Revista de Medicina Desportiva (English) May 2018 - Page 25

symptoms seems to be a favorable prognosis predictor independent of the degree of spondylolistheses. Con- clusion. Most cases of back pain in the young athlete are rightly related to self-limited sprains and muscle pathology. The persistence of the pain and its recurrence are strongly associated with the degenerative pathology of the lumbar disc and/ or overuse injuries, like spondyloly- sis. The prevalence of spondylolysis is not higher in the young athlete compared to non-athlete, although participation in sports involving repeated hyperextension maneu- vers, such as gymnastics, wrestling and diving, seems to be dispropor- tionately associated with higher rates of spondylolysis. After medical treatment, 80% of athletes present symptomatic relief, irrespective of the existing radiological changes. In cases that don’t respond to the con- servative treatment, direct surgical repair of the pars interarticularis, with internal fixation and bone grafting, can produce high rates of pain relief in high-competition athletes allow- ing them the return to sports. Dr. João Cabral Ortopedia Pediátrica, Coimbra. Anterior dislocation of the shoulder. What to do? Shoulder dislocation is a rare but increasingly common pathology in the pediatric population (chil- dren and adolescents) due to the increased sporting activity organ- ized in childhood. The injury in one or several static/dynamic stabiliz- ers may cause shoulder instability, leading to pain, dysfunction, and decreased shoulder performance. The pediatric population has some specificities, such as the colla- gen composition that is changing throughout the child’s development, gradually transitioning from the type III (elastic) predominant at the birth to type I (non-elastic) dur- ing adolescence until adult stage. Individuals with a higher propor- tion of type III collagen will be more susceptible to shoulder instabil- ity, however, tend to improve with conservative treatment, since the type III collagen is less susceptible to permanent plastic deformity compared to type I collagen. Another particularity is the presence of the proximal humerus growth cartilage, which is susceptible to injury. The acute scapular waist trauma can result on epiphysioly sis fractures of the proximal humerus, more often Salter-Harris type I or II. On the initial approach to a suspected anterior dislocation of the shoulder, there must be characterized the mechanism of injury, the previous symptoms, the pattern of pain, the presence of previous injuries and the eventual sense of instability. Prior to the reduction of the dislo- cation, it should be performed the neurological evaluation of the upper limb, namely the motor and sensory function of the hand (radial nerve, median and ulnar), the flexion force of the elbow (musculocutaneous nerve) and the sensitivity of the lateral region proximal arm (axillary nerve). A radiographic study, with face and shoulder profile and axil- lary incidences should also be car- ried out. There are several reduction methods described in the literature, being the most common the Kocher and the Milch method. Regardless of the technique, traction maneuvers should be done smoothly and in line with the arm without untimely maneuvers with forced movements. After the reduction of the disloca- tion, the shoulder is immobilized in adduction and internal rotation for a period of 1 to 6 weeks, followed by another neurological examination and radiographic study. After the resolution of the acute frame and in the presence of chronic instabil- ity, it becomes essential to perform specific maneuvers to test ligament laxity and to cause the reproduc- tion of the symptoms. In instability suspected or for the characterization of any structural injuries, the most commonly used exams are magnetic resonance imaging (MRI), the arthro- MRI, which allows to add informa- tion with greater detail than the MRI only, and the CT scan that allows the characterization of bone injuries. The clinical history, the physical examination and imaging findings allow to characterize the pattern of shoulder instability and identify the extent of injuries of the static and/or dynamic stabilizers. The definitive treatment of this pathology can be conservative (therapeutic physical agents, anti-inflammatory drugs and strengthening of scapulothoracic muscles and the muscle rotators of the shoulder) or surgical, directed for the repair of capsulolabrais / bone injuries and retension of the capsule. The factors that increase the risk of recurrent instability are the multiple pre-surgical disloca- tions, the presence of Hill-Sachs injury and the loss of bone at the glenoid greater than 13.5%. The patients with immature skeleton mostly benefit from conservative treatment, having a recurrence rate of less than 5% (the elastic- ity of the child’s soft tissues with immature skeleton protects it from permanent capsulolabrais lesions, decreasing the likelihood of reloca- tion). Patients with skeletal maturity should be treated as young adults, with a strong recommendation for early surgical stabilization, as they present 3-20% likelihood of recur- rent instability. Prof. Doctor João Páscoa Pinheiro (photo), Dr. Amílcar Cordeiro, Dra. Joana Martins Medicina Física e Reabilitação, Coimbra. Avulsions / apophysis avulsions: diagnosis and treatment Pelvic avulsion is a characteristic pathology of the child and adoles- cent and also it presents a close correlation with sports activity. 1 The most frequent age of appearance is between 13 and 16 years, since it is at this age that there is the appear- ance of the ossification nucleus and there is fusion to the pelvic region. 1.2 These injuries most commonly occur at the ischial tuberosity, at the anterior-inferior iliac spine and at the anterior-superior iliac spine. The mechanism typically involved in these injuries is a strong and sudden contraction of the musculotendi- nous unit, most commonly during a sprint/run, kick, fall or jump. The Revista de Medicina Desportiva informa may 2018 · 23