Stinger/Burner Nerve Injury

A “stinger” or “burner” is a common transient injury that occurs in contact sports such as football. The injury occurs from stretching the upper trunk of the brachial plexus or compression of the C5-C6 nerve root.

contactStretching of the brachial plexus is the mechanism of injury typically seen in high school aged athletes suffering from this condition. This injury occurs from a direct blow, causing the shoulder to be depressed and forcing the neck into lateral flexion, causing the neck to bend toward the opposite side.

stretchingCompression of the nerve root is the basis of injury most often associated with older athletes. It is not a cervical cord injury and it is not a transient quadriplegia.

compressionThe patient will complain of burning pain, numbness, and weakness with painful symptoms starting above the shoulder, going down to the arm. Symptoms will begin immediately after the trauma occurs and can last from several minutes up to several weeks after the accident, but they will usually resolve themselves. A stinger or burner is a transient, intensely painful nerve injury that may result in time loss from competition.

burner pain

When the injury occurs, the athlete should stop participating in sports until full recovery of strength, sensation, and pain-free range of motion is reestablished to the cervical spine. Treatment consists of alternating between ice and heat, anti-inflammatory medications, and rehabilitation exercises. An MRI may be necessary to rule out a herniated disc. Surgery is usually not necessary for a Stinger/Burner injury.


Carrying Angle of the Elbow

The carrying angle of the elbow is the clinical measurement of the varus-valgus angulation of the arm with the elbow fully extended and the forearm fully supinated. With the arms extended at the sides and the palms facing forward, the forearm and hands are normally slightly away from the body.

axis The intersection of the axis of the upper arm and axis of the forearm defines the carrying angle. The carrying angle is greater in shorter persons compared to taller persons. The shorter the forearm bone length is, the greater the carrying angle will be. The normal carrying angle of the elbow is between 5-15°. The carrying angle is greater in women and in throwing athletes. It is difficult to assess if there is a flexion contracture of the elbow. This angle permits the forearms to clear the hips in swinging movements during walking, and is important when carrying objects.

carrying angleCubitus varus is the opposite of cubitus valgus, causing the elbow to have inward angulation towards the midline of the body. Cubitus valgus is a deformity which causes the forearm when it is fully extended to be angled away from the body in a greater degree than normal. Supracondylar fractures usually occur in children.

If the fracture is malaligned and if it heals in a malaligned position, the fracture may develop into a severe varus deformity of the elbow which decreases the carrying angle of the elbow. This decrease of the carrying angle causes the elbow to have more of an inward angulation towards the midline of the body. This creates what is called a “gunstock deformity”. The deformity is caused by fracture malunion. This is usually a cosmetic deformity with little functional limitation.leading

A fracture of the lateral condyle of the humerus can lead to:

  1. Cubitus Valgus
  2. Stretching of the ulnar nerve

If the fracture did not heal or the fracture is malaligned, the medial part of the humerus will grow and the lateral part will not grow. The forearm will drift into valgus malalignment. The carrying angle will increase (cubitus valgus) and the ulnar nerve will be stretched and may need transposition. The nonunion of the lateral condyle of the humerus may need fixation in order to stop progression of the valgus deformity. 30° of varus or valgus angulation is tolerated in fractures of the humerus without any clinical functional significance.thirty


Haemarthrosis of the Knee

Hemarthrosis is blood inside the knee or bleeding into the knee joint space. The swelling and fluid inside the knee joint is usually relieved with an aspiration. During the aspiration, the physician will insert the needle on the lateral side of the knee, just above the upper border of the patella. The needle enters below the patella into the suprapatellar bursa which is continuous with the joint cavity. This aspiration technique is different than how physicians perform injections. For a knee injection, the needle is inserted at the lower border of the patella on either side of the patellar tendon at the soft spot.

aspiration v inspirationThe color of the fluid aspirated—not bloody effusion—is probably due to synovial irritation caused by chronic processes such as gout, pseudogout, arthritis, rheumatoid arthritis, or degenerative meniscus. A degenerated meniscus may be associated with swelling and fluid collection; usually not bloody. The peripheral portion of the meniscus is vascular (about 3-5 mm). The blood supply of the meniscus originates from the medial and lateral genicular arteries. Although a degenerative meniscus effusion is not bloody, a traumatic tear of the meniscus may cause bleeding inside the knee joint.

arthrA bloody effusion could be trauma related or non-trauma related. For example, hemarthrosis can be caused by trauma or injury to the structures of the knee such as the ACL, PCL, or meniscus. Hemarthrosis can also occur due to tibial plateau fractures, chondral fractures, patellar dislocations, or a meniscal tear. Non-traumatic conditions that can cause hemarthrosis include: PVNS, sickle cell anemia, hemophilia, anticoagulation, or hemorrhage following total knee replacement.

Hemoarthrosis from trauma or injury indicates a significant knee injury such as ACL (75-80%) or a meniscal tear. If aspirations of the knee after trauma shows hemarthrosis, early evaluation of the injury may be necessary to define the extent of damage. The physician may get an MRI early.

meniscusAbsence of hemarthrosis does not mean a less severe ligament injury—the blood may escape without distending the capsule. A severe injury may cause minimal or severe joint effusion. More than 20cc of fluid may affect the quadriceps function and prevent full extension of the knee. A hematoma should be evacuated. The bloody aspirate should be examined for fat to rule out a fracture. The aspirate may vary in color depending on the severity of the injury and the duration of the symptoms. Fat is less dense than blood and fat floats on the surface, whereas blood is heavier and stays on the bottom.

mri.The presence of a fat/fluid level is diagnostic of a fracture even if a fracture is not seen on an x-ray (occult). Fat/fluid level is usually seen with tibial plateau, chondral, and patellar fractures. The cross table lateral view of the knee shows it well. When a fat/fluid level is seen, look for intra-articular fractures. Lipohemarthrosis is only seen on horizontal x-ray beams with the beam parallel to the floor. It occurs in 40% of all fractures inside the joint.


Intrinsic Plus Hand Contracture

Contractures of the intrinsic muscles of the fingers disrupts the delicate and complex balance of the intrinsic and extrinsic muscles. Sometimes, it is called Intrinsic Plus Hand. The hand assumes a posture with a hyper flexed metacarpophalangeal (MCP) joint and a hyperextended proximal interphalangeal (PIP) joint. Contracted interossei and lumbrical muscles deform the natural cascade of the fingers. Severe disability may result because of weakness in grip and pinch strength as well as difficulty in grasping large objects.


Intrinsic Contracture of the hand is caused by trauma, spasticity, ischemia, rheumatological disorders, vascular injuries, and compartment syndrome.

bunnellWhen testing the digit for intrinsic muscle or capsular tightness, you will perform the Bunnell Test. When the MCP joint is in extension, the intrinsic contracture (interosseous and lumbrical muscle contracture) impedes the flexion of the PIP joint. When the MCP joint is flexed, the PIP joint flexion increases.

Bunnel IITo treat intrinsic tightness, physical therapy is usually recommended first—passive stretching and orthotics in mild cases. Surgery is performed if the condition is severe or if noticed too late. Surgery will consist of a distal intrinsic release of the oblique fibers and preserving the proximal transverse fibers. Options for surgical management are diverse and decided by the cause and severity of the contracture.

When testing for extrinsic tightness, you will place the MCP join in flexion and try to passively flex the PIP joint. The PIP motion is less with the MCP joint flexed than when it is extended (opposite of intrinsic contracture). Treatment consists of aggressive therapy and tenolysis. PIPjoint contracture

A PIP joint contracture is determined when the loss of motion of the PIP joint is the same with the MCP joint extended or flexed. Intrinsic minus hand, or Claw Hand, is a condition usually secondary to a crush injury caused by contracture of the intrinsic muscles of the hand. Intrinsic minus hand is characterized by the flexion of the PIP and DIP joints as well as the extension of the MCP joint.