Analysis of upper and lower extremity peripheral nerve injuries in a population of patients with multiple injuries

BACKGROUND

The purpose of this study was to determine the prevalence, cause, severity, and patterns of associated injuries of limb peripheral nerve injuries sustained by patients with multiple injuries seen at a regional Level 1 trauma center.

METHODS

Patients sustaining injuries to the radial, median, ulnar, sciatic, femoral, peroneal, or tibial nerves were identified using a prospectively collected computerized database, maintained by Sunnybrook Health Science Centre, and a detailed chart review was undertaken.

RESULTS

From a trauma population of 5,777 patients treated between January 1, 1986, and November 30, 1996, 162 patients were identified as having an injury to at least one of the peripheral nerves of interest, yielding a prevalence of 2.8%. These 162 patients sustained a total of 200 peripheral nerve injuries, 121 of which were in the upper extremity. The mean patient age was 34.6 years (SEM +/- 1.1 year), and 83% of patients were male. The mean injury severity score was 23.1 (+/-0.90), and the mean length of hospital stay was 28 days (+/-1.8).

CONCLUSIONS

Motor vehicles crashes predominated (46%) as the cause of injury. The most frequently injured nerve was the radial nerve (58 injuries), and in the lower limb, the peroneal nerve was most commonly injured (39 injuries). Diagnosis of a peripheral nerve injury was made within 4 days of admission to Sunnybrook Health Science Centre in 78% of the cases. Surgery was required to treat 54% of patients. Head injuries were the most common associated injury, occurring in 60% of patients. Other common associated injuries included fractures and dislocations. The present report aims to aid in identification and treatment of peripheral nerve injuries.

Age-related prevalence of rotator cuff tears in asymptomatic shoulders

To determine the prevalence of rotator cuff tears in asymptomatic shoulders we conducted a prospective clinical and ultrasonographic study of 411 volunteers. We anticipated an age-dependent outcome and divided the patients into 4 age-groups. Overall, we found evidence of a rotator cuff tear in 23% of the patients. In group 1 (aged 50 to 59 years), 13% (22 of 167) of the patients had tears; in group 2 (aged 60 to 69 years), 20% (22 of 108) of the patients had tears; in group 3 (aged 70 to 79 years), 31% (27 of 87) of the patients had tears; and in group 4 (age > 80 years), 51% (25 of 49) of the patients had tears. An astonishingly high rate of rotator cuff tears in patients with asymptomatic shoulders was thus demonstrated with increasing patient age. At this stage it remains unclear, however, which parameters convert an asymptomatic rotator cuff tear into a symptomatic tear. As a result, rotator cuff tears must to a certain extent be regarded as "normal" degenerative attrition, not necessarily causing pain and functional impairment.

A conceptual model for work-related neck and upper-limb musculoskeletal disorders

This paper presents a conceptual model for the pathogenesis of work-related musculoskeletal disorders. The model contains sets of cascading exposure, dose, capacity, and response variables, such that response at one level can act as dose at the next. Response to one or more doses can diminish or increase the capacity for responding to successive doses. The model is used as a framework for discussing the development of work-related muscle, tendon, and nerve disorders. It is intended as a beginning, to be modified to explain new findings as they become available. In research, it can help to identify areas needing additional data for the development and expression of work-related musculoskeletal disorders. Researchers can use it to design laboratory and field studies. In practice, it demonstrates the relationship between common exposure factors and different responses. This information can be used to evaluate and design jobs for the prevention of work-related musculoskeletal disorders.

Racial differences in the evaluation of pediatric fractures for physical abuse

CONTEXT

Child maltreatment is a significant problem within US society, and minority children have higher rates of substantiated maltreatment than do white children. However, it is unclear whether minority children are abused more frequently than whites or whether their cases are more likely to be reported.

OBJECTIVES

To determine whether there are racial differences in the evaluation and Child Protective Services (CPS) reporting of young children hospitalized for fractures.

DESIGN, SETTING, AND PATIENTS

Retrospective chart review conducted at an urban US academic children's hospital among 388 children younger than 3 years hospitalized for treatment of an acute primary skull or long-bone fracture between 1994 and 2000. Children with perpetrator-admitted child abuse, metabolic bone disease, birth trauma, or injury caused by vehicular crash were excluded.

MAIN OUTCOME MEASURES

Ordering of skeletal surveys and filing reports of suspected abuse.

RESULTS

Reports of suspected abuse were filed for 22.5% of white and 52.9% of minority children (P<.001). Abusive injuries, as determined by expert review, were more common among minority children than among white children (27.6% vs 12.5%; P<.001). Minority children aged at least 12 months to 3 years (toddlers) were significantly more likely to have a skeletal survey performed compared with their white counterparts, even after controlling for insurance status, independent expert determination of likelihood of abuse, and appropriateness of performing a skeletal survey (adjusted odds ratio [OR], 8.75; 95% confidence interval [CI], 3.48-22.03; P<.001). This group of children was also more likely to be reported to CPS compared with white toddlers, even after controlling for insurance status and likelihood of abuse (adjusted OR, 4.32; 95% CI, 1.63-11.43; P =.003). By likelihood of abuse, differential ordering of skeletal surveys and reporting of suspected abuse were most pronounced for children at least 12 months old with accidental injuries; however, differences were also noted among toddlers with indeterminate injuries but not among infants or toddlers with abusive injuries. Minority children at least 12 months old with accidental injuries were more than 3 times more likely than their white counterparts to be reported for suspected abuse (for children with Medicaid or no insurance, relative risk [RR], 3.08; 95% CI, 1.37-4.80; for children with private insurance, RR, 3.74; 95% CI, 1.46-6.01).

CONCLUSION

While minority children had higher rates of abusive fractures in our sample, they were also more likely to be evaluated and reported for suspected abuse, even after controlling for the likelihood of abusive injury. This suggests that racial differences do exist in the evaluation and reporting of pediatric fractures for child abuse, particularly in toddlers with accidental injuries.

Patterns of skeletal fractures in child abuse: systematic review

OBJECTIVES

To systematically review published studies to identify the characteristics that distinguish fractures in children resulting from abuse and those not resulting from abuse, and to calculate a probability of abuse for individual fracture types.

DESIGN

Systematic review.

DATA SOURCES

All language literature search of Medline, Medline in Process, Embase, Assia, Caredata, Child Data, CINAHL, ISI Proceedings, Sciences Citation, Social Science Citation Index, SIGLE, Scopus, TRIP, and Social Care Online for original study articles, references, textbooks, and conference abstracts until May 2007.

STUDY SELECTION

Comparative studies of fracture at different bony sites, sustained in physical abuse and from other causes in children <18 years old were included. Review articles, expert opinion, postmortem studies, and studies in adults were excluded. Data extraction and synthesis Each study had two independent reviews (three if disputed) by specialist reviewers including paediatricians, paediatric radiologists, orthopaedic surgeons, and named nurses in child protection. Each study was critically appraised by using data extraction sheets, critical appraisal forms, and evidence sheets based on NHS Centre for Reviews and Dissemination guidance. Meta-analysis was done where possible. A random effects model was fitted to account for the heterogeneity between studies.

RESULTS

In total, 32 studies were included. Fractures resulting from abuse were recorded throughout the skeletal system, most commonly in infants (<1 year) and toddlers (between 1 and 3 years old). Multiple fractures were more common in cases of abuse. Once major trauma was excluded, rib fractures had the highest probability for abuse (0.71, 95% confidence interval 0.42 to 0.91). The probability of abuse given a humeral fracture lay between 0.48 (0.06 to 0.94) and 0.54 (0.20 to 0.88), depending on the definition of abuse used. Analysis of fracture type showed that supracondylar humeral fractures were less likely to be inflicted. For femoral fractures, the probability was between 0.28 (0.15 to 0.44) and 0.43 (0.32 to 0.54), depending on the definition of abuse used, and the developmental stage of the child was an important discriminator. The probability for skull fractures was 0.30 (0.19 to 0.46); the most common fractures in abuse and non-abuse were linear fractures. Insufficient comparative studies were available to allow calculation of a probability of abuse for other fracture types.

CONCLUSION

When infants and toddlers present with a fracture in the absence of a confirmed cause, physical abuse should be considered as a potential cause. No fracture, on its own, can distinguish an abusive from a non-abusive cause. During the assessment of individual fractures, the site, fracture type, and developmental stage of the child can help to determine the likelihood of abuse. The number of high quality comparative research studies in this field is limited, and further prospective epidemiology is indicated.

Acute injuries in soccer, ice hockey, volleyball, basketball, judo, and karate: analysis of national registry data

OBJECTIVE

To determine the acute injury profile in each of six sports and compare the injury rates between the sports.

DESIGN

Analysis of national sports injury insurance registry data.

SETTING

Finland during 1987-91.

SUBJECTS

621,691 person years of exposure among participants in soccer, ice hockey, volleyball, basketball, judo, or karate.

MAIN OUTCOME MEASURES

Acute sports injuries requiring medical treatment and reported to the insurance company on structured forms by the patients and their doctors.

RESULTS

54,186 sports injuries were recorded. Injury rates were low in athletes aged under 15, while 20-24 year olds had the highest rates. Differences in injury rates between the sports were minor in this adult age group. Overall injury rates were higher in sports entailing more frequent and powerful body contact. Each sport had a specific injury profile. Fractures and dental injuries were most common in ice hockey and karate and least frequent in volleyball. Knee injuries were the most common cause of permanent disability.

CONCLUSIONS

Based on the defined injury profiles in the different sports it is recommended that sports specific preventive measures should be employed to decrease the number of violent contacts between athletes, including improved game rules supported by careful refereeing. To prevent dental injuries the wearing of mouth guards should be encouraged, especially in ice hockey, karate, and basketball.

The injury mechanisms of osteoporotic upper extremity fractures among older adults: a controlled study of 287 consecutive patients and their 108 controls

The risk factors for falls in older adults are well known but knowledge on the direct injury mechanisms that result in various osteoporotic fractures has been very sparse. The purpose of this study was therefore to clarify the injury mechanisms of osteoporotic upper extremity fractures of older adults and to compare these mechanisms with those of the control fallers, and in this way to obtain reliable insight into the etiology and pathogenesis of upper extremity fractures and thus to enable fracture prevention. One hundred and twelve patients with a fresh fracture of the proximal humerus, 65 patients with an elbow fracture, 110 patients with a wrist fracture and 108 controls (no fracture, or a fracture other than the case fracture) were interviewed and examined between September 1995 and December 1997. The inclusion criteria of the subjects were that the patient was 50 years of age or older at the time of the accident, and that the fracture/injury had occurred as a result of low-energy trauma (typically a fall from standing height or less) within a week before the interview and examination. In 97% of patients with a proximal humerus or elbow fracture, and in all patients (100%) with a wrist fracture, the fracture was a result of a fall. In the control group this figure was 93%. In a polychotomous logistic regression analysis the intergroup differences in the fall directions (adjusted by gender, age and functional capacity) were statistically highly significant (chi 2 = 43.6, d.f. = 15, p < 0.001). Most of the patients with a proximal humerus fracture or elbow fracture reported that they had fallen 'obliquely forward' (43% and 38%) or 'to the side' (29% and 26%), whereas in the wrist fracture group the main fall direction was also 'obliquely forward' (34%) but the other fall directions (i.e., 'forward', 'to the side', 'obliquely backward' and 'backward') were quite equally represented (13-19%). The odds ratio (OR) for an obliquely forward fall resulting in a proximal humerus fracture was 3.5 [95% confidence interval (CI) 1.4-9.2), as compared with the fall directions of the controls and the 'obliquely backward' fall direction. In a logistic regression analysis the patients with a wrist fracture managed to break their fall (e.g., with an outstretched arm) more frequently than the patients in the other groups (OR 3.9; 95% CI 2.0-7.3). The patients with a proximal humerus fracture, in turn, managed to break their fall less frequently than the controls (OR 0.33; 95% CI 0.14-0.80). The same was true of the patients with an elbow fracture, although the difference was not significant (OR 0.49%; 95% CI 0.19-1.3). As objective evidence for a direct fall-induced impact on the fracture site, 68% of patients with a proximal humerus fracture revealed a fresh subcutaneous hematoma on the shoulder/upper arm, while such a hematoma was rare in the controls (2%) (p < 0.001). Correspondingly, 62% of patients with an elbow fracture showed a similar hematoma on the elbow area, while this was seen in none of the controls (p < 0.001). In patients with a wrist fracture a hand/wrist hematoma was seen in 58% of the victims, as compared with 18% of the controls (p < 0.001). The study shows that the most typical osteoporotic upper extremity fractures of older adults have their specific injury mechanisms. A great majority of these fractures occur as a result of a fall and a subsequent direct impact of the fractured site. Effective fracture prevention could be achieved by minimizing the obvious risk factors of falling and reducing the fall-induced impact force with injury site protection.

Randomized placebo-controlled trial of brisk walking in the prevention of postmenopausal osteoporosis

OBJECTIVE

to evaluate the effects of brisk walking on bone mineral density in women who had suffered an upper limb fracture.

DESIGN

randomized placebo-controlled trial. Assessments of bone mineral density were made before and at 1 and 2 years after intervention. Standardized and validated measures of physical capacity, self-rated health status and falls were used.

SETTING

district general hospital outpatient department.

SUBJECTS

165 women drawn from local accident and emergency departments with a history of fracture of an upper limb in the previous 2 years. Women were randomly allocated to intervention (self-paced brisk walking) or placebo (upper limb exercises) groups.

INTERVENTION

both groups were seen at 3-monthly intervals to assess progress, measure physical capacity and maintain enthusiasm. The brisk-walking group were instructed to progressively increase the amount and speed of walking in a manner that suited them. The upper limb exercise placebo group were asked to carry out a series of exercises designed to improve flexibility and fine hand movements, appropriate for a past history of upper limb fracture.

RESULTS

drop-outs from both intervention and placebo groups were substantial (41%), although there were no significant differences in bone mineral density, physical capacity or health status between drop-outs and participants. At 2 years, among those completing the trial, bone mineral density at the femoral neck had fallen in the placebo group to a greater extent than in the brisk-walking group [mean net difference between intervention and placebo groups 0.019 g/cm2, 95% confidence interval (CI) -0.0026 to +0.041 g/cm2, P = 0.056]. Lumbar spine bone mineral density had increased to a similar extent (+0.017 g/cm2) in both groups. The cumulative risk of falls was higher in the brisk-walking group (excess risk of 15 per 100 person-years, 95% CI 1.4-29 per 100 person-years, P < 0.05). There were no significant differences in clinical or spinal x-ray fracture risk or self-rated health status between intervention and placebo groups.

CONCLUSION

the promotion of exercise through brisk-walking advice given by nursing staff may have a small, but clinically important, impact on bone mineral density but is associated with an increased risk of falls. Self-paced brisk walking is difficult to evaluate in randomized controlled trials because of drop-outs, placebo group exercise, limited compliance and lack of standardization of the duration and intensity of walking. Further work is needed to evaluate the best means of safely achieving increased activity levels in different groups, such as older women and those at high risk of fractures.

Exposure-response relationship in the hand-arm vibration syndrome: an overview of current epidemiology research

The complex of vascular, neurologic, and osteoarticular disorders occurring in the upper limbs of vibration-exposed workers is called hand-arm vibration syndrome. There is epidemiologic evidence for an increased occurrence of peripheral sensorineural disorders in occupational groups working with vibrating tools. An excess risk for wrist osteoarthrosis and for elbow arthrosis and osteophytosis has been reported in workers exposed to shocks and low-frequency vibration of high magnitude from percussive tools. However, there are too few epidemiology data to enable reliable conclusions to be drawn about exposure-response relationships for both sensorineural disturbances and bone and joint disorders caused by hand-transmitted vibration. Cross-sectional and longitudinal epidemiology studies have shown that occupational exposure to hand-transmitted vibration from a great variety of hand-held tools is significantly associated with an increased occurrence of digital vasospastic disorders called vibration-induced white finger (VWF). The proposal of an exposure-response relationship for VWF has been included in an annex to the international standard ISO 5349. The findings of several epidemiology studies have shown a poor agreement between the risk for VWF observed in various occupational groups and that predicted by the ISO 5349 model. Both overestimation and underestimation of the occurrence of VWF have been reported by investigators. It has been argued that the current ISO frequency-weighting curve for hand-transmitted vibration may be inappropriate for the assessment of vibration-induced adverse vascular effects. Alternative exposure-response relationships for VWF have been suggested in recent epidemiology studies. The epidemiology data used to construct current exposure-response relationships for vibration-induced injuries are primarily derived from cross-sectional studies. Future epidemiology research should be based on prospective cohort studies because the design characteristics of such studies permit the study of cause-effect relationships and the formulation of etiologic hypotheses.

Musculoskeletal disorders in farmers and farm workers

Farming is a physically arduous occupation and this places farm workers at potential risk of musculoskeletal disorders such as osteoarthritis (OA) of the hip and knee, low back pain (LBP), neck and upper limb complaints, and hand-arm vibration syndrome (HAVS). This review considers the epidemiological evidence concerning such risks. The strongest evidence relates to OA of the hip, for which the public health impact is likely to be considerable. There is also weaker, but suggestive evidence that farmers more often have knee OA and LBP than workers in occupations with fewer physical demands. Tractor drivers, in particular, seem to have more LBP. Relatively little information exists on the risks of soft tissue rheumatism in the limbs and neck. For some outcomes, the link with occupational risk factors (such as heavy loading of joints and whole-body vibration) is sufficient to suggest the course that future prevention should take, but for several outcomes more research is first needed.

Prediction of upper extremity impact forces during falls on the outstretched hand

Among the most common causes of upper extremity fracture is a fall on the outstretched hand. Yet few data exist on the biomechanical factors which affect injury risk during this event. In this study, we measured impact forces during low-height (0-5 cm), forward falls onto the outstretched hand, and found that these are governed by an initial high-frequency peak and a subsequent, lower-frequency oscillation. This behavior was well-simulated by a two-degree-of-freedom, lumped-parameter mathematical model. Increases in body mass caused greater increases in the peak magnitude of the low-frequency component (Fmax2) than the high-frequency component (Fmax1). However, increases in fall height more strongly influenced Fmax1, which exceeded Fmax2 for all but very low fall heights. Model predictions suggest that fall heights greater than 0.6 m carry significant risk for wrist fracture, since above this height, peak forces surpass the average fracture force of the distal radius. Finally, while the shoulder experiences lower peak force than the wrist (since Fmax1 is not transmitted proximally), it undergoes considerably greater deflection, and thereby absorbs the majority of impact energy during a fall.

Adverse effects in blood donors after whole-blood donation: a study of 1000 blood donors interviewed 3 weeks after whole-blood donation

BACKGROUND

There are no reports in the transfusion medicine literature that describe adverse reactions and donor arm injuries after whole-blood donation based on solicited information.

STUDY DESIGN AND METHODS

The present study solicited adverse reaction and donor arm injury information from 1000 randomly selected whole-blood donors approximately 3 weeks after the whole-blood donation. Two 16-gauge phlebotomy needles in use were also compared.

RESULTS

Thirty-six percent of the donors had one or more adverse effects (AEs). The most common systemic AEs were fatigue (7.8%), vasovagal symptoms (5.3%), and nausea and vomiting (1.1%). The most common arm findings were bruise (22.7%), arm soreness (10.0%), and hematoma (1.7%). Men were half as likely as women to have an AE (23% AE vs. 48% AE, p < 0.0001). Repeat blood donors had fewer AEs than first-time blood donors (36% AE vs. 47% AE, p < 0.007), and African-American donors had numbers of AEs similar to those of Caucasian donors (31% AE vs. 38% AE, p = 0.30). The two phlebotomy needles did not differ in causing blood donor AEs.

CONCLUSION

AEs after donation and complaints may be more common than previously thought. The postdonation interview is a good tool for defining the blood donor's experience. It can also be used to evaluate and potentially improve blood donor safety and comfort.

Cricket

In this study we analysed technique, ball speed and trunk injury data collected at the Australian Institute of Sport (AIS) from 42 high performance male fast bowlers over a four year period. We found several notable technique inter-relationships, technique and ball speed relationships, and associations between technique and trunk injuries. A more front-on shoulder alignment at back foot contact was significantly related to increased shoulder counter-rotation (p < 0.001). Bowlers who released the ball at greater speeds had an extended front knee, or extended their front knee, during the front foot contact phase (p < 0.05). They also recorded higher braking and vertical impact forces during the front foot contact phase and developed those forces more rapidly (p < or =0.05). A maximum hip-shoulder separation angle occurring later in the delivery stride (p = 0.05) and a larger shoulder rotation to ball release (p = 0.05) were also characteristics of faster bowlers. Bowlers suffering lower back injuries exhibited typical characteristics of the 'mixed' technique. Specifically, the hip to shoulder separation angle at back foot contact was greater in bowlers who reported soft tissue injuries than in non trunk-injured bowlers (p = 0.03), and shoulder counter-rotation was significantly higher in bowlers who reported lumbar spine stress fractures than non trunk-injured bowlers (p = 0.01). The stress fracture group was also characterised by a larger hip angle at front foot contact and ball release, whereas a more flexed front knee at ball release characterised the non trunk-injured group.

Cricket injuries: a longitudinal study of the nature of injuries to South African cricketers

OBJECTIVE

To determine the incidence and nature of injuries sustained by elite cricketers during a three season period in order to identify possible injury patterns.

METHODS

Thirty six physiotherapists and 13 doctors working with 11 provincial and the South African national teams completed a questionnaire for each cricketer who presented with an injury during each season to determine anatomical site of injury, month of injury during the season, diagnosis, mechanism of injury, whether it was a recurrence of a previous injury, whether the injury had recurred again during the season, and biographical data.

RESULTS

A total of 436 cricketers sustained 812 injuries. Bowling (41.3%), fielding and wicketkeeping (28.6%), and batting (17.1%) accounted for most of the injuries. The lower limbs (49.8%), upper limbs (23.3%), and back and trunk (22.8%) were most commonly injured. The injuries occurred primarily during first class matches (27.0%), limited overs matches (26.9%), and practices (26.8%) during the early part of the season. Acute injuries made up 64.8% of the injuries. The younger players (up to 24 years) sustained 57% of the first time injuries, and the players over 24 years of age sustained 58.7% of the injuries that recurred from a previous season. The injuries were mainly soft tissue injuries predominantly to muscle (41.0%), joint (22.2%), tendon (13.2%), and ligament (6.2%). The primary mechanism of injury was the delivery and follow through of the fast bowler (25.6%), overuse (18.3%), and fielding (21.4%).

CONCLUSION

The results indicate a pattern of cause of injury, with the young fast bowler most likely to sustain an acute injury to the soft tissues of the lower limb while participating in matches and practices during the early part of the season.

Cross-sectional study of the relationship between repetitive work and the prevalence of upper limb musculoskeletal disorders

BACKGROUND

This study examined the relationship of repetitive work and other physical stressors to prevalence of upper limb discomfort, tendinitis, and carpal tunnel syndrome.

METHODS

Three hundred fifty-two workers from three companies participated. Job exposure levels for repetition and other physical stressors were quantified using an observational rating technique. Ergonomic exposures were rated on a 10-point scale, where 0 corresponded to no stress and 10 corresponded to maximum stress. Job selection was based on repetition (three categories: high, medium, and low) to ensure a wide range of exposures. Physical evaluations on all participating workers were performed by medical professionals and included a self-administered questionnaire, physical exam, and limited electrodiagnostic testing.

RESULTS

Repetitiveness of work was found to be significantly associated with prevalence of reported discomfort in the wrist, hand, or fingers (odds ratio (OR) = 1.17 per unit of repetition; OR = 2.45 for high vs. low repetition), tendinitis in the distal upper extremity (OR = 1.23 per unit of repetition; OR = 3.23 for high vs. low repetition), and symptoms consistent with carpal tunnel syndrome (OR = 1.16 per unit of repetition; OR = 2.32 for high vs. low repetition). An association was also found between repetitiveness of work and carpal tunnel syndrome, indicated by the combination of positive electrodiagnostic results and symptoms consistent with carpal tunnel syndrome (OR = 1. 22 per unit of repetition; OR = 3.11 for high vs. low repetition).

CONCLUSIONS

These findings indicate that repetitive work is related to upper limb discomfort, tendinitis, and carpal tunnel syndrome in workers. Further research with a wider range of exposures is needed to evaluate the effects of other physical stresses alone and in combination.

Epidemiology of collegiate baseball injuries

OBJECTIVE

We sought to establish injury incidence, onset, location, type, and severity for a collegiate baseball team. The second objective was to compare the number of musculoskeletal problems for which baseball players sought treatment with those that resulted in time lost or modified participation.

METHODS

This was a prospective, epidemiologic study. A complaint was defined as any evaluation by a player to the medical staff that required either evaluation or treatment. An injury was defined as any complaint that resulted in altered participation or time lost from practice or game participation. Participants were Division I collegiate baseball team with one athletic trainer and one academic sports medicine specialist. All members of the collegiate baseball team were studied over a 3-year period to determine the overall incidence of injury per 1,000 exposures (A-E) to practice or participation, injuries sustained over 3 years by collegiate baseball players.

RESULTS

Overall there were 277 complaints and 52 injuries (19%). The A-E rate was 5.83. Forty-six percent of the injuries occurred in practice and 54% in games. Seventy-three percent of the injuries resulted in < 7 days lost from sport, and 25% resulted in > 21 days lost participation. The most common origin of injury was strains (23%), sprains (19%), and contusions (17%). Fifty-eight percent of the injuries were to the upper extremity, 15% to the trunk/back, and 27% to a lower extremity. Upper extremity injuries accounted for 75% of the total time lost from the sport. When divided by position, the shoulder injuries occurred in pitchers (69%), infielders (19%), and outfielders (12%). Rotator cuff tendinitis was the most frequent complaint, was the most frequent injury, and resulted in the most time lost from the sport.

CONCLUSIONS

Defining injury as time lost or as altered participation underestimates the frequency with which players seek evaluation and treatment. Injuries are divided widely across anatomic site, but upper extremity injuries cause the most time lost from the sport. Further study of the origin and prevention of upper extremity injuries in baseball is warranted.

Frequency of Adverse Events in the Placebo Arms of COVID-19 Vaccine Trials: A Systematic Review and Meta-analysis

Importance

Adverse events (AEs) after placebo treatment are common in randomized clinical drug trials. Systematic evidence regarding these nocebo responses in vaccine trials is important for COVID-19 vaccination worldwide especially because concern about AEs is reported to be a reason for vaccination hesitancy.

Objective

To compare the frequencies of AEs reported in the placebo groups of COVID-19 vaccine trials with those reported in the vaccine groups.

Data Sources

For this systematic review and meta-analysis, the Medline (PubMed) and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched systematically using medical subheading terms and free-text keywords for trials of COVID-19 vaccines published up to July 14, 2021.

Study Selection

Randomized clinical trials of COVID-19 vaccines that investigated adults aged 16 years or older were selected if they assessed solicited AEs within 7 days of injection, included an inert placebo arm, and provided AE reports for both the vaccine and placebo groups separately. Full texts were reviewed for eligibility by 2 independent reviewers.

Data Extraction and Synthesis

Data extraction and quality assessment were performed independently by 2 reviewers, adhering to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline and using the Cochrane risk-of-bias tool. Meta-analyses were based on random-effects models.

Main Outcomes and Measures

The primary outcomes were the proportions of placebo recipients reporting overall, systemic, and local (injection-site) AEs as well as logarithmic odds ratios (ORs) to evaluate group differences. Outcomes were tested for significance using z tests with 95% CIs.

Results

Twelve articles with AE reports for 45 380 participants (22 578 placebo recipients and 22 802 vaccine recipients) were analyzed. After the first dose, 35.2% (95% CI, 26.7%-43.7%) of placebo recipients experienced systemic AEs, with headache (19.3%; 95% CI, 13.6%-25.1%) and fatigue (16.7%; 95% CI, 9.8%-23.6%) being most common. After the second dose, 31.8% (95% CI, 28.7%-35.0%) of placebo recipients reported systemic AEs. The ratio between placebo and vaccine arms showed that nocebo responses accounted for 76.0% of systemic AEs after the first COVID-19 vaccine dose and for 51.8% after the second dose. Significantly more vaccine recipients reported AEs, but the group difference for systemic AEs was small after the first dose (OR, -0.47; 95% CI, -0.54 to -0.40; P < .001; standardized mean difference, -0.26; 95% CI, -0.30 to -0.22) and large after the second dose (OR, -1.36; 95% CI, -1.86 to -0.86; P < .001; standardized mean difference, -0.75; 95% CI, -1.03 to -0.47).

Conclusions and Relevance

In this systematic review and meta-analysis, significantly more AEs were reported in vaccine groups compared with placebo groups, but the rates of reported AEs in the placebo arms were still substantial. Public vaccination programs should consider these high rates of AEs in placebo arms.

Triceps tendon rupture in weight lifters

Triceps tendon avulsion injuries are rare. We report four weight lifters with triceps tendon raptures, two of whom had received local steroid injections for pain in the triceps. All four patients had taken oral anabolic steroids before injury. All patients had closed avulsion of the triceps tendon from its insertion into the olecranon. Three patients were injured while bench pressing heavy weights, and one patient was injured while swinging a baseball bat. Satisfactory results were achieved after surgical reinsertion of the tendon.

Shoulder-arm morbidity following axillary dissection and sentinel node only biopsy for breast cancer

AIMS

The purpose of this study was to examine the outcome of shoulder-arm morbidity in patients with breast cancer after various axillary staging procedures. We used a new specific summation score to compare conventional axillary node dissection (AD) and sentinel node only biopsy for postoperative shoulder-arm morbidity.

METHODS

Eighty-five patients undergoing conventional AD and 66 patients undergoing sentinel node biopsy were evaluated both subjectively (questionnaire) and objectively (clinical examination) for reduced muscle strength, limited range of motion, lymphedema and pain, dysesthesias and loss of sensitivity. The symptoms elicited were rated by their severity with a single summation score describing all symptoms reported.

RESULTS

Subjective evaluation of patients undergoing breast conserving surgery showed a highly significant difference in favor of SNB only (P< or =0.002). On clinical examination the outcome of patients with SNB only was also significantly or highly significantly better (difference in arm volume:P =0.007; difference in arm muscle strength: P=0.016; loss of sensitivity: P<0.001). Of a total score of 100 (=no symptoms), the mean for AD patients was 80.2 vs 92.8 for SNB patients (P=0.001). In patients undergoing total mastectomy the difference was only significant for pain sensations and total scores.

CONCLUSIONS

SNB appears to reduce morbidity. Summation scores are a suitable and practicable tool for describing the symptoms associated with axillary surgery.

Self-injurious behavior and Prader-Willi syndrome: behavioral forms and body locations

With few exceptions (e.g., Lesch-Nyhan syndrome), the specific nature of self-injury in relation to identified genetic syndromes associated with mental retardation is poorly understood. In the present study we surveyed the families of 62 persons with Prader-Willi syndrome to determine the prevalence, topographies, and specific body locations of self-injurious behavior. Self-injury was reported for 81% of the participants. Skin-picking was the most prevalent form, with the front of the legs and head being disproportionately targeted as preferred self-injury body sites. Individuals with the 15q11-q13 deletion injured significantly more body sites than did individuals with maternal disomy 15. Results are discussed in relation to previous self-injury body site findings and implications for the relevance of syndrome-specific behavioral phenotypes.

Pushrim biomechanics and injury prevention in spinal cord injury: Recommendations based on CULP-SCI investigations

Over 50 percent of manual wheelchair users with spinal cord injury (SCI) are likely to develop upper-limb pain and injury. The majority of studies related to pain have implicated wheelchair propulsion as a cause. This paper draws from a large multisite trial and a long-standing research program to make specific recommendations related to wheelchair propulsion that may decrease the risk of upper-limb injury. The studies include over 60 subjects over 1 yr after a traumatic SCI below the second thoracic level. Specific aspects of the propulsive stroke that may relate to injury include cadence, magnitude of force, and the pattern of the hand during the nonpropulsive part of the stroke. Lower peak forces, slower cadence, and a circular propulsive stroke in which the hand falls below the pushrim during recovery may help prevent injury. In addition, wheelchair users should use the lightest weight adjustable wheelchair possible. Future work should include interventional trials and larger studies that allow for more complex statistical models that can further detail the relationship between wheelchair propulsion, user characteristics, and upper-limb injuries.

Differing injury patterns in snowboarding and alpine skiing

This is a study of all people presenting to ski patrollers with ski and snowboard injuries during the 1995 season. There were 476 casualties of whom 396 were skiers and 57 were snowboarders. Information was collected retrospectively on the mechanism, region and injury, and also personal details of the casualties. The information was compared with the numbers of ski and snowboard injuries for the 1994 season. Injuries due to snowboarding increased in frequency, from 4 per cent in 1994 to 11 per cent in 1995. Snowboarders were younger, predominantly male, and were more often beginners than were skiers. They most commonly sustained ligament strains, dislocations and fractures, with the hand and forearm and shoulder most affected. Skiers sustained more ligament strains and soft tissue bruising, particularly of the knee and thumb. Snowboarders sustain a different pattern of injuries compared with skiers, and this has important implications for preventing accidents in the instruction of novices.

Hand and arm injuries associated with repetitive manual work in industry: a review of disorders, risk factors and preventive measures

Musculoskeletal disorders are the most common self-reported, work-related illness in the UK, with upper limb disorders ranking second only to back complaints. The rapid increase in disablement cases, the reduced productivity resulting from the disorders, and, perhaps, the threat of litigation which is on the increase, has led to an increased awareness of the problems and an increasing desire to reduce the incidence of such disorders. This paper reviews the problem of upper limb disorders and focuses on those disorders that could be associated with repetitive manual work in industry. The disorders are described and categorized, and potential occupational risk factors are discussed and related to the injuries. In addition, a number of preventive measures, in the form of ergonomics design changes and changes in workplace practice are reviewed. There are frequent calls for well-designed epidemiological studies, so that meaningful dose-response relationships can be drawn up. A significant part of good study design is associated with measurement and analysis of the user-tool interface and the working environment. With this in mind, a variety of measurement techniques are described. Furthermore, this paper highlights the need for study designs to be founded on a better understanding of the potential damage mechanisms, and points the way towards which areas should be investigated.

Golf injuries: a review of the literature

Golf is one of a few activities that people of all ages and skill level can play. Injury as with all sports can occur. The low back is the most common injury sustained whilst playing golf, and the dynamic action of the golf swing is a major contributing factor to injury. The golf swing is a complex movement that utilises the whole body in a coordinated fashion and when repeated frequently can result in injury. Injury can be overuse or traumatic in nature. Overuse injuries predominate in the professional golfer, and amateur golfer injury tends to occur secondary to an incorrect golf swing. Upper limb injuries are also common due to their role in linking the fast moving golf club with the power-generating torso. Fortunately, injury from a club or ball strike is rare. More common are the overuse injuries associated with the back, neck and shoulder. Most golf injury data have been collected retrospectively and further epidemiological study of a prospective nature is required to determine injury incidence and factor relating to the onset of injury.