JUNIORBONES
Orthopaedics and trauma for junior orthopaedic trainees and medical students
  • Home
    • About
  • Patient evaluation
    • History
    • Examination >
      • Shoulder examination
      • Hip examination
      • Knee examination
      • Foot & ankle examination
      • Spine examination
  • Trauma
    • Orthopaedic emergencies
    • Common trauma referrals >
      • Proximal humerus injuries >
        • Shoulder dislocation
        • Proximal humerus (shoulder) fractures
      • Upper-limb long bone fractures
      • Elbow injuries >
        • Adult elbow fractures
        • Paediatric supracondylar elbow fracture
      • Distal radius fractures
      • Spine trauma
      • Pelvic & acetabular fractures
      • Proximal femur fracture
      • Lower-limb long bone fractures
      • Knee injuries >
        • Fractures at the knee
        • Soft tissue knee injuries
      • Foot & ankle injuries >
        • Ankle fractures
        • Foot fractures
      • Peri-prosthetic fractures
      • Paediatric trauma
      • Septic arthritis >
        • Septic native joints
        • Septic joint replacement
  • Orthopaedic conditions
    • Osteoarthritis
    • Inflammatory & infective arthritis
    • Other joint disorders
    • Spine
    • Paediatric orthopaedics
    • Orthopaedic pathology
  • Cases blog
  • Trauma guidelines
  • Book downloads
  • Authors
  • Contact

Anterior Shoulder Dislocation

7/6/2015

0 Comments

 
Picture
[1] Cunningham, N. Fennessey, G. (2012)
Picture[2]
Read the case below and attempt to answer the questions. 
Steven, a 19 year old professional basketball player, presents to the ED  with right shoulder pain and deformity after his arm was pulled backwards when he was defending another player in a basketball game 2 hours ago.

1. From the photo of Steven to the left, describe what you see?
There is obvious asymmetry between Steven’s shoulders, his right acromion and humeral head are prominent, his right arm is slightly abducted and internally rotated, and is being supported by his left hand.

2. Describe the likely mechanism of injury?
The shoulder is abducted and externally rotated when an anterior force is applied to the arm.

3. What focused physical examination would you undertake?
ALWAYS – check neurovascular status, rule out concurrent injuries (brachial plexus, vascular and cervicle)
5% of anterior dislocations are associated with axillary neuropraxia- should resolve within weeks. It will be difficult to assess deltoid function, therefore check dermatomal innervation (skin over distal deltoid) AND remember the entire brachial plexus is also at risk, not just the axillary nerve.

Apprehension Sign: patient is supine with shoulder off side of bed, abduct shoulder to 90 degrees and elbow to 90 degrees then externally rotate shoulder, positive test is facial expression of ‘apprehension’

Relocation Sign: decreased apprehension with anterior force applied on shoulder, when conducted apprehension maneuver descrived above.

Sulcus Sign: arm adducted by side, place inferior traction on elbow, if a depression occurs just below the acromion, then sulcus sign is positive.


4. What imaging would you order?
1. Xray – AP, lateral (scapular Y), axillary (if possible)
            Other views: stryker view (shows Hill-Sacks lesion), west point view (shows glenoid bone loss)

2. CT if delayed presentation, complex fracture dislocation, osteoperotic patient


5. An AP Xray was taken of Steven's right shoulder, describe it and the diagnosis.

Always start with: Patient details, date, any previous Xrays to compare to, any additional views.
AP view: Head of humerus is anterior to the glenoid and inferior to the coracoid.
Always remember to ask for lateral/other views?
Diagnosis: subcoracoid anterior dislocation.

6. What closed reduction methods could you use to relocate Steven's shoulder?
Closed Reduction manoeuvres
Ensure adequate analgesia, ideally anaesthetic involvement.
1.   Cunninghams Method: Ensure patient sits up straight during the entire maneuver. Have patients arm adducted, elbow at 90 degrees and arm in neutral position. Begin by firmly massaging trapezius muscle on affected side, beginning proximally and working towards shoulder, then deltoid and finally massage biceps muscle
2.   Kocher’s tractionless manoeuvre: Humerus adducted, elbow flexed at 90 degrees and arm in neutral position. Then externally rotate arm and humerus (keeping humerus adducted to body) then move humerus anteriorly (keeping body still) and finally internally rotate arm.

7. You have successfully reduced Steven's shoulder, what is the next step?
1.     Place in neutral brace
2.     Recheck neurovascular status
3.     Repeat Xrays
4.     Refer to fracture clinic within 1/52

8. What injuries are associated with anterior dislocations?

1.     Labral and cartilage injuries:
  1. Bankart Lesion: avulsion of the anterior labrum and anterior band of the IGHL – present in 80% of patients with anterior dislocations
  2. Humeral avulsion of the glenohumeral ligament
  3. Glenoid labral articular defect
  4. Anterior labral periosteal sleeve avulsion


2.     Fractures:
  1. Hill-Sachs deformity: a compression fracture of the posterosuperior aspect of the humeral head 
  2. Bony Bankart lesion: fracture of the anterior inferior glenoid
  3. Greater tuberosity fracture
  4. Lesser tuberosity fracture


References:
[1] Cunningham, N., Fennessey, G. (2012) Shoulderdislocation.net. Retrieved on 6 June 2015 from http://shoulderdislocation.net/anatomy/dislocated-anatomy
[2] Matthew, S., Stevenson, H. Physio-pedia. Retrieved on 6 June 2014 from http://www.physio-pedia.com/Shoulder_Dislocation#References
0 Comments

Paediatric Supracondylar Fracture

3/3/2015

0 Comments

 
Picture
Picture
A classic paediatric injury which can have catastrophic consequences.

A 5 year old boy falls off a trampoline and presents with the injury shown below. What must be assessed and what are the principles of management?

Do you know any guidelines that help in decision making?

Immediate assessment and management
Is the injury open or closed? 
It is crucial to examine the motor and sensory components of the radial, ulna and median (including the anterior interosseous) nerves. In young children it is often easier to ask them to give you the thumbs up and the "OK" sign. 
Distal perfusion needs to be assessed including the presences of pulses, warmth and capillary refill
Early surgical treatment is needed for displaced fractures
Emergency surgery is necessary if the limb perfusion is impaired or skin viability is threatened. The vascular team should be informed if the limb is pulseless or cold, and reduction needs to be performed as soon as possible. Perfusion normally recovers once the fracture is reduced.
Immobilise the arm in a backslab for comfort until surgery.

Gartland classification:
Type I - Nondisplaced - anterior humeral line intersects the capitellum, an intact olecranon fossa, no medial or lateral displacement.

Type II - Partially displaced - usually fragment is extended but not completely translated with some cortical contact. The anterior humeral line does not intersect the capitellum. Some rotational displacement and tilt into varus may be present. Subdivision: 
IIa - minimally displaced, no rotation
IIb - rotational deformity

Type III - Displaced - circumferential break in the cortex with displacement of the fracture fragments. The distal fragment is generally displaced posteriorly with the metaphyseal fragment impaled into the brachialis muscle and anterior soft tissues.


Types IIb and III nearly always need reduction and fixation with K-wires.

Further Reading / Guidelines
The British Orthopaedic Association have recently brought out BOAST number 11 describing the standards of care for paediatric supracondylar fractures.
0 Comments

Colles Fracture

10/1/2015

0 Comments

 
This is a 73 year old lady who fell over onto her dominant outstretched left hand. Her radiographs are shown below:
Picture
What do you assess for when reviewing the radiographs of a Colles fracture? 
What are the treatment options and what would influence your decision?


Radiographic assessment should include:
- Fracture location, displacement and angulation
- Radial height. Normal = 11mm
- Radial inclination. Normal = 22 degrees
- Articular step off. The joint surface should be congruous.
- Volar tilt. Normal = 11 degrees

Picture
Picture
Options are numerous and arguments can be made for each. There still remains little evidence of one modality over another.
1. A simple plaster of Paris can be used if the fracture is in an adequate position. This example is not and needs better reduction.
2. An attempt should always be made to reduce an acute fracture under a local block eg. haematoma block. A backslab should then be applied followed by a plaster of Paris at a later date.
3. Manipulation under anaesthesia is an option if the fracture is significantly displaced. It then needs to be held with a plaster of Paris. Often the distal fragment(s) are held in place onto the proximal bone with K-wires to prevent displacement. The wires can also be used to joystick the fragments back in to position. The wires are usually pulled out in clinic 4-6 weeks later.
4. Open reduction and internal fixation. Volar plating has become increasingly common. It allows accurate reduction of the fracture, rigid internal fixation and early mobilisation (AO principles). There are however higher risks with the surgery and metalwork.
5. External fixation is an option if the fracture is severely comminuted. It may be spanning (across the joint) or bridging (across the fracture only, which has the advantage of allowing joint mobilisation). Again K-wires can help augment the fixation.
0 Comments

Knee osteoarthritis

24/11/2014

0 Comments

 
Another common one. A 62 year old male presents with worsening right knee pain and deformity. He underwent a knee injury in the 1980s but has managed to work and play sports on it up until recently. He has had a previous steroid injection with only very transient relief. Non-surgical management in the form of activity modification, analgesia, use of a walking aid and an off-loading brace have failed.


Picture
Picture
Picture
What are the surgical options and their particular advantages / disadvantages?
This patient has fairly severe osteoarthritis with varus deformities of both knees.

Surgical options include:

High tibial osteotomy. Indications include:
- healthy patient in whom early failure of a TKR would be expected (less than 50 years old)
- non-obese and compliant with post-op rehabilitation
- predominantly one compartment involved
- no flexion contracture and good range of movement

A medial opening wedge or lateral closing wedge valgus osteotomy can be used to offload the diseased part of the joint. The patient needs to be non-weight bearing until the osteotomy has united which can be many weeks. The surgery alters the anatomy of the knee and can make a later knee replacement more difficult and less effective. A good outcome would be to maintain the knee for 8-12 years


Unicondylar Knee Replacement
Advantages compared to total knee replacement include:
- less blood loss, faster rehab and less morbidity
- smaller incision
- preserves the ACL and other knee compartments which may mean more normal knee kinematics
- compared to an osteotomy the rehabilitation is faster, it is easier to convert to a total knee replacement, has fewer short-term complications and should last longer.

Indications:
- controversial
- younger patients with normal lateral and patello-femoral compartments
- no fixed flexion deformity, intact ACL, varus <10 degrees, good range of motion

The down side is that the revision rate is much higher in the joint registries and conversion of a unicondylar knee replacement to total knee replacement is not universally as effective or predictable as a primary total knee replacement.


Total Knee Replacement
A total knee replacement is probably still the gold standard and would be my choice for the above patient. Predictable pain relief should be expected in the majority of patients and they can mobilise straight away. It is however designed for retirement level activities - which is why the above two options are attractive to some people.

0 Comments

Neck of femur fracture

9/10/2014

0 Comments

 
This is a common scenario and one you will certainly be asked about in exams and in the trauma meeting.

A 92 year old lady fell when the driver of a bus braked too hard. She was unable to mobilize due to right hip pain. She is otherwise healthy and mobilizes normally with one stick. Her leg is short and externally rotated. Her radiographs are shown below.


Picture
Picture
What are your management priorities?
How would you definitively treat this (fixation with screws, hemi-arthroplasty, total hip replacement, dynamic hip screw) and what are the controversies?
Are there any guidelines that would help?


This lady has a displaced intracapsular left neck of femur fracture. She should be resuscitated and then admitted promptly. She should be assessed routinely by the orthogeriatricians and operated on within 36 hours (BOA standard for trauma). NICE guidelines suggest the femoral head should be replaced (hemi or THR) and in this case a total hip replacement could be argued (she walks with only one stick, is not cognitively impaired and is medically fit) . An anterolateral approach and cemented components are preferable.

BOAST guidelines:
  • Prompt admission (<4 hours) to ward
  • Secondary prevention and falls assessment
  • Multidisciplinary team management
  • MRI if X-rays are inconclusive
  • Immediate and sufficient analgesia
  • Identify and treat co-morbidities so as not to delay surgery
  • Operate within 36 hours on a planned trauma list
  • Operate to allow the patient to fully weight bear
  • Orthogeriatric input and assessment within 72 hours
  • Assess for cognitive impairment and delirium
  • Consider surgery even if it is palliative
  • DVT prophylaxis
  • Educate patient and family about treatment, care and rehabilitation
  • Submit data to National Hip Fracture database
0 Comments

Welcome to Juniorbones!

7/10/2014

0 Comments

 
This blog will bring weekly interesting cases to the website to stimulate discussion and learning. If you have any comments or questions please feel free to post them. Please also let us know how we're doing and if there are any special topics you would like us to cover. Thanks!
0 Comments
Forward>>

    AuthorAc

    Francois Tudor and James Donaldson recently completed their orthopaedic training and wish to share their knowledge and interest in orthopaedics. This blog will provide weekly interesting cases that we hope will help you learn and develop your knowledge in orthopaedics, updated by resident, Moni Brunt-Mackenzie 

    Archives

    December 2015
    October 2015
    September 2015
    August 2015
    July 2015
    June 2015
    March 2015
    January 2015
    November 2014
    October 2014

    Categories

    All

    RSS Feed

Powered by Create your own unique website with customizable templates.