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 endfeel

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

Pathology
SLAP Lesion Bankart Lesion A SLAP lesion is a tear that occurs Disruption of the labrum and the where the tendon of the biceps contiguous anterior band of the muscle meets the superior labrum. inferior glenohumeral ligamentous complex (Widjaja , Tran, Bailey, Most common in Proper, 2006 ) throwing/overhead athletes and in males greater than females Bony Bankart lesionsoccur when (DAlessandro , Fleischli , Conner, some of the glenoid bone is broken 2000) off with the anterior labrum Classified into 4 types: Type I: fraying Type II: detachment Type III: bucket handle labral tear Type IV: labral tear extending into biceps tendon

Mechanism of Injury
SLAP Lesion Falling on the arm/shoulder (FOOSH) Bankart Lesion Traumatic, anterior dislocation of glenohumeral joint - FOOSH Sudden, traumatic inferior pull on - Abduction combined with the arm external 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 (DAlessandro , Fleischli , Conner, 2000) - Direct blow . rotation

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

Signs and Symptoms

SLAP Lesion Deep shoulder pain localized to anterosuperior shoulder between the A.C joint and the coracoid (DAlessandro , Fleischli , Conner, 2000) Clicking, catching or popping Bankart Lesion 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 Findings
SLAP Lesion Bankart Lesion Combination of tests used together Anterior apprehension test may yield the best results (sensitivity and specificity values Load and shift test between 70-95%) - 2 of the 3 relatively sensitive Pain and clicking with compression tests (O'Brien, apprehension, or and rotation of the shoulder compression-rotation test) combined with 1 of the 3 relatively Looseness or apprehension when specific tests (Speed, Yergason, or the shoulder is tested for laxity biceps load II test) (Oh, Kim, Kim, Gong, and Lee, 2008)

Management
SLAP 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, highspeed, overhead strengthening (DAlessandro , Fleischli , Conner, 2000) Bankart Lesion 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

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
DAlessandro 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. 6:4650. Gotlin R. (2008). Sports Injuries Guidebook. Champaign, IL: Human Kinestics Gutierrez G. (1996). Office management of scaphoid fractures. Physician and Sports Medicine, 24:6070c. 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), 353359. Phillips T, Reibach A, Slomiany W. (2004). Diagnosis and management of scaphoid fractures.American Family Physician.70:879884. 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):4368. Yin Z, Zhang J, Kan S, Wang X. (2010). Diagnosing suspected scaphoid fractures: a systematic review and meta-analysis.Clinical Orthopaedics and Related