Scaphoid Fracture

Pathology

• The most commonly fractured carpal bone, most often occurring in young men aged 15-30

• They are rare in young children and the elderly due to the relative weakness of the radius bone in these age groups (Phillips, Reibach and Slomiany, 2004).

• Can be classified as either displaced, unstable or undisplaced, stable (Yin, Zhand, Kan and Wang, 2010)

Mechanism of Injury

• Primarily traumatic, often caused by a fall onto an outstretched hand (FOOSH) where the wrist in extended and radially deviated (Phillips, Reibach and Slomiany, 2004)

• The injury often occurs during sporting activities or a motor vehicle accident

Signs and Symptoms

• Persistent, deep pain on the dorsum of the hand/wrist near the base of the first MCP (Phillips, Reibach and Slomiany, 2004)

• Difficulty gripping and grabbing objects (Gutierrez, 1996)

• The pain may be aggravated by thumb/wrist movement or gripping an object.

Objective Findings

• Swelling, bruising and tenderness on palpation on radial side of wrist over the snuff box (Gutierrez, 1996)

• Snuffbox tenderness is 90% sensitive and 40% specific for indication of a Scaphoid fracture (Freeland, 1989)

• Decreased AROM of the affected wrist, especially wrist extension and radial deviation

• Decreased PROM with an empty end-feel

Management

• Acute• RICE, immobilization for 6-8 weeks, NSAIDs

• Post- Immobilization• Joint mobilization to increase movement, muscle and joint

stretching, increase strength and endurance of wrist extensors and flexors, and thumb muscles

• Displaced fractures • Are prone to non-union and therefore should be treated

operatively (Phillips, Reibach and Slomiany, 2004))

SLAP and Bankart Repairs

PathologySLAP Lesion Bankart Lesion

A SLAP lesion is a tear that occurs where the tendon of the biceps muscle meets the superior labrum.

Most common in throwing/overhead athletes and in males greater than females (D’Alessandro , Fleischli , Conner, 2000)

Classified into 4 types:• Type I: fraying• Type II: detachment• Type III: bucket handle labral tear• Type IV: labral tear extending into biceps tendon

Disruption of the labrum and the contiguous anterior band of the inferior glenohumeral ligamentous complex (Widjaja , Tran, Bailey, Proper, 2006 )

Bony Bankart lesions occur when some of the glenoid bone is broken off with the anterior labrum

Mechanism of InjurySLAP Lesion Bankart Lesion

•Falling on the arm/shoulder (FOOSH)

•Sudden, traumatic inferior pull on the arm

•Lifting injury or repetitive overhead activity with the arm where superior labrum is most vulnerable to injury

•Large deceleration force of the biceps tendon during throwing motion (D’Alessandro , Fleischli , Conner, 2000)

• Traumatic, anterior dislocation of glenohumeral joint - FOOSH - Abduction combined with external . rotation - Direct blow

• Bankart tears occur in >85% of anterior shoulder dislocations (Widjaja , Tran, Bailey, Proper, 2006)

Signs and SymptomsSLAP Lesion Bankart Lesion

Deep shoulder pain localized to anterosuperior shoulder between the A.C joint and the coracoid (D’Alessandro , Fleischli , Conner, 2000)

Clicking, catching or popping

Shoulder pain which is not localized in a specific point and the pain gets worse when the arm is held behind the back (Gotlin, 2008)

Onset of symptoms usually occurs after a traumatic event such as a shoulder dislocation

They also feel weakness and instability of the shoulder (Gotlin, 2008)

Objective FindingsSLAP Lesion Bankart Lesion

Combination of tests used together may yield the best results (sensitivity and specificity values between 70-95%) - 2 of the 3 relatively sensitive tests (O'Brien, apprehension, or compression-rotation test) combined with 1 of the 3 relatively specific tests (Speed, Yergason, or biceps load II test) (Oh, Kim, Kim, Gong, and Lee, 2008)

Anterior apprehension test

Load and shift test

Pain and clicking with compression and rotation of the shoulder

Looseness or apprehension when the shoulder is tested for laxity

ManagementSLAP Lesion Bankart Lesion

Conservative Treatment/Pre-op: rest, NSAID, ROM exercises and rotator cuff strengthening

Arthroscopic surgery: reattaches the labrum to the glenoid• Phase I(0-4 weeks): immobilization• Phase II (4 weeks-2months): A/PROM, progressive resistance exercises• Phase III (2-4 months): Highly sport-specific, functional, high-speed, overhead strengthening(D’Alessandro , Fleischli , Conner, 2000)

Nonoperative:• Sling use for 1-3 weeks, avoidance of combined abduction and ER (Kim et al, 2003)• Rotator cuff and periscapular muscle strengthening

Operative:•Immobilization for 3-4 weeks•AAROM and AROM for weeks 6-12, then strengthening begins•Return to contact sports 20-24 weeks post-op (Kim et al, 2003)

Autolysis of Distal Clavicle

Pathology• Painful deterioration of distal clavicle caused by minor shoulder

trauma and strenuous exercise (Mestan and Bassano, 2001)• Repetitive trauma or stress from training causes small fractures at

the distal end of the clavicle. If there is insufficient recovery time the bone will start to dissolve (osteolysis)

• The exact cause of the osteolysis is still unknown and subject to debate; hypotheses include avascular necrosis, autonomic dysfunction, synovial hyperplasia and hyperemia (Mestan and Bassano, 2001 and Resnick and Niwayama, 1995)

• Affects males greater than females• Those at greater risk include: weightlifters, body builders, air-

hammer operators, soldiers, and handball players (Resnick and Niwayama, 1995)

Mechanism of Injury

• Atraumatic distal clavicular autolysis is thought to arise from a stress failure syndrome that involves resorption of the distal clavicle (Schwarzkopf et al, 2008)

• Result of strenuous physical exercise involving the upper extremities, including weightlifting, handball and baseball (Mestan and Bassano, 2001)

Signs and Symptoms• Insidious aching pain in the AC region that is

exacerbated by weight training (Schwarzkopf et al, 2008)

• The pain may radiate to the surrounding deltoid or trapezium and is relieved by prolonged rest (Schwarzkopf et al, 2008)

• Frequently, patients report difficulty sleeping on the affected side

• Activities such as push-ups, bench presses, power clean exercises, dips on the parallel bars, and throwing motions make the symptoms worse

Objective Findings

• Patients have point tenderness over the affected AC joint and pain with a cross-body adduction maneuver (Schwarzkopf et al, 2008)

• Patients generally have full range of motion (ROM) of the glenohumeral joint

Management

• Conservative– Avoidance of provocative maneuvers,

modification of weight training techniques, ice massage, and NSAIDs (Schwarzkopf et al, 2008)

• Surgery– Distal clavicle resection has been shown to

alleviate pain and return patients to previous activity levels (Flatow, Duralde, Nicholson, Pollock, Bigliani, 1995)

References• D’Alessandro D, Fleischli J, Conner, P. (2000). Superior Labral Lesions:

Diagnosis and Management. Journal of Athletic Training. 35(5):286-292.• Flatow E, Duralde X, Nicholson G, Pollock R, Bigliani L. (1995). Arthroscopic

rescection of the distal clavicle with a superior approach. Journal of Shoulder and Elbow Surgery. 4(1):41-50.

• Freeland P. (1989). Scaphoid tubercle tenderness: a better indicator of scaphoid fractures? Archives of Emergency Medicine. 6:46–50.

• Gotlin R. (2008). Sports Injuries Guidebook. Champaign, IL: Human Kinestics• Gutierrez G. (1996). Office management of scaphoid fractures. Physician and

Sports Medicine, 24:60–70c.• Kim S, Ha K, Jung M, Lim M, Kim Y, Park J. (2003). Accelerated Rehabilitation

After Arthroscopic Bankart Repair for Selected Cases: A Prospective Randomized Clinical Study. Arthroscopy. 19(7).

• Mestan M, Bassano J. (2001). Posttraumatic osteolysis of the distal clavicle: analysis of 7 cases and a review of the literature. Journal of Manipulative and Physiological Therapeutics. 24(5):356-361.

• Oh, J., Kim, J., Kim, W., Gong, H., & Lee, J. (2007). The evaluation of various physical examinations for the diagnosis of type II superior labrum anterior and posterior lesion. American Journal of Sports Medicine, 36(2), 353-359.

• Phillips T, Reibach A, Slomiany W. (2004). Diagnosis and management of scaphoid fractures. American Family Physician. 70:879–884.

• Resnick, D., & Niwayama, G. (1995). Diagnosis of bone and joint disorders (3rd ed.). Philadelphia: Saunders.

• Schwarzkopf R, Ishak C, Elman M, Gelber J, Strauss D, Jazrawi L. (2008). Distal Clavicular Osteolysis A Review of the Literature. Bulletin of the NYU Hospital for Joint Diseases 66(2):94-101.

• Widjaja A, Tran A, Bailey M, Proper S. (2006) Correlation between Bankart and Hill-Sachs lesions in anterior shoulder dislocation. ANZ Journal of Surgery. 76(6):436–8.

• Yin Z, Zhang J, Kan S, Wang X. (2010). Diagnosing suspected scaphoid fractures: a systematic review and meta-analysis. Clinical Orthopaedics and Related Research . 468 (3): 723–34.