingBone healing

InjuryInjury

Fracture - boneFracture - bone Strain – tendon, muscleStrain – tendon, muscle Sprain – ligamentSprain – ligament

Grading ligament injuryGrading ligament injury Grade 1 – microscopic tearGrade 1 – microscopic tear Grade 2 – partial tearGrade 2 – partial tear Grade 3 – complete tearGrade 3 – complete tear

Muscle Injury Muscle Injury

1 degree1 degree (mild) - pain,swelling (mild) - pain,swelling 2 degree2 degree (moderate) – (moderate) –

pain ,swelling,weaknesspain ,swelling,weakness 3 degreee3 degreee (severe) – complete (severe) – complete

rupturerupture

- marked pain , swelling, - marked pain , swelling, weaknessweakness

Muscle injuryMuscle injury

Effect of injuryEffect of injury

1.tendon,ligament,joint 1.tendon,ligament,joint capsulecapsule

- fibrosis- fibrosis

- cell proliferation- cell proliferation

- joint stiffness- joint stiffness

- decrease - decrease strength,flexibility strength,flexibility

Effect of injuryEffect of injury

2. muscle2. muscle

- atrophy- atrophy 3.Bone3.Bone

- decrease bone - decrease bone mass,strengthmass,strength

TreatmentTreatment 1. First aid for prevent injury1. First aid for prevent injury 2. Control pain and definite 2. Control pain and definite

treatmenttreatment 3. Rehabilitation3. Rehabilitation

1.F1.First aidirst aid

RICERICE R- Rest R- Rest I - IceI - Ice C-Compression C-Compression E- Elevate E- Elevate

1.Rest 1.Rest - prevent more injury- prevent more injury

- 24 hr- 24 hr

2.Ice 2.Ice - control pain- control pain

- vasoconstrict- vasoconstrict

- ↓muscle spasm- ↓muscle spasm

- ice and plastic bag- ice and plastic bag

- 20 min ( q 2-4 hr in 24 hr)- 20 min ( q 2-4 hr in 24 hr)

3.Compression with elastic 3.Compression with elastic bandagebandage

AdvantageAdvantage

1. compression force 1. compression force

2. static ice pack2. static ice pack

3. ↓temp for control swelling3. ↓temp for control swelling 4.Elevation for control swelling4.Elevation for control swelling

- ↑venous and lymphatic drain- ↑venous and lymphatic drain

2.Control pain2.Control pain and definite and definite treatmenttreatment

2.1 Medication2.1 Medication Paracet Paracet – control pain but not – control pain but not

interfere inflammationinterfere inflammation NSAIDSNSAIDS – control pain and – control pain and

inflammation (diclofenac)inflammation (diclofenac) Muscle relaxantMuscle relaxant – – control musle control musle

spasm ( norgesic)spasm ( norgesic)

2.2 Conservative2.2 Conservative

Injury grade Injury grade 1, 2 ( partial 1, 2 ( partial tear)tear)

Cast Cast Brace Brace Support Support

(knee,ankle)(knee,ankle)

2.3 Surgery 2.3 Surgery Grade 3 ( complete tear)Grade 3 ( complete tear) 1.Direct Repair1.Direct Repair 2.Reconstruction2.Reconstruction

Ligament injuryLigament injury

3.Rehabilitaion3.Rehabilitaion

Active exerciseActive exercise FlexibilityFlexibility StrengthStrength EnduranceEndurance Fitness (cardiovascular)Fitness (cardiovascular) Proprioception Proprioception

On – Field managementOn – Field management

Evaluation and Evaluation and Question ?Question ?

1.Continue to play?1.Continue to play? ( fracture , tear ( fracture , tear

ligament)ligament) 2.First aid treatment?2.First aid treatment? ( RICE)( RICE) 3.Prevent injury?3.Prevent injury? ( support, taping)( support, taping)

Evaluation and ExaminationEvaluation and Examination 1.Talk 1.Talk - conscious ( GCS)- conscious ( GCS) - unconscious ( aware head and - unconscious ( aware head and

C-spine injury)C-spine injury) - mechanism of injury- mechanism of injury 2.Observation2.Observation - Airway- Airway - Breathing- Breathing - Circulation - Circulation - Disability- Disability

Evaluation and ExaminationEvaluation and Examination

3.Palpation3.Palpation

- maximal point tender- maximal point tender

- swelling- swelling

- muscle spasm- muscle spasm 4.Motion4.Motion

- active- active

- passive- passive

Common Common Musculoskeletal Musculoskeletal injuryinjury

1.Shoulder1.Shoulder injuryinjury

Fracture clavicleFracture clavicle Shoulder diclocationShoulder diclocation Acromioclavicular(AC) joint Acromioclavicular(AC) joint

separationseparation Rotator cuff muscle injuryRotator cuff muscle injury

Anatomy of shoulderAnatomy of shoulder

Shoulder examinationShoulder examination

DeformityDeformity Palpate tenderPalpate tender pointpoint ROM ROM

- flex / extend- flex / extend

- abduct- abduct

- ER / IR- ER / IR

Anatomy shoulderAnatomy shoulder

1.Diagnosis ???1.Diagnosis ???

1.1 Fracture clavicle1.1 Fracture clavicle

- Fall, direct injuryFall, direct injury- Tender ,deformityTender ,deformity- Most common – Most common –

middle 1/3middle 1/3

- Treatment –Treatment –conservativeconservative

Figure-of-8 Figure-of-8 4-6week4-6week

Figure – of - 8Figure – of - 8

On field -Arm sling , ice packOn field -Arm sling , ice pack

2.Diagnosis ???2.Diagnosis ???

1.2 Shoulder dislocation1.2 Shoulder dislocation Anterior dislocation – Anterior dislocation –

common 90%common 90% Hold arm in adduct,ERHold arm in adduct,ER Axillary nerve injuryAxillary nerve injury Ruler signRuler sign

( loss of ( loss of

deloiddeloid

mass )mass )

Most common mechanism – Most common mechanism – flex ,abduct and ERflex ,abduct and ERoverhead sportoverhead sport - tennis- tennis

treatmenttreatment

Arm sling Arm sling Ice packIce pack Close Close

reductionreduction Interlocking sling 3 weekInterlocking sling 3 week

(prevent recurrence )(prevent recurrence ) Age Age < 20 yr – 90%< 20 yr – 90%

Close reduction Close reduction with sedationwith sedation( traction – ( traction – countertraction)countertraction)

1.3 Acromioclavicular(AC) 1.3 Acromioclavicular(AC) joint separationjoint separation

Fall, direct injuryFall, direct injury Tender,deformityTender,deformity

Anatomy of AC joint Anatomy of AC joint AC(Acromioclavicular ligament)AC(Acromioclavicular ligament)CC(Coracoclavicular ligament)CC(Coracoclavicular ligament)

Grade of injuryGrade of injury

treatmenttreatment On Field – ice pack, arm slingOn Field – ice pack, arm sling Grade 1,2 – conservative 2 weekGrade 1,2 – conservative 2 week Grade 3 - surgeryGrade 3 - surgery

1.4 Rotator cuff muscle1.4 Rotator cuff muscle injuryinjury Common in overhead sport Common in overhead sport

( tennis,baseball,swimming)( tennis,baseball,swimming) Tender at shoulderTender at shoulder

Rotator cuffRotator cuff 4 muscle4 muscle 1.supraspinatus – 1.supraspinatus –

abductabduct 2.subscapularis – IR 2.subscapularis – IR 3.Teres minor3.Teres minor – ER– ER 4.infraspinatus - ER4.infraspinatus - ER

Rotator cuff muscleRotator cuff muscle injuryinjury

Tender around Tender around shouldershoulder

Night painNight pain Weakness Weakness

abduct,ER,IR or abduct,ER,IR or resistresist

FilmFilm MRIMRI

treatmenttreatment

RICERICE Arm sling Arm sling Medication 2-4 Medication 2-4

weekweek Surgery – Surgery –

rotator cuff rotator cuff repairrepair

2.Elbow and forearm injury2.Elbow and forearm injury Elbow dislocationElbow dislocation FractureFracture around elbowaround elbow

Anatomy Anatomy

ElbowElbow examinationexamination

DeformityDeformity Swelling – hemartrosisSwelling – hemartrosis TenderTender ROM – Flex (bicep)ROM – Flex (bicep)

- extend (tricep)- extend (tricep) Sensation , motor (nerve Sensation , motor (nerve

injury)injury)

Nerve sensationNerve sensation

3.Diagnosis???3.Diagnosis???

2.1Elbow dislocation2.1Elbow dislocation Fall with elbow extendFall with elbow extend Posterior dislocationPosterior dislocation Swelling ,deformitySwelling ,deformity Brachial artery and median,ulnar Brachial artery and median,ulnar

nervenerve injuryinjury

Clinical and film elbow Clinical and film elbow

treatmenttreatment Close Close

reduction reduction under under sedation sedation with with long arm slab long arm slab 2-3 week2-3 week

4.Diagnosis ???4.Diagnosis ???

2.2 fracture around elbow2.2 fracture around elbow

Common fracture around Common fracture around elbowelbow

Distal Distal humeroushumerous

Olecranon Olecranon Radial Radial

head,neckhead,neck

Deformity , pain , swellingDeformity , pain , swelling

Treatment Treatment

Acute – splint in extend positionAcute – splint in extend position Definite – surgeryDefinite – surgery 6-12 week6-12 week

2.3 Tennis elbow2.3 Tennis elbow Common in tennis ,badmintonCommon in tennis ,badminton Tender at lateral epicondyleTender at lateral epicondyle Extensor tendon injuryExtensor tendon injury

TreatmentTreatment 1.Medication1.Medication 2.Local steroid2.Local steroid 3.splint3.splint

2.4 Golfer elbow2.4 Golfer elbow

Commomn in golfCommomn in golf Tender medial epicondyleTender medial epicondyle Flexor tendon injuryFlexor tendon injury

Treatment Treatment

1.Medication 1.Medication 2.Local steroid2.Local steroid 3.Splint3.Splint 4.Stretching4.Stretching

5.Diagnosis???5.Diagnosis???

Anatomy of forearmAnatomy of forearmrotation , lengthrotation , length

Forearm,wrist examForearm,wrist exam Deformity,Deformity, shorteningshortening SwellingSwelling TenderTender ROM – F/EROM – F/E

- supinate /pronate- supinate /pronate Nerve injuryNerve injury

3.Forearm and wrist fracture3.Forearm and wrist fracture

Fracture both bone forearm Fracture both bone forearm

( proximal, middle, distal)( proximal, middle, distal) CommonCommon Direct injuryDirect injury

3.1Fracture forearm3.1Fracture forearm Fall on extend ,direct injuryFall on extend ,direct injury Deformity,swellingDeformity,swelling Check vascular, nerveCheck vascular, nerve

3.1Fracture forearm3.1Fracture forearm

Treatment Treatment Splint in extend position (long)Splint in extend position (long) Displace Displace

- Age - Age <10 yr– long arm cast <10 yr– long arm cast (4-8 week) (4-8 week) - Age ≥ 10 yr - surgery - Age ≥ 10 yr - surgery

3.2Muscle , tendon injury3.2Muscle , tendon injury

Tender when Tender when resistresist

Pain , Pain , swelling swelling

Treat – Treat – medicationmedication

and splintand splint

(2-4 week)(2-4 week)

3.3Wrist injury3.3Wrist injury

Fracture distal end Fracture distal end radius radius

Tendon injuryTendon injury CommonCommon in tennisin tennis

treatmenttreatment splint in resting position splint in resting position fracturefracture

- Non displace – SAC- Non displace – SAC

- Displace – surgery - Displace – surgery Tendon injuryTendon injury – wrist support – wrist support

4.Back injury4.Back injury

Muscle strain - commonMuscle strain - common Fracture -rareFracture -rare

4.1Back strain4.1Back strain

CommonCommon Pain on movementPain on movement Point of tender paravertebral Point of tender paravertebral

musclemuscle MedicationMedication

1-2 week1-2 week

4.2 Fracture4.2 Fracture spinespine RareRare Severe injurySevere injury Check neurological statusCheck neurological status SensationSensation MotorMotor L1-2 hip flexionL1-2 hip flexion

L3-4 knee extendL3-4 knee extend

L4 ankle dorsiflexionL4 ankle dorsiflexion

L5 L5 big toe extendbig toe extend

Log rollLog roll

TransferTransfer 3 person3 person 1.head and 1.head and

neckneck 2.Back and hip2.Back and hip 3.thigh3.thigh and legand leg

5. Neck injury5. Neck injury

5.Neck and C-spine injury5.Neck and C-spine injury Serious injurySerious injury Spinal cord injurySpinal cord injury Mechanism -Flex,extend,axial Mechanism -Flex,extend,axial

load and rotationload and rotation

ApproachApproach ABC ABC Conscious Conscious

( GCS ) ( GCS ) E4V5M6E4V5M6

Sensation, Sensation, motor , reflexmotor , reflex

Motor examMotor exam

“ “KEY” muscles KEY” muscles C5-elbow flexionC5-elbow flexionC6-wrist extension C6-wrist extension C7-elbow extensionC7-elbow extension

- wrist flexion- wrist flexionC8-finger flexionC8-finger flexionT1-finger abductionT1-finger abduction

Treatment Treatment Rigid cervical hard collarRigid cervical hard collar Philadelphia collarPhiladelphia collar

TransferTransfer ( prevent injury)( prevent injury)

Investigation ( film, MRI)Investigation ( film, MRI)

6.Thigh injury6.Thigh injury Quadriceps muscle Quadriceps muscle

injury, ruptureinjury, rupture CommonCommon Running , soccerRunning , soccer Pain on knee extendPain on knee extend

or resistor resist

Quadriceps muscle injury, Quadriceps muscle injury, rupturerupture

Clinical diagnosis Clinical diagnosis UltrasoundUltrasound MRIMRI

Treatment Treatment Splint / RICESplint / RICE MedicationMedication Conservative -Conservative -

cylinder cast 4 cylinder cast 4 weekweek

Surgical repairSurgical repair

Prevention injuryPrevention injury

Quadriceps exerciseQuadriceps exercise stretchingstretching