The Fortius Clinic Lecture Series - January 2015 Issue

Ski Injuries

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In this issue:

Mr Steve Corbett talks about clavicle fractures and other injuries to the shoulder - pg 04

When a sprain is more than a sprain - Ioan Jones Skiers Thumb - Donald Samut - pgs 08 & 09

Mr Andrew Davies on acute knee injuries, options and outcomes - pg 10

Snowboarder’s ankle, and other such injuries from Mr Pete Rosenfeld - pg 14

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The Fortius Lecture EveningEvery month the Fortius Clinic hosts a lecture evening for physiotherapists, Sports and Exercise Medicine professionals, led by a different team of specialists. The evening event is held in central London. If you would like to be added to our invitation list, please email RSVP@ fortiusclinic.com.]

Fortius Clinic as a Football Medical Centre of Excellence

Fortius Clinic has been officially inaugurated as a FIFA Medical Centre of Excellence by Chairman of the FIFA Medical Committee and President of the FIFA Medical Assessment and Research Centre, Dr Michel D’Hooghe, at an official ceremony held in central London on Thursday 29th January.In receiving the award, Fortius Clinic joins a prestigious list of 37 Medical Centres and Clinics worldwide that have also been accredited to this high standard, and awarded the coveted F-MARC.Speaking at the official inauguration Ceremony, Dr D’Hooghe explained the vision behind the F-MARC.“The vision behind creating a network of medical centres across the world is to ensure that players on all continents know who to turn to for expert care in football medicine, such as the prevention of injuries, early detection of risk factors for sudden cardiac death, as well as state-of-the-art diagnosis and therapy services”.

He went on to explain the role of the FMARC centres, “Accredited Centres are committed to modern management of football injuries, academic and applied research and knowledge transfer to the football family.”Welcoming Dr D’Hooghe to the Clinic, Jim McAvoy, Chief Executive of Fortius Clinic said“Fortius is now in its 4th year and we are extremely proud of our record - for delivering high quality care to all of our patients. We are fiercely protective of our reputation for excellence and I want to thank the whole Fortius team for their hard work and dedication to Fortius. We enjoy a special reputation in elite sport and we are proud that our high standards of performance in football are being recognised today.”

Fortius knee surgeon Mr Andy Williams received the award from Dr D’Hooghe, on behalf of the Clinic. “It is a great honour to have been recognised as a contributor to football medicine in the UK and internationally”, he said.Mr Williams also commented “ Fortius Clinic is committed to continuing our contribution to football medicine, in research, in practice and in the education of other health professionals. It is important that knowledge and advances in football medicine are shared and practically implemented so that every player can benefit.”

“We look forward to working with our partners, the other FMARC centres in the global network, and all those in the FIFA family to continue to push forward with advances in research and practice in football medicine.”The Fortius Clinic is a leading Orthopaedic and Sports Injury Clinic, and a centre of excellence in the diagnosis and treatment of musculoskeletal conditions, both surgical and nonsurgical.Consultants and specialists at Fortius are at the forefront of their fields. They provide care for a wide spectrum of patients, from high performance and recreational athletes with sports injuries, to people with arthritis, rheumatology, musculoskeletal conditions, chronic pain and fatigue syndromes.Since opening in 2001, Fortius Clinic has established an international reputation for sports exercise medicine and orthopaedics, and has become the clinic of choice for many of the UK’s elite Sports professionals.

January Issue - Ski Injuries

Welcome back to the lecture series as we resume after the Christmas break, which now seems like a long time ago!

Some of you will have met me at recent events, I will now be running our monthly lecture evening, working with Mary Jones on content planning.

My contact number is below if you’d like to speak to anyone about the event, request topics or suggest improvements.

Ski Injuries is a very current topic for this time of year, as evidenced by the great turnout, despite the chilly weather and a new location. It was great to see so many of you and have such a busy room in the Marylebone Hotel.

Our three speakers covered the common skiing injuries, concentrating on aspects that we don’t cover in the other sessions. Consultant Knee Surgeon Mr Andrew Davies outlined the acute Knee injuries that physios are most likely to see, with options and outcomes. Shoulder & Elbow Surgeon Mr Steve Corbett spoke about clavicle fractures, and other shoulder injuries that may be easily missed. Foot & Ankle Surgeon Mr Peter Rosenfeld emphasized the differences between skiing and snowboarding and looked at common foot injuries across the two sports with particular emphasis on peroneal injuries.

Within this newsletter we’ve included a couple of relevant articles from other consultants at Fortius: Mr Donald Sammut’s write-up of skiers thumb, and Mr Ioan Tudur Jones’ tips for spotting when a sprain is more than a sprain.

We’ve also reported on our official inauguration as a FIFA Football Medical Centre of Excellence, which took place at the end of January. Read about the FMARC and what the accreditation means for Fortius on the following page.

Meg Williams, Business Development Executive

Email meghan.williams@fortiusclinic.comTelephone 0203 195 2445

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FEATURE | SKI INJURIES & THE SHOULDER

Shoulder injuries represent about 10% of skiing injuries or 15% of snowboarding injuries. And it’s suggested that it is potentially twice as common to get shoulder injuries in boarders than skiers. Not surprisingly, injuries are secondary to falls. Pole planting is another common way to cause injury around the shoulder, and if you want to do aerials either deliberately or by accident, those are also a key way to injure your shoulder.

Interestingly, somebody did some work around ski injuries and saw that actually you are at far more risk, genuinely far more risk, of sustaining injury on the first day on the slopes compared to the other days. So that isn’t a myth and certainly it is my own perception that it is normally the first day or the last day, after a few glasses of wine at lunchtime. That same study looked at age range as well and suggested those susceptible to injury are under 17 or over 26 - leaving a very narrow window of people who are not susceptible to injury! The use of rented or borrowed gear amongst boarders was very much associated with injury. This suggests people, I will say, going out infrequently rather than those who are well versed in techniques and avoiding falls.

So, the most common bone injuries around the shoulder are: • clavicle fractures• greater tuberosity fractures• humeral fractures. You can get scapular and glenoid fractures not infrequently.

With Joint injuries, you have: • AC joint injuries• Glenohumeral joint dislocation• Sternoclavicular joint dislocation And then with soft tissue: • Rotator cuff - you have a number of soft tissue injuries under this

label• Bursitis will follow after any injury where patients come back with

inflammation• Pec major and biceps ruptures.

In this lecture, I’d like to spend some time on the subject of clavicle fractures.

Clavicle fractures account for 2.6% of all fractures, constituting one in every 20 adult fractures. We can divide these fractures into areas of the clavicle. The most common area as we see is the mid clavicle, more than 75% of clavicular fractures are located in the midshaft. Then the lateral clavicle, and unusually, a medial clavicle fracture.

The majority of clavicle fractures are traditionally treated non operatively.

So which clavicle fractures might be we wish to worry about when the patient comes in to see you or me?

THE WARNING SIGNSYou can have a simple break where everything stays in alignment,

a cortical alignment fracture. You can have a displaced fracture. You can have a minimally displaced fracture, or you can have a comminuted or wedge type fracture. It is those more complicated fractures that would interest us as surgeons, and the ones that should worry you as the physiotherapist.

Often with these injuries physios are the first port of call when the patients come back from their ski trip. They have already had their x-ray in the valleys. They may or may not have been advised about surgery. These are the sorts of injuries that you probably want to get a second opinion fairly quickly. The warning words you may hear as the patient describes the fracture to you are very much along the lines of… “they said it was shortened”, “the bones were overlapping by 1 cm or 2 cm.” If the patient talks about a butterfly fragment, where 2 oblique fractures form a fragment in the shape of a butterfly wing, that should give you a bit of concern.

And if patients that you are treating are not pretty much okay when you get to three months, that should start raising concerns about whether that fracture is uniting or has malunited.

So, as I said, the ones to worry about are the cases with the shortening. The reason for the shortening is obviously the pull of the muscles from the pecs and the sternocleidomastoid, trapezius which are going to displace those fragments. So not only is it cosmetically disfiguring, but it does have an effect on outcome. A recent study of 52 patients who were treated with the figure-of-eight brace, very common in Europe, to pull the shoulder blades back, showed that 30% of patients were unhappy with their treatment and there was a high rate of non-union, 15% that didn’t unite, most of which were associated with that shortening.

A number of patients will experience associated neurology with a shortening and a significant displacement, because even if the fracture is trying to heal, the callus that forms around the bones can often irritate the brachial plexus. Sometimes we see patients who develop neurological symptoms very much due to that irritation. Most of the time you can leave that and it resolves over two to three months as the callus matures. But it is not insignificant, and again much more common when there is a shortening, with a quarter of such cases experiencing residual pain.

Many patients with non-union or severe shortening will come in complaining, not of severe pain in the shoulder, but about the scapular pain - the pain going up into their neck, maybe some bursitis - because the whole of those mechanics will get changed by that shortened strut at the front of the shoulder. Somehow we have to compensate.

So looking at these patients again, with conservative treatment, 15/30 were unhappy. Looking at shoulder strength, and referencing that study of 52 patients with conservative treatment, compared with the normal side, there are significant changes in shoulder strength on non-operative treated clavicle, with weakness in most modalities.

So we have identified a series of patients who probably would benefit from surgery initially.

EVOLUTION OF CLAVICLE PLATESOne of the problems that we had over the number of years was the fact that most of plates that we were given to fix clavicle fractures were straight, unlike the clavicle which isn’t straight., but rather a sort of S-shape. Not only did the old plates stand off the clavicle, but patients didn’t like them, and they broke because they were trying to contour to a bone that actually was a different shape. So a few years ago, S-shaped plates were developed. Now we are into generation 4 and you can get different waveforms, different thickness, different widths. You can put them on the top of the shoulder, you can put them on the top of the clavicle, or you can put them on the front of the clavicle.

Armed with those plates, the Canadians did a trial of a well over 100 patients a few years ago, looking at management of these clavicle fractures. They divided patients between plated and non op. The patients treated by surgery had better constant scores following that surgery, with improved functional outcome and a lower rate

of malunion and non-union when compared with non-operative treatment. (J Bone Joint Surg Am. 2007 Jan;89 (1):1-10.) Similarly DASH scores, which are looking at their functional activities, showed that their speed of recovery is much greater.

So of course, if you are doing surgery with a clavicular plate, there is the risk of introducing infection, that risk is actually quite small, that was 3 in 62, we would normally say less than 1%. The risk of non-union if you plate in the right circumstances is significantly less than with the non-operative treatment. Mal-union you correct because you are going to put it back in the right place and obviously the average time to union for these fractures is significantly quicker if you have plated appropriately. Complications are 30% of any complication with surgery, over 60% with non-operative. And we have just repeated this study across London and part of the UK. We are still going through the process now and the followup and are hoping to get the results out in the next six months, but I think we are going to see very similar findings.

But with clavicle fractures with indications for plating, there is an age factor. We don’t necessarily race in to plate clavicle fractures in very elderly patients, but if there’s displacement and shortening of 2 cm, and I would argue less then that, those should be considered for plating. There is always a lot of concern about the skin, because the clavicle comes up. It’s very, very rare that it will come through the skin, I have seen it maybe no more than a couple of occasions and only when there is a very thin spike, literally like a toothpick, that will come through but very rarely does the whole bone come through. Clearly, if you do get that effect of a skin break then you have to sort it out because that will get infected and won’t heal.

OPEN FRACTURESOpen fractures are associated with neurovascular injury or massive injury and we would not expect somebody to walk into our clinics with a floating shoulder. That’s where the clavicle’s gone, the glenoid is gone with scapular fracture. I would hope that somebody would have sorted that out before they sent them home.

Clinical deformity is a difficult one. I have seen patients who years down the line have come in with all these secondary symptoms of shoulder, neck, shoulder blade… and we have lengthened them on a couple of occasions and it has resolved their problems, but it is not something that I undertake lightly.

So once again, those key warning words, if somebody comes in with a clavicle fracture that has been seen in France, and if they say, “Oh yeah, they say it is bit short and there is a butterfly fragment, but all is well in this figure-of-eight”, I would certainly suggest you get another review for that. Certainly if you are seeing patients two or three months down the line, and they are not improving, and indeed are not pretty much okay in three months, they need to be reviewed as well with regards to potential non-union.

POST-OP MANAGEMENT If you have plated, then personally I stick people in the sling only for four weeks. Do they need it? Probably not with the plate, and you could potentially go more aggressive, but what you don’t want is a non union. So most people accept the sling for about four weeks. They can do some simple movements, but I don’t want them lifting up high. I don’t want to overstress the biology that is going on in the shoulder at the time. But again, at three months and certainly sometimes prior to that you would expect people to be back doing most things and certainly into sport etc. The cyclist or jockeys, just as an aside, clearly if you plate, they want to be back on their horses the next day literally. If you should ever operate on a plastic surgeon with a clavicular fracture, which I have done, even though they may assure you that they are going to wear the sling for a fortnight, you find them operating probably in the theatre next to you two days later. Of course you can do these things, but you do run the risk of the fracture not healing.

DISTAL CLAVICLE FRACTURES This fracture is considered separately from fractures elsewhere in the clavicle, because of its tendency to heal slowly or not at all. The warning words there are displacement, and whether the

Steve Corbett Trauma and Orthopaedic surgeon, shoulder

This article is taken from the lecture transcript

IN THIS TALK I AM GOING TO TRY TO CONCENTRATE ON SOME OF THE INJURIESTHAT WE DON’T NORMALLY COVER IN THE SHOULDER SERIES. WE’VE COVERED DISLOCATION AND ROTATOR CUFF INJURIES BEFORE, SO I AM GOING TO TALKABOUT SOME OF THE OTHER COMMON INJURIES THAT WE SEE IN THE SHOULDER, AS WELL AS THOSE WHICH ARE SLIGHTLY MORE UNUSUAL AND THEREFORE OFTEN MISSED.

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only a quarter of them will be perfused, three quarters of them are ischemic, slightly reversed in a three part fracture.

DISPLACEMENT OF TUBEROSITIES AND HEAD SPLITOptions for treatment if you are going to need a surgery, obviously a whole variety of ways, nailing put a nail in, that’s a nail and the tuberosities are sewn back round. You can put plates in, these are called Filos plates which will hold in place, you can do a hemiarthroplasty in if you think the head is not going to survive so you put a half replacement there. And then more recently it is now a lot of discussion about whether reverse shoulder replacement for proximal humeral fractures is a good thing to do. So if the whole thing is smashed up, is there any point trying to fix it? Probably not, if the humeral head isn’t going to be viable. What about hemiarthroplasty? Could we get good results? Often not. I know there are people in this room who have seen people who have had hemiarthroplasties on the slopes, literally. If you think about it, if the greater tuberosity is gone, they got nothing to insert the cuff on so they come back, and say “what are we going to do about that, doctor?” So reverse shoulder replacement is becoming more popular, particularly in more elderly patients, because then you don’t need the rotator cuff, you are going to work off your deltoid. Little bit controversial that.

NEUROVASCULAR INJURY I reviewed an extreme case where the only possible treatment was in fact amputation, because the patient was left with undiagnosed

nurovascular injury, basically compartment syndrome, for quite some time, actually for a couple of days in hospital, and he lost the arm. Clearly we woud hope that we are not going to see that sort of thing, but always have it in mind if the patient starts talking about nerve problems and vascular problems.

PEC MAJOR TENDON Last one a pec major tendon test. I know of a patient coming on Wednesday who tells me he has ruptured his pec skiing last week. More common now, because actually we look for it more, and because we are more inclined to repair these. Five or ten years ago people were very skeptical about repairing pec tendons. Why? Because it is not the easiest access and certainly when they become chronic, and curl down, retrieving it can be quite a struggle. But over time we move on and we have different ways of dealing with this. The warning signs are the bruising. Okay that is excessive bruising. That is either a fracture, probably proximal humeral fracture in the mid shaft of the humerus, or he has a got a pec tear. And actually they are often missed in casualty or on the slopes, and it is physios who often diagnose these because they start to develop a bit of asymmetry. So please refer them early because it is so much easier to repair these now in those first two or three weeks, than it is when sending them along in two or three months or six or eight months.

coracoclavicular ligaments are intact.

You can have a fracture where the coracoclavicular ligaments remain intact; or one in which the coracoclavicular ligaments are torn from the medial fragment and only the trapezoid ligament remains attached to the lateral fragment. And that means the risk of non-union in that fracture is actually quite high, certainly compared to most other fractures in and around the shoulder. So that’s one where we certainly would be considering fixing that.

There are different ways of doing it, you can use a hook plate which is there temporarily and then they have to come out. I genuinely have seen people who have no idea that those plates need to come out, but if you leave them in, they will cause cuff tears. I would normally take out hook plate somewhere between two or three months.

So that is clavicle fractures. Now let’s look at Greater tuberosity fractures.

GREATER TUBEROSITY FRACTURES These fractures are far less common. About 2% of proximal humerus fractures. Often due to the fall on the shoulder, but not only that. You can also get greater tuberosity fractures in my experience where you land on the elbow and you get like a nutcracker effect. So the greater tuberosity is rammed up under the acromion.

Life is easy if your x-ray shows such a fracture, and if it is displaced, you are going to fix it. But what we see is quite a number of these injuries are not picked up on an x-ray. Myself and Phil Aarons collected 25 patients in 18 months, most of them with skiing injuries, all of whom had normal x-rays. But when they were sent for MRI, you could see that actually they had a greater tuberosity fracture.

So the problem is not that they have got that injury; it is the expectation of the patient who has been told on an x-ray there is no fracture because they expect to get better therefore maybe over six weeks or eight weeks. And when they come back at eight weeks and they still can only just get their arm up to here, they are not very happy. But if you know at the outset or early on in their management pathway what the actual problem is, you can give them much more realistic expectation of recovery. I would be saying to that patient, “Its going to be at least three months until you’ve got a good functional range of movement.”

And sometimes what we do is once I am happy that a bone, if you want this healed, in about eight weeks if the patient is struggling, we will put in some kind of injection to speed up the recovery from the inflammatory condition around the cuff and the bursa. So I would be very careful about that sort of injury, really common with skiing and really commonly missed and the patients then lose a bit of confidence in a whole host of people if they are told after two months that they have a break, their response is “Why wasn’t I told before?”

AC JOINTAC joint, another fall on to the shoulder. Again, this is normally onto ice rather than soft snow. Obviously you can get pain and reduced range of movement. You will get tenderness at the AC joint, often you get the swelling and deformity. The degree of injuries depend upon which ligaments are involved in the disruption. You have got your simple AC ligaments between the acromion and the clavicle or you’ve got those big coracoclavicular ligaments. And as you know we classify those injuries into three types, basically from a sprain, or where it sits out of the joint a little bit, maybe 50%, to where it comes out and is 100% displaced. The type 4 it actually goes backwards rather than up. Type 5 is where you hang your coat off it when they come through the door, and type 6 nobody has ever seen it; it is a theoretical thing that the collarbone is going to go down.

So within these classifications we are still very traditional in the way that we would manage ACJ injury. That said, there are a number of us who are looking at this in a slightly different way now. So traditionally you would say type 1s and 2s you don’t need surgery; 4, 5, and 6 you do; 3 is a question mark.

And what we’re finding with Grade 3s, is that in essence you get compensators and non-compensators. So you can have somebody with a grade 3 who at three weeks has already got a very good range

of movement. But you can also get patients with a grade 3 injury at three weeks who are still struggling to get that control. And so some people have got what you could call a compensation mechanism and some people haven’t. And how that exactly relates to the injury as yet we don’t know. But with these grade 3, if somebody is struggling at three weeks, we are finding that they will continue to struggle until they have something done and it depends how long you want them to struggle for. If they are doing well at three weeks, they almost certainly will continue to do well and will not need any operative intervention. So if we have already screened out grade 5s, which they probably do on the slopes, the grade 3s if you hear that term in your practice it would give me a warning. If you see an x-ray or the patient says, “Oh yeah, all seemed in line, but there was a widening of the overall joint, it looked much bigger”. That would imply that it has gone backwards. Widening of the AC joint is only associated with posterior-anterior instability and in the longer term if people are struggling at three months despite the fact that you have screened out as many as possible either on the day of injury or three weeks, if they are still struggling at three months again, they are the sort of patients certainly should be reviewed. It is always worth requesting x-rays including the axillary view, to show the AP plane. Has that collarbone gone backwards? Becuase not only you have got this movement, you have got back movement, and you also got a rotational movement within the clavicle, all of which are contributing to your overall mechanics.

If we see AC joint dislocations, we then repair them with a Dacron ligament - wrap it round the coracoid, pull the clavicle down, and put a screw in the top to hold everything in place. That screw then there, lwith an average of about 5% of screws getting taken out.

HUMERAL FRACTURESQuick run through humeral fractures, more common than you might anticipate, but that’s because there is a spread of humeral fractures. More common in snowboarders than skiers and interestingly skiers are more likely to get more proximal fractures. The boarders actually come down the arm a little bit, mid humerus and distal humerus, around the elbow. It can be associated with dislocation of the shoulder.

A recent series showed that skiers with humeral fractures tended to be more skilled, older, and fell less frequently, than controls. Whereas snowboarders were less skilled, younger, and fell at a similar rate to controls. So there is a change, but whether that’s a demographic, because skiers are probably a little older than the snowboarders I don’t know. Most proximal humeral fractures are undisplaced or minimally displaced so you can leave them. This would include the greater tuberosity. Outcomes are pretty good for most patients. Interestingly, this study showed that if you start physio early, within the first couple of weeks, you get a better outcome. So even though they have a break there, getting going sooner rather than later.

So when we are deciding on who to operate, there are a whole lot of considerations: there’s the anatomy; there’s what you think as a surgeon; your experience; where you have been trained; what objective data we have, and also what the socio-economic effects are, somebody being out of work, or whatever. And in terms of the overall fractures, there is a whole range of proximal humeral fractures, and clearly our treatment is not the same for each and every one of them.

One of the things that we do consider is the blood supply around the humeral head. And anything that is going to disrupt that blood supply is going to cause us a concern about the viability of the humeral head. It is not just about, “Is this going to heal?” It is also, “if it heals, is that bone going to be maintained?” So the predictions of ischemia in a four part fracture, are that only a quarter of them will be perfused, three quarters of them are ischemic, slightly reversed in a three part fracture. And if you look, the risk of AVM in four part fractures is as high as 75%. So you can fix it beautifully but the head just dissolves before your eyes and then you are going and doing a further operation. So these are the predictions of ischemia which I just sort of mentioned, and here you can see a four part fracture,

Steve Corbett Trauma and Orthopaedic surgeon, shoulder His primary interest is arthroscopic shoulder and elbow surgery, and the reconstruction of complex shoulder and elbow injuries.

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It would be quite easy but I suspect rather dull to reel off a list of all the trauma we see following our yearly pilgrimage to the snow. There is plenty written about various common simple fractures.

Foot and ankle trauma is not that common whilst skiing or snowboarding

simply because the combination of a rigid boot and bindings generally protects the foot. All the energy tends to be transferred to the other joints. That’s why my knee colleagues are so busy.

The common fractures and the dramatic fracture are easy to diagnose and are generally picked up locally at the resort or at the local trauma centre. They are usually managed well locally, but prompt review on your return with a foot and ankle specialist is a good idea.

If, however you are reading this article, in pain, unable to ski / board with an injured foot that has been diagnosed as a sprain or bruising then please read on.

A sprain is simply a torn ligament. A ligament is a fibrous structure that holds two bones together. Ankle sprains are of course common, but not common within the confines of a ski or hard snowboarding boot. The boot and bindings are usually so stiff, that the amount of movement needed to tear a ligament is fairly unlikely.

There are 2 injuries however that we do see, that are often missed.

One is a fracture of the Talus bone, commonly known as a Snowboarders fracture. The other a rupture of the ligaments that hold the ankle and leg together, known as a Syndesmosis injury.

The mechanism of injury is the key. A ski boot or boarding boot / bindings, positions the foot and ankle in a slight dorsi flexed position. Dorsi flexion is when your centre of gravity is pushed forward over the foot. You are leaning forward and the weight is pushing through the front of your foot. This is a very stable position for the ankle, since the Talus bone is wedged in between the Tibia (the shin bone) and the Fibula (slender outer bone).This is a great position for skiing since it feels strong and stable, and allows you to load an edge and carve. If however you hit an unexpected depression, (such as when in powder), or if you mistime a landing things can go wrong. The recoil of the ski/ board and your ongoing forward momentum will thrust the ankle and foot into further dorsi flexion. Essentially your ski boot – foot will be pushed upwards and in this position the Talus is essentially crushed between the foot and the leg.

One of 2 injuries then happens. If you continue to flex forward, falling to the outside the outer side of talus eventually breaks. This is called a lateral process fracture or a “Snowboarder fracture”.

If you fall forward and rotate as you do

so then the huge rotational force generated can rupture the ligaments holding the fibula and tibia together resulting in a Syndesmosis injury.

Both are often misdiagnosed because patients can often walk, albeit with pain. X rays often initially look normal to casual inspection. Patients are advised rest and elevation.

Unfortunately both need prompt treatment and a period of absolute rest, initially at least in a plaster or boot to get a good result.

If your tale of woe fits this pattern and your injury seems more than a simple sprain, then prompt review is needed on your return.

When a sprain is more than a sprainBy Mr Ioan Tudur Jones, originally posted on the PhysioVal blog Jan 9, 2015.

All joints depend on ligaments for their stability and movement.

In the thumb, the Metacarpophalangeal joint (second joint) is subject to considerable sideways stress while gripping and the ligaments on either side act as stabilisers. Sudden, excess, force can tear one of these

ligaments, usually the ulnar collateral ligament which is on the side of the xthumb facing the index (see image). The ligament can pull out of the bone often taking with it a small bone fragment. This sort of injury occurs in a fall when the thumb is forced away from the index or if the thumb is caught in a ski pole strap. It is also a common injury on the rugby field.

The thumb is immediately painful and swollen. It may feel and look unstable and distorted. Bruising usually develops particularly if the bone is involved.

If the tear is partial (some of the ligament is intact), the thumb is not unstable, but still painful. This sort of injury responds to accurate and secure splintage, usually for some weeks (see image). This rests the ligament and allows the fibres to bridge the gap and heal.

If the tear is full, and the ligament is completely detached, this usually requires surgery, to reinsert it into bone and to stabilize the joint. This surgery is successful if it is performed within the first two weeks after injury.

The diagnosis is made by examination supplemented by Xray and/or ultrasound.

In most cases, diagnosed correctly and treated promptly, the ligament can be restored to its full strength and the thumb functions perfectly well.

In neglected cases, or in those diagnosed late, chronic instability and pain are likely.

The Skier’s ThumbWritten and drawn by Mr Donald Sammut

Our ski service offers patients urgent access to consultant orthopaedic surgeons, physicians and radiologists, with specific expertise in winter sports injuries. The service includes same day and next-day urgent appointments, X-Ray, MRI and Ultrasound scanning facilities, post-injury treatment, advice and rehabilitation plans.

If you would like to refer a patient to see one of our specialists please call 0203 195 2445 or email skiinjuries@fortiusclinic.com.

To refer a patient to see Mr Tudur Jones, or any of our specialists please call 0203 195 2442 or email appointments@fortiusclinic.com.

To refer a patient to see Mr Sammut, or any of our specialists please call 0203 195 2442 or email appointments@fortiusclinic.com.

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PRE-EXISTING MEDICAL PROBLEMSThe first group of skiers you are going to see are the groups coming through now. They are all going skiing at February half term, and theyre just coming out of a really good party season, where they’ve been drinking lots, eating lots, and they are now panicking as they contemplate going skiing in six weeks time. So they stop drinking, they’re all on diets, trying to get on with their work and trying to do lots of exercise and they get in to trouble because they have already got pre-existing problems. They may have early arthritis, or low-grade meniscal tears, they may have a degree of instability, or a range of other previous injuries. So there are coping strategies for these people when you see them and they are simple things. So if it is a severe osteoarthritic I have got a tranche of patients that come every year for one injection to get them through two skiing holidays. It is very pragmatic management. They know they get the pain taken away from arthritis, they can do it. They don’t want a knee replacement yet. They just need to get through that winter season and it works and if you do not inject them every three weeks then it is going to be fine and it is very functional.

The other ones who come are the patients who talk to you about bracing for their knees. And there are lots of them. Now there are functional braces for people who have got proven instability, be it MCL or ACL and you get a brace that will control that and make them safer and more comfortable. And then there are the simple soft braces, which I call the “there there, now now” braces. They

just calm patients down and they definitely seem to make people feel better and just keep them warmer undertheir ski trousers. But they do give them some feedback and I think they are functional in that sense because they compress the joint. So I would encourage people who have got low-grade arthritic, low-grade instability, generally poor knees to use them.

The biggest thing they can do is to do the physical conditioning but do it in a logical program. There are many good ones out there, for example welove2ski.com, which have clips and videos all the way through and gives you a three month program. I think that is quite a nice one. And then another coping strategy is a change in what you do, forget the vertical drop or the heliskiing if your knees are rubbish. You want to be cruising down a nice blue run, going to a restaurant meeting your family and that’s fine. So it is a change in what you do.

So in our etiology of the ski injury, it is not just the traumatic injury but it is the medical pre-existing ones. And then we’ve got the degenerates - they are coping in normal life and they go to Val d’Isere for a crazy week and after two days they are in agony, their knee is swollen and they are miserable and that is where there is a medical pre-existing degenerative knee, which is then pushed to failure.

And then we get the functional failures, the people who have just got no muscle left. They try and after three days, they can’t out of bed let alone trying to go out and ski. And unfortunately skiing is very high

energy and it’s very high impact. There was some research done using knee replacement which showed that this is something that Thou Shalt Not Ski With because they used pressure transducers to show that the equivalence of skiing a blue run is sprinting a 100 meter race. It puts the same load across your tibia especially and knee replacements are not renowned for their soft receptive absorption surfaces. They are hard and they will loosen and they will fail. So don’t forget the common things that can be stirred up, things like Gout, and Pseudo Gout, all these things that already exist, and can give you flare ups at the time. These patients need to get themselves seen and sorted and get themselves fit. Very classic one is the chondrocalcinosis group of patients, with most of them having meniscal tears. Most of these tears don’t actually matter, you can take it as a given if they have chondral calcinosis they probably have a meniscal tear. The calcium deposition within the joint is the problem and gives them the pain and those people again can respond very well to steroid injection.

When they’re doing lots of exercise it’s surprising how many people blow up the prepatellar bursa and the pain can be out of proportion and so severe that people think it is an infection and the worse thing that can happen is somebody sticks a knife into it and drain it thinking it is an infection. They often look very red, very very inflamed indeed and the treatment is anti-inflammatories, rest, and ice.

TRAUMATIC INJURIESI am not going to talk greatly about fractures because with any significant fracture they really won’t have got off the mountain. They will be taken to a treatment centre, and generally our experience of most of the centres for treating straightforward fractures is very good.

For ligamentous injuries things are slightly different. Meniscals are different case again, and we’ll talk about that. So why does it happen? Well, you’ve got a great big plank strapped to the leg. You’re wearing a rigid boot that will allow you about 20 degrees of flexion at the most in a nice soft pair of boots and theoretically if they fit well your ski boots are moulded to your feet. So if you lean one way or lean the other your foot doesn’t move, it just stays where it is so if you carve you can press on your little toe, press on your big toe as you are making your carving turns with your lovely new skis. Unfortunately that’s not the case. Most people change weight, they change size, their boots are old, or they’re hired boots, and they may slop around, because often the comfortable fit is the dangerous fit, and there is a huge rotational moment when the ski is attached to. If you ask people about their injuries they are all low velocity or medial, they are low velocity, classics, getting off a ski lift, standing to stop beside the slope; “I then started to go backwards, I twisted, I fell, there was a pop, or a snap”. Commonly the binding doesn’t release and if you are going to go and do something like skiing you probably ought to know a little bit about how the bindings work. Because of the force across the binding, you should be able to self release by pushing your foot out of the binding and should check it before you go realistically. But most people will go to the hire shop, they will say how much do you weigh, how many times have you skied before and are you any good, and if you say good they will go crunk, crunk, crunk on the binding so it won’t came off. If you say you have skied one week they will turn it the other way and it will come off just when you don’t want it to. There is no answer!

And then we come to the different patterns which are direct varus and valgus blows and they are more the higher speeds of injury that we see involving true rotation. It is a direct trauma or a rotational trauma. People have thought about it. So there is now even a thing called the knee binding, it is an American product. They would guarantee to refund the cost of binding if you tore your ACL, and the concept is that the release of the heel of the boot is vertical not just lateral, so ski boot tend to release laterally at the back and anteriorly and laterally at the front. But there are different sorts of bindings and some of the ‘geeky’ techier bindings for people who like ski touring have got very high ACL rupture rate because they don’t actually release at the front so if the heel comes out, you are still attached by the toe, and even if you fall it will take you. This is

designed theoretically to release, I don’t think that there is any data out yet, they are very confident about it but there isn’t any hard data on the market saying that it actually works.

MENISCAL INJURIESSo starting off with the meniscal injuries, the meniscal injuries we see from skiing are often slightly different pattern and that’s what interests me. They are often more peripheral so our classic meniscal injury is a split or a tear, this is a white on white tear, [IMAGE] it is not going to heal, it is an older person, it is going to probably be resected if it is symptomatic, straight forward clicking, locking, giving way and swelling. Joint line pain often related to like deep flexion so if you make him squat or duck walk in the clinic, they can lock. So it is either repair, resect or neglect. If it doesn’t hurt them it doesn’t matter if they’ve got meniscal tear and resecting a big meniscal tear if it is asymptomatic is probably areally bad idea because at least it is going to be sudden shock absorption. However there are ones you want to repair.

I repaired three of these last week in people all under the age of 18 and they all had bucket handle lateral meniscal tears from skiing. One had been picked up in resort, one was noted by a very good GP, one went through A&E at a large London Teaching Hospital, then the GP, and was picked up by a very good physiotherapist. But a bucket handle tear means you are going to lose that massive amount of meniscus and you have then lost your shock absorber. A lot of people skiing or boarding are young people, who have got their whole sporting life ahead of them. So if you have any suspicion at all then they actually deserve to be investigated and have a scan. If we can, we will repair them. If we can repair, we like to use vertical sutures because they are twice as strong as using horizontal sutures. It can be an all inside technique, unfortunately they will hate us all afterwards because they are in a brace from 0-60 degrees for six weeks, but they can full weight bear. But these injuries are normally in conjunction with other injuries when it comes to a skiing injury.

So we want to repair young people. Anybody who is young, who has got a locked knee, worry about it, and anyone who has a good history of meniscal injury they need to be seen, assessed, scanned and potentially repaired. The younger they are, the further we will push the threshold of what will be repaired. So in a 12 year old I will repair a white on white tear, put seven sutures in it, I don’t care, I will try and put it back together again. If it is me, I am afraid, my colleague will be chopping my meniscus out with exactly the same injury, because I’m too old.

Peripheral injuries red-on-red, red-on-white, the longitudinal type tears not the ragged tears, and especially if they are associated with rebuilding the ACL because the success

rate goes up dramatically for meniscal repair. It is probably simply because you fill the knee with blood and all those stem cells from drilling bone cavities. We need them fresh, so anything that is sat on for six weeks, anybody with a locked knee who sits on it, you have got a risk attached to it. There are always risk attached to meniscal repair but the biggest single risk is failure. The other ones I do not think I will get too excited about. With an isolated tear of the meniscus with an intact ACL the meniscal repair should produce healing in an up to a 2 cm lesion, of 2 in 3, about 70%. If it is with an ACL reconstruction, these figures may go up to 90% and they vary between 75% to about 93% , depending on which study you read but I would say that we are heading for a 90% ballpark, which is a really good result. However if you repair the meniscus and don’t deal with their ACL then you have a 1 in 3 chance of success so it is a bit pointless, actually.

TIBIAL PLATEAU FRACTURESSo moving away from meniscus onto the bony bits. The only things I end up seeing are tibial plateau fractures, and 99% of them are being fixed overseas. I have seen two this week, one from a woman who collided with her son head-on while skiing, she had a very nasty Schatzker - a lateral depression type tibial plateau fracture and she has had a really nice piece of work done in Austria. They put her back together again, she has come back in a brace on crutches and she can start to mobilize. So she’ll be a in brace for six weeks, range of motion, touch weightbearing and start to get things going because it’s an intra-articular fracture. So they are not the ones we see, they’re the ones that have been hoovered up already. The ones we tend to see are small fractures. The commonest ones we see are just like the humeral fracture Steve was talking about that aren’t visible on x-ray. So we see people who have got a fracture that is diagnosed on an MRI. They’ve got pain that is just a bit out of proportion, they’ve got no meniscal tear, their knee is stable, they have got bit of knee effusion, you say what on earth are you moaning about? Well actually they have got a fracture. We tell them to touch weightbear, they can do range of motion work straight away with you guys, they can start with strengthening, static bike, minimal resistance just get the motion going within the knee, you can do all of that as the bone will heal over a six-week period. So it is a six weeks of unit length of time for these reallly missed fractures. Fundamentally, the tibial plateau fractures are two groups, those that are fixed already, and those that are minor or they are going to be MRI diagnosis only.

FEATURE | SKI INJURIES & THE KNEELecture by Mr Andrew Davies Orthopaedic surgeon, Knee

I’M GOING TO TALK A LITTLE BIT ABOUT SOME OF THE ACUTE EMERGENCIES YOU’RE GOING TO SEE WHEN THEY COME BACK TO YOU FOLLOWING A SKIING INJURY, HOW THEY ARE INITIALLY MANAGED AND SOME CONCEPT OF PATIENT’S OPTIONS AND OUTCOMES

This article is taken from the lecture transcript

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ACL-MCL RUPTUREWe don’t see many knee dislocations in skiing in a true sense of what we consider knee dislocation. However the commonest big ski injury we see is an ACL-MCL rupture, combined injury. Technically you could call this dislocation, but we do not see many three and four ligament injuries, thankfully. So starting with the MCL, what does it do? Well really it resists any form of valgus movement. It is the commonest injury sustained while skiing and the commonest and the best is still the beginners snowplough, a bilateral MCL injury, they are doing a snow plough and just lose control and collapse inwards, and can feel them both going, and it depends on when they catch themselves as to whether they go and do the whole thing. I have had unfortunately one poor lady who managed the ACL and MCL meniscus, both knees exactly that injury, on her first morning, the first day.

Just going back to that incidence of injury for a moment, it is actually an exponential curve for skiing. It starts from day 1, then drops like a stone. The curve levels off after we have done 100 weeks of skiing, we have actually plateaud out to the lowest incidence prognosis.

Okay so the MCL valgus force would give us tearing or straining sensation and they often get pain enough to present with a locked knee because they can’t move it, it is too painful. And what are we seeing, well we are initially seeing sprains and a partial tear in the fibres and they are often acutely tender, so if you go and just prod them there, they’ll jump through the ceiling and they’ll think you’re very good because you’ve diagnosed it with one finger tap.

Grade 2 injuries are more of a problem, they are the ones that actually open up and this is my single biggest concern with ski injuries. Because people feel a bit of laxity and think they’ll be alright, and some of them will be, but many of them won’t be alright and will require intervention, I will come back to that. Grade 3 you take their knee and put a valgus force on it, it just flaps around in the breeze because you’ve ripped it and normally to have a grade 3 injury, you have to have injured something else as well. You have to rip the capsule, ACL, +/- PCL to get a grade 3 ACL injury. I only see about 5 of them in a whole year, it is very, very rare, but we do see a lot of grade 2 injuries and they are the ones that are commonly missed. So for Grade 2 we are looking for that medial pain and instability and you are testing it at 30 degrees of flexion. On an MRI scan, we will see fibres running up nicely, we will see something has happened here [IMAGE ] It is usually to the anterior border in a grade 1 injury and extends to the larger volume of tissue that’s involved as you go through and there is a 15% incidence of meniscal tear associated with an MCL injury. So in a skiing group that means one in seven are going to have a meniscal tear within six

months on. So there again worth chasing, worth looking at. So the grade 1 people we exclude a meniscal tear and get them moving, stop them from getting a fixed flexion deformity, push them even if it hurts to get things going. Ninety percent plus will be settled very rapidly over six-week period. The grade 2 injuries if it is an isolated grade 2 injury, we are going to get them into a brace straightaway and brace them from 10-30 degrees or 0-30 degrees, part weightbearing only and they have to wear it at night, they have to wear it all the time. And they’ll hate you for doing it. However the plus side is you can say that actually 15-20 years ago they would stick him in a plaster like this for the whole six weeks. And interestingly there is an American Surgeon who has got some data and shows the results from the plaster are still better, but nobody will tolerate it. If it is a grade 3 injury, I have already said they are extremely rare and actually need to be operated on, because they are so unstable and they have got an associated capsular or other injury. So there is no option for those people. For the grade 1 injuries we would expect by six to eight week’s they will be about 95% better, in a little bit of pain but should have full range of motion and should be getting going again starting to rebuild quads and will be heading back to full sports activity. So if they injure it at Christmas they should be fit again to go skiing at half term to do it all over again. The grade 2s will actually need a brace for the full six weeks and then they will need to be re-assessed to see if the laxity has healed because some of them just do not heal, and are still lax. The longer they wait from the moment of injury to bracing, the more likely it is not to heal, so there my single message on grade 2 MCL injuries from skiing is get into the brace, as rapidly as possible and get them seen. The little braces you see going are a waste of time. The brace we are talking about goes all the way from the ankle to the groin and can be worn on top of their trousers. The grade 3 injuries again take a long time to rehabilitate after surgery and they will have been immobilized and fixed.

ACL INJURYMoving on to other commonest injury from skiing which is the ACL injury. What does it do, it provides rotary and anteroposterior stability and it provides proprioception. Do you need an ACL to ski, no you don’t. Not doing the blue runs and the red runs, if you’re going to do jump runs and things like that you do need the stability. If you are just cruising around, you don’t need an ACL so it is no indication for someone to have surgery just to get back to skiing. It is always this twisting injury, lots of them will tell you they heard a pop and then rapid effusion, they’re usually got up by a friend on the slopes, they put their ski back on and they try and ski and they fall over again. They do that one or two times and then they’re taken off the mountain by a blood waggon, or if they are any good they ski down on one leg, go to the lift and

are taken off. They go to the local clinic and the diagnostic rate and success rate will be about 90% accurate, they are really very good because they see so many of them. Some people however don’t get a rapid effusion, they don’t have a pop, they have a bit of pain, a bit of a problem fully extending the knee and that’s about it. And they even go on and ski and they came back. And then you see them, you assess them, and you find they are unstable. They are a problem group. The diagnoses are really made on history more than anything else and these people have often locked knee because they have got the stump of their ACL blocking the notch so they cannot fully extend. They often have a meniscal tear with it at the same time. How do you test them? Well, anterior drawer I’m not that keen on, Lachman test, yes very good, pivot shift really important. I am going to reiterate the Lachman test, I’m sure that you’re all brilliant at it, it is really easy to do, put it over your knee, 30 degrees of flexion and control them move and you can feel whethere there is an endpoint or not in the translation. If they have got a hard endpoint coming forward that’s usually a very good sign unless it is a meniscus blocking their translation. If they are soft coming forward from their side-to-side’s very different then you should be concerned about anteroposterior disability from an ACL. And then of course a really definitive test is that, the pivot. [IMAGE?] that is the ACL injury really. You can cope with AP instability, but what you cannot cope with is that. Remember that is the knee actually going back into joint, it was out, it is relocating.

So what we worry about: locked knees, people with hemarthrosis intense effusion. They often have other injuries and fresh meniscal injury could be repaired. If you haven’t got a meniscal injury, you got an isolated ACL injury, your result should be really, really good. If you have a chronic ACL deficient knee then I am afraid you are probably going to head towards osteoarthritic change. And there are some myths. So if you are truly unstable, you can rehabilitate the knee, you don’t actually cure the instability but you improve everything that goes on around it. And it will help you, together with your altered behaviour pattern, to cope with it. The trial of conservative therapy is perfectly reasonable in somebody my age, although I would probaby have mine reconstructed but in a 20-year-old or a 25-year-old, sending them back out to play sport with no an ACL is quite sporting these days because of the high incidence of injury to other structures within the knee and there is another myth that surgery gives you arthritis. We did a meta analysis and looked at results from ACL surgery and incidences of osteoarthritis, published in the American Journal of Sports and Medicine, and what it showed was that actually, for people left alone with chronic ACL deficientcy, their incidences of osteoarthritis is significantly higher, but you can stratify it into ACL only,

ACL plus meniscus, ACL plus chondral, and each added bit you get takes you further up there in terms of risk.

So who do we operate on? The young, the active they do twisting sports, people who have failed because of the management and any in the multi ligament category. We want to get them back, be active, and we want to protect their meniscus because if you have an ACL rupture, you’ve got a 1% month-on-month risk of tearing meniscus. And that is the single biggest stat from anything related to ACL surgery these days. And we don’t want them to end up like that. And the hamstring reconstruction, which is the gold standard these days is straight forward, it is a 40-minute operation, they are off work for one to two weeks. We know they’re in rehab by six weeks, they look normal, they’re walking normally. What we don’t want is the old days of surgery. The people you are seeing, they have not been braced, they are walking, usually by seven days they are walking and they should have normal gait by that six-week mark. Often if they can survive their single legged hop test, we can advance them to jogging at around 12 weeks and all their goals are achievement based not chronological, I have just given dates or times for reference. We know the outcome is pretty good for a big knee injury, it’s 90-95% in terms of success. So it works, does have risks. The risk I really worry about is graft failure, because as I just said it is 5-10%.

The slightly older ones now, the posterolateral corner (PLC) of the knee is a very rare injury, it is 2% of significant knee injuries and it is normally a direct varus force, which rips the structures on the side. It is often combined with an ACL-PCL injury so again this is not a common skiing injury and is often quite a subtle thing and is a rotational element. It is a big force so again you would have to ski into something like a rock or something quite significant in terms of loading it. It is very common in rugby actually. And these people have lateral pain and have varus instabilities so it is the opposite direction. We all have some varus instability to a degree, we all open up. They do a lot more than other people and with the chronic injuries they get an abnormal gait and you look out for things things like a footdrop or neurological patterns of injury. And the other thing you look for is a dial test. So you flex the knee up at 30 and 90 degrees and actually rotate it out and you can see that on the affected side it rotates to a significant degree and that is very easy to do, just get them to lie on their front, just dial their feet out at 30 and 90 degrees. It is really a simple test, very easy to do in the clinic.

This one is a bad one, if you miss this one, you could have a problem, especially if they have a varus knee to start with. This is the one we need to be operating on within two to three weeks and it is really an augmented

reconstruction, up to about six weeks. If we miss it and you have got varus knee, then later I am afraid you may just condemmed them to an osteotomy. So if you miss the boat, the soft tissue put in will not do the job because everything else will stretch out. It is commonly associated with the fibular head fracture and the thing we worry about is the comprenial nerve which can be injured, giving you a footdrop. So they can look quite messy at the time because everything is just ripped off but we can actually put them back together quite nicely with a loop of hamstring, as I say avoid the nerve, and in fact in some of them we could do it with a nice little mini-incision. For these people it is still only a 24-hour stay in hospital. You can brace them and we go 30-60-90 at two-week intervals then two weeks of full range of motion but wearing the brace and full weightbearing, and they are normally back to full sport by six months, certainly the rugby players have got back.

PCL INJURY The PCL component is the biggest resistance to posterior forces, so you don’t often injure it skiing, unless you hit something. So we see it with tobogganing, that’s the commonest snow sport that gives you the PCL injury and for people who play ice hockey because they just injure everything. What do we look for? We look for that a sag, a positive posterior Lachman and a reverse pivot shift test. That is the big give away in the clinic, you flex the knees up to 90 degrees and see what happens, does it sag back. If it does, especially if your finger slides off the femur and hits the tibia they have lost the step off and that is a grade 3 injury and that actually needs to be seen. Grade 1s, with conservative management rehab they will generally do very well. Grade 2 we may have bracing these and pushing them forward in a thing called a PCL Jack brace because we can convert them from a 2 to a 1 or a 3 to a 2 by use of a brace. That makes a significant difference to their outcome and it means that some of them can actually avoid surgery that they may otherwise have required. Grade 3, brace, rehab potentially reconstructed. But if they are a multiligament injury we’ll reconstruct all of them.

SO IN SUMMARY…With the skiing it is all about the history, how did they do it? Lock knee, think the ACL injuries, the MCL injuries, don’t worry too much with the PCL, it’s unlikely but meniscal is the one that we think of most, or MCL injury or ACL injury. They are absolutely crucial to make the diagnosis and get them seen and assessed. If they are Valgus stress positive think MCL, Varus stress positive, think the lateral side of the knee, if they have got a sag think of their PCL, if they have got positive Lachman or pivot remember they will only let you pivot them once, they’ll never let you do it again and don’t forget other things because the problem with skiing is that it brings out everything else we have got already.

Andrew Davies’ Top Safe Skiing Tips1.Be fit,

2. Don’t drink and ski, you wouldn’t drink and drive!

3. If anybody says we are going for a last run, I go straight home and I never ever, ever, ever go out.

4. If you are learning, learn properly

5. Remember when you go out to have the local emergency numbers in your phone

6. Don’t overestimate your ability when you are looking at some quite nasty stuff.

7. Please do understand about ski bindings, roughly it is your weight in kilos divided by 10 is the ballpark figure. You crank it up or down depending on mobility.

8. If you are going to go off piste, please, please get a guide

9. Helmets - always wear one - skiing is the top 10 under 16 head injuries causing severe damage

10. If you are going to get off piste and do anything frankly take a shovel and probe and know how to use it.

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way of doing it. You do not disrupt the sheath. You can rehab straight away. There is no need for mobilization, so the remaining tendon doesn’t get stuck down. An open repair is a bigger insult to the tendon, the sheath has to be opened, you’re going to have to rest it for two to three weeks and let the wounds heal and the sheath repair and then you have got all the problems with rehab having it stuck down for about three weeks. So, ideally a tendinoscopic repair will be better. Sometimes you need to do a reconstruction and if it looks like a horse’s tail and there is nothing left and the two ends aren’t together so then we will start to really just cobble things together to get something towards the other end. It is much better than doing a graft. A graft involves injury to another tendon and the peroneal tendons will do okay and leave you with little functional loss. So, we tend not to use the graft with peroneal tendons unless it is second time surgery. If we look at dislocation again, classically, it is forced dorsiflexion, but actually it has been reported in every single position: flexion, dorsiflexion, inversion, eversion, abduction and adduction. And this is the thing to alert you to it - if someone says they’ve sprained their ankle in the ski boot and it hurts behind the fibula and there is no fracture, it’s going to be a peroneal tendon dislocation or split, splits tend to be a bit lower down they tend to be at the tip of the fibula. There is not any evidence on conservative management of dislocations. All the papers, and there are few, say that it fails and that we should be doing surgery. I have got a couple of patients who have dislocated tendons and have no problems at all and that‘s really quite unusual. I will monitor them for signs of instability and if they have got instability problems, then do a reconstruction. I will monitor them for signs of instability and if they have got instability problems, then do a reconstruction. [big deletion] The results are very good - you have got 100% return to sports in three months and I have no recurrences in a three-year followup. It is a good operation, and works very well. So, it isn’t one that you would hold off from particularly, because the result of the surgery is so good and the very limited results of conservative treatment are quite poor. and the results are very good. You have got 100% return to sports in three months. I have no recurrences in a three-year followup. It is a good operation, and works very well. So, it isn’t one that you would hold off from particularly, because the result of the surgery is so good and the very limited results of conservative treatment are quite poor.

So going to snowboarding, coming back to consideration of the forces through the subtalar joint and fractures that are often missed.

They happen in the area which is just where you put your thumb when you are pushing on the ATFL, and so what happens is you examine them and you push on the anterolateral part of their ankle, lower end of the fibula and they go “OW” so you diagnose an ATFL injury, and decide to treat it as a sprain. You can’t pick these fractures up clinically, because they are masked. X-rays can be helpful but can come back perfectly normal. Send it for a CT and it’s possible to see a subtle displaced fracture, almost like a rim fracture, off the talar process.

UNDISPLACED INJURIES

You can leave alone. I would treat pretty much as you would a sprain. So weightbear as tolerated in the boot, lots of physiotherapy to rehab the ankle and the peroneal tendons for the function and the control and the stability. If they are displaced, then if the fragment is big enough, screw it back on and it is very simple elegant little operation, which works well. If the piece is comminuted and you can’t get screws across it just take it out. There are no attachments to this piece of bone, so there is no instability doing that and the articular surface of the piece you’re losing is usually quite small, but occasionally they can extend far in to the joint and you are actually going to lose a sizable chunk of the subtalar joint and in which case we’ll fix them back on and wait and see how they do. If you fix them back on nonweightbear them for the first two weeks, partial weightbear them for two weeks and then fully weightbear for two weeks. And then middle facet injuries, which is a chondral injury to the middle facet and it really is an impact injury to the talar neck and you can get the osteochondral injuries with it. It is more something

to be aware of, I think it is quite rare, but if your x-ray and your CT does not show anything that may be the problem. There isn’t any acute treatment that you would start at this stage and you would just monitor the pain and manage as you would a sprain.

For lower limb injuries, a lot of it is down to the boot. In the 1970s, you had low soft flexible boots for skiing and lot more ankle fractures in that time. But now you have hard shell boots which fix to the skis and pretty much all the forces are transmitted to mid tibia and above, and up to the knee and beyond except for rotation. Boarding is right back where skiing was in the 1970s, with many boarders, especially beginners, wearing soft boots. With soft boots, the bindings don’t really release and what is actually clasped in the binding is the heel. It’s your heel which is attached to the board and everything else moves around it and hence the greater incidences of subtalar injuries.

Looking at injury patterns, ankle injuries account for 6% of skiing injuries and 16% of snowboarding injuries, and again that relates to the styles and the boots and the different biomechanics. I’m going to talk to you today about Peroneal injury because it is probably the more common soft tissue injury that you are going to see, the fractures are much more standard. Most of these injuries we’ve covered before in relation to other problems. There’s calf strain from hyperextension, and the occasional Achilles injury, and syndesmosis injuries that we’ve all talked about before. On snowboarding, I am going to talk about the subtalar injuries because they’re the unusual ones and they’re the ones that get missed and they’re the ones that you are going to see.

So, we are going to look at peroneal tendon injuries, you have got peroneus brevis and peroneus longus and they’re held in a sheath behind the fibula called retinaculum and they can get all the things that tendons get. You can get inflammation, you can get splits and tears and you can rupture, and you can get dislocation. If we are looking to examine it, really you are looking for that peroneal tendon injury behind the fibula and somebody has got posterior fibular pain from a skiing injury it is almost certainly going to be the peroneal tendons and it is very unlikely to be a fibular fracture. So consider whether this is a split, is this a tear, or is this a dislocation? And look for dysfunction. For example, look for the too few toes sign.

The peroneals usually act like a strap to centralise the ankle on the hind foot so when that strap effect is lost, the hind foot sways out covering up those lateral toes – the too few toes sign.

With the tendon sheath injuries you can either have dislocatable tendons that you can dislocate with your thumb and if it is not that acute, normally you see it after 10 days or two weeks because it has

been missed, it is easy just to feel with your thumb and see if you can just flick those tendons over the edge of the fibula or you may get a snapping tendon where you can dislocate it and then as they activate their foot and the peroneals it snaps back into place. You might also see a permanently dislocated tendon and we’ve got some of those later.

INVESTIGATION There isn’t one investigation that tells you all. Ultrasound is very sensitive at picking up tears, but the problem with Ultrasound is that’s all it tells you about. It doesn’t tell you about the bone injuries, it doesn’t tell you about the cartilage or anything else. But quite often that is the information you want in a badly injured ankle, and so a combination of an ultrasound and an MRI is really the ideal here. MRI is not good at seeing peroneal tendons. The tendons come down and then angulate away and an MRI doesn’t like things at an angle and so you get a blurred image.

CONSERVATIVE TREATMENT If we go back, it’s the standard conservative management, which is rest, reduction of activity, anti-inflammatories, physiotherapy, and maintaining function and the same with tendon tears and this is really the workhorse of the treatment here. This is where you are going to get it better, manual therapy controlled with the antagonistic and agonistic pairing and management and control of subtalar positioning, and then letting it recover and rehabilitating to get strong again. Most peroneal tendon splits don’t end up in surgery and most of it can be treated with physiotherapy and conservative treatment and it is going to take a few weeks to months to settle down.

RUPTURESA colleague at St Mary’s has got a peroneus longus rupture at the moment, a complete rupture after spraining her ankle, and she is now 12 weeks and everything is doing fine. There is about a 6 cm gap in the peroneus longus and she has almost no functional loss that bothers her. Peroneus brevis is different and you may well find that peroneus brevis injury does need repair and reconstruction.

if ithey’re split and the split is causing inflammation and problems and is not settling down then we can go in with keyhole and just remove the smaller part of the split. You have still left the majority of the tendon in place and that will continue to function and that’s a nice

FEATURE | SKI INJURIES & THE ANKLELecture by Mr Peter Rosenfeld Orthopaedic Foot and Ankle surgeon

This article is taken from the lecture transcript

SKIING AND SNOWBOARDING ARE ENTIRELY DIFFERENT SPORTS AND YOU CAN’TREALLY RELATE THE TWO. ANKLE INJURIES ACCOUNT FOR 6% OF SKIING INJURIES AND 16% OF SNOWBOARDING INJURIES. I’M GOING TO LOOK AT COMMON LOWER LIMB INJURIES ACROSS THE TWO SPORTS WITH PARTICULAR EMPHASIS ON PERONEAL INJURIES.

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The speakers at the February lecture are:

Mr Damian Fahy, Consultant Spinal Surgeon

Dr Pippa Bennett, Consultant in Sports & Exercise Medicine

Professor Ernest Schilders, Consultant Hip & Groin Surgeon

The next lecture is fully booked but to be added to the waiting list please email RSVP@fortiusclinic.com

Contact the Fortius Clinic If you would like to refer a patient to one of our consultants, please get in touch:

17 Fitzhardinge Street, London, W1H 6EQ

Tel: 0203 195 2442 Fax: 0203 070 0106

Email: info@fortiusclinic.com Web: www.fortiusclinic.com

Achilles Tendinopathy clinicThe monthly UTC Tendinopathy clinic is proving extremely popular. This is a unique opportunity as the service is not offered elsewhere in Europe or the US. The specialist insight delivered by the clinic is designed to support the patient’s ongoing physio care - following attendance at the clinic, patients return for physio locally with a detailed rehab plan based on the ultrasound tissue characterisation.If you would like to book an appointment for a patient please call 0203 195 2442.

Booking for FISIC ’15

is now openEarly bird ticket ticket

rates apply.

For more information please visit the FISIC ‘15 website - www.fisic.co.uk

or call Harriet Webb on 0203 195 2434 (harriet.webb@fortiusclinic.com)

THE ADOLESCENT ATHLETE

INTRODUCING...Two new consultants start at Fortius this month, Mr Koen Lagae and Dr Chris Seifert.

Consultant Knee SurgeonDr Koen Lagae is a Knee Surgeon and sports knee specialist. He is expert in ACL reconstructions and total knee replacements with special interest in PCL reconstruction, meniscal transplant, and mutiligament knee injuries, and complex knee issues.

Consultant in Pain Management & AnaesthesiaDr Seifert is a Consultant Pain Specialist and Foundation Fellow of the Faculty of Pain Medicine of the Royal College of Anaesthetists.

Dr Koen Lagae is current head of the Knee department and head of Orthopaedic Department, Monica campus Hospital Antwerp. He is also part of a specialist group of orthopaedic surgeons at SPM clinic Antwerp Belgium, the biggest Sports

medicine facility in Belgium.Dr Lagae is a Founding member of the Belgian Knee Society, a lecturer and instructor for Smith and Nephew Endoscopy international, a member of BVOT and a member of ESSKA.

He specialises in the accurate diagnosis and treatment of neck, back and related nerve root pain. Further areas of his specialist expertise include the management of Complex Regional Pain Syndromes (RSDs) and the use of Botulinum Toxin for muscular pain and migraines. He is regularly involved

in the treatment of sportsmen and women, particularly the members of the British Equestrian Team.His philosophy is that early diagnosis and minimally invasive interventional therapy substantially reduce the likelihood of disability.

DR CHRIS SEIFERT

DR KOEN LAGAE

For further information or to book an appointment, please contact us:

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