HTHSCI 2F03 Lecture Notes - Lecture 13: Osteotomy, Paracetamol, Gracilis Muscle

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26 Dec 2020

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The Shoulder

Shoulder Dislocation

Classification

 Anterior

 95% of shoulder dislocations.

 Direct trauma or falling on hand

 Humeral head dislocates antero-inferiorly

 Posterior

 Caused by direct trauma or muscle contraction

(seen in epileptics).

Associated Lesions

Bankart Lesion

 Damage to anteroinferior glenoid labrum.

Hill-Sachs Lesion

 Cortical depression in the posterolateral part of the

humeral head following impaction against the glenoid

rim during anterior dislocation.

 Occurs in 35-40% of anterior dislocations.

Presentation

 Shoulder contour lost: appears square

 Bulge in infraclavicular fossa: humeral head

 Arm supported in opposite hand

 Severe pain

Specific Management

 Assess for neurovascular deficit: esp. axillary N.

 Sensation over “chevron” area before and after

reduction.

 Occurs in 5%

 X-ray: AP and transcapular view

 Reduction under sedation (e.g. propafol)

 Hippocratic: Longitudinal traction c

¯ arm in 30O

abduction and counter traction @ the axilla

 Kocher’s: external rotation of adducted arm,

anterior movement, internal rotation

 Rest arm in a sling for 3-4wks

 Physio

Complications

 Recurrent dislocation

 90% of pts. <20yrs with traumatic dislocation

 Axillary N. injury

Recurrent Shoulder Instability

TUBS: Traumatic Unilateral dislocations with a Bankart lesion

often require Surgery

 Mostly young patients: 15-30yrs

 Surgery involves a Bankart repair

AMBRI: Atraumatic Multidirectional Bilateral shoulder

dislocation is treated with Rehabilitation, but may require

Inferior capsular shift

Impingement Syndrome / Painful Arc

Pathology

 Entrapment of supraspinatus tendon and subacromial

bursa between acromion and grater tuberosity of

humerus.

 → subacromial bursitis and/or supraspinatous

tendonitis

Presentation

 Painful arc: 60-120O

 Weakness and ↓ ROM

 +ve Hawkin’s test

 Plain radiographs: may see bony spurs

 US

 MRI arthrogram

 Conservative

 Rest

 Physiotherapy

 Medical

 NSAIDs

 Subacromial bursa steroid ± LA injection

 Surgical

 Arthroscopic acromioplasty

Differential of Painful Arc

 Impingement

 Supraspinatous tear or partial tear

 AC joint OA

Frozen Shoulder: Adhesive Capsulitis

Presentation

 Progressive ↓ active and passive ROM

 ↓ ext. rotation <30O

 ↓ abduction <90O

 Shoulder pain, esp. @ night (can’t lie on affected side)

Cause

 Unknown, may follow trauma in elderly

 Commonly assoc. c

¯ DM

 Conservative: rest, physio

 Medical

 NSAIDs

 Subacromial bursa steroid ± LA injection

Rotator Cuff Tear

 2

O to degeneration or a sudden jolt or fall

 Partial tears → painful arc

 Complete tear

 Shoulder tip pain

 Full range of passive movement

 Inability to abduct the arm

 Active abduction possible following passive

abduction to 90O

 Lowering the arm beneath this → sudden drop

 “drop arm” sign

Rx: open or arthroscopic repair

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Supracondylar Fractures of the Humerus

Presentation

 Common in children after FOOSH

 Elbow very swollen and held semi-flexed.

 Sharp edge of proximal humerus may injure brachial

artery which lies anterior to it.

Classification

Extension

 Commonest type

 Distal fragment displaces posteriorly

 Gartland further classified extension type:

 Type 1: non-displaced

 Type 2: angulated c

¯ intact posterior cortex

 Type 3: displaced c

¯ no cortical contact

Flexion

 Less common

 Distal fragment displaces anteriorly

Specific Management

 Ensure there is no neurovascular damage

 If radial pulse absent or damage to brachial

artery suspected, take urgently to theatre for

reduction ± on-table angiogram.

 Median nerve is also vulnerable

 Restore the anatomy

 No displacement → flex the arm as fully as

possible and apply a collar and cuff for 3wks –

triceps acts as sling to stabilise fragments.

 Displacement → MUA + fixation with K-wires +

collar and cuff with arm flexed for 3wks.

Specific Complications

Neurovascular Injury

 Brachial artery

 Radial nerve

 Median nerve: esp. anterior interosseous branch

 Supplies deep forearm flexors (FPL, lateral half

of FDP and pronator quadratus)

Compartment syndrome

 Monitor closely during the first 24h

 Pain on passive extension of the fingers (stretches

flexor compartment) is early sign.

 Mx: try extension of the elbow, surgical Rx may be

needed.

 Volkmann’s ischaemic contracture can result → fibrosis

of flexors → claw hand.

Gunstock Deformity

 Valgus, varus and rotational deformities in the coronal

plane do not remodel and → cubitus varus.

 Cubitus varus deformity is referred to as a “gunstock”

deformity.

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Femoral and Tibial Fractures

Specific Management

 Resus and Mx life-threatening injuries first.

 X-Match

 Tibial #: 2 units

 Femoral #: 4 units

 Assess neurovascular status: esp. distal pulses

 If open

 Abx and ATT

 Take to theatre urgently for debridement,

washout and stabilisation

 Fixation methods

 Intramedullary nail

 Ex-fix

 Plates and screws

 MUA c

¯ fixed traction for 3-4mo

Specific Complications

 Hypovolaemic shock

 Neurovascular

 SFA: swelling and check pulses

 Sciatic nerve

 Compartment syndrome

 Respiratory complications

 Fat embolism

 ARDS

 Pneumonia

Ankle Injuries

Ligament Strains

 Typically twisting inversion injury

 Strains anterior talofibular part of lateral collateral

ligament

 Medial deltoid ligament strains are rare.

 May be assoc. c

¯ malleolar avulsion #s

Ankle Fracture

Ottowa Ankle Rules

 X-ray ankle if pain in malleolar zone + in any of:

 Tenderness along distal 6cm of posterior tib / fib

including posterior tip of the malleoli.

 Inability to bear weight both immediately and in

Weber Classification

 Relation of fibula # to joint line

 A: below joint line

 B: at joint line

 C: above joint line

 Weber’s B and C represent possible injury to the

syndesmotic ligaments between tib and fib → instability

 Weber A

 Boot or below-knee POP

 Non-displaced Weber B/C

 Below-knee POP

 Displaced Weber B/C

 Closed reduction and POP if anatomical

reduction achieved

 ORIF if closed reduction fails

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Document Summary

Caused by direct trauma or muscle contraction (seen in epileptics). Cortical depression in the posterolateral part of the humeral head following impaction against the glenoid rim during anterior dislocation. Assess for neurovascular deficit: esp. axillary n. Sensation over chevron area before and after reduction. Hippocratic: longitudinal traction c arm in 30o abduction and counter traction @ the axilla. Kocher"s: external rotation of adducted arm, anterior movement, internal rotation. Rest arm in a sling for 3-4wks. Tubs: traumatic unilateral dislocations with a bankart lesion often require surgery. Ambri: atraumatic multidirectional bilateral shoulder dislocation is treated with rehabilitation, but may require. Entrapment of supraspinatus tendon and subacromial bursa between acromion and grater tuberosity of humerus. 2o to degeneration or a sudden jolt or fall. Inability to abduct the arm abduction to 90o. Lowering the arm beneath this sudden drop. Supplies deep forearm flexors (fpl, lateral half of fdp and pronator quadratus)

HTHSCI 2F03 Lecture Notes - Lecture 13: Osteotomy, Paracetamol, Gracilis Muscle

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