Hockey Lacerations: Life in the NHL

As evidenced by Zach Werenski of the Columbus Blue jackets last week hockey players are tough and always want to come back and finish the game. Our job as team physicians is to protect the players and make sure there is no additional damage beyond the face laceration. Additional injuries can include eye damage, facial bone fractures, dental injuries and concussions.

With the St. Louis Blues we are fortunate to have excellent consultants to help me rule out any other injuries. We have a dentist (Ron Sherstoff) and oral surgeon (Ken Kram) present at every game. Additionally, we have opthalmologists (Gil Grand) and plastic surgeons (Tom Francel) available some nights in the arena, but always available for follow up exam.

With every facial laceration we do a neurological exam to rule out a concussion and if there is any doubt we will hold the player and do additional testing. 

To finish the story of Zach Werenski he returned for the game in a shield, but he developed significant bruising and swelling. He tweeted his own picture after the game below and then was diagnosed with a blowout fracture of his upper facial bones surrounding his eye.He missed the rest of the playoffs with Columbus

Shoulder Separations

It is football season with hockey not too far behind so we are beginning to see shoulder separation injuries showing up at the Washington University Orthopedic Injury Clinic. Patients always are confused as is the media on the difference between a shoulder separation and a shoulder dislocation. A Shoulder Disloction and its Treatment as previously reviewed on this blog refers to the humeral head (ball) sliding off the glenoid (socket). This frequently needs to be put back in place and frequently requires surgery to prevent future episodes.

A shoulder separation on the other hand is typically treated conservatively and rarely requires surgical reconstruction except in severe circumstances such as the injury Sam Bradford sustained while playing for Oklahoma. The injuries most commonly occur in contact sports but are also frequently seen in cycling injuries when riders fly over the handle bars and land on their shoulder. It is typically a blow to the point of the shoulder that drives the shoulder blade down and stretches or tears the ligaments that connect the collar bone (clavicle). These ligaments are called the coracoclavicular

ligaments and are 2 tough bands running from the collar bone to the coracoid -- a bony prominence projecting from the scapula. It also occurs frequently in hockey when players are checked into the boards or fall and hit the ice. Typically it causes local pain in the shoulder area with limited range of motion and weakness. Initially it is treated with a sling ice. A plain x-ray showing the depressed shoulder blade and ruling out a fracture is all that is necessary. An MRI is not required.

Physical Therapy is begun soon after the injury with a focus on motion and strength. Once the pai n is tolerable and full motion and strength is regained the athlete can return to sports with no long term sequelae except some prominence of the clavicle in that area.

 There are 6 grades of injury with most falling into Grades 1,2 and 3. Grades 1 and 2 are always treated conservativeley. Grade 3 with worse ligament damage and more deformity is still usually handled without surgery. Occasionally throwers or other overhead repetitive workers require repair/reconstruction of the ligaments. Fortunately, despite several injuries of the Type 3 severity with the St. Louis Blues we have never had to perform a surgical reconstruction. Grade 1 injuries typically require 1-2 weeks for recovery, Grade 2 2-4 weeks of recovery and Grade 3 treated without surgery are 6 week injuries.

Oblique Muscle Strains

Once again this season baseball players have been affected by oblique muscle strains. Most recently it impacted the St. Louis Cardinals when their All Star infielder Matt Carpenter sustained the injury missing a month of games including the All Star Game. Why are these such significant injuries for some sports and playing positions while you never hear about them in other sports?

The oblique muscles reside on both sides of the abdomen and chest running from the pelvis to the chest and ribs in the front and chest and spine in the back. There are 2 muscle groups on each side--- the internal and external obliques. Rather than running straight vertically or horizontally they run “obliquely” across the body and thus their name is derived.

These muscles are critical for rotational activities and that is why they are more impactful for certain sports. While challenging for any athlete an oblique muscle strain is the worst for those athletes that repetitively rotate. Thus baseball pitchers and hitters are highly affected. Hockey players are also bothered by it while shooting especially during slap shots.

We have had several with the St. Louis Blues over the years that resulted in several man games lost. It much less frequently affects sports that are more linear such as track, swimming, football or basketball. It is an infrequent injury even for quarterbacks and I can’t remember a significant oblique injury with loss of time for any of the Rams quarterbacks.

Treatment is similar to other muscle strains and involves conservative management with ice, NSAIDs and rehabilitation including stretching and strengthening. Nothing seems to shorten

the recovery which for baseball position players is typically a month. If anything more than a minor strain for a pitcher it can cost 6-8 weeks. Cortisone injections can be utilized, but still time is the best ally and cortisone is relatively a quick fix. These muscle strains typically are diffuse over a relatively large area and thus difficult to pinpoint for an injection. Likewise there is no scientific evidence that platelet rich plasma (PRP) or stem cell injections will speed recovery. That is why these are difficult injuries for the athletes and the fans that follow them. It is hard to be patient.

St. Louis Blues Team Physicians

Our Group is dedicated to care for the injured athlete and provides care for a variety of sports teams in the region. Here is a story describing our work with the St. Louis Blues
St. Louis Blues Team Physicians