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A Silicone Splint to Prevent Diving Injuries of the Thumb
PRACTICE FORUM
A Silicone Splint to Prevent Diving Injuries of the Thumb Therapists who treat sports-related injuries frequently have to use a significant amount of creativity to return the injured athlete to their activity. In addition, we might be asked to protect the athlete from injuries that could occur. Our decisions on what materials to use can also be difficult, based on the environment in which the athlete performs their sports. In this particular article, the author has the challenge of providing something for the divers that is water resistant and does not limit their performance.—PEGGY FILLION, OTR/L, CHT, Practice Forum Editor
A SILICONE SPLINT TO PREVENT DIVING INJURIES OF THE THUMB Carla Doyle, MOTR/L, CHT BONES Physical Therapy & Sports Medicine Sonora, CA
Paul LaStayo, PhD, PT, CHT University of Utah Division of Physical Therapy Department of Orthopaedics Department of Exercise and Sports Medicine Salt Lake City, UT
Edward Damore, MD San Jose, CA
Most diving injuries occur upon entry into the water.1 A survey completed by 37 divers in 1980 reported that 61% had an upper extremity injury.1 In the past 25 years, there has been a newly adopted flat hand entry technique (Figure 1) that now supercedes the original closed fist technique.7,8 Although the open-handed technique results in a smoother entry, the danger is that the diver is at a greater risk of hand and wrist injuries.7 The closed fist technique surface area exposed to injury is less than half that of the open hand technique.5,8 The evolution toward the open hand technique has the potential for a perfect entry without a splash, creating a sound like a paper being torn which is called a ‘‘rip’’ entry.7 There are three different phases to the open hand dive: takeoff, flight, and entry.1 From a 10 m Correspondence and reprint requests to Carla Doyle, MOTR/L, CHT, BONES Physical Therapy & Sports Medicine, Sonora, CA; e-mail: ,[email protected].. 0894-1130/$ e see front matter Ó 2006 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved. doi:10.1197/j.jht.2006.07.029
platform, entrance velocity can reach an estimated 35 mph.4,7 The technique requires a diver’s hands to interlock with elbows and wrists extended and radially deviated, forearms pronated, and palms facing the water at point of entry.7,8 The hands push through the water at entry described as ‘‘punching a hole in the surface.’’7 With the increased difficulty of dives being performed, there is less time to prepare for entry leaving the divers often trying to ‘‘save’’ the dive at point of entry.7,8 Injury of the ulnar collateral ligament (UCL) of the thumb MP joint often results from missing the grab position with the opposite hand before entry.1,7 After the entry, the diver pulls his or her arms forward or to the side known as the ‘‘swim out.’’1 Transitioning from the ‘‘grab’’ position to the ‘‘swim out’’ position is often the time when a diver’s thumb becomes excessively deviated at the metacarpal phalangeal (MP) joint. Our example is a 17-year-old competitive female platform diver who came to the hand clinic with a diving injury. She was diving off a 10 m platform and ‘‘jammed’’ her right thumb. She was diagnosed with a partial UCL tear. The diver’s thumb was splinted continuously for four weeks. The diver was to return to practice but still had pain with all activities and needed protection from another injury. Despite numerous trials of splinting and taping, nothing seemed to provide adequate protection. Therefore, we fabricated a silicone splint as described in this article.
Considerations For Protective Splint 1. Thumb position needs to be in radial abduction for the ‘‘grab’’ position (Figure 1). 2. Significant MP protection needed in transition from ‘‘grab’’ to ‘‘swim’’ position.
OctobereDecember 2006 425
2. Thermo-form Thumb Support (North Coast Medical) Problems a. Not enough MP joint protection b. Thermoplastic insert not heat resistant c. Crossed over the wrist d. Too rigid for entry e. Disintegration in chlorine
3. Modabber Thumb with Stay FIGURE 1. Flat hand entry technique, ‘‘Grab’’position.
3.
4. 5. 6. 7.
a. Transition of ‘‘grab’’ to ‘‘swim’’ position often hyperabducts/extends MP due to right thumb ‘‘getting caught’’ by the left hand’s first web space. b. Hands forcibly separate, fingers abduct, and wrist pulls into flexion for ‘‘swim out.’’ Splints need to be hard enough to provide support but not injury at entry. ‘‘In young divers who do not have the strength to keep their elbows locked at entry, contusion of the dorsum of the hand on the cranium is not uncommon.’’7 Tolerate pool submersion. Keeps shape when exposed to pool deck and hot tub temperatures (between dive use). The collateral ligament of the thumb is taut in flexion and ‘‘somewhat lax’’ in extension.6 The splint should allow for ‘‘maximal functional use of the hand as well as comfort.’’3
Splints Used Previously and Then Perceived Problems Many divers with injuries or those trying to prevent injuries use a semirigid thumb and/or wrist brace ‘‘to provide added stability and protection against the forces of impact.’’1 These splints are primarily designed to prevent hyperextension and hyperabduction of the thumb.2 Some of the complaints and problems we found with the prefabricated splints are as follows:
1. Comfort Cool Thumb Spica splint (North Coast Medical) Problems a. Not enough MP joint protection b. Thermoplastic insert not heat resistant c. Crossed over the wrist d. Disintegration in chlorine
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JOURNAL OF HAND THERAPY
(Hely & Weber) Problems a. Not enough MP joint protection b. Metal stays too rigid for entry c. Universal size-poor fit d. Disintegration in chlorine
4. Quick Cast Sport Thumb Kit (North Coast Medical) Problems a. Too rigid for entry
5. Santa Barbara Thumb Splint (Hely & Weber) Problems a. Metal stays too rigid for entry b. Universal size-poor fit c. Disintegration in chlorine
Different Silicone Products (i.e., RTV-11* vs. RTV-88) Considerations 1. 2. 3. 4. 5. 6. 7. 8.
Viscosity Hardness Drying time Skin integrity Cost Availability Molding Ease in fabrication
*RTV-11 is categorized as an electronic chemical that is manufactured and supplied by GE silicones. The substance is a white, two-component, low viscosity compound. The silicone cures at room temperature to become a soft pliable rubber. RTV-11 is most commonly used for high and low voltage electrical assemblies and is used to cushion against mechanical shock and vibration. RTV11 can be obtained through local venders, which
Fabrication of Splint for Mold
FIGURE 2. Thermoplastic splint for RTV-11 mold.
can be found through an Internet search of ‘‘RTV11’’ or directly from GE at 1-800-255-8886.
Materials Needed to Fabricate RTV Splint 1. One to two rolls of 2-inch Kerlix or stretch gauze. Kerlix for more rigid support during the acute phase of injury. Gauze for prevention against further injury. 2. Thin splinting material (1/12 inches or 3/32 inches). 3. One pint RTV-11 with tube of catalyst. 4. One pair of gloves. 5. Tongue depressor. 6. Pie tin/drip pan. 7. Water bottle.
1. Using thin splinting material, fabricate the splint for the RTV-11 mold. Fabricate a circumferential, hand-based splint. Include MP and interphalangeal (IP) joints of thumb. Position thumb according to patient’s request depending on their particular handhold for the dive (typically in radial abduction and full extension). Include MP joints of index finger, middle finger, ring finger, and small finger but leave IP joints free. Pinch material between the web space but not too firm for ease in removal. Ulnar side of hand does not need to be sealed. 2. Remove splint from patient after hardened by ‘‘popping’’ the seals. 3. Trim away excess web space material. Reheat web space and pinch 1⁄4 inch of web space (from ulnar aspect thumb to web to radial aspect of the index finger MP joint) to allow for appropriate thumbhole size after molding RTV-11 on splint. Smooth surface pinched (Figure 2).
Fabrication of Mold 1. Apply 2-inch Kerlix or gauze exteriorly around splint fabricated. No more than two layers thick. Easiest application is a figure-eight wrap around thumb through web space and then around ulnar aspect. Kerlix or gauze should cover area desired to immobilize (basically a short thumb spica). Also, build in excess
FIGURE 3. (A) Kerlix wrap over thermoplastic splint. (B) Optional placement of thermoplastic splint.
OctobereDecember 2006 427
2.
3.
4.
5.
toward the MP joints, wrist and ulnar aspect of hand to allow trimming of the edges and for a clean and aesthetically pleasing finish (Figures 3A and 3B). Cotton tape works well in small pieces to secure the Kerlix and allow the RTV to permeate through the tape and reach the Kerlix. Donn latex gloves. Environment should be well ventilated. Mix 1/3 tube of catalyst into 1/3 of RTV-11 pint in pie tin using tongue depressor. Cover remaining RTV-11 and catalyst for future molds/splints. (One pint can yield three molds if used appropriately.) Apply RTV-11 mixture to Kerlix covered splint (Figure 4). Apply generously. RTV-11 is very viscous so place pie tin directly under splint while holding and working on it. Continue to retrieve RTV-11 from pie tin and reapply to mold until thickness of splint desired is achieved. Thumb MP joint should be immobilized, thumb IP joint free for the grab position, and thumb carpometacarpal joint to be slightly supported. This varies depending on the diver’s preference keeping in mind the protection needed. Allow to dry elevated off the surface with neck of water bottle through thumbhole. (Drying time varies on environment and thickness of material. May take up to 24 hours.)
Finishing Silicone Diving Splint 1. Once RTV-11 is no longer tacky, remove from thermoplast splint. 2. Trim silicone diving splint to allow full AROM (active range of motion) of thumb IP joint and wrist. Full wrist extension should be attainable without contact from splint (Figures 5A and 5B).
FIGURE 5. (A) Trimmed silicone diving splint. (B) Unrestricted thumb interphalangeal joint and wrist should be achieved after trimming splint.
How to Donn & Doff the Silicone Diving Splint Taping the diver’s thumb prior to donning the splint is based on the individual’s preference. Some divers choose to wrap the thumb with athletic tape prior to the splint. Donning the silicone diving splint is done the same as a short, hand-based thumb spica splint. Optional is using Coban tape over the splint prior to securing the splint with athletic tape. The Coban tape might add to the longevity of the splint but is not necessary.
Splint Considerations
FIGURE 4. Application of RTV-11 to Kerlix covered splint.
428
JOURNAL OF HAND THERAPY
We recommend that the patient’s mold be saved for future fabrications. Also the remainder of the pint of RTV-11 could make one to two more splints. Splint is secured with Johnson & Johnson athletic tape and 2-inch Coban tape if desired. Some divers may choose to tape under the silicone diving splint (Figures 6Ae6C). Splint should be rinsed with water and dried after use.
The splint should last several years depending on care and frequency used.
Concluding Clinical Thoughts Platform diving has been recognized as an Olympic sport for almost 100 years. We found that appropriate protection to decrease the risk of thumb injuries has been limited. The currently available splints and braces seem to not provide adequate protective positioning. Also, various tape-wrapping techniques have been known to untether during dives. The silicone diving splint appears to meet the considerations for a platform diver. Our clinical opinion is that it has value as both a protective splint following injury and as well as prophylacticly.
REFERENCES
FIGURE 6. (A) Johnson & Johnson athletic tape and 2-inch Coban used to secure silicon diving splint. (B) Different taping techniques may vary. (C) Finished protective silicon diving splint secured with taping.
1. Anderson SJ, Rubin BD. Sports Medicine & Rehabilitation: A Sport Specific Approach. Philadelphia, PA/St. Louis, MO: Hanley & Belfus, Inc./Mosby; 1994. 110e122. 2. Fillion PL. Ulnar collateral ligament thumb sling. J Hand Ther. Jan/Mar 2004;17:1. [Online]. 3. Galindo A, Lim S. A metacarpophalangeal joint stabilization splint. J Hand Ther. 2002;15:83–4. 4. Kimball RJ, Carter RL, Schneider RC. Competitive diving injuries. In: Sports Injuries: Mechanisms, Prevention and Treatment. Philadelphia, PA: Lippincott, Williams, & Wilkins; 1985, Chapter 10, pp 192e211. 5. LeViet Dominique T, Lantieri Laurent A, Loy Stephan M. Wrist and hand injuries in platform diving. J Hand Surg [Am]. Sept 1993;18A(5):876–80. 6. Miller RJ. Dislocations and fracture dislocations of the metacarpophalangeal joint of the thumb. Hand Clin. 1988;4: 45–65. 7. Rubin BD. Springboard and Platform Diving Injuries. pp 1e18. North Tustin Sports Medicine Center, Santa Ana CA & the Department of Orthopaedic Surgery, University of California, Irvine, CA. Sports Medicine Digest; 1987. [Online]. 8. Vincent J, Walsh PA. Sports Medicine Report: Risking Wrist Injury. United States Diving, Inc., 2004, pp 1e4.
OctobereDecember 2006 429
A Silicone Splint to Prevent Diving Injuries of the Thumb Therapists who treat sports-related injuries frequently have to use a significant amount of creativity to return the injured athlete to their activity. In addition, we might be asked to protect the athlete from injuries that could occur. Our decisions on what materials to use can also be difficult, based on the environment in which the athlete performs their sports. In this particular article, the author has the challenge of providing something for the divers that is water resistant and does not limit their performance.—PEGGY FILLION, OTR/L, CHT, Practice Forum Editor
A SILICONE SPLINT TO PREVENT DIVING INJURIES OF THE THUMB Carla Doyle, MOTR/L, CHT BONES Physical Therapy & Sports Medicine Sonora, CA
Paul LaStayo, PhD, PT, CHT University of Utah Division of Physical Therapy Department of Orthopaedics Department of Exercise and Sports Medicine Salt Lake City, UT
Edward Damore, MD San Jose, CA
Most diving injuries occur upon entry into the water.1 A survey completed by 37 divers in 1980 reported that 61% had an upper extremity injury.1 In the past 25 years, there has been a newly adopted flat hand entry technique (Figure 1) that now supercedes the original closed fist technique.7,8 Although the open-handed technique results in a smoother entry, the danger is that the diver is at a greater risk of hand and wrist injuries.7 The closed fist technique surface area exposed to injury is less than half that of the open hand technique.5,8 The evolution toward the open hand technique has the potential for a perfect entry without a splash, creating a sound like a paper being torn which is called a ‘‘rip’’ entry.7 There are three different phases to the open hand dive: takeoff, flight, and entry.1 From a 10 m Correspondence and reprint requests to Carla Doyle, MOTR/L, CHT, BONES Physical Therapy & Sports Medicine, Sonora, CA; e-mail: ,[email protected].. 0894-1130/$ e see front matter Ó 2006 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved. doi:10.1197/j.jht.2006.07.029
platform, entrance velocity can reach an estimated 35 mph.4,7 The technique requires a diver’s hands to interlock with elbows and wrists extended and radially deviated, forearms pronated, and palms facing the water at point of entry.7,8 The hands push through the water at entry described as ‘‘punching a hole in the surface.’’7 With the increased difficulty of dives being performed, there is less time to prepare for entry leaving the divers often trying to ‘‘save’’ the dive at point of entry.7,8 Injury of the ulnar collateral ligament (UCL) of the thumb MP joint often results from missing the grab position with the opposite hand before entry.1,7 After the entry, the diver pulls his or her arms forward or to the side known as the ‘‘swim out.’’1 Transitioning from the ‘‘grab’’ position to the ‘‘swim out’’ position is often the time when a diver’s thumb becomes excessively deviated at the metacarpal phalangeal (MP) joint. Our example is a 17-year-old competitive female platform diver who came to the hand clinic with a diving injury. She was diving off a 10 m platform and ‘‘jammed’’ her right thumb. She was diagnosed with a partial UCL tear. The diver’s thumb was splinted continuously for four weeks. The diver was to return to practice but still had pain with all activities and needed protection from another injury. Despite numerous trials of splinting and taping, nothing seemed to provide adequate protection. Therefore, we fabricated a silicone splint as described in this article.
Considerations For Protective Splint 1. Thumb position needs to be in radial abduction for the ‘‘grab’’ position (Figure 1). 2. Significant MP protection needed in transition from ‘‘grab’’ to ‘‘swim’’ position.
OctobereDecember 2006 425
2. Thermo-form Thumb Support (North Coast Medical) Problems a. Not enough MP joint protection b. Thermoplastic insert not heat resistant c. Crossed over the wrist d. Too rigid for entry e. Disintegration in chlorine
3. Modabber Thumb with Stay FIGURE 1. Flat hand entry technique, ‘‘Grab’’position.
3.
4. 5. 6. 7.
a. Transition of ‘‘grab’’ to ‘‘swim’’ position often hyperabducts/extends MP due to right thumb ‘‘getting caught’’ by the left hand’s first web space. b. Hands forcibly separate, fingers abduct, and wrist pulls into flexion for ‘‘swim out.’’ Splints need to be hard enough to provide support but not injury at entry. ‘‘In young divers who do not have the strength to keep their elbows locked at entry, contusion of the dorsum of the hand on the cranium is not uncommon.’’7 Tolerate pool submersion. Keeps shape when exposed to pool deck and hot tub temperatures (between dive use). The collateral ligament of the thumb is taut in flexion and ‘‘somewhat lax’’ in extension.6 The splint should allow for ‘‘maximal functional use of the hand as well as comfort.’’3
Splints Used Previously and Then Perceived Problems Many divers with injuries or those trying to prevent injuries use a semirigid thumb and/or wrist brace ‘‘to provide added stability and protection against the forces of impact.’’1 These splints are primarily designed to prevent hyperextension and hyperabduction of the thumb.2 Some of the complaints and problems we found with the prefabricated splints are as follows:
1. Comfort Cool Thumb Spica splint (North Coast Medical) Problems a. Not enough MP joint protection b. Thermoplastic insert not heat resistant c. Crossed over the wrist d. Disintegration in chlorine
426
JOURNAL OF HAND THERAPY
(Hely & Weber) Problems a. Not enough MP joint protection b. Metal stays too rigid for entry c. Universal size-poor fit d. Disintegration in chlorine
4. Quick Cast Sport Thumb Kit (North Coast Medical) Problems a. Too rigid for entry
5. Santa Barbara Thumb Splint (Hely & Weber) Problems a. Metal stays too rigid for entry b. Universal size-poor fit c. Disintegration in chlorine
Different Silicone Products (i.e., RTV-11* vs. RTV-88) Considerations 1. 2. 3. 4. 5. 6. 7. 8.
Viscosity Hardness Drying time Skin integrity Cost Availability Molding Ease in fabrication
*RTV-11 is categorized as an electronic chemical that is manufactured and supplied by GE silicones. The substance is a white, two-component, low viscosity compound. The silicone cures at room temperature to become a soft pliable rubber. RTV-11 is most commonly used for high and low voltage electrical assemblies and is used to cushion against mechanical shock and vibration. RTV11 can be obtained through local venders, which
Fabrication of Splint for Mold
FIGURE 2. Thermoplastic splint for RTV-11 mold.
can be found through an Internet search of ‘‘RTV11’’ or directly from GE at 1-800-255-8886.
Materials Needed to Fabricate RTV Splint 1. One to two rolls of 2-inch Kerlix or stretch gauze. Kerlix for more rigid support during the acute phase of injury. Gauze for prevention against further injury. 2. Thin splinting material (1/12 inches or 3/32 inches). 3. One pint RTV-11 with tube of catalyst. 4. One pair of gloves. 5. Tongue depressor. 6. Pie tin/drip pan. 7. Water bottle.
1. Using thin splinting material, fabricate the splint for the RTV-11 mold. Fabricate a circumferential, hand-based splint. Include MP and interphalangeal (IP) joints of thumb. Position thumb according to patient’s request depending on their particular handhold for the dive (typically in radial abduction and full extension). Include MP joints of index finger, middle finger, ring finger, and small finger but leave IP joints free. Pinch material between the web space but not too firm for ease in removal. Ulnar side of hand does not need to be sealed. 2. Remove splint from patient after hardened by ‘‘popping’’ the seals. 3. Trim away excess web space material. Reheat web space and pinch 1⁄4 inch of web space (from ulnar aspect thumb to web to radial aspect of the index finger MP joint) to allow for appropriate thumbhole size after molding RTV-11 on splint. Smooth surface pinched (Figure 2).
Fabrication of Mold 1. Apply 2-inch Kerlix or gauze exteriorly around splint fabricated. No more than two layers thick. Easiest application is a figure-eight wrap around thumb through web space and then around ulnar aspect. Kerlix or gauze should cover area desired to immobilize (basically a short thumb spica). Also, build in excess
FIGURE 3. (A) Kerlix wrap over thermoplastic splint. (B) Optional placement of thermoplastic splint.
OctobereDecember 2006 427
2.
3.
4.
5.
toward the MP joints, wrist and ulnar aspect of hand to allow trimming of the edges and for a clean and aesthetically pleasing finish (Figures 3A and 3B). Cotton tape works well in small pieces to secure the Kerlix and allow the RTV to permeate through the tape and reach the Kerlix. Donn latex gloves. Environment should be well ventilated. Mix 1/3 tube of catalyst into 1/3 of RTV-11 pint in pie tin using tongue depressor. Cover remaining RTV-11 and catalyst for future molds/splints. (One pint can yield three molds if used appropriately.) Apply RTV-11 mixture to Kerlix covered splint (Figure 4). Apply generously. RTV-11 is very viscous so place pie tin directly under splint while holding and working on it. Continue to retrieve RTV-11 from pie tin and reapply to mold until thickness of splint desired is achieved. Thumb MP joint should be immobilized, thumb IP joint free for the grab position, and thumb carpometacarpal joint to be slightly supported. This varies depending on the diver’s preference keeping in mind the protection needed. Allow to dry elevated off the surface with neck of water bottle through thumbhole. (Drying time varies on environment and thickness of material. May take up to 24 hours.)
Finishing Silicone Diving Splint 1. Once RTV-11 is no longer tacky, remove from thermoplast splint. 2. Trim silicone diving splint to allow full AROM (active range of motion) of thumb IP joint and wrist. Full wrist extension should be attainable without contact from splint (Figures 5A and 5B).
FIGURE 5. (A) Trimmed silicone diving splint. (B) Unrestricted thumb interphalangeal joint and wrist should be achieved after trimming splint.
How to Donn & Doff the Silicone Diving Splint Taping the diver’s thumb prior to donning the splint is based on the individual’s preference. Some divers choose to wrap the thumb with athletic tape prior to the splint. Donning the silicone diving splint is done the same as a short, hand-based thumb spica splint. Optional is using Coban tape over the splint prior to securing the splint with athletic tape. The Coban tape might add to the longevity of the splint but is not necessary.
Splint Considerations
FIGURE 4. Application of RTV-11 to Kerlix covered splint.
428
JOURNAL OF HAND THERAPY
We recommend that the patient’s mold be saved for future fabrications. Also the remainder of the pint of RTV-11 could make one to two more splints. Splint is secured with Johnson & Johnson athletic tape and 2-inch Coban tape if desired. Some divers may choose to tape under the silicone diving splint (Figures 6Ae6C). Splint should be rinsed with water and dried after use.
The splint should last several years depending on care and frequency used.
Concluding Clinical Thoughts Platform diving has been recognized as an Olympic sport for almost 100 years. We found that appropriate protection to decrease the risk of thumb injuries has been limited. The currently available splints and braces seem to not provide adequate protective positioning. Also, various tape-wrapping techniques have been known to untether during dives. The silicone diving splint appears to meet the considerations for a platform diver. Our clinical opinion is that it has value as both a protective splint following injury and as well as prophylacticly.
REFERENCES
FIGURE 6. (A) Johnson & Johnson athletic tape and 2-inch Coban used to secure silicon diving splint. (B) Different taping techniques may vary. (C) Finished protective silicon diving splint secured with taping.
1. Anderson SJ, Rubin BD. Sports Medicine & Rehabilitation: A Sport Specific Approach. Philadelphia, PA/St. Louis, MO: Hanley & Belfus, Inc./Mosby; 1994. 110e122. 2. Fillion PL. Ulnar collateral ligament thumb sling. J Hand Ther. Jan/Mar 2004;17:1. [Online]. 3. Galindo A, Lim S. A metacarpophalangeal joint stabilization splint. J Hand Ther. 2002;15:83–4. 4. Kimball RJ, Carter RL, Schneider RC. Competitive diving injuries. In: Sports Injuries: Mechanisms, Prevention and Treatment. Philadelphia, PA: Lippincott, Williams, & Wilkins; 1985, Chapter 10, pp 192e211. 5. LeViet Dominique T, Lantieri Laurent A, Loy Stephan M. Wrist and hand injuries in platform diving. J Hand Surg [Am]. Sept 1993;18A(5):876–80. 6. Miller RJ. Dislocations and fracture dislocations of the metacarpophalangeal joint of the thumb. Hand Clin. 1988;4: 45–65. 7. Rubin BD. Springboard and Platform Diving Injuries. pp 1e18. North Tustin Sports Medicine Center, Santa Ana CA & the Department of Orthopaedic Surgery, University of California, Irvine, CA. Sports Medicine Digest; 1987. [Online]. 8. Vincent J, Walsh PA. Sports Medicine Report: Risking Wrist Injury. United States Diving, Inc., 2004, pp 1e4.
OctobereDecember 2006 429