1. Musculo-skeletal sport injury Kriangkamol Benjawongsathien, MD Orthopaedic department Buddhachinnaraj Hospital

2. Sport injury

3. Stage of injury 1.Inflammatory phase 1.Inflammatory phase 2.Reparative phase 2.Reparative phase 3.Remodeling phase 3.Remodeling phase

4. 1.Inflammatory phase 24-72 hr 24-72 hr hematoma clot formation hematoma clot formation Chemical mediator-vasodilate (prostaglandin( PG)) Chemical mediator-vasodilate (prostaglandin( PG)) Pain,warm,swelling Pain,warm,swelling

5. 2.Reparative phase 1- 6 week 1- 6 week Fibroblast – collagen filling defect Fibroblast – collagen filling defect Osteoblast Osteoblast Fibroblast Fibroblast

6. 3.Remodeling phase Maturation,tensile strength Maturation,tensile strength balance balance Month-year Month-year Bone ( 1- 2 year) Bone ( 1- 2 year) Ligament ( 6- 12 month) Ligament ( 6- 12 month)

7. Bone healing

8. Injury Fracture - bone Fracture - bone Strain – tendon, muscle Strain – tendon, muscle Sprain – ligament Sprain – ligament Grading ligament injury Grading ligament injury Grade 1 – microscopic tear Grade 1 – microscopic tear Grade 2 – partial tear Grade 2 – partial tear Grade 3 – complete tear Grade 3 – complete tear

10. Muscle Injury 1 degree (mild) - pain,swelling 1 degree (mild) - pain,swelling 2 degree (moderate) – pain,swelling,weakness 2 degree (moderate) – pain,swelling,weakness 3 degreee (severe) – complete rupture 3 degreee (severe) – complete rupture - marked pain, swelling, weakness - marked pain, swelling, weakness

11. Muscle injury

12. Effect of injury 1.tendon,ligament,joint capsule 1.tendon,ligament,joint capsule - fibrosis - fibrosis - cell proliferation - cell proliferation - joint stiffness - joint stiffness - decrease strength,flexibility - decrease strength,flexibility

13. Effect of injury 2. muscle 2. muscle - atrophy - atrophy 3.Bone 3.Bone - decrease bone mass,strength - decrease bone mass,strength

14. Treatment 1. First aid for prevent injury 1. First aid for prevent injury 2. Control pain and definite treatment 2. Control pain and definite treatment 3. Rehabilitation 3. Rehabilitation

15. 1.F irst aid 1.F irst aid RICE RICE R- Rest R- Rest I - Ice I - Ice C-Compression C-Compression E- Elevate E- Elevate

16. 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)

17. 3.Compression with elastic bandage 3.Compression with elastic bandage Advantage Advantage 1. compression force 1. compression force 2. static ice pack 2. static ice pack 3. ↓temp for control swelling 3. ↓temp for control swelling 4.Elevation for control swelling 4.Elevation for control swelling - ↑venous and lymphatic drain - ↑venous and lymphatic drain

18. 2.Control pain and definite treatment 2.1 Medication 2.1 Medication Paracet – control pain but not interfere inflammation Paracet – control pain but not interfere inflammation NSAIDS – control pain and inflammation (diclofenac) NSAIDS – control pain and inflammation (diclofenac) Muscle relaxant – control musle spasm ( norgesic) Muscle relaxant – control musle spasm ( norgesic)

19. 2.2 Conservative Injury grade 1, 2 ( partial tear) Injury grade 1, 2 ( partial tear) Cast Cast Brace Brace Support (knee,ankle) Support (knee,ankle)

20. 2.3 Surgery Grade 3 ( complete tear) Grade 3 ( complete tear) 1.Direct Repair 1.Direct Repair 2.Reconstruction 2.Reconstruction

21. Ligament injury

22. 3.Rehabilitaion Active exercise Active exercise Flexibility Flexibility Strength Strength Endurance Endurance Fitness (cardiovascular) Fitness (cardiovascular) Proprioception Proprioception

23. On – Field management Evaluation and Question ? Evaluation and Question ? 1.Continue to play? 1.Continue to play? ( fracture, tear ligament) ( fracture, tear ligament) 2.First aid treatment? 2.First aid treatment? ( RICE) ( RICE) 3.Prevent injury? 3.Prevent injury? ( support, taping) ( support, taping)

24. Evaluation and Examination 1.Talk 1.Talk - conscious ( GCS) - conscious ( GCS) - unconscious ( aware head and C-spine injury) - unconscious ( aware head and C-spine injury) - mechanism of injury - mechanism of injury 2.Observation 2.Observation - Airway - Airway - Breathing - Breathing - Circulation - Circulation - Disability - Disability

25. Evaluation and Examination 3.Palpation 3.Palpation - maximal point tender - maximal point tender - swelling - swelling - muscle spasm - muscle spasm 4.Motion 4.Motion - active - active - passive - passive

27. Common Musculoskeletal injury Common Musculoskeletal injury

28. 1.Shoulder injury Fracture clavicle Fracture clavicle Shoulder diclocation Shoulder diclocation Acromioclavicular(AC) joint separation Acromioclavicular(AC) joint separation Rotator cuff muscle injury Rotator cuff muscle injury

29. Anatomy of shoulder

30. Shoulder examination Deformity Deformity Palpate tender point Palpate tender point ROM ROM - flex / extend - flex / extend - abduct - abduct - ER / IR - ER / IR

31. Anatomy shoulder

32. 1.Diagnosis ???

33. 1.1 Fracture clavicle - Fall, direct injury - Tender,deformity - Most common – middle 1/3 - Treatment – conservative Figure-of-8 Figure-of-8 4-6week 4-6week

34. Figure – of - 8

35. On field -Arm sling, ice pack

36. 2.Diagnosis ???

37. 1.2 Shoulder dislocation Anterior dislocation – common 90% Anterior dislocation – common 90% Hold arm in adduct,ER Hold arm in adduct,ER Axillary nerve injury Axillary nerve injury Ruler sign Ruler sign ( loss of deloid mass )

38. Most common mechanism – flex,abduct and ER overhead sport - tennis

40. treatment Arm sling Arm sling Ice pack Ice pack Close Close reduction reduction Interlocking sling 3 week (prevent recurrence ) Interlocking sling 3 week (prevent recurrence ) Age < 20 yr – 90% Age < 20 yr – 90%

41. Close reduction with sedation ( traction – countertraction)

42. 1.3 Acromioclavicular(AC) joint separation Fall, direct injury Fall, direct injury Tender,deformity Tender,deformity

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

44. Grade of injury

45. treatment On Field – ice pack, arm sling On Field – ice pack, arm sling Grade 1,2 – conservative 2 week Grade 1,2 – conservative 2 week Grade 3 - surgery Grade 3 - surgery

46. 1.4 Rotator cuff muscle injury Common in overhead sport ( tennis,baseball,swimming) Common in overhead sport ( tennis,baseball,swimming) Tender at shoulder Tender at shoulder

47. Rotator cuff 4 muscle 4 muscle 1.supraspinatus – abduct 1.supraspinatus – abduct 2.subscapularis – IR 2.subscapularis – IR 3.Teres minor – ER 3.Teres minor – ER 4.infraspinatus - ER 4.infraspinatus - ER

48. Rotator cuff muscle injury Tender around shoulder Tender around shoulder Night pain Night pain Weakness abduct,ER,IR or resist Weakness abduct,ER,IR or resist Film Film MRI MRI

49. treatment RICE RICE Arm sling Arm sling Medication 2-4 week Medication 2-4 week Surgery – rotator cuff repair Surgery – rotator cuff repair

50. 2.Elbow and forearm injury Elbow dislocation Elbow dislocation Fracture around elbow Fracture around elbow

51. Anatomy

52. Elbow examination Deformity Deformity Swelling – hemartrosis Swelling – hemartrosis Tender Tender ROM – Flex (bicep) ROM – Flex (bicep) - extend (tricep) - extend (tricep) Sensation, motor (nerve injury) Sensation, motor (nerve injury)

53. Nerve sensation

54. 3.Diagnosis???

55. 2.1Elbow dislocation Fall with elbow extend Fall with elbow extend Posterior dislocation Posterior dislocation Swelling,deformity Swelling,deformity Brachial artery and median,ulnar nerve injury Brachial artery and median,ulnar nerve injury

56. Clinical and film elbow

57. treatment Close reduction under sedation with long arm slab 2-3 week Close reduction under sedation with long arm slab 2-3 week

58. 4.Diagnosis ???

59. 2.2 fracture around elbow

60. Common fracture around elbow Distal humerous Distal humerous Olecranon Olecranon Radial head,neck Radial head,neck

61. Deformity, pain, swelling

62. Treatment Acute – splint in extend position Acute – splint in extend position Definite – surgery Definite – surgery 6-12 week 6-12 week

63. 2.3 Tennis elbow Common in tennis,badminton Common in tennis,badminton Tender at lateral epicondyle Tender at lateral epicondyle Extensor tendon injury Extensor tendon injury

64. Treatment 1.Medication 1.Medication 2.Local steroid 2.Local steroid 3.splint 3.splint

65. 2.4 Golfer elbow Commomn in golf Commomn in golf Tender medial epicondyle Tender medial epicondyle Flexor tendon injury Flexor tendon injury

66. Treatment 1.Medication 1.Medication 2.Local steroid 2.Local steroid 3.Splint 3.Splint 4.Stretching 4.Stretching

67. 5.Diagnosis???

68. Anatomy of forearm rotation, length

69. Forearm,wrist exam Forearm,wrist exam Deformity, Deformity, shortening shortening Swelling Swelling Tender Tender ROM – F/E ROM – F/E - supinate /pronate - supinate /pronate Nerve injury Nerve injury

70. 3.Forearm and wrist fracture Fracture both bone forearm Fracture both bone forearm ( proximal, middle, distal) ( proximal, middle, distal) Common Common Direct injury Direct injury

71. 3.1Fracture forearm Fall on extend,direct injury Fall on extend,direct injury Deformity,swelling Deformity,swelling Check vascular, nerve Check vascular, nerve

72. 3.1Fracture forearm Treatment Treatment Splint in extend position (long) Splint in extend position (long) Displace Displace - Age <10 yr– long arm cast (4-8 week) - Age ≥ 10 yr - surgery - Age <10 yr– long arm cast (4-8 week) - Age ≥ 10 yr - surgery

73. 3.2Muscle, tendon injury Tender when resist Tender when resist Pain, swelling Pain, swelling Treat – medication Treat – medication and splint and splint (2-4 week) (2-4 week)

74. 3.3Wrist injury Fracture distal end radius Fracture distal end radius Tendon injury Tendon injury Common in tennis Common in tennis

75. treatment splint in resting position splint in resting position fracture fracture - Non displace – SAC - Non displace – SAC - Displace – surgery - Displace – surgery Tendon injury – wrist support Tendon injury – wrist support

76. 4.Back injury Muscle strain - common Muscle strain - common Fracture -rare Fracture -rare

77. 4.1Back strain Common Common Pain on movement Pain on movement Point of tender paravertebral muscle Point of tender paravertebral muscle Medication Medication 1-2 week

78. 4.2 Fracture spine Rare Rare Severe injury Severe injury Check neurological status Check neurological status Sensation Sensation Motor L1-2 hip flexion Motor L1-2 hip flexion L3-4 knee extend L3-4 knee extend L4 ankle dorsiflexion L4 ankle dorsiflexion L5 big toe extend L5 big toe extend

80. Log roll Transfer Transfer 3 person 3 person 1.head and neck 1.head and neck 2.Back and hip 2.Back and hip 3.thigh and leg 3.thigh and leg

81. 5. Neck injury

82. 5.Neck and C-spine injury Serious injury Serious injury Spinal cord injury Spinal cord injury Mechanism -Flex,extend,axial load and rotation Mechanism -Flex,extend,axial load and rotation

83. Approach ABC ABC Conscious ( GCS ) E4V5M6 Conscious ( GCS ) E4V5M6 Sensation, motor, reflex Sensation, motor, reflex

84. Motor exam “KEY” muscles “KEY” muscles C5-elbow flexion C5-elbow flexion C6-wrist extension C6-wrist extension C7-elbow extension C7-elbow extension - wrist flexion - wrist flexion C8-finger flexion C8-finger flexion T1-finger abduction T1-finger abduction

85. Treatment Rigid cervical hard collar Rigid cervical hard collar Philadelphia collar Philadelphia collar

86. Transfer ( prevent injury)

87. Investigation ( film, MRI)

88. 6.Thigh injury Quadriceps muscle injury, rupture Quadriceps muscle injury, rupture Common Common Running, soccer Running, soccer Pain on knee extend Pain on knee extend or resist or resist

89. Quadriceps muscle injury, rupture Clinical diagnosis Clinical diagnosis Ultrasound Ultrasound MRI MRI

90. Treatment Splint / RICE Splint / RICE Medication Medication Conservative - cylinder cast 4 week Conservative - cylinder cast 4 week Surgical repair Surgical repair

91. Prevention injury Quadriceps exercise Quadriceps exercise stretching stretching