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Musculoskeletal

Soft Tissue Clinic Current Awareness Newsletter

February/March 2016

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Contents Your Local Librarian ..................................................................................................................... 3

New from Cochrane Library .......................................................................................................... 5

New Activity in UptoDate ............................................................................................................. 6

Current Awareness Database Articles related to Musculoskeletal Soft Tissue ................................ 9

Acute soft tissue injuries ................................................................................................................. 9

Musculoskeletal ............................................................................................................................ 16

Sports Injuries ............................................................................................................................... 27

Journal Tables of Contents ......................................................................................................... 29

The American Journal of Sports Medicine .................................................................................... 29

British Journal of Sports Medicine ................................................................................................ 29

Journal of Acute Medicine ............................................................................................................ 29

Emergency Medicine Journal ........................................................................................................ 29

Spine .............................................................................................................................................. 29

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New from Nice Evidence

No current new evidence

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New from Cochrane Library

Immobilisation versus early ankle movement for treating acute lateral ankle ligament injuries in adults

David J Keene , Mark A Williams , Anand H Segar , Christopher Byrne and Sarah E Lamb

Online Publication Date: February 2016

You have free access to this content

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD012101/abstract

Motor control exercise for acute non-specific low back pain

Luciana G Macedo , Bruno T Saragiotto , Tiê P Yamato , Leonardo OP Costa , Luciola C Menezes Costa , Raymond WJG Ostelo and Christopher G Maher

Online Publication Date: February 2016

You have full text access to this content

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD012085/abstract

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New Activity in UptoDate

New updates in point-of-care evidence summarising tools UpToDate

Hamstring muscle and tendon injuries

Authors: Karl B Fields, MD; Spencer T Copland, MD; John S Tipton, MD

Literature review current through: Feb 2016. | This topic last updated: Feb 09, 2016.

INTRODUCTION — Hamstring muscle injuries occur frequently among recreational and elite athletes. Several terms, including posterior thigh injury, hamstring strain, hamstring tendinopathy, and hamstring tear, are used to describe such injuries, but they are not always synonymous. In most cases, the severity of the injury determines treatment and the amount of time the athlete must take off from sport [1-9].

For the purpose of this review, we will define hamstring injury as any strain or tear, including avulsion, of any of the muscles or tendons within the hamstring group, including the biceps femoris, semitendinosus, and semimembranosus muscles.

http://www.uptodate.com/contents/hamstring-muscle-and-tendon-injuries?source=search_result&search=musculoskeletal+injury&selectedTitle=9~150

Severe extremity injury in the adult patient

Authors: Jeremy W Cannon, MD, FACS;Todd E Rasmussen, MD, FACSSection Editors

Literature review current through: Feb 2016. | This topic last updated: Feb 18, 2016.

INTRODUCTION — Trauma to the extremities represents one of the most common injury patterns seen in emergency medical and surgical practice. As extremity injuries are evaluated, each of four functional components (nerves, vessels, bones, and soft tissues) must be considered individually and together. If three of these four elements are injured, the patient has a “mangled extremity” [1,2]. Achieving the best outcome in patients with severe extremity injuries requires a multidisciplinary approach with oversight by the general or trauma surgeon and commitment from other specialists including orthopedic, vascular, and plastic surgeons, as well as rehabilitation specialists. In most instances, limb salvage can be attempted even if the patient has a mangled extremity. However, at times, the injury to the extremity is so severe that primary amputation at the initial operation is required to save the patient’s life.

http://www.uptodate.com/contents/severe-extremity-injury-in-the-adult-patient?source=search_result&search=soft+tissue+injury&selectedTitle=1~150

Posterior cruciate ligament injury

Authors: James MacDonald, MD, MPH, FAAFP, FACSM; Richard Rodenberg, MD

Literature review current through: Feb 2016. | This topic last updated: Mar 10, 2016.

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INTRODUCTION — The posterior cruciate ligament (PCL) is the primary restraint to posterior translation of the tibia at the knee joint [1-4]. The bulk of injuries to this ligament occur in combination with other internal derangements of the knee in association with multi-ligament trauma; isolated PCL injuries are uncommon [5,6]. The PCL is the knee ligament least frequently injured during sports [5-7]. Over time, increasing knowledge of the anatomy and biomechanics of this ligament has highlighted its importance with regard to knee stability and function. As isolated injury is uncommon, the natural history of injury has yet to be elucidated fully.

http://www.uptodate.com/contents/posterior-cruciate-ligament-injury?source=search_result&search=soft+tissue+injury&selectedTitle=3~150

Splinting of musculoskeletal injuries

Author: Rana Kronfol, MD

Literature review current through: Feb 2016. | This topic last updated: Feb 23, 2016.

INTRODUCTION — Splinting plays a major role in the management of musculoskeletal injuries, particularly those involving extremity fractures and joint dislocations. Immobilization of the extremity through splinting decreases pain and bleeding and prevents further soft tissue, vascular, or neurologic compromise [1-7]. Splinting may provide definitive treatment for some injuries [8-10].

Compared with casts, splints permit swelling and may prevent neurovascular compromise. The clinician should perform splinting immediately after the injury and maintain splinting or casting until the injury has healed completely.

The basic principles, method of application, and description of specific splints for the upper and lower extremities will be discussed here.

http://www.uptodate.com/contents/splinting-of-musculoskeletal-injuries?source=search_result&search=musculoskeletal+injury&selectedTitle=5~150

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Current Awareness Database Articles related to

Musculoskeletal Soft Tissue

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

following categories:

• Acute Soft Tissue injuries

• Musculoskeletal

• Sports Injuries

If you would like any of the following articles in full text, or if you would like a more focused

search on your own topic, then get in touch: library@uhbristol.nhs.uk

Acute soft tissue injuries

Title: Skeletal muscle atrogene expression and insulin resistance in a rat model of polytrauma. Citation: Physiological reports, Feb 2016, vol. 4, no. 2, 2051-817X (February 2016) Author(s): Akscyn, Robert M, Franklin, John L, Gavrikova, Tatyana A, Messina, Joseph L Abstract: Polytrauma is a combination of injuries to more than one body part or organ system. Polytrauma is common in warfare, and in automobile and industrial accidents. The combination of injuries can include burn, fracture, hemorrhage, and trauma to the extremities or specific organ systems. Resistance to anabolic hormones, loss of muscle mass, and metabolic dysfunction can occur following injury. To investigate the effects of combined injuries, we have developed a highly reproducible rodent model of polytrauma. This model combines burn injury, soft tissue trauma, and penetrating injury to the gastrointestinal (GI) tract. Adult, male Sprague-Dawley rats were anesthetized with pentobarbital and subjected to a 15-20% total body surface area scald burn, or laparotomy and a single puncture of the cecum with a G30 needle, or the combination of both injuries (polytrauma). In the current studies, the inflammatory response to polytrauma was examined in skeletal muscle. Changes in skeletal muscle mRNA levels of the proinflammatory cytokines TNF-α, IL-1β, and IL-6 were observed following single injuries and polytrauma. Increased expression of the E3 ubiquitin ligases Atrogin-1/FBX032 and TRIM63/MuRF-1 were measured following injury, as was skeletal muscle insulin resistance, as evidenced by decreased insulin-inducible insulin receptor (IR) and AKT/PKB (Protein Kinase B) phosphorylation. Changes in the abundance of IR and insulin receptor substrate-1 (IRS-1) were observed at the protein and mRNA levels. Additionally, increased TRIB3 mRNA levels were observed 24 h following polytrauma, the same time when insulin resistance was observed. This may suggest a role for TRIB3 in the development of acute insulin resistance following injury. © 2016 The Authors. Physiological

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Reports published by Wiley Periodicals, Inc. on behalf of the American Physiological Society and The Physiological Society.

Title: Experiences with the flow-through radial forearm flap as a bridge in lower extremity reconstruction. Citation: Microsurgery, Feb 2016, vol. 36, no. 2, p. 128-133, 1098-2752 (February 2016) Author(s): Ozkan, Omer, Ozkan, Ozlenen, Bektas, Gamze, Cinpolat, Ani Abstract: Various techniques have been proposed in order to overcome recipient vessel problems in microsurgery. In cases with no suitable recipient vessels close to the defect, the flow-through flap is a valuable and reliable alternative for accessing healthy recipient vessels in a single stage. We describe our experiences with combined flaps and discuss the advantages of the flow-through radial forearm flap as a bridge. Between 2003 and 2009, eight combined flaps were used to reconstruct soft-tissue defects of lower extremities. Seven patients had acute or subacute wound with exposed bone and vascular injury caused by trauma, one had a chronic nonhealing wound. The flow-through radial forearm flap was used as a bridge flap with combined a cover flap in all cases. Radial forearm flaps provided recipient vessel lengthening. In one patient, the distal ALT flap failed and replaced with latissimus dorsi flap. Other postoperative courses were uneventful and all of flaps survived. In one patient although the flaps were healthy, sepsis developed and the extremity was amputated. Recovery and ambulation were achieved in the remaining patients. Combined flaps with the flow-through radial forearm flap are an appropriate technique for overcoming recipient vessel problems. Although the technique involves a more complicated procedure and increases the number of microvascular anastomoses, it is a valuable, safe and comfortable alternative in selected cases.

Title: Management of the Morel-Lavallée Lesion. Citation: The Orthopedic clinics of North America, Jan 2016, vol. 47, no. 1, p. 115-125, Author(s): Greenhill, Dustin, Haydel, Christopher, Rehman, Saqib Abstract: Morel-Lavallée lesions are closed degloving injuries sustained during violent soft tissue shear that separate the subdermal fat from its strong underlying fascia. Lesions most often occur in the peritrochanteric region, and patients may have concomitant polytrauma. As a result, a hematoma develops that has a high rate of acute bacterial colonization and chronic recurrence. Conservative treatment outcomes are best for those managed acutely. However, diagnosis is often delayed or missed. Furthermore, there is no universally accepted treatment algorithm. Diagnosis and treatment depend on a surgeon's thorough understanding of the cause, pathophysiology, imaging characteristics, and treatment options of Morel-Lavallée lesions.

Title: An unusual cause of limp Citation: International Emergency Nursing, Jan 2016, vol. 24, no. 1, p. 71-73, 1755-599X

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Author(s): Bethel, James Abstract: Highlights - Acute patella tendon rupture is rare. - Acute patella tendon rupture is easily misdiagnosed. - Patients may suffer serious adverse consequence of delayed or missed diagnosis. - The emergency practitioner should be circumspect in the assessment of knee trauma. [...] A 38-year-old male re-presented to the ED five days after being discharged with a diagnosis of soft tissue injury to the left knee. Re-attendance was prompted by increased inability to weightbear and loss of joint function. The patient limped into the department and was asked to lie supine for examination. Even a cursory visual examination revealed marked infra-patellar swelling with a loss of contour and definition to this aspect of the joint. Pain was not a significant part of the presentation being scored at 2/10 at worst. The patient was an otherwise active adult who had become frustrated by his inability to indulge in any sort of sporting activity since discharge. After visiting the gym that morning he had been advised by one of the staff to re-attend as there was a possibility that he may have a more significant injury than previously diagnosed. 21 references

Title: Diclofenac patch for the treatment of acute pain caused by soft tissue injuries of limbs: a randomized, placebo-controlled clinical trial. Citation: The Journal of sports medicine and physical fitness, Jan 2016, vol. 56, no. 1-2, p. 92-99 Author(s): Predel, Hans G, Pabst, Helmut, Schäfer, Axel, Voss, Diedrich, Giordan, Nicola Abstract: This study aimed to assess the efficacy and the safety of a newly-developed patch containing diclofenac sodium 140 mg in patients affected by acute soft tissue sport injuries, such as contusion, strain and sprain with a randomised, double-blind, placebo-controlled trial. One hundred and sixty-four subjects were recruited within 3 hours of a soft-tissue sport injury and were equally assigned to receive diclofenac or placebo patch applied twice a day for 7 days. The primary study endpoint was reduction in severity of pain on movement from baseline to 48 hours measured by Visual Analogue Scale. Secondary outcomes were reduction of pain on movement and at rest, reduction of pain on pressure, time to efficacy onset, global efficacy assessment and use of rescue analgesics. The reduction of pain on movement from baseline to day 2 was markedly greater in the diclofenac group compared with placebo (treatment effect: -24.25 mm, P<0.001 between groups). Statistically significant improvements were also observed in the diclofenac group compared to placebo for the secondary variables of pain on movement and at rest, pain on pressure, time to efficacy onset and global patient and investigator efficacy assessment. Local adverse reactions at the application site were reported in comparable rates in the two groups. The diclofenac patch could be a safe and effective alternative to the oral administration of non-steroidal anti-inflammatory drugs in the treatment of minor sport injuries.

Title: Magnetic hydroxyapatite nanoworms for magnetic resonance diagnosis of acute hepatic injury. Citation: Nanoscale, Jan 2016, vol. 8, no. 3, p. 1684-1690, 2040-3372 (January 7, 2016)

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Author(s): Xu, Yun-Jun, Dong, Liang, Lu, Yang, Zhang, Le-Cheng, An, Duo, Gao, Huai-Ling, Yang, Dong-Mei, Hu, Wen, Sui, Cong, Xu, Wei-Ping, Yu, Shu-Hong Abstract: Inorganic non-metallic biomaterials, including the silicon frustule of a unicellular diatom, the carbonate shell of a mollusk and the calcium skeleton of the vertebrate, which are the main constituent part of an organism, serve as the supportive and protective components of soft tissue. Among them, hydroxyapatite, which primarily makes up the enamel and bone, is widely used in tissue engineering. Recently, the inorganic nonmetallic biomaterials, especially the applications of hydroxyapatites have attracted great attention. Herein, we report a novel synthesis method of magnetic functionalized hydroxyapatite nanocomposites. By simply tuning the ratios of reactants, a series of hydroxyapatite-Fe3O4 worm-shaped nanocomposites (HAP-ION nanoworms) are obtained. In addition, layer-by-layer surface modifications with chitosan (CH) and sodium alginate (SA) were employed to improve the solubility and biocompatibility, and low cytotoxicity and no hemolysis were observed. With the increase of iron oxide nanocrystals, the magnetic properties of the magnetic assembled nanoworms were enhanced, which resulted in better performance of magnetic resonance (MR) imaging. Owing to the intravenous injection of HAP-ION nanoworms, the contrast to noise ratio (CNR) of hepatic MR imaging in vivo was enhanced obviously, which should be beneficial for hepatic injury grading and further therapeutic treatment.

Title: Referral outcomes of attendances at general practitioner led urgent care centres in London, England: retrospective analysis of hospital administrative data. Citation: Emergency medicine journal : EMJ, Mar 2016, vol. 33, no. 3, p. 200-207 Author(s): Cowling, Thomas E, Ramzan, Farzan, Ladbrooke, Tim, Millington, Hugh, Majeed, Azeem, Gnani, Shamini Abstract: To identify patient and attendance characteristics that are associated with onwards referral to co-located emergency departments (EDs) or other hospital specialty departments from general practitioner (GP) led urgent care centres (UCCs) in northwest London, England. We conducted a retrospective analysis of administrative data recorded in the UCCs at Charing Cross and Hammersmith Hospitals, in northwest London, from October 2009 to December 2012. Attendances made by adults resident in England were included. Logistic regression was used to model the associations between the explanatory variables-age; sex; ethnicity; socioeconomic status; area of residence; distance to UCC; GP registration; time, day, quarter, year; and UCC of attendance-and the outcome of onwards referral to the co-located EDs or other hospital specialty departments. Of 243 042 included attendances, 74.1% were managed solely within the UCCs without same day referral to the EDs (16.8%) or other hospital specialty departments (5.7%), or deferred referral to a fracture, hand management or soft tissue injury management clinic (3.3%). The adjusted odds of onwards referral was estimated to increase by 19% (OR 1.19, 95% CI 1.18 to 1.19) for a 10 year increase in a patient's age. Men, patients registered with a GP and residents of less socioeconomically deprived areas were also more likely to be referred onwards from the UCCs. The majority of patients, across each category of all explanatory variables, were

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managed solely within the UCCs, although a large absolute number of patients were referred onwards each year. Several characteristics of patients and their attendances were associated with the outcome variable.

Title: Spontaneous Iliopsoas Tendon Tear: A Rare Cause of Hip Pain in the Elderly. Citation: Geriatric orthopaedic surgery & rehabilitation, Mar 2016, vol. 7, no. 1, p. 30-32 Author(s): Rubio, Manolo, Rodriguez, Mary, Patnaik, Soumya, Wang, Peter Abstract: Hip pain is one of the most common reasons for the elderly to present to the emergency department, and the differential diagnosis spectrum is vast. Iliopsoas injury is a relatively uncommon condition that may present with hip or groin pain. It is usually seen in athletes due to trauma, particularly flexion injuries. However, spontaneous iliopsoas tendon tear is extremely rare, and only a small number of cases have been reported; it has an estimated prevalence of 0.66% in individuals from 7 to 95 years. Risk factors include aging, use of steroids, and chronic diseases. Magnetic resonance imaging (MRI) using its high soft-tissue contrast resolution remains the most valuable imaging modality. A prompt diagnosis and treatment, which is usually conservative, is important to improve the quality of life in this group of patients. We describe a case of spontaneous iliopsoas tendon tear in an elderly woman.

Title: A Case of Simultaneous Traumatic Dorsal Dislocation of All Five Metatarsophalangeal Joints Treated Successfully With Closed Reduction. Citation: The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons, Mar 2016, vol. 55, no. 2, p. 423-426, Author(s): Bhide, Pushkar P, Anantharaman, Chinnadurai, Mohan, Ganesan, Abstract: Simultaneous dislocation of multiple metatarsophalangeal joints is a rare injury, because of the impediment presented by the anatomy of the lesser metatarsophalangeal joints. To the best of our knowledge, only 1 case of simultaneous dislocation of all 5 metatarsophalangeal joints has been previously reported in peer-reviewed studies. Owing to the same anatomic structures that obstruct relocation, closed reduction has been known to fail in a large proportion of cases. We report a case of simultaneous dorsal dislocation of all 5 metatarsophalangeal joints of the right foot after a motor vehicle accident. The highlight of our case was successful closed reduction after application of the reduction maneuver to all lesser metatarsophalangeal joints simultaneously in the second attempt with the patient under anesthesia. On confirming the stability of the reduction, the foot was immobilized in a short-leg, posterior slab cast for 3 weeks without placing Kirschner wires across the joints. At the 3-month follow-up evaluation, the patient had reacquired their preinjury level of activity with a good range of motion . At the 2-year follow-up evaluation, this range of motion was maintained with no radiologic evidence of arthrosis. We have inferred that the reduction was successful the second time because the maneuver freed the soft tissue structures from the contiguous impingement in the metatarsophalangeal joints by the exact reversal of the mode of injury using simultaneous application of the maneuver

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to all the lesser metatarsophalangeal joints. We encourage a trial of this modification of the closed reduction method in the emergency setting before proceeding to open reduction, because the results of closed reduction can be biologically rewarding without the risks associated with open surgical dissection

Title: Actions to improve documented pain assessment in adult patients with injury to the upper extremities at the Emergency Department - A cross-sectional study. Citation: International emergency nursing, Mar 2016, vol. 25, p. 3-6 Author(s): Sturesson, L, Lindström, V, Castrén, M, Niemi-Murola, L, Falk, A-C Abstract: Pain is one of the most common symptoms in the Emergency Department (ED) and is the cause of more than half of the visits to the ED. Several attempts to improve pain management have been done by using, for example, standards/guidelines and education. To our knowledge no one has investigated if and how different actions over a longitudinal period affect the frequency of pain documentation in the ED. Therefore the aim of this study was to describe the frequency of documented pain assessments in the ED. A cross-sectional study during 2006-2012 was conducted. The care of patients with wrist/arm fractures or soft tissue injuries on upper extremities was evaluated. Despite various actions our result shows that mandatory pain assessment in the patient's computerized medical record was the only successful intervention to improve the frequencies of documentation of pain assessment during care in the ED. During the study period, no documentation of reassessment of pain was found despite the fact that all patients received pain medication. To succeed in increasing the frequency of documented pain assessment, mandatory pain rating is a successful action. However, the re-evaluation of documented pain assessment was nonexisting. Copyright © 2016 Elsevier Ltd. All rights reserved.

Title: Use of giant-sized flow-through venous flap for simultaneous reconstruction of dual or multiple major arteries in salvage therapy for complex upper limb traumatic injury. Citation: Injury, Feb 2016, vol. 47, no. 2, p. 364-371 Author(s): Zheng, Da-Wei, Li, Zhang-Can, Shi, Rong-Jian, Sun, Feng, Xu, Li, Shou, Kui-Shui Abstract: Salvage repair after complex upper limb traumatic injury is surgically challenging due to underlying major arterial impairment with complicating a large-sized soft tissue defect. The purpose of this study was to evaluate the effectiveness and safety of using a giant-sized (≥100 cm(2)) flow-through venous flap for reconstruction of dual or multiple forearm, metacarpal, or digital arteries after complex upper limb traumatic injury. Seven patients were consecutively hospitalized for emergency salvage repair after complex upper limb traumatic injury between March 2012 and May 2014. The forearm and palmar artery defects were repaired using the calf great saphenous vein flap and the volar forearm venous flap, respectively. The flow-through venous flap ranged from 9.5cm×12.0cm to 12.0cm×20.0cm (mean, 158.4 cm(2)) in size. The flaps and affected limbs survived uneventfully in five patients, with one patient experiencing distal flap marginal necrosis and a second patient requiring amputation of the affected limb. Computed tomography

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angiography showed patent vessels in all patients. The mean total active motion of the repaired fingers was 199.5° versus 258.8° for the contralateral counterpart (77.1%). The sensory return was determined to be S2 in 2 patients, S3 in 3 patients and S3+ in 1 patient. The disability scores for the arm, shoulder, and hand ranged from 4.6-18.2 (mean, 11.3), and the mean Michigan hand outcomes questionnaire score was 7.8±0.9. The flow-through venous flap is an effective and safe treatment alternative for salvage therapy of a ≥100-cm(2) complex upper limb traumatic injury with dual or multiple major arterial impairment. This technique allows simultaneous reconstruction of dual or multiple artery injuries and an extensive soft tissue defect. Serious surgical site infection remains a major safety concern and necessitates radical debridement in complicating cases.

Title: Identification of Peroneal Tenosynovitis by Point-of-Care Ultrasonography. Citation: The Journal of emergency medicine, Feb 2016, vol. 50, no. 2, p. e79. Author(s): Shewmaker, Diana M, Guderjahn, Ole, Kummer, Tobias Abstract: Ankle pain is a frequent chief complaint, and although peroneal tendon disorders are relatively uncommon, if treated inappropriately they may cause persistent pain and dysfunction. Peroneal tendon disorders, including the tendon sheath inflammatory condition tenosynovitis, are a major cause of chronic lateral ankle pain. Although magnetic resonance imaging has emerged as the modality of choice to assess the majority of these injuries, dynamic ultrasonography detects tendon pathology such as tenosynovitis. A 69-year-old woman presented to the Emergency Department (ED) after several months of atraumatic, progressive right foot and ankle pain. On physical examination, she had swelling and point tenderness posterior and inferior to the lateral malleolus, which was exacerbated by eversion. Plain radiography of the foot and ankle showed only soft tissue swelling. Bedside ultrasonography performed by the emergency physician quickly identified findings consistent with peroneal tenosynovitis without tears. Management with a walking boot and nonsteroidal antiinflammatory drugs was initiated prior to discharge. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In this case of peroneal tenosynovitis, point-of-care ultrasonography was used to promptly and accurately identify hyperemia, synovial thickening, and a marked effusion within the right peroneal tendon sheath. Nonoperative treatment of tenosynovitis was initiated in the ED while findings were subsequently confirmed with magnetic resonance imaging. Emergency physicians should be aware of the utility of identifying tenosynovitis by point-of-care ultrasonography, which can expedite nonoperative management and prevent long-term complications.

Title: A cause of severe thigh injury: Battery explosion. Citation: Annals of medicine and surgery (2012), Feb 2016, vol. 5, p. 49-51 Author(s): Görgülü, Tahsin, Torun, Merve, Olgun, Abdulkerim Abstract: In parallel with technological improvements, humankind encounter with equipments/devices transforming chemical energy to electrical energy. Especially automobile batteries, watch and mobile phone batteries are the most encountered ones. In

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the literature, there are mainly facial burn cases due to mobile phone battery explosion. On the other hand very few examples of serious lower limb. injury is present. 12-year-old female patient referred to emergency room with skin and soft tissue injuries on bilateral anteromedial thigh area as a result of battery explosion. The widest axis of skin defect was approximately 16 × 8 cm on the right side, and 17 × 4 cm on the left side. In addition, there were tattooing caused by chemical injury and multiple pin-point like lesions extending to dermal level on anterior region of thigh. Chemically dirty and necrotized dermal and subdermal tissues were debrided and foreign materials were removed from regions with multiple tattooing. Left thigh was closed primarily. In order to close the defect on right anterior thigh, skin flap from right medial thigh is advanced in Y-V fashion. Battery explosion causing lower extremity tissue defect is a type of injury that is rarely seen in the literature. Regardless of battery size and energy level, they should be considered as potential explosive material and protector masks, clothing should be worn during contact with this type of material.

Musculoskeletal Title: Comparison of skin pressure measurements with the use of pelvic circumferential compression devices on pelvic ring injuries. Citation: Injury, Mar 2016, vol. 47, no. 3, p. 717-720 Author(s): Prasarn, Mark L, Horodyski, MaryBeth, Schneider, Prism S, Pernik, Mark N, Gary, Josh L, Rechtine, Glenn R Abstract: Pelvic circumferential compression devices are commonly used in the acute treatment of pelvic fractures for reduction of pelvic volume and initial stabilisation of the pelvic ring. There have been reports of catastrophic soft-tissue breakdown with their use. The aim of the current investigation was to determine whether various pelvic circumferential compression devices exert different amounts of pressure on the skin when applied with the force necessary to reduce the injury. The study hypothesis was that the device with the greatest surface area would have the lowest pressures on the soft-tissue. Rotationally unstable pelvic injuries (OTA type 61-B) were surgically created in five fresh, whole human cadavers. The amount of displacement at the pubic symphysis was measured using a Fastrak, three-dimensional, electromagnetic motion analysis device (Polhemus Inc., Colchester, VT). The T-POD, Pelvic Binder, Sam Sling, and circumferential sheet were applied in random order for testing. The devices were applied with enough force to obtain a reduction of less than 10mm of diastasis at the pubic symphysis. Pressure measurements, force required, and contact surface area were recorded with a Tekscan pressure mapping system. The mean skin pressures observed ranged from 23 to 31kPa (173 to 233mm of Hg). The highest pressures were observed with the Sam Sling, but no statistically significant skin pressure differences were observed with any of the four devices (p>0.05). The Sam Sling also had the least mean contact area (590cm(2)). In greater than 70% of the trials, including all four devices tested, skin pressures exceeded what has been shown to be pressure high enough to cause skin breakdown (9.3kPa or 70mm of Hg). Application of commercially available pelvic binders as well as circumferential sheeting commonly results in mean skin

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pressures that are considered to be above the threshold for skin breakdown. We therefore recommend that these devices only be used acutely, and definitive fixation or external fixation should be performed early as patient physiology allows. There may be some advantage of use of a simple sheet given its low cost, versatility, and ability to alter contact surface area.

Title: Accuracy of magnetic resonance imaging in predicting the intraoperative tear characteristics of pectoralis major ruptures. Citation: Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.], Mar 2016, vol. 25, no. 3, p. 463-468 Author(s): Chang, Edward S, Zou, Jiyao, Costello, Joanna M, Lin, Albert Abstract: Magnetic resonance imaging (MRI) is the preferred study of choice for pectoralis major ruptures. Because this is a rare injury, no large case series have evaluated the efficacy of MRI for diagnosing and characterizing pectoralis major ruptures. We hypothesized that MRI would be accurate for diagnosis of the location and grade of pectoralis major tears. The study included 36 operative cases of pectoralis major ruptures with detailed descriptions of tear location and grade and satisfactory preoperative MRIs. Two musculoskeletal fellowship-trained radiologists interpreted the MRIs, which were then compared with the operative findings for location: tendon-bone junction or myotendinous junction, and tear grade (G): G2 (incomplete high grade partial tear) or G3 (complete tear). The sensitivity, specificity, positive predictive value, and negative predictive value were calculated. The MRI sensitivity was 1.00 for diagnosing complete G3 tears at the sternal head and clavicular head in acute ruptures. The sensitivity of MRI for diagnosing tendon-bone tears at the sternal and clavicular heads was 0.93 and 0.90, respectively. The sensitivity of MRI in diagnosing myotendinous and G2 tears diminishes, but specificity and negative predictive value remain high for sternal and clavicular head ruptures. Our data support the use of MRI in diagnosing the tear grade and location of pectoralis major tendon ruptures, particularly for acute, tendon-bone, and G3 tears. The diagnostic accuracy of MRI decreases when chronic tears are evaluated. MRI remains a useful adjunct in diagnosing and guiding treatment of pectoralis major ruptures.

Title: The effect of annular repair on the failure strength of the porcine lumbar disc after needle puncture and punch injury. Citation: European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, Mar 2016, vol. 25, no. 3, p. 906-912, Author(s): Yang, Chih-Hong, Chiang, Yueh-Feng, Chen, Chia-Hsien, Wu, Lien-Chen, Liao, Chun-Jen, Chiang, Chang-Jung Abstract: The purpose was to quantify the structural integrity of annulus fibrosis (AF) after injuries with repair. Punctures in the AF of 6-month-old porcine spine specimens were made with 18-, 20-, 22-, 24-, and 26-gauge needles. Leakage testing was performed immediately

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after needle puncture (Group 1), after the puncture was repaired with a modified purse-string suture (MPSS) (Group 2), and after needle puncture with immediate repair (Group 3). Punch injuries repaired with the MPSS alone, or with an AF graft and MPSS were also examined. There was no leakage from 26-gauge needle punctures. Pressures at which the nucleus pulposus leaked from the 24-, 22-, 20- and 18-gauge needle punctures (Group 1) were 4.28, 2.03, 1.27, and 1.06 MPa, respectively. Failure pressure after repair (Group 2, 3) was significantly greater than without (Group 1). Failure pressure in Group 3 was much greater than in Group 2 with 18- and 20-gauge punctures. Punch injury repaired with a graft and MPSS had significantly greater failure pressure than repair with MPSS alone (1.88 vs. 1.02 MPa, p = 0.0001). The MPSS can restore the mechanical integrity of the AF after needle puncture. An annular graft along with a MPSS may increase the structural integrity of the AF after a punch injury. As this was an acute animal study, the measurements and results may not directly translate to the human intervertebral disc.

Title: Concussion Increases Odds of Sustaining a Lower Extremity Musculoskeletal Injury After Return to Play Among Collegiate Athletes. Citation: The American journal of sports medicine, Mar 2016, vol. 44, no. 3, p. 742-747, Author(s): Brooks, M Alison, Peterson, Kaitlin, Biese, Kevin, Sanfilippo, Jennifer, Heiderscheit, Bryan C, Bell, David R Abstract: Previous studies have identified abnormalities in brain and motor functioning after concussion that persist well beyond observed clinical recovery. Recent work suggests subtle deficits in neurocognition may impair neuromuscular control and thus potentially increase risk of lower extremity musculoskeletal injury after concussion. To determine the odds of sustaining an acute lower extremity musculoskeletal injury during the 90-day period after return to play from concussion in a cohort of National Collegiate Athletic Association (NCAA) Division I collegiate athletes. Cohort study; Level of evidence, 3. Included in this study were 87 cases of concussion among 75 athletes (58 men; 17 women) participating in NCAA Division I football, soccer, hockey, softball, basketball, wrestling, or volleyball at a single institution from 2011 to 2014. The 90-day period after return to play for each case of concussion was reviewed for acute noncontact lower extremity musculoskeletal injury. Each 90-day period after return to play was matched to the same 90-day period in up to 3 controls. Control athletes without a history of concussion in the previous year were matched to concussed athletes by sport team/sex, games played, and position. A total of 182 control (136 men; 46 women) 90-day periods were reviewed for acute injury. Conditional logistic regression was used to assess the association between concussion and subsequent risk of acute lower extremity musculoskeletal injury. The incidence of acute lower extremity musculoskeletal injury was higher among recently concussed athletes (15/87; 17%) compared with matched controls (17/182; 9%). The odds of sustaining an acute lower extremity musculoskeletal injury during the 90-day period after return to play were 2.48 times higher in concussed athletes than controls during the same 90-day period (odds ratio, 2.48; 95% CI, 1.04-5.91; P = .04). Concussed athletes have increased odds of sustaining an acute lower extremity musculoskeletal injury after return to play than their nonconcussed teammates. The study results suggest further investigation of neurocognitive

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and motor control deficits may be warranted beyond the acute injury phase to decrease risk for subsequent injury

Title: Association Between Serum 25(OH)D Level and Nonspecific Musculoskeletal Pain in Acute Rehabilitation Unit Patients. Citation: JPEN. Journal of parenteral and enteral nutrition, Mar 2016, vol. 40, no. 3, p. 367-373, Author(s): Matossian-Motley, Debbie L, Drake, Diane A, Samimi, John S, Camargo, Carlos A, Quraishi, Sadeq A Abstract: Nonspecific musculoskeletal pain can be difficult to manage in acute rehabilitation unit (ARU) patients. We investigated whether vitamin D status is a potential modifiable risk factor for nonspecific musculoskeletal pain in ARU patients. This cross-sectional study focused on 414 adults from an inpatient ARU in Mission Viejo, California, between July 2011 and June 2012. On ARU admission, all patients had serum 25-hydroxyvitamin D (25(OH)D) levels measured and were assessed for nonspecific musculoskeletal pain. We performed multivariable logistic regression to test the association of serum 25(OH)D level with nonspecific musculoskeletal pain while adjusting for clinically relevant covariates. Among these 414 patients, mean (SD) 25(OH)D level was 29 (12) ng/mL, and 30% had nonspecific musculoskeletal pain. After adjustment for age, sex, race, body mass index, Functional Independence Measure score, Deyo-Charlson Comorbidity Index, fractures, steroid use, history of osteoporosis/osteomalacia, and patient type (orthopedic, cardiac, neurological, spinal cord injury, or traumatic brain injury), serum 25(OH)D level was inversely associated with nonspecific musculoskeletal pain (odds ratio [OR] per 10 ng/mL, 0.67; 95% confidence interval [CI], 0.48-0.82). When 25(OH)D level was dichotomized, patients with levels <20 ng/mL had higher odds of nonspecific musculoskeletal pain (OR, 2.33; 95% CI, 1.23-4.17) compared with patients with levels ≥20 ng/mL. In adult patients, serum 25(OH)D level on admission to ARU was inversely associated with nonspecific musculoskeletal pain. These data support the need for randomized, controlled trials to test the role of vitamin D supplementation to improve nonspecific musculoskeletal pain in ARU patients.

Title: Time to return to full training is delayed and recurrence rate is higher in intratendinous ('c') acute hamstring injury in elite track and field athletes: clinical application of the British Athletics Muscle Injury Classification. Citation: British journal of sports medicine, Mar 2016, vol. 50, no. 5, p. 305-310, Author(s): Pollock, Noel, Patel, Anish, Chakraverty, Julian, Suokas, Anu, James, Stephen L J, Abstract: The British Athletics Muscle Injury Classification describes acute muscle injuries and their anatomical site within muscle based on MRI parameters of injury extent. It grades injuries from 0 to 4 and classifies location based on a myofascial (a), musculotendinous (b) or intratendinous (c) description. This is a retrospective cohort study that assessed time to return to full training (TRFT) and injury recurrence in the different British Athletics classifications for hamstring injuries sustained by elite track and field (T&F) athletes over a

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4-year period. The electronic medical records (EMRs) of 230 elite British T&F athletes were reviewed. Athletes who sustained an acute hamstring injury, with MRI investigation within 7 days of injury, were included. MRI were graded by two musculoskeletal radiologists using the British Athletics Muscle Injury Classification. The EMRs were reviewed by 2 sports physicians, blinded to the new classification; TRFT and injury recurrence were recorded. There were 65 hamstring injuries in 44 athletes (24±4.4 years; 28 male, 16 female). TRFT differed among grades (p<0.001). Grade 3 injuries and 'c' injuries took significantly longer and grade 0 injuries took less TRFT. There were 12 re-injuries; the injury recurrence rate was significantly higher in intratendinous (c) injuries (p<0.001). There was no difference in re-injury rate between number grades 1-3, hamstring muscle affected, location (proximal vs central vs distal), age or sex. This study describes the clinical application of the British Athletics Muscle Injury Classification. Different categories of hamstring injuries had different TRFT and recurrence rate. Hamstring injuries that extend into the tendon ('c') are more prone to re-injury and delay TRFT. Full Text: Available from Highwire Press in British Journal of Sports Medicine

Title: Deep Vein Thrombosis and Pulmonary Embolism in a Mountain Guide: Awareness, Diagnostic Challenges, and Management Considerations at Altitude. Citation: Wilderness & environmental medicine, Mar 2016, vol. 27, no. 1, p. 100-106 Author(s): Hull, Claire M, Rajendran, Dévan, Fernandez Barnes, Arturo Abstract: High intensity exercise is associated with several potentially thrombogenic risk factors, including dehydration and hemoconcentration, vascular trauma, musculoskeletal injuries, inflammation, long-distance travel, and contraceptive usage. These are well documented in case reports of venous thrombosis in track and field athletes. For mountaineers and those working at high altitude, additional risks exist. However, despite there being a high degree of vigilance for "classic" conditions encountered at altitude (eg, acute mountain sickness, high altitude pulmonary edema, and high altitude cerebral edema), mainstream awareness regarding thrombotic conditions and their complications in mountain athletes is relatively low. This is significant because thromboembolic events (including deep vein thrombosis, pulmonary embolism, and cerebral vascular thrombosis) are not uncommon at altitude. We describe a case of deep vein thrombosis and pulmonary embolism in a male mountain guide and discuss the diagnostic issues encountered by his medical practitioners. Potential risk factors affecting blood circulation (eg, seated car travel and compression of popliteal vein) and blood hypercoagulability (eg, hypoxia, environmental and psychological stressors [avalanche risk, extreme cold]) relevant to the subject of this report and mountain athletes in general are identified. Considerations for mitigating and managing thrombosis in addition to personalized care planning at altitude are discussed. The prevalence of thrombosis in mountain athletes is uncharted, but lowlanders increasingly go to high altitude to trek, ski, or climb. Blood clots can and do occur in physically active people, and thrombosis prevention and recognition will demand heightened awareness among participants, healthcare practitioners, and the altitude sport/leisure industry at large.

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Title: Work-related musculoskeletal disorders among physical therapists: an online survey. Citation: Disability and rehabilitation, Mar 2016, vol. 38, no. 6, p. 552-557 Author(s): Vieira, Edgar R, Svoboda, Stephanie, Belniak, Alexandra, Brunt, Denis, Rose-St Prix, Colleen, Roberts, Lisa, da Costa, Bruno R Abstract: To evaluate the rates and characteristics of musculoskeletal disorders (MSDs) in physical therapists (PTs) according to their specialty and setting. Participants completed an online questionnaire including 15 demographic questions, 7 work-related and 8 injury-related questions for 9 different body parts. Complete responses were obtained from 121 PTs; 96% reported MSD symptoms during the previous 12 months, 64% affecting at least 3 body parts. The body parts with the highest prevalence of symptoms were the low back (66%) and the neck (61%). For PTs specialized in acute care, geriatrics and pediatrics, the body part most commonly affected was the low back, while for PTs specialized in orthopedics and neurology, the body part most commonly affected was the neck. Regarding work settings, the low back was the most commonly affected for PTs working in skilled nursing facilities, outpatient clinics and hospitals, and the neck in PTs working in academic and home health settings. MSDs are common among PTs; the body parts most often affected were the low back and neck. The prevalence and body parts affected varied by practice setting and specialty area. The findings can help informing the design of evidence-based rehabilitation, prevention, training and educational programs. Implications for Rehabilitation Rehabilitation of injured physical therapists needs to address the symptoms of the multiple body parts that are usually affected (e.g. back, wrists and hands). Rehabilitation of injured physical therapists needs to take into consideration their job demands, practice setting and specialty area. The findings can inform the design of rehabilitation, prevention, training and educational programs for physical therapists.

Title: Age- and gender-specific clinical characteristics of acute adult spine fractures in China. Citation: International orthopaedics, Feb 2016, vol. 40, no. 2, p. 347-353 Author(s): Tian, Ye, Zhu, Yanbin, Yin, Bing, Zhang, Fei, Liu, Bo, Chen, Wei, Zhang, Yingze Abstract: The purpose of this study was to investigate the age- and gender-specific clinical characteristics of adult spine fractures in China. A retrospective investigation was performed on consecutive patients with acute spinal fractures in 83 hospitals of 31 provinces in China between January 2010 and December 2011. All adult patients (≥16 years) with spinal column fracture were included, while pathologic, old, and periprosthetic fractures were excluded. Each patient was analysed by reviewing the medical records and initial radiographs. There were 54,533 adult patients with spinal column fractures, accounting for 14.57 % of overall fractures. The medium age was 57 years (range 16-100 years). There were 27,466 male patients with medium age of 49 years and 27,067 females with medium age of 63 years. The male to female ratio was 1.01:1 in study. It was 1.74:1 in patients less than 59 years, and 0.51:1 above 60 years. The most common injury site was L1, which accounted for 33.83 % of cases. In the AO classification, the 53A and 52A groups comprised 85.53 % of all

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fractures. This study demonstrates the age- and gender-specific clinical characteristics of adults spine fractures and reveals a significant relationship among ages, sex, fracture localisation and complexity of spine fractures. Using the age of patients, the likelihood of sustaining adult spine fractures is predictable.

Title: Musculoskeletal overuse injuries and heart rate variability: Is there a link? Citation: Medical hypotheses, Feb 2016, vol. 87, p. 1-7 Author(s): Gisselman, Angela Spontelli, Baxter, G David, Wright, Alexis, Hegedus, Eric, Abstract: Accurate detection and prevention of overuse musculoskeletal injuries is limited by the nature of somatic tissue injury. In the pathogenesis of overuse injuries, it is well recognized that an abnormal inflammatory response occurs within somatic tissue before pain is perceived which can disrupt the normal remodeling process and lead to subsequent degeneration. Current overuse injury prevention methods focused on biomechanical faults or performance standards lack the sensitivity needed to identify the status of tissue injury or repair. Recent evidence has revealed an apparent increase in the prevalence and impact of overuse musculoskeletal injuries in athletics. When compared to acute injuries, overuse injuries have a potentially greater negative impact on athletes' overall health burden. Further, return to sport rehabilitation following overuse injury is complicated by the fact that the absence of pain does not equate to complete physiological healing of the injured tissue. Together, this highlights the need for exercise monitoring and injury prevention methods which incorporate assessment of somatic tissue response to loading. One system primarily involved in the activation of pathways and neuromediators responsible for somatic tissue repair is the autonomic nervous system (ANS). Although not completely understood, emerging research supports the critical importance of peripheral ANS activity in the health and repair of somatic tissue injury. Due to its significant contributions to cardiac function, ANS activity can be measured indirectly with heart rate monitoring. Heart rate variability (HRV) is one index of ANS activity that has been used to investigate the relationship between athletes' physiological response to accumulating training load. Research findings indicated that HRV may provide a reflection of ANS homeostasis, or the body's stress-recovery status. This noninvasive marker of the body's primary driver of recovery has the potential to incorporate important and as yet unmonitored physiological mechanisms involved in overuse injury development. We hypothesize that abnormal somatic tissue response to accumulating microtrauma may modulate ANS activity at the level of HRV. Exploring the link between HRV modulation and somatic tissue injury has the potential to reveal the putative role of ANS homeostasis on overuse musculoskeletal injury development.

Title: Tenogenic differentiation of mesenchymal stem cells and noncoding RNA: From bench to bedside. Citation: Experimental cell research, Feb 2016, vol. 341, no. 2, p. 237-242 Author(s): Lu, Ying-Fei, Chan, Kai-Ming, Li, Gang, Zhang, Jin-Fang

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Abstract: Tendon is a critical unit of musculoskeletal system that connects muscle to bone to control bone movement. More population participate in physical activities, tendon injuries, such as acute tendon rupture and tendinopathy due to overuse, are common causing unbearable pain and disability. However, the process of tendon development and the pathogenesis of tendinopathy are not well defined, limiting the development of clinical therapy for tendon injuries. Studying the tendon differentiation control pathways may help to develop novel therapeutic strategies. This review summarized the novel molecular and cellular events in tendon development and highlighted the clinical application potential of non-coding RNAs and tendon-derived stem cells in gene and cell therapy for tendon injuries, which may bring insights into research and new therapy for tendon disorders.

Title: Accuracy of High-Resolution Ultrasonography in the Detection of Extensor Tendon Lacerations. Citation: Annals of plastic surgery, Feb 2016, vol. 76, no. 2, p. 187-192, Author(s): Dezfuli, Bobby, Taljanovic, Mihra S, Melville, David M, Krupinski, Elizabeth A, Abstract: Lacerations to the extensor mechanism are usually diagnosed clinically. Ultrasound (US) has been a growing diagnostic tool for tendon injuries since the 1990s. To date, there has been no publication establishing the accuracy and reliability of US in the evaluation of extensor mechanism lacerations in the hand. The purpose of this study is to determine the accuracy of US to detect extensor tendon injuries in the hand. Sixteen fingers and 4 thumbs in 4 fresh-frozen and thawed cadaveric hands were used. Sixty-eight 0.5-cm transverse skin lacerations were created. Twenty-seven extensor tendons were sharply transected. The remaining skin lacerations were used as sham dissection controls. One US technologist and one fellowship-trained musculoskeletal radiologist performed real-time dynamic US studies in and out of water bath. A second fellowship trained musculoskeletal radiologist subsequently reviewed the static US images. Dynamic and static US interpretation accuracy was assessed using dissection as "truth." All 27 extensor tendon lacerations and controls were identified correctly with dynamic imaging as either injury models that had a transected extensor tendon or sham controls with intact extensor tendons (sensitivity = 100%, specificity = 100%, positive predictive value = 1.0; all significantly greater than chance). Static imaging had a sensitivity of 85%, specificity of 89%, and accuracy of 88% (all significantly greater than chance). The results of the dynamic real time versus static US imaging were clearly different but did not reach statistical significance. Diagnostic US is a very accurate noninvasive study that can identify extensor mechanism injuries. Clinically suspected cases of acute extensor tendon injury scanned by high-frequency US can aid and/or confirm the diagnosis, with dynamic imaging providing added value compared to static. Ultrasonography, to aid in the diagnosis of extensor mechanism lacerations, can be successfully used in a reliable and accurate manner.

Title: Decreased Knee Joint Loading Associated With Early Knee Osteoarthritis After Anterior Cruciate Ligament Injury. Citation: The American journal of sports medicine, Jan 2016, vol. 44, no. 1, p. 143-151,

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Author(s): Wellsandt, Elizabeth, Gardinier, Emily S, Manal, Kurt, Axe, Michael J, Buchanan, Thomas S, Snyder-Mackler, Lynn Abstract: Anterior cruciate ligament (ACL) injury predisposes individuals to early-onset knee joint osteoarthritis (OA). Abnormal joint loading is apparent after ACL injury and reconstruction. The relationship between altered joint biomechanics and the development of knee OA is unknown. Altered knee joint kinetics and medial compartment contact forces initially after injury and reconstruction are associated with radiographic knee OA 5 years after reconstruction. Case-control study; Level of evidence, 3. Individuals with acute, unilateral ACL injury completed gait analysis before (baseline) and after (posttraining) preoperative rehabilitation and at 6 months, 1 year, and 2 years after reconstruction. Surface electromyographic and knee biomechanical data served as inputs to an electromyographically driven musculoskeletal model to estimate knee joint contact forces. Patients completed radiographic testing 5 years after reconstruction. Differences in knee joint kinetics and contact forces were compared between patients with and those without radiographic knee OA. Patients with OA walked with greater frontal plane interlimb differences than those without OA (nonOA) at baseline (peak knee adduction moment difference: 0.00 ± 0.08 N·m/kg·m [nonOA] vs -0.15 ± 0.09 N·m/kg·m [OA], P = .014; peak knee adduction moment impulse difference: -0.001 ± 0.032 N·m·s/kg·m [nonOA] vs -0.048 ± 0.031 N·m·s/kg·m [OA], P = .042). The involved limb knee adduction moment impulse of the group with osteoarthritis was also lower than that of the group without osteoarthritis at baseline (0.087 ± 0.023 N·m·s/kg·m [nonOA] vs 0.049 ± 0.018 N·m·s/kg·m [OA], P = .023). Significant group differences were absent at posttraining but reemerged 6 months after reconstruction (peak knee adduction moment difference: 0.02 ± 0.04 N·m/kg·m [nonOA] vs -0.06 ± 0.11 N·m/kg·m [OA], P = .043). In addition, the OA group walked with lower peak medial compartment contact forces of the involved limb than did the group without OA at 6 months (2.89 ± 0.52 body weight [nonOA] vs 2.10 ± 0.69 body weight [OA], P = .036). Patients who had radiographic knee OA 5 years after ACL reconstruction walked with lower knee adduction moments and medial compartment joint contact forces than did those patients without OA early after injury and reconstruction

Title: Thoracic dysfunction in whiplash-associated disorders: a systematic review and meta-analysis protocol. Citation: Systematic reviews, Jan 2016, vol. 5, no. 1, p. 26., Author(s): R Heneghan, Nicola, Smith, Richard, Rushton, Alison Abstract: Whiplash-associated disorder (WAD) research has largely focused on the neck, yet symptoms often include other areas. The prevalence of acute thoracic spine pain is reported ~66 %, which is perhaps unsurprising given the mechanism of injury involves a forceful loading/eccentric contraction of posterior thoracic structures such as the trapezius. Many individuals with WAD experience disability and pain beyond normal tissue healing time, termed chronic WAD. With the thoracic spine contributing to neck mobility, and 23 % of individuals complaining of thoracic pain 1 year post injury, it is time to look beyond the neck to fully understand the anatomical dysfunction in WAD. A systematic review protocol has been designed and will be reported in line with Preferred Reporting Items for Systematic

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Reviews and Meta-Analyses Protocols (PRISMA-P). A sensitive topic-based search strategy is planned from inception to the current date. Databases, grey literature and registers will be searched using terms and keywords derived from a scoping search. Two reviewers will independently search information sources, assess studies for inclusion and extract data. A third reviewer will check for accuracy. Data to be extracted include summary data: sample size and characteristics, timescales to reflect disorder state, patient-reported or performance-based measure and findings. Risk of bias within studies will be assessed using the Newcastle-Ottawa Scale. Quantitative meta-analysis approach will be used for homogenous data and where appropriate presented using subgroups. All other results will be presented using narrative summaries. Subgroups will, where possible, be based on patient-reported or performance-based measure of dysfunction and/or stage of condition (acute/sub-acute or chronic). Strength of the overall body of evidence will be assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE). This is the first study to bring together evidence of thoracic dysfunction post whiplash and provide new insights into the scope and nature of thoracic dysfunction in WAD. With current management options being largely focused to a primary neck complaint and many patients going to become chronic in their presentations, this review may stimulate research and clinical interest in a largely under investigated, yet anatomically and kinematically related, spinal region. PROSPERO CRD42015026983 . Full Text: Available from BioMed Central in Systematic Reviews

Title: Bicycle-Related Shoulder Injuries: Etiology and the Need for Protective Gear. Citation: The Israel Medical Association journal : IMAJ, Jan 2016, vol. 18, no. 1, p. 23-26, Author(s): Goldstein, Yariv, Dolkart, Oleg, Kaufman, Ehud, Amar, Eyal, Sharfman, Zachary T, Rath, Ehud, Mozes, Gavriel, Maman, Eran Abstract: The popularity of bicycle riding for recreation, exercise and transportation has grown enormously in recent years, which has led to an increased incidence of bicycle-related injuries. While these injuries involve mainly the musculoskeletal system, data on shoulder-specific injuries incurred while bike riding are lacking. Classifying these shoulder injuries may provide insight and assistance in the creation and implementation of effective protective gear and measures. To investigate the types and mechanisms of shoulder injuries among cyclists. This study retrospectively examined all cyclists who incurred shoulder injuries while riding and were admitted to the emergency department and shoulder clinic between January 2008 and November 2013. The study included 157 subjects with various bicycle-related shoulder injuries treated with either conservative or surgical measures. Eighty-four percent of injuries were caused by a direct blow to the shoulder, 7% by falling on an outstretched hand, 6% were traction injuries, and 3% were due to hyperabduction. Nine different clinical types of injury were observed; the most common injuries were clavicle fractures (32%), followed by acromioclavicular joint dislocations (22%), rotator cuff tears (22%), and humeral fractures (8%). Fifty-one percent of subjects were managed with conservative care and the remaining patients required surgical interventions. Shoulder

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injuries incurred while riding a bicycle span the entire spectrum of shoulder injuries and often result in debilitating conditions. Although the use of helmets is increasing, there is currently no effective protective gear or measures to prevent riders from suffering shoulder injuries.

Title: Musculoskeletal Health Literacy in Patients With Foot and Ankle Injuries: A Cross-Sectional Survey of Comprehension. Citation: Foot & ankle specialist, Feb 2016, vol. 9, no. 1, p. 31-36, Author(s): Rosenbaum, Andrew J, Tartaglione, Jason, Abousayed, Mostafa, Uhl, Richard L, Mulligan, Michael T, Alley, Max, DiPreta, John A Abstract: Approximately 33% of Americans have inadequate health literacy, which is associated with decreased medical knowledge, increased hospitalization and use of emergency care, and worse control of diseases. In this study, the Literacy in Musculoskeletal Problems (LiMP) questionnaire was used to evaluate the prevalence of limited musculoskeletal literacy in patients presenting to the emergency department (ED) with foot and ankle-related complaints, as these individuals may be at increased risk for inferior outcomes. In this cross-sectional study, individuals ≥18 years of age presenting with foot and ankle-related complaints to the ED were invited to participate. Participants completed a demographic survey and the LiMP questionnaire, with scores ≥6 indicative of adequate musculoskeletal literacy. The prevalence of adequate health literacy and the influence of demographic parameters was assessed. P values <.05 were considered significant. The mean LiMP score was 5 ± 2.06. Limited musculoskeletal health literacy was seen in 32% of participants (18/56). Although gender (male), a current or prior employment in a health care field, and having previously seen a physician for a musculoskeletal complaint correlated with higher literacy rates, these values did not reach statistical significance (P > .05). However, Caucasians and those with higher levels of education (equal to or more than college) were significantly more likely to possess adequate literacy (P = .008, P = .04, respectively). Approximately one third of patients presenting to the ED with foot and ankle-related complaints have limited musculoskeletal literacy and may lack the necessary skills required for making informed decisions regarding their care. This is concerning and has tremendous socioeconomic implications, as more than 23 000 people per day require medical care for ankle sprains in the United States, with average treatment costs for this injury in the ED setting estimated at $1498. Identification of those most at risk is thus crucial and will facilitate the development of interventions geared toward those most vulnerable. Prognostic, Level IV study.

Title: A report of three cases and review of the literature on rectal disruption following abdominal seatbelt trauma. Citation: Annals of the Royal College of Surgeons of England, Feb 2016, vol. 98, no. 2, p. 86-90 Author(s): El Kafsi, J, Kraus, R, Guy, R

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Abstract: Seatbelt associated blunt trauma to the rectum is a rare but well recognised injury. The exact mechanism of hollow visceral injury in blunt trauma is unclear. Stress and shear waves generated by abdominal compression may in part account for injury to gas containing structures. A 'seatbelt sign' (linear ecchymosis across the abdomen in the distribution of the lap belt) should raise the suspicion of hollow visceral injuries and can be more severe with disruption of the abdominal wall musculature. Three consecutive cases of rectal injury following blunt abdominal trauma, requiring emergency laparotomy and resection, are described. Lumbar spine injury occurred in one case and in the other two cases, there was injury to the iliac wing of the pelvis; all three cases sustained significant abdominal wall contusion or muscle disruption. Abdominal wall reconstruction and closure posed a particular challenge, requiring a multidisciplinary approach. The literature on this topic is reviewed and potential mechanisms of injury are discussed.

Title: Clinical profile of patients with traumatic cervical spine injury in the emergency department of a tertiary care hospital. Citation: Journal of emergencies, trauma, and shock, Jan 2016, vol. 9, no. 1, p. 43-44, 0974-2700 (2016 Jan-Mar) Author(s): Wills, Shiju Jesudas, Pandian, Gautham Raja, Bhanu, Thomas Kurien, Kumar, Kirthi Sathya, Murugan, Yuvaraja, Abhilash, Kundavaram Paul Prabhakar Source: Medline Full Text: Available from ProQuest in Journal of Emergencies, Trauma and Shock Available from National Library of Medicine in Journal of Emergencies, Trauma, and Shock

Sports Injuries

Title: The training-injury prevention paradox: should athletes be training smarter and harder? Citation: British journal of sports medicine, Mar 2016, vol. 50, no. 5, p. 273-280 Author(s): Gabbett, Tim J Abstract: There is dogma that higher training load causes higher injury rates. However, there is also evidence that training has a protective effect against injury. For example, team sport athletes who performed more than 18 weeks of training before sustaining their initial injuries were at reduced risk of sustaining a subsequent injury, while high chronic workloads have been shown to decrease the risk of injury. Second, across a wide range of sports, well-developed physical qualities are associated with a reduced risk of injury. Clearly, for athletes to develop the physical capacities required to provide a protective effect against injury, they

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must be prepared to train hard. Finally, there is also evidence that under-training may increase injury risk. Collectively, these results emphasise that reductions in workloads may not always be the best approach to protect against injury. This paper describes the 'Training-Injury Prevention Paradox' model; a phenomenon whereby athletes accustomed to high training loads have fewer injuries than athletes training at lower workloads. The Model is based on evidence that non-contact injuries are not caused by training per se, but more likely by an inappropriate training programme. Excessive and rapid increases in training loads are likely responsible for a large proportion of non-contact, soft-tissue injuries. If training load is an important determinant of injury, it must be accurately measured up to twice daily and over periods of weeks and months (a season). This paper outlines ways of monitoring training load ('internal' and 'external' loads) and suggests capturing both recent ('acute') training loads and more medium-term ('chronic') training loads to best capture the player's training burden. I describe the critical variable-acute:chronic workload ratio-as a best practice predictor of training-related injuries. This provides the foundation for interventions to reduce players risk, and thus, time-loss injuries. The appropriately graded prescription of high training loads should improve players' fitness, which in turn may protect against injury, ultimately leading to (1) greater physical outputs and resilience in competition, and (2) a greater proportion of the squad available for selection each week. Full Text: Available from Highwire Press in British Journal of Sports Medicine

Title: Pathological changes in the lumbar intervertebral discs among professional field hockey players. Citation: The Journal of sports medicine and physical fitness, Jan 2016, vol. 56, no. 1-2, p. 85-91 Author(s): Ogurkowska, Małgorzata, Kawałek, Krzysztof Abstract: Acute injuries or chronic overloading can be the cause of lower back pain. Long-term, highly-specialized training can cause the musculoskeletal system to become overloaded. Field hockey is an example of a sport which, due to the players' non-ergonomic positions, can lead to degenerative changes in the lumbar spine. The aim of this study was to evaluate the condition of the lumbar spine among 20 male players of the Polish national team in field hockey, aged between 24 and 35 years of age, and having trained in the discipline of field hockey for a period of between 14 and 26 years. CT scans were used to determine the height of vertebrae and intervertebral discs. The study showed a number of differences in lumbar discs and vertebrae that are typical results of overloading. A significant decrease in disc height was observed, as well as changes in the shape of the vertebrae, which acquired a wedge shape. Analysis of the Relative Height Coefficient showed that these changes are both severe and exacerbated by years of training. This research proves that field hockey as an active sport strongly affects the lumbar section of the spine. As a therapeutic procedure, a special regime including muscle stretching and lumbar spine stabilization exercises should be created for both advanced and beginner players.

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Journal Tables of Contents

The most recent issues of the following journals:

The American Journal of Sports Medicine

British Journal of Sports Medicine

Journal of Acute Medicine

Emergency Medicine Journal

Spine

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papers in full text then get in touch: Library@uhbristol.nhs.uk

The American Journal of Sports Medicine March 2016; 44 (3) http://ajs.sagepub.com/content/44/3.toc

British Journal of Sports Medicine April 2016, Volume 50, Issue 7 http://bjsm.bmj.com/content/current

Journal of Acute Medicine December 2015 Volume 5, Issue 4, http://www.e-jacme.com/current

Emergency Medicine Journal April 2016, Volume 33, Issue 4 http://emj.bmj.com/content/current

Spine March 2016 - Volume 41 - Issue 6 http://journals.lww.com/spinejournal/pages/currenttoc.aspx

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