My Orthopedic Surgery

Youth sports participation carries an inherent risk of injury, including overuse injuries. Little leaguer's shoulder, a stress fracture of the proximal humerus that presents as lateral shoulder pain, usually is self-limited. Little leaguer's elbow is a medial stress injury; treatment consists of complete rest from throwing for four to six weeks followed by rehabilitation and a gradual throwing program. Spondylolysis is a stress fracture of the pars interarticularis. Diagnostic modalities include plain film radiography, bone scan, computed tomography, single photon emission computed tomography, and magnetic resonance imaging. Treatment usually is conservative. Spondylolisthesis is the forward or anterior displacement of one vertebral body over another and may be related to a history of spondylolysis. Diagnosis is made with plain film radiography and graded according to the amount of displacement. Osgood-Schlatter disease presents as anterior knee pain localized to the tibial tubercle. Diagnosis is made clinically, and most patients respond to conservative measures. Calcaneal apophysitis (or Sever's disease) is a common cause of heel pain in young athletes, presenting as pain in the posterior aspect of the calcaneus. (Am Fam Physician 2006;73:1014-22. Copyright © 2006 American Academy of Family Physicians.)
KYLE J. CASSAS, M.D., and AMELIA Cassettari-WAYHS, M.D., Methodist Health System, Dallas, Texas

Trainers' Page Humerus (upper arm bone) fractures are not common in athletics. Humerus fractures account for approximately 3% of all fractures. Due to the low incidence rate of humerus fractures, Athletic Trainers may not see more than one in their professional career. Treatment of a humerus fracture begins with a visit to the emergency room to determine the type of fracture. The physician needs to determine if the fracture is complex or simple. This will help to determine if surgery in needed. Also, the athlete needs to be evaluated for possible nerve or circulation problems due to the fracture. Entrapment of nerves and arteries are highly possible with a humerus fracture. Prior to transport, both the vascular and neural integrity must be assessed and stabilized. If the fracture is stable, treatment may consist of only sling and swath immobilization for 6 weeks. Some physicians will utilize a “clam-shell” immobilizer if they feel that a sling and swath will not immobilize the fracture sufficiently. If the fracture is complex in nature, open reduction with internal fixation (ORIF) surgery may be necessary. This can be accomplished with a plate and screws or with an intermedullary (IM) rod or nail. Both methods of internal fixation are very invasive and have potential complications. ORIF with a plate and screws results in a stabilized fracture that should heal with little complications. Early rehabilitation should concentrate on range of motion exercises for the elbow, shoulder, wrist, and hand. Rehabilitation exercises will progress, as the fracture heals, to include strength training for the shoulder, arm, forearm, wrist and hand. ORIF with a rod or nail is much more complex. The nail is inserted on the superior aspect of the head of the humerus. To accomplish this, the rotator cuff tendons are split and sewn back together. Rehabilitation is then limited by the healing rate of the rotator cuff tendon. These athletes are rehabilitated like an open rotator cuff repair. Passive motion is started early to prevent adhesive capsulitis of the shoulder, elbow, and wrist. This is progressed to active motion and active strengthening as the cuff heals. Return to sports participation is allowed after full fracture healing, return of normal range of motion, and return of full strength. This will take 3 to 6 months for this type of injury. Complications The humerus is a complex boney structure that is difficult to treat when fractured in a complex fashion. The most common complication of a humerus fracture is impingement of the radial nerve. The radial nerve runs posteriorly along the humerus in the spiral groove (see diagram). If the humerus is fractured distally or midshaft, the radial nerve can become entrapped in the fracture site or a fracture fragment. This graphic shows the radial nerve becoming entrapped in the fracture more distally. The nerve can also become entrapped when the physician performs a closed reduction of a displaced fracture. It is estimated that up 18% of all humerus fractures involve damage to the radial nerve. Due to this, many humerus fractures show signs of radial nerve entrapment upon initial examination. Treating physicians will observe the patients who exhibit radial nerve palsy for spontaneous healing. Radial nerve palsy results in the inability to extend the wrist and fingers as seen in the picture. Recovery rates are relative to the type of fracture and amount of nerve impingement. In 75% - 90% of the patients treated with a closed reduction, full recovery will occur in 3 to 4 months. This depends upon the amount of nerve damage, presence of scar tissue and swelling. Nerve will heal at the rate of approximately 1 mm per month. If after 3 - 4 months the nerve palsy is still present, surgical exploration of the nerve may be necessary. This surgery will focus on determining the cause of the nerve impingement. The physician may order an EMG to determine the amount of nerve damage. This study will show if the nerve is conducting electricity. If the nerve is still functioning, there is hope for a full or partial recovery. If surgery is required, the doctor will attempt to find the source of the palsy. This could range from the nerve being stretched over the healing bone, entrapment in scar tissue, a partially severed nerve, a completely severed nerve, or entrapment of the nerve in the healed bone. Exact surgical treatment will depend upon the ultimate cause of the entrapment.

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