Frozen Shoulder Related to Influenza Vaccine Administration.

ABSTRACT: Shoulder pain is often a transient physical finding after vaccination. We present the case of a 46-year-old woman who presented clinically with frozen shoulder that was progressively worse and temporally related to her yearly influenza vaccination. The patient failed conservative management, and 7 months postvaccination, the patient underwent shoulder manipulation under anesthesia with good results. Vaccination-related shoulder dysfunction after high-deltoid intramuscular penetration and infiltration into the subdeltoid/subacromial bursa can cause a severe local inflammatory response that clinically may present as frozen shoulder. A case report and review of the literature on suspected frozen shoulder injury related to vaccine administration is presented. A greater understanding of the shoulder anatomy and use of the correct intramuscular vaccination administration technique is important to prevent this rare postvaccination complication.

Adequate performance of cardiopulmonary resuscitation techniques during simulated cardiac arrest over and under protective equipment in football.

OBJECTIVE: To investigate (1) cardiopulmonary resuscitation (CPR) adequacy during simulated cardiac arrest of equipped football players and (2) whether protective football equipment impedes CPR performance measures. DESIGN: Exploratory crossover study performed on Laerdal SimMan 3 G interactive manikin simulator. SETTING: Temple University/St Luke's University Health Network Regional Medical School Simulation Laboratory. PARTICIPANTS: Thirty BCLS-certified ATCs and 6 ACLS-certified emergency department technicians. INTERVENTIONS: Subjects were given standardized rescuer scenarios to perform three 2-minute sequences of compression-only CPR. Baseline CPR sequences were captured on each subject. MAIN OUTCOME MEASURES: Experimental conditions included 2-minute sequences of CPR either over protective football shoulder pads or under unlaced pads. Subjects were instructed to adhere to 2010 American Heart Association guidelines (initiation of compressions alone at 100/min to 51 mm). Dependent variables included average compression depth, average compression rate, percentage of time chest wall recoiled, and percentage of hands-on contact during compressions. RESULTS: Differences between subject groups were not found to be statistically significant, so groups were combined (n = 36) for analysis of CPR compression adequacy. Compression depth was deeper under shoulder pads than over (P = 0.02), with mean depths of 36.50 and 31.50 mm, respectively. No significant difference was found with compression rate or chest wall recoil. CONCLUSIONS: Chest compression depth is significantly decreased when performed over shoulder pads, while there is no apparent effect on rate or chest wall recoil. Although the clinical outcomes from our observed 15% difference in compression depth are uncertain, chest compression under the pads significantly increases the depth of compressions and more closely approaches American Heart Association guidelines for chest compression depth in cardiac arrest.

Intratympanic hemorrhage and concussion in a football offensive lineman.

BACKGROUND: A 26-year-old arena football lineman participating in a "bull in the ring" blocking and tackling drill was blindsided by an opposing teammate. He sustained a direct helmet-to-helmet blow to the right temporal area. OBJECTIVES: This case describes a unique mechanism of ear barotrauma (intratympanic hemorrhage) and concussion caused by helmet-to-helmet contact in American football. CASE REPORT: Initial sideline evaluation revealed mild headache, confusion, dizziness, photophobia, and tinnitus, all consistent with a concussion diagnosis. Physical examination revealed a large postauricular contusion over the right mastoid process and diffuse right intratympanic hemorrhage on examination. No hemotympanum or effusion of the middle ear was noted. Abnormalities were seen on vestibular testing and visual accommodation and convergence testing. Computed tomography and magnetic resonance imaging were performed with attention to the temporal bones and were normal. Neuropsychological testing was abnormal compared to baseline. Audiology testing was within normal limits. Diagnosis was intratympanic hemorrhage secondary to barotrauma caused by helmet-to-helmet contact, with mastoid contusion and season-ending concussion. CONCLUSIONS: The tympanic membrane (TM) is a highly vascular membrane that is very sensitive to variations of atmospheric pressure. Overpressure can enter the external auditory canal, stretching and displacing the TM medially and causing injury to the tympanic membrane secondary to barotrauma. This concussed football player was never able to return to play due to his postconcussive symptoms. He had no residual hearing or ear problems.

Evaluation of standard endotracheal intubation, assisted laryngoscopy (airtraq), and laryngeal mask airway in the management of the helmeted athlete airway: a manikin study.

OBJECTIVES: Physicians at sporting events must rarely manage the airway of a helmeted athlete. This poses challenges for providers who do not regularly engage in airway management. In a manikin model, our purpose was to determine (1) if standard endotracheal intubation (ETI) of a simulated helmeted athlete is adversely affected by bright-light conditions and (2) if the use of laryngeal mask airway (LMA) or Airtraq improves airway management success. DESIGN: This is a randomized, prospective, crossover study. SETTING: The study was conducted at a 500-bed community-based hospital with residency training programs in family medicine and emergency medicine, as well as a fellowship in sports medicine. PARTICIPANTS: We randomized 42 residents to manage the airway of a simulated helmeted athlete in c-spine immobilization using ETI, Airtraq, and LMA. Each method was attempted under bright light and in standard light. MAIN OUTCOME MEASURES: Our main outcomes were success or failure of airway and time to airway. Secondary outcome was perceived difficulty in airway management as a factor of environmental factors. RESULTS: Airway success rates were 93% for ETI, 99% for LMA, and 75% for Airtraq. Standard ETI was significantly faster than intubation using the Airtraq (P = 0.0001) and had greater success (P = 0.004). Time to airway was faster with LMA than with standard ETI (P < 0.00001). There was no impact of bright light on ETI time (P = 0.61). CONCLUSIONS: These results suggest that both ETI and LMA may be acceptable choices for management of the airway in the helmeted athlete. Time to airway was significantly decreased with the use of LMA, regardless of the experience level of the intubator. Lighting conditions had no effect on success.

Cervical spine injury management in the helmeted athlete.

The relative incidence of catastrophic cervical spine injury in sports is low compared to other injuries. However, the potential catastrophic and life-altering consequences of spine injury cause understandable concern regarding the prehospital management and care of the cervical-spine-injured athlete. This is complicated when injured athletes participate in equipment-intensive sports, such as football, where helmets and facemasks are potential barriers to obtaining immediate access to the athlete's airway. Cervical spine injuries in these cases necessitate delicate and precise management, often involving the combined efforts of multiple health-care providers. The outcome of a catastrophic cervical spine injury is dependent on the efficiency of this management process and timeliness of transfer to a controlled environment for diagnosis and treatment.

Community-associated methicillin-resistant Staphylococcus aureus survival on artificial turf substrates.

OBJECTIVE: Artificial turf has been suggested as a risk factor for community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA). This is an experimental study looking at survival of CA-MRSA on artificial turf. METHODS: MRSA strain USA-300-0114 was grown as either planktonic cells or biofilms in liquid cultures of beef heart infusion broth overnight at 37 °C. Beakers containing ProGrass (Pittsburgh, PA) turf were inoculated at the dirt interface with either ∼5 × 10 planktonic bacteria or with biofilms. The inoculum included varying nutrient conditions consisting of spent medium, saline, or 5% mucin. The beakers were incubated at 37 °C in ambient air. The main outcome measure was the number of surviving colony-forming units determined by plating on mannitol salt agar. RESULTS: Survival was biphasic with a colony-forming unit drop from ∼5 × 10 to ∼5 × 10 after the first week followed by survival of between 10 and 10 bacteria until termination of the experiment (20-50 d). Survival was dependent on nutrients, and washed cells survived less than 1 d. Mucin could serve as a nutrient source and slightly increased surviving numbers to 10-10 bacteria. Biofilm formation did not influence survival. CONCLUSIONS: CA-MRSA survivability on artificial turf surfaces is dependent on the availability of nutrients. These results suggest that CA-MRSA could survive on artificial turf in significant numbers for 1 wk, and lower numbers for at least 1 month, if supplied with appropriate nutrients. Outdoor environmental conditions may affect these findings.

National athletic trainers' association position statement: acute management of the cervical spine-injured athlete.

OBJECTIVE: To provide certified athletic trainers, team physicians, emergency responders, and other health care professionals with recommendations on how to best manage a catastrophic cervical spine injury in the athlete. BACKGROUND: The relative incidence of catastrophic cervical spine injury in sports is low compared with other injuries. However, cervical spine injuries necessitate delicate and precise management, often involving the combined efforts of a variety of health care providers. The outcome of a catastrophic cervical spine injury depends on the efficiency of this management process and the timeliness of transfer to a controlled environment for diagnosis and treatment. RECOMMENDATIONS: Recommendations are based on current evidence pertaining to prevention strategies to reduce the incidence of cervical spine injuries in sport; emergency planning and preparation to increase management efficiency; maintaining or creating neutral alignment in the cervical spine; accessing and maintaining the airway; stabilizing and transferring the athlete with a suspected cervical spine injury; managing the athlete participating in an equipment-laden sport, such as football, hockey, or lacrosse; and considerations in the emergency department.

Summary of the National Athletic Trainers' Association position statement on the acute management of the cervical spine-injured athlete.

The incidence of catastrophic cervical spine injury in sports is low compared with other injuries. However, cervical spine injuries necessitate delicate and precise management, often involving the combined efforts of a variety of health care providers. The outcome of a catastrophic cervical spine injury depends on the efficiency of this management process and timeliness of transfer to a controlled environment for diagnosis and treatment. The objective of the National Athletic Trainers' Association (NATA) position statement on the acute care of the cervical spine-injured athlete is to provide the certified athletic trainer, team physician, emergency responder, and other health care professionals with recommendations on how to best manage a catastrophic cervical spine injury in an athlete. Recommendations are based on current evidence pertaining to prevention strategies to reduce the incidence of cervical spine injuries in sport; emergency planning and preparation to increase management efficiency; maintaining or creating neutral alignment in the cervical spine; accessing and maintaining the airway; stabilizing and transferring the athlete with a suspected cervical spine injury; managing the athlete participating in an equipment-laden sport such as football, hockey, or lacrosse; and imaging considerations in the emergency department.

Reliability and validity of goniometric turnout measurements compared with MRI and retro-reflective markers.

There is no consensus on a valid and reliable method of measuring turnout. However, there is a building awareness that such measures need to exist. Total turnout is the sum of hip rotation, tibial torsion, and contributions from the foot. To our knowledge, there has been no research that directly measures and then sums each individual component of turnout to verify a total turnout value. Furthermore, the tibial torsion component has not previously been confirmed by an imaging study. The purpose of this study was to test the validity and reliability of a single total passive turnout (TPT) test taken with a goniometer by comparing it with the sum of the individual components. Fourteen female dancers were recruited as participants. Measurements of the subjects' right and left legs were gathered for the components of turnout. Tibial torsion was measured using Magnetic Resonance Imaging (MRI). Retro-reflective marker assisted measurements were used to calculate the static components of TPT. Hip external rotation, TPT, and total active turnout (TAT) were measured by goniometer. Additional standing turnout values were collected on rotational disks. Tibial torsion and hip rotation were summed and compared with three whole-leg turnout values using Two-Tailed T-Tests and Pearson product-moment correlation coefficients. Tibial torsion measurements in dancers were found to demonstrate substantial variation between subjects and between legs in the same subject. The range on the right leg was 16 degrees to 60 degrees, and the range on the left leg was 16 degrees to 52 degrees. Retro-reflective markers and biomechanical theory demonstrated that when the knee is extended and locked, "screwed home," it will not factor into a whole-leg turnout value. TAT and turnout on the disks were not statistically significant when compared with the summed total. Statistical significance was achieved in four of the eight measurement series comparing TPT with the summed value of tibial torsion and hip rotation. The advantages of a standard, valid, and reliable method of measuring turnout are many, and the risks are few. Some advantages include improved training techniques, mastery of the use of turnout at an earlier age, better dancer and teacher compliance with suggested turnout rates, understanding the use of parallel position, understanding the etiology of many dance-related injuries, and possible development of preventative measures.

Cardiac arrest on the links: are we up to par? Availability of automated external defibrillators on golf courses in southeastern Pennsylvania.

OBJECTIVES: A growing number of golfers are senior citizens, and it may be predicted that the number of golf-related medical emergencies, including the incidence of cardiac arrest, will increase. This study was designed to survey the level of preparedness of golf courses in southeastern Pennsylvania to respond to cardiac arrest among their members. METHODS: A telephone survey of all of the 180 golf courses in the area was conducted to determine their type (public/private), volume in rounds per year, presence of automated external defibrillator (AED) devices, number of employees, and percentage of employees with cardiopulmonary resuscitation (CPR) training. Participants also were asked to estimate the time needed to reach the farthest point on their course in order to estimate a maximum time to the application of an AED device. RESULTS: A total of 131 of 180 golf courses completed the survey (53 private, 78 public) for an overall response rate of 73%. Private courses reported a greater average number of employees with CPR training [private = 9.1, public = 3.6; p = 0.001] and in AED presence [public = 9%, private = 58.5%; p = 0.0001]. Public courses support a higher volume of play than do private courses [public = 32,000, private = 24,000; p = 0.001], yet have far fewer employees [public=25, private=44; p = 0.004]. The longest time necessary to reach the most remote point on the course was between four and five minutes in all courses. Analysis was performed using the Student's t-test and Pearson's Chi-square as appropriate. CONCLUSION: Neither public nor private golf courses are well equipped to respond to cardiac arrest, but outcomes on public courses likely are to be far worse.

Determination of safe return to play for athletes recovering from infectious mononucleosis: a review of the literature.

OBJECTIVE: Infectious mononucleosis is an acute self-limited disorder diagnosed by clinical and hematologic measures. This paper reviews the literature regarding the decision-making process for return to play in individuals at risk for complications due to infectious mononucleosis. DATA SOURCES: Computerized literature search identified articles using the keywords infectious mononucleosis, athlete, injury, exercise, spleen rupture, and spleen radiography. Symptoms, physical examination, hematological markers, and radiographic evaluation were considered. CONCLUSIONS: No strong evidence-based information supports use of a single parameter to predict the safe return to sports participation. Current consensus supports that athletes be afebrile, well hydrated, and asymptomatic with no palpable liver or spleen. Clinical judgment incorporating these criteria 1 month after diagnosis has been suggested as a safe predictor for gradual return to competition. These conditions for return to play do not guarantee that the spleen has returned to normal size and compliance, or that the risk of spleen rupture has returned to baseline. For those athletes participating in contact sports who wish to return to sports in an earlier time frame, or those with an equivocal examination, radiographic modalities may be used to help determine liver and spleen size. Further studies are required to support this practice.

Computed Tomography is Diagnostic in the Cervical Imaging of Helmeted Football Players With Shoulder Pads.

OBJECTIVE: Prospective, observational case series evaluating the value of cervical spine computed tomography (CT) scans in the initial evaluation of a helmeted football player with suspected cervical spine injury. SUBJECTS: Five asymptomatic male football players, fully equipped and immobilized on a backboard. DESIGN: Multiple 3.0-mm, helically acquired, axially displayed CT images of the cervical spine were obtained from the skull base inferiorly through T1, with images filmed at soft tissue and bone windows. Sagittal and coronal reformatted images were performed. Software was used to minimize metallic artifact. MEASUREMENTS: All series were reviewed by a Board-certified neuroradiologist for image clarity and diagnostic capability. RESULTS: Lateral scout films demonstrated mild segmental degradation, depending on the location of the metallic snaps overlying the spine. Anteroposterior scout films and bone window images were of diagnostic quality. The soft tissue windows showed minimal localized artifact occurring at the same levels as in the lateral scout views. This minimal beam-hardening streak artifact did not affect the diagnostic quality of the soft tissue windows. Reconstructed images were uniformly of clinical diagnostic quality. DISCUSSION: When CT scans were reviewed as a unit, sufficient information was available to allow reliable clinical decisions about the helmeted football player. In light of recent publications demonstrating the difficulty of obtaining adequate radiographs to evaluate cervical spine injury in equipped football players, helmeted athletes may undergo CT scanning without any significant diagnostic limitations.

Management of the helmeted athlete with suspected cervical spine injury.

Improper handling of an unstable neck injury may result in iatrogenic neurologic injury. A review of published evidence on cervical management in the helmeted athlete with a suspected spinal injury is discussed. The approach to the neck-injured helmeted athlete and the algorithms for on-field and emergency department evaluations are reviewed. The characteristics of the fitted football helmet allow safe access for airway management, and helmets and shoulder pads should not be initially removed unless absolutely necessary. Prehospital and emergency personnel should be trained in the indications for removal and in proper helmet, shoulder pad, and facemask removal techniques. If required, both helmet and shoulder pads should be removed simultaneously. Radiographs with equipment in place may be inadequate, and the value of computed tomography and magnetic resonance imaging in these helmeted patients has been studied. If adequate films cannot be obtained with equipment in place, helmet and shoulder pads may need to be removed before radiographic clearance. A plan should be formulated to prepare for such unexpected clinical scenarios as cervical spine injuries, and skills should be practiced. Airway and cervical spine management in these helmeted athletes is an area of ongoing research.

MRI is nondiagnostic in cervical spine imaging of the helmeted football player with shoulder pads.

BACKGROUND: It is currently recommended that helmet and shoulder pads remain in place during the initial clinical and radiographic evaluation of the helmeted athlete with a potential cervical spine injury. The objective of this prospectively designed, single-subject study was to determine whether MRI may play a role in the initial evaluation and management of the helmeted football player with a cervical spine injury. METHODS: One male athlete was fitted using equipment (football helmet [Riddell], shoulder pads [Douglas]) worn during the collegiate season at Lehigh University. Standard MRI using a routine clinical 0.7 T high field open MRI scanner (GE Signa System, Milwaukee, WI) was employed for the evaluation using standard clinical parameters (sagittal T1, fast spin echo [FSE] T2, STIR, and axial FSE T2 series). A single board-certified, fellowship-trained neuroradiologist reviewed all series. Studies were evaluated for image clarity and diagnostic capability in this clinical setting. RESULTS: All standard MRI series were of extremely limited quality, even using sequences and slice selection designed to minimize artifact associated with metals (FSE T2-weighted series). When all MRI series were reviewed as a whole, sufficient evidence was not available to allow clinical decision making. CONCLUSIONS: The amount and type of metal within the standard football helmet and shoulder pads result in sufficient field inhomogeneity and SKEW artifact to preclude adequate evaluation of the cervical structures, rendering MRI evaluation in this setting not clinically useful. This study shows that current MRI techniques play no role in the clearance of the cervical spine (with currently available brands of helmet and shoulder pads in place) without prior equipment removal or manipulation.