Adult cricketers mostly get injuries to the upper limbs, followed by injuries o the lower limbs and the head. For children, the most common injury site is the head and face, followed by the fingers and hands.

Shoulder injuries

Thrower’s shoulder

It involves injury to the tendons of the rotator cuff (the muscles around the shoulder joint), and may include weakness around the scapula (shoulder blade). There may be associated bursitis (inflammation of the joint sac) within the shoulder.

One specific mechanism for the development of thrower’s shoulder  is the stretching of the anterior ligaments as a result of continuous throwing, which may lead to anterior instability. It may also involve posterior capsular tightness, leading to secondary damage.

Shoulder  pain that gradually worsens when the player throws the ball, and, at a later stage, even when the player is bowling. There are a number of potential causes: poor throwing technique, shoulder muscle imbalance, previous injury, shoulder instability, too much or too little practice, and poor posture.

Traumatic injury to the shoulder

Classically occurs when a fielder dives for the ball and lands hard on an outstretched arm. The injury could include damage in the form of tears to the tendons, cartilage, in and around the shoulder, and dislocation of the shoulder may occur. Pain caused by this kind of injury usually limits participation in the game.

Management includes appropriate diagnosis, which will require referral to an orthopedic surgeon. If the injury is significant, surgery may be necessary. Following this, it is essential that the cricketer be appropriately rehabilitated to prevent weakness of selected muscles, which may in turn lead to future overuse injuries.

Impingement Syndrome

Impingement Syndrome, which is caused by the tendons of the rotator cuff muscles becoming ‘impinged’ as they pass through a narrow bony space called the Subacromial space – so called because it is under the arch of the acromion. With repetitive pinching, the tendon(s) become irritated and inflamed.This can lead to thickening of the tendon which may cause further problems because there is very little free space, so as the tendons become larger, they are impinged further.

Shoulder pain comes on gradually over a long period. Pain when  lifting the arm above 90 degrees. Pain on internal (medial rotation) movements – for example  reaching up behind your back.

Glenohumeral instability

It is most commonly caused by indirect force to the arm moving to outward direction or fall on outstretched arm when it is in internally rotated position.

There is tearing of the glenohumeral ligament and capsule that  causes  joint laxity and subluxation. Pain over the shoulder, inability to use the arm and paresthesia in the arm are usual symptoms. On examination movement of the arm is painful and limited.

Initial treatment is RICE and analgesics as needed and immobilization for 2-3 weeks.

Subluxation may require reduction of joints by Orthopaedician

Glenoid labral tears

Glenoid labrul tears are commonly seen in cricketers while throwing activity due to repetitive microtrauma.

A feeling of clicking or snapping in the joint  with pain mostly during the acceleration phase. Player feels that speed of the throwing motion is decreased.

Initial management is rest, analgesics and sling immobilization. Long term physiotherapy is flexibility and posterior rotator cuff muscles strengthening exercises.

Scapulo thoracic problems

It is common in sports requiring repetitive shoulder motion as in cricket. There is dull ache or pain in shoulder girdle  and pain feels with shoulder elevation movement. Malalignment along the lower scapular border leads to bursitis.

Management is rest and NSAIDS and physiotherapy If conservative treatment fails consult a doctor.

Biceps tendinitis problems

It may be associated with glenohumeral instability or impingement syndrome. There is a snapping feel in the region of anterior shoulder joint. Arm rotation is difficult due to pain.

Management is RICE and analgesics and strengthening exercises of shoulder rotators. Counterforce bracing proximal to biceps belly is useful. If severe cases surgery is recommended.

Management and rehabilitation

Pain management and rehabilitation are the two mainstays of treatment for this condition. Physiotherapy treatment can reduce acute (short-term) inflammation and chronic (long-term) degeneration of the cuff where a tear is not present. The objective of physiotherapy treatment is to limit inflammation using Ice Therapy (never apply ice directly to the skin). Anti-inflammatory medication prescribed by a doctor is often helpful.

Rehabilitation is focused on both stability and strength around the shoulder joint. It is essential that there is a balance of strength and stability around the shoulder and surrounding joints. Rehabilitation and correction of the cricketer’s throwing technique is important to prevent the recurrence of injury.

In cases where structural damage has occurred, the appropriate management would be referral to a shoulder specialist for possible surgical repair.

It is important that any increase in the amount of training or competition must be gradual in order to prevent overload of the Rotator Cuff muscles. In particular, bowling and fielding practice should be increased gradually to allow the Rotator Cuff tendons to adapt.

Elbow Injuries

Medial Epicondylitis

There is pain in the medial aspect of elbow joint. It is common in the fielders while repetitive throw the ballot the centre.

Pain on the inside of the elbow when you grip something hard. Weakness in the hand and wrist may be present.In severe cases pain becomes more severe and constant.

Management is RICE and analgesics.physiotherapy like Laser and Ultrasound is effective.If not cured with conservative treatment surgery is recommended.

Median Nerve Entrapment Syndromes

Sites of compression include at the proximal or the middle forearm.

Signs and symptoms: These include pain in the front part of forearm that is exacerbated with activity and relieved by rest; decreased sensation in the thumb, index finger, long finger, and radial side of the ring finger; weakness of thenar muscles.

Treatment includes rest and anti-inflammatory medications. Surgical treatment includes exploration of the median nerve in the proximal forearm, and the release of all sites of possible compression.

Ulnar Nerve Entrapment Syndromes

Sites of compression at the medial side of elbow joint. It may be because of direct trauma as ball travelling to the boundary and hits the fielder or repetitive elbow flexion.

Symptoms include pain in the forearm, which radiates, numbness, tingling in the little and half ring fingers. Wasting or weakness of intrinsic hand muscles, and the reproduction of symptoms with elbow flexion, with or without wrist extension.

Treatment include  pillow splints during night  to keep the elbow extended. Rest and anti-inflammatory medications are also useful. Surgical methods focus on releasing the nerve along its course at sites of compression.

Triceps tendinitis

There is inflammation at the triceps muscle-tendon unit. It is because of repetitive microtrauma to the muscle as in full elbow extension movement.There is pain and swelling at the posterior aspect of elbow joint.

Initial treatment is RICE and NSAIDS. Physiotherapy like Laser and ultrasonics to relief the pain.

Osteochondritis Dissecans

Seen most frequently in young  players. Cause is repetitive stress to radial head due to rotation, extension and valgus overload.Pain increases with the sporting activity. Intermittent clicking and locking of elbow joint .X-rays shows presence of loose bodies.

Initial treatment is rest for 6-12 weeks and casting followed by physiotherapy.

Wrist and hand injuries

Mallet finger-Can occur in any activity while playing cricket where the finger is subject to jamming. Pain at the distal interphalangeal joint . Cricketer is unable to extend the distal interphalangeal joint. X-ray shows bony avulsion from the distal phalanx. Splinting for 6-12 weeks and rest is required.

Volar plate rupture-The volar plate is fibrocartilage structure reinforcing the palmar aspect of interphalangeal jont. An injury to the finger at this level can also damage the volar plate. Treatment can include splinting and occasionally hand surgery.

Collateral ligament tears-It result from valgus and varus stress to the metacarpophalangeal  joint and interphalangeal joint. Pain and swelling at the involved joint and on examination joint laxity is present. Initial treatment is rest and splinting for 3 weeks. If unstable then refer for surgical repair.

Fracture-Fracture can occur in carpals, metacarpals and phalanges caused by direct trauma from either an axial load or compressive forces. There is pain and swelling over the area. There is varying degree of angular and rotational deformity depending on the type of fracture.

Treatment of finger fractures differ for the type. These fractures are generally immediately treated by means of the “so called” buddy strapping  technique, by which the injured finger is attached to the adjacent finger, with some stability and support.  A hand specialist needs to be consulted as soon as possible. Any fracture takes six weeks to heal completely.

In a limited number of cases surgery may be required. Physiotherapy is important for pain management, swelling control, and to ensure that the finger and hand do not become stiff and weak during the period of healing.

Web space splitting (especially between thumb and index finger) when players dive in the field and their hands collide with the ground, or catch a ball awkwardly. This also sometimes includes a joint dislocation.

If web space is split, with joint dislocations, with or without fractures, a hand specialist is crucial.

Split webbings have a high incident of reoccurrence, as the scar tissue that heals is very weak and vulnerable to the same impact forces, and special taping might be essential for a good few weeks after the injury. Sometimes specially designed gloves have to be made if it continues to re occur despite all efforts – these have to be cleared by cricket governing bodies, boards, and umpires for each match/season.

PREVENTION

1.Always warm up and stretch

2.Suitable and properly fitted footwear should be worn

3.Wear protective gear during practice as well, not just during formal play

4.Have physical training before the start of the season

5.Make sure you have proper instruction on how to do skills (ex. bowling)

6.Have good sportsmanship, just have fun

7.Have a first aid kit on hand and be able to use it for minor injuries

8.Have a way to reach medical personnel in case of emergency situations

UPPER LIMB INJURIES IN WEIGHT LIFTING

Weightlifting is among common athletic activities leading to injuries. Using proper technique during weight training and knowing your limits prevents workout injuries. And knowing proper rehabilitation after suffering weightlifting injuries helps maintain conditioning and recovery.

Such injuries are classified in two main categories: instability and impingement injuries. When shoulder joint moves out of its socket, weight trainers often suffer instability injuries, including pain and possible dislocation. Impingement injuries follow excessive friction between shoulder muscles and the shoulder blades during overhead activities such as weightlifting.

Weightlifting has many benefits for the human body that include increasing strength, muscular endurance, cardiovascular endurance, bone density and flexibility. However, improper training like overloading muscles too much, neglecting certain muscles or creating muscle imbalances potentially injure muscles through weightlifting. Consult a doctor if you experience any of these problems.

SHOULDER INJURIES

Weight-lifting shoulder injuries arise from the repeated movement of soft tissues in the shoulder in conjunction with and sometimes between bones and joints.When you raise your arms during weightlifting, a series of muscles known as scapular stabilizers move to keep bones in the right place — sort of like the gears of a clock working together to move the hands. All at once, rotator cuff muscles coordinate movement of arm and shoulder bones. If any of these steps is off balance, bones bump into and sometimes sandwich tissue, leading to pain and injuries over time.

TORN ROTATOR CUFF

The rotator cuff is composed of six muscles that hold your shoulder blade and humerus — upper arm — together. There are multiple reasons why you can damage your rotator cuff, but a common reason for damage when lifting weights is because you may be lifting a weight that is too heavy for shoulder to support. Performing an exercise with poor technique, that loads the rotator cuff muscles improperly, will also make you susceptible to injuring the muscles. Lifting weights over your head and performing pulling motions are the most common types of exercises to hurt your rotator cuff through weightlifting.

If you experience shoulder stiffness,have pain on movement and difficulty in overhead lifting of arm, have trouble rotating your arms, feel the shoulder joint moving out of place and are too weak to carry out normal daily activities, you likely have a shoulder injury requiring medical evaluation or treatment

TENDINITIS/TENDONOSIS

The tendons attach the muscle to the bone. In order to achieve rapid movement and contraction, the tendons are housed in sheaths, allowing them to move smoothly. Overuse of the tendons, including shoulder tendons, can create friction in the sheaths, causing heat to build up. Excessive strain or lifting weights that are too heavy can eventually lead to inflammation, altered tissue alignment and irregular movement. These issues will not allow the tendon to move smoothly, and cause pain in the affected area.

BURSITIS

A bursa is a small fluid-filled sack that acts as a cushion and lubricating shield between tendons and ligaments and bone. There numerous bursa around the larger joints of the body. Direct trauma to the shoulder, like dropping a weight on it, can cause the bursa to become inflamed and irritated. More commonly though, the bursitis develops from overuse or repetitive strain from weightlifting and not appropriately treating existing shoulder injuries.

STRAIN/SPRAIN

These injuries can happen from a rapid stretch or change in direction of the tissue when the body is fatigued. Additionally, lifting a weight that is too heavy and trying to power through it by adding a swinging motion to the exercise versus a lifting motion can also cause injury to these soft tissues in the shoulder.

Treatment

Weightlifters suffering shoulder swelling and pain to visit doctors for immediate diagnosis and treatment, because continuing workout regimens under such conditions often leads to more serious injuries. However, doctors may clear patients for certain lower-impact exercises — sometimes under the supervision of trainers — to maintain conditioning and aid in the healing process. A number of modifications to weightlifting regimens, shifting stress and burden from the affected areas while allowing conditioning during the healing process. Such modifications include lifting and squatting exercises that avoid shoulder movement or securing a weight bar with crossed arms over the chest region, again shifting stress away from the shoulders.

Beside healing exercise doctors sometimes prescribe anti-inflammatory medications to reduce swelling and discomfort. Early detection and treatment through exercise helps avoid the need for surgery.

Injury Prevention

Prevention techniques for shoulde injuriesinjuries include exercises to keep that portion of your body strong and avoiding overworking of the shoulder during weightlifting. The Sport Injury Bulletin recommends never increasing weightlifting workloads by more than 10 percent per week to reduce injury risk. Consulting sports medicine specialists before beginning workout regimens also helps identify existing problems in shoulder function and range of motion. And workout techniques evaluated by professional trainers often mean fewer injuries.

Straining to finish that last hammer curl may be the difference between buff or broken when working out. The shoulder is one of the most mobile joints in the human body and is surrounded by muscles, tendons, ligaments, bursa, nerves and blood vessels. Damage to any one of these structures can cause pain and a loss of function in the shoulder.

ELBOW INJURIES

Weight lifting provides you with a number of benefits including increased strength, bone mass and metabolism, but it doesn’t come without risk.Elbow injuries do not occur as often as other injuries.

In addition to the bones, numerous ligaments, muscles and nerves run through the joint in a complex arrangement, all working intimately together to contribute to the movement of the forearm. The elbow joint is under mechanical stress that leaves it susceptible to injury during weight lifting.

Biceps tendinosis commonly results from repetitive elbow flexion while the forearm remains in a supinated position. Repetitive biceps curls are an example of this type of exercise.

Triceps tendinosis commonly results from repetitive elbow extension, particularly forceful extension. If you experience pain in the back of your arm, especially while forcefully extending your elbow, you might suspect triceps tendinosis. Performing too many triceps extensions could result in this injury.

Anterior capsule strain might occur when the elbow hyperextends. You might incur this type of injury during a preacher curl while using too much weight. If you allow your elbows to fully extend, but you cannot control the the movement your elbow might hyperextend.

Radial tunnel syndrome remains fairly uncommon, primarily because it occurs with repetitive pronation and supination of the forearm, or back-and-forth rotation of the forearm. Some athletes, like baseball players, perform internal and external rotation exercises of the forearm that could result in this type of injury.

Ulnar nerve entrapment results in pain in the elbow as well as tingling in the ring and little fingers. While it commonly occurs with weight lifting, no specific exercise is identified as a contributing factor.

Treatment and Prevention

To help prevent any weight-lifting related injury, including elbow injuries, it’s important that consult a professional before starting a weight-lifting program. Make sure you know how to perform exercises properly and that you don’t try to lift too much weight.Work your way up to lifting more weight, and don’t overdo it or lift more than you comfortably can. When lifting heavier amounts, recruit a spotter to make sure you don’t compromise your form. And, if you experience pain, stop the exercise and follow “R.I.C.E”: rest, apply ice, compress the injury, and keep your elbow elevated.

WRIST INJURIES

Wrist injuries can occur during to weight training and they can cause wrist pain. If you are weight training and experiencing wrist pain it is important to stop immediately and seek medical attention.

SYNDESMOSIS INJURY

This common injury is often seen in weight training when the athlete tries more weight than he or she can handle. It is characterized by interosseous membrane damage and this membrane is fibrous and connects the two lower arm bones. Pain is the symptom and as damage continues and starts to include other tendons and ligaments the pain can become very severe and the damage can become irreversible. Treatment can include cartilage-stimulating supplements, wrist braces and ice massages on the affected wrist.

TENDINITIS

Tendinitis is an overuse injury in which a tendon in the wrist becomes irritated, inflamed and swollen. Pain, redness and warmth are the usual symptoms. Treatment often includes immobilization or rest, nonsteroidal anti-inflammatory drugs, physical therapy, icing the affected wrist and in severe cases, surgery.

CARPAL TUNNEL SYNDROME

Carpal tunnel is characterized by pressure on your median nerve and it is also an overuse injury. You may experience numbness or tingling, pain that radiates to thumb,index and middle finger, weak grip, wrist pain, muscle wasting in severe cases and weakness.Treatment usually includes splinting the affected wrist, not stressing the wrist, nonsteroidal anti-inflammatory drugs.If these measures fail to resolve the sypmtoms then surgery is required.

WRIST STRAIN

A strain occurs when a tendon or muscle is pulled or twisted and is classified as an overuse injury. Symptoms include muscle spasms, pain, limited motion, weakness, inflammation, cramping and swelling.Treatment includes icing the affected wrist, splinting or bracing the wrist, nonsteroidal anti-inflammatory drugs and in severe cases, surgery.

Treatment and Prevention

In initial phase, to reduce pain and swelling follow the R I C E protocol that is to take Rest, apply Ice and put on Compression/Elevation bandage .Do not go for weight training exercises as it will make the healing longer. If not cured, consult a specialist .

UPPER LIMB INJURIES IN BOXERS-

Boxing is a contact sports demands strength and speed, both of which pushes muscles and tendons to perform more than normal capacity. Soft tissue in the arms, shoulders and hand is under constant pressure, often suffering injuries. Therefore soft–tissue injuries, sprains and strains but occasional fractures are also seen.

Local swelling, increased local temperature and pain are clinical finding of soft tissue damage. Fractures shows deformity of bony fragments and loss of movement in addition.

SHOULDER INJURIES

ROTATOR CUFF INJURIES

The rotator cuff muscles of shoulder joint can tear because of acute trauma or chronic overuse. An acute tear usually occurs due to a sudden, powerful movement, such as a boxing jab. A chronic tear develops over time..

Punching off-balance, punching too hard, a powerful jab that misses its target completely can cause shoulder dislocation and ligament tears. Other tears in the rotator cuff or ligaments can occur if the fighters punch poorly or have not stabilized the core muscles.

A partial or incomplete tendon rupture is effectively treated by non-surgical methods including splinting, anti-inflammatory medication, ice, heat, physical therapy and occasionally local injections.

In contrast, the complete tendon rupture is optimally treated by surgical repair. In all cases, before the fighter resumes punching, the hand must be thoroughly healed and rehabilitated as long as three months.

BICEPS TENDON RUPTURE

Boxers maintain a “guard” with elbows down and fists up, held in front of the face to deflect an opponent’s attack. Bending the elbows also allows you to generate power for your own punches. Strong biceps and triceps — muscles at the back of your upper arm -help for both while guarding and punching.

Biceps tendon tears are either partial or complete. Often a product of overuse and repetitive movement, tears can begin as frayed tendon fibers.

Tear to shoulder attachment of biceps tendon can result in muscle weakness, inability to bend elbow and rotate palm upward.

Tears to the elbow attachment of biceps tendon — are less common but potentially more severe than previous one. It occur when the elbow is suddenly straightened while you are bending it. For boxers, this injury is sidelining. If full use of the arm is desired, surgery is often the course of action.

For severe injuries, or for athletes who need full range of motion, surgery is recommended. Non-athletes and older patients with tears may opt for non-surgical rehabilitation.

HAND INJURIES.

.

CARPAL FRACTURES

Scaphoid fractures are the most common and problematic fractures account for approximately %60 of all carpal fractures. These usually occur while landing on hand during a fall.

The usual time to achieve union is nine to 12 weeks if the fracture is treated acutely. Healing time may be shortened by percutaneus cannulated screw fixation enable the athlete to return to boxing in about six weeks.

Displaced acute fractures are treated with open Reduction and internal fixation (ORIF)

Delayed union and non union scaphoid fractures are treated with open

reduction internal fixation with a vascularized graft .

FRACTURES OF THE METACARPAL SHAFT

These fractures are usually the result of a direct blows

.

The clinical symptoms are point tenderness, pain and local swelling, deformity if there is displacement of the fractured fragments. Metacarpal shaft fractures should be evaluated for displacement, angulation, rotation and shortening.

Theses fractures can bet reated in plasters, however there can be a deformity and altered grip.

These fractures in boxers are best treated by surgery. Returned to boxing should be delayed for a minimum of 3 months.

FRACTURES OF THE METACARPAL NECK

In boxers the most commonly seen metacarpal neck fracture is the fifth metacarpal.

This injury is known as a Boxer’s fracture.

Clinical symptoms include pain, swelling, loss of full joint extension, and either ulnar or radial subluxation of the extensor tendon.

The treatment is closed reduction and fixation with K- wires. If it fails, open reduction and internal fixation becomes the treatment of choice.

FRACTURE OF THE BASE OF THE FIRST METACARPAL (BENNETT’S FRACTURE)

Bennett’s fracture is an intra–articular fracture of the base of the first metacarpal. It

is usually unstable.

The treatment is anatomic reduction and K- wire fixation of the base of the first metacarpal to the trapezium. Repair should be protected by a thumb spica cast for 4 weeks.

INTERPHALANGEAL JOINTS

Stability of the interphalangeal joints depends on bony congruence, collateral ligaments, the volar plate and the extensor tendon. Treatment is usually splinting.

DISLOCATION OF THE INTERPHALANGEAL JOINTS

Dislocations of the interphalangeal joints are two types the common posterior

dislocation and the rare anterior dislocation

.

Clinical findings are acute swelling and pain accompanied by deformity

.

Treatment is closed reduction and splinting for a period of 3 weeks.

CHONDRAL LESIONS

Traumatic articular cartilage lesions may result from a single injury or occur with repetitive blows.

Symptoms are localized pain, especially with motion.Radiographs, arthrography and ligament tests are normally performed to evaluate this condition.

Treatment consists of rest and the avoidance of impact and lifting for 3 to 4 months.

BOXER’S KNUCKLE

Boxers may injure their knuckle either as a single traumatic event or from repetitive blows. Most often such injury results in a longitudinal tear of the extensor

digitorum communis tendons combined with disruption of the dorsal joint capsule

.

A boxer presents with pain over the metacarpo phalangeal (MCP) joint and lag in active extension at the metacarpo phalangeal joint.

Treatment involves surgical repair followed by 6 weeks of immobilization; then, an aggressive rehabilitation program. The boxer should not return to punching until normal motion and full strength have been restored.

BOUTONNIERE DEFORMITY

Rupture of the central slip of the extensor tendon at its insertion at the base of

the middle phalanx should be treated immediately. Any delay in treatment may result

in a boutonniere deformity .

Clinically, the patient presents with maximum tenderness on the dorsal surface of the proximal inter phalangeal (PIP) joint. Full active extension of the PIP joint may be lost.

Injuries presenting within three weeks of injury must be splinted for 6-8 weeks.

The PIP joint should be splinted in extension while the DIP joint is allowed to flex.

TENOSYNOVITIS OF THE HAND AND WRIST

Tenosynovitis of the hand and wrist is quite common in boxing. Treatment includes rest, splinting and corticosteroid injection. In case of recurrent symptoms or in the late stages of fibrosis, injection is less helpful, and surgical decompression is recommended.

DORSAL WRIST GANGLION

Dorsal ganglion, the most frequent soft-tissue tumor of the hand is common in the boxers. History of specific trauma has been noted in 15% of visible ganglions.The clinical symptoms are with point tenderness over the ganglion.Symptoms usually worsened with wrist movement.

Initial treatment may be with local injection of corticosteroids. The definite treatment

is surgical excision.

Prevention

A boxer with minor injuries, who fears more serious injuries in the future, ask to examine his punching technique and do exercises to keep his muscles strong. Faulty punching technique may be the problem, rather than a weakness in the muscles, so the fighter should enlist his coach to examine the extension and form of his technique with the gloves off.

As with all sports injuries, optimal management of the boxer’s hand must focus on innovative concepts of prevention. Improved training techniques, rotational hand taping and wrapping, anatomically designed protective devices for training, and enhanced safety features of gloves for bouts are necessary to lessen the incidence of potentially disabling hand injuries.

Rehabilitation

The job of a physiotherapist is to treat “injury or dysfunction with exercises and other physical treatments of the disorder.” The role of physiotherapy in boxing is twofold. Boxers are treated on a regular basis by a physiotherapist, both for prevention — sometimes called prehabilitation — and rehabilitation of injuries.

The role of rehabilitation is to rest it and use the traditional RICE treatment — rest, ice, compression and elevation.

Strength training is important to prevent these types of injuries in boxing. Specific exercises, such as using resistance bands or free weights, help strengthen your muscles and ligaments.Stretching exercises are important to maintain flexibility of the muscles and range of motion of the joint.

A boxer is advised to squeeze a tennis ball, use a hand grip, or try a theraball to strengthen hands, wrists and forearms. He can emulate climbers by hanging onto a chinup bar by his fingertips.

patient was immobilized in above elbow slab for 3 weeks.  At 4 weeks patient reported in our out patient department with weakness of flexion and supination. patient was advised repair od distal bicerps tendon. transverse incision given in cubital fossa and ruptured tendon with frayed edges delivered.

locking nonabsorbable sutures passed through distal end.

Stured delivered to dorsum of forearm into second incision. radial tuberosity identified and window made into cortex.

Through the  drill hole on side of window sutures delivered inside out so that once sutures are tied over endobutton end of tendon enters into window thus  giving stable fixation and better chances of  healing.

• There should be negative tilt of the keyboard that is rows of keys farthest away from you should be  slightly lower so that while typing wrists are not bent upwards.
• Height of keyboard should be such that wrists are in neutral position while shoulders are relaxed and elbows are bent less than 90degrees.
• Use arm to navigate mouse rather than side to side movements of wrists
• Mouse should be at same height as keyboard by its side.
• Keep fingers and thumb relaxed on the keyboard and don’t use excessive force to activate keys.

Posture

• Wrist should be horizontal in line with forearm so that wrist is not bent upwards or downwards. More that 15 degrees variation either way increases pressure on median nerve.
• Middle finger should be in line with the forearm, neither angled towards thumb or little finger.

1. Position the monitor in centre, in front of the keyboard so that you are facing it directly.
2. Top of the screen should be at eye level. A screen that is too high or too low will cause awkward positioning of the head, neck, shoulders and back.
3. Tilt your monitor upward so that the base is slightly closer to you. This improves legibility of print and reduces eye strain.
4. Install the monitor on a swivel arm so you can easily make small adjustments in height and distance. Especially if you sharing your computer height of chair must be adjustable.

The above mentioned article was published from Edinburgh, United Kingdom. Authors assessed efficacy of primary arthroscopic Bankart repair and also compared the results with arthroscopic lavage. This study is very well designed double blind prospective trial. It included 84 patients aged between 15-35 years.

Authors concluded in this study in Bankart repair group risk of all instability reduced by 82%. The functional scores were better, treatment costs were lower and patient satisfaction was higher after arthroscopic repair. Regarding cost according to authors initial cost is high because of surgery but subsequently because of recurrent instability no. of working days lost and additional procedures are also required. There fore authors recommended early arthroscopic Bankart repair even after first time traumatic anterior dislocation of shoulder.

Further I would invite comments from my orthopedic colleagues regarding this study and its conclusions.

Let me introduce you to AO Fellowships which are awarded by AO foundation through AO education. I came to know about AO Hand fellowships when I was visiting Massachusetts general hospital (Harvard University), Boston there I met AO hand fellow that time I came to know that AO institutes fellowships in hand & spine besides trauma.

I started fellowship on 10^th November 2008 at “Zentrum fur ambulante Diagnostik und Chirurgie” at Freiburg, Germany with Dr. med Klaus Lowka one of the pioneers of hand surgery in Germany and practicing hand surgery since 1979.

In 2008 clinic was celebrating its 15^th anniversary. At this clinic between around 2500 hand surgeries are done per year. In the subsequent submissions I would be narrating cases and surgeries we performed.

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