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