clinical evaluatin'

! for the diagnosis of nongrscocca

bacterial arthritis.

Methods: Devew of t4 studies mehiling 6242

patients of which 653 had positive srnova: cu tire

(gold standard diagnostic tnol forseptx afnts).

Results:Age,diabetes nelStos.rbearztod

arthritis, jointsurgery, hip or knee prosthesis,sc r

infection, and human immunodeficiency erastype

t infection significantly increase the proPati ity of

septic arthritisJoint pain, history of joctswtfrg.

and fever are found m >50

*

of cases.The presence

ol inoeased WBC increasesthe Iiielzood rano for

counts <2SOOO/pL:W,0.32;95

*

a.0.23 0.43

for counts >25000/pL LR.2.9:95

*0.2J-3.4:foe

counts elOOOOOipL:IR.2B.0:95

*

0,C.0-66.C|.A

polymorphonuclear cell count of ?90

* mueasesoe

IR of septic arthritis hy 3.4.*

!e a PMI cel coat of

<90% reducestheLR by 0.34.

Conclusions Clinical findings may pe used a idem ’

patients with monoarticular arthritis who may

have septic arthritis,laboratory findingsfrom as

arthrocentesis are also required and helpful poor a

Oram stain and culture.

Table 7. Treatment of Osteomyelitis

Acute Osteomyelitis Chronic Osteomyelitis

IV antibiotics 4-6 wk:started empirically and adjusted alter obtaining Surgical debridement

blood and aspiratecultures

± surgery (liD)for abscess or significant involvement

* hardware removal(if present)

Antibiotics:both local(e.g.antibiotic beads) and systemic (IV)

Septic Arthritis

•joint infection with progressive destruction if left untreated

Etiology

•most commonly caused by S.aureus in adults

•consider coagulase-negative Staphylococcus in patients with prior joint replacement

•consider,V.gonorrhocac in sexually active adults, and newborns

•most common route of infection is hematogenous

•risk factors: young/elderly (age >80 yr), prosthetic joint, recent joint surgery,skin infection/ulcer,

IV drug use,recent intra-articular corticosteroid injection, immunocompromised (cancer, DM,

alcoholism,RA) +

Activate Windows

GtrtcrSettfng5To“

at?ivateJWmtfov

0R12 Orthopaedic Surgery Toronto Notes 2023

Clinical Features

• inability/refusal to hear weight, localized joint pain, erythema, warmth,swelling, pain on active and

passive ROM, ± fever Posterior Shoulder Dislocation

Up to 60-80% are missed on initial

presentation dueto poor physical exam

and radiographs

Investigations

• x-ray (to rule out fracture, tumour, metabolic bone disease), ESR,CRP, WBC, blood cultures

• joint aspirate: cloudy yellow fluid, WBC >50000 with >90% neutrophils, protein level >4.4 rng/dL,

joint glucose level <60% blood glucose level, no crystals, positive Gram stain results

• listen for heart murmur (if concern for infective endocarditis, use Duke Criteria)

There are 4Joints inthe Shoulder

Glenohumeral.AC.sternoclavicular (SC),

scapulothoradc

Treatment

• IV antibiotics, empiric therapy (based on age and risk factors), adjust following joint aspirate C&S

results

• non-operative

• therapeutic joint aspiration,serially if necessary

• operative

• arthroscopic or open irrigation and drainage

Shoulder passive ROM:abduction180°,adduction - 45°.flexion -180°.

extension - 45°.int rotation -level of

T4,ext.rotation -‘

90°likely more...

Shoulder

Factors Causing Shoulder Instability

, Shallow glenoid

• Loose capsule

• Ligamentous laxity

Frequency of Dislocations

. Anterior shoulder >Posterior

shoulder

• Posterior hip>Anterior hip

• The glenohumeral joint is the most

commonly dislocated joint in the

body since stability is sacrificed for

motion

Shoulder Dislocation

•complete loss of continuity between the two articular surfaces of the glenohumeral joint; may be

anterior or posterior

Investigations

- anterior dislocation x-rays: AP, trans-scapular, and axillary views ofthe shoulder

•posterior dislocation x-rays: AP, trans-scapular, and axillary views of the shoulder; orCT scan

Table 8. Anterior and Posterior Shoulder Dislocation

Anterior Shoulder Dislocation (>90%) Posterior Shoulder Dislocation(5%)

MECHANISM

Adducted,internally rotated,flexedarm

FOOSK

3Es (epilepticseizure. EtOH.electrocution)

Blow to anterior shoulder

Abducted externally rotated/hyperextended arm

Blow toposterior shoulder

Involuntary,usually Iraumalic; voluntary,atraumatic

CLINICAL FEATURES

Symptoms Pain,arm slightly abducted and externally rotated with

inability to internally rotate

Pain,arm is held in adduction and internal rotation;

externalrotation is blocked

"Squared off shoulder

Positiveapprehension test: palientlooks apprehensive

with gentle shoulder abduction and externalrotation to 90”

Positiveposterior apprehension (“jerk") test:with

as humeral head is pushed anteriorly and recreates feeling patientsupine.flex elbow 90° and adduct,internally

rotate the arm while applying a posterior force to the

shoulder;patient will“jerk* back with the sensation of

Anterior shoulder flattening,prominent coracoid,

palpable mass posterior to shoulder

Shoulder Exam

1.Manubrium

2.Sternoclavicular joint

3.Clavicle

4.Coracoid process

5.AC joint

6.Acromion

7.Humerus

8.Glenohumeral joint

,9.Scapula

Figure 9. Shoulder joints

of anterior dis'ocation

Positiverelocation test:a posteriorly directed force

applied durmgthe apprehension test relieves apprehension subluxaton

since anterior subluxation is prevented

Positivesulcus sign:presence of subacromial indentation recurrent posterior instability.NOT lor acute injury

with distal traction on humerus indicates inferior shoulder

Note:the posterior apprehension test is used to test for :

er

§

instability e

These tests are more commonly used for chronic recurrent

instability

Axillary nerve:sensory patch over deltoid and deltoid

contraction

Musculocutaneous nerve: sensory patch on lateral

forearm and biceps contraction

FullRenovascular exam as per anterior shoulder

dislocation

Neurovascular Exam

Including

Coracoid

V process

RADIOGRAPHIC FINDINGS

Axillary View

Trans scapular 'Y° View Humeral head is anterior to the center of the "MercedesBent"sign

Sub- coracoid lie of the humeral head is most common

Acromion

Humeral headis posterior /

Humeral headis posterior tocenter of "Mercedes-Bent*

Humeral head is anterior

sign 2

AP View Partial vacancy of glenoid fossa (vacant glenoid sign) and

>6 mm space between anterior glenoidrim and humeral

head (positive rim sign),humeral head may resemble a

lightbulb due to internal rotation (lightbulb sign)

tReverseHill-Sachs lesion (75% of cases):divot in

anterior humeral head

*Reverse bony Bankart lesion:avulsion of the posterior

glenoid labrum from the bony glenoid rim

r -t

I

_ L J

1_ Humcru Hill-Sachs and Bony

Bankart Lesions

? Hill-Sachs lesion:compression fractureof posterior

humeral head due to forceful impaction of ananteriorly

dislocated humeralhead against the glenoid rim

- Bony Bankart lesion:avulsion of the anterior glenoid

labrum (with attached bone fragments) from the glenoid

-

1

+ I

e

rim Figure 10. Mercedes-Benz

Activate Windows

GotoSsttfngsto activate'Windows.

OR13 Orthopaedic Surgery TorontoNotes 2023

Table 8. Anterior and Posterior Shoulder Dislocation Bankart

Anterior Shoulder Dislocation(>90%) Posterior Shoulder Dislocation (5%)

TREATMENT

Closed reduction withIV sedation and muscle relaxation

Traction-countertraction: assistant stabilizes torso with

a folded sheet wrapped across the chest while the surgeon

applies gentle steady traction

Stimson:while patient lies prone with arm hanging over

table edge,hang a 5 lb weight on wrist lor 15-20 min

Hippocratic method:place heel into patient’s axilla and

apply traction to arm

Cunningham'smethod:gentle longitudinal support

and traction of the arm at the patient's side,massage/

relaxation of deltoid,trapezius,and biceps to allow

atraumatic shoulder reduction,low-risk,low pain;if not

successful try above methods

Obtain post-reduction x-rays

Check post-reduction MVS

Sling x 3 wk (avoid abduction and external rotation),

followed by shoulder rehabilitation (dynamic stabilizer

strengthening)

Closed reduction with IV sedation and muscle relaxation

Interior traction on a Hexed elbow with pressure on the

back of the humeral head

Obtain post-reduction x-rays

Check post-reduction NVS

Sling in abduction and external rotation x 3 wk.

followed by shoulder rehabilitation [dynamic stabilizer

strengthening)

Hill-Sachs

Figure 11. Posterior view of anterior

dislocation causing Hill-Sachs and

Bankart lesions

Prognosis

• recurrence rate depends on age of first dislocation

• <20 yr 65-95%; 20-40 yr = 60-70%;>40 yr 2- 4%

Specific Complications

• recurrent dislocation (most common complication)

• unreduced dislocation

• shoulder stiffness

• rotator cuff or capsular or labral tear (Bankart/SLAP lesion)

• injury to axillary nerve/artery,brachial plexus

I

u->

§

I

-

-5 a

s

—«

r.

O

Antorior apprehension sign Sulcus sign

s

I

S sa i

s >-

5 4

e

Posterior apprehension sign Traction-countertraction

Figure 12. Shoulder maneuvers

+

Activate Windows

Go to Settings to activate Windows.

OR!l Orthopaedic Surgery Toronto Notes 2023

Supraspinatus

\ ligament

Acromion L

—

Rotator Cuff Disease

Coracoid

• rotator cuff consists of 4 muscles that act to stabilize the humeral head within the glenoid fossa process 4k

Table 9. Rotator Cuff Muscles (SITS)

Muscle Muscle Attachments Nerve Supply Muscle Function

Proximal Distal

Scapula Greater tuberosity ol

humerus

Greater tuberosity of

humerus

Greater tuberosity ol

humerus

lesser tuberosity of

humerus

Supraspinatus Suprascapular nerve Abduction

Infraspinatus Scapula Suprascapular nerve Eitemal rotation 1

--

Teres Minor Scapula Axillary nerve filernalrotation ASubscapularis I

-

Joint capsule

capular body j

Subscapularis Scapula Subscapular nerve Internal rotation and

adduction

Infraspinatus

Teres minor 5

SPECTRUM OF DISEASE: IMPINGEMENT. TENDONITIS, MICRO OR MACRO TEARS

Figure 13. Lateral view of the

muscles of the rotator cuff

Etiology

• narrowing ofsubacromial space

• most commonly due to a relative imbalance of rotator cuff and larger shoulder muscles,allowing for

superior translation and subsequent wear of the rotator cuff muscle tendons

• glenohumeral (rotator cuff) muscle weaknessleading to abnormal motion of humeral head

scapular muscle weakness leading to abnormal motion of acromion - poor posture

• acromial abnormalities,such as congenital narrow space or osteophyte formation or Type Ill

acromion morphology

1. outlet/subacromial impingement:

“

painful arc syndrome,” compression of rotator cuff

tendons (primarily supraspinatus) and subacromial bursa between the head of the humerus

and the undersurface of acromion, AC joint, and CA ligament

2. bursitis and tendonitis

3. rotator cuff thinning and tear if left untreated

Bigliani Classification of Acromion

Morphology

• Type I -flat

• Type II - curved

• Type III - hooked

Screening Out Rotator Cuff Tears

• No night pain (SN 87.7%)

• No painful arc (SN 97.5%)

• No impingementsigns(SN 97.2%)

• No weakness

Returning to the bedside;Using the

history and physical examination to

identify rotator cuff tears

J Am eeriatr Sac 2m«:K33-K37

Clinical Features

• insidious onset, but may present as an acute exacerbation of chronic disease, night pain,and difficulty

sleeping on affected side

• pain worsens with active motion (especially overhead); passive movement generally permitted

• weakness and loss of ROM, especially between 90-130°(e.g. trouble with overhead activities)

• tenderness to palpation over greater tuberosity

• rule out bicep tendinosis (Speed’s test) and SLAP lesions (O'

Brien’s test)

Investigations

• x-ray:AP view may show sclerosis of the undersurface of the acromion or greater tuberosity, high

riding humerus relative to glenoid, indicating large tear, evidence of chronic tendonitis

• MR1:coronal/sagittal, oblique, and axial orientations are useful for assessing full/partial tears and

tendinopathy ± arthrogram: geyser sign (injected dye leaks out of joint through rotator cuff tear)

• arthrogram: not commonly used but can assess full thicknesstears, difficult to assess partial tears

• ultrasound:may be a useful adjunct but limited ability to evaluate other intra-articular pathology

Treatment

• non-operative

first line treatment, rotator cuff injury treatment begins with physiotherapy (regardless ofseverity

on MR1 findings)

• physiotherapy, activity modification, non-narcotic analgesia ± steroid injection

• mild or moderate cases frequently improve

• progression to surgery if necessary

• operative

severe tear or impingement that is refractory to 2-3 mo physiotherapy and 1 -2 corticosteroid

injections

arthroscopic or open surgical repair (i.e. acromioplasty, rotator cuff repair)

Ruling in Rotator Cuff Tears-98%

probability of rotator cuff tear if all 3of

the following are present:

• Supraspinatus weakness

• External rotation weakness

• Positive impingementsign(s)

Diagnosis of rotator cuff tears.

Uriel 2001:357:765-770

Does thisPatient with Shoulder Faia have Rotator

Cull Disease’The Rational Clinical Euniaation

Systematic Review

JAMA 2013:310:837-847

Study: 5 studies of suficien:gcalty netd ‘

3

30-203 shouldersand a peeve e

*

te of ICO ranging

from 33-81%.

Results/Condosions: Jmong pan prpvocatiotesis, a positive pairfal ait test fad the gaetes:

specificity aid sensitnrty (SP 81%.SI 21%).Amrg

strength tests,a positveeftrael rotetion lag as:

and internal rotation lag as!were the nnstamiraa

fnr fidl-thicknesstears$P47%.SI 94%:SP 92%.

SH 83% respectively).The Menal rotation legtesJ

was therefore also the mast accs-aa far Meutdywg

patients without a ful-tticksess aar.

A positive drop arm test is helpful to ; dertify patients

with RCD (SN 24%. SP93%L

r T

L J

+

Activate Windows

"

GcrterSettmgrtcrsctTvate Windowsr

0R15 Orthopaedic Surgery Toronto Notes 2023

Table 10. Rotator Cuff Special Tests

Test Examination Positive Test

Supraspinatus:place the shoulder in90’of

adduction and 30’of horizontal flexion (from

the scapular plane) and internally rotate the

arm so that the thumb is pointing toward

the floor

Subscapularis:internally rotate arm so dorsal

surface of hand rests on lower back;patient

instructed to actively lift hand away from back

against examiner resistance (use Belly Press

Test if too painful)

Infraspinatus and teres minor;arm positioned

at patient's side in 90" of flexion:patient

instructed to externally rotate arm against the

resistance of the examiner

Rotator cuff impingement;passive shoulder

flexion

Rotator cuff impingement: shoulder flexion to

90’and passive internal rotation

Rotator cuff tendinopathy: patient instructed

to actively abduct the shoulder

Apply resistance to the forearm when the arm

is in forward flexion with the elbows fully

extended

SLAP lesion:forward flexion of the arm to

90’while keeping the arm extended.Arm is

adducted 10-15"

Internally rotate the arm so thumbis facing

down and apply a downward force.Repeat the

test with arm externally rotated

Jobe'

s Test (i.e.Empty Can Test) Weakness withactnre resistance suggests a

supraspinatustear

lift-off Test Inability to actively lift hand away from back

suggests a subscapularis tear

Posterior-Cuff Test Weakness withactive resistance suggests

posterior cuff tear

Pam elicited between130-170" suggests

impingement

Painwithinternalrotation suggests

impingement

Pain withabduction >90’suggests

tendinopathy

Pam in thebicipital groove

fleer's Test

Hawkins-Kennedy Test

Painful Arc Test

Speed's Test

O'Brien's Test Pain or clicking in the glenohumeral joint in

internalrotation but not externalrotation

r

\

)

/

Jobe s test Lift-off test Posterior cuff test

2

Neer's test s

r

-

Ur

£

130-170"

i

0

Hawkins-Kennedy test I

CM

1Z.

I

©

Figure 14. Rotator cuff tests

n

L J

+

Activate Windows

Go to Settingsto-acitvyLe Wtndovrt.

0R16 Orthopaedic Surgery Toronto Notes 2023

Acromioclavicular Joint Pathology

•subluxation or dislocation of AC joint

•2 main ligament groups attach clavicle to scapula: AC and CC ligaments

Mechanism

•fall onto shoulder with adducted arm or direct trauma to point of shoulder (usually fall onto the

posterosuperior aspect of the lateral shoulder)

Pneumothorax or pulmonary contusion

are potential complications of severe

clavicle fracture and rarely severe AC

joint dislocation

Clinical Features

•pain with adduction of shoulder and/or palpation over AC joint

•palpable step deformity between distal clavicle and acromion (with dislocation) i.e. piano key sign

•limited ROM

Investigations

•x-rays: bilateral AP, Zanca view (10-15° cephalic tilt), axillary

Treatment

•non-operative

sling 1-3 wk, ice, analgesia,early ROM, and rehabilitation

•operative

» indication: Rockwood Class IV-VI (111 if labourer or high level athlete)

• number of different approaches involving AC/CC ligament reconstruction or screw/hook plate

insertion

Table 11. Rockwood Classification of Acromioclavicular Joint Separation

Grade Features Treatment

I Joint sprain,absence of complete tear of eitherligament Non-operative

Complete tear of AC ligament,incomplete tear of CC Non-operative

ligament,without marked elevation oflateral clavicular

head

II

Complete tear of AC and CC ligaments,>5 mm elevation Most non-operative,operative iflabourer or high level

at AC joint,superior aspect of acromion is below the

inferior aspect of the clavicle

athlete

Will heal with step deformity,although most fully

funcbonalin 4-6 mo

Based on the anatomical structure the displaced clavicle Operative in most cases

is in proximity to (posterior,very superior,inferior)

IV-VI

Grade AC Ligament CC Ligament Reducible Treatment

I Sprained Normal N,A Non-operative

Non-operative

Most non-operative,

operativeif labourer or

high-level athlete

Will heal withstep

deformity.alLhough most

fully functional in 4-6 mo

Operativein mostcases

II lorn Sprained Yes

III lorn Torn Yes

IV-VI lorn Torn No

Rockwood separations IV-VI are determinedbased on direction ot displacement

IV:Distal clavicle displaced posteriorly into trapezius (seen on axillary XR)

V:Distal clavicle herniated through dellotrapezial fascia into subcutaneous tissue

VI:Distal davide displaced interior to acromion or coracoid under conjoined tendon (rare)

Opea iedictioiaidlitenalFiiati:a vs.

iMsirgicalTreataeitiiDisplacedMidshaft

Qavide Fradares:A Meta-dialysis

J(topIrac=a 203J2(7)a2)5-e2!3

Purpose:Compare c.icotes frpn DBF ard»-

eperane treaheeats aispacednd-shaft dander

fradires.

Methods Keta aa'ysisittSKIsreportag

xpuini

.toctxuai outcomes,and ssbsegoei:

surgeres patedsolderthasKyr.

Destlts: 9 ia:dp=zed ditaltrialsniI02)ata

patents iere ".ded.OJLF lasassocated•a

sgahcadly loaer toe®

*

rate ofLTV compared

toH5'

«

‘

or aeMt-ope-avre teat-ect gtozps (M

0.8.95% CL 0.0S-0-31).Fatctozal ooicaces.rated

by ether DASH or Coestadsetres.mere s 3 cScacty

betteritOlf gp to 6 wo.lieseidodegelectre

pate reoovaL derate ot szbsegsett szrger es«s

sgaScaatly loweri«ieODD cohort(Aftis.W%.

M0-36.95% C10.2A-0.5SL

Coidisiots OBf isassocatediisgtocao:

redochoos«ootswesaadeerier fsscboual

octtoses n dspaced -dstaftdatdi-fradres.

Clavicle Fracture

• incidence: proximal (5%), middle (80%), or distal (15%) third of clavicle

• common in children (unites rapidly without complications)

Mechanism

• fall on shoulder (87%), direct trauma to clavicle (7%),100SH (6%)

Clinical Features

• pain and tenting of skin

• arm is clasped to chest to splint shoulder and prevent movement

Investigations

• evaluate N VS of entire upper limb

• x-ray:AF, 45" cephalic tilt (superior/inferior displacement), 45° caudal tilt (AP displacement)

• Cl : useful for medial physeal fractures and sternoclavicular injury

+

Activate Windows

Goto JClli1

0R17 Orthopaedic Surgery Toronto Notes 2023

Treatment

• medial and middle-third clavicle fractures

• for nondisplaced fractures,simple sling for I -2 wk pm

early ROM and strengthening once pain subsides

» if fracture is shortened >2 cm, consider ORIF

• distal

-third clavicle fractures

• undisplaced (with ligaments intact):sling for 1-2 wk

• displaced (CC ligament injury):ORIF

Specific Complications (see General FractureComplications,OR7 )

• cosmetic bump (most common complication)

• shoulder stiffness, weakness with repetitive activity

• pneumothorax, brachial plexus injuries,and subclavian vessel (all very rare)

Associated Injuries with Clavicle

Fractures

• Up to 9% ol clavicle fractures are

associated with other fractures (most

commonly rib fractures)

• Majority of brachial plexus injuries

are associated with proximal third

fractures

Frozen Shoulder (Adhesive Capsulitis)

•disorder characterized by progressive pain and stiffness of the shoulder, usually resolving

spontaneously within 18 mo

Stages of Adhesive Capsulitis

1. Freezing phase:gradual onset,diffuse

pain (lasts 6-9mo)

2. Frozen phase:decreased ROM

impacts function (lasts 4-9 mo)

3. Thawing phase:gradual return of

motion (lasts 5-26 mo)

Mechanism

•primary adhesive capsulitis

idiopathic, often associated with DM

usually resolves spontaneously in 9-18 mo

•secondary adhesive capsulitis

• due to prolonged immobilization

• shoulder-hand syndrome:CRPS/RSD characterized by arm and shoulder pain, decreased motion,

and diffuse swelling

• following Ml,stroke,shoulder trauma

• poorer outcomes

Clinical Features ft

•gradual onset (weeks to months) of diffuse shoulder pain with:

• decreased active AND passive ROM

• pain worse at night and often preventssleeping on affected side

increased stiffness as pain subsides: continuesfor 6-12 mo after pain has disappeared

Conditions Associated with an

Increased Incidence of Adhesive

Capsulitis

• Prolonged immobilization (most

significant)

• Female gender

• Age >49

• DM (Sx)

• Cervical disc disease

• Hyperthyroidism

. Stroke

- Ml

• Trauma and surgery

• Autoimmune disease

Investigations

•x-ray:AP (neutral, internal/external rotation),scapular Y, and axillary views of the shoulder

may be normal, or may show demineralization from disease

Treatment

•freezing phase

maintenance of active and passive ROM (physiotherapy)

NSAlDs and steroid injections if limited by pain

•thawing phase

aggressive physiotherapy, possible manipulation under anesthesia and early physiotherapy

• arthroscopy for debridement/decompression

Humerus

Proximal Humeral Fracture

Mechanism

• young: high energy trauma (MVC)

• elderly: l

'

OOSH from standing height in osteoporotic individuals

Clinical Features

• proximal humeral tenderness, deformity with severe fracture,swelling, painful ROM, bruising

extends down arm and chest

• physical exam usually reveals diminished forward elevation, with or without disuse atrophy of deltoid

and periscapular musculature

Necr Classification

Based on 4 parts of humerus

• Greater tuberosity

• Lesser tuberosity

• Humeral head

- Shaft

One-part fracture: any of the 4 parts

withnone displaced

Two-part fracture:any of the 4 parts

with1displaced

Three-part fracture:displaced fracture

of surgical neck + displaced greater

tuberosity or lesser tuberosity

Four-part fracture:displaced fracture

of surgical neck + both tuberosities

n

L J

Investigations

• test axillary nerve function (deltoid contraction and skin over deltoid)

• x-rays:AP, trans-scapular, and axillary- views of the shoulder are essential

• CT’

scan:to evaluate for tuberosity or articular involvement and fracture displacement, and if the

diagnosis of non-union is unclear

+

Activate Windows

Go to Settings to activate Window:

OR18 Orthopaedic Surgery Toronto Notes 2023

Classification

• Neer classification is based on 4 fracture locations or‘parts'

• displaced: displacement >1 cm and/or angulation >45°

• the Neer system regards the number of displaced fractures, not the fracture line, in determining

classification

• ± dislocated/subluxed: humeral head dislocated/subluxcd from glenoid

Treatment

• assess for and treat osteoporosis if needed

• non-operative

nondisplaced and minimally displaced (85% of patients): broad arm sling immobilization, begin

ROM within 14 d to prevent stiffness

• most displaced fractures in low-demand elderly patients

• operative

• OR1F (anatomic neck fractures,displaced, associated irreducible glenohumeral joint dislocation)

or 1M nail (surgical neck)

hemiarthroplasty or reverse TSA may be necessary, especially in elderly

minimally invasive percutaneous pinning and intramedullary nail fixation are indicated in rare

instances

Specific Complications (seeGeneral FractureComplications,OR7)

• AVN, nerve palsy (45%; typically axillary nerve),malunion, post-traumatic arthritis, persistent pain

and weakness, frozen shoulder '

Greater tuberosity

Lesser tuberosity

Humeral Shaft Fracture v

11 Mechanism

• young: high energy trauma (direct blows/M VC)

• elderly: FOOSH, twisting injuries, mctastascs

Clinical Features

• pain,swelling, weakness ± shortening, motion/crepitus at fracture site

• must test radial nerve function before and after treatment: look for drop wrist,sensory impairment in

dorsum of hand

'Anatomical neck

Surgical neck

t 1

.

;

Investigations

• x-ray: AP and lateral views of the humerus, including the shoulder and elbow joints

Figure 15. Fractures of the proximal

Treatment humerus

• in general, humeralshaft fractures are treated non-operatively

• non-operative

± reduction; can accept deformity due to compensatory ROM ofshoulder

hanging cast (weight of arm in cast providestraction acrossfracture site) with collar and cuff

sling immobilization untilswelling subsides, then Sarmiento functional brace, followed by ROM

Acceptable Humeral Shaft Deformities

for Non-Operative Treatment

• <20° anterior angulation

• <30° varus angulation

•

<3cm of shortening

• operative

indications:see NO CAST sidebar,OR6, pathological fracture, “floating elbow” (simultaneous

unstable humeral and forearm fractures)

ORIF: plating (most common), IM rod insertion, external fixation (rare)

Specific Complications (seeGeneral Iracture Complications, OR7)

(§

>

• failure of functional bracing (seen in up to 30% of patients)

• radial nerve palsy: expect spontaneous recovery in 3-4 mo, otherwise send for EMli

• non-union: most frequently seen in middle 1/3

• decreased ROM

• compartment syndrome

Risk of radial nerve and brachial artery

Injury

Distal Humeral Fracture

The anterior humeral line refersto an

imaginary line drawn along the anterior

surface of the humeral cortex that

passesthrough the middle third of the

capitellum when extended interiorly.

In subtle supracondylar fractures, the

anterior humeral line is disrupted,

typically passing through the anterior

third of the capitellum

Mechanism

• young: high energy trauma (MVC)

• elderly:lower energy falls in patients with osteoporotic bone

Clinical Features

• elbow pain and swelling

• assess brachial artery (ecchymosis over anteromedial forearm issuggestive of brachial artery injury)

r T

L J

+

Activate Windows

<3cFto Settings to activate Windows

0R19 Orthopaedic Surgery Toronto Notes 2023

Investigations

• x-ray:AP and lateral views of the humerus and elbow

• Clscan:helpful when suspecting shear fracture of capitulum or trochlea, and for preoperative

planning

• assess NVS:radial, ulnar, and median nerve

Classification

• supracondylar, distal single column, distal bicolumnar, and coronal shear fractures

Treatment

• goal is to restore a functional ROM of at least 30-130°flexion (unsatisfactory outcomes in 25%)

• non-operative (paediatric patients and elderly patients with medical comorbidities)

cast immobilization (in supination for lateral condyle fracture; pronation for medial condyle

fractures):short immobilization and early range of motion

• operative

• indications: displaced,supracondylar, bicolumnar

• closed reduction and percutaneous pinning (children);OKU'

; total elbow arthroplasty (complex

bicolumnar in elderly)

adult fractures are almost always treated operatively due to risk of elbow stiffness with nonoperative management

Elbow

Supracondylar Fracture

•subclass of distal humerusfracture:extra-articular,fracture proximal to capitulum and trochlea,

usually transverse

•most common in paediatric population (peak age ~7 yr),rarely seen in adults

•AIN (median nerve) injury commonly associated with extension type

Mechanism

•>96% are extension injuries via 1

'

OOSH (e.g.fall off monkey bars); <4% are flexion injuries

Clinical Features

•pain,swelling, point tenderness

•neurovascular injury: median and radial nerves, radial artery

Three Joints at the Elbow

Humeroradial joint

Humeroulnar joint

Radioulnar joint

Normal carrying angle of elbow is ~10°

of valgus

Humera

Investigations

•x-ray: AR and lateral views of the elbow

disruption of anterior humeral line suggests supracondylar fracture

• fat pad sign: a sign of effusion and can be indicative of occult fracture

assess NVS:median and radial nerves, radial artery

Treatment

•non-operative

• nondisplaced (paediatric): closed reduction with long arm plaster slab in 90°flexion x 3 wk

•operative

• indications:see NO CAST sidebar, OR6; displaced >50%, vascular injury, open fracture

requires closed reduction plus percutaneous pinning followed by limb cast with elbow flexed <90°

in adults,OK1F is necessary

Specific Complications (see General Fracture Complications,OR7)

•stiffnessis most common

•brachial artery injury (kinking can occur if displaced fracture), median or ulnar nerve injury,

compartment syndrome (leads to Volkmann's ischemic contracture), malalignment cubitus varus

(distal fragment tilted into varus)

Figure 16. X-ray of transverse

displaced supracondylar fracture of

humerus with elbow dislocation

[/

Anterior Humeral Line

apitellum

Radio-Capitellar Line

• i

uv

-m

*

j

Radial Head

©Oasmond Ballance 2006

Figure 17. Lateral view of elbow

ri

L J

Capitellum moves posteriorly to the

anterior humeral line in extension type

fractures and anteriorly in fhxion type

fractures

+

Activate Windows

TSo to Settings to activate Windows,

OR20 Orthopaedic Surgery Toronto Notes 2023

Radial Head Fracture

• a common fracture of the upper limb in young adults (85% occur between 30-60 yr)

Mechanism

• FOOSH with elbow extended and forearm pronated

Clinical Features

• marked local tenderness on palpation over radial head (lateral elbow)

• decreased ROM at elbow, ± mechanical block to forearm pronation and supination

• pain on pronation/supination

Terrible Triad

Radial head fracture

Coronoid fracture

Elbow dislocation

Investigations

• x-ray:AF and lateral views of the elbow

• enlarged anterior fat pad ("sail sign”) or the presence of a posterior fat pad on lateral view

indicates effusion, which could occur with occult radial head fractures

Table 12. Classification and Treatment of Radial Head Fractures

Mason Class Radiographic Description Treatment

Elbow slab or sling x 3-5 d withearly ROM

ORIf if:angulation >30",involves >1/3 of Iheradial head,or if

>3 nun of joint incongruity exists,block to forearm rotation

Radial head excision t prosthesis (if ORIF not feasible)

Comminuted fracture with posterior elbow dislocation Radial head ORIF or radial head excision with prosthesis

Nondisplaced fracture (< 2 mm)

Displaced fracture|>2mm)

1

Figure 18.Lateral x-ray of elbow with

effusion (“sail sign”)

2

3 Comminuted fracture

4

To avoid stiffness,do not immobilize

elbow joint >2-3 wk

Treatment

the gold standard in management

• arthroscopic repair can be considered:offers improved visualization and enhances soft tissue

preservation of the joint

• ORIF remains

Specific Complications (seeGenera/ FractureComplications,OR7)

• myositis ossificans - calcification of muscle

• recurrent instability (if MCL injured and radial head excised)

Olecranon Fracture

Mechanism

• direct blow:fall onto point of elbow (posterior aspect)

• indirect blow:FOOSH (typically transverse/oblique fracture)

Clinical Features

• localized pain, palpable defect

• ± loss of active extension due to avulsion of triceps tendon

Investigations

• x-ray: AF and lateral (require true lateral to determine fracture pattern)

Treatment

• non-operative

• non-displaced (<2 mm,stable):cast x 2-3 wk (elbow in 90° flexion, often in full elbow extension),

then gentle ROM

• operative

displaced ± non-intact extensor mechanism

Elbow Dislocation

• third most common joint dislocation after shoulder and patella

• simple: dislocation with no associated features

• complex:dislocation with associate features (fracture along with anterior capsule and/or collateral

ligaments disrupted)

Mechanism

• elbow hyperextension via FOOSH or valgus/supinalion stress during elbow flexion

• usually the radius and ulna are dislocated together, alternatively the radial head dislocates in isolation

and the ulna is fractured (see Monteggia Fracture, OR22 )

• 80% are posterior/posterolateral, anterior are rare and usually devastating +

Activate Windows

Go to Settings to activate Windows.

0R21 Orthopaedic Surgery Toronto Notes 2023

Clinical Features

• elbow pain,swelling, deformity

• flexion contracture

• ± absent radial or ulnar pulses

Investigations

• x-ray: AP and lateral views of the elbow

• assess N VS:brachial artery, median and ulnar nerves

Elbow Dislocation

The radio-capitellar line refers to an

imaginary line along the longitudinal axis

of the radial neck that passesthrough

the centre of the capitellum, regardless

of the degree of elbow florion. If the

radio-capitellar line does not pass

through Ihe centre of the capitellum a

dislocation should be suspected

Treatment

• non-operative

• closed reduction under conscioussedation (post-reduction x-rays required)

• Parvin’s method: patient lies prone with arm hanging down; apply gentle traction downwards on

wrist; as olecranon slips distallv,gently lift up the arm at elbow to reduce joint

• long-arm splint with forearm in neutral rotation and elbow in 90° flexion

• early ROM (<2 wk)

• operative

• indications: complex fracture dislocation or persistent instabilitv after closed reduction

• OR1P

Specific Complications (see GeneralFractureComplications.UK7)

• stiffness (loss of extension),intra-articular loose body,neurovascular injury (ulnar nerve, median

nerve, brachial artery), radial head fracture

• recurrent instability uncommon

Epicondylitis

• lateral

the lateral

epicondylitis

epicondyle

= “tennis elbow,

” inflammation of the common extensor tendon as it insertsinto #

• medial epicondylitis = “golfer’

s elbow,

"