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SPORTS SURGERY SURGICAL MANAGEMENT OF UPPER LIMB INJURIES IN CYCLISTS

– Written by Richard Knight, Len Funk, Adam Watts and Mike Hayton, United Kingdom

Upper limb injuries are extremely common ULNAR NERVE COMPRESSION (‘HANDLE- palsy at the causes pain and altered in cycling and can be separated into non- BAR PALSY’) sensation to the little and ring fingers, if traumatic conditions, such as peripheral The ulnar nerve passes along the volar/ the compression is exclusively affecting the nerve compressions, and acute traumatic ulnar aspect of the wrist, passing through motor branch, cyclists may present with injuries, such as scaphoid and clavicle Guyon’s canal and into the hypothenar painless wasting of the interossei muscles fractures. This article aims to give an eminence and . This makes it between the metacarpals, wasting of the first overview of these injuries and injury particularly susceptible to compressive web space and clawing of the little and ring patterns which commonly affect elite injury in cyclists while they are gripping on fingers. Although predominantly a clinical cyclists, how to minimise their impact and the hoods or on the drops, as this applies the diagnosis, nerve conduction studies can how they can be managed surgically. most direct pressure at the Guyon’s canal1. confirm the diagnosis and localise the site Non-traumatic pathologies which The ulnar nerve supplies sensation to the of compression. The majority of cases settle commonly affect the hand of the cyclist are ulnar portion of the hand and the little and with non-operative management, although ulnar nerve compressions at the Guyon’s ring fingers. Its motor branches supply the surgical decompression and exploration canal, median nerve compressions at the intrinsic muscles of the hand (hypothenar is required as a matter of urgency when carpal tunnel and hypothenar hammer muscles, adductor pollicis, the interossei there is motor nerve involvement. It should syndrome. Figure 1 shows the superficial and the fourth and fifth lumbricals). It is be noted however that in some severe location of both the median and ulnar nerve important to remember that depending cases, particularly with motor symptoms, and also the ulna artery at the wrist. In on which zone of Guyon’s canal is affected, the symptoms and muscle loss may not this axial 3T MRI the ulna nerve is actually symptoms can be motor only, sensory fully recover despite decompression. This seen to be split into the sensory and motor only or a mixed pattern. This means that highlights the need for increased awareness branch as it passes through Guyon’s canal. although classic presentation of ulnar nerve and early operative measures when motor

476 Median nerve in the Ulna nerve and artery Flexor retinaculum carpal tunnel in Guyon's canal

Figure 1: 3T MRI axial section of the wrist showing the superficial position of the nerves. Both the sensory and motor branches of the ulnar nerve can be seen.

symptoms and signs of weakness and be more extended in these riders, but artery aneurysm or thrombosis. This is wasting are identified. Non-operativeaffected patients are not limited to these usually related to repeated blunt trauma measures for sensory involvement include grip patterns. Typical symptoms include to the hypothenar eminence, although a thicker, padded handlebar tapes and padded reduced sensation and pins and needles single, significant blunt trauma can cause gloves to minimise the contact pressures at affecting the thumb, index and middle sufficient damage to the vessel to cause Guyon’s canal. One study showed a decrease fingers, rarely with weakness or wasting of subsequent thrombosis or aneurysms. These in peak pressure over the palm by 10 to 29% the thenar eminence. Again, the diagnosis changes frequently lead to distal ischaemia, simply by using protective gloves1. Where is often clinical in classical cases but nerve ulceration and ultimately necrosis. As well possible, adoption of a cycling position conduction studies can confirm the site of as cyclists, sports which involve repeated which minimises the weight through the compression in equivocal cases. Although trauma to the hypothenar eminence, such upper limb should be encouraged. All riders likely to be a localised compression as golf, hockey, volleyball and baseball, should also be aware of their hand position neuropathy, other medical causes and can be affected. Patients can present with and to change this periodically throughout more proximal lesions at the elbow and a sudden acute event or a more gradual a ride. Despite the perception that ulnar cervical spine should always be excluded. picture. Symptoms generally consist of pain nerve/handlebar palsies are a ‘chronic’ The majority of cases resolve with non- over the hypothenar eminence and any of condition, it should be remembered that operative measures, similar to those for the fingers, although the ring finger tends to permanent ulnar nerve damage can occur ulnar nerve compression. An image-guided be more commonly affected. Cold sensitivity within hours or within a single ride and as steroid injection around the median nerve and paraesthesia are also common. Clinical a result, cyclists should be aware of these may improve symptoms but tends to have examination may reveal subtle blanching of strategies to reduce the risk of permanent a transient effect. If symptoms do not the digits with splinter haemorrhages, up to injury. improve with non-operative measures, a digital ischaemia, ulceration and gangrene. surgical release of the carpal tunnel should Rarely, a palpable mass representing an MEDIAN NERVE COMPRESSION be considered. ulnar artery aneurysm can be identified. Median nerve compression at the carpal Treatment depends on the acuteness of tunnel also frequently affects cyclists. It HYPOTHENAR HAMMER SYNDROME presentation and the severity of symptoms. tends to affect mountain bikers and road This is a rare and probably under- In mild cases presenting chronically, activity cyclists who prefer to ride on the tops reported condition which causes digital modification and non-surgical treatments of the handlebars, as the wrist tends to ischaemia as a consequence of an ulnar can be sufficient. In acute cases with

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digital ischaemia some form of surgical intervention in the form of fibrinolysis or embolectomy is required, occasionally with complete excision of the affected ulnar artery segment and subsequent reconstruction.

SCAPHOID FRACTURE Although many injuries in the hand and wrist occur due to falls by cyclists, one of the commonest and potentially most serious is a fracture of the scaphoid . Precise mechanisms of injury can vary, but any fall onto an outstretched hand in which there is pain around the wrist should raise the suspicion of a scaphoid fracture. Initial symptoms are radial-sided wrist pain, lack of wrist extension and difficulty loading the wrist in extension. The three most reliable Figure 2: Plain radiograph of a non-union proximal pole scaphoid. Increased sclerosis of the and reproducible areas to test scaphoid proximal pole is also visible, suggesting that will eventually fragment. tenderness are: • The anatomical snuff box. necrosis leading to . Figure 2 shows with a compression screw. Displaced • Over the greater tuberosity on the volar a scaphoid proximal pole non-union. The scaphoid waist fractures should also be surface of the scaphoid. proximal pole has become sclerotic and fixed surgically, but evidence is divided on • Pain on performing the scaphoid will eventually fragment due to avascular the management of undisplaced scaphoid compression test. necrosis. waist fractures, with much research Lack of wrist extension compared to the Scaphoid fractures can broadly be placed ongoing. Given no clear consensus in the opposite side is a particularly important into three categories: distal pole, waist and management of undisplaced waist fractures, clinical sign and should alert the clinician proximal pole fractures. This is a reflection many surgeons treating elite athletes would to wrist internal derangement that may be of the relatively poor blood supply to the advocate fixation of these fractures to permit a scaphoid fracture or intrinsic ligament which flows in a retrograde early return to training and/or competitions injury. direction from distal to proximal. Any and avoid the problems that prolonged Plain radiographs often reveal a fracture of the scaphoid potentially immobilisation may cause in the athlete, scaphoid fracture, however radiographs disrupts the blood supply and can lead to such as skin maceration due to sweating may be normal, even with a fracture and, avascular necrosis of the proximal scaphoid. under the cast. Although advice regarding if suspected, should be repeated after Traditionally distal pole fractures have been return to sport varies, many surgeons who 10 days of immobilisation. MRI is now treated in plaster for 6 to 12 weeks. A thumb fix fractures would not require prolonged commonly used to exclude or diagnose extension does not need to be incorporated casting postoperatively and an early return an acute scaphoid fracture and will show in this plaster. Proximal pole fractures have to non-contact or low-impact activities may the fracture and oedema immediately. A a poor union rate and can develop avascular be offered. However, these activities are timely diagnosis is important to reduce the necrosis. They are therefore almost always likely to be restricted until bony union is risk of scaphoid non-union and avascular treated via an open or percutaneous fixation confirmed, usually via CT scan.

THE ELBOW Fractures around the elbow Typical fractures seen following a fall from a bike are radial head fractures, that Any fracture of the scaphoid may be part of a fracture dislocation and olecranon fractures. These injuries may be potentially disrupts the blood open and are often heavily contaminated supply and can lead to avascular with grit from the road. This requires immediate attention with surgical cleaning necrosis of the proximal scahpoid to reduce the risk of infection. Radial head fractures can involve only part of the radial head or the head and

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fracture that may occur as an avulsion due to a fall on to an outstretched hand with the triceps contracting, or a multifragmentary fracture which is due to a direct blow or a fall onto the elbow. The fracture always enters the elbow joint and therefore may damage the articular cartilage. With transverse fractures, the triceps aponeurosis sometimes remains intact, in which case the fracture fragments stay together. Swelling and bruising are usually evident. A breach of the skin indicates a direct blow Figure 3: . to the elbow. A gap may be palpable and the patient will be unable to extend the elbow against resistance. An undisplaced 4a 4b transverse fracture that does not separate when the elbow is X-rayed in flexion can be treated without surgery. Casting is not recommended, but a sling can be used for comfort. Operative repair is recommended for displaced fractures and those with instability of the ulno-humeral or radio- capitellar joints. A plate and screws should be used in all cases except those with simple transverse fractures with a stable joint, in whom a suture repair or tension band wiring can be used. Immediate post- operative mobilisation is recommended. Stiffness used to be common, but with early mobilisation the residual loss of movement should be minimal. Non-union sometimes occurs after inadequate reduction and fixation – if elbow function is good, it can be ignored; if not, rigid internal fixation 4c 4d and bone grafting will be needed. Ulnar nerve symptoms can develop. These usually settle spontaneously. Osteoarthritis is a late complication, especially if reduction is less than perfect.

Fracture dislocation of the elbow dislocations occur as a result of forces applied through the that acts as a long ‘lever ’ to multiply Figure 4: Elbow fracture dislocations. (a) terrible triad, (b) posteromedial fracture forces across the elbow. These forces can dislocation, (c) dislocation, (d) Essex-Lopresti lesion. be ‘twisting’ or rotational forces, bending forces or axial loads. The elbow will appear neck of the . Most partial radial block to forearm rotation, then surgery may deformed if the it remains dislocated, but head fractures can be treated with early be advised to reduce the fragment and fix spontaneous reduction is common. active movement and pain control, with it to allow movement. More fragmented satisfactory outcomes by about 6 weeks. and displaced injuries may require surgical Lateral or external rotation injury (terrible The cyclist should be advised that while treatment, especially if there is associated triad) they may not regain all elbow extension, elbow instability. Elbow dislocation with fracture of the they can expect a functional range of Olecranon fractures can be divided in to radial head, coronoid process and medial movement in time. If there is a mechanical two broad categories: a simple transverse collateral ligament rupture is known as

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Figure 5: Fixation of a clavicular fracture with titanium plates.

a terrible triad injury. The injury is now anterior fractures carry a better prognosis dislocates in a posterior direction rela- well-understood and no longer earns the because the radial head is often intact. In tive to the humerus. The majority of ‘terrible’ title, but as with other elbow apex posterior fractures, the radial head dislocations occur as a result of a fall on to injuries, stiffness is a common problem. is driven in to the capitellum resulting in an outstretched hand with the elbow in The treatment is usually surgical with comminuted radial head fracture that may extension. Approximately 8% of cases will radial head fixation or replacement and be associated with coronoid fracture and result in recurrent instability of the elbow. lateral ligament repair. Coronoid fixation is ligament injury. Simple dislocations may be associated with only required if the fracture extends to the damage to surrounding nerves and blood medial facet. Opinion varies about the need Axial load vessels, especially if the injury is open – to repair the medial ligament. Axial loads through the forearm from suggesting a more high-energy injury. The a high energy fall on to the hand result in patient will present supporting the elbow in Medial or internal rotation injury fracture of the radial head and proximal slight flexion. Unless swelling is severe the (posteromedial fracture dislocation) migration of the radius relative to the ulna. deformity is obvious. The bony landmarks This results in an isolated fracture of This rare injury is associated with rupture of (olecranon and epicondyles) may be the anteromedial facet of the coronoid and the central condensation of the interosseous palpable and abnormally placed. However, lateral ligament complex. Often dismissed membrane of the forearm which should in severe injuries the pain and swelling as a ‘tip of coronoid’ fracture, this injury be addressed to produce a satisfactory are so marked that examination of the pattern has only been recognised relatively outcome. elbow is impossible. Nevertheless, the hand recently. CT will identify the subtle coronoid should be examined for signs of vascular fracture in a patient that typically reports Complications or nerve damage. Treatment is by prompt a fall backwards on to the hand. In many Joint stiffness is common and may reduction, which may require sedation. cases non-operative management will involve both the elbow and the forearm. An assessment by an experienced upper result in rapid progression to osteoarthritis. Even with minimally displaced fractures, limb surgeon is required to determine the Treatment consists of lateral ligament the elbow can take several months to need for surgical intervention to prevent repair, with or without fixation of the recover and stiffness may occur. Recurrent recurrent dislocation. An MRI can assist coronoid fragment, depending on its size. instability of the elbow may also be seen. this decision. If surgery is not required, or after stabilisation, the arm is held in a collar Proximal and dislocation Simple dislocation of the elbow and cuff with the elbow flexed above 90 of the radial head (Monteggia fracture Dislocation of the ulno-humeral joint degrees. After 1 week the patient gently dislocation) is the second most common major joint moves the elbow while lying supine with Monteggia fracture dislocation is a dislocation after the . A simple the shoulder flexed to 90 degrees and the proximal ulna fracture with dislocation dislocation is one without a fracture (flake forearm in neutral rotation. The collar of the radial head from the radiocapitellar avulsions at the ligament insertions may and cuff are discarded when the patient joint. These can be divided into those with be seen). Injuries are usually classified is comfortable. Passive ‘stretching’ of the an apex anterior ulna fracture and those according to the direction of displacement. elbow is to be avoided. The long-term with an apex posterior ulna fracture. Apex In more than 90% of cases the forearm results are usually good.

480 Figure 6: Acromioclavicular joint separation.

SHOULDER Clavicle showed they returned to cycling following Shoulder injuries are common in These common cycling fractures occur surgical fixation at around 3.8 weeks with cyclists, with the most common being following a direct fall onto the lateral aspect evidence that they tend to return sooner acromioclavicular joint injuries, clavicle of the shoulder, falls onto an outstretched than advised by their surgeon given the fractures, greater tuberosity fractures and hand or direct trauma. Diagnosis is nearly good pain relief that stabilisation provides3. traumatic rotator cuff tears. Again, current always immediately apparent with obvious evidence regarding management of acute subcutaneous deformity. Diagnosis can Acromioclavicular joint injuries needs to be balanced with the be confirmed with anteroposterior and 30 Acromioclavicular joint (ACJ) injuries need of the athlete and the ultimate aim of degrees cephalad tilt radiographs. In the occur following a fall onto the point of the returning to competitive sport as soon as general population, the majority of clavicle shoulder in such a way that the scapula is possible. fractures can be managed non-operatively forced inferiorly by the impact, relatively using simple sling immobilisation for 2 to displacing the clavicle superiorly. As a result, 4 weeks, then mobilising as pain allows, the acromioclavicular and coracoclavicular with return to sports at approximately 3 ligaments are sequentially torn with months. Indications for surgical fixation damage to the ACJ itself and disruption Path0laxity in the general population in isolated to the deltopectoral fascia or trapezium. clavicle fractures include open fractures, These injuries range from a simple ‘’ can result those with shortening of more than of the ACJ ligament to complete separation 2 cm and high-energy injuries with of the ligament and displacement of the from a single comminution. Although non-operative joint. Traditional classification systems management of clavicle fractures is a are based on the pathology and judged dislocation well-accepted treatment strategy in the radiologically. There is no level one evidence or repeated general population, there is a non-union relating to treatment or outcomes of these. rate of up to 13% in these injuries2 and elite Most surgeons still use radiographs for traumatic and professional cyclists are unlikely to classification including the Zanca view accept such a lengthy rehabilitation period. (15 degrees cephalad radiographs of the events Titanium plates are mostly used nowadays, ACJ) for classification, often comparing the as there is less risk of peri-plate fracture bilateral shoulder joint. However MRI may and they generally do not require removal be more useful in determining the extent electively. One study of professional cyclists of soft tissue injury and this is being used

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with increasing frequency. ACJ disruption Greater tuberosity fractures Rotator cuff tears is a difficult pathology to treat, with many Although greater tuberosity fractures Acute traumatic rotator cuff tear occurs patients remaining symptomatic at 6 are commonly associated with shoulder frequently in shoulder trauma with or months. In particular, overhead athletes and dislocations, they frequently occur in without dislocation, but are frequently those involved in contact sports struggle to isolation, again in a fall directly onto the underdiagnosed, possibly due to the lack maintain high-level performance. In non- shoulder or onto an outstretched hand. of initial obvious radiological findings. high-level overhead athletes there is little While radiographs clearly define displaced Therefore a high index of suspicion is evidence to suggest which patients and fractures with or without associated required in riders following a fall, even with which injuries benefit from surgery, with dislocations, undisplaced fractures may normal radiographic findings, particularly one review of the literature concluding that not be apparent, requiring the need for in those patients with shoulder pain for grade 3 injuries “clinical results seem to further imaging in the form of MRI or persistent for more than 1 week. A full be comparable between the operative and ultrasound scan. A displaced greater clinical assessment of the rotator cuff should conservative treatments, but complications tuberosity fracture is usually displaced be made and any deficit or lag acted upon. are more evident in the surgery group”. posterosuperiorly due to the resulting Even without focal signs, any patient with Therefore, given the minimal overhead unopposed action of the rotator cuff and if persistent symptoms should be imaged demands required in elite cyclists, the left untreated, may lead to impingement with an ultrasound scan or MR arthrogram, authors would not propose acute surgical against the acromion if mal-union occurs. If as arthroscopic surgical repair in the acute fixation, given that the long-term outcomes associated with a dislocation, the majority phase is preferable. appear to be similar with or without of displaced fractures reduce following surgery and traditional techniques carry reduction of the humeral head. These are Shoulder dislocations a not insignificant failure rate. In general, typcically managed non-operatively in the Traumatic shoulder dislocations may we would recommend a sling and early general population but in elite, non-contact occur in cyclists following a fall. Mechanisms mobilisation as pain allows, with return athletes who will not tolerate a period of can include a fall directly onto the shoulder to sports (non-contact) as able. A clinical immobilisation, surgical fixation is possible itself or onto an outstretched hand. More review at 3 months to consider surgery often via minimally invasive techniques, than 90% are anterior dislocations with should only be considered if the patient permitting early mobilisation and return to the majority being reduced by closed remains symptomatic. training. reduction techniques. Acute management

482 Acromioclavicular joint disruption is a difficult pathology to treat, with many patients remaining symptomatic at 6 months

of these injuries is straightforward in with the increasing competitive and 5. Krøner K, Lind T, Jensen J. The most cases, but dislocations are associated commercial pressures on the elite cyclist, epidemiology of shoulder dislocations. with several other pathologies including: has led to surgical management becoming Arch Orthop Trauma Surg 1989; 108:288- neurological injury (13.5% clinically, up to more common. Although all types of 290. 48% demonstrated with electromyography), surgery come with associated risks, 6. Brownson P, Donaldson O, Fox M, Rees J, greater tuberosity fractures (16%), rotator these are frequently low and may bring Rangan A, Jaggi A et al. BESS/BOA Patient cuff tears, as well as Bankart’s, Hill-Sach’s advantages in rehabilitation times and Care Pathways: traumatic anterior and SLAP (superior labral tear from anterior return to competition, which often is the shoulder instability. Shoulder Elbow 2015; to posterior) lesions. It is these associated ultimate aim of the elite athlete. 7:214-226. injuries and the relative risk of future dislocations which leads to controversy in the long-term management, with multiple surgical techniques used depending on the pathology – it is beyond the scope of this article to describe these. If recurrent dislocations do occur, 90% occur within 2 years. There is an inverse association Richard Knight M.B.Ch.B., F.R.C.S. of recurrent dislocation with age, i.e. the References older the patient the less likely a future Upper Limb fellow dislocation, as well as level and types of sport, 1. Slane J, Timmerman M, Ploeg HL, Thelen DG. The influence of glove and hand e.g. increased risk with contact/overhead Len Funk M.B.Ch.B., B.Sc. (Sports Physiol), position on pressure over the ulnahr sports. In those managed non-operatively, M.Sc. (Engin), F.R.C.S. (Tr & Orth), F.F.S.E.M. nerve during cycling. Clin Biomech mobilisation can begin immediately as pain (Bristol, Avon). 2011; 26:642-648. Consultant Shoulder Surgeon allows, with long-term slings or external rotation splints no longer advocated6. 2. Murray IR, Foster CJ, Eros A, Robinson CM. Risk factors for After Adam Watts M.B.B.S., B.Sc., F.R.C.S. (Tr & Orth) CONCLUSION nonoperative treatment of displaced In summary, there are many and varied midshaft fractures of the clavicle. J Bone Consultant Elbow Surgeon upper limb injuries which occur in the Joint Surg Am 2013; 95:1153-1158. elite cyclist. Although many of these are 3. Taylor F, Watts A, Walton M, Funk L.Return Mike Hayton M.B.Ch.B., B.Sc. (Hons), F.R.C.S. immediately apparent and commonly to Biking following (Tr & Orth), F.F.S.E.M. fixation. Presented at Wrightington Gold well-managed, many are not and delayed Consultant Hand and Wrist Surgeon management can lead to a poor prognosis Medal Research Day 2013, Wigan, UK. and further time away from competition. 4. Ceccarelli E, Bondì R, Alviti F, Garofalo Wrightington Hospital While many of the injuries described have R, Miulli F, Padua R. Treatment of acute classically been managed non-operatively grade III acromioclavicular dislocation: Wigan, United Kingdom in the general population, the advancement a lack of evidence. J Orthop Traumatol Contact: in surgical techniques available combined 2008; 9:105-108. [email protected]

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