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Musculoskeletal Soft Tissue Clinic Current Awareness Newsletter

July/August 2016

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Contents Your Local Librarian ...... 2 New from Cochrane Library ...... 3 New Activity in UptoDate ...... 3 Current Awareness Database Articles related to Musculoskeletal Soft Tissue ...... 6 Acute soft tissue ...... 6 Musculoskeletal ...... 8 Sports Injuries ...... 15 Journal Tables of Contents ...... 27 The American Journal of Sports Medicine ...... 27 British Journal of Sports Medicine ...... 27 Journal of Acute Medicine ...... 27 Journal ...... 27 Spine ...... 27

Your Local Librarian Whatever your information needs, the library is here to help. As your outreach librarian I offer literature searching services as well as training and guidance in searching the evidence and critical appraisal – just email me at library @uhbristol.nhs.uk

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LITERATURE SEARCHING: We provide a literature searching service for any library member. For those embarking on their own research it is advisable to book some time with one of the librarians for a 1 to 1 session where we can guide you through the process of creating a well-focused literature research and introduce you to the health databases access via NHS Evidence. Please email requests to [email protected]

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New from Cochrane Library

Surgical versus conservative interventions for treating anterior cruciate ligament injuries Authors: A Paul Monk, Loretta J Davies, Sally Hopewell, Kristina Harris, David J Beard, Andrew J Price First published: 3 April 2016 Assessed as up-to-date: 18 January 2016 Editorial Group: Cochrane Bone, Joint and Muscle Trauma Group Abstract: Background: Rupture of the anterior cruciate ligament (ACL) is a common , mainly affecting young, physically active individuals. The injury is characterised by joint instability, leading to decreased activity, which can lead to poor knee-related quality of life. It is also associated with increased risk of secondary osteoarthritis of the knee. It is unclear whether stabilising the knee surgically via ACL reconstruction produces a better overall outcome than non-surgical (conservative) treatment. Objectives: To assess the effects of surgical versus conservative interventions for treating ACL injuries. http://onlinelibrary.wiley.com/?attach_external_tab&150532960&4&0&0&0&0&iexplore

New Activity in Up-to-Date New updates in point-of-care evidence summarising tools Up-To-Date

Throwing injuries of the upper extremity: Clinical presentation and diagnostic approach Author: Craig Young, MD Literature review current through: Jun 2016. | This topic last updated: Jun 28, 2016. INTRODUCTION — Millions of people throughout the world participate in sports that involve throwing or throwing-like movements. These movements range from classic ball throwing, as performed by baseball pitchers or cricket bowlers, to throwing implements other than balls, such as a javelin, to throwing-like actions that do not involve a ball directly, such as a tennis serve or volleyball spike. All such movements involve complex biomechanics and great stresses being placed on the musculoskeletal system. Improper biomechanics, excessive stress beyond the capacity of an individual's musculoskeletal system, or cumulative trauma from throwing too frequently can cause injury. Differences in the mechanics of non-classic throwers make such athletes susceptible to other injuries not discussed in this topic. 4

The clinical presentation of throwing related injuries and an approach to diagnosing them are reviewed here. Throwing biomechanics, treatment of specific injuries, and physical examination of the shoulder are discussed separately. https://www.uptodate.com/contents/throwing-injuries-of-the-upper-extremity-clinical- presentation-and-diagnostic- approach?source=search_result&search=injury+diagnosis&selectedTitle=4~150

Severe extremity injury in the adult patient Authors: Jeremy W Cannon, MD, FACS’ Todd E Rasmussen, MD, FACS Literature review current through: Jun 2016. | This topic last updated: Feb 18, 2016. INTRODUCTION — Trauma to the extremities represents one of the most common injury patterns seen in emergency medical and surgical practice. As extremity injuries are evaluated, each of four functional components (nerves, vessels, bones, and soft tissues) must be considered individually and together. If three of these four elements are injured, the patient has a “mangled extremity” [1,2]. Achieving the best outcome in patients with severe extremity injuries requires a multidisciplinary approach with oversight by the general or trauma surgeon and commitment from other specialists including orthopedic, vascular, and plastic surgeons, as well as rehabilitation specialists. In most instances, limb salvage can be attempted even if the patient has a mangled extremity. However, at times, the injury to the extremity is so severe that primary amputation at the initial operation is required to save the patient’s life. The initial management of severe extremity injury will be reviewed here. The management of minor extremity injuries, including isolated fracture management, is discussed elsewhere. https://www.uptodate.com/contents/severe-extremity-injury-in-the-adult- patient?source=search_result&search=Severe+extremity+injury+in+the+adult+patient&selectedTitle=1~150

Overview of running injuries of the lower extremity Author: Lisa R Callahan, MD Literature review current through: Jun 2016. | This topic last updated: May 10, 2016. INTRODUCTION — Running is one of the world's most popular forms of exercise, with millions of regular participants. In the United States alone, up to 40 million people run regularly, with more than 10 million running at least 100 days a year [1]. Although running is an effective way to achieve many health benefits, it is associated with a high risk of injury; yearly, up to half of runners report an injury [2]. Although some injuries are traumatic, most are due to overuse. Given the popularity of running and the high rate of associated overuse injuries amenable to nonsurgical management, the primary care physician is likely to manage many injured runners and should be familiar with the diagnosis and treatment of the more common problems. The diagnosis and management of common lower extremity injuries associated with running are reviewed here. Detailed discussions of some specific injuries are found separately. 5

https://www.uptodate.com/contents/overview-of-running-injuries-of-the-lower- extremity?source=search_result&search=Overview+of+running+injuries+of+the+lower+extremity&selectedTitl e=1~150

Evaluation and acute management of cervical spinal column injuries in adults Authors: Amy Kaji, MD, PhD; Robert S Hockberger, MD, FACEP Literature review current through: Jun 2016. | This topic last updated: Dec 02, 2015. INTRODUCTION — This topic review discusses the evaluation and initial management of injuries to the cervical spinal column in adults, including the appropriate use of imaging studies. The importance of early recognition and appropriate management of such injuries is underscored by their association with . Descriptions of the range of spinal column fractures and other injuries, the management of spinal cord injuries, and spinal are discussed separately. https://www.uptodate.com/contents/evaluation-and-acute-management-of-cervical-spinal-column-injuries- in- adults?source=search_result&search=Evaluation+and+acute+management+of+cervical+spinal+column+injurie s+in+adult&selectedTitle=1~150

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Current Awareness Database Articles related to Musculoskeletal Soft Tissue

Below is a selection of articles recently added to the healthcare databases, grouped in the following categories:

• Acute Soft Tissue injuries

• Musculoskeletal

• Sports Injuries

If you would like any of the following articles in full text, or if you would like a more focused search on your own topic, then get in touch: [email protected]

Acute soft tissue injuries

Title: Review of Pancreaticoduodenal Trauma with a Case Report. Citation: The Indian journal of surgery, Jun 2016, vol. 78, no. 3, p. 209-213 Author(s): Poyrazoglu, Yavuz, Duman, Kazim, Harlak, Ali Abstract: Complex anatomical relation of the duodenum, pancreas, biliary tract, and major vessels plays to obscure pancreaticoduodenal injuries. Causes of pancreaticoduodenal injuries are (traffic accidents, sport injuries) in 25 % of cases and penetrating abdominal injuries (stab wounds and firearm injuries) in 75 % of cases. Duodenal injuries are reported to occur in 0.5 to 5 % of all cases and are observed in 11 % of abdominal firearm wounds, 1.6 % of abdominal stab wounds, and 6 % of blunt trauma. Retroperitoneal and deep abdominal localization of duodenum as an organ contribute to the difficulty in diagnosis and treatment. There are three important major points regarding treatment of duodenal injuries: (1) operation timing and decision, (2) Intraoperative detection, and (3) post-operative care. Therefore, it is difficult to diagnose and treat duodenal trauma. We would like to present a 21-year-old male patient with pancreaticoduodenal injury who presented to our emergency service after firearm injury to his abdomen and discuss his treatment with a short review of related literature.

Title: A review of 26 cases of frostbite in an abaverified center Citation: Journal of Care and Research, May 2016, vol./is. 37/(S139 Author(s): McKenna A., Burnett M., Rogers A., Jeschke M. Abstract: Introduction: Accidental cold-related injury is a potentially life-threatening condition that can lead to significant morbidity and life-long effect. An increase in participation in outdoor activities and the epidemic of homelessness coupled with a 7

statistically significant worsening of freezing weather conditions has led to an increase in both the incidence and severity of frost bite injury. The aim of this study is to identify the different resuscitative requirements, management challenges and potential complications in this thermal injury group. Methods: A REB approved chart review of all patients admitted to an adult regional American Burn Association-verified burn center in the last 10 years. All patients were included. The diagnosis of frost bite was made clinically by a staff burns physician and the severity of frostbite was further delineated by tissue biopsy and bone scans in certain cases. Demographic, etiologic, critical care, surgical and outcome data was recorded and analyzed with descriptive statistics. Results: 26 patients were admitted, aged 18 to 86 years with a median age of 32. 10 patients were hypothermic on arrival with an average exposure to freezing temperatures of 6 hours (1 - 24). Most cases were 3rd degree and the TBSA ranged from 1 - 55%. 50% of cases were associated with intoxication, 27% were homeless, 23% were sports related and 19% had suffered an MVA in the snow. TBSA >13% required fluid above maintenance fluid, blood transfusions +/- inotropic support. Some patients required up to 12 liters IVF/day for 6 - 19 days until normal physiology returned. 5 patients were ventilated (3 - 34 days) one required HFO ventilation. 9 patients required 2 or more surgical procedures and 16 amputations were performed. There were 14 critical care complications; 3 , 2 AKI, 1 SVT, 1 ARDS, 3 VAP, 1 bacteraemia, 1 heart failure, 2 catheter associated UTI and 1 brachial plexus palsy. There were 12 wound infection/healing complications and in all patients the time to healing was prolonged (32 - 133 days). There was one mortality in the group and he died due to acute congestive heart failure. The LOS/TBSA was 0.24 - 33 (median 7 days/%TBSA). Conclusions: Frostbite in the young male population is associated with sports or alcohol in contrast with the older patients whose injury is associated with MVA or homelessness. Our major cases of frostbite required fluid resuscitation, critical care management and multiple extensive surgeries. Our frostbite injuries are associated with a high wound complication rate (46%) prolonged time to healing and prolonged LOS in comparison to their burn injury counterparts. The incidence and severity of these cases has increased dramatically in the last 3 years. Applicability of Research to Practice: There is little evidence in the literature to support clinical practice in this area.

Title: MRI Findings of Injury to the Longus Colli Muscle in Patients With Neck Trauma. Citation: AJR. American journal of roentgenology, Aug 2016, vol. 207, no. 2, p. 401-405, Author(s): Takhtani, Deepak, Scortegagna, Eduardo, Cataltepe, Oguz, Abstract: The longus colli muscle (LCM) forms the bulk of the deep flexor muscles of the neck. To our knowledge, very little information on the effects of trauma on this muscle group has been published. We describe MRI findings related to injury of the LCM in patients with a history of neck trauma. A radiology department database was searched to identify patient medical records from 2008 to 2013 that included the keywords "longus colli" and "deep flexors." Patients with fractures and ligament injuries were excluded. Patients with other obvious large soft-tissue injuries and nontraumatic conditions were also omitted. A total of 12 patients met the inclusion criterion of having an isolated or predominant injury to the LCM. Five patients had been involved in a motor vehicle accident, and seven patients had fallen. Eleven patients had undergone a CT examination before MRI was performed. No fractures were noted on CT. MRI examinations of the cervical spine were obtained for the 8

following reasons: for increased prevertebral soft-tissue swelling noted on a CT scan plus neck pain (n = 6), for neck pain only (n = 4), or as part of a routine protocol for assessment of obtunded patients (n = 2). Eight of the 12 patients had isolated injury to the LCM. The remaining four patients also had minor injuries to the other neck muscles. The MR image showed swelling and T2 hyperintensity in the LCM and revealed free fluid in the prevertebral space. Isolated injury to the LCM may occur in neck injuries. The MRI findings indicating such injury include increased T2 signal, swelling of the muscle, and the presence of prevertebral fluid.

Title: Diagnosing myocardial contusion after blunt chest trauma Citation: Journal of Tehran University Heart Center, 2016, vol./is. 11/2(49-54) Author(s): Alborzi Z., Zangouri V., Paydar S., Ghahramani Z., Shafa M., Ziaeian B., Radpey M.R., Amirian A., Khodaei S. Abstract: A myocardial contusion refers to a bruise of the cardiac muscle, the severity of which can vary depending on the severity of the injury and when the injury occurs. It is a major cause of rapid death which happens after blunt chest trauma and should be suspected at in the . We demonstrated that suspected myocardial contusion patients who have normal electrocardiograms (ECGs) and biomarker tests can be safely discharged. However, if the test results are abnormal, the next steps should be echocardiography and more advanced measures. Diagnosing myocardial contusion is very difficult because of its nonspecific symptoms. If a myocardial contusion happens, cardiogenic shock or arrhythmia must be anticipated, and the patient must be carefully monitored.

Musculoskeletal

Title: Use of Femoral Nerve Blocks to Manage Hip Fracture Pain among Older Adults in the Emergency Department: A Systematic Review. Citation: CJEM, Jul 2016, vol. 18, no. 4, p. 245-25 Author(s): Riddell, Madison, Ospina, Maria, Holroyd-Leduc, Jayna M Abstract: Hip fractures are a common source of acute pain amongst the frail elderly. One potential technique to adequately manage pain in this population is the femoral nerve block. The objective of this systematic review was to provide updated evidence for the use of femoral nerve blocks as a pain management technique for older hip fracture patients in the emergency department (ED). Data Sources Searches of Medline, EMBASE, and the Cochrane Central Register of Controlled Trials were conducted between December 2010 and May 2014. The reference list of a previous systematic review was also searched. Study Selection We included randomized control trials examining the use of femoral nerve blocks in the ED among older adults (65 years of age or older) with acute hip fracture. Data Extraction Among 93 citations reviewed, seven trials were included. Four studies employed a single femoral nerve block, while three studies employed continuous (catheter-placed) femoral blocks. All but one of the studies were found to have a high risk of bias. Data 9

Synthesis All studies reported reductions in pain intensity with femoral nerve blocks. All but one study reported decreased rescue analgesia requirements. There were no adverse effects found to be associated with the femoral block procedure; rather, two studies found a decreased risk of adverse events such as respiratory and cardiac complications. Femoral nerve blocks appear to have benefits both in terms of decreasing the pain experienced by older patients, as well as limiting the amount of systemic opioids administered to this population.

Title: The accuracy of point-of-care ultrasound as a diagnostic tool for patella fractures. Citation: American Journal of Emergency Medicine, 2016, vol./is. 34/8(1576-1578) Author(s): Kilic, Turgay Yılmaz, Yesilaras, Murat, Atilla, Ozge Duman, Turgut, Ali Abstract: Objective Bedside ultrasonography in the diagnosis of fractures is frequently used by emergency medicine physicians. We aimed to determine the diagnostic accuracy of ultrasonography compared to x-ray in patella fractures. Methods This prospective study was performed of patients aged > 18 years admitted to the emergency department (ED) with acute knee injury and tenderness on the patella. The patients underwent x-ray after the ultrasonographic examination. A computed tomography was obtained from patients with suspicion of a fracture but normal or insufficient graphy. The x-rays were reported by an orthopedic surgeon who was blinded to the sonographic examination. Results Two hundred six patients with knee injuries were admitted to the ED during the study. A total of 114 patients were excluded, thus data were analyzed from the remaining 92 patients. Fracture prevalence was 16.3%. The sensitivity and specificity of the PoCUS were 93.3 (66-99.7) and 94.8 (86.5-98.3), respectively. Conclusion Point-of-care ultrasound has a high sensitivity and specificity for the diagnosis of patella fractures in patients with knee injury and tenderness on the patella.

Title: Postsplinting x-rays of nondisplaced hand, wrist, ankle, and foot fractures are unnecessary. Citation: American Journal of Emergency Medicine, 2016, vol./is. 34/8(1625-1626) Author(s): Schuld, Jill C., Volker, Mark L., Anderson, Sarah A., Zwank, Michael D. Abstract: Background: Acute nondisplaced fractures (NDFs) are common in the emergency department (ED), and providers often obtain postsplinting x-rays to identify displacement that potentially occurs during the splinting process. Our objectives are to (1) determine how often x-rays are obtained after splinting of NDFs, (2) identify if postsplinting x-rays change treatment management in the ED, and (3) identify if there are medical complications at follow-up.Methods: A retrospective chart review of ED patients who were discharged with hand, wrist, ankle, or foot fractures was conducted to determine patients with definite NDFs that were verified by a radiologist, underwent splinting, and either had postsplint x-rays or not. Bone displacement during the splinting procedure was determined by the postsplint x- rays in the ED. Internal movement of bones or management change was also determined for patients who did not undergo postsplint x-rays in the ED but had obtained an x-ray at their follow-up visit (in-network providers only).Results: Our results demonstrate that no patients required further manipulation or operative management due to the splinting that occurred in the ED. These results take into account both patients who had postsplint x-rays 10

conducted in the ED (27 patients) and those who received x-rays in follow-up consults (179 patients). There was minimal incidence of interval movement in the latter group (14 patients), none of which resulted in management change.Conclusion: These data conclude that postsplinting x-rays of NDFs are unnecessary. Removal of this procedure from routine practice will help decrease patient and hospital cost, time, and radiation exposure.

Title: A retrospective audit on the management of patients presenting with confirmed fractured neck of femur to the Southmead Accident and Emergency Department Citation: Anaesthesia, June 2016, vol./is. 71/(35) Author(s): Rowe M., Woodward T. Abstract: Fractured neck of femur was the topic of a national audit commissioned by the College of Emergency Medicine in 2012 [1]. The results demonstrated wide variations in performance seen in emergency departments across the country. We present an audit of the management of patients presenting with fractured neck of femur to the Southmead Hospital Emergency Department (North Bristol NHS Trust) against nationally agreed standards [2]. Data were also collected on seven additional variables in an attempt to validate the Nottingham Hip Fracture Score as a predictor of length of stay in these patients. Methods Case notes of 50 patients with a diagnosis of fractured neck of femur from within the last 6 months were identified and examined retrospectively by hand. Data collected included: time of arrival, pain score on arrival, pain category (mild to severe), time analgesia given, reason analgesia not given, time of re-evaluation of pain score, whether pre-hospital analgesia was given, time to X-ray, time to admission, time to surgery, whether a regional nerve block was performed, serum lactate, serum haemoglobin, whether pressure areas were risk assessed, MMTS < 6, whether patient was from an institution, number of comorbidities, malignancy, length of stay or death within 30 days of admission. Data were analysed using the Macintosh spreadsheet application Numbers. Results For moderate pain scores, 11% of patients received analgesia within 30 min (target 75%) and 44% received analgesia within 60 min of arrival (target 98%). For patients with severe pain scores, 22.2% received analgesia within 20 min (target 50%), 33.3% within 30 min (target 75%) and 83.3% within 60 min (target 98%). A total of 58% of patients identified has having a fractured neck of femur received diagnostic imaging within 60 min of arrival to the emergency department and 62% were admitted to a hospital ward within 4 h. Provision of regional anaesthesia for patients with fractured neck of femur was good and 76% of patients received either a femoral nerve block or a fascia iliaca block. Discussion Current management of neck of femur patients at Southmead fails to meet the standards set by the College of Emergency Medicine. Since 2012 Southmead has improved the delivery of analgesia to patients in severe pain and time to imaging, performing above the national median achieved 3 years ago. Areas to improve include the timely administration of analgesia to patients in moderate pain and admission times. The additional data collected provide an interesting insight into the characteristics of this patient population. We hope to use these data to validate the Nottingham Hip Fracture Score as a predictor of length of stay in the future.

Title: Utility of computed tomographic imaging of the cervical spine in trauma evaluation of ground-level fall. 11

Citation: The journal of trauma and acute care surgery, Aug 2016, vol. 81, no. 2, p. 339-344 Author(s): Benayoun, Marc D, Allen, Jason W, Lovasik, Brendan P, Uriell, Matthew L, Abstract: Computed tomography (CT) of the cervical spine (C-spine) is routinely ordered for low-risk mechanisms of injury, including ground-level fall. Two commonly used clinical decision rules (CDRs) to guide C-spine imaging in trauma are the National Emergency X- Radiography Utilization Study (NEXUS) and the Canadian Cervical Spine Rule for Radiography (CCR). Retrospective cross-sectional study of 3,753 consecutive adult patients presenting to an urban Level I emergency department who received C-spine CT scans were obtained over a 6-month period. The primary outcome of interest was prevalence of C-spine fracture. Secondary outcomes included fracture stability, appropriateness of imaging by NEXUS and CCR criteria, and estimated radiation dose exposure and costs associated with C-spine imaging studies. Of the 760 patients meeting inclusion criteria, 7 C-spine fractures were identified (0.92% ± 0.68%). All fractures were identified by NEXUS and CCR criteria with 100% sensitivity. Of all these imaging studies performed, only 69% met NEXUS indications for imaging (50% met CCR indications). C-spine CT scans in patients not meeting CDR indications were associated with costs of $15,500 to $22,000 by NEXUS ($14,600-$25,600 by CCR) in this single center during the 6-month study period. For ground-level fall, C-spine CT is overused. The consistent application of CDR criteria would reduce annual nationwide imaging costs in the United States by $6.8 to $9.6 million based on NEXUS ($6.4-$15.6 million based on CCR) and would reduce population radiation dose exposure by 0.8 to 1.1 million mGy based on NEXUS (0.7-1.9 million mGy based on CCR) if applied across all Level I trauma centers. Greater use of evidence-based CDRs plays an important role in facilitating emergency department patient management and reducing systemwide radiation dose exposure and imaging expenditures. Diagnostic study, level III.

Title: Importance of Pelvic Radiography for Initial Trauma Assessment: An Orthopedic Perspective. Citation: The Journal of emergency medicine, Jun 2016, vol. 50, no. 6, p. 852-858 Author(s): Verbeek, Diederik O, Burgess, Andrew R Abstract: Many institutions have abandoned the routine for selective pelvic x-ray (PXR) for initial imaging in blunt trauma patients undergoing computed tomography (CT) scanning. Our aim was to examine the association between selective use of PXR and time to diagnosis of (major) pelvic fractures, as well as prioritization of key immediate interventions (including hip reduction and pelvic arterial embolization). We conducted a 1-year review of early management of pelvic fracture patients undergoing pelvic CT scanning. Time interval and sequence of initial imaging and key immediate interventions were recorded. Of 218 pelvic fracture patients, 79 (36%) had no initial PXR, and instead had an initial CT scan. Time to first pelvic imaging in those patients was 48 min (standard deviation [SD] = 47 min vs. 2 min [SD = 6 min] with PXR; p < 0.001). Of 40 hip dislocations, 15 (38%) were detected first on CT scan. Overall, 22 (55%) required a second CT scan after reduction in the emergency department. No initial PXR was performed in 42 of 120 (35%) pelvic ring fracture patients and in 16 of 61 (26%) unstable pelvic ring fractures. Time to pelvic arterial embolization was longer in 4 patients without initial PXR than in 14 patients with PXR (296 min [SD = 206 min] vs. 170 min [SD = 76 min], respectively, p = 0.038). Selective PXR was associated with a 12

significant delay in recognition of (major) pelvic fractures, including those with associated hip dislocations and (potential) pelvic bleeding. PXR remains a useful screening tool to rapidly determine the need for immediate interventions and to allow early planning before CT scanning

Title: Timing of pulmonary in femur fracture patients: Incidence and outcomes. Citation: The journal of trauma and acute care surgery, Jun 2016, vol. 80, no. 6, p. 952-956 Author(s): Kim, Youn-Jung, Choi, Dae-Hee, Ahn, Shin, Sohn, Chang Hwan, Seo, Abstract: Femur fracture is a well-recognized risk factor for pulmonary (PE). Despite recent reports of early PE after , the incidence and outcomes of PE in femur fracture patients are unknown. The aims of the study were to determine the incidence of PE after a femur fracture and to evaluate its timing and clinical significance. We included all consecutive adult patients (≥18 years old) with femur fracture admitted to our emergency department from January 2010 to December 2014 who underwent subsequent PE computed tomography within 72 hours. Of 453 stable patients, 28 with a confirmed diagnosis of acute PE were compared against those without PE. Of 1,301 femur fracture patients who presented at our hospital, 453 were included in our present analysis, of whom 28 developed PE (2.2%). Proximal PE, defined as emboli located within the main or lobar arteries, constituted 78.6% and subsegmental PE constituted 21.4% of these 28 cases. The femur fracture sites were mainly intertrochanteric (50.3%) and the neck (43.9%). The median interval from injury to computed tomography was 13.0 hours (IQR, 9.0-24.0 hours). PE was detected in 57.1% (16 of 28) of patients in the first 24 hours after injury and in 89.3% (25 of 28) in the first 48 hours. Overall mortality was 0.7%, and no patient in the early PE group died of their injury. PE arises in femur fracture patients in the immediate period following injury and shows an incidence somewhat higher than commonly appreciated in other trauma events but is not fatal. Epidemiologic/prognostic study, level III.

Title: The Epidemiology of Finger Dislocations Presenting for Emergency Care Within the United States. Citation: Hand (New York, N.Y.), Jun 2016, vol. 11, no. 2, p. 192-196 Author(s): Golan, Elan, Kang, Kevin K, Culbertson, Maya, Choueka, Jack Abstract: There are little demographic data on finger dislocation injuries. This study examines the epidemiological characteristics of patients presenting for emergency care of finger dislocations within the United States. The National Electronic Injury Surveillance System was queried for finger dislocation injuries treated in US emergency departments between 2004 and 2008. Weighted estimates, in conjunction with Census data, were used to analyze patient demographics, injury locales, and incidence rates within and between, demographic groups. During the 5-year study period, an estimated 166 561 finger dislocations were treated in 1 499 222 917 person-years: an incidence rate of 11.11 per 100 000 person-years. Males were predominantly affected (78.7%) at an incidence rate of 17.8 per 100 000. The rate in females was 4.65 per 100 000 person-years. Most dislocations occurred in the 15- to 19-year age group (38.6 dislocations per 100 000 person-years). Among racial groups, blacks (16.8) were affected more than whites (7.72) or patients 13

characterized as "other" (4.90). In terms of injury venue, 35.9% of cases took place at a sporting or recreational facility. In addition, 44.7% of sports-related dislocations occurred while playing either basketball or football. In the United States, finger dislocations appear to occur most often in black males 15 to 19 years of age and among sports participants, particularly basketball and football players.

Title: Assessment, management and treatment of acute fingertip injuries.

Citation: Emergency nurse : the journal of the RCN Accident and Association, Jun 2016, vol. 24, no. 3, p. 29 Author(s): Kearney, Anthony, Canty, Louise Abstract: Fingertip injuries with nail bed trauma can require specialist hand surgery, depending on severity. However, most of these injuries can be managed in well-equipped emergency departments by emergency nurses with an in-depth knowledge and understanding of the anatomy and physiology of the fingernail and surrounding structures, assessment and examination, pain management and treatment. This article describes the surface and underlying anatomy and physiology of the nail, the most common mechanisms of injury, relevant diagnostic investigations, and initial assessment and management. It also discusses treatment options, referral pathways, and patient discharge advice.

Title: The Role of Elevated Lactate as a Risk Factor for Pulmonary Morbidity After Early Fixation of Femoral Shaft Fractures. Citation: Journal of orthopaedic trauma, Jun 2016, vol. 30, no. 6, p. 312-318 Author(s): Richards, Justin E, Matuszewski, Paul E, Griffin, Sean M, Koehler, Daniel M, Abstract: To evaluate lactate levels before reamed intramedullary nailing (IMN) of femur fractures treated with early fixation. Retrospective study. Three academic, tertiary care trauma centers. Age ≥18 years, ≥17, admission lactate ≥ 2.5 mmol/L, elevated preoperative lactate = preoperative lactate ≥ 2.5 mmol/L. Reamed IMN of femur fracture within 24 hours. Total duration of mechanical ventilation, pulmonary complications (PC) = duration of mechanical ventilation ≥5 days. Four hundred and fourteen patients identified; 294/414 (71.0%) with admission lactate ≥ 2.5 mmol/L. No difference in PC among the groups (86/294, 29.3% vs. 28/120, 23.3%; P = 0.22). Median admission lactate: 3.7 (interquartile range: 3.0-4.6); median preoperative lactate: 2.8 (interquartile range: 1.9-3.5). 184/294 (62.6%) demonstrated an elevated preoperative lactate (≥ 2.5 mmol/L) before fracture fixation. No difference in elevated preoperative lactate and vent days (4.8 ± 9.9 vs. 3.9 ± 6.0, P = 0.41) or PC (50/86, 58.1% vs. 134/208, 64.4%; P = 0.31). There was no difference in PC when preoperative lactate was considered separately for a lactate ≥3.0 (34/123, 27.6% vs. 52/171, 30.4%; P = 0.61), ≥3.5 (21/79, 26.6% vs. 65/215, 30.2%; P = 0.54), or ≥4.0 (14/50, 28.0% vs. 72/244, 29.5%; P = 0.83). Multivariable linear regression modeling demonstrated that admission lactate [coefficient of variation: 0.84, standard error: 0.33, 95% confidence interval (CI): 0.20-1.49] was correlated with duration of mechanical ventilation, after adjusting for emergency department Glasgow Coma Scale, age, chest (AIS) score, abdominal AIS, and admission glucose. Logistic 14

regression demonstrated admission lactate was also significantly associated with PC (odds ratio: 1.26, 95% CI: 1.03-1.53) after controlling for age, admission Glasgow Coma Scale, chest AIS, abdominal AIS, admission pulse and admission glucose; preoperative lactate was not a risk factor (odds ratio: 0.84, 95% CI: 0.65-1.09) for PC. Median admission lactate of 3.7 mmol/L was associated with duration of mechanical ventilation ≥5 days, whereas median preoperative lactate of 2.8 mmol/L was not, when multisystem trauma patients with a femoral shaft fracture were treated with reamed IMN within 24 hours after admission. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Title: Acute patellar dislocation with multiple ligament injuries after knee dislocation and single session reconstruction. Citation: JPMA. The Journal of the Pakistan Medical Association, Jun 2016, vol. 66, no. 6, p. 757-760 Author(s): Gormeli, Gokay, Gormeli, Cemile Ayse, Karakaplan, Mustafa, Gurbuz, Sukru, Abstract: Knee dislocation is a relatively rare condition of all orthopaedic injuries. Accompanying multiple ligament injuries are common after knee dislocations. A 41-year-old male presented to the emergency department suffering from right knee dislocation in June 2013. The patient had anterior cruciate ligament, medial collateral ligament (MCL), medial patellofemoral ligament (MPFL) rupture, and lateral meniscal tear. A single-bundle anatomic reconstruction, medial collateral ligament reconstruction, medial patellofemoral ligament reconstruction and meniscus repair were performed in single session. At twelve months follow-up; there was 160o flexion and 10° extension knee range of motion. Lysholm knee score was 90. Extensive forces can cause both MCL and MPFL injury due to overload and the anatomical relationship between these two structures. Therefore, patients with valgus instability should be evaluated for both MPFL and MCL tears to facilitate successful treatment.

Title: Prehospital Pain and Analgesic Therapy in Elderly Patients with Hip Fractures. Citation: Pain practice : the official journal of World Institute of Pain, Jun 2016, vol. 16, no. 5, p. 545-551 Author(s): Oberkircher, Ludwig, Schubert, Natalie, Eschbach, Daphne-Asimenia, Abstract: As a part of aging, hip fractures are becoming more common. The connection between increased pain and a poor outcome has previously been shown. Therefore, even in prehospital situations, analgesic therapy appears to be reasonable. We established a prospective study with 153 patients to evaluate the patients' pain levels during the prehospital phase of treatment and prehospital analgesic therapy. We performed a prospective study on 153 patients the age of 60 years or older in a University hospital setting between 2010 and 2011 who suffered hip fracture. Analgesics given and the type of medical staff that was involved were documented. Pain was measured using the NRS upon initial contact of the medical staff and upon admission to our emergency department. Initial pain level evaluated by EMS (emergency medical service) was 6.8 (SD = 2.7). Twenty-two percent of the patients reported an NRS of 10 as the highest value following their injury. 15

Forty-three of 153 patients (28%) received analgesics. The mean initial pain score for those 43 patients who did receive pain medication was 7.0 (SD = 2.6). However, this score dropped to a mean of 2.8 (SD = 1.4) upon hospital arrival (P < 0.001). The patients who did not receive pain medication had an initial pain score of 4.5 (SD = 1.9). Upon admission to the hospital, this score decreased to a mean of 4.0 (SD = 1.7, P = 0.092). Only a minority of patients with hip fractures received prehospital analgesia. The administration of prehospital analgesia was associated with significant pain relief

Sports Injuries

Title: Return to Sport After Tibial Shaft Fractures: A Systematic Review. Citation: Sports health, Jul 2016, vol. 8, no. 4, p. 324-330 Author(s): Robertson, Greg A J, Wood, Alexander M Abstract: Acute tibial shaft fractures represent one of the most severe injuries in sports. Return rates and return-to-sport times after these injuries are limited, particularly with regard to the outcomes of different treatment methods. To determine the current evidence for the treatment of and return to sport after tibial shaft fractures. OVID/MEDLINE (PubMed), EMBASE, CINAHL, Cochrane Collaboration Database, Web of Science, PEDro, SPORTDiscus, Scopus, and Google Scholar were all searched for articles published from 1988 to 2014. Inclusion criteria comprised studies of level 1 to 4 evidence, written in the English language, that reported on the management and outcome of tibial shaft fractures and included data on either return-to-sport rate or time. Studies that failed to report on sporting outcomes, those of level 5 evidence, and those in non-English language were excluded. Systematic review. Level 4. The search used combinations of the terms tibial, tibia, acute, fracture, athletes, sports, nonoperative, conservative, operative, and return to sport. Two authors independently reviewed the selected articles and created separate data sets, which were subsequently combined for final analysis. A total of 16 studies (10 retrospective, 3 prospective, 3 randomized controlled trials) were included (n = 889 patients). Seventy-six percent (672/889) of the patients were men, with a mean age of 27.7 years. Surgical management was assessed in 14 studies, and nonsurgical management was assessed in 8 studies. Return to sport ranged from 12 to 54 weeks after surgical intervention and from 28 to 182 weeks after nonsurgical management (mean difference, 69.5 weeks; 95% CI, -83.36 to -55.64; P < 0.01). Fractures treated surgically had a return-to-sport rate of 92%, whereas those treated nonsurgically had a return rate of 67% (risk ratio, 1.37; 95% CI, 1.20 to 1.57; P < 0.01). The general principles are to undertake surgical management for displaced fractures and to attempt nonsurgical management for undisplaced fractures. Primary surgical intervention of undisplaced fractures, however, may result in higher return rates and shorter return times, though this exposes the patient to the risk of surgical complications, which include surgical site infection and .

Title: Hamstring strength and flexibility after hamstring strain injury: a systematic review and meta-analysis. 16

Citation: British journal of sports medicine, Aug 2016, vol. 50, no. 15, p. 909-920 Author(s): Maniar, Nirav, Shield, Anthony J, Williams, Morgan D, Timmins, Ryan G, Abstract: To systematically review the evidence base related to hamstring strength and flexibility in previously injured hamstrings. Systematic review and meta-analysis. A systematic literature search was conducted of PubMed, CINAHL, SPORTDiscus, Cochrane Library, Web of Science and EMBASE from inception to August 2015. Full-text English articles which included studies which assessed at least one measure of hamstring strength or flexibility in men and women with prior hamstring strain injury within 24 months of the testing date. Twenty-eight studies were included in the review. Previously injured legs demonstrated deficits across several variables. Lower isometric strength was found <7 days postinjury (d=-1.72), but this did not persist beyond 7 days after injury. The passive straight leg raise was restricted at multiple time points after injury (<10 days, d=-1.12; 10-20 days, d=-0.74; 20-30 days, d=-0.40), but not after 40-50 days postinjury. Deficits remained after return to play in isokinetically measured concentric (60°/s, d=-0.33) and Nordic eccentric knee flexor strength (d=-0.39). The conventional hamstring to quadricep strength ratios were also reduced well after return to play (60:60°/s, d=-0.32; 240:240°/s, d=-0.43) and functional (30:240°/s, d=-0.88), but these effects were inconsistent across measurement methods. After hamstring strain, acute isometric and passive straight leg raise deficits resolve within 20-50 days. Deficits in eccentric and concentric strength and strength ratios persist after return to play, but this effect was inconsistent across measurement methods. Flexibility and isometric strength should be monitored throughout rehabilitation, but dynamic strength should be assessed at and following return to play.

Title: A snapshot of chronic ankle instability in a cohort of netball players. Citation: Journal of science and medicine in sport / Sports Medicine Australia, May 2016, vol. 19, no. 5, p. 379-383 Author(s): Attenborough, Alison S, Sinclair, Peter J, Sharp, Tristan, Greene, Andrew, Abstract: Ankle injuries account for the highest percentage of injuries in netball, yet the chronic nature of ankle sprains is under reported within this population group. Chronic ankle instability is a term used to describe certain insufficiencies that persist after an acute ankle sprain. The aim of this study was to investigate recurrent sprain, perceived ankle instability and mechanical ankle instability in a cohort of netball players. Cross-sectional study. Ninety-six female netball players (24.1±7.9 years) were recruited (42 club players and 54 inter-district players). Recurrent sprain was defined as two or more lifetime sprains to the same ankle. Perceived ankle instability was quantified with the Cumberland Ankle Instability Tool - Youth. Mechanical ankle instability was quantified via inversion-eversion rotations using an ankle arthrometer at torques of 3Nm. Forty-seven percent of the cohort had recurrently sprained an ankle. Of the 69 players with a previously sprained ankle, 64% had a moderate-severe degree of perceived ankle instability. The total inversion-eversion angle was 31.1±8.7 degrees. Club players had more cases of moderate-severe perceived ankle instability (p=0.01) and larger inversion-eversion angles (p=0.001) compared to inter- district players. Recurrent ankle sprain and perceived ankle instability are easily identifiable aspects of chronic ankle instability shown to be prevalent within this cohort. Additional research is required to quantify a cut-off value for mechanical instability. Club netball 17

players were found to have more counts of moderate-severe perceived ankle instability and larger inversion-eversion angles when compared to the inter-district netball players.

Title: The Relationship Between Training Load and Injury, Illness and Soreness: A Systematic and Literature Review. Citation: Sports medicine (Auckland, N.Z.), Jun 2016, vol. 46, no. 6, p. 861-883, Author(s): Drew, Michael K, Finch, Caroline F Abstract: Clinically it is understood that rapid increases in training loads expose an athlete to an increased risk of injury; however, there are no systematic reviews to qualify this statement. The aim of this systematic review was to determine training and competition loads, and the relationship between injury, illness and soreness. The MEDLINE, SPORTDiscus, CINAHL and EMBASE databases were searched using a predefined search strategy. Studies were included if they analysed the relationship between training or competition loads and injury or illness, and were published prior to October 2015. Participants were athletes of any age or level of competition. The quality of the studies included in the review was evaluated using the Newcastle-Ottawa Scale (NOS). The level of evidence was defined as strong, 'consistent findings among multiple high-quality randomised controlled trials (RCTs)'; moderate, 'consistent findings among multiple low- quality RCTs and/or non-randomised controlled trials (CCTs) and/or one high-quality RCT'; limited, 'one low-quality RCT and/or CCTs, conflicting evidence'; conflicting, 'inconsistent findings among multiple trials (RCTs and/or CCTs)'; or no evidence, 'no RCTs or CCTs'. A total of 799 studies were identified; 23 studies met the inclusion criteria, and a further 12 studies that were not identified in the search but met the inclusion criteria were subsequently added to the review. The largest number of studies evaluated the relationship between injuries and training load in rugby league players (n = 9) followed by cricket (n = 5), football (n = 3), Australian Football (n = 3), rugby union (n = 2),volleyball (n = 2), baseball (n = 2), water polo (n = 1), rowing (n = 1), basketball (n = 1), swimming (n = 1), middle-distance runners (n = 1) and various sports combined (n = 1). Moderate evidence for a significant relationship was observed between training loads and injury incidence in the majority of studies (n = 27, 93 %). In addition, moderate evidence exists for a significant relationship between training loads and illness incidence (n = 6, 75 %). Training loads were reported to have a protective effect against injury (n = 9, 31 %) and illness (n = 1, 13 %). The median (range) NOS score for injury and illness was 8 (5-9) and 6 (5-9), respectively. A limitation of this systematic review was the a priori search strategy. Twelve further studies were included that were not identified in the search strategy, thus potentially introducing bias. The quality assessment was completed by only one author. The results of this systematic review highlight that there is emerging moderate evidence for the relationship between the training load applied to an athlete and the occurrence of injury and illness. The training load applied to an athlete appears to be related to their risk of injury and/or illness. Sports science and medicine professionals working with athletes should monitor this load and avoid acute spikes in loads. It is recommended that internal load as the product of the rate of perceived exertion (10-point modified Borg) and duration be used when determining injury risk in team-based sports. External loads measured as throw counts should also be monitored and collected across a season to determine injury risk in throwing populations. 18

Global positioning system-derived distances should be utilised in team sports, and injury monitoring should occur for at least 4 weeks after spikes in loads.

Title: Imaging of Sports-related Hand and Wrist Injuries: Sports Imaging Series. Citation: Radiology, Jun 2016, vol. 279, no. 3, p. 674-692, Author(s): Cockenpot, Eric, Lefebvre, Guillaume, Demondion, Xavier, Chantelot, Christophe, Abstract: Hand and wrist injuries are common occurrences in amateur and professional sports and many of them are sport-specific. These can be divided into two categories: traumatic injuries and overuse injuries. The aim of this article is to review the most common hand and wrist sports-related lesions. Acute wrist injuries are predominantly bone fractures, such as those of the scaphoid, hamate hook, and ulnar styloid. Ligament lesions are more challenging for radiologists and may lead to carpal instability if undiagnosed. Overuse wrist injuries are mainly represented by tendinous disorders, with De Quervain syndrome and extensor carpi ulnaris tendon disorders being the most common among them; however, there are other possible disorders such as impaction syndromes, stress fractures, and neurovascular lesions. Finally, finger lesions, including closed-tendon injuries (mallet and boutonniere injuries, jersey finger, and boxer's knuckle), flexor pulley injuries, and skier's thumb, should also be detected.

Title: Adding Injury to Insult: A National Analysis of Combat Sport-Related Facial Injury. Citation: The Annals of otology, rhinology, and laryngology, Aug 2016, vol. 125, no. 8, p. 652-659 Author(s): Hojjat, Houmehr, Svider, Peter F, Lin, Ho-Sheng, Folbe, Adam J, Shkoukani, Abstract: To estimate the incidence of patients presenting to emergency departments (EDs) for sustained from participation in combat sports and evaluate injury patterns and patient demographics. The National Electronic Injury Surveillance System (NEISS) was evaluated for facial injuries from wrestling, boxing, and martial arts leading to ED visits from 2008 to 2013. Relevant entries were examined for injury mechanism, location, type, as well as other patient characteristics. There were 1143 entries extrapolating to an estimated 42 395 ED visits from 2008 to 2013. Injury rates for boxing, marital arts, and wrestling were, respectively, 44, 56, and 120 injuries per 100 000 participants. Males comprised the majority (93.7%). A plurality of injuries involved lacerations (46.0%), followed by fractures (26.2%) and contusions/abrasions (19.3%). The proportion of fractures was highest among boxers (36.9%). Overall, the most common mechanisms of injury were punching, kicking, and head butting. The significant number of ED visits resulted from combat sports facial trauma, reinforcing the importance of familiarity with injury patterns among practitioners managing facial trauma. As most injuries involve individuals younger than 19 despite guidelines suggesting children and adolescents avoid combat sports, these findings may be used for patient education and encouragement of the use of personal protective equipment. Furthermore, injury patterns reported in this analysis may serve as an adjunct for enhancing clinical history taking and physical examination.

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Title: Patient with a Hook of the Hamate Fracture Presenting as Vascular Occlusion: Diagnosis Made with Bedside Ultrasound. Citation: The Journal of emergency medicine, Jul 2016, vol. 51, no. 1, p. 63-65, 0736-4679 Author(s): Maier, Richard M, Hughes, Mary, Katranji, Abdalmajid Abstract: Hook of the hamate fractures are particularly rare carpal fractures with significant morbidity if not diagnosed early. Classically, these fractures occur from localized blunt trauma to the hook of the hamate in racket sports. Common complaints include pain localized in the hypothenar eminence and reduced grip strength. Hook of the hamate fractures have the potential to cause significant injury to the ulnar nerve and artery. We present the case of a 43-year-old man with hypothenar pain, paresthesias of the fifth finger and ulnar aspect of the fourth finger, and pallor of the fourth and fifth fingers. Using bedside ultrasonography, the patient was found to have a fracture of the hook of the hamate that was causing compression of the ulnar artery. WHY SHOULD AN BE AWARE OF THIS?: Fracture of the hook of the hamate is often not seen on x- ray studies, and fracture fragments can cause compression of adjacent structures, including the ulnar and median nerves and ulnar artery. Bedside ultrasound may be a useful adjunct in the diagnosis of this carpal fracture when standard x-ray studies do not show a fracture and clinical presentation is concerning for the diagnosis. Copyright © 2016 Elsevier Inc. All rights reserved.

Title: Retrospective analysis of 616 air-rescue trauma cases related to the practice of extreme sports. Citation: Injury, Jul 2016, vol. 47, no. 7, p. 1414-1420 Author(s): Gosteli, Gaël, Yersin, Bertrand, Mabire, Cédric, Pasquier, Mathieu, Abstract: Extreme sports (ESs) are increasingly popular, and accidents due to ESs sometimes require helicopter emergency medical services (HEMSs). Little is known about their epidemiology, severity, specific injuries and required rescue operations. Our aims were to perform an epidemiological analysis, to identify specific injuries and to describe the characteristic of prehospital procedures in ES accidents requiring HEMSs. This is a retrospective study, reviewing all rescue missions dedicated to ESs provided by HEMS REGA Lausanne, from 1 January 1998 to 31 December 2008. ES were classified into three categories of practice, according to the type of risk at the time of the fall. Among the 616 cases meeting inclusion criteria, 219 (36%) were clearly high-risk ES accidents; 69 (11%) and 328 (53%) were related to potential ES, but with respectively low or indeterminate risk at the time of the fall. In the high-risk ES group, the median age was 32 years and 80% were male. Mortality at 48h was 11%, almost ten times higher than in the other two groups. The proportion of potentially life-threatening injuries (the National Advisory Committee for Aeronautics (NACA) score≥4) was 39% in the high-risk ES group and 13% in the other two groups. Thirty per cent of the cases in the high-risk ES group presented an Injury Severity Score (ISS) >15, compared with 7% in the other groups. Thoracolumbar vertebral fractures were the most common injuries with 32% of all cases having at least one, involving the T12- L2 junction in 56% of cases. The other most frequent injuries were traumatic brain injuries (16%), rib fractures (9%), (8%) and femoral (7%), cervical (7%), ankle (5%) and pelvic (5%) fractures. Median time on site for rescue teams was higher in the confirmed 20

high-risk ES group, with 50% of prehospital missions including at least one environmental difficulty. High-risk ESs led to high-energy accidents, characterized by a large proportion of severe injuries and axial traumas (spine, thorax, pelvis and proximal femur). We identified a considerable percentage of thoracolumbar vertebral fractures, mainly in the T12-L2 junction. HEMSs dedicated to high-risk ESs implied longer and more complex interventions.

Title: Locomotive biomechanics in persons with chronic ankle instability and lateral ankle sprain copers. Citation: Journal of science and medicine in sport / Sports Medicine Australia, Jul 2016, vol. 19, no. 7, p. 524-530 Author(s): Doherty, Cailbhe, Bleakley, Chris, Hertel, Jay, Caulfield, Brian, Ryan, John, Abstract: To compare the locomotive biomechanics of participants with chronic ankle instability (CAI) to those of lateral ankle sprain (LAS) copers. Cross-sectional study. Twenty- eight participants with CAI and 42 LAS copers each performed 5 self-selected paced gait trials. 3-D lower extremity temporal kinematic and kinetic data were collected for these participants from 200ms pre- to 200ms post-heel strike (period 1) and from 200ms pre- to 200ms post-toe off (period 2). The CAI group displayed increased hip flexion bilaterally during period 1 compared to LAS copers. During period 2, CAI participants exhibited reduced hip extension bilaterally, increased knee flexion bilaterally and increased ankle inversion on the 'involved' limb. They also displayed a bilateral decrease in the flexor moment pattern at the knee. Considering that all of the features which distinguished CAI participants from LAS copers were also evident in our previously published research (within 2-weeks following acute first-time LAS); these findings establish a potential link between these features and long-term outcome following first-time LAS. Clinicians must be cognizant of the capacity for these movement and motor control impairments to cascade proximally from the injured joint up the kinetic chain and recognise the value that gait re-training may have in rehabilitation planning to prevent CAI.

Title: Effects of anterior cruciate ligament injury on neuromuscular tensiomyographic characteristics of the lower extremity in competitive male soccer players. Citation: Knee surgery, sports , arthroscopy : official journal of the ESSKA, Jul 2016, vol. 24, no. 7, p. 2264-2270 Author(s): Alvarez-Diaz, Pedro, Alentorn-Geli, Eduard, Ramon, Silvia, Marin, Miguel, Abstract: To investigate the effects of anterior cruciate ligament injury on mechanical and contractile characteristics of the skeletal muscles of the lower extremity in competitive soccer players through tensiomyography (TMG). All competitive male soccer players with confirmed acute anterior cruciate ligament tear included underwent resting TMG assessment of muscles of both lower extremities before anterior cruciate ligament reconstruction. The same values were obtained from a sex- and sports level-matched control group. The maximal displacement, delay time, contraction time, sustained time, and half-relaxation time were obtained for the following muscles in all subjects: vastus medialis, vastus laterals, rectus femoris, semitendinosus, biceps femoris, gastrocnemius medialis, and gastrocnemius lateralis. The majority of TMG parameters were higher in the injured 21

compared to the control group. The contraction time of the vastus medialis, vastus lateralis, and rectus femoris was significantly higher in the injured compared to the control group (p = 0.003, p = 0.001, and p < 0.001, respectively). The biceps femoris was the only hamstring muscle with significant differences between groups, with increased contraction time and maximal displacement in the injured compared to the control group (p = 0.002 and p < 0.001, respectively). The gastrocnemius medialis was clearly more affected than the gastrocnemius lateralis, with contraction time, half-relaxation time, and maximal displacement significantly higher (p = 0.01, p = 0.03, and p < 0.001, respectively), and the sustained time significantly lower (p = 0.01), in the injured compared to the control group. The contraction time of the vastus medialis, vastus lateralis, rectus femoris, semitendinosus, and biceps femoris was significantly higher in the injured compared to non-injured side in the anterior cruciate ligament-injured group (p = 0.007, p = 0.04, p = 0.004, p = 0.02, and p = 0.02, respectively). Anterior cruciate ligament injury caused a decrease in contraction velocity (in quadriceps, hamstrings and gastrocnemius medialis), resistance to fatigue (in quadriceps and gastrocnemius medialis), and muscle tone/stiffness (in hamstrings and gastrocnemius medialis). Overall, it was demonstrated that these effects were worst in the quadriceps and gastrocnemius medialis compared to the hamstring and gastrocnemius lateralis. These findings may contribute to a better design of rehabilitation programs in order to optimize the recovery and potentially increase sport performance at return to sport. Prognostic study, Level II.

Title: Acute Shoulder Injuries in Adults. Citation: American family physician, Jul 2016, vol. 94, no. 2, p. 119-127, Author(s): Monica, James, Vredenburgh, Zachary, Korsh, Jeremy, Gatt, Charles Abstract: Acute shoulder injuries in adults are often initially managed by family physicians. Common acute shoulder injuries include acromioclavicular joint injuries, clavicle fractures, glenohumeral dislocations, proximal humerus fractures, and rotator cuff tears. Acromioclavicular joint injuries and clavicle fractures mostly occur in young adults as the result of a sports injury or direct trauma. Most nondisplaced or minimally displaced injuries can be treated conservatively. Treatment includes pain management, short-term use of a sling for comfort, and physical therapy as needed. Glenohumeral dislocations can result from contact sports, falls, bicycle accidents, and similar high-impact trauma. Patients will usually hold the affected arm in their contralateral hand and have pain with motion and decreased motion at the shoulder. Physical findings may include a palpable humeral head in the axilla or a dimple inferior to the acromion laterally. Reduction maneuvers usually require intra-articular lidocaine or intravenous analgesia. Proximal humerus fractures often occur in older patients after a low-energy fall. Radiography of the shoulder should include a true anteroposterior view of the glenoid, scapular Y view, and axillary view. Most of these fractures can be managed nonoperatively, using a sling, early range-of-motion exercises, and strength training. Rotator cuff tears can cause difficulty with overhead activities or pain that awakens the patient from sleep. On physical examination, patients may be unable to hold the affected arm in an elevated position. It is important to recognize the sometimes subtle signs and symptoms of acute shoulder injuries to ensure proper management and timely referral if necessary.

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Title: The effects of accumulated muscle fatigue on the mechanomyographic waveform: implications for injury prediction. Citation: European journal of applied physiology, Aug 2016, vol. 116, no. 8, p. 1485-1494, Author(s): Tosovic, D, Than, C, Brown, J M M Abstract: Muscle fatigue has been identified as a risk factor for spontaneous muscle injuries in sport. However, few studies have investigated the accumulated effects of muscle fatigue on human muscle contractile properties. This study aimed to determine whether repeated bouts of exercise inducing acute fatigue leads to longer-term fatigue-related changes in muscle contractile properties. Maximum voluntary contraction (MVC), electromyographic (EMG) and mechanomyographic (MMG) measures were recorded in the biceps brachii of 11 participants for 13 days, before and after a maximally fatiguing exercise protocol. The exercise protocol involved participants repetitively lifting a weight (concentric contractions only) equal to 40 % MVC, until failure. A significant (p < 0.05) acute pre- to post-exercise decline of biceps brachii MVC and median power frequency (MPF) was observed each day, whilst no difference existed between pre-exercise MVC or MPF values on subsequent days (days 2-13). However, decreases in number of lift repetitions and in pre-exercise MMG values of muscle belly displacement, contraction velocity and half-relaxation velocity were observed through to day 13. Whilst MVC and MPF measures resolved by the following day's test session, MMG measures indicated an ongoing decrement in muscle performance through days 2-13 consistent with the decline in lift repetitions observed. These results suggest that MMG may be more sensitive in detecting accumulated muscle fatigue than the 'gold standard' measures of MVC/MPF. Considering that muscle fatigue leads to injury, the on-going monitoring of MMG derived contractile properties of muscles in athletes may aid in the prediction of fatigued-induced muscle injury.

Title: Outcomes and complications of endoscopically-assisted percutaneous achilles tendon repair Citation: Arthroscopy - Journal of Arthroscopic and Related Surgery, June 2016, vol./is. 32/6 SUPPL. 1(e20) Author(s): Phisitkul P., Rungprai C. Abstract: Introduction: Open repair of acute Achilles tendon rupture is considered as a standard surgical treatment while percutaneous technique has gained increasing popularity especially under endoscopic control. However, there is a lack of currently research reporting outcomes and complications following this technique. Methods: A retrospective chart reviews with prospectively collecting data were performed in 30 patients with 30 legs who underwent endoscopically-assisted percutaneous Achilles tendon repair using 6-portal technique between 2008 and 2015. The minimum follow up to be included in the study was 6 months (mean, 49.3 months; range, 6 to 76 months). The primary outcome was FAAM, SF- 36, and VAS. The secondary outcomes included operative time, recovery time, and complications. Results: There were 30 patients (24male and 6 female)with mean age of 36.7 years. An average of tourniquet time was 39.6 minutes (range, 23-67 minutes). There was significant improvement of VAS (7.1/10 to 0.1/10), SF-36 (PCS (38.8 to 49.9) and MCS (49.0 to 51.8)), FAAM(Activity, 19.0 to 88.4 and Sport, 0 to 65.6). An average time to return to activity of daily living, work, and sports were 6 weeks, 7 weeks, 3.6 months respectively. The 23

complications included hypertrophic scar without pain (6.7%), superficial wound infection (3%). There was no re-rupture, deep vein thrombosis, sural nerve injury, and painful scar in this study. Conclusion: Endoscopically assisted percutaneous Achilles tendon repair demonstrated significant improvement in terms of functional outcomes as measured with the FAAM, SF-36, and VAS. This technique is safe and feasible for treatment patients with acute rupture of Achilles tendon.

Title: Acute Medial Plantar Fascia Tear. Citation: The Journal of orthopaedic and sports physical therapy, Jun 2016, vol. 46, no. 6, p. 495. Author(s): Pascoe, Stephanie C, Mazzola, Timothy J Abstract: A 32-year-old man who participated in competitive soccer came to physical therapy via direct access for a chief complaint of plantar foot pain. The clinical examination findings and mechanism of injury raised a concern for a plantar fascia tear, so the patient was referred to the physician and magnetic resonance imaging was obtained. The magnetic resonance image confirmed a high-grade, partial-thickness, proximal plantar fascia tear with localized edema at the location of the medial band.

Title: The "Heel Hook"-A Climbing-Specific Technique to Injure the Leg. Citation: Wilderness & environmental medicine, Jun 2016, vol. 27, no. 2, p. 294-301, Author(s): Schöffl, Volker, Lutter, Christoph, Popp, Dominik Abstract: Acute injuries in rock climbing either come from a fall onto the lower leg or from performing a hard move and injuring the upper extremity. Further evaluations of lower leg injuries in rock climbing athletes have been performed recently finding sport characteristics such as peroneal tendon dislocations or chronic deformations of the feet. One injury mechanism described in case reports is the so-called heel hook position, which is used more frequently today compared with the beginngs of rock climbing. In addition, the number of these injuries is expected to rise with the increase in popularity of climbing and bouldering. Therefore, it is important to further analyze this pathology. We investigated 17 patients with injuries of the lower extremities after performing a heel hook.

Title: Groin Injuries (Athletic Pubalgia) and Return to Play. Citation: Sports health, Jul 2016, vol. 8, no. 4, p. 313-323, Author(s): Elattar, Osama, Choi, Ho-Rim, Dills, Vickie D, Busconi, Brian Abstract: Groin pain is a common entity in athletes involved in sports that require acute cutting, pivoting, or kicking such as soccer and ice hockey. Athletic pubalgia is increasingly recognized as a common cause of chronic groin and adductor pain in athletes. It is considered an overuse injury predisposing to disruption of the rectus tendon insertion to the pubis and weakness of the posterior inguinal wall without a clinically detectable hernia. These patients often require surgical therapy after failure of nonoperative measures. A variety of surgical options have been used, and most patients improve and return to high- 24

level competition. PubMed databases were searched to identify relevant scientific and review articles from January 1920 to January 2015 using the search terms groin pain, sports hernia, athletic pubalgia, adductor strain, osteitis pubis, stress fractures, femoroacetabular impingement, and labral tears. Clinical review. Level 4. Athletic pubalgia is an overuse injury involving a weakness in the rectus abdominis insertion or posterior inguinal wall of the lower abdomen caused by acute or repetitive injury of the structure. A variety of surgical options have been reported with successful outcomes, with high rates of return to the sport in the majority of cases. Title: Cerebral Blood Flow Alterations in Acute Sport-Related Concussion Citation: Journal of Neurotrauma, July 2016, vol./is. 33/13(1227-1236 Author(s): Wang Y., Nelson L.D., Laroche A.A., Pfaller A.Y., Nencka A.S., Koch K.M. Abstract: Sport-related concussion (SRC) is a major health problem, affecting millions of athletes each year. While the clinical effects of SRC (e.g., symptoms and functional impairments) typically resolve within several days, increasing evidence suggests persistent neurophysiological abnormalities beyond the point of clinical recovery after injury. This study aimed to evaluate cerebral blood flow (CBF) changes in acute SRC, as measured using advanced arterial spin labeling (ASL) magnetic resonance imaging (MRI). We compared CBF maps assessed in 18 concussed football players (age, 17.8 +/- 1.5 years) obtained within 24 h and at 8 days after injury with a control group of 19 matched non-concussed football players. While the control group did not show any changes in CBF between the two time- points, concussed athletes demonstrated a significant decrease in CBF at 8 days relative to within 24 h. Scores on the clinical symptom (Sport Concussion Assessment Tool 3, SCAT3) and cognitive measures (Standardized Assessment of Concussion [SAC]) demonstrated significant impairment (vs. pre-season baseline levels) at 24 h (SCAT, p < 0.0001; SAC, p < 0.01) but returned to baseline levels at 8 days. Two additional computerized neurocognitive tests, the Automated Neuropsychological Assessment Metrics and Immediate Post- Concussion and Cognitive Testing, showed a similar pattern of changes. These data support the hypothesis that physiological changes persist beyond the point of clinical recovery after SRC. Our results also indicate that advanced ASL MRI methods might be useful for detecting and tracking the longitudinal course of underlying neurophysiological recovery from concussion.

Title: Sports-Related Concussion Results in Differential Expression of Nuclear Factor-κB Pathway Genes in Peripheral Blood During the Acute and Subacute Periods. Citation: The Journal of head trauma rehabilitation, Jul 2016, vol. 31, no. 4, p. 269-276 Author(s): Gill, Jessica, Merchant-Borna, Kian, Lee, Hyunhwa, Livingston, Whitney S, Abstract: To determine changes in global gene expression in peripheral leukocytes in the acute and subacute periods following a sports-related concussion in athletes. Samples were collected at 2 universities in Rochester, New York. Fifteen contact sport athletes who experienced a sports-related concussion, and 16 nonconcussed teammates served as controls. Blood samples were collected at the start of the season (baseline), within 6 hours of injury (acute), and at 7 days (subacute) postinjury. Differential gene expression was measured using the GeneChip 3' in vitro transcription Expression kit and Affymetrix 25

microarrays, and genes with fold difference of 2 or more were identified using Partek. Whole genome differential gene expression, and cognitive and balance measures to asses for clinical symptoms pre- and postinjury. In the concussed athletes, we observed 67 downregulated and 4 upregulated genes in the acute period and 63 downregulated and 2 upregulated genes in the subacute period compared with baseline. Of these, there were 28 genes from both time points involved in the inflammatory response. No significant differences in gene expression were detected in the control group. Our findings suggest that recovery from sports-related concussion relates to modulation of inflammation through cytokine and chemokine gene pathways, which can contribute to future development of personalized therapeutic agents.

Title: Outcomes in patients with chronic achilles tendon rupture after repair with tendon transfer Citation: Foot and Ankle Surgery, June 2016, vol./is. 22/2 SUPPL. 1(85-86) Author(s): D'Ambrosi R., Maccario C., Usuelli F.G. Abstract: Background: Chronic Achilles rupture are relatively uncommon and the aim of management is to reconstruct Achilles tendon to a functional length and achieve normal plantar flexion strength. Aim: The purpose is to evaluate the clinical results and return to sport in patients undergoing reconstruction of the Achilles tendon with minimally invasive technique tendon graft augmentation. Methods: 8 patients treated for chronic Achilles tendon rutpure (more than 30 days from the injury and gap >6 cm) underwent reconstruction with minimally invasive technique according Maffulli with semitendinosus graft augmentation. Main Outcome Measures: Patients were evaluated at a minimum follow-up of 24 months after surgery through The American Orthopaedic Foot and Ankle Society (AOFAS), The Achilles Tendon Total Rupture Scores (ATRS), the calf circumference of the operated limb and the controlateral and the eventual return to sports activity carried out before the trauma. Results: The minimum follow-up was 24 months after surgery. The mean age at operation was 50.5 years. Patients were 5 men and 3 women. No patient reported complications or re-ruptures. The average AOFAS was 92, while the average ATRS 87. The average size of the calf operated was 37.5 cm, while the controlateral 38.5 cm. All patients returned to their daily activities, and 6 out of 8 patients have returned to sports activities prior to the accident Conclusion: The treatment of Achilles tendon rupture with minimally invasive technique with semitendinosus graft augmentation can be considere safe, infact no complications have been reported, and allows patients to come back to their sports activity.

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Lunchtime Drop -in Sessions

July - December 2016

All sessions are 1 hour

Literature Searching An in-depth guide to formulating an effective search strategy and getting the most out of searching key healthcare databases.

Critical Appraisal

How to assess the strengths and weaknesses of research methods.

Examining different research designs, bias and validity, and frameworks for systematically appraising a medical paper.

Medical Statistics A basic introduction to the key statistics in medical articles.

Giving an overview of statistics that compare risk, test confidence, analyse clinical investigations, and test difference.

Information Resources A comprehensive overview of Library subscription resources, freely available online resources and ‘grey literature’.

August (12pm) October (12pm) Tue 2nd Critical Appraisal Fri 7th Statistics

Wed 10th Statistics Mon 10th Information resources

Thurs 18th Information resources Tue 18th Literature Searching

Fri 26th Literature Searching Wed 26th Critical Appraisal

September (1pm) November (1pm) Fri 2nd Critical Appraisal Thurs 3rd Statistics Mon 5th Statistics Fri 11th Information resources Tue 18th Information resources Mon 14th Literature Searching Wed 21st Literature Searching Tues 22nd Critical Appraisal Thurs 29th Critical Appraisal Wed 30th Statistics

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Journal Tables of Contents

The most recent issues of the following journals:

 The American Journal of Sports Medicine  British Journal of Sports Medicine  Journal of Acute Medicine  Emergency Medicine Journal  Spine

Click on the journal links for the most recent tables of contents. If you would like any of the papers in full text then get in touch: [email protected]

The American Journal of Sports Medicine July 2016; 44 (7) http://ajs.sagepub.com/content/current

British Journal of Sports Medicine August 2016, Volume 50, Issue 16 http://bjsm.bmj.com/content/current

Journal of Acute Medicine June 2016 Volume 6, Issue 2, p29-54 http://www.e-jacme.com/

Emergency Medicine Journal August 2016, Volume 33, Issue 8 http://emj.bmj.com/

Spine July 15, 2016 - Volume 41 - Issue 14 http://journals.lww.com/spinejournal/pages/currenttoc.aspx

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Library Opening Times

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Level 5, Education and Research Centre

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