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Orthopedic Surgery: Schwartz Notes up to Midterm

Key Points
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Definitive tx in open fractures may be delayed until the wound is sufficiently cleaned and
healthy tissue is available
Fractures of the scapula generally result from significant MOI: look for additional injuries to
the head, lungs, ribs, and spine
Shoulder one of MC dislocated joints: MC anterior; posterior associated with seizures or
electric shock
Humeral shaft fracture: direct trauma or FOOSH (esp. elderly); look for radial nerve
damage
Osteoarthritis
o 22% of US population, expected to be 25% by 2030
o Wt loss of 11 pounds decrease risk of knee osteoarthritis in women by 50%
o Regular physical activity lowers incidence as well
Smaller incisions, better cosmesis BUT there is decreased visualization intra-op (increased
risk of malposition, fracture, nerve, vascular injuries)

Orthopedic Trauma
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Injuries include fractures, joint damage, and soft tissue damage


Goal of treatments is to restore nl anatomy, immobilize injured extremities (pain relief and
healing), and repair/reconstruct injuries to restore function
Long bone fractures
o Transverse (B)
o Oblique (C)
o Spiral (D)
o Segmental (E)
o Comminuted (F)
Fractures result from high energy trauma and falls on the
extremity.
Majority heal with immobilization, different methods depend on the fracture.
Methods for Immobilization
o Splint or cast
MC used
Splints are preferred for acute injury they are not circumferential and allow
for swelling
o Closed reduction
Displaced or angulated fractures
Necessary to properly realign the bone
Analgesia, local or general anesthesia, +/- muscle relaxants
Performed with axial tractions and reversal of MOI, splint, and post-reduction
Xray and neurovascular exam
o Internal Fixation
Screws across a fracture site create stability and compression which
promotes healing
Plates placed on cortex to create long areas of fixation
Intramedullary rods commonly used for long bone (femur and tibia)
Marrow generally removed with a reamer prior to insertion
Screws through rod proximal and distal to fracture
o External Fixation

Orthopedic Surgery: Schwartz Notes up to Midterm


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Utilized when patients are severely injured or when soft tissue damage or
swelling where it is unsafe to make incisions or undergo surgery
Involves placement of pins proximal and distal to fracture through healthy
tissues
Pins are connected by rods placed on the outside of the extremity

Open Fractures
o Occur when the bone breaks through the skin
o Typically result from high energy injuries and associated with significant damage to
the surrounding soft tissues and contamination of the wound
o Require immediate irrigation and debridement in OR and antibiotics to prevent
wound infections and osteomyelitis
o Look for surrounding neurovascular injuries
o Definitive treatment generally delayed until the wound is sufficiently cleaned and
healthy tissue is available to cover the fracture
Compartment Syndrome
o ORTHOPEDIC EMERGENCY!
o Significant swelling within a compartment of an injured extremity that jeopardizes
blood flow to the limb
o Increased pressure compromises perfusion to muscles resulting in ischemia or
necrosis
o S+S
Pain, numbness, passive stretch to muscles of compartment causes severe
pain
o Dx
Based on clinical exam
Can be measured by placing needles in compartment (necessary for
unconscious patients)
o TX EMERGENT FASCIOTOMY! Overlying tight fascia is released through long incisions
ASAP to prevent irreversible necrosis and contractures of nerves and muscles,
which can result in loss of function

Treatment of Fractures and Dislocations


Clavicle Fractures
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One of the MC fractures


Occur following fall onto shoulder
Fracture often evident on inspection
Most treated non-op with sling, ROM exercises, and gradual return to nl activity
o Significantly displaced, shortened, or penetrating fractures are treated with open
reduction internal fixation (plate and screw fixation)
Majority occur in the middle third of the clavicle
Distal clavicle fracture less common
o May occur with coracoclavicular ligament ruptures

Orthopedic Surgery: Schwartz Notes up to Midterm


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o Can be more troublesome


o At risk for non-union
o If + displacement, surgical tx recommended
AC Joint Injuries
o Fall on the shoulder or FOOSH
o Results in tears of AC and coracoclavicular ligaments
o Step-off separation of AC joint may show up on Xray
o Most tx with sling and gentle ROM
o Severe displacement may require open reduction and surgical repair
SC Joint Injuries
o ONLY articulation between the upper extremity and the axial skeleton
o Injuries are rare
o Anterior more common and closed reduction can be attempted followed with sling
immobilization
o Posterior can be dangerous
Pulmonary or neurovascular compromise
Closed reduction under general anesthesia with vascular surgeon present
(incase of vascular injury)

Scapula Fractures
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Significant MOI, look for associated head, lung, rib, and spine injuries
Most tx non-op with exception of glenoid fractures
Intraarticular fractures (displacement of glenoid articulating surface) indicates need for
open reduction and internal fixation

Shoulder Dislocations
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One of the MC dislocated joints


MC anterior dislocation
o Often associated with injuries to labrum (Bankart lesions), impression fractures of
humeral head (Hill-Sachs lesions), and rotator cuff tears
Posterior dislocations
o Seizures or electric shock
Xray needed for Dx
o Important because missing dislocation can result in sig. debilitation of shoulder
o Axillary view most important
Managed with closed reduction with short-period of sling immobilization

Proximal Humerus Fractures


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Occurs most frequently in elderly patients following fall onto shoulder


Also occur in high energy trauma
Neer Classification (divides proximal humerus into 4 parts)
o Humeral head
o Greater tuberosity
o Lesser tuberosity
o Humeral shaft
If suspicion of intraarticular fracture CT
Majority are minimally displaced and can be treated with sling followed by ROM and
pendulum exercises
Displaced and humeral head fractures are at increased risk for osteonecrosis surgery
Open reduction internal fixation with plate and screws

Orthopedic Surgery: Schwartz Notes up to Midterm


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Older patients with osteoporosis and comminuted fractures prosthetic replacement or


HEMIARTHROPLASTY

Humeral Shaft Fractures


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Direct trauma or FOOSH (esp. elderly)


Radial nerve at risk for injury careful neurovascular exam
o Neuropraxia stretching of the nerve, function usually returns around 3-4 months
Acceptable degree of angulation
o Majority heal on own
o Coaptation splint or functional bracing (plastic clamshell with Velcro straps)
o Close f/u and serial Xrays important to verify healing
o ROM begin 1-2 weeks post-injury
Significant angulation
o Commonly treated with open reduction and plate fixation
o Protect the radial nerve
o Intermedullary nailing also possible but caries risk of shoulder pain

Distal Humerus Fractures


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Fall on elbow or FOOSH


MC supracondylar
o Above elbow joint
o Do not involve articular surface
Minimally displaced
o Posterior long arm splint with 90 degree flexion
Articular surface involvement
o Plate fixation
o May need 2 plates (medial and posterior)
Comminuted
o Total elbow replacement (esp. elderly)
o Prosthetic distal humerus, proximal ulna, radial head
Elbow fractures are notorious for developing STIFFNESS
o Early motion paramount for successful outcome
o ROM began as soon as patient can tolerate therapy

Elbow Dislocations
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Common
Typically occur posteriorly after FOOSH
Results in injury to joint capsule and rupture of LCL +/- MCL involvement +/- fractures of
the radial head, coronoid, or humeral epicondyles
Simples
o Urgently reduced under sedation
o Brief treatment long arm splint (7-10 days)
o Too long of splinting w/o early ROM results in stiffness
Associated with fractures
o Surgically if instability
o Terrible Triad
Elbow dislocation

Orthopedic Surgery: Schwartz Notes up to Midterm


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Radial head fraction


Coronoid fracture
Terrible triad unstable and often require fixation/replacement of all structures
depending on the size of the fracture

Radial Head Fractures


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Most can be treated non-op with sling 1-2 days followed by ROM
Displaced or blocks sup/pron of forearm Surgery
o Well reduced 1-2 screws
o Multiple pieces radial head replacement with metallic implant
o Elderly excision of radial head (may contribute to elbow instability or wrist
symptoms over time)

Olecranon Fractures
-

Follow fall directly on a flexed elbow


Nondisplaced
o Splint 45-90 degrees short period followed by ROM to prevent stiffness
Displaced
o Triceps inserts on olecranon and tension may displace fracture
o Surgical tx
Simple transverse
o Tension band to promote healing
Comminuted
o Plate and screw
o Hardware may be irritation
o May be requested to be removed after healing

Forearm Fractures
-

High energy trauma or FOOSH


Two bones
o Plate and screw fixation
Isolated ulnar shaft
o nightstick fracture
o Direct blow to side of forearm
o Simple cast
o Angulated or displaced open reduction and plate fixation
Ulnar shaft + radial head dislocation
o Monteggia fracture
o Radial head fracture may be missed without Xray
o Ulnar shaft fracture raised suspicion about additional radial head fracture
o Surgery
Ulna plate and screw
Radial head reduction
Radial shaft + disruption of DRUJ
o Plate and screw fixation
o DRUJ assessed for stability and may need wires temporarily

Pelvic Fractures
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High energy trauma associated with head, chest, abdominal, and urogenital injuries

Orthopedic Surgery: Schwartz Notes up to Midterm


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Elderly may suffer after a fall


o Usually fractures pubic rami
o Stable injury managed non-op with protected wt bearing
HEMORRHAGE CAN BE LIFE THREATENING!
o Often due to venous plexus injury in posterior pelvis
o Or due to large vessel injury (i.e gluteal artery)
o IMMEDIATE RESCUSITATION (fluids and transfusions)
FIRST LINE TREATMENT
o Pelvic binder or sheet to control bleeding
DEFINITIVE
o Surgical exploration OR
o Interventional radiology
External fixators placed in surgery
Retrograde urethrogram for GU injuries
Pelvis is a closed circuit must have two places of disruption (fractures or ligamentous
tears)
o AP open book injury
Hinge on intact posterior ligaments
Widening at pubic symphysis
o Lateral
Crush injury to ileum, sacrum, and pubic rami
o Vertical
Unstable
Disrupt strong posterior ligaments
Associated with significant blood loss and visceral injuries
Sacral fractures difficult to see on Xray CT
o Can result in nerve injury
Treatment depends on fracture pattern
o Stable, minimally displaced non-op with protected wt bearing
o Open book surgically with plates a screws

Acetabular Fractures
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Occurs when femoral head driven into hip socket in high energy trauma
CT important to visualize pattern
Generally require surgery to restore congruent, stable, acetabulum
o Prevent early degenerative changes and osteoarthritis
o Should utilized experienced surgeons

Hip Dislocations
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High energy trauma


MC posteriorly
Potential injury to sciatic nerve or fracture of acetabulum or femoral head
EMERGENT REDUCTION!
o High risk of osteonecrosis of femoral head with delated reduction
o can be done in ER with adequate sedation and muscle relaxation (some pts require
anesthesia)
If reduction unsuccessful or fracture fragment gets trapped in joint surgery
Hip dislocation + femoral head fracture at risk for OSTEONECROSIS OF FEMORAL HEAD
+ OSTEOARTHRITIS!

Hip Fractures

Orthopedic Surgery: Schwartz Notes up to Midterm


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Associated with significant M+M


Elderly after grounds level falls, F>M, osteoporosis risk
Hip fracture puts patients at increased risk for:
o DVT
o PE
o Pneumonia
o Deconditioning
o Pressure sores
o Death (mortality rate 1st year 25%)
Surgery to prevent complications and help patients move ASAP to reduce risk
TREATMENT OF CHOICE SURGERY!
o 24-48 hours
o Unless need to optimize patient before
o Functional outcome = based on level of mobility and independence BEFORE surgery
o Patients may require aid with assistive ambulatory devices, rehab, or long-term
nursing facility

Femoral Neck Fractures


-

Occur with the capsule of the hip joint


Blood supply
o Medial and lateral circumflex arteries
o Fractures at risk for osteonecrosis
Non displaced
o Low risk of osteonecrosis
o In situ internal fixation
o Begin protected wt bearing immediately after surgery
Displaced
o High risk of osteonecrosis
o Prosthetic replacement
o MC hemiarthroplasty replacement of femoral neck and head with metal stem
Patients with severe osteoarthritis and pain BEFORE injury
o Total hip replacement (acetabulum also replaced with prosthesis)
o Wt bearing immediately after surgery

Intertrochanteric Hip Fracture


-

Occur between greater and lesser trochanters of proximal femur


Abundant blood supply
o Osteonecrosis uncommon
o Fixed with internal fixation
Displaced
o Realign using traction and rotation

Subtrochanteric Hip Fractures


-

Distal to lesser trochanter


Area of high biomechanical stress
High energy trauma and elderly patient after a fall
Tend to be significantly displaced and may be difficult to reduce
Treatment with surgery
In most cases, protected wt bearing can begin soon after

Orthopedic Surgery: Schwartz Notes up to Midterm


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Femoral Shaft Fractures
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High energy trauma


Associated with other injuries
Long bone fractures put patients at risk for thromboembolic events and ARDS
o Important to fix quickly, ideally within 24 hours
Hemodynamically unstable or with other life-threatening injuries
o External fixator until safe to undergo surgery

Distal Femur Fractures


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Fall from height or high energy trauma


Elderly patients with osteoporosis after fall on knee
Most require surgery
o Can involve articular surface of knee joint so anatomic reduction of joint surface is
crucial
o Plates and screws
o Early ROM to prevent stiffness
Intraarticular
o No wt bearing until signs of healing

Knee Dislocations
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Rare but devastating, can be limb-threatening


o Close proximity of popliteal artery behind the knee (may kink or tear)
o ACL and PCL torn with injuries to MCL, LCL, joint capsule, and menisci
o IMMEDIATE REDUCTION +/- vascular surgeon
o Pay attention to neurovascular exam before and after
MRI will identify torn structures
Multi-ligamentous reconstruction
Stiffness common post-op complication

Patella/Extensor Mechanism Injuries


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Injuries from fall on knee or from forcible contraction of quads


Non displaced patella non-op with cast or knee immobilizer (full extension), wt bearing
permitted
Displaced or comminuted require surgery
Loss of knee extension treated with suture repair, post-op knee extension with progression
flexion over weeks in hinged knee brace
Patella dislocation
o Common when femur forcibly internally rotated on an externally rotated tibia while
foot is planted on the ground
o Typically dislocate laterally and reduce spontaneously
o Significant knee effusion
o Positive apprehension test lateral force to patella elicits pain and sensation of
impending dislocation
o Can be reduced by extending knee with manual reduction
o Treated with temporary knee immobilization
o High risk for recurrence may require surgical intervention

Tibial Plateau Fractures


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Axial loads sustained in falls from height or high energy trauma


Associated with injuries to menisci and cartilage

Orthopedic Surgery: Schwartz Notes up to Midterm


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CT to visualize intraarticular involvement


Minimally displaced
o Non-op without movement until heals
Displaced
o Surgery to restore smooth contour of articular surface
o Plates and screws +/- bone graft/substitutes
o Strict non-wt bearing for weeks until it begins to heal, early ROM encouraged
Common to have complications of knee stiffness and osteoarthritis

Tibial Shaft Fractures


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MC long bone fracture


High energy trauma and direct blows (transverse or comminuted), severe twisting (spiral)
Minimal angulation
o Reduction and casting
o Transition to functional brace
o Slow return to wt bearing
o May need immobilization for several months (fractures can be slow to heal)
Angulation
o PREFERRED Intramedullary nail with interlocking screws, wt bearing soon after
surgery
Plate and screw placement increase risk of wound breakdown
Often occur along with tibial shaft fractures

Tibial Plafond (Pilon) Fractures


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Distal tibial articular surface of ankle joint


High energy from axial compression or shear force
Associated with
o Significant soft tissue injury
o Severely comminuted intraarticular fragments
o Wound healing problems
Difficult to treat
o Usually managed with external fixation until swelling subsides (days to weeks)
o Surgery
o Non wt bearing for weeks until healing
Complications
o Ankle pain and stiffness
o Arthritis
o Wound healing problems
o Infection
o Nonunion
o May need ankle fusion in future

Ankle Dislocations
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Complex hinge joint


o Distal tibial plafond
o Medial malleolus
o Lateral malleolus
o Talus
Ligaments
o Medial

Orthopedic Surgery: Schwartz Notes up to Midterm


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Deltoid
Syndesmotic between tibia and fibula
Lateral
Anterior talofibular
Posterior talofibular
Calcaneofibular
Result from severe twisting injury
Often occur with fractures
Can place significant pressure on skin and result in neurovascular compromise
PROMPT REDUCTION! Followed by splinting
o
o

Ankle Fractures
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Twisting injuries
Depends on:
o Direction of force
o Position of foot and ankle at time of injury
Initial treatment
o Closed reduction and placement of well-padded splint
o Swelling often significant therefore elevate the foot
Surgery
o Delayed 1-2 weeks until swelling decreases to limit the risk of wound healing
problems

Malleolar Fractures
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Lateral
o Isolated require anatomic reduction
o Talus may sublux
1mm of talar shift decreased surface contact between talus and tibia by 40%
Increased risk or arthritis
o Closed reduction and casting may be successful
o If cannot be reduced, open reduction internal fixation
Medial
o Isolated usually avulsion injury
o Minimally displaced tx with cast or walking boot
o Displaced fixed with screws
Bimalleolar
o Generally require surgery
o More unstable
Talux will sublux or completely dislocate laterally
o Surgery
Reduction and fixation of both
o Trimalleolar
Posterior articular surface of distal tibia (posterior malleolus) can be fractured
as well
Fixed if involving >25% of surface

Syndesmosis Injuries
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Several ligaments between distal tibia and fibula


Provide stability at ankle joint (resist axial, rotational, and translational forces)

Orthopedic Surgery: Schwartz Notes up to Midterm


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Widening of space between distal tibia and fibula post-reduction indicative of injury
o Place screws laterally
o Keep non wt bearing for several weeks
o Screws generally removed after 12 weeks, but can be left in place (often
asymptomatic)

Calcaneal Fractures
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Fall from height often associated with other injuries (lumbar)


Often intraarticular
Can result in collapse of wt bearing posterior facet
CT better visualize
Most treated non-op in well-padded splint w/o wt bearing 12 weeks
Displaced intraarticular surgical management once swelling subsites
Despite treatment, can be debilitating
o Heel pain
o Arthritis

Talus Fractures
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Forced dorsiflexion of ankle causes


talar neck to impact anterior distal
tibia
Blood supply
o May be jeopardized
o Risk of osteonecrosis (common
complication)

Nondisplaced
o Cast
o 15% risk osteonecrosis
Displaced
o Surgical with screw fixation
o 30-100% risk osteonecrosis
o High risk arthritis

Foot Fractures
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Isolated tarsal fractures rare


o Non-op cast or boot
Lisfranc ligament
o Connects 2nd metatarsal head to medial cuneiform
o Important midfoot stabilizer
o Follow torsional forces or crush injuries
o Require surgery (anatomic reduction important for successful outcome)
Metatarsal
o Twisting or crush
o Non-op with hard soled shoe and wt bearing as tolerated
o Close attention to base of 5th metatarsal
Jones Fracture
Fractures at metaphyseal-diaphyseal junction proximal 5 th metatarsal can
jeopardize blood flow
At risk for nonunion
Close f/u to assess healing
May need screw fixation
o MPJ injuries and phalangeal fractures
Symptomatic tx
Buddy taping
Wt bearing as tolerated in hard soled shoe

Ligamentous and Cartilaginous Injuries of the Joints


HIP
Femoroacetabular Impingement (FAI)
- Pathologic impingement of anterior femoral head-neck junction against anterosuperior
labrum
- Caused by
o Abnl bony offset at femoral head-neck junction
o Abnl acetabular anteversion
o Excessive anterolateral acetabular bony rim coverage pincer lesion
- Recognition may be difficult
- Presentation
o Anterior groin pain exacerbated by hip flexion or pain over greater trochanter
o Grinding or popping
o Pain with flexion and internal rotation after prolonged sitting
o Decreased internal rotation out of proportion to loss of other ROM and limited
flexion
o Impingement test - elicited by 90 degrees flexion, aDduction, and internal
rotation almost always positive
- Imaging
o Xray, CT, MRI, MRA
- Treatment
o Surgical open acetabuloplasty, hip arthroscopy more popular (improved functional
outcome with low complication rates)
- Complications
o Labral tears
o Cartilage delamination
o Osteoarthritis

SHOULDER
Rotator Cuff
-

Among the most common reasons for visit to orthopedic sports specialist
Forceful or repeated overhead pulling movements
Provides shoulder movement and glenohumeral joint stability
Injuries lead to pain, weakness, and restricted movement of the arm
Arthroscopic techniques considered equal or superior to open techniques for most
indications
Rehab post-op important in restoring strength, motion, and function
Three stages of rehab
o First 4-6 weeks
Immobilization sling
Passive exercise therapist
o After 4-6 weeks
Active exercise
o At 8-12 weeks
Muscle strength and improvement of control increase by starting
strengthening exercise program

Shoulder Instability
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MC etiology related to trauma (esp. shoulder dislocation)


After one dislocation, vulnerable to repeat episodes of instability (younger>older)
Most stability provided by rotator cuff and shoulder capsule
MC dislocation anterior-inferior
o Pain on an internally rotated shoulder
Xray
o AP
o Axillary
o Y view of shoulder
MRI following successful reduction
Relocation
o Gentle traction and slight aBduction
o Sedation helpful
Prolonged immobilization not recommended
o Leads to stiffness
o Does NOT reduce shoulder redislocation rate
Recurrent
o Consider surgical stabilization
o Open Bankart repair, Latarjet repair
o Arthroscopic FRONT-LINE TREATMENT FOR RECURRENT INSTABILITY!
o Post-op shoulder immobilized with sling, ROM, then strengthening

Superior Labrum and Biceps Tendon


-

Labrum helps to deepen socket and stabilize GH joint. Also serves as attachment point for
many shoulder ligaments and one biceps tendon
Superior labrum AP (SLAP)
o Lesion anterior and posterior to attachment of biceps tendon +/- biceps tendon
involvement
o Trauma or repetitive shoulder motion
Xray looks for concomitant injuries or osteoarthritic changes
MRI to visualize labrum and other soft tissue
May do gadolinium arthrogram (more sensitive for labral injury detection)
Conservative
o NSAIDs
o PT
Surgery
o If no improvement with conservative
o SLAP injuries with biceps tendon involvement may require tenotomy or tenodesis
Post-op
o Shoulder immobilization in sling 4 weeks
o PT improves ROM and prevents scar tissue/stiffness from developing
o Strengthening exercise about 4-6 weeks post-op
o Return to action 3-4 months after surgery (early interval throwing)

Impingement Syndromes
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Minor trauma or repetitive injury


Pain/discomfort due to irritation of tissues in sub acromial space
Caused by simple bursitis or tendonitis of the long head of the biceps or supraspinatus
tendon
Occasionally can progress to tears of supraspinatus tendon
o Confirm with MRI or US
Conservative
o Rest, NSAIDs, PT
If pain not relieves, injection of local anesthetic and cortisone
Surgery
o Goal to excise bursa to create more sub acromial space
o Arthroscopic bursectomy and sub acromial decompression via acromioplasty
o If rotator cuff (supraspinatus tendon) is injured, arthroscopic repair is usually
indicated to restore function
Sometimes accompanies by bony resection of inferior portion of acromion

Acromioclavicular Joint
-

Gliding synovial joint (not very mobile)


Stabilized by three ligaments
o Superior AC ligament
o Inferior AC ligament
o Coracoclavicular ligament
Injuries generally during contact sports (football, ice hockey) and may cause displacement
of the joint
AC Sprain shoulder separation
o Type I symptomatic tx
o Type II symptomatic tx
o Type III controversy
Early vs delayed surgical reconstruction

Frank tearing of coracoclavicular ligaments + significant displacement


surgery

KNEE
Knee
-

Largest joint
Pivotal hinge joint (flexion, extension, medial + lateral rotation)
Bears axial load, torsion, and shear forces
Vulnerable to acute injury and osteoarthritis

Menisci
-

Crescent-shaped fibrocartilage
o Joint stability
o Shock absorption
o Load distribution
o Proprioception
Sudden tears during sports (contact) or while squatting and twisting the knee
S+S
o Pain, stiffness, swelling
o Catching or locking of the knee, buckling or giving way
o Impaired ROM
Xray for concomitant injury, alignment, and osteoarthritis
MRI to visualize menisci and soft tissue
Partial (subtotal) meniscectomy MC surgical procedure
o Important to preserve load-distributing function to prevent osteoarthritis
o Orthobiologics
Most common tears: radial and longitudinal
Less common
o Root can be devastating, alter knee contact forces
Meniscus transplantation in young patients
Post-op
o Immobilized with brace
o Wt bearing protected to allow meniscus to heal
o Healing complete, ROM and strength to be regained
o PT integral part of healing
o Return to play 4-6 months post-op

Collateral Ligaments
-

MCL most frequently injured knee ligament


o Occurs after excessive valgus stress of the knee
o Often associated with medial meniscus injury and ACL injury to form the unhappy
triad
o Unhappy triad occurs most commonly in contact sports
o Good healing potential
Grade I + II improve with brace and activity modification
Grade III treated non-op initially, many improve with conservative
o Majority occur in mid-substance or at the femoral insertion side
o Small subset of grade III tibial sided tears associated with worse outcome and need
for surgical repair
LCL less common
o Most are managed conservatively
Return to sports

o
o

Good ROM and normal gait pattern


Functional brace advised during sport

Cruciate Ligaments
-

Central within intercondylar notch of knee


3D biomechanical function but simply provide AP and rotational stability of the knee
ACL common sports injury
o Sudden cutting and stopping (soccer, basketball) or contact (football)
o Torn ACL results in altered knee biomechanics and kinematics
o May result in early degenerative changes in joint
o Torn ACL will NOT heal without surgery!
o TREATMENT OF CHOICE SURGICAL ACL RECONSTRUCTION!
Young and active patients!
Sedentary lifestyle without disabling instability conservative (bracing and
PT)
o Presentation
Pain, swelling, instability
Loss of ROM
Joint line tenderness (associated meniscus injury)
Discomfort while walking
o Xray evaluate joint and associated osseous injury
o MRI to visualize ACL and other soft tissue
NOT required for diagnosis
Useful for pre-surgical planning and assessment of concomitant injuries
o Reconstruction
Tendon-graft
Patellar, hamstring, and quadriceps tendon
Harvest from same knee (autografts) during same procedure
Alternatively, donor graft (allograft) can be used
Auto>allo for healing potential
PCL injuries less common
o Bent knee hitting dashboard in car accident or falling on a knee that is bent during
running
o Rupture PCL generally better tolerated than ACL
o Have the potential to heal on their own and do not result in much knee instability
o Grade I + II non-op
o Grade III have increased incidence of osteoarthritis
Patellofemoral
Medial knee
o Indication for surgery
Age
Activity level
Presence of concomitant injuries
o MC used techniques
inlay
Transtibial