Injury Considerations in Adaptive Sports David M Popoli, MD

Prelude

By the Numbers <5% 33% vs. 0.6% 12.8% vs. 72.1% <5% -- percentage of adults who participate in 30 minutes of physical activity each day 33% -- percentage of adults who receive the recommend amount of physical activity each week – 150 minutes 0.6% -- percentage of adults with a disability who receive the recommend amount of physical activity each week. 75.6% -- percentage of persons with a disability reported being physically inactive during a usual week 12.8% -- percentage of persons without a disability who reported being physically inactive during a usual week. *U.S. Department of Health and Human Services. Healthy People 2010.

FES Rowing http://news.bbc.co.uk/sport2/hi/other_sports/disability_sport/4099805.stm

The Case 44 yo FES rower, normal state of health T4 paraplegia “Feeling funny” @ 3min into exercise Resolves with discontinuing exercise

Differential Dehydration Hypoglycemia Hypotension Electrolyte disturbance Arrhythmia Autonomic dysreflexia

Quick Triage Recent illness -- ? dehydration/hypotension Recent travel -- ? dehydration/hypotension Ate snack after work ? Lytes ? AD SBP 200s, HR 40s, flushing No arrhythmia

Autonomic Dysreflexia Bladder Bowel Skin Bladder #1 – usually bladder distention, but also consider UTI, stones Bowel – distention, bowel program, hemorrhoids, fissure Skin – constricting clothing, pressure ulcer, blister/burn, ingrown toenails

Initial Management Sit up Screen clothing, shoes, skin, bladder, bowel Other thoughts? Up to induce hypotension No tight clothing items, no bands, shoes ok, no pressure ulcers, friction burngs, bladder not distented, bowel regiment normal

Other causes? Scrotal compression Exercise-induced AD* Trauma? Recently traveled and “cracked my knee on a transfer.” Bone mineral density loss can be significant, up to 6-8% per year after injury, generally *Ashley et al. Evidence of autonomic dysreflexia during functional electrical stimulation in individuals with spinal cord injuries. Paraplegia (1993) 31, 593–605; doi:10.1038/sc.1993.95

Treatment Non-operative Traditional repair LISS

Non-Operative vs. Traditional Non-operative management = bulky dressing with posterior splint, then early ROM to avoid complications with decreased knee ROM that would affect sitting. Anatomical alignment less important because no weight bearing. + no surgery, no risk of hardware issues/osteomyelitis. - risk of non-union, skin infections, frequent dressing changes, limited activity, ? Decreased knee ROM versus repair Traditional operative repair = retrograde intramedullary nail + bilcortical screws. + improved alignment, higher rate of union, fewer skin infections – surgery, risk of operative infection, risk of revision Cass, J. Operative Versus Nonoperative Management of Distal Femur Fracture in Myelopathic, Nonambulatory Patients. Orthopedics Nov 2008; 31 (11). Hierholzerj et al. Outcome analysis of retrograde nailing and less invasive stabilization system in distal femoral fractures: A retrospective analysis. IJO 2001; 45 (3): 243-250. http://www.healthmegamall.com/prodView-Femur-Fluffi-Splint--All-Sizes_c12813_p55127.htm

Less-Invasive Stabilization System Plating techniques generally were frowned upon because of reduced bone quality. Plate locking often loosened. Performance on KOOS similar to femoral nail, complication rates equal (or slightly lower in some studies) New technique with some serious benefits – lateral approach, no intraarticular issues, unicortiacal screws stay away from blood supply, earlier stability = earlier mobilization. *Badke et al. Treatment of Distal Femoral Fractures with the Less Invasive Stabilization System (LISS) in Paraplegics. Eur J Trauma 2005; 5: 499-502

Take Home Keep AD in your mind Get to the bottom of AD Considerations for bone health

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