Traditionally, sports Injuries have been sub-optimally managed through Emergency Departments (ED) in the public health system due to a lack of adequate referral processes. Fractures are ruled out through plain radiographs followed by a reactive process involving patient initiated further follow up and investigation. Consequently, significant soft tissue and chondral injuries can go undiagnosed during periods in which early intervention can significantly affect natural progression. The purpose of this quality improvement project was to assess the efficacy of an innovative Sports Injury Pathway introduced to detect and treat significant soft tissue injuries. A Sports Injury Pathway was introduced at Fiona Stanley Hospital (WA, Australia) in April 2019 as a collaboration between the ED, Physiotherapy and Orthopaedic Departments. ED practitioners were advised to have a low threshold for referral, especially in the presence of a history of a twisting knee injury, shoulder dislocation or any suggestion of a hip tendon injury. All referrals were triaged by the Perth Sports Surgery Fellow with early follow-up in our Sports Trauma Clinics with additional investigations if required. A detailed database of all referrals was maintained, and relevant data was extracted for analysis over the first 3 years of this pathway. 570 patients were included in the final analysis. 54% of injuries occurred while playing sport, with AFL injuries constituting the most common contact-sports injury (13%). Advanced Scope Physiotherapists were the largest source of referrals (60%). A total of 460 MRI scans were eventually ordered comprising 81% of total referrals. Regarding Knee MRIs, 86% identified a significant structural injury with ACL injuries being the most common (33%) followed by isolated meniscal tears (16%) and multi-ligament knee injuries (11%). 95% of Shoulder MRI scans showed significant pathology. 39% of patients required surgical management, and of these 50% were performed within 3 months from injury. The Fiona Stanley Hospital Sports Injury Pathway has demonstrated its clear value in successfully diagnosing and treating an important cohort of patients who present to our Emergency Department. This low threshold/streamlined referral pathway has found that the vast majority of these patients suffer significant structural injuries that may have been otherwise missed, while providing referring practitioners and patients access to prompt imaging and high-quality Orthopaedic sports trauma services. We recommend the implementation of a similar Sports Injury Pathway at all secondary and tertiary Orthopaedic Centres

In response to the COVID-19 pandemic public health measures were implemented to limit virus spread. After initial implementation of a province-wide lockdown (Stage 1), there followed a sequential ease of restrictions through Stages 2 and 3 over a 6-month period from March to September 2020 (Table 1). We aimed to determine the impact of COVID-19 public health measures on the epidemiology of operative paediatric orthopaedic trauma and to determine differential effects of each stage of lockdown. A retrospective cohort study was performed comparing all emergency department (ED) visits for musculoskeletal trauma and operatively treated orthopaedic trauma cases at a Level-1 paediatric trauma center during Mar-Sep 2020 (pandemic), compared with Mar-Sep 2019 (pre-pandemic). All operative cases were analyzed based on injury severity, mechanism of injury (MOI) and anatomic location (AL). Comparisons between groups were assessed using chi-square testing for categorical variables, and student t-tests and Fisher's exact tests for continuous variables. During the pandemic period, ED visits for orthopaedic trauma decreased compared to pre-pandemic levels by 23% (1370 vs 1790 patients) and operative treatment decreased by 28% (283 vs 391 patients). There was a significant decrease in the number of operative cases per day in lockdown Stage 1 (1.25 pandemic vs 1.90 pre- pandemic; p < 0 .001) and Stage 2 (1.65 pandemic vs 3.03 pre-pandemic; p< 0.001) but no difference in operative case number during Stage 3 (2.18 pandemic vs 2.45 pre-pandemic; p=0.35). Significant differences were found in MOI and AL during Stage 1 (p < 0 .001) and Stage 2 (p < 0 .001) compared to pre-pandemic. During Stage 1 and 2, playground injuries decreased by 95% and 82%, respectively; sports injuries decreased by 79% and 13%, and trampoline injuries decreased 44% and 43%, compared to pre-pandemic. However, self-propelled transit injuries (bicycles/skateboards) increased during Stage 1 and Stage 2 by 67% and 28%, respectively compared to pre- pandemic. During lockdown Stage 3 there were no differences in MOI nor AL. There were no significant differences in injury severity in any lockdown stage compared to pre-pandemic. COVID-19 lockdown measures significantly reduced the burden of operative paediatric orthopaedic trauma. Differences in volume, mechanism and pattern of injuries varied by lockdown stage offering evidence of the burden of operative trauma related to specific childhood activities. These findings will assist health systems planning for future pandemics and suggest that improvements in safety of playgrounds and self-propelled transit are important in reducing severe childhood injury requiring operative intervention. For any figures or tables, please contact the authors directly

Aims. To determine the impact of COVID-19 on orthopaediatric admissions and fracture clinics within a regional integrated care system (ICS). Methods. A retrospective review was performed for all paediatric orthopaedic patients admitted across the region during the recent lockdown period (24 March 2020 to 10 May 2020) and the same period in 2019. Age, sex, mechanism, anatomical region, and treatment modality were compared, as were fracture clinic attendances within the receiving regional major trauma centre (MTC) between the two periods. Results. Paediatric trauma admissions across the region fell by 33% (197 vs 132) with a proportional increase to 59% (n = 78) of admissions to the MTC during lockdown compared with 28.4% in 2019 (N = 56). There was a reduction in manipulation under anaesthetic (p = 0.015) and the use of Kirschner wires (K-wires) (p = 0.040) between the two time periods. The median time to surgery remained one day in both (2019 IQR 0 to 2; 2020 IQR 1 to 1). Supracondylar fractures were the most common reason for fracture clinic attendance (17.3%, n = 19) with a proportional increase of 108.4% vs 2019 (2019 n = 20; 2020 n = 19) (p = 0.007). While upper limb injuries and falls from play apparatus, equipment, or height remained the most common indications for admission, there was a reduction in sports injuries (p < 0.001) but an increase in lacerations (p = 0.031). Fracture clinic management changed with 67% (n = 40) of follow-up appointments via telephone and 69% (n = 65) of patients requiring cast immobilization treated with a 3M Soft Cast, enabling self-removal. The safeguarding team saw a 22% reduction in referrals (2019: n = 41, 2020: n = 32). Conclusion. During this viral pandemic, the number of trauma cases decreased with a change in the mechanism of injury, median age of presentation, and an increase in referrals to the regional MTC. Adaptions in standard practice led to fewer MUA, and K-wire procedures being performed, more supracondylar fractures managed through clinic and an increase in the use of removable cast. Cite this article: Bone Joint Open 2020;1-7:424–430

Anterior cruciate ligament (ACL) injuries are one of the most common ligament injury occurring in young and active individuals. Reconstruction of the torn ligament is the current standard of care. Of the many factors which determine the surgical outcome, fixation of the graft in the bony tunnels has significant role. This study compared the clinical and functional outcome in patients who underwent ACL reconstruction by standard anteromedial portal technique with single bundle hamstring graft anchored in the femoral tunnel using rigidfix and cortical button with adjustable loops. The tibial fixation and rehabilitation protocol were same in both groups. 107 patients underwent ACL reconstruction over a two-year period (87 males, 20 females, 44 after motor vehicle accident, 34 after sports injuries, 79 isolated ACL tear, 21 associated medial meniscus tear, 16 lateral meniscus tear and 11 both menisci). Rigid fix group had 47 patients and adjustable loop 60 patients. Clinical evaluation at end of one year showed better stability in rigid fix group regarding Lachman, anterior drawer, pivot shift tests, KT 1000 arthrometer side to side difference and hop limb symmetry index. However, the differences were not statistically significant. Functional evaluation using IKDC 2000 subjective score and Lysholm score showed better results in rigidfix group than variable loop, but was not statistically significant. However, lower scores were noted in patients with concomitant meniscal injury than in isolated acl tear patients and this was statistically significant in both groups. Rigidfix seems to give better graft fixation on femoral side than variable loop, but by the end of one year the functional outcome is comparable in isolated acl reconstructions

The prevalence of knee osteoarthritis (OA) in The United States is approximately 40 million cases, and this number is expected to rise to 60 million by the year 2020. Multiple non-operative treatment options are available for patients, including bracing. Braces can also be used for “pre-habitation” prior to total knee arthroplasty (TKA), after TKA, after traumatic sports injuries, and in neurologic patients. Although, the AAOS recommendations for brace use for treatment of knee osteoarthritis (OA) are “inconclusive”, recent studies have shown improved functional outcomes with the use of off-loader braces for the treatment of uni-compartmental knee OA. In addition, supplemental modalities such as transcutaneous electrical nerve stimulation (TENS) and neuromuscular electrical stimulation (NMES) have demonstrated improved subjective and functional outcomes. These off-loader braces and supplemental modalities are easy to use, may decrease pain, delay TKA, and improve clinical outcomes following surgery. In addition, they may decrease the use of other costly knee OA treatment options such as pain medications and intra-articular injections

With associated snow sports injury risks being well documented, the scope for preventative medicine is clear. This article focuses on potential precautions taken by skiers/snowboarders and how they vary between different snow sport groups. A total of 181 randomly selected individuals from the Whistler/Blackcomb Medical Centre, Canada, took part in this questionnaire-based cohort study, examining snow sports activity, preventive measures, and protective equipment use. Most individuals were ski area residents of advanced expertise, with 50% having had a previous snow-riding injury. The most commonly reported significant ski injury was anterior cruciate ligament (ACL) rupture, while in snowboarders, it was wrist fracture. Skiers were more likely to improve fitness levels before going onto the slopes, whereas crossover riders (both skiing and snowboarding) were more likely to take lessons. Most individuals used eye and sun protection and had adequately warm clothing. Beyond basic precautions, protective equipment and preventive measures are used infrequently. It is suggested that by increasing awareness and use of such equipment, injury rates may be reduced

Pelvic fractures in children are rare and potentially disastrous injuries. Using medical records and radiographs over a three year period from January 2008 to March 2011 at an academic hospital we retrospectively analysed the incidence, the associated data and management of these injuries. Results. During this time period 633 paediatric patients where admitted with trauma related injuries; only 19 had pelvic fractures, an incidence of 0.03%. The majority of these patients (13) were involved in PVA's; while MVA (3), fall from height (1) and sports injuries (1) made up the rest. Males (13) were injured more commonly and the average age of the patients was 9 years (3–14). There is debate of over the ideal paediatric pelvic fracture classification system in the literature. However, 13 pelvic fractures were classified stable; 3 were unstable fractures with disruption of the pelvic ring. In addition 2 iliac wing fractures and 1 avulsion (apophyseal) fracture were found. 58% of the patients had associated injuries, however, only 2 of the 19 had associated abdominal viscus injuries. Neither of these required exploratory laparotomy and were managed conservatively. The treatment of these pelvic fractures in our unit was patient specific and largely conservative. 17 patients' pelvic fractures were treated with bed rest, analgesia and mobilisation as pain allowed while the remaining 2 had pelvic external fixators. No ORIF's were performed. Associated orthopaedic injuries were managed accordingly. The average hospital stay of a patient with a pelvic fracture was 15 days (3–48 days). There were no mortalities during this time period

Background. Adductor muscle and tendon injuries are commonly seen in sport. Complete adductor avulsions have been described and can be managed non-operatively or operatively. A rare variant of this injury is the complete avulsion of the adductor complex with the pectineus and rectus abdominus amounting to a complete sleeve avulsion from the pubis. This is a severe injury that is increasingly recognised due to improved imaging and lower diagnostic threshold. Purpose. We describe the surgical management of twelve athletes with this severe injury. Study design. Prospective case series - Level of evidence, 4. Methods. All the injuries were prospectively collected onto our institutional pelvic sports injury database. This series summarises the outcome in twelve consecutive cases where surgery was undertaken after presentation with an acute avulsion (6–34 days) in athletes. The procedure comprised anatomical reattachment of the avulsed tissues with mesh reinforcement of the inguinal wall in seven patients. An independent physiotherapist reviewed all patients. Results. One patient developed a superficial wound infection treated with antibiotics. Transient complaints of local numbness were common but all twelve sportsmen returned to high-level sport (five elite) at an average of thirteen weeks (10–21 weeks). Conclusion. Awareness of the possibility of this complex injury is important and there should be a low threshold for investigation. In elite athletes operative intervention is associated with good clinical outcomes and successful return to sport

Introduction. As modern day lifestyle is becoming more active so is the incidence of meniscal injuries on rise. An injury to the meniscus is a common orthopedic problem with the incidence of meniscal injury resulting in meniscectomy of 61 per 100,000 populations per year. The common practice in diagnosis of the meniscal injury involves clinical examination followed by radiological or arthroscopic confirmation. The clinical tests commonly performed are joint line tenderness (JLT), McMurray's Test (Non-weight bearing test) and Childress Test (Weight Bearing Test). Aim. In our study, we performed the comparative analysis of the validity parameters for components of clinical examination in form of Joint line tenderness, McMurray's test and Childress Test. Methodology. A retrospective analysis was performed on the database established using Orchard Sports Injury Classification System-8. Codes KC2 and KC3 (Meniscal injuries) were identified for single examiner for duration from 2004–2007. Out of 88 patients considered for the study, 62 patients were stratified in whom only clinical examination was performed followed by arthroscopic evaluation. The validity parameters considered were accuracy, specificity, sensitivity, positive predictive value (PPV) and negative predictive value (NPV). Results. Joint line tenderness had accuracy of 85.47%, sensitivity of 89.09%, and specificity of 57.14%, PPV of 94.23% and NPV of 40%. McMurray's test yielded a accuracy of 88.7%, sensitivity of 89.65%, specificity of 75%, PPV of 98.11%, NPV of 33.33% while Childress test accurately predicted meniscal injury 87.09% and was sensitive for 94.73% with specificity of 40%, PPV of 94.73% and NPV of 40%. Conclusion. We can summarise that though the JLT, McMurray's Test and Childress Test provide a variable yet effective diagnostic value, all through can provide a composite diagnostic yield improving the outcome of clinical examination in meniscal injuries

Ankle sprains have been shown to be the most common sports related injury. Ankle sprain may be classified into low ankle sprain or high ankle sprain. Low ankle sprain is a result of lateral ligament disruption. It accounts for approximately 25% of all sports related injuries. The ankle lateral ligament complex consists of three important structures, namely the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL) and posterior talofibular ligament (PTFL). The ATFL is the weakest and most easily injured of these ligaments. It is often described as a thickening of the anterolateral ankle capsule. The ATFL sits in a vertical alignment when the ankle is plantarflexed and thus is the main stabiliser against an inversion stress. T he CFL is extracapsular and spans both the tibiotalar and talocalcaneal joints. The CFL is vertical when the ankle is dorsiflexed. An isolated injury to the CFL is uncommon. Early diagnosis, functional management and rehabilitation are the keys to preventing chronic ankle instability following a lateral ligament injury. Surgery does not play a major role in the management of acute ligament ruptures. Despite this up to 20% of patients will develop chronic instability and pain with activities of daily living and sport especially on uneven terrain. Anatomic reconstruction for this group of patients is associated with 90% good to excellent results. It is important that surgery is followed by functional rehabilitation. One of the aims of surgery in patients with recurrent instability is to prevent the development of ankle arthritis. It should be noted that the results of surgical reconstruction are less predictable in patients with greater than 10 year history of instability. Careful assessment of the patient with chronic instability is required to exclude other associated conditions such as cavovarus deformity or generalised ligamentous laxity as these conditions would need to be addressed in order to obtain a successful outcome. High ankle sprain is the result of injury to the syndesmotic ligaments. The distal tibiofibular joint is comprised of the tibia and fibula, which are connected by anterior inferior tibiofibular ligament, interosseous ligament and the posterior inferior tibiofibular ligament (superficial and deep components). The mechanism of injury is external rotation and hyperdorsiflexion. High index of suspicion is required as syndesmotic injuries can occur in association of low ankle sprains. The clinical tests used in diagnosing syndesmotic injuries (external rotation, squeeze, fibular translation and cotton) do not have a high predictive value. It is important to exclude a high fibular fracture. Plain radiographs are required. If the radiograph is normal then MRI scan is highly accurate in detecting the syndesmotic disruption. Functional rehabilitation is required in patients with stable injuries. Syndesmotic injuries are often associated with a prolonged recovery time. Accurate reduction and operative stabilisation is associated with the best functional outcome in patients with an unstable syndesmotic injury. Stabilisation has traditionally been with screw fixation. Suture button syndesmosis fixation is an alternative. Early short-term reviews show this alternate technique has improved patient outcomes and faster rehabilitation without the need for implant removal

Hamstring muscle strain is a common sports related injury. It has been reported in a variety of sports, following acceleration or deceleration while running or jumping. Injury may vary from simple muscle strains to partial or complete rupture of the hamstring origin. Avulsion fracture of the ischial tuberosity has also been described. Simple hamstring muscle strains are treated conservatively. Surgical exploration and repair is currently advocated for partial or complete rupture of the hamstring origin. A few case series exists in literature suggesting the benefits of early intervention. We report a series of 8 athletes who presented between 2002 and 2006 with complete tear of their hamstring origin. Avulsion of the ischial tuberosity was excluded in these cases. After confirming the diagnosis, early surgical exploration and repair or reattachment was performed. The patients were braced for 8 weeks. This was followed by specialist physiotherapy and a supervised rehabilitation programme over 6 months. All patients were followed up to monitor return to normal activities and sports. The sciatic nerve was scarred to the avulsed tendon in three cases. Neurolysis led to a rapid relief of symptoms. Cases where the hamstring origin had retracted more than 3 cm required a figure 7 incision. There were no major complications including nerve palsies. An excellent functional outcome was noted by 12 months in all 8 patients. 7 of them returned to their previous level within 6-9 months of injury. One person despite a very good recovery, opted out of sports. No other complications were seen as a result of the surgical procedure. In conclusion, a tear of the origin of hamstring muscles is a significant injury. Early surgical repair and physiotherapy is associated with a good outcome and enables an early return to high level sports

This study was performed to assess the incidence of generalised ligament laxity in patients presented with recurrent shoulder dislocations. Prospective data was collected for 38 patients with recurrent shoulder dislocations and 43 patients with clavicle fractures as a control group between May 2007 and July 2009, including demographic details, mechanism of injury, number of dislocations and hyperlaxity. Clinical examination was used to assess the ligament laxity using the Beighton score. The mean age was 29 years with a range from 14-40 years. There were 36 males and 2 females. The left shoulder was involved in 21 patients; right in 13 patients and 4 patients had bilateral shoulder dislocations. The average number of dislocations was 3 with a range from 2-17, while the average number of subluxations was 4.5 with a range from 0-35. The average Beighton score for the patients with recurrent shoulder dislocations was 2.8 with a range from 0-8. 17 patients (45%) in this group had a Beighton score of 4 or more as compared to the control group that had only 12 patients (27%) There was a statistically significant difference between the 2 groups with a P value of < 0.05. 8 patients (21%) fulfilled the Brighton criteria for BJHS. The most common cause of recurrent shoulder dislocation was sports related injuries in 26 patients (68%). The most common sport was football in 14 patients (37%) followed by rugby in 10 (26%) patients. We looked at the incidence of generalised ligament laxity in patients with recurrent shoulder dislocations and found a statistically significant difference as compared with the control group. 21% of the patients fulfilled the Brighton criteria for BJHS but 45% had a Beighton score of 4 or more. Appropriate advice should be given to these patients with hyperlaxity and the timing of shoulder stabilisation should be carefully decided

Fractures of distal tibia are common and often present with dilemma of appropriate and safe management. The use of locking plates has changed the way these fractures have been managed as it avoids extensive soft tissue dissection and periosteal stripping. The aims of this study were to look at the results of stabilization and analyse the complications of fractures of distal tibia treated with Locked plates. We carried out a retrospective study of patients who underwent surgical treatment for distal tibial fractures using MIPO (Minimally invasive Percutaneous Osteosynthesis) technique. The data was gathered from theatre data base. We studied a period between Nov 2006 to May 2009. We collected patient demographics as well as the type of fractures, mechanism of injury, radiological union and associated complications. There were no open fractures in the study. The limb was splinted for two weeks after surgery in a back slab. The patients were followed up at 6 weeks, 3, 6, 9 and 12 months after surgery. There were 45 patients in the study with 29 males & 16 females between ages of 20 – 87 (avg. 49 yrs). 24 patients sustained injury due to a fall, 12 were involved in RTA and the remaining 9 were sports related injuries. The mean time to surgery was 3.15 days (1 – 7) and surgery was carried either by the consultant or their direct supervision. The mean hospital stay was 7 days (2 – 35) and mean time to radiological evidence of callus was 9 weeks. All patients eventually returned to their preinjury employment. 76% showed radiological union at 6 months and 90% at 9 months. There were 3 superficial wound infections, 2 deep infections whilst 2 needed bone grafting and 1 implant failure. 2 patients developed mild form of CRPS which resolved at 12 months. 11 patients had metal discomfort of which 9 had removal of hardware. All these patients had the tip snapped off. MIPO with LCP is a reliable and reproducible technique in treatment of closed unstable fracture of distal tibia. Patients must be counselled about implant removal after fracture union. Avoid snapping the tip of the LCP