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
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