Optimizing sleep to maximize performance: implications and recommendations for elite athletes.

Despite a growing body of literature demonstrating a positive relationship between sleep and optimal performance, athletes often have low sleep quality and quantity. Insufficient sleep among athletes may be due to scheduling constraints and the low priority of sleep relative to other training demands, as well as a lack of awareness of the role of sleep in optimizing athletic performance. Domains of athletic performance (e.g., speed and endurance), neurocognitive function (e.g., attention and memory), and physical health (e.g., illness and injury risk, and weight maintenance) have all been shown to be negatively affected by insufficient sleep or experimentally modeled sleep restriction. However, healthy adults are notoriously poor at self-assessing the magnitude of the impact of sleep loss, underscoring the need for increased awareness of the importance of sleep among both elite athletes and practitioners managing their care. Strategies to optimize sleep quality and quantity in athletes include approaches for expanding total sleep duration, improving sleep environment, and identifying potential sleep disorders.

Pain sensitivity and modulation in primary insomnia.

Sleep of good quantity and quality is considered a biologically important resource necessary to maintain homeostasis of pain-regulatory processes. To assess the role of chronic sleep disturbances in pain processing, we conducted laboratory pain testing in subjects with primary insomnia. Seventeen participants with primary insomnia (mean ± SEM 22.6 ± 0.9 yrs, 11 women) were individually matched with 17 healthy participants. All participants wore an actigraph device over a 2-week period and completed daily sleep and pain diaries. Laboratory pain testing was conducted in a controlled environment and included (1) warmth detection threshold testing, (2) pain sensitivity testing (threshold detection for heat and pressure pain), and (3) tests to access pain modulatory mechanisms (pain facilitation and inhibition). Primary insomnia subjects reported experiencing spontaneous pain on twice as many days as healthy controls during the at-home recording phase (p < 0.05). During laboratory testing, primary insomnia subjects had lower pain thresholds than healthy controls (p < 0.05 for heat pain detection threshold, p < 0.08 for pressure pain detection threshold). Unexpectedly, pain facilitation, as assessed with temporal summation of pain responses, was reduced in primary insomnia compared to healthy controls (p < 0.05). Pain inhibition, as assessed with the diffuse noxious inhibitory control paradigm (DNIC), was attenuated in insomnia subjects when compared to controls (p < 0.05). Based on these findings, we propose that pain-inhibitory circuits in patients with insomnia are in a state of constant activation to compensate for ongoing subclinical pain. This constant activation ultimately may result in a ceiling effect of pain-inhibitory efforts, as indicated by the inability of the system to adequately function during challenge.

Monteggia fractures in adults.

The records concerning ten consecutive years of experience with Monteggia fractures in adult patients at a level-one trauma center were retrospectively reviewed. Forty-eight patients who had been followed for a minimum of two years (average, 6.5 years; range, two to fourteen years) were identified. There were twenty-five women and twenty-three men, and the average age was fifty-two years (range, eighteen to eighty-eight years). According to the classification of Bado, there were seven type-I, thirty-eight type-II, one type-III, and two type-IV injuries. Twenty-six patients (68 percent) who had a Bado type-II fracture had an associated fracture of the radial head; ten of these patients also had a fracture of the coronoid process as a single large fragment. The ulna was fixed with a tension band-wire construct supplemented with screws in three patients (all of whom had a Bado type-II fracture). An ulnar diaphyseal fracture was fixed with an intramedullary Steinmann pin in one patient. The remaining patients had fixation with a plate and screws. The fracture of the radial head was treated with either complete or partial excision of the fragments in twelve patients (with replacement with a silicone prosthesis in two), open reduction and internal fixation in ten patients, and no intervention in four patients. Nine patients, all of whom had a Bado type-II fracture, needed a reoperation within three months after the initial operation; five had revision of a loose ulnar fixation device, three had resection of the radial head, and one had removal of a wire that had migrated from the radial head into the elbow articulation. Other important complications included proximal radioulnar synostosis in three patients, ulnar malunion in three, posterolateral rotatory instability of the ulnohumeral joint in one, and instability of the distal radioulnar joint in one. At the most recent follow-up examination, which was performed after all of the reoperations and reconstructive procedures had been done, the average score according to the system of Broberg and Morrey was 86 points (range, 15 to 100 points). The result was excellent for eighteen patients, good for twenty-two, fair for two, and poor for six. Six of the eight patients who had an unsatisfactory (fair or poor) result had had a Bado type-II fracture with a concomitant fracture of the radial head. These unsatisfactory results were related to a malunited fracture of the coronoid process in two patients, a proximal radioulnar synostosis in one, a malunited fracture of the coronoid process and a proximal radioulnar synostosis in one, a malunion of the ulna in one, and painfully restricted rotation of the forearm after operative fixation of a comminuted fracture of the radial head in one. The other two unsatisfactory results were in a patient who had had a Bado type-I fracture and in one who had had a Bado type-IV fracture. The results of the present series are much better than those reported in most earlier studies, suggesting that stable anatomical fixation of the ulnar fracture (including associated fracture fragments of the coronoid process) with a plate and screws inserted with use of current techniques of fixation leads to a satisfactory result in most adults who have a Monteggia fracture. The posterior (Bado type-II) fracture is the most common type of Monteggia fracture in adults. Problems with the elbow related to fractures of the coronoid process and the radial head, which are common with Bado type-II Monteggia fractures, remain the most challenging elements in the treatment of these injuries.

Transolecranon fracture-dislocation of the elbow.

OBJECTIVE: To characterize the prevalence, morphology, and prognosis of anterior (transolecranon) fracture-dislocations of the elbow. DESIGN: Retrospective case series. SETTING: A consecutive series of thirteen patients from a single level-one trauma center, plus four patients from the practices of two of the senior authors. PATIENTS: Three of seventeen patients had simple, oblique fractures of the olecranon, and fourteen had complex, comminuted fractures of the proximal ulna, including fragmentation of the olecranon in seven patients, large coronoid fragments in eight patients, and segmental fractures of the ulna in six patients. Fourteen patients were male and three were female, with an average age of thirty-eight years (range, 18 to 78 years). INTERVENTION: All fractures were treated by open reduction and internal fixation. Two one-third tubular plates had to be revised to 3.5-millimeter dynamic compression plates within six weeks of the initial operation. MAIN OUTCOME MEASURE: Elbow performance rating of Broberg and Morrey. RESULTS: At an average follow-up of twenty-five months, overall outcome was rated as excellent in seven patients, good in eight, and fair in two. Mild posttraumatic arthritis was noted in only two patients. Large coronoid fragments and extensive comminution of the trochlear notch did not preclude a good result provided that stable, anatomic fixation was achieved. CONCLUSIONS: Anterior elbow dislocations occur most often as a fracture-dislocation in which the distal humerus is driven through the olecranon, thereby causing a complex, comminuted fracture of the proximal ulna. This injury is frequently confused with anterior Monteggia lesions by virtue of the readily apparent radiocapitellar dislocation. Stable restoration of the appropriate contour and dimensions of the trochlear notch of the ulna will lead to a good result in most cases.

Contoured LCDC plating of the proximal ulna.

Comminuted fractures of the proximal ulna, particularly in combination with dislocation of the radial head, represent complex injuries which threaten both elbow and forearm motion. Thirty-seven complex proximal ulna fractures were treated with a dorsally applied, limited-contact titanium plate, contoured to fit the anatomy of the olecranon and proximal ulna. Twenty-four patients had Monteggia fracture/dislocations, and 13 had isolated but complex fractures of the proximal ulna. After an average follow up of 24 months, good or excellent functional results were achieved in 27 patients.

Complex fracture patterns of the upper extremity.

Combined skeletal injuries to the upper limb present complex management problems because they may result in dysfunction of the terminal unit of the upper limb-the hand. This article explores complex patterns of skeletal and soft tissue injuries, including complex soft tissue trauma with closed and open fractures; the floating shoulder, elbow, and forearm; and the role of skeletal fixation in conjunction with the complex fracture patterns. As the functional capacity of the upper limb reflects an integration of all its component parts, a combined approach to skeletal and soft tissue trauma is of fundamental importance in upper limb trauma.

Delayed onset of forearm compartment syndrome: a complication of distal radius fracture in young adults.

The signs and symptoms of elevated intracompartmental pressure in the volar forearm compartment developed on a delayed basis (range 18-54 h) in the absence of constricting casts or dressings in eight limbs after high-energy intraarticular fractures of the distal end of the radius. Intracompartment pressures averaged 80 mm Hg in the six limbs tested. Despite urgent decompression and fracture fixation with delayed wound closure, final functional outcomes were compromised in seven cases, reflecting the severity of the articular injuries, and poor in one case, in which a wrist fusion was later required. If potentially serious complications are to be prevented, careful observation of these patients, often for periods of 48 h, is important. Selective recording of forearm intracompartmental pressures may be advised in at-risk patients.

External fixation of the distal radius. A biomechanical study.

External fixation is a useful method of treating unstable fractures of the distal radius. There is a lack of information regarding the behaviour of mini-fixation systems, particularly under cyclical loading, which would be expected to occur at the wrist. This laboratory study was designed to investigate the mechanical characteristics of nine current fixation systems. A programme of loading was devised to mimic forces acting on the distal radius. Wooden dowel was used to mount the fixator. Distraction and compression forces were applied in an Instron rig. Displacement was monitored throughout the load programme. No fixator failed at the loads tested. The small Hoffman rectangular frame proved stiffest in compression and extension, but was heavier than other devices. A trend of progressive, permanent deformation became apparent in those fixators which contain plastic or composite materials. This feature has implications for loss of fracture reduction in the clinical setting.

Extra-glenohumeral joint shoulder surgery in rheumatoid arthritis: The role of bursectomy, acromioplasty, and distal clavicle excision.

Twenty-four painful shoulders in patients with rheumatoid arthritis have been studied before and after extra-glenohumeral joint surgery. Preoperative local anesthetic injections were used to localize sites of pain and served as a basis for the surgical procedure performed. Radiographs were graded with the Larsen classification; 17 shoulders had radiographic evidence of advanced glenohumeral disease. Surgery included subacromial bursectomy, anterior acromioplasty, and excision of the outer end of the clavicle. At an average follow-up of 30 months (range 18 to 50 months) for 22 of the shoulders, 19 had minimal pain. Average motions improved in flexion from 68° to 121° and in external rotation from 23° to 52°. Two experienced infections, one superficial and one deep. One further operation has been necessary to treat the shoulder arthritis. Extra-glenohumeral joint surgery, planned according to the results of preoperative injection testing, has a useful role in management of the shoulder in rheumatoid arthritis, even when the glenohumeral joint is involved radiographically.