Football and netball seasonA review of the apophysis and the acute shoulder:

assessment

Simon Locke

Sport and Exercise Physician

Apophyseal injuries; How to

diagnose and manage?

Goals for tonight

• Recognise

– Skeletal maturity assessment

• Assess

• Investigate

• Manage

ApophysisThe apophysis is a normal bony outgrowth

that arises from a secondary ossification centre

and fuses with the bone in course of time.

Apophysis a site of tendon or ligament

attachment

Pelvic apophyses appearance/closing

Site Appearance (yrs) Fusing complete (yrs)

Iliac crest 13-15 15-17

ASIS 14 16

Ischium 15-17 19-25

Rossi et al (2001) Average age avulsion fractures 13.8 years

Schuett et (2015) Average age avulsion fractures 14.5 years

Maturity Risser staging

Mechanism apophyseal injuries

• Timing

• Peak Height Velocity (12 girls, 14 boys)– Bone density weakest

– Bone grow before MT unit – increasing stress at apophysis

• Acute

• Avulsion fractures

• Sprinting, kicking, jumping sports

• Overuse

• Long distance running

• Baseball pitching – elbow

• Gymnastics

*Rossi et al 2001

Case History• Patient

– Male, 14yrs

• Event

– Footy training

– Sprinting or sprinting to kick

• Symptoms

– Sudden onset pain, limp or cannot continue

• Local tenderness

• Function loss – ROM, strength

Injury site and prevalence

IT 11%

Males 82%

ASIS 30%

Males 75%

AIIS 49%

Males 82%

Relative Percentages of Pelvic

Avulsion Fracture Locations

• Ischial tuberosity – 54%

• AIIS – 22%

• ASIS – 19%

• Pubic Symphysis – 3%

• Iliac Crest – 1%

http://crashingpatient.com

Rossi F, Dragoni S. Acute Avulsion Fractures of

the Pelvis in Adolescent Competitive Athletes.

Skeletal Radiol. 2001;30(3):127-31.

Fracture type

• Associations

• Increasing age / maturity– Risser stage 0 - AIIS avulsion – 85% of all avulsion

injuries

– Risser 4 – ASIS, Iliac Crest – 84%

• Sex (males)– 76% of all avulsion fractures

Schuett et al 2015

Fracture displacement

• 69% of all fractures displaced <10mm

• 24% of all fractures displace 10-20mm

• 7% displaced >20mm

Schuett et al 2015

Prognosis

• Multiple fractures (14%)

• Bilateral avulsion injuries (6%)

• 98% conservative success

• Pain > 3 mos 14% (? Recurrence – 7%)

• AIIS most likely 4.47 times

– Postulates – sub spinal impingement, labral injury

• Non union (2%)

• Ischial tuberosity

• >20 mm displacement

Schuett et al 2015

Assessment• Age 14 yr male

• Sport

• Mechanism - sudden

• Examination• Local tenderness,

• ROM, weakness)

• Plain Xray (AP pelvis, frog leg lateral)• Fracture site, displacement

• Skeletal Maturity – Risser

• Triradiate physis status

Management

• Conservative

• 98% heal

• NWB crutches – 4-6 weeks

• Rehabilitation

• ROM, strength

• Gradual return to sport (fitness)

• Return to sport (10-12 weeks)

Surgical indications

• Risk appears 2%

• Displacement >20mm

• Persistent pain and disability >3 mos

Schuett et al 2015

ASIS Avulsion Fracture

Ischial Avulsion Fracture

11 yr male sprinting

Shoulder Injuries:

Acute dislocating

Instability

Clinical Problem

• 22 yo footballer

• Occupation – electrician subcontractor/ own business

• 1st Dislocated – last weekend

• Relocated in ER

• Current management IR

• When can I return to footy?• Definitive management

• Recurrence risk

• Impact on occupation

• Football importance

Why Bother?

• Are shoulder and upper limb injuries common?

• Dislocation

• Instability

• How do they happen?

• Approach to investigations – Xr, MR

• Treatment

Shoulder injuries are common in

athletes!!

QAS Screening injury Prevalence

Figure 4: Proportion of QAS athletes with current injuries by anatomical site

28.7%

23.8%

47.5%

Head, neck and spine

Shoulder girdle andupper limb

Pelvis, hip and lower limb

Shoulder Injuries in elite College Football (NFL)

Shoulder Injury Injury (%) Surgery (%,Y)

AC separation 41 12

Anterior Instability 21 76

RC tendon 10 13

Clavicle # 4 0

Posterior

Instability4 78

SLAP 2 40

RC tear 2 100

SC separation 2 0

MD Instability 2 50

Kaplan AJSM 2005

Injury Risk

Previous shoulder injury

Reported

Observed

Increasing player experience

Athletes have multiple injuries

1.3 per injured player*

*Kaplan AJSM 2005

Shoulder Anatomy

ClavicleACJointAcromion

Coracoid

Shoulder

Joint

Ligaments

SubscapularisTendon

BicepsTendon

Anterior Dislocation mechanism

• Arm forced into extension, abduction and

external rotation (ABER)

• Ant. capsule stretched torn

• Humeral head slips anteriorly

• Acute Injury - Intense pain / Paraesthesia

• Chronic Injury - Recurrent dislocation

• Subluxation

Anterior Dislocation

• Sharp contour of shoulder joint

• Prominent acromion

Anterior Dislocation

Anterior displacement of humerus

Defect of humeral head (HS lesion)

Chip fracture of inferior rim of

glenoid (Bankart)

Glenoid Labrum tear on MRI

Natural History Anterior Dislocation

Recurrence

85-90% recurrence young adults

Age

90% <20

65% 20-25 (Hovelius)

30% >30 (Simonet and Coldfield)

Sport

High risk

Robinson, C. M. et al. J BJS 2006

Recurrence after initial dislocation

Anterior Dislocation

Treatment

Reduction

Analgesia

ice, analgesics

Immobilization ER

Surgery

Rehabilitation

Immobilisation In ER

Basic Science – Cadaver study, MR“Coaptation zone” adduction +IR to 30º ER

MR Bankart lesion and glenoid closer in ER

Clinical Study Recurrence**Immobilisation 3/52

Follow-Up 15.9 mthsAll (40 yrs) IR (30%), ER (0%)

Young (<29 yrs) IR (45%), ER (0%)

Apprehension Sign +ve IR (14%), ER (5%)

*Itoi JBJS 1999,2001

**Itoi Am Acad OS 2003

Acute Dislocation Treatment Decisions

• Reduction – anterior

• Immobilisation (Recurrence rate)

Yes (90%) versus No

IR (45%) versus ER (0%)*

• Surgery, Risk Factors

• Age, Sport

*McCarty Clin Sports Med23,2004

Treatment Options

Conservative

Surgical – anterior instability

Open versus arthroscopy

Quality of life post treatment (work, family)

Prospective studies of Recurrence rates

Surgery recurrence 4-15%

Non Operation recurrence (age related) 30-80%

Instability - Clinical problem

22yo footballer – electrician (subcontractor/owner)

Tackled opponent with arm outside

Felt shoulder move

Pain on front of shoulder

Questions:

When can I play again?

What treatment do I need?

Shoulder Instability Injuries

• Anterior

• Inferior

• Posterior

• Multidirectional

Instability (MDI)

Recurrence following self report of

instability

• Self reported PH of instability:

• Dislocation HR 5.5(2.5-12.1)

• Instability HR 3.6 (1.8-7.4)

• Most common in 1st 2 years after initial event

Cameron et al JBJS 2013

Return To Play No Surgery*

• Is a safe return possible?

• Is there a difference between dislocation and subluxation injury?

• Is there a risk of further injury?

• Can the athlete protect themselves?

• Do they meet return to play criteria?• No Pain

• Normal ROM

• Normal Strength, Function, Sports, Skills

*McCarty Clin Sports Med23,2004

Final scenario

• Footballer 30 yrs age (final season)

• Married 2 children (2,4yrs)

• Own business

• What is your management?

• How do I get the best outcome for my patient?