Polo & Equestrian Injuries to the Upper Limbs PoloBarbados Magazine Dr. Alejandro Badia Is one of the leading experts in his field and he has dealt with a number of serious injuries to Barbados polo and other sports people. His detailed analysis of the potential injuries and their treatment provides a deep insight into the dangers of sport, but of more importance, the medical solutions. While competitive and recreational polo rely significantly upon core and lower extremity strength and endurance, it is actually the upper extremity, which is usually involved in traumatic or overuse injuries. This is due to the simple fact that the legs are constrained in the stirrups, and the participant has to use the upper limb to cushion a fall and hopefully roll. Besides injuries from a fall or collision, there are a wide variety of both traumatic and atraumatic injuries involving the hand, wrist, elbow and shoulder region due to the demanding use of the mallet. Fortunately, most of these injuries will not prevent the athlete from returning to their sport. Studies on incidence of polo injuries indicate that 40% involve the upper limb with facial lacerations being the second most common category of injury. It is, of course, head and cervical spine injuries that are the true danger. Fortunately, the majority of these can be prevented by the simple use of a helmet and a face protector. However, protective gear is not practical for the upper limb since hand, wrist and elbow mobility is critical to performing the complex functions of riding and wielding the polo mallet. Traumatic injuries Traumatic injuries are most common. However, there are certain chronic injuries or conditions that can occur with the prolonged awkward position required during riding. Gripping the reins and mallet can aggravate tendinitis usually involving the flexor tendons. Carpal tunnel syndrome, which is a compression neuropathy of the median nerve at the wrist, can be exacerbated by the specific functions required of various equestrian related sports including polo. This requires evaluation by a hand surgeon or a neurologist and simple nerve conduction studies will establish the diagnosis. The definitive treatment is, despite popular opinion, quite simple. This involves release of the transverse carpal ligament, which is a minute outpatient surgical procedure under local anesthesia that is often done endoscopically. It is an unfortunate myth that the public has been led to believe that this is due to typing or computer use.   Other chronic conditions such as lateral epicondylitis (tennis elbow) as well as shoulder bursitis can often be aggravated and conservative treatment suffices. While tennis and golf are traditionally associated to these chronic tendinopathies, gripping the reins for hours can exacerbate the rider predisposed to this condition. Failure of conservative treatment via, steroid injection or rehab is now an indication for the FAST procedure, a minimally invasive solution involving high energy ultrasound to eliminate the common non-healing tendinous lesions. Allowing computers, to get back riding within 1-2 weeks. Osteoarthritis, particularly at the base of the thumb, as is common in middle-aged women, is aggravated by hand positioning during riding. The key for these chronic injuries is to be evaluated by a hand and upper extremity specialist because these diagnoses are often less clear and obvious thus resulting in their diagnosis. The classic fracture discussed amongst horse riders and polo athletes is that of the collarbone, or clavicle.  This occurs when the rider is thrown and the resultant force to the shoulder girdle leads to a break. Fortunately, most clavicle fractures are treated conservatively, with a sling or in youngsters, a figure-of-eight type brace, but it has become increasingly common for prominent athletes to require fixation in order to achieve the best result. Acme trademarks for brought this condition to public eye when he was once seen playing only 3 weeks after plate/screw stabilization of a common injury also ubiquitous in cycling. More important than the common clavicle fracture are the fractures of the wrist, often the scaphoid bone by portion of the forearm where it meets the hand, and is far and the most common fracture in the adult population. It wasn’t until recently that these fractures had been revolutionized by a new method of fixation that was developed by previous colleagues about 10 or even 15 years ago. This involves a mini compression screw that allows for rapid recovery of function with essentially no long-term deficit. Riders can return to their sport within several months after this injury using this new technique. However, the most classic polo injury about the wrist is the dreaded scaphoid fracture that is now managed with a compression screw to allow early motion and avoid stiffness and atrophy from prolonged casting. Until recently, there was a high incidence of scaphoid nonunions where the fracture never heals and leads to chronic issues that needs more aggressive reconstruction. The current protocol of offering early percutaneous (tiny incision) screw fixation has minimized these complications and is preferable for the athlete who wants to get back in the saddle sooner.  More subtle injuries to the wrist include ligament tears between the small carpal bones, which require an astute examination by a wrist specialist in order to establish a diagnosis. This is the most common cause of chronic wrist pain and is an entity that requires careful attention. The clinician should be experienced in wrist arthroscopy since this is the only sure way to establish the diagnosis, and can offer minimally invasive treatment. The smaller bones in the hand can also be involved in trauma from a fall or an ill placed swing of the mallet, including phalangeal and metacarpal fractures, but these tend to be less common. Fortunately, major fractures occur only during high-speed falls or in older riders who may have osteoporosis. Complex fractures about the elbow can occur and there is a great variation in the fracture patterns. It is important that an upper extremity specialist evaluate these injuries, as recovery of full elbow range of motion is often difficult. Fractures

Don’t Blame Your Job or Screens for That Painful Wrist or Hand Numbness HealthNewsDigest.com June 4, 2019 – It is natural to want to ascribe a simple cause to a problem. If your wrist hurts or your hands are numb it must be because of typing. However, according to Alejandro Badia MD, an orthopedic surgeon specializing in treatment of the upper limbs, including hands and wrists says “don’t blame that painful wrist on any physical requirements of your job, including time spent on a computer keyboard or other device. That’s because the problem – carpal tunnel syndrome – is more likely due to hormonal changes, underlying inflammatory diseases or simple wrist anatomy”. The syndrome occurs when the median nerve, extending from the forearm to the hand through the narrow tunnel of bone and ligaments on the wrist’s palm side, becomes pinched and inflamed from irritated tendons or other conditions that cause swelling in the wrist canal. Symptoms, which begin gradually and worsen over time, include wrist or forearm pain; persistent burning, tingling or numbness in the fingers; and decreased hand strength, explains Dr. Badia, founder and chief medical officer of the Badia Hand to Shoulder Center and OrthoNOW®, a group of walk-in orthopedic clinics. The National Institutes of Health reports women are three times more likely than men to experience carpal tunnel syndrome. The higher risk among females is likely due to their anatomically narrower wrist channels and the disorder’s suspected relationship to metabolic and hormonal-level changes during pregnancy and menopause, Dr. Badia says.   “Hormones are chemical substances that impact every organ and structure in the body. Variations in the levels of these substances – such as what occurs in menopause and pregnancy — can lead to fluid retention and thicken the extracellular matrix in the wrist, resulting in pressure on the median nerve” Dr. Badia says. Statistics indicate that 20 percent or more of pregnant women develop carpal tunnel syndrome. Other conditions increasing risk among both sexes, researchers say, are wrist injury, inflammatory and nerve-related diseases like rheumatoid arthritis and diabetes, and a dysfunctional thyroid. The thyroid controls metabolism – how the body utilizes energy from food. What studies fail to show conclusively is any defined relationship between constant use of the wrist and development of carpal tunnel syndrome, Dr. Badia indicates. “Repetitive wrist activities — like typing on a computer keyboard or handling a cash register — may further aggravate symptoms but are not linked to actual development of the syndrome,” he says. “The ‘myth’ that workplace responsibilities cause the problem has resulted in misdirection of billions of dollars into workers’ compensation to treat a condition that commonly occurs in the general population and is unrelated to on-the-job requirements.”   In fact, carpal tunnel syndrome is described as far back as 1025 AD when medieval Persian physician, Avicenna, correctly detailed the wrist problem in his book Canon of Medicine,according to authors of a 2018 article in Integrative Medicine Research. Avicenna suggested that chronic nerve impingement in the wrist is due to both physical disorders and lifestyle factors, such as improper nutrition and lack of sleep. Whatever causes the syndrome, Dr. Badia encourages early diagnosis. “If left untreated, the syndrome can eventually make it difficult for patients to form a fist, coordinate their fingers and do simple, manual tasks like buttoning a shirt or blouse. The disorder may even lead to a wasting of muscle at the base of the thumb,” he says. Initial, recommended therapies tend to be conservative, involving wrist splints at night, anti-inflammatory medications and injection of corticosteroids. Some studies have supported the use of vitamin B6 and or B12.   Should the problem persist, the nerve compression prove severe enough or a physician determine the syndrome is causing deterioration of hand muscles, then minor procedure may be proposed. “The procedure is performed in an outpatient setting under local anesthesia. It involves dividing the ligament that serves as the roof of the carpal tunnel to increase space in the wrist canal and take pressure off the nerve,” Dr. Badia says. “Using a recent treatment breakthrough called endoscopic release, the surgeon can divide the carpal tunnel ligament through a tiny cut in the crease of the wrist without making a larger, open incision,” Carpal tunnel syndrome cannot always be prevented, but risks may be reduced. Dr. Badia offers these tips: Be cautious of hand position during sleep. When sleeping the hand is typically closer to the heart which can cause fluid to pool in the wrist canal. . Relax grip when using tools, pens or other items. Be aware of posture while walking or sitting. Hunching places strain on wrists and hands. Avoid bending the wrist too high or too low. Take breaks when doing any prolonged activities involving hands or wrists. Keep hands warm in a cold environment. Cold hands are a risk factor for developing carpal tunnel syndrome. Alejandro Badia, MD, FACS, internationally renowned hand and upper-limb surgeon and founder of Badia Hand to Shoulder Center and OrthoNOW®, a walk-in orthopedic care clinic. He is a member the American Society for Surgery of the Hand, American Association for Hand Surgery and the American Academy of Orthopedic Surgeons. He is a specialist in treating all problems related to the hand and upper extremity including trauma, sports injury, joint reconstruction, nerve injuries and arthroscopic surgeries.www.OrthoNOWcare.com, www.DrBadia.com