Surgery...To Cut or Not to Cut? That is the Question.

Sean Sreniawski, DMSc, PA-C, ATC

IAPA Fall CME Conference November 4, 2021

Objectives

Differentiate Differentiate rotator cuff tears which require conservative management versus surgical intervention to an Orthopaedic surgeon.

Differentiate Differentiate meniscus injuries which require conservative management versus surgical intervention to an Orthopaedic surgeon.

Differentiate Differentiate finger tendon injuries which require conservative management versus surgical intervention to an Orthopaedic surgeon.

Rotator Cuff Tears

Shoulder pain

Decreased motion

Traumatic

Degenerative

Rotator Cuff-Anatomy

Rotator Cuff-Function

Evaluation

• History and Physical Exam

• FOOSH injury

• Pain over lateral deltoid

• Pain worse at night

• Postive Empty Can Test

• Postive Drop Arm Test

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Diagnostics

• Radiographs

• Magnetic Resonance Imaging (MRI)

• Magnetic Resonance Arthrogram (MRA)

• Dynamic Musculoskletal Ultrasound

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Rotator Cuff Tear

• Mod to Severe OA

• Chronic Tear seen above

Rotator Cuff Tear

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Treatment Options... It Depends

• Duration of Symptoms

• Age

• Shoulder Dominance

• Type of Tear (Partial or Full thickness)

• Comorbidities

• Activity level

• Occupation

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Surgical Indications for Rotator Cuff Tears

Acute Full Thickness Tear Acute on Chronic

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Nonoperative Management

• Partial Thickness Tears

• Reevaluate 2-3 months

• Physical Therapy

• Activity modification

• Stretching the shoulder capsule

• Strengthening to stabilize

• Tailored to patient needs

Positive Chronic Rotator Cuff Tear

Pain >3 mon, Muscle atrophied, tendon retracted

Acute on Chronic Tear

PT for 6 wks min Glucocorticoid inj

revevaluateSurgical Repair

Chronic Tear

PT for 6 wks min Glucocorticoid inj

revevaluate

Take Away Points Rotator Cuff Tears

Acute Partial tears initially treat conservatively

Symtomatic chronic tears intially treat conservatively

Conservative treatment: Physical Therapy

• activity modification, capsule stretching, and muscle strengthening

Chronic tears will need referral that do not improve with nonop tx

Acute Full thickness tear in an otherwise healthy patient-referral

Acute Full thickness tear in patient with comorbidities-referral

Meniscus Tears

• Impair Knee motion

• Knee Effusion

• Premature osteoarthritis

• Isolation vs Association

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MeniscusAnatomy

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Meniscus Tear MOI

Meniscus Tear History

• Variability in presentation

• Small tears go unoticed from days to weeks

• Large tears have associated

• Stiffness

• Popping

• Catching

• Locking

Meniscus Physical Exam

Joint line tenderness

Inability to fully extend

knee

Loss of smooth

passive ROMJoint Effusion

Pain with Thessaly or Apley Test

Catching with McMurray

Test

Diagnostic Imaging

• Plain Radiographs

• MRI?

Approach to Treatment and Orthopedic Referral

• Bracing

• Physical Therapy

• Strengthening the muscular support of the knee

• Defining type and extent of the tear

• Determining the need for surgery

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Conservative Treatment

24-48 hr delay in symptoms

Swelling is minimal

Full AROM

Pain with provocative tests in deep flexion

Moderate to severe OA

Surgical Treatment

• Younger demographic

• Acute twisting injury

• Mechanical symptoms

• Persistent knee effusion

• Positive Provacative Tests

• Little improvement after 6 weeks

Type of Tear

• Small intrasubstance or vertical tear

• Presence of OA

Conservative

• Large tears in contact with articular cartilage

• Bucket handle tears – unable to extend knee

Knee Arthroscopy

Tear Types

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Take Away Points Meniscus Tears

The presentation of meniscal injuries are variable

Management depends on many factors

Intrasubstance and vertical tears w/o symptoms-nonoperatively

Severe tears with early pain, effusion, and loss of motion-referral

Chronic degenerative tears managed nonoperatively

Mallet Finger Injuries

Mallet Finger

Mallet Finger

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Mallet Finger Evaluation

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Diagnostic Imaging

• Radiographs

• AP, lateral and oblique

• Ultrasound• Hockey stick probe

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Orthopedic Referral

• Unable to passively extend

• Laceration to extensor tendon

• Volar subluxation

• Avulsion Fracture > 30%

• Chronic presentation

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Chttps://upload.orthobullets.com/question/4362/images/malletfinger.jpglick to add text

Mallet Finger Treatment• Splint immobilization

• Extension or hyperextension

• Stack, aluminum, or Kleinart

• 6 weeks initially

• 2-4 weeks at night

• Follow every two weeks

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Take Away Points Mallet Finger

• Rupture of extensor tendon inertion on DIP by forced finger flexion

• Inability to actively extend DIP joint

• 6-8 weeks splinted in extension or hyperextension

• Surgical referral needed:

• Fracture nvolvement of > 1/3 of joint surface

• DIP joint cannot passively extend

• DIP joint subluxation

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References

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3. Harryman DT 2nd, Sidles JA, Clark JM, et al. Translation of the humeral head on the glenoid with passive glenohumeral motion. J Bone Joint Surg Am 1990; 72:1334.

4. Kuhn JE, Dunn WR, Sanders R, et al. Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: a multicenter prospective cohort study. J Shoulder Elbow Surg 2013; 22:1371.

5. Keener JD. Surveillance of conservatively treated rotator cuff tears is warranted. Commentary on an article by Stefan Moosmayer, MD, PhD, et al.: "The natural history of asymptomatic rotator cuff tears. a three-year follow-up of fifty cases". J Bone Joint Surg Am 2013; 95:e101 1.

6. Strauss EJ, Salata MJ, Kercher J, et al. Multimedia article. The arthroscopic management of partial-thickness rotator cuff tears: a systematic review of the literature. Arthroscopy 2011; 27:568.

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References

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5. Lee SY, Jee WH, Kim JM. Radial tear of the medial meniscal root: reliability and accuracy of MRI for diagnosis. AJR Am J Roentgenol 2008; 191:81.

6. Alizadeh A, Babaei Jandaghi A, Keshavarz Zirak A, et al. Knee sonography as a diagnostic test for medial meniscal tears in young patients. Eur J Orthop Surg Traumatol 2013; 23:927.

7. Brimmo OA, Smith PA, Cook CR, et al. Sonographic diagnosis of an acute lateral meniscus tear in a division I collegiate American football player. J Knee Surg Rep 2015; 1:57.

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References

1. Bendre AA, Hartigan BJ, Kalainov DM. Mallet finger. J Am Acad Orthop Surg 2005; 13:336.

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6. Handoll HH, Vaghela MV. Interventions for treating mallet finger injuries. Cochrane Database Syst Rev 2004; :CD004574.

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References

1. Facca S, Nonnenmacher J, Liverneaux P. [Treatment of mallet finger with dorsal nail glued splint: retrospective analysis of 270 cases]. Rev Chir Orthop Reparatrice Appar Mot 2007; 93:682.

2. Lin JS, Samora JB. Surgical and Nonsurgical Management of Mallet Finger: A Systematic Review. J Hand Surg Am 2018; 43:146.

3. Weber P, Segmüller H. [Non-surgical treatment of mallet finger fractures involving more than one third of the joint surface: 10 cases]. Handchir Mikrochir Plast Chir 2008; 40:145.

4. Thillemann JK, Thillemann TM, Kristensen PK, et al. Splinting versus extension-block pinning of bony mallet finger: a randomized clinical trial. J Hand Surg Eur Vol 2020; 45:574.

5. Yoon JO, Baek H, Kim JK. The Outcomes of Extension Block Pinning and Nonsurgical Management for Mallet Fracture. J Hand Surg Am 2017; 42:387.e1.

6. Kalainov DM, Hoepfner PE, Hartigan BJ, et al. Nonsurgical treatment of closed mallet finger fractures. J Hand Surg Am 2005; 30:580.

7. Valdes K, Naughton N, Algar L. Conservative treatment of mallet finger: A systematic review. J Hand Ther 2015; 28:237.

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9. Katzman BM, Klein DM, Mesa J, et al. Immobilization of the mallet finger. Effects on the extensor tendon. J Hand Surg Br 1999; 24:80.

10. Hart RG, Kleinert HE, Lyons K. The Kleinert modified dorsal finger splint for mallet finger fracture. Am J Emerg Med 2005; 23:145.

Thank You for Your Attention!