Post on 12-Jul-2020
Lower Extremity & Shoulder
Orthopedic Review
WAPA Spring Conference
April 24, 2017
Seattle, Washington
Fred Huang, MDProliance Orthopedic Associates
A Division of Proliance Surgeons, Inc.
What We Aren’t Covering
❖ Lumbar spine and foot conditions
❖ Musculoskeletal infections & tumors
❖ Inflammatory arthritis (i.e. rheumatoid
arthritis, psoriatic arthritis, Reiter’s)
❖ Great reference:
▪ Miller’s Review of Orthopedics
Ankle Sprains
❖ Most often an inversion injury
❖ Lateral ligaments most
commonly injured:
▪ Anterior talo-fibular ligament
▪ Calcaneo-fibular ligament
▪ Posterior talo-fibular ligament
❖ Grades 1, 2, and 3
❖ Ottawa Rules for imaging
Source: www.intermountainhealthcare.org
Source: www.bodyflow.com.au
Ankle Sprains
❖ Grades 1 and 2 treated with RICE
▪ R = rest
▪ I = ice
▪ C = compression
▪ E = elevation
❖ NSAID’s, taping/bracing, and PT
❖ Grade 3 injuries sometimes immobilized for
several weeks (walking boot vs. cast)
❖ Some grade 3 injuries treated operatively
Source: www.bodyflow.com.au
Achilles Tendon Ruptures
❖ Usually occur in patients 35-50 years old
❖ “Somebody kicked me in the back of the leg!”
❖ Tears are about 5 cm above the calcaneal attachment
❖ Diagnosed with a positive Thompson test❖ Squeezing the calf muscle produces no ankle plantar flexion
❖ Cast treatment: reliable but slightly higher risk of subsequent re-rupture
❖ Surgical treatment: reduces risk of re-rupture but introduces surgical risks
❖ Non-operative with early motion/rehab best?
Ankle Fractures
❖ Isolated lateral malleolus fracture – unstable???
❖ Bimalleolar fracture - unstable
❖ Trimalleolar fracture - unstable
❖ Syndesmosis injury ▪ i.e. disruption of ligaments that
stabilize the distal tibio-fibular joint
▪ “High” ankle sprains
Lateral Malleolus Fracture
❖ If minimally displaced and
no major ligament injury,
cast treatment sufficient
(stress view important)
❖ If significantly displaced or
unstable, treat with ORIF
(open reduction and
internal fixation)
Trimalleolar Ankle Fracture
Trimalleolar Fracture Fixation
Maissoneuve Injury
❖ Involves ligamentous injury at ankle with bony injury of proximal fibula
❖ Ankle swelling medially (deltoid ligament injury) and in the distal leg (syndesmosis ligament injury)
❖ Proximal fibula fracture not seen on ankle films –must order full length tibia/fibula films
Maissoneuve Injury
❖ Stress views helpful
❖ Surgical treatment always
❖ Syndesmosis stabilization with 1 or 2 screws
❖ Screws will break or loosen when full activities allowed due to motion at distal tibio-fibular joint
❖ Screws often removed electively prior to resumption of full activities
Other Ankle Conditions
❖ Peroneal tendon tears – posterolateral pain/swelling
❖ Most often degenerative – longitudinal tears in the peroneus brevis
❖ Peroneal tendon subluxation – often associated w/ an acute injury
(SURGERY to repair retinaculum?)
❖ Ankle arthritis❖ Often post-traumatic. Can also be inflammatory or just primary DJD.
❖ Fusion (versus arthroplasty?)
❖ Lateral process fractures of the talus❖ Frequently occur in snowboarders
❖ Forceful ankle dorsiflexion with eversion and axial loading
❖ Treated with excision vs. ORIF (or cast if non-displaced)
Common Knee Injuries
❖Meniscal Tears
❖ACL Tears
❖Multi-ligament Injuries
❖Tibial Plateau Fractures
Age Related Injury Patterns
❖ Teenagers▪ Ligament and meniscal tears
▪ Patellar dislocations
▪ Growth plate injuries
❖ Adults▪ Ligament and meniscal tears
▪ Some tibial plateau fractures
❖ Elderly▪ More tibial plateau fractures
Patello-femoral Pain
❖ Frequent cause of ANTERIOR knee pain
❖ Worsened by squatting, stair-climbing, and lunges
❖ Often associated with anterior knee crepitus
(chondromalacia patella)
❖ Usually no joint line tenderness
❖ Effusions possible, but rare
❖ MRI’s often “normal” – or may show PF chondromalacia
❖ Treatment consists of activity modification, formal PT,
NSAID’s, weight loss, and occasional steroid injections
❖ PT: patellofemoral rehab & hip abductor strengthening
❖ Easy diagnostic tool: Single-leg deep knee bend test
Patellar Instability
❖ Almost all patellar dislocations are lateral and in teenagers
❖ Medial patellofemoral ligament fails
❖ Surgical treatment for recurrent instability and/or loose bodies and/or “extreme” anatomy
❖ Reduce by extending the knee +/- direct pressure at the lateral patella
Growth Plate Fractures
❖ Growth plate
injuries
▪ <15 for
females
▪ <18 for males
❖ Not always
readily
apparent on
initial x-rays
Imaging: Growth Plate Fractures
❖ Salter-Harris classification
(know types I through V)
Meniscal Tears
❖ Clinical Symptoms
▪ Swelling
▪ Catching +/- locking
▪ Difficulty with pivoting and squatting
❖ Physical Exam Findings
▪ Effusion
▪ Joint line tenderness
▪ Positive McMurray’s maneuver
Meniscal Tears
❖ Arthroscopic surgery if mechanical symptoms present (meniscectomy)
❖ Degenerative tears: associated with minimal or no trauma – if DJD present surgery not usually pursued
❖ Bucket-handle tears –often amenable to repair
Types of Ligament Injuries
❖ ACL very common
❖ MCL most common with ski injuries
▪ Usually treated non-operatively with brace
❖ Combination injuries (ACL w/ MCL most common,
but any combo possible)
❖ PCL involved frequently in multi-ligament injuries
ACL Tears
❖ Twisting on a planted foot (non-contact)
❖ Unable to continue sporting activity
❖ Effusion within 1 hour
❖ Lachman testMost accurate test in awake patients; pivot-shift better but not usually tolerated unless done under anesthesia
Source: Knee Ligament InjuriesThe Staywell Company, 2001
❖ A. Increased posterior translation of tibia with stress when knee flexed 90 degrees
❖ B. Increased anterior translation of tibia with stress when knee flexed 20 degrees
❖ C. Increased anterior translation of femur with stress when knee flexed 20 degrees
❖ D. Increased posterior translation of tibia with stress when knee flexed 20 degrees
ARS Question: What is a positive
Lachman test?
MRI – ACL Tear
ACL Tears - Treatment
❖ Non-operative treatment (Brace? PT?)PT reasonable for patients with isolated ACL tears who
do <1 hour of ACL-dependent sports per week
❖ Surgical treatment▪ Timing of surgery
▪ Graft options: autograft versus allograft
▪ Associated procedures: meniscal repair vs.
meniscectomy, cartilage procedures
ACL Reconstruction
Multi-ligament Knee Injuries
❖ Higher energy mechanism than ACL tears
❖ Knee (tibio-femoral) dislocation?
❖ Critical to assess neurovascular function:
▪ Motor/sensory function at the ankle/foot
▪ Palpable distal pulses? (Popliteal artery injury?)
▪ Further vascular testing required (CT-angiogram vs. arterial ultrasound or arteriogram)
Multi-ligament Knee Injuries
❖ More frequently treated operatively than
isolated ligament injuries
❖ Allograft tissue almost always used
❖ Rehab more difficult, post-op stiffness
common, and return to sports less likely
Multi-ligament Knee Injuries
Other Important Knee Ligments
▪ ACL, PCL, MCL, and LCL = “big 4”
▪ PLC injuries: the posterolateral corner is a complex
collection of soft tissue structures between the lateral
femur, proximal fibula, and proximal tibia, most often
injured in conjunction with the PCL and/or LCL
▪ PMC injuries: the posteromedial corner is also known
as the posterior oblique ligament (from medial femur
to posteromedial proximal tibia)
▪ ALL injuries: the anterolateral ligament runs from the
posterolateral femur to the anterolateral tibia
▪ Injuries involving any of these 3 ligaments usually
result in rotational knee instability
Chondral and Osteochondral
Lesions of the Knee
❖ Can be associated with a childhood
problem (osteochondritis dissecans
lesion) or a single traumatic event
❖ Better prognosis if uni-polar and in
younger patients (<40 years old)
❖ Treatment options:
❖ Debride/remove lesion only
❖ Micro-fracture (if underlying bone
healthy)
❖ Graft/fix fragment
❖ Osteochondral plugs (auto vs
allografts)
Chondral and Osteochondral
Lesions of the Knee
Chondral and Osteochondral
Lesions of the Knee
Diagnosis of Knee DJD
❖ 3 compartments of the knee:
▪ 1. Patello-femoral
▪ 2. Medial tibio-femoral
▪ 3. Lateral tibio-femoral
❖ Physical Exam:
▪ Stiffness
▪ Deformity (varus = bow-legged,
valgus = knock-kneed)
▪ Effusions common
Knee DJD – Radiographic Findings
❖ Hallmarks of DJD
▪ 1. Loss of cartilage thickness
▪ 2. Bony sclerosis
▪ 3. Osteophytes (bone spurs)
▪ 4. Bone cysts
▪ 5. Joint subluxation
❖ Weight-bearing
radiographs a must
▪ 1. Compare with other side
▪ 2. Flexed view important
Knee DJD – Treatment Options
❖ Standard treatments:
▪ 1. NSAID’s and acetaminophen
▪ 2. Glucosamine/chondroitin
▪ 3. Activity modification & wt. loss
▪ 4. Intra-articular steroid injections
▪ 5. Hyaluronic acid injections
▪ 6. Novel injections (PRP/stem cells)
▪ 7. Unloader braces
▪ 8. Neoprene sleeves
▪ 8. Osteotomy surgery
▪ 10. Knee replacement –
unicompartmental versus total knee
replacement
Varus Knee DJD
Proximal Tibial Osteotomy
❖ Intermediate solution that improves pain and function usually for usually < 10 years
❖ Allows for continued impact activities
❖ Associated with a long recovery time (to allow for healing of osteotomy)
❖ Does not “burn bridges”
Knee DJD – Total Knee Replacement
❖ Reliable solution that improves pain and function usually for >15 years
❖ Implants not intended for impact activities
❖ Intensive therapy and exercises critical post-op to obtain good ROM
❖ New interest in multi-modal pain management, smaller incisions, accelerated rehab, and rapid postop discharge
Total Knee Replacement Risks
❖ DVT/PE
❖ Infection
❖ Peri-prosthetic fracture
❖ Early component
loosening or failure
❖ Post-operative stiffness
ARS Question: Best method for
DVT prevention after TKA surgery?❖ A. Coumadin (dose-adjusted with goal INR 2.0-
2.5) for 4 weeks
❖ B. ASA 81mg BID for 4-6 weeks, with SCD’s while
an inpatient
❖ C. Daily Lovenox or Arixtra or Fragmin injections
for 1 month
❖ D. Xarelto orally starting the day after surgery for
28 days
Tibial Plateau Fractures
❖ Wide spectrum of injury
patterns
❖ Medial and/or lateral; tibial
eminences (cruciate injury)
❖ Split and/or depressed
fragments
❖ Increasing displacement
means more severe cartilage
injury; post-traumatic arthritis
more likely to develop
Tibial Plateau Fractures
❖ CT scans helpful in defining the fracture
❖ Anticipate other injuries (meniscal tears, ligament tears, arterial or neurologic deficits)
Tibial Plateau Fixation with
Lateral Ligament Repair
Hip Fractures
❖ Common in the elderly
▪ Low energy trauma
▪ Osteoporosis
❖ Higher energy injuries
in adults – MVA/MCA,
fall from heights
❖ Variety of fractures and
treatment options
Femoral Neck Fractures
❖ If non-displaced or impacted in
a stable position, screw
fixation suitable
❖ If displaced not likely to heal in
elderly patients, thus usual
treatment is an endoprosthesis
(i.e. hemi-arthroplasty)
❖ Select patients are managed
with total hip arthroplasty
Intertrochanteric Hip Fractures
❖ Occur distal to the femoral neck, where the blood supply is very good
❖ Unlike femoral neck fractures, non-union rarely a concern
Intertrochanteric Fracture Fixation
❖ Fixation usually stable enough to allow for early full weight-bearing
❖ Some surgeons prefer nails for these fractures –protects the entire length of the femur and incisions much smaller
Femoral Shaft Fractures
Most are treated with medullary rods/nails with interlocking screws
Percutaneous technique reduces soft tissue trauma to gluteal muscles and facilitates recovery
Femoral Rodding
Percutaneous Femoral Rodding
Subtrochanteric Femoral Stress Fractures
Associated with Bisphosphonates
❖ Fosamax, Boniva, Actonel, Zometa
❖ Decrease osteoclast activity, but also impair osteoblast activity
❖ Better bone density, but bone architecture is less “coordinated”
❖ Osteonecrosis of the jaw and stress fractures of the proximal femoral shaft – ask about jaw and thigh pain
❖ Stop drug if on it > 3-5 years
❖ Alternatives: Forteo (PTH) or Prolia?
Diagnosis of Hip DJD
❖ Most commonly causes GROIN pain❖ Less frequently causes lateral hip pain and/or buttock pain
❖ Patients often c/o referred pain to the ipsilateral thigh/knee
❖ Symptoms worse with weight-bearing and better with rest
❖ Physical Exam:▪ Reduction of motion, especially internal rotation
▪ Pain worsened with passive internal rotation of the hip in flexion
▪ Possible shortening of the affected extremity
Diagnosis of Hip DJD
External rotation
Internal rotation
PAIN !!!!
Hip DJD – Radiographic Findings
❖ Hallmarks of DJD
▪ 1. Loss of cartilage thickness
▪ 2. Bony sclerosis
▪ 3. Osteophytes (bone spurs)
▪ 4. Bone cysts
▪ 5. Femoral head deformity
Hip DJD – Treatment Options
❖ Standard treatments:
▪ 1. NSAID’s and acetaminophen
▪ 2. Glucosamine/chondroitin
▪ 3. Activity modification
▪ 4. Intra-articular steroid injections
▪ 5. Total hip replacement
Hip DJD – Total Hip Replacement
❖ Reliable solution that improves pain and function, but not designed for impact activities
❖ Posterior approach:▪ Higher dislocation risk (2-3%)
▪ More familiar anatomy – but requires gluteus maximum split
❖ True anterior approach:▪ Much lower dislocation risk (<1%)
▪ Learning curve, special equipment
▪ Quicker recovery (1st 3-4 months)
Total Hip Replacement Risks
❖ DVT/PE
❖ Infection
❖ Component loosening or failure
❖ Leg length discrepancy
❖ Dislocation
❖ Intra-operative or peri-prosthetic
fracture
❖ Adverse soft tissue reaction
(Metal-on-metal articulation)
Miscellaneous Hip Conditions❖ Trochanteric bursitis
❖ Lateral hip pain, worsened with direct pressure (side-lying)
❖ PT (ITB stretching), NSAID’s, and cortisone injections
❖ Hip labral tears and FAI (femoro-acetabular impingement)
❖ Often degenerative, an early sign of DJD (Cam vs Pincer)
❖ Traumatic labral injury – best indication for arthroscopic surgery
– probably better results compared to degenerative tears
❖ Femoral head osteonecrosis
❖ Associated with chronic steroids, prior
trauma, clotting disorders, alcoholism
❖ Drilling (if no collapse) versus arthroplastySource: newsday.com
ARS Question: 80 yr old with hip
pain after a fall 2 days ago
❖ A. Hip adductor strain
❖ B. Acute femoral head osteonecrosis
❖ C. Hip labral tear
❖ D. Occult femoral neck fracture
Shoulder Overview
▪ History and Physical Exam
▪ Traumatic Injuries▪ Fractures, dislocations, torn structures
▪ Atraumatic Conditions▪ Inflammation / Repetitive Stress
▪ Degeneration – possible tearing?
▪ Arthritis
▪ Frozen shoulders
▪ Case Scenarios
Shoulder Exam
▪ Remember the 5 S’s
▪ SPAN (i.e. ROM)
▪ SMOOTHNESS
▪ STABILITY
▪ STRENGTH
▪ SPECIAL
SPAN
▪ Important to test ACTIVE and PASSIVE
range of motion (ROM)
▪ Most important to measure:
▪ Forward elevation (i.e. flexion)
▪ Abduction
▪ External rotation (at side & in abduction)
▪ Internal rotation (scarecrow & behind back)
SMOOTHNESS
▪ Yes or No
▪ Crepitus may be elicited with active
ROM testing (glenohumeral DJD)
▪ Or may be most notable with passive
ROM tesing (impingement/bursitis)
▪ Scapulo-thoracic crepitus extremely
common – rarely pathologic
STABILITY
▪ Anterior shoulder instability most common
▪ Apprehension testing – creates sense of
impending dislocation (pain not accurate)
▪ Relocation maneuver – reduced sense of
impending dislocation with examiner exerting
pressure at anterior humerus and no change in
arm position
▪ Posterior shoulder instability also possible
▪ Jerk test positive for painful clunk with
posterior loading as shoulder reduces
STRENGTH
▪ Test wrist and grip strength first
▪ Then test elbow flexion/extension
▪ Shoulder strength assessment:
▪ External rotation at side (infraspinatus)
▪ Abduction (middle deltoid)
▪ Forward elevation (anterior deltoid)
▪ Empty can (supraspinatus)
▪ Belly-press/Napoleon test (subscapularis)
SPECIAL
▪ Hawkins impingement test (FE 90 degrees then
passive internal rotation) positive for impingement
▪ Pain with cross-body adduction and AC palpation
positive for AC DJD
▪ Saw sign positive for bicipital tendinitis/partial
biceps tendon tears
▪ Speed sign positive for SLAP tear and/or biceps
tendon pathology
▪ O’Brien’s test positive for SLAP tears
▪ Crank test positive for GH DJD or labral tears
Clavicle Fractures
▪ Due to a fall onto the point of the shoulder
▪ Distal fragment (and entire arm) drops down
▪ Deformity, swelling, ecchymosis
▪ Supportive care usually adequate, deformity
will persist, non-union possible
▪ Surgery if > 2-3cm shortening and >150%
displacement – high chance for 2nd surgery for
HW removal if ORIF performed
Clavicle Fractures
AC Separations
▪ Again, falling onto the point of the shoulder
▪ Football (getting tackled) or falling off a bike
▪ Deformity with prominent distal clavicle
▪ Types I-VI
▪ Types IV, V, and VI rare, but may warrant surgery
AC Separations
Proximal Humerus Fractures
▪ Usually due to a fall onto the shoulder
▪ Common in the elderly
▪ How many “parts”? (up to 4); CT helpful
▪ Decision on treatment depends on fracture
pattern AND patient’s unique situation
▪ Options:
▪ Shoulder immobilizer
▪ Closed reduction and pinning vs ORIF vs
arthroplasty
Proximal Humerus Fractures
Shoulder Dislocations
▪ Anterior dislocations by far the most common
▪ If still dislocated expect deformity and severe
pain
▪ Can try reduction without sedation if addressed
promptly
▪ Foot in armpit and PULL!!!
Shoulder Dislocations
Source: www.aaos.org
Shoulder Dislocations
SLAP Tears
▪ Notorious for vague pain (“dead-arm”)
▪ Traction or jamming injury
▪ Superior labrum (and often biceps anchor)
detach from the superior glenoid
▪ Surgical intervention (selective SLAP repair
in young pts with traumatic injury, otherwise
debride labrum then do biceps tenodesis)
▪ Often a degenerative finding – surgery may
not be the best option
SLAP Tears
Impingement Syndrome
▪ Also referred to as subacromial bursitis
and/or rotator cuff tendinitis
▪ Pain worse with overhead activities
▪ Often associated with popping/grinding
▪ Recent change in activities?
Biceps Tendinitis
▪ Involves long head of the biceps tendon
▪ Runs in the bicipital groove in between the
subscapularis and supraspinatus tendons
▪ Anterior shoulder pain often extending into
biceps muscle belly
▪ Best test: positive Saw or Speed signs
▪ Chronic cases can eventually result in rupture
of the tendon – POPEYE deformity
Rotator Cuff Tendinosis
▪ Occurs in everyone; normal “wear and tear”
▪ Represents normal age-related degeneration of
the tendons at a microscopic level
▪ Most often affects the supraspinatus tendon
▪ Pain, maybe weakness, but can be effectively
treated without surgery
▪ NSAID’s, PT, and activity modification
▪ Cortisone injections into subacromial space
▪ Wait at least 4 months in between injections
Rotator Cuff Tears
▪ Most common age: 50’s and 60’s
▪ When full-thickness patients will recruit
deltoid to compensate for supraspinatus
weakness; mid-range pain is the worst
▪ Night pain very common, and often severe
▪ Most often attritional tears that develop
gradually over time
▪ Acute tears: outcome probably better if
addressed surgically within 4-6 months
Rotator Cuff Tears
AC Joint Arthritis
▪ Extremely common in anyone over 40
▪ Expect enlargement of the distal clavicle
▪ Focal pain at the superior shoulder, doesn’t
usually radiate
▪ Pain worse with lifting, cross-body adduction,
and straps over the AC joint
▪ Cortisone injections into AC joint helpful
▪ Ultimate option: distal clavicle resection
AC Joint Arthritis
Glenohumeral Arthritis
▪ Not nearly as common as AC arthritis
▪ Often post-traumatic (multiple prior
dislocations, or prior surgery for instability)
▪ ROM decreases as severity of arthritis
increases
▪ NSAID’s and glenohumeral injections helpful
▪ Ultimate option: Shoulder arthroplasty
Glenohumeral Arthritis
Frozen Shoulders
▪ AKA adhesive capsulitis
▪ The “low back pain” of the shoulder
▪ Associated with endocrine disorders
▪ Pain 24/7 frequently, biceps pain common
▪ Females > males
▪ 3 phases
FREEZING
Courtesy Walt Disney World Studios
FROZEN
Courtesy Walt Disney World Studios
THAWING (SUMMER!)
Courtesy Walt Disney World Studios
Case #1
▪ 38 year old RHD male with complaints of
3 weeks of R shoulder pain after recent
yardwork (tree trimming)
▪ Age – helps eliminate a few possibilities
▪ ROM: active = passive. Decreased
abduction otherwise ROM full
▪ Smooth? No, mildly painful crepitus noted
▪ Stable? Strong? Yes to both
▪ Best special test(s)? 3 are relevant
Case #1
▪ A. Glenohumeral DJD
▪ B. Long head biceps tendon rupture
▪ C. Shoulder bursitis/impingement syndrome
▪ D. Adhesive capsulitis
Case #2
▪ 64 year old RHD female with complaints
of 3 months of shoulder pain and weakness
▪ Age and relevant history
▪ ROM: active < passive; Full passive ROM
▪ Smooth? No, painful crepitus noted
▪ Stable? Yes
▪ Strong? Yes with ER/IR testing
▪ Best special test(s)? One most important
Case #2
▪ A. Glenohumeral DJD
▪ B. Supraspinatus full-thickness tear
▪ C. Traumatic SLAP tear
▪ D. Adhesive capsulitis
Case #3
▪ 49 year old RHD female with complaints
of 6 months of L shoulder pain and
stiffness after L mastectomy surgery
▪ MRI shows SLAP tear
▪ Age and relevant history
▪ ROM: active = passive, but limited in all ways
▪ Smooth? Stable? Strong? Yes to all
▪ Best special test? Probably only 1 or 2
Case #3
▪ A. Glenohumeral DJD
▪ B. Supraspinatus full-thickness tear
▪ C. Shoulder subacromial bursitis
▪ D. Adhesive capsulitis
Occult Femoral Neck Fracture
❖ After trauma, if films negative but exam positive --> MRI (or bone scan) helps to make the diagnosis
❖ Should be treated
“semi-urgently”
❖ Screw fixation usually adequate since fracture is non-displaced
Thank You
Renton Covington Maple Valley
www.prolianceorthopedicassociates.com