Part Two

1
Part Two

• Spine
• Shoulder girdle
• Arm Hand
• Head trauma
• Skin disorders
• Pharmacology
• Heat stresses
• Special Topics

2
The Hip Pelvis

• Head of Femur
• Anatomical neck
• Acetabulum
• Acetabular labrum
• ischial tuberosity
• pubic symphysis
• pubic tubercles
• A.S.I.S.
• Greater trochanter

3
The Hip Pelvis

• Coccyx
• Sacroiliac line(s)
• Ischial tuberosities

4
The Hip pelvis

• Anterior view of R. hip.
• Notice winding of the joint capsule, tightens
  with extension of the hip joint.

5
The Hip Joint

• The angle of the neck to the shaft -

Angle coxa valgus
Angle coxa varus
6
The Hip Joint

• The orientation of the neck to the shaft -
  femoral torsion.

Angle anteversion
Angle retroversion
7
The Hip Joint

• The greater Trochanter in abduction will compress
  the superior lip of the acetabular labrum

8
Doing the Splits
Flexion extension splits Notice pelvic
rotation to the extended side.
9
Doing the Splits

• Abduction splits
• Notice external rotation of femurs, moves greater
  trochanter out of the way.

10
Muscles of Thigh

• Anterior View

11
Hip musculature

• Key words
• Gluteus maximus
• Gluteus minimus
• Gluteus medius
• Piriformis
• Sciatic foramen
• hamstrings

12
Hip Injuries

• Hip Pointer
• Sx
• ecchymosis
• Pain w/ abdominal use
• Etiology subperiostial haematoma
• Tx RICE, modalities,
• flourimethane???

13
Pelvic Aches Pains

• Sacroiliac spain
• Coccyx
• Piriformis syndrome
• Greater trochanteric bursitis
• Hip dislocation
• Osteitis pubis/pubic apophysitis

14
Spine

• Regions
• Cervical
• Thoracic
• Lumbar
• Sacral
• Vertebral structure

15
Vertebral Bodies

• Facet orientation
• Pars interarticularis
• Intervertebral disc
• Annulo fibrosis
• Nucleus pulposis
• Spinal foramen
• Vertebral foramen

16
Thoracic vertebral body

• Facet orientation

17
Lumbar vertebral Body

• Facet orientation

18
Intervertebral Disc Normal vs prolapsed/herniated
19
Injuries

• Compression Fx

20
Injuries

• Spondylolysis
• Spondylolysthesis

21
Scoliosis

• S - shaped spine
• Congenital
• functional

22
Scoliosis

• S - shaped spine
• Congenital
• functional

23
Other Injuries

• Stingers
• Unilateral - Mx stretch to brachial plexus
• Bilateral - compression to nerve roots
• Thoracic muscle spasm
• Diaphragm spasm

24
HKIN 361

• No. 3

25
The Shoulder - Anatomy
26
Shoulder Anatomy
27
Stabilization of the Shoulder (Ant.)

• Static
• Corco-acromio lig.
• Coraco-clavicular
• Acromio-clavicular
• sterno-clavicular
• Dynamic
• Biceps (long head)
• Triceps (long head)
• Coracobrachialis
• Pectoralis major m.
• Rotator cuff

28
Stabilization of the Shoulder (post)

• supraspinatus
• infraspinatus
• teres minor
• teres major
• triceps (long head)
• deltoid

29
Rotator Cuff
30
Injuries - throwing tendonitis

• Mx
• Blocked humeral rotation
• Acceleration
• deceleration

31
Injuries - throwing tendonitis

• Prevention
• Strong rotator cuff
• Long follow through
• Gradual warmup stretching program

32
Injuries - dislocation

• Anterior
• Subcoracoid
• Subglenoid
• Posterior

33
Injuries - dislocation

• S x
• extreme pain w/ 1st time
• Obvious loss of shoulder conformation
• Humeral head in the axilla
• Mx
• Direct blow
• Change in shoulder fulcrum
• Tx
• Monitor vital signs distal to the injury
• Transport to emergency

34
Injuries - shoulder dislocation

• Blocked throw

35
Injuries - A - C separation

• Mx
• Scapular retraction
• Scapular depression
• Causes
• Fall on outstretched arm
• Fall on point of the shoulder

36
Injuries - A - C separation

• Grade I
• Sx
• Pain 1-2, swelling 1
• Reduced ROM
• No obvious deformity
• Tx
• R.I.C.E.
• RTA when pain is tolerable

37
Injuries - A - C separation

• Grade II
• Sx
• Pain 2-3
• Obvious lift of clavicle
• Loss of function
• Tx
• R.I.C.E.
• RTA when pain is tolerable

38
Injuries - A - C separation

• Grade III
• Sx
• Loss of strut
• Pain -ve (usually)
• Loss of function
• Tx
• conservative
• surgical

39
Injuries - sternoclavicular separation

• Rides up and out.

40
Injuries - Shoulder impingement

• Subacromial bursitis
• Coracoacromial ligament
• Supraspinitus tendon

41
Injuries - fractures

• Immobilize and transport

42
Elbow - Anatomy

• Radius
• ulna
• Olecranon
• Capitulum
• Trochlea
• Medial epicondyle
• Lateral epicondyle

43
Forearm extensors
44
Forearm flexors
45
Extensor attachment
46
Injuries - epicondylitis

• Medial epicondylitis
• (Little League Elbow)
• Mx traction forces on the apophysis
• Sx pain with resisted wrist flexion
• Tx ICER, sterength flexibility

• Lateral epicondylitis
• (tennis elbow)
• Mx eccentrics during backhand
• Sx pain with resisted extension of middle digit
• Tx ICER, Strength flexibility

47
Injuries - dislocation

• MX hyperextension
• rotation
• Sx shortened arm
• obvious deformity
• Pain
• Tx immobilize transport, ice

48
Injuries - dislocation
49
Injuries - forearm fx.
50
Wrist - anatomy

• Problem areas
• Head of radius
• Scaphoid bone
• Lunate bone
• Tunnel of Guyon

51
Wrist - anatomy

• Intrinsic muscles
• Extrinsic muscles
• Retinacular straps

52
Wrist - anatomy

• Carpel ligament
• Carpel tunnel

53
Wrist - injuries

• Mx hyperextension
• radial deviation
• Sx painful ROM or thumb in opposition
• Tx cast immobilization for 12 weeks, rehab

54
Wrist - injuries

• Surgical treatment for non-union

55
Wrist - injuries - metacarpel fx

• Mx
• Axial load
• Transverse blow
• Sx swelling, pain
• Tx O.R.I.F.

56
finger dislocation

• Mx
• Hyperextension
• Axial load
• Sx deformity, pain
• Tx reduction, splint, I.C.E.

57
Mallet finger

• Mx hyperflexion
• Sx lack of DIP extension
• Tx refer for splinting

58
Swan neck deformity

• Mx progression from mallet finger
• Sx deformity
• Tx refer to Orthopaedic

59
Swan neck deformity
60
Boutinniere deformity

• Mx hyperflexion of PIP jt.
• Sx hyperextension of DIP jt
• Tx refer for splinting

61
Boutinniere deformity
62
Wrist injuries - fractures

• Cause fall on outstretched arm
• Tx immobilize and transport to Emerg.

63
HKIN 361

• Part 4
• Head trauma, Rx, heat stress, skin disorders

64
Head Brain - anatomy

• Meninges
• Vascular supply
• Cerebral Spinal Fluid
• Spinal Cord

65
Head Brain trauma

• Cerebral haemorrhages
• Epidural localized bleeding and clotting
• subdural venous blood drains to the base of the
  brain, depresses the respiration centre.
• Subarachnoid not in athletics

66
Head Trauma

• Coup and Contracoup
• Concussion
• Massive neural inputs jam the reticular
  activating system which shuts the system down,
  resulting in loss of consciousness (LOC).
• Severity of concussion is related to length of
  LOC
• Severe concussion is possible with no LOC

67
Concussion - signs

• Nausea
• Headache
• Dizziness
• Slurred speech
• pupils
• Tinnitus
• Nystagmus
• Retrograde amnesia
• Post traumatic amnesia
• Positive neurologic signs balance, coordination

68
Concussion - grades

• Grade I
• No loss of consciousness
• Dizzy
• Glazed eyes
• No other symptoms
• All symptoms have cleared on recheck at 15
  minutes
• RTA after 15 minutes

69
Concussion - grades

• Grade II
• May be LOC
• Minor signs symptoms persist beyond 15 minutes
• Retrograde amnesia
• No neurologic signs
• Send to MD. RTA with MD clearance (usually 1-2
  weeks)

70
Concussion - grades

• Grade III
• Definite LOC
• Minor signs symptoms persist beyond 15 minutes
• Retrograde amnesia
• Evidence of post traumatic amnesia
• Evidence of neurologic signs
• Transport to Emerg.

71
Head Trauma - on field protocol

• DONT LET THE ATHLETE MOVE
• With LOC, assume C-spine.
• Do sensory testing
• Scratch front and back of shoulder, brachium,
  antebrachium, hand, side of thumb and little
  finger, pelvis, thigh, calf, foot. Test
  bilaterally and ask athlete to respond when
  he/she feels something.
• Do motor testing
• Start distal, work proximal
• No movement of joints
• Only looking for some resistance
• Upper lower body, ilaterally

72
Protocol cont.

• Ask how it happened
• Palpate for fx deformity
• Tell them to remember 3 colours2 objects -
  retest in five minutes.
• Ask the date, Ask them to count backward by 3s
  from thirty
• Check pupil response to light, and tracking
• Check for CSF (skull Fx)
• rhinorrhea
• ottorrhea

73
Protocol cont.

• Ask athlete if they think they can move their
  head. Allow very limited flexion rotation
• Ask them to sit up - support them
• Ask to see a pain free range of motion.
• Help them to stand - continue to support - remove
  from playing surface.
• At sideline, check
• Balance - Rhomberg test -be prepared to catch
• Coordination - finger-to-nose test
• Coordination - hopping on one foot
• RETEST IN 10 MINUTES

74
HEAD TRAUMA - COMPLICATIONS

• Lucid interval
• Subject becomes asymptomatic for minutes-hours.
• Relapses and suffers LOC
• Subdural haemorrhage
• Secondary impact syndrome
• Concussion sensitizes athletes brain to subdural
  haemorrhage with subsequent trauma

75
Lacerations

• To suture or steristrip?
• Suture if
• It has a jagged edge
• It is in hair
• It is irregular in shape
• Bleeding too much
• Steristrip if
• Small w/ straight edge
• You can clean it properly

76
Lacerations

• To suture or steristrip?
• Suture if
• It has a jagged edge
• It is in hair
• It is irregular in shape
• Bleeding too much
• Steristrip if
• Small w/ straight edge
• You can clean it properly

77
Lacerations

• To suture or steristrip?
• Suture if
• It has a jagged edge
• It is in hair
• It is irregular in shape
• Bleeding too much
• Steristrip if
• Small w/ straight edge
• You can clean it properly

78
Jaw fractures - lower mandible
79
Jaw fractures - zygomatic arch
80
Eye trauma - hyphema

• Sx
• Meniscus of blood
• Tx
• refer

81
Eye trauma - corneal abrasion

• Sx
• Gritty feeling under
• Eyelid
• Tx
• Cover rest
• Ophthalmic antibiotic

82
Ear trauma - cauliflower

• MX
• Dermis/epidermis separation
• Sx
• Swelling, redness, sensitive to touch
• Tx
• Take to emerg to get drained, pack for pressure

83
Ear trauma - cauliflower

• MX
• Dermis/epidermis separation
• Sx
• Swelling, redness, sensitive to touch
• Tx
• Take to emerg to get drained, pack for pressure

84
Ear trauma - cauliflower

• MX
• Dermis/epidermis separation
• Sx
• Swelling, redness, sensitive to touch
• Tx
• Take to emerg to get drained, pack for pressure

85
Swimmers ear

• Mx infection by Pseudemonas organisms, or
  surface bacteria
• Sxcanal is sore to touch swollen
• Tx antibiotic cream
• Prevention dry the ear after showering/swimming,
  dont put Q-tips in your ear!!

86
Nosebleeds

• Dont pack the nose with baton or anything else

87
Nosebleeds

• Tx
• Apply direct pressure for 5 - 10 minutes.
• Slowly release the side walls of the nose
• Tilt head to the bleeding side
• Place ice compressover bridge of nose, or back of
  the neck

88
Skin Disorders

• Fungi, viruses, bacteria and mites

89
Skin disorders - Fungus

• BAD NEWS 1 they look horrible
• BAD NEWS 2 they are hard to get rid of
• GOOD NEWS they are easy to get rid of
• They like warm, moist, dark

90
Skin disorders - fungus

• Tinea pedis/cruris
• Sx rash starts between toes spreads
• Tx
• Expose to light
• Keep good air circulation
• Use antifungal Rx for three months

91
Skin disorders - ringworm

• Tinea corporis

92
Skin disorders - nail fungus

• Sx deformed nail, usually darker colour than
  other toes.
• Tx requires oral antifungal agents which have
  significant side effects

93
Skin disorders - viruses

• BAD NEWS Once you have them, they are yours for
  life
• GOOD NEWS they have very limited environmental
  tolerances the immune system can usually keep
  them out of sight they like a healthy host

94
Viruses - warts

• Tx liquid nitrogen

95
Viruses - plantar wart

• Tx salicate plasters until exposed. Quite
  painful. Refer to MD

96
Viruses - herpes simplex type I
97
Viruses - herpes simplex type II
98
Viruses - herpes zoster

• Caused by chicken-pox virus

99
Viruses - molluscum contagiosum

• Highly contagious

100
Viruses - molluscum contagiosum

• Highly contagious

101
Skin disorders - bacterial

• BAD NEWS 1 they dont care whether you are
  healthy or dead
• BAD NEWS 2 they would just as soon kill you as
  look at you
• BAD NEWS 3 they can evolve resistance to drugs
  rapidly

102
Bacterial infections - impetigo
103
Bacterial infections - impetigo
104
Bacterial infections - dermatitis
105
Skin disorders - scabies

• Sx raised papillae, look like a ppimple but
  dont form white head
• Tx cover the entire body (except haired areas)
  with Kwellada lotion. Repeat.

106
Skin disorders

• Tx
• Isolate the athlete from others including all
  clothing he/she may have touched
• Refer immediately
• Ensure the athlete takes THE ENTIRE PRESCRIPTION

107
HKIN 361Unit 5
Unit five

• Pharmacology, Heat stress, Extreme environments,
  nutrition

108
Pharmacology

• Anti-inflammatory medications
• Steroidal Cortizone/Cortisol
• Non-steroidal
• A.S.A.
• N.S.A.I.D. Meds
• Ibuprofen (advil)
• Fenoprofen (Motrin)
• Clinoril
• Sindulac
• Indocin
• Phenylbutazone

109
Acetylsalicylic Acid (A.S.A.)

• Rx Effect
• Anti-inflammatory
• Analgesic
• antipyretic

• Side Effects
• G.- I. Upset
• Peptic ulcers
• Platelet dysfunction

110
N.S.A.I.D. Meds

• Rx Effects
• Anti-inflammatory
• Analgesic
• antipyretic

• Side Effects
• G I upset
• Constipation/diarrhea
• Dry mouth
• tinnitus

111
Phenylbutazone (Bute)

• Rx Effects
• Rapid reduction in swelling inflammation
• VERY strong!! (used for horses)

• Side Effects
• Aplastic anemia
• Agranulocytosis
• Hypersensitivity
• embryotoxicity

112
Pharmacology

• Analgesic Medication
• Narcotic Codeine
• Non-Narcotic
• A.S.A.
• Acetaminophen (Tylenol)
• N.S.A.I.D. Meds

113
Codeine

• Rx Effect
• Very effective
• Fast acting

• Side Effects
• Very addictive
• Dry mouth
• G-I upset

114
Acetaminophen

• Rx Effect
• Analgesic
• antipyretic

• Side Effects
• Decreased G-I upset
• No platelet dysfunction

115
Pharmacology

• Muscle Relaxant Medications
• Sedative hypnotics
• Librium,Valium
• Methocarbamol
• Robaxin

116
Sedative hypnoticsBenzodiazapines

• Rx Effects
• Calming effect
• Mild sedation
• Decreased muscle tonus
• anticonvulsant

• Side Effects
• Habituation/withdrawal
• Increased reaction time

117
Methocarbamol

• Rx Effects
• Decreased muscle tonus
• Decreased alertness

• Side Effects
• Decreased awareness
• Increased reaction time

118
Tx for muscle spasm

• Break the pain spasm cycle with ANALGESICS during
  the DAY.
• Break the pain spasm cycle with MUSCLE RELAXANTS
  at NIGHT

119
Pharmacology

• Other pain-suppressants
• Local Anaesthetics
• Lidocaine
• Xylocaine
• Topical Anaesthetics
• Flourimethane

120
D.M.S.O. (Dimethylsulfoxide)

• Rx Effects
• Decreased swelling
• Decreased inflammation
• Decreased pain

• Side Effects
• Garlic breath
• Changes cell membrane permeability
• Damage to lens in animal studies

121
Caffeine

• Rx Effects
• Peripheral vasodilation
• Cerebral vasoconstriction
• Increased FFA utilize
• CNS stimulant

• Side Effects
• Hydrolytic
• Increased B.P.
• Extrasystole
• Diuretic
• Increased GI tract motility

122
Amphetamines

• Ephedra (Ma Huang, Hydroxycut)
• Benzadrine (bennys)
• Epinephrine
• Norepinephrine
• Increased alertness, decreased drowsiness, sense
  of confidence, decreased fatigue.
• Confusion, poor judgement.

123
Heat Stress

• Hyperthermia
• Heat cramps
• Heat exhaustion
• Heat Stroke
• Hypothermia

124
Hyperthermiaprevention

• Correct apparel
• Keep athletes active to maintain body temp
• Increase food intake
• Abstain from alcohol
• Rehydrate often
• Monitor weather conditions

125
Heat cramps

• Sx
• Severe muscle spasms from dehydration or
  electrolyte loss

• Tx
• Rest, rehydrate with electrolyte drink, gentle
  stretching of muscles

126
Heat Exhaustion

• Sx
• Shock-like symptoms
• Rapid, weak pulse
• Rapid shallow breathing
• Pallor
• Cool clammy skin
• Dizzy or uncoordinated
• Dilated pupils

• Tx
• Rest in cool or shaded area
• Rehydrate with cool water
• Apply ice to neck, femoral area

127
Heat stroke

• Sx
• Extremely hot
• Nausea, irritability,vomiting
• Dry flushed skin
• Pulse rapid and bounding
• Respiration gasping
• Constricted pupils
• LOC, seizures

• Tx
• LIFE THREATENING
• 911
• Force evaporation
• Ice bags in armpits and crotch
• Do not move abruptly!!
• Wait for paramedics

128
Hypothermia
Deg. Celcius symptoms treatment
35.5 37 Intense shivering Rewarm, get out of environment/clothes
33 - 35 Violent jerky movements, speech slurred Warm fluid IN, warm clothing ON
30 32 Muscular rigidity, irrational, amnesia Medical crisis. Rewarm by conduction
lt30 Stuperous, LOC,muscular rigidity, arrhythmias As above. No sudden movements
129
Hypothermia

• Rewarm with warm fluid whenever possible
• Rewarm by conduction if unconscious
• Do not use alcohol to rewarm, even mild
  hypothermia
• Get out of the cold /wet climate

130
Nutrition Fluid replacement

• Substrate proportions
• Protein 10 - 15 (20 for heavy trainers)
• CHO 55 60(55 for heavy trainers)
• FFA 30

131
Nutrition Fluid replacement

• Inadequate intakes
• Iron endurance trainers, women. Eat dark leafy
  greens, raisons, spinach
• Vit.B12 amongst vegetarians (essential)
• Vit.C amongst heavy trainers (tissue repair)
• K losses from sweat

132
How Much??

• SERVINGS/DAY
• Good 6 Grains, preferably whole
• Food 5 Fruit, veggies
• Maximizes 4 Meat, substitute
• Benefits 3 Beans (3 times per week)
• Daily 2 Dairy

133
Sweat Losses

• 1.5l per hour
• 1.0 l per 600 Kcal
• 1.0 l per 6 miles
• Fe 1 2 mg / day with sweat gt 3.0 litre
• K 4 5 mg / day with sweat lt 7 litres
• 500 ml 15 minutes pre-exercise
• 125 150 ml every 15 minutes during

134
Extreme Environments

• Hypobaric.
• Live high, train low
• Increased hemoglobin from increased serum
  erythropoietin, response to hypoxic conditions
• Acclimatization is slow, and best below 3000m.
• Training high causes loss of blood plasma
  decreased performance.

135
Extreme Environments

• Hyperbaric. (pressurized dives)
• No legumes before a dive
• For dives requiring NO decompression, no flights
  within 12 hrs
• For dives requiring decompression, no flights for
  24 hrs.
• Free dives never more than 30 m. (lung damage)

136
Extreme Environments

• Hyperbaric. (free diving)
• Hyperventilation is dangerous
• Blows off carbon dioxide, no change to oxygen
  tension
• Compression causes good oxygen saturation even as
  oxygen is dangerously low
• May blackout, increased CO2 levels force
  inspiration - drowning

137
Jet Lag

• Caused by transmeridian changes
• Traveling east is worse than west
• Circadian rhythm is affected by light/dark cycles
• Acclimatization 1 day per hour change 7 14
  days for changes greater than 5 hours
• Light exercise when arriving
• Use caffeine to help get on destination cycle
• Pre-exposure to zeitgebers using light/dark