An Additional Electrodiagnostic Tool for Ulnar Neuropathy: Mixed across the Elbow.

Background Diagnosing ulnar neuropathy at the elbow (UNE) remains challenging despite guidelines from national organizations. Motor testing of hand intrinsic muscles remains a common diagnostic method fraught with challenges. Objective The aim of the study is to demonstrate utility of an uncommon nerve conduction study (NCS), mixed across the elbow, when diagnosing UNE. Methods Retrospective analysis of 135 patients, referred to an outpatient University-based electrodiagnostic laboratory with suspected UNE between January 2013 and June 2019 who had motor to abductor digiti minimi (ADM), motor to first dorsal interosseus (FDI), and mixed across the elbow NCS completed. To perform the mixed across the elbow NCS, the active bar electrode was placed 10-cm proximal to the medial epicondyle between the biceps and triceps muscle bellies. The median nerve was stimulated at the wrist followed by stimulation of the ulnar nerve at the ulnar styloid. The difference between peak latencies, labeled the ulnar-median mixed latency difference (U-MLD), was used to evaluate for correlation between the nerve conduction velocities (NCV) of ADM and FDI. Results Pearson r -values = -0.479 and -0.543 ( p < 0.00001) when comparing U-MLD to ADM and FDI NCV across the elbow, respectively. The negative r -value describes the inverse relationship between ulnar velocity across the elbow and increasing U-MLD. Conclusion Mixed across the elbow has moderate-strong correlation with ADM and FDI NCV across the elbow. All three tests measure ulnar nerve function slightly differently. Without further prospective data, the most accurate test remains unclear. The authors propose some combination of the three tests may be most beneficial when diagnosing UNE.

Loperamide as a Potential Drug of Abuse and Misuse: Fatal Overdoses at the Medical University of South Carolina.

Loperamide is an over-the-counter, µ-opioid receptor agonist commonly used as an antidiarrheal agent. Loperamide was thought to have minimal abuse potential due to its low bioavailability and limited central nervous system activity; however, there have been increasing reports of loperamide misuse in supratherapeutic doses to achieve euphoria and/or avoid opioid withdrawal. A literature review suggests a rise in loperamide abuse was inevitable, with substantial increases in reported cases over the last decade. Five fatal cases of toxic medication use where loperamide was listed as a primary or contributory cause of death were identified at the Medical University of South Carolina. The characteristic autopsy demographics and findings are described, and the mechanisms of abuse and toxicity of loperamide are reviewed. Loperamide overdoses are a growing concern from both a forensic and clinical standpoint, and the frequency of reported cases will likely increase as awareness grows within the medical and toxicological communities.

Exertional Heat Illness in American Football Players: When Is the Risk Greatest?

CONTEXT: Knowledge about the specific environmental and practice risks to participants in American intercollegiate football during preseason practices is limited. Identifying risks may mitigate occurrences of exertional heat illness (EHI). OBJECTIVE: To evaluate the associations among preseason practice day, session number, and wet bulb globe temperature (WBGT) and the incidence of EHI. DESIGN: Descriptive epidemiology study. SETTING: Sixty colleges and universities representing 5 geographic regions of the United States. PATIENTS OR OTHER PARTICIPANTS: National Collegiate Athletic Association football players. MAIN OUTCOME MEASURE(S): Data related to preseason practice day, session number, and WBGT. We measured WBGT every 15 minutes during the practice sessions and used the mean WBGT from each session in the analysis. We recorded the incidence of EHIs and calculated the athlete-exposures (AEs). RESULTS: A total of 553 EHI cases and 365 810 AEs were reported for an overall EHI rate of 1.52/1000 AEs (95% confidence interval [CI] = 1.42, 1.68). Approximately 74% (n = 407) of the reported EHI cases were exertional heat cramps (incidence rate = 1.14/1000 AEs; 95% CI = 1.03, 1.25), and about 26% (n = 146) were a combination of exertional heat syncope and heat exhaustion (incidence rate = 0.40/1000 AEs; 95% CI = 0.35, 0.48). The highest rate of EHI occurred during the first 14 days of the preseason period, and the greatest risk was during the first 7 days. The risk of EHI increased substantially when the WBGT was 82.0°F (27.8°C) or greater. CONCLUSIONS: We found an increased rate of EHI during the first 14 days of practice, especially during the first 7 days. When the WBGT was greater than 82.0°F (27.8°C), the rate of EHI increased. Sports medicine personnel should take all necessary preventive measures to reduce the EHI risk during the first 14 days of practice and when the environmental conditions are greater than 82.0°F (27.8°C) WBGT.

An analysis of specific lower extremity injury rates on grass and FieldTurf playing surfaces in National Football League Games: 2000-2009 seasons.

BACKGROUND: Players in the National Football League (NFL) sustain injuries every season as the result of their participation. One factor associated with the rate of injury is the type of playing surface on which the players participate. HYPOTHESIS: There is no difference in the rate of knee sprains and ankle sprains during NFL games when comparing rates of those injuries during games played on natural grass surfaces with rates of those injuries during games played on the artificial surface FieldTurf. STUDY DESIGN: Descriptive epidemiology study. METHODS: The NFL records injury and exposure (ie, game) data as part of its injury surveillance system. During the 2000-2009 NFL seasons, there were 2680 games (5360 team games) played on grass or artificial surfaces. Specifically, 1356 team games were played on FieldTurf and 4004 team games were played on grass. We examined the 2000-2009 game-related injury data from those games as recorded by the injury surveillance system. The data included the injury diagnosis, the date of injury, and the surface at the time of injury. The injury data showed that 1528 knee sprains and 1503 ankle sprains occurred during those games. We calculated injury rates for knee sprains and ankle sprains-specifically, medial collateral ligament (MCL) sprains, anterior cruciate ligament (ACL) sprains, eversion ankle sprains, and inversion ankle sprains-using incidence density ratios (IDRs). We used a Poisson model and logistic regression odds ratios to validate the IDR analysis. A multivariate logistic regression model was used to adjust the odds ratio for weather conditions. RESULTS: The observed injury rate of knee sprains on FieldTurf was 22% (IDR = 1.22, 95% confidence interval [CI], 1.09-1.36) higher than on grass, and the injury rate of ankle sprains on FieldTurf was 22% (IDR = 1.22, 95% CI, 1.09-1.36) higher than on grass. These differences are statistically significant. Specifically, the observed injury rates of ACL sprains and eversion ankle sprains on FieldTurf surfaces were 67% (P < .001) and 31% (P < .001) higher than on grass surfaces and were statistically significant. The observed injury rates of MCL sprains and inversion ankle sprains were also not significantly higher on FieldTurf surfaces (P = .689 and .390, respectively). CONCLUSION: Injury rates for ACL sprains and eversion ankle sprains for NFL games played on FieldTurf were higher than rates for those injuries in games played on grass, and the differences were statistically significant.

Rotational stiffness of football shoes influences talus motion during external rotation of the foot.

Shoe-surface interface characteristics have been implicated in the high incidence of ankle injuries suffered by athletes. Yet, the differences in rotational stiffness among shoes may also influence injury risk. It was hypothesized that shoes with different rotational stiffness will generate different patterns of ankle ligament strain. Four football shoe designs were tested and compared in terms of rotational stiffness. Twelve (six pairs) male cadaveric lower extremity limbs were externally rotated 30 deg using two selected football shoe designs, i.e., a flexible shoe and a rigid shoe. Motion capture was performed to track the movement of the talus with a reflective marker array screwed into the bone. A computational ankle model was utilized to input talus motions for the estimation of ankle ligament strains. At 30 deg of rotation, the rigid shoe generated higher ankle joint torque at 46.2 ± 9.3 Nm than the flexible shoe at 35.4 ± 5.7 Nm. While talus rotation was greater in the rigid shoe (15.9 ± 1.6 deg versus 12.1 ± 1.0 deg), the flexible shoe generated more talus eversion (5.6 ± 1.5 deg versus 1.2± 0.8 deg). While these talus motions resulted in the same level of anterior deltoid ligament strain (approxiamtely 5%) between shoes, there was a significant increase of anterior tibiofibular ligament strain (4.5± 0.4% versus 2.3 ± 0.3%) for the flexible versus more rigid shoe design. The flexible shoe may provide less restraint to the subtalar and transverse tarsal joints, resulting in more eversion but less axial rotation of the talus during foot∕shoe rotation. The increase of strain in the anterior tibiofibular ligament may have been largely due to the increased level of talus eversion documented for the flexible shoe. There may be a direct correlation of ankle joint torque with axial talus rotation, and an inverse relationship between torque and talus eversion. The study may provide some insight into relationships between shoe design and ankle ligament strain patterns. In future studies, these data may be useful in characterizing shoe design parameters and balancing potential ankle injury risks with player performance.

Eversion during external rotation of the human cadaver foot produces high ankle sprains.

While high ankle sprains are often clinically ascribed to excessive external foot rotation, no experimental study documents isolated anterior tibiofibular ligament (ATiFL) injury under this loading. We hypothesized that external rotation of a highly everted foot would generate ATiFL injury, in contrast to deltoid ligament injury from external rotation of a neutral foot. Twelve (six pairs) male cadaveric lower extremity limbs underwent external foot rotation until gross failure. All limbs were positioned in 20° of dorsiflexion and restrained with elastic athletic tape. Right limbs were in neutral while left limbs were everted 20°. Talus motion relative to the tibia was measured using motion capture. Rotation at failure for everted limbs (46.8 ± 6.1°) was significantly greater than for neutral limbs (37.7 ± 5.4°). Everted limbs showed ATiFL injury only, while neutral limbs mostly demonstrated deltoid ligament failure. This is the first biomechanical study to produce isolated ATiFL injury under external foot rotation. Eversion of the axially loaded foot predisposes the ATiFL to injury, forming a basis for high ankle sprain. The study helps clarify a mechanism of high ankle sprain and may heighten clinical awareness of isolated ATiFL injury in cases of foot eversion prior to external rotation. It may also provide guidance to investigate the effect of prophylactic measures for this injury.

Hamstring muscle strains in professional football players: a 10-year review.

BACKGROUND: Investigations into hamstring strain injuries at the elite level exist in sports such as Australian Rules football, rugby, and soccer, but no large-scale study exists on the incidence and circumstances surrounding these injuries in the National Football League (NFL). HYPOTHESIS: Injury rates will vary between different player positions, times in the season, and across different playing situations. STUDY DESIGN: Descriptive epidemiology study. METHODS: Between 1989 and 1998, injury data were prospectively collected by athletic trainers for every NFL team and recorded in the NFL's Injury Surveillance System. Data collected included team, date of injury, activity the player was engaged in at the time of injury, injury severity, position played, mechanism of injury, and history of previous injury. Injury rates were reported in injuries per athlete-exposure (A-E). An athlete-exposure was defined as 1 athlete participating in either 1 practice or 1 game. RESULTS: Over the 10-year study period 1716 hamstring strains were reported for an injury rate (IR) of 0.77 per 1000 A-E. More than half (51.3%) of hamstring strains occurred during the 7-week preseason. The preseason practice IR was significantly elevated compared with the regular-season practice IR (0.82/1000 A-E and 0.18/1000 A-E, respectively). The most commonly injured positions were the defensive secondary, accounting for 23.1% of the injuries; the wide receivers, accounting for 20.8%; and special teams, constituting 13.0% of the injuries in the study. CONCLUSION: Hamstring strains are a considerable cause of disability in football, with the majority of injuries occurring during the short preseason. In particular, the speed position players, such as the wide receivers and defensive secondary, as well as players on the special teams units, are at elevated risk for injury. These positions and situations with a higher risk of injury provide foci for preventative interventions.

Development and validation of a computational model to study the effect of foot constraint on ankle injury due to external rotation.

Recent studies, using two different manners of foot constraint, potted and taped, document altered failure characteristics in the human cadaver ankle under controlled external rotation of the foot. The posterior talofibular ligament (PTaFL) was commonly injured when the foot was constrained in potting material, while the frequency of deltoid ligament injury was higher for the taped foot. In this study an existing multibody computational modeling approach was validated to include the influence of foot constraint, determine the kinematics of the joint under external foot rotation, and consequently obtain strains in various ligaments. It was hypothesized that the location of ankle injury due to excessive levels of external foot rotation is a function of foot constraint. The results from this model simulation supported this hypothesis and helped to explain the mechanisms of injury in the cadaver experiments. An excessive external foot rotation might generate a PTaFL injury for a rigid foot constraint, and an anterior deltoid ligament injury for a pliant foot constraint. The computational models may be further developed and modified to simulate the human response for different shoe designs, as well as on various athletic shoe-surface interfaces, so as to provide a computational basis for optimizing athletic performance with minimal injury risk.

Repeat concussions in the national football league.

BACKGROUND: Repeat concussion is an important issue in the National Football League (NFL). An initial description of repeat injuries was published for 6 years (1996-2001). HYPOTHESIS: The characteristics and frequency of repeat concussion in the NFL have not changed in the subsequent 6 years (2002-2007). STUDY DESIGN: Case control. METHODS: From 1996 to 2007, concussions were reported using a standardized form documenting signs and symptoms, loss of consciousness and medical action taken. Data on repeat concussions were analyzed for the 12 years and compared between the 2 periods. RESULTS: In 2002-2007, 152 players had repeat concussions (vs 160 in 1996-2001); 44 had 3+ head injuries (vs 52). The positions most often associated with repeat concussion in 2002-2007 were the defensive secondary, kick unit, running back, and linebacker. The odds for repeat concussion were elevated for wide receivers, tight ends, and linebackers but lower than in the earlier period. During 2002-2007, over half of players with repeat concussion were removed from play, and fewer immediately returned (vs 1996-2001). The average duration between concussions was 1.25 years for 2002-2007 and 1.65 years for the 12-year period. Over 12 years, 7.6% of all repeat concussions occurred within 2 weeks of the prior concussion. CONCLUSIONS: The defensive secondary, kick unit, running back, and linebacker have the highest incidence of repeat concussion. During 2002-2007, more than half of players with repeat concussion were removed from play, and only a fraction immediately returned. Although concussion was managed more conservatively by team physicians in the recent 6 years, repeat concussions occurred at similar rates during both periods.

Concussions involving 7 or more days out in the national football league.

BACKGROUND: Positions, signs, symptoms, and medical management of National Football League players with concussions involving 7 or more days out (7+) from play were compared for two 6-year study periods (2002-2007 vs 1996-2001). HYPOTHESIS: More players were held out 7+ days in the 2002-2007 period without significant difference in concussion signs and symptoms. STUDY DESIGN: Cohort. METHODS: From 1996 through 2007, National Football League team physicians reported concussion signs and symptoms, medical action taken, and follow-up management. RESULTS: During the 2002-2007 period, 143 (16.7%) and 33 (3.86%) concussed players were out 7+ days and 21+ days, respectively, compared with 73 (8.2%) and 7 (0.79%) in the 1996-2001 period, a significant difference (z = 5.39, P < .01). The positions with the highest fraction of 7+ days out were the quarterback (24.5% vs 16.1%), linebacker (19.7% vs 4.6%), and wide receiver (19.5% vs 8.2%) in the later versus earlier period. The player positions with the highest odds for being out 7+ days were quarterback (odds ratio = 1.80 vs 4.02), linebacker (odds ratio = 1.28 vs 0.65), and wide receiver (odds ratio = 1.25 vs 1.15). The highest incidence of 7+ days out occurred after passing plays (32.2% vs 37.0%), followed by kickoffs (18.9% vs 21.9%). The majority of players with 7+ days out were removed from the game on the day of injury (74.8% vs 72.6%); a smaller fraction were returned to play on the day of injury in the later 6 years (3.5% vs 6.8%). CONCLUSIONS: The positions with the highest odds for being out 7+ days with concussion were quarterbacks, linebackers, and wide receivers. In the more recent 6-year period, more players were managed conservatively by being held out 7+ days, even though the signs and symptoms of their concussions were similar to those in the earlier period.

A biomechanical investigation of ankle injury under excessive external foot rotation in the human cadaver.

Numerous studies on the mechanisms of ankle injury deal with injuries to the syndesmosis and anterior ligamentous structures but a previous sectioning study also describes the important role of the posterior talofibular ligament (PTaFL) in the ankle's resistance to external rotation of the foot. It was hypothesized that failure level external rotation of the foot would lead to injury of the PTaFL. Ten ankles were tested by externally rotating the foot until gross injury. Two different frequencies of rotation were used in this study, 0.5 Hz and 2 Hz. The mean failure torque of the ankles was 69.5+/-11.7 Nm with a mean failure angle of 40.7+/-7.3 degrees . No effects of rotation frequency or flexion angle were noted. The most commonly injured structure was the PTaFL. Visible damage to the syndesmosis only occurred in combination with fibular fracture in these experiments. The constraint of the subtalar joint in the current study may have affected the mechanics of the foot and led to the resultant strain in the PTaFL. In the real world, talus rotations may be affected by athletic footwear that may influence the location and potential for an ankle injury under external rotation of the foot.

Injuries to kickers in American football: the National Football League experience.

BACKGROUND: Very little information is available regarding the incidence, causative mechanisms, and expected duration of time lost after injuries to kickers (placekickers and punters) in American football. HYPOTHESIS: Lower extremity musculotendinous injuries are the most common type of injury in American football kickers. The injuries related to punting differ from injuries related to placekicking. STUDY DESIGN: Descriptive epidemiologic study. METHODS: A retrospective review of all documented injuries to kickers in the National Football League over a 20-year period (1988-2007) was performed using the League's injury surveillance database. The data were analyzed from multiple perspectives, with emphasis on the type of kick or activity at the time of injury and the factors that affect return to play after injury. RESULTS: There were 488 total injuries over the 20-year period: 72% involved the lower extremity, 9% involved the lumbosacral spine, and 7% involved the head. Muscle-tendon injuries (49%) were the most common, followed by ligamentous injuries (17%). There was a significantly higher risk of injury in games (17.7 per 1000) than during practice (1.91 per 1000). Most injuries (93%) did not require surgery, and the mean time to return to play was 15 days if no surgery was necessary. Kickers over 30 years of age took longer to return to play (mean, 21 days) than younger kickers (mean, 12 days) after nonsurgical injuries (P = .03). Mean return to play after injuries that required surgery was 121 days. Lumbosacral soft tissue injury, lateral ankle sprains, and shoulder injuries were more likely to occur in punters than placekickers. CONCLUSION: Kicking athletes face a low risk of injury in professional American football. Injuries most commonly involve the lower extremities. Training and injury prevention efforts should reflect that punting is associated with different injuries than placekicking, and that older kickers take longer to recuperate than younger kickers after certain injuries.

Twelve years of national football league concussion data.

BACKGROUND: Concussion in the National Football League (NFL) remains an important issue. An initial description of the injury epidemiology involved 6 years from 1996 to 2001. HYPOTHESIS: The increased attention to concussions may have resulted in team physicians being more conservative in treating players in recent years. STUDY DESIGN: Two consecutive 6-year periods (1996-2001 and 2002-2007) were compared to determine changes in the circumstances associated with the injury, the patterns of signs and symptoms, and the players' time loss from participation in the NFL. METHODS: During 2002-2007, concussions were recorded by NFL team physicians and athletic trainers using the same standardized reporting form used from 1996 to 2001. Player position, type of play, concussion signs and symptoms, loss of consciousness, and medical action taken were recorded. RESULTS: There were 0.38 documented concussions per NFL game in 2002-2007-7.6% lower than the 0.42 in the earlier period (1996-2001). The injury rate was lower in quarterbacks and wide receivers but significantly higher in tight ends during the second 6 years. The most frequent symptoms were headaches and dizziness; the most common signs were problems with information processing and immediate recall. During 2002-2007, a significantly lower fraction of concussed players returned to the same game, and more were removed from play. Most concussed players (83.5%) returned to play in < 7 days; the percentage decreased to 57.4% with loss of consciousness. The number of players returning in < 7 days was 8% lower during 2002-2007 and 25% lower for those with loss of consciousness. CONCLUSION: The most recent 6 years of NFL concussion data show a remarkable similarity to the earlier period. However, there was a significant decrease in the percentage of players returning to the same game, and players were held out of play longer. CLINICAL RELEVANCE: There was a more conservative management of concussion in NFL players from 2002 to 2007 even though the clinical signs and symptoms remained similar to the earlier 6-year period.

Knee articular cartilage injuries in the National Football League: epidemiology and treatment approach by team physicians.

This study describes the epidemiology of knee articular cartilage injuries in the National Football League (NFL) and the typical treatment approach by NFL team physicians. All knee articular cartilage injuries in the league database from 1992 to 2006 were reviewed, and team physicians were surveyed about their treatment approach to these injuries. A total of 118 cases were identified, for an average of 8 per year, with a higher injury rate during games compared with practice. Approximately half of the injuries occurred in linemen, and the most common site of injury was the femoral condyle. Forty-six percent of these injuries were treated surgically, with slower return to play after surgery (124 versus 36 days, P < .01). Among team physicians, microfracture was the most popular treatment approach (43%), followed by debridement (31%) and nonoperative management (13%). More research is needed to compare long-term outcomes based on lesion size in these athletes.

Treatment advances for medically inoperable non-small-cell lung cancer: emphasis on prospective trials.

Advances in technology have changed the treatment of patients with early stage non-small-cell lung cancer who are not healthy enough for standard surgical resection. Previously, patients with severe underlying cardiopulmonary dysfunction were often dissuaded from pursuing definitive therapy, even though most patients died from their lung cancer and not as a result of comorbid medical illness. Recent advances in the technology to treat early stage disease have led to new-found enthusiasm for treating and studying high-risk patients. This Review focuses on the management of these patients, including use of conformal radiotherapy, stereotactic body radiation therapy, sublobar resection, intraoperative brachytherapy, and radiofrequency ablation. Ongoing challenges are presented and prospective data are emphasised.

Football playing surface and shoe design affect rotational traction.

BACKGROUND: High rotational traction between football shoes and the playing surface may be a potential mechanism of injury for The abstract goes here and covers two columns. the lower extremity. HYPOTHESIS: Rotational traction at the shoe-surface interface depends on shoe design and surface type. STUDY DESIGN: Controlled laboratory study. METHODS: A mobile testing apparatus with a compliant ankle was used to apply rotations and measure the torque at the shoe-surface interface. The mechanical surrogate was used to compare 5 football cleat patterns (total of 10 shoe models) and 4 football surfaces (FieldTurf, AstroPlay, and 2 natural grass systems) on site at actual surface installations. RESULTS: Both artificial surfaces yielded significantly higher peak torque and rotational stiffness than the natural grass surfaces. The only cleat pattern that produced a peak torque significantly different than all others was the turf-style cleat, and it yielded the lowest torque. The model of shoe had a significant effect on rotational stiffness. CONCLUSION: The infill artificial surfaces in this study exhibited greater rotational traction characteristics than natural grass. The cleat pattern did not predetermine a shoe's peak torque or rotational stiffness. A potential shoe design factor that may influence rotational stiffness is the material(s) used to construct the shoe's upper. CLINICAL RELEVANCE: The study provides data on the rotational traction of shoe-surface interfaces currently employed in football. As football shoe and surface designs continue to be updated, new evaluations of their performance must be assessed under simulated loading conditions to ensure that player performance needs are met while minimizing injury risk.

Hip injuries and labral tears in the national football league.

BACKGROUND: Injuries to the hip account for approximately 10% of all injuries in football, but definitive diagnosis is often challenging. Although these injuries are often uncomplicated contusions or strains, intra-articular lesions are increasingly found to be sources of hip pain. PURPOSE: The objective was to define the incidence and etiologic factors of intra- and extra-articular hip injuries in the National Football League (NFL). STUDY DESIGN: Descriptive epidemiology study. METHODS: The NFL Injury Surveillance System was used to define all hip-related injuries from 1997 to 2006. Injuries were included if the athlete missed more than 2 days. All hip and groin injuries were included for evaluation. The authors also report on NFL players with intra-articular injuries seen at their institution outside of the NFL Injury Surveillance System. RESULTS: There were a total of 23 806 injuries from 1997 to 2006, of which 738 were hip injuries (3.1%) with an average of 12.3 days lost per injury. Muscle strains were the most common injury. Intra-articular injuries resulted in the most time lost. Contact injuries most likely resulted in a contusion, and noncontact injuries most often resulted in a muscle strain. In the authors' institutional experience, many of the athletes with labral tears have persistent adductor strains that do not improve despite adequate therapy. CONCLUSION: Hip injuries represent a small but substantial percentage of injuries that occur in the NFL. A majority of these injuries are minor, with a return to play within 2 weeks. Intra-articular injuries are more serious and result in a significant loss of playing time. The "sports hip triad" (labral tear, adductor strain, and rectus strain) is described as a common injury pattern in the elite athlete.

Upper extremity injuries in the National Football League: part II: elbow, forearm, and wrist injuries.

BACKGROUND: Very little information is available regarding the incidence, causative mechanisms, and expected duration of time lost following upper extremity injuries in professional American football players. HYPOTHESES: (1) Upper extremity injuries in professional American football players are a common cause of missed time from practice and game participation. (2) The effect of upper extremity injuries differs as a function of the site involved and the athlete's position. STUDY DESIGN: Descriptive epidemiologic study. METHODS: A retrospective review of all documented injuries to the elbow, forearm, and wrist sustained by all players in the National Football League over a 10-year period (1996-2005) was performed using the League's injury surveillance database. An injury was considered significant if it resulted in premature cessation of (or absence from) at least 1 practice, game, or training event. The data were analyzed from multiple perspectives, with emphasis on the type of injury, athlete position, and activity at the time of injury. RESULTS: There were 859 total injuries over the 10-year period: 58% involved the elbow, 30% involved the wrist, and 12% involved the forearm. Ligamentous injuries were the most common diagnosis in the elbow and wrist, with wrist sprains the most common of all diagnoses. Fractures were the most common injury occurring in the forearm. For all 3 anatomic locations, game injuries were much more common than practice injuries by a factor of 2.8 to 1. Forearm injuries led to a mean of 42 days lost, wrist injuries led to a mean of 27 days lost, and elbow injuries led to an average of 22 days lost. Fractures and dislocations led to the greatest amount of time lost (47 days and 53 days, respectively). Tackling was the activity most often (24%) implicated as causing injuries to the elbow, forearm, and wrist. Offensive and defensive linemen were most commonly injured. Elbow injuries were the most common at these positions, constituting approximately 75% of all injuries. Defensive backs sustained the greatest number of forearm injuries, approximately double the total number at any other position. CONCLUSION: Upper extremity trauma is a significant issue for professional football players. In particular, the high incidence rates of elbow injuries in linemen and forearm injuries in defensive backs warrant further scrutiny.

Upper extremity injuries in the National Football League: part I: hand and digital injuries.

BACKGROUND: Very little has been published regarding the incidence of and duration of time lost after hand injuries in professional American football players. HYPOTHESES: (1) Hand, first ray, and finger injuries in professional American football players represent a common cause of missed time from practice and game participation. (2) The effect of upper extremity injuries differs as a function of the anatomic site involved, injury type, and athlete's position. STUDY DESIGN: Descriptive epidemiologic study. METHODS: A retrospective review of all documented injuries to the hand, first ray, and fingers sustained by American football players in the National Football League over a 10-year period (1996-2005) was performed using the League's injury surveillance database. The data were analyzed from multiple perspectives, with emphasis on the type of injury, athlete position, and activity at the time of injury. RESULTS: A total of 1385 injuries occurred to the hand, first ray, and fingers over the 10 seasons studied. Of these injuries, 48% involved the fingers, 30% involved the first ray, and 22% involved the hand, with game injuries more common than practice injuries at each location. Metacarpal fractures and proximal interphalangeal joint dislocations were the 2 most common injuries. Offensive and defensive linemen were the most likely to sustain a hand injury; 80% of hand injuries were metacarpal fractures. The most common injuries to the first ray were fractures (48%) and sprains (36%), which occurred most often in athletes playing a defensive secondary position. Finger injuries were most commonly dislocations at the level of the proximal interphalangeal joint, typically involving the ulnar 2 digits. Finger injuries were most common in wide receivers and defensive secondary players. The act of tackling produced the most injuries (28%). CONCLUSION: Upper extremity trauma, especially injury to the hand, first ray, and fingers, is a significant source of morbidity for professional football players. The results of this study may be used to implement preventive measures to help minimize these injuries.

Gamma Knife surgery in the management of radioresistant brain metastases in high-risk patients with melanoma, renal cell carcinoma, and sarcoma.

OBJECT: The purpose of this study was to examine the results of using Gamma Knife surgery (GKS) for brain metastases from classically radioresistant malignancies. METHODS: The authors retrospectively reviewed the records of 76 patients with melanoma (50 patients), renal cell carcinoma (RCC; 23 patients), or sarcoma (3 patients) who underwent GKS between August 1998 and July 2007. Overall patient survival, intracranial progression, and local progression of individual lesions were analyzed. RESULTS: The median age of the patients was 57 years (range 18-85 years) and median Karnofsky Performance Scale (KPS) score was 80 (range 20-100). Sixty-two patients (81.6%) had uncontrolled extracranial disease. A total of 303 intracranial lesions (average 3.97 per patient, range 1-27 lesions) were treated using GKS. More than 3 lesions were treated in 30 patients (39.5%). Median GKS tumor margin dose was 18 Gy (range 8-30 Gy). Thirty-seven patients (48.7%) underwent whole brain radiation therapy. The actuarial 12-month rate for freedom from local progression for individual lesions was 77.7% and was significantly higher for RCC compared with melanoma (93.6 vs 63.0%; p = 0.001). The percentage of coverage of the prescribed dose to target volume was the only treatment-related variable associated with local control: 12-month actuarial rate of freedom from local progression was 71.4% for lesions receiving >or= 90% coverage versus 0.0% for lesions receiving < 90% (p = 0.00048). Median overall survival was 5.1 months after GKS and 8.4 months after the discovery of brain metastases. Univariate analysis revealed that KPS score (p = 0.000004), recursive partitioning analysis class (p = 0.00043), and single metastases (p = 0.028), but not more than 3 metastases, to be prognostic factors of overall survival. The KPS score remained significant after multivariate analysis. Overall survival for patients with a KPS score >or= 70 was 7.1 months compared with 1.3 months for a KPS score 3 metastases. Higher rates of local tumor control were achieved for RCC in comparison with melanoma, and this may have an effect on survival in some patients. Although outcomes generally remained poor in this study population, these results suggest that GKS can be considered as a treatment option for many patients with radioresistant brain metastases, even if these patients have multiple lesions.