NEWS ISSUE 05 I WINTER 2011 Welcome Message Winter is here and with that comes a long line of winter sports. The cold weather and early snow O RTHOSPORTS LOcATIONS brings skiing and snowboarding to mind, to prepare for the ski season Drs Sher and Bruce gave > concord 02 9744 2666 lectures to the ski patrol in readiness for the busy season of snow sport injuries. > Hurstville 02 9580 6066 Winter also means Rugby, Netball, Hockey, AFL, Soccer and many other sports that bring with > Olympic Park 02 9735 3637 them a vast array of knee, ankle, shoulder, foot, hip and general orthopaedic traumas. > Penrith 02 4721 1865 Leading on from the completion of our knee examination series, we commence our shoulder > Randwick 02 9399 5333 examination series on page 3. > Sydney 02 9735 3637 We hope you enjoy this issue of Orthosports News. The Team at Orthosports Or visit our website www.orthosports.com.au The Young Patient who Dislocates their WhO arE WE? Orthosports is a professional Shoulder for the First Time association of Orthopaedic Surgeons based in Sydney. This is one of the most controversial topics in orthopaedics. The literature has established We specialise in joint replacement, that the younger the patient, the higher the risk arthroscopic and reconstructive of recurrence (up to 90% in persons under 20 surgery. years). With each instability episode, increasing Orthosports also includes a team damage is done to the articular cartilage and of Sport & Exercise Medicine other structures of the shoulder. One can Physicians who are dedicated to extrapolate from that, that the more frequent Fig 3. X-ray showing Fig 4. MRI showing promoting excellence in the treatment the number of dislocations, the higher the risk bony Bankart lesion torn anterior labrum of musculoskeletal disorders in of developing Glenohumeral arthritis. and Hill Sachs lesion both adults and children. When a patient dislocates the shoulder the Our team of surgeons has particular labrum can tear (a bankart lesion), the capsule the shoulder is strong, usually at about 6 to 8 expertise in hip and knee is stretched and bony damage can occur to the weeks after the injury, the patient is generally replacement, AcL Reconstruction, Humeral head (a Hill Sachs lesion) or Glenoid allowed back to full activity. If the dislocation knee and shoulder arthroscopy, (a bony bankart lesion). recurs then surgery is recommended. open shoulder surgery, trauma, In these active young patients, if there is a foot and ankle surgery, fracture large labral tear then arthroscopic surgery is management, paediatrics and recommended to repair the labrum and reduce many subspecialist procedures. the risk of recurrent dislocations. The surgery All of our practices are conveniently carries a 4 to 6 month rehabilitation period and located next to physiotherapy, x-ray the success rate is approximately 90%. and imaging facilities. Our mission is to have the facilities to offer everything our Fig 1. Arthroscopic Fig 2. Arthroscopic patients may need but also to be picture of torn Anterior picture of Hill Sachs small enough to look after the little Labrum lesion details that make all the difference to patient care. When there is a large labral tear or significant bony damage, the risk of recurrence and more Fig 5. Arthroscopic Fig 6. Diagram of labral Our WEbSiTE iS subsequent damage to the joint is very high. This risk is amplified if the patient is young, photo of labral repair repair using anchors yOur OrThOpaEdic active and plays contact sports. rESOurcE If there is significant bony damage then a A general approach to the first time dislocator If you haven’t visited our website larger and more complicated procedure is is to initially perform a thorough history and recently, please take the time to visit required to compensate for the bone loss examination. A plain x-ray will assess the bony and take a look around. It contains which involves transferring the coracoid damage. If it is possible to arrange an MRI descriptions of many common surgical process into the defect. conditions and procedures as well as with intra articular contrast, this will give a lectures, animations and videos of good view of the labrum. In summary, a dislocated shoulder is not a benign injury and can do significant structural damage lectures given by our surgeons and If the MRI reveals no bony or labral damage, to the joint. This damage can be minimised by sports physicians over recent years. commence physiotherapy immediately. There early surgery in the high risk individual. www.orthosports.com.au is no evidence in the literature to suggest that sling immobilisation is of any benefit. Once Dr Jerome Goldberg www.orthosports.com.au 1 Management of Treatment of Bunions acute ankle Sprains The term “bunion” is commonly used to describe any enlargement or deformity around the great toe. The origin of the term “bunion” is Acute ankle sprains are an extremely common injury in both sport and the general from the latin word bunio, meaning turnip. The most common cause of a community. The ‘garden variety’ ankle sprain bunion deformity is due to hallux valgus, where there is lateral deviation involves the lateral ligament complex. It of the great toe, and a medial eminence. generally occurs in a position of plantar flexion and inversion, where the foot ‘rolls AETIOLOGY to establish the diagnosis and dictate under’ the ankle. clinical assessment of the Studies have shown that painful hallux appropriate treatment. ankle is very important as it should not be valgus is a problem of the shoe wearing assumed that all ankle sprains are lateral Treatment population, occurring in up to 33% of ligament sprains. Important conditions to Non-operative management usually people as compared to 2% of the unshod exclude are: alleviates symptoms associated with persons. The fact that hallux valgus hallux valgus. Patients are encouraged 1. Syndesmosis does not occur in everyone wearing to use wide shoes with a wide toe box. sprains – This injury shoes, or does occur in the unshod Shoes can be stretched by a shoemaker is a disruption of the population suggests that there is an to relieve pressure points over the inferior tibiofibula underlying hereditary component that ligaments. It is bunion. Podiatric care, with the use of may predispose to this condition. important to bunion pads, night splints, or bunion differentiate this The first metatarso-phalangeal joint is posts, have been shown to be effective injury as it runs a subjected to a number of deforming in relieving symptoms. These products more protracted time forces. When the toe is straight, these have not been effective at preventing the course (roughly twice forces are balanced and do not cause progression of the deformity. as long as a lateral a deformity. Once hallux valgus occurs, When conservative management has ligament sprain)and the pull of tendons around the joint failed to relieve symptoms, operative External rotation test occasionally requires becomes imbalanced, allowing for further management is considered. Proper surgery. On history worsening of the deformity. Pressure correction of the deformity involves a the patient describes a dorsiflexion and on the medial eminence from shoes, external rotation mechanism, which is quite rebalancing of the forces around the and altered pressure on the great toe different to the plantar flexion inversion first metatarsophalangeal joint. I have commonly causes pain. mechanism of a lateral ligament injury. had excellent results with a procedure clinically pain is felt with forced external Painful hallux valgus occurs far more known as the ScARF osteotomy. The rotation of the foot with the ankle in a commonly in females than males. While first metatarsal is cut and the bone neutral position. deformities may first arise in the teenage shifted laterally to re-align the bony 2. Fractures – The common fractures population, patients usually seek treatment deformity. This procedure, popularised by accompanying an ankle sprain include either for this condition around the sixth decade a French surgeon, Louis Barouk, allows medial or lateral malleoli, the base of 5th of life due to worsening of the deformity, for correction of large deformities, and metatarsal or one of the midfoot bones, such difficulty with shoe wear, and pain and patients are allowed to immediately bear as the navicular. Imaging guidelines known deformity in the great toe or lessor toes. weight on the operated foot. Surgery can as the Ottawa ankle rules provide guidelines be done on both feet simultaneously. for when to x-ray an injured ankle and have DIAGNOSIS been shown to reduce radiology requirements The majority of patients report pain over for emergency departments by 30%. the medial eminence of the great toe. 3. peroneal tendon Up to half of patients will report pain subluxation – The underneath the second metatarsal head, peroneal tendons are usually due to transfer of weight bearing held in place by the to this part of the foot as the deformed peroneal retinaculum, first ray is unable to share load. which may be ruptured in an acute Pain can be present all of the time, but Before After ankle sprain. This patients usually report worsening of pain Above: the most common cause of a bunion leads to instability of with shoe wear and improvement of pain is Hallux valgus. With the scarf osteotomy these tendons. with open toed shoes or thongs. procedure, the first metatarsal is cut and the clinically this may be I prefer to order standing or weight diagnosed by asking bone shifted laterally to realign the bony deformity. the patient to actively bearing radiographs as they better Stirrup brace demonstrate the true deformity. The dorsiflex and externally KEYPOINTS rotate the foot, whilst palpating for the tendons presence or absence of arthritis and snapping from posterior to anterior over the the anatomic structure of the foot • Bunions are mainly due to hallux valgus, malleolus.