Chest pain in athletes

Instabilities and Osteoarthritis of the Sternoclavicular Joint

Injury to the sternoclavicular joint (SCG) is very rare, accounting for 3% of shoulder injuries and < 1% of instabilities. Consequently, both the treatment of acute instabilities and their subsequent states (chronic instabilities/SCG arthrosis) are controversial. While treatment has so far been mostly conservative, in recent years there has been a trend towards surgical therapy.Considerable violence, such as that found in traffic accidents or contact sports, can tear the extremely stable ligaments between the medial clavicle and sternum. While anterior dislocation is easier to reduce in most cases, instability remains in up to 50% of cases. In most cases, posterior instability requires rapid reduction, particularly due to the anatomical proximity to important cardio-pulmonary structures. If this succeeds, the rate of persistent instabilities is low. For chronic instability, reconstruction/augmentation of the ligament apparatus with tendon grafts in the "Figure of 8 configuration" has proven to be the standard technique in recent years.

Diagnostic Evaluation of Nontraumatic Chest Pain in Athletes

This article is a clinically relevant review of the existing medical literature relating to the assessment and diagnostic evaluation for athletes complaining of nontraumatic chest pain. The literature was searched using the following databases for the years 1975 forward: Cochrane Database of Systematic Reviews; CINAHL; PubMed (MEDLINE); and SportDiscus. The general search used the keywords chest pain and athletes. The search was revised to include subject headings and subheadings, including chest pain and prevalence and athletes. Cross-referencing published articles from the databases searched discovered additional articles. No dissertations, theses, or meeting proceedings were reviewed. The authors discuss the scope of this complex problem and the diagnostic dilemma chest pain in athletes can provide. Next, the authors delve into the vast differential and attempt to simplify this process for the sports medicine physician by dividing potential etiologies into cardiac and noncardiac conditions. Life-threatening causes of chest pain in athletes may be cardiac or noncardiac in origin, which highlights the need for the sports medicine physician to consider pathology in multiple organ systems simultaneously. This article emphasizes the importance of ruling out immediately life threatening diagnoses, while acknowledging the most common causes of noncardiac chest pain in young athletes are benign. The authors propose a practical algorithm the sports medicine physician can use as a guide for the assessment and diagnostic work-up of the athlete with chest pain designed to help the physician arrive at the correct diagnosis in a clinically efficient and cost-effective manner.

Misses and errors in upper extremity trauma radiographs

OBJECTIVE

The article reviews a select group of traumatic upper extremity injuries that can be easily misinterpreted on radiographs.

CONCLUSION

The awareness of these specific injuries and an understanding of their underlying pathophysiology and the role that radiographs can play in their evaluation will give the reader the best opportunity to make the important imaging findings and guide appropriate treatment.

Instability and degenerative arthritis of the sternoclavicular joint: a current concepts review

BACKGROUND

Injuries to the sternoclavicular (SC) joint typically occur with high-energy mechanisms such as those obtained in automobile accidents or contact sports. Many disorders of the SC joint can be treated nonoperatively. However, surgical treatment may be indicated for locked posterior dislocations; symptomatic, chronic instability; or persistent, painful osteoarthritis that fails nonoperative therapy.

PURPOSE

To provide an updated review on the current diagnosis and management of instability and degenerative arthritis of the SC joint.

STUDY DESIGN

Current concepts review.

METHODS

A preliminary PubMed database search using the terms sternoclavicular instability, dislocation, arthritis, resection, and stabilization was performed in August 2012. All anatomic and biomechanical studies, review articles, case reports, case series, and technique papers that were relevant to the topic were included.

RESULTS

The search identified 929 articles, 321 of which, after screening of the titles and abstracts, were considered potentially relevant to this study. Of the 321 articles, 30 were anatomic or imaging studies, 2 were biomechanical studies, 69 were review papers, 189 were case series or reports, and 31 were technique papers. The majority of these studies were classified as evidence level 4, with a few scattered level 3 studies. Because the level of evidence obtained from this search was not adequate for systematic review (or meta-analysis), a current concepts review of the diagnosis and management of SC joint instability and degenerative arthritis is presented.

CONCLUSION

Injuries to the SC joint are uncommon. Recognition and classification of these injuries are critical to proper management, thus minimizing potential long-term sequelae such as posttraumatic arthritis and recurrent instability. Although nonoperative therapy is the modality of choice in anterior dislocations, posterior dislocations require special attention because of the presence of vulnerable posterior hilar structures. Surgical management of chronic instability and degenerative arthritis of the SC joint includes resection arthroplasty of the medial clavicle with or without reconstruction of the sternoclavicular ligaments with graft material. Although resection is typically performed open, an arthroscopic technique is described that theoretically decreases operating and recovery times while also decreasing the risk of iatrogenic injury. Currently, when reconstruction is needed for stability, a figure-of-8 graft reconstruction is the recommended method based on biomechanical data and small clinical series.

Long-term outcome after joint reconstruction or medial resection arthroplasty for anterior SCJ instability

INTRODUCTION

In the present study, the long-term results of 11 patients with anterior sternoclavicular joint (SCJ) instability are reported. All included patients had an anterior SCJ instability and due to delayed diagnosis, operative treatment was not done immediately.

METHOD

The patients had a mean age of 29.2 years (range 16-63 years). One patient sustained concomitant injuries. Six patients had resection arthroplasty. Five patients had reconstruction of the SCJ with transosseous tension band PDS fixation or ligament reconstruction with additional wire cerclage. The results of treatment were evaluated after a mean follow-up period of 9.9 years (range 1-27 years) using the ASES, DASH and power-, age and gender adjusted Constant-Murley Score.

RESULTS

In general, the mean values of the different scores (ASES 79.8; DASH 11.8; Constant-Murley 81%) demonstrated good outcome. The outcome evaluation of the patients who had SCJ reconstruction did not differ significantly from the patients who had medial resection arthroplasty. The rate of postoperative pain or instability was low using visual analog scale and did not differ significantly between the groups. The outcome results of the reconstruction group were equal to the results of the resection group when SCJ-reconstruction was performed soon after SCJ injury. One patient in the resection group (6 patients) demonstrated poor results due to continued instability of the remaining clavicle.

CONCLUSION

We concluded that patient selection and a specific clinical indication for operative treatment are crucial. Resection of the medial clavicle results in good functional outcome when the costoclavicular ligament is preserved or reconstructed.

Differential diagnosis of chest symptoms in the athlete

Chest pain is a common complaint of athletes in all age groups. In athletes, chest pain is often attributed to "chest tightness," and treatment for bronchospasm is considered. However, the causes of the pain are wide and varied, and the pain is referable to the many organ systems that localize to the thorax. Therefore, when treatment with bronchodilators fails, it becomes important to consider other nonasthmatic causes of the pain. These causes can be organized by system and are explained in this article. Cardiac causes are the most feared and, fortunately, are very rare in the adolescent setting. With a thorough knowledge of etiologies of chest pain, the physician can often make a diagnosis with only a history and a physical exam.