Slide 1

CPT William Cooper D.O. Department of Orthopaedic Surgery DeWitt Army Community Hospital Slide 2 Topics Reviewed Pectoralis Rupture AC joint sprains Shoulder dislocations Clavicular fractures Biceps Rupture Radial head fractures Elbow Dislocation Skiers thumb Perilunate injuries Scaphoid fractures TFCC tears Jersey Finger Mallet Finger Sagittal Band rupture Slide 3 Slide 4 Slide 5 Pectoralis Major Rupture Excessive tension on maximally eccentrically contracted muscle Weightlifters Localized swelling and ecchymosis Palpable defect Weakness with adduction and internal rotation Most common in men 20-50 Complete rupture most common Slide 6 Slide 7 Pectoralis Major Rupture Treatment Surgical repair to bone for complete tears Nonoperative for partial tears Outcome Less than ideal Weakness, decreased ROM, increased muscle fatigue Cosmesis Slide 8 AC joint sprains AKA separated shoulder Mechanism: Blow to top of shoulder May result from fall onto outstretched arm or elbow Focal tenderness and pain with shoulder motion Cross-chest adduction test usually positive Slide 9 Cross-Chest Adduction Test AC joint Adduct shoulder Patient pushes elbow up against resistance Pain in AC = + test false + test in RC pathology Slide 10 Types of AC joint sprains Slide 11 AC joint sprains: Radiology eval Standard AP shoulder views inadequate usually over-penetrate the AC joint Image both sides for comparison Get specific AC joint view (Zanca) AP with 10 cephalic incline Axillary view can show posterior dislocation Slide 12 Normal AC joint Slide 13 Grade II AC joint sprain Slide 14 Grade III AC joint sprain Slide 15 Weighted AC x-rays seldom unmask unstable injures Bossart PJ et al. Lack of efficacy of weighted radiographs in diagnosing acute acromioclavicular separations. Ann Emerg Med 1988; 117:20-24. Slide 16 Management of mild AC joint sprains (types I and II) Ice, analgesia Sling 1-3 weeks Early ROM as pain permits Strength exercises after full ROM achieved Return to sports after pain-free function achieved Slide 17 Management of type III AC joint sprints Initially same as for I and II Referral to ortho advisable within 72 hours Most authors advocate conservative management Outcome just as good as surgery, with quicker recovery time Slide 18 Acute management of severe AC joint sprains (types IV, V, VI) Ice, analgesia Management of any complications (type VI associated with clavicle fxs, rib fxs, and brachial plexus injuries) Sling/swath Early referral Slide 19 Clavicular Fractures One of the most common fractures Classification Middle third - most common (thinnest section) Distal third Proximal third Image with AP thorax and 45 AP cephalic tilt Rule out neurological or vascular compromise; pneumothorax in 3% Slide 20 Slide 21 Lateral third clavicle fracture Slide 22 ER Management of Clavicular Fractures Ice, analgesics, arm support for all Referral rule: Any displaced, non-middle-third fractures Shortening/displacement >2cm Non-displaced fxs: sling; ROM prn comfort Displaced middle-third fractures: figure 8 splint Re-image in 7 days to assure reduction. If not, refer for shoulder spica cast Slide 23 Shoulder dislocations Most commonly dislocated large joint Anterior in 97% Mechanism: force on abducted/externally rotated shoulder Exam: Shoulder externally rotated Fullness anteriorly; acromion prominent post. Neurovascular testing Slide 24 Radiology of shoulder dislocations AP and axillary views; optional scapular lateral (Y) Velpeau view Look for fractures (not a contra- indication to reduction) Always pre-reduction x-rays in primary cases Optional pre-reduction x-rays in recurrent cases Always post-reduction x-rays Slide 25 Anterior shoulder dislocation Slide 26 Slide 27 Posterior shoulder dislocation Slide 28 Hill-Sachs deformity Slide 29 Bankart lesion Slide 30 Shoulder dislocation reduction techniques Types of maneuvers Traction (Stimson, self-reduction, Hippocrates, Eskimo,Milch) Scapular manipulation Leverage (Kocher) Combined maneuvers (slump, Snowbird) Slide 31 The Stimson technique for anterior shoulder dislocation reduction. Slide 32 J. Bone Joint Surg. Am., Dec 2009; 91: 2775 2782 The FARES method Significantly more effective, faster, and less painful method of reduction of an anterior shoulder dislocation in comparison with the Hippocratic and Kocher methods Slide 33 Slide 34 Post-reduction treatment for shoulder dislocation Ice 72 hrs, NSAID 7-14 days Immobilization 3-6 weeks Capsule needs time to heal Physical Therapy referral for rehab Less immobilization (1 week) and quicker rehab in pts >40 (to prevent stiffness) and in recurrent dislocators Slide 35 Indications for early orthopedic referral for pts with shoulder dislocation Displaced greater tuberosity fxs (>1 cm post- reduction) Glenoid rim fxs displaced >5mm Irreducible dislocations (soft tissue interposition) Young athletes Slide 36 Biceps Tendon Rupture Proximal rupture Most common in age > 60 Usually degenerative changes present initially Usually hear/feel snap Some may experience pain relief afterwards Popeye deformity Treatment nonoperative Unless young patient with traumatic rupture Slide 37 Biceps Tendon Rupture Distal Biceps Rupture Much less common (5% of biceps ruptures) Middle aged patients Usually tendonopathy/degenerative changes present which predispose Forceful, eccentric overload of the partially flexed elbow Up to 50% loss of supination power has been documented after rupture Treatment is surgical Slide 38 Biceps Tendon Rupture The Hook Test for Distal Biceps Tendon Avulsion Am J Sports Med November 2007 35 1865-1869; published online before print August 8, 2007 Slide 39 Does this happen in distal biceps rupture??? Slide 40 Elbow trauma Fractures Dislocations Ligament sprains Look for compartment syndrome Rule out neurovascular injury Slide 41 Slide 42 Slide 43 Slide 44 Slide 45 Axioms in elbow trauma radiograph evals Look for fat pads signs (capsular effusion) Anterior fat pad (from coronoid fossa) may be normal; compare to other side Posterior fat pad (from olecranon fossa) is always abnormal Compare to x-rays of other side in children If elbow cant be extended, obtain AP/lat of both humerus and forearm Slide 46 Slide 47 Fat pad signs Slide 48 Elbow fractures Supracondylar, epicondylar Radial head/neck Olecranon Coronoid process **Consult current texts or your friendly local orthopedist for treatment of each. Slide 49 Radial head/neck fractures Common fracture in adults FOOSH usually Detection may require oblique view Assure proper alignment of head on capitellum (radiocapitellar line) Slide 50 Radial head fracture types Type I: less than 2 mm displacement Type II: angulated or >2 mm displaced Type III: comminuted Slide 51 Radiocapitellar line Slide 52 Radial head fracture Slide 53 ER treatment of Radial head/neck fractures Consider aspiration of hemarthrosis to relieve pain Type I Posterior splint a few days Sling; AROM when tolerated Physical therapy in 3 weeks Types II and III - splint and refer Slide 54 Slide 55 Elbow Dislocations Defined by the direction of the forearm bones 80% posterolateral Slide 56 Elbow Dislocations Treatment Simple dislocations no associated fracture 1 week immobilization Splint in 90 degrees flexion with forearm pronated Begin therapy/ROM Good long term results Complex dislocations fracture present Surgery Radial head and neck 50-60% of time Instability within 30 degrees of full extension may be an indication for acute ligamentous repair. Lateral ligamentous complex is always repaired MCL if instability persists Slide 57 Terrible Triad Elbow Injury Elbow dislocation Fractures Radial head Coronoid process Treatment Ligamentous repair, ORIF of the coronoid, and either ORIF or prosthetic replacement of the radial head Persistent instability - hinged external fixator. The primary goal in all elbow dislocations is early motion Slide 58 Perilunate Dislocations Result from forced dorsiflexion, ulnar deviation, and supination of the wrist Approximately 25% missed in E.R. Emergent reduction and stabilization of these injuries are recommended Slide 59 Perilunate Dislocations Treatment Repair of ligamentous structures Percutaneous pinning Acute carpal tunnel syndrome may be present Necessitates release Late diagnosis associated with poor outcomes Slide 60 Skiers Thumb Pathoanatomy Sprain of ulnar collateral ligament of thumb MCP Grades I, II, and III I = no laxity II = laxity but intact III = complete tear Slide 61 Skiers Thumb Mechanism of injury Forced abduction and hyperextension of thumb FOOSH with thumb caught in extension Diagnosis History Radiographs Physical exam Slide 62 Skiers Thumb Slide 63 Skiers thumb: exam Anesthesia (block) Valgus stress to MCPJ in extension Over 20 opening is probably grade III tear Slide 64 Skiers Thumb Stener lesion 64% of Grade III injuries Adductor aponeurosis interposed Prohibits reattachment of ligament MRI and arthrogram are sensitive Slide 65 Stener Lesion Slide 66 Skiers Thumb: Treatment Grades I & II Thumb spica splint 2-4 weeks, then Splint or tape 3 months Grade III Controversial Surgery Refer to Ortho Slide 67 Scaphoid Fracture History FOOSH Dull, deep, ache in radial side of wrist Slide 68 Scaphoid Fracture: Anatomy Blood supplied from distal pole The more proximal the fracture, the greater the risk of avascular necrosis (AVN) or delayed union Slide 69 Slide 70 Scaphoid Fracture: Examination Minimal swelling Tenderness in snuff box Pain with axial load Slide 71 Scaphoid tubercle fracture Slide 72 Scaphoid fracture: Radiographs AP Lateral Oblique Scaphoid view **Normal plain films dont rule out a scaphoid fracture Slide 73 Slide 74 Slide 75 Scaphoid Fracture Treatment Non-displaced fracture of waist or distal pole Long arm thumb spica cast 6 weeks Then, short arm thumb spica cast for 2- 6 weeks Replace cast/get x- rays Q2 wks to assess healing Slide 76 Scaphoid Fracture: Treatment (cont) Clinically suspected fracture with normal plain films Treat as non-displaced fracture Short-arm thumb spica cast F/U in 10 days for repeat x-rays Consider bone scan/MRI if x-rays neg but fx suspected CT Slide 77 Scaphoid Fracture: Referral criteria Proximal fractures Angulated; displaced >1mm Scapholunate dissociation Presentation > 2 wks Early return to play necessary Non-union or AVN Slide 78 Triangular Fibrocartilage Complex (TFCC) Tear Mechanism of injury Fall on dorsiflexed and ulnar deviated wrist Axial load with forearm in hyperpronation Patient c/o ulnar sided wrist pain, swelling, loss of grip strength Slide 79 TFCC Thickened pad of connective tissue that functions as a cushion for ulnar axial loads Articular disc Meniscus Ulnar collateral ligament Slide 80 TFCC tear: Examination (cont) Tenderness just distal to ulnar styloid Slide 81 TFCC tear: Examination (cont) Press test Patient presses arms of chair to lift body off seat 100% sensitive Slide 82 TFCC tear: Examination (cont) TFCC load test Pain = positive test Slide 83 TFCC tear: Examination (cont) Rule out injury to distal radio-ulnar joint (DRUJ) Squeeze radius/ulna together and passively rotate forearm Painful in DRUJ injury No pain in isolated TFCC tear Slide 84 TFCC Tear: Radiography Plain films Positive ulnar variance (ulna 1-5 mm longer than radial articular surface) a/w TFCC tear Assess for fracture or ulnar subluxation MRI or Arthrography optional to confirm Slide 85 MRI: TFCC tear Slide 86 TFCC Tear: Treatment Long arm cast with forearm neutral for 4-6 weeks Referral criteria: Associated injuries including DRUJ instability Persistent pain after immobilization Slide 87 Jersey Finger Avulsion of the FDP tendon from its insertion Ring finger most commonly affected Occurs with sudden hyperextension during finger flexion May be seen on plain x-ray Type I - retraction of tendon into palm Type II - retraction to PIP Type III - associated with a large, bony articular Slide 88 Exam --Finger held in forced extension --Tender along volar aspect of DIP --Unable to flex DIP Slide 89 Jersey Finger Type I injuries must be repaired early (within 1 week) because of loss of blood supply to the tendon Splint in position Arthrodesis is generally favored over late (>3 months) repair due to finger stiffness after tendon grafting Slide 90 Mallet Finger Avulsion of the terminal extensor tendon X-ray used to rule out fracture. Treated with prolonged (>6 weeks) extension splinting Results are almost uniformly good. Chronic injuries Swan-neck deformities due to chronic overpull of the extensor tendon at the PIP with flexion of the distal interphalangeal joint (DIP Slide 91 Mallet Finger Slide 92 Sagittal Band Rupture Boxer's knuckle Typically occurs in pugilists due to forceful subluxation of the extensor tendon Index and long fingers in professionals Ring and small fingers in amateurs Acute injuries are treated with extension splinting for 4 weeks Chronic injury will lead to persistent extensor tendon subluxation Repaired or reconstructed Slide 93 Slide 94 QUESTIONS