Download Sports Medicine Miller Review

Sports Medicine
Knee Anatomy
o Simultaneous rotation and translation
o Articular cartilage
 Type II collagen
 Mostly water
 Increased water and decreased
proteoglycans w/ DJD
 When torn, heals with type I collagen
(fibrocartilage)
o ACL
 33mm x 11mm
 2 bundles
 AM tight in flexion
 PL tight in extension
 Supplied by middle geniculate
artery
o PCL
 Wider than ACL
 2 bundles
 AL tight in flexion
 PM tight in extension
o Meniscofemoral ligaments
 Humphrey anterior
 Wrisberg posterior
o MCL
 Attaches to meniscus (deep portion)
o LCL
 Tight in extension
 Capsule most distal extent is posterior to
fibula
o Strength
 MCL > PCL > ACL > LCL
o PL corner
 Superficial: biceps, ITB
 Deep: LCL, popliteus, popliteofibular lig,
posterolateral capsule
o PF joint
 Patella increases moment arm of
quadriceps
 Fully engaged @ 40 deg
 Forces = 3-5 x body weight
 Medial patellofemoral ligament
 Acts as checkrein
 Primary restraint to dislocation
o Meniscus
 Medial - semicircular
 Broad attachments to horn
 Firm attachments
 Wider post than ant
Lateral – circular/C-shaped
 Attachments close to ACL
 Loosely attached
 Post/ant = in width
 Posterior horn of MM 2nd stabilizer to
anterior translation
 Meniscus is type I collagen
 Transmit 90% of load w/ knee in flexion
 transmit 50% of load w/ knee in extension
 Lateral meniscus 2x excursion of medial
o Transm greater % of load compared to
MM
ER asymmetry (Dial test)
 If dial at just 30, then PLC injury
 If dial at 30 and 90, then PLC and PCL
injury
Patella baja – associated w/ arthrofibrosis
OCD – lateral aspect Medial femoral condyle
Stress radiographs
 For PCL measurement
 If > 12 mm, then probably PCL and PLC
injury
ACL
 Bone bruise
 Lateral femoral condyle (mid 1/3)
 Lateral tibial plateau (post 1/3)
Posterior horn MM tear
 AL and PM portals for best visualization
- Quad rupture > 40
- Patella rupture < 40
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Meniscal tears
- Higher risk in ACL-deficient knee
- Medial > lateral
- ACL injury – lateral meniscus more common
o Small lat tears can be tx nonsurg
- MRI false positives for
o Anterior horn MM
o Intraseptal degeneration – called tears
- Repair peripheral vertical tears 1-4 cm in
length
o Most peripheral 25% of MM and 15%
of LM have consistent vasc supply
o Branches from sup, inf, lat geniculate
A supply this zone
Sports Medicine
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o Area in PL aspect of lat meniscus by
popliteus is watershed area hypovascular
Improved meniscal healing w/ combined ACL
reconstruction
Inside-out technique strongest (vertical
mattress suture)
Longtitudinal tears heal better than complex
tears
Acute tears (< 8 wks) have better results than
chronic
Degen changes on XX and dec in fx shown
earlier in pt w/ lateral menisc than those w/
medial menisc
Meniscal repair risks
o Medial: saphenous N/V, popliteal
vessels
o Lateral: peroneal N, popliteal vessels
 Place retractor deep to head of
gastroc
Strongest repair
o Vertical mattress suture
Meniscus transplantation
o Avoid grade IV chondrosis –
indications controversial
o Mechanical alignment should be nl
o grafts w/o bony base have higher fail
rate
Meniscal cysts
o Associated w/ LM horizontal tears – to
periphery
o Tx: arthroscopic decompression,
partial meniscecetmy
Discoid meniscus
o Type I incomplete
o Type II complete
o Type III Wrisberg (no coronary
attachments) – free
 Tx w/ meniscus repair
o If discoid no tear – then leave it alone
o Dx: MRI w/ 3 consecutive images w/
sagittal continuity
OCD in knee
- Only operate on adults or kids who are
symptomatic
- Articular cartilage defects
- Atraumatic ON
o Related to steroids
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o Wedge-shaped
o Core decompression
SONK
o Subchondral insufficiency fracture
o Can follow arthroscopy in older pt
 Several month recovery
Arthroscopic synovectemy as good as open
synovectemy
o Just need multiple portals
Medial plicae most common
ACL injuries
- Cannot primary repair
o Covered by myofibroblast-like cells w/
alpha-smooth muscle actin
- Operative tx reduces incidence of chondral
and meniscal injury
- Injuries while jumping have inc in intra-art inj
- Females w/ fourfold inc risk of ACL tears
- Graft choices
o PT: anterior knee pain
 Contralateral pat tendon lead to
dec morb on reconst knee,
faster pt recovery
o Hamstring: fixation failure
 Highest strength and stiffness
o Quad
o Allograft
 HIV risk 1:1 million
 Slow chronic immunol resp to
tissue
o Preconditioning of grafts can reduce
stress relaxation by 50%
o Irradiation of > 3 mrads required to
kill HIV (but affects structural
properties)
o Late arthritis related to meniscal
integrity
- Postop rehab
o ROM - extension first
 Especially w/ medial sided
surgery (patellar dislocation,
MCL repair)
o Avoid isokinetic quad strengthening
15-30 deg during early rehab
o Immediate weightbearing reduces PF
pain
- Reconstruction complications
o Tunnel placement
Sports Medicine
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Femoral 1-3 mm w/in over-top
position
 Tibial should be posteromedial
aspect of ACL footprint
 Posterior to Blumensaat’s Line
o Arthrofibrosis
o Hdwr failure (early cause of failure –
1st 6 wks)
o Missed concurrent injuries
o Most patellar fractures occur 8-12 wks
postop
 Reduced w/ smaller blade,
triangular graft, bone grafting
lesion, drilling holes at corners,
less rectangular graft
 Cyclops lesion
 Dx w/ ‘click’ at
terminal extension
 Fibroproliferative tissue
blocks extension
Loss of motion prevented w/
o Full ROM preop
o Correct tunnel placement
 If femoral tunnel anterior (in
front of blumensaat’s line) –
strain in flexion
 Tunnel too posterior – strain in
extension
 “over-the-top” position
 Tibial tunnel angle of
75 deg or more in
coronal plane ass w/
greater loss of flexion
and anterior laxity
Sport-specific validated measures of outcome
o Knee Injury and OA Score
o IKDC questionnaire
Outcomes
o 44% w/ PBTB had 3 deg loss of ROM
o 43% w/ hamst had hamst weakness
o 43% using pat tend more stable by KT1000 than hamst (1-3 mm)
o 89% no diff in ant/PF pain
o pat tend w/ more kneeling pain
Prevention of ACL injury
o Skier training
o Female athlete – NM training,
plyometrics beneficial (land in less
extension)
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o ACL bracing only effective in skiers
Midsubstance ACL tears in young children
o Femoral tunnel causes growth
problems
o Soft tissue graft for young
o Use a vertical tunnel
PCL injury
- MOI: blow to tibia
- Hyperflexion
- If bony avulsion off tibia,
o Then ORIF
- Isolated PCL
o Nonoperative
o Quad rehabs
o Extension brace for 2-4 wks for grade
III injuries
o Late chondrosis in MFC and patella
o If post drawer improves w/ internal
rotation, then nonoperative (PLC tight)
- Postop
o Immobilize in extension, quad rehab
- Inlay technique results in less graft attrition
and failure
o Posteromedial approach b/w
semimembranosus and medial gastroc
- 2-bundle technique results in better stability in
extension and flexion
- increased OA in medial and PF compartments
in cadaver studies without PCL
MCL injury
- MOI: valgus contact
- Open only at 30 deg
- Tx: hinged knee brace 6-8 wks
- Delay ACL reconstruction in combined
ACL/MCL injuries
LCL injury rare
- Tx: isolated – brace
- Combined – repair/reconstruction
PL corner
- Includes biceps tendon, IT band, popliteus, PF
lig, arcuate lig, LCL
o Biceps femoris is dyn lat stab of knee
o IT band is anterolat stab of knee
o Popliteus ER femur
Sports Medicine
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o PF lig prev resist to post transl, ER of
tibia
 Controls PL rotation of tib on
femur
o LCL prim static restraint to varus
stress, second restraint to ER of tibia
Combined PCL > ACL
If missed, may be late cause of failure of
ACL/PCL reconstruction
Grade I and II instab tx w/ 3-wk period of
immob w/ knee in ext
PE:
o ER asymmetry
o ER recurvatum
o PL drawer
o Tx: acute w/ supplementation (free
graft)
 Reconst recreating popliteus
tenson and LCL fare best
 Reconstruct chronic –
popliteofibular ligament
Knee Dislocation
- inj to popliteal A more likely w/ post disloc
o inj by stretching second to tether of
vessesl at add hiatus or
o direct contusion by post tib plat
- inj to common peroneal N. more likely w/ PL
disloc
o estim 20-30% disloc
- Delay surgery to
o Allow vasc monitoring
o Reduce risk of arthrofibrosis
Proximal tib-fib dislocation
- MOI fall on flexed knee
- Anterolateral common
- Closed reduction – flexion and pressure
- Postop – immobilize in extension
- Tx: chronic – prox fib resection
Bioabsorbable materials
- Polyglycolic acid – absorbs in weeks
- Polydioxadone – absorb in months
- PLLA – absorbs in knees
Prepatellar bursitis
- In wrestlers – then aspirate
ITB syndrome
- Hill runners
- PE: Ober Test
o Abduct, extend position – then adduct
the leg
- Tx: stretching
Recurrent patellar instability
- XX: patella alta, sulcus sign
- RF: patella alta, lig laxity, lat fem condyle
hypoplasia, lat insertion of pat tendon, inc Q
angle
- Fulkerson
o Contraindicated in pt w/
superomedial patellar arthritis (will
concentrate stresses in that area
more)
Knee Plica
- three synovial plica described: suprapatellar,
medial shelf, infrapatellar
Lateral patellar compression
- Tight lateral retinaculum
- inc Q angle
- Only indication for surgery release – tilt on
XX, refractory rehab
o 60-90% successful results
Patellar chondrosis
- Tubercle elevation – can elevate 1 cm
PF syndrome
- Tx: rehab
o Closed chain short arc quad
exercises, 0-30 extension
- PF contact pressures lowest b/w 0-30 knee
flexion
Extensor Mech Disruption
- delay in surg repair is factor most sign
diminishes results b/c contracture of tissue
Bipartite patella
- Male > female
- Superolateral portion of patella
Athletic Pubalgia
Sports Medicine
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Lower abdominal, inguinal pain at extremes of
exertion
o Abd hyperextension
o Thigh hyperabduction
Pain at origin of rectus abdominus
Males > females
PE: pain w adduction, pain w/ valsalva
Tx: conservative
Sports hernia
- Endoscopy?
Rectus Femoris Tightness
- Modified Thomas test
Adductor Strain
- Common in hockey
Snapping hip
- External – ITT over GT in flexion
o Tx: conservative or z-plasty
- Internal – extend hip from FABER (iliopsoas)
o Tx: conservative or lengthening
- Intra-articular
o Labrum, loose body
o Tx: hip arthroscopy
Hip dislocation
- 90% posterior
- look for post acetabular fx on obturator
oblique
o aspirate hip if find (to relieve pressure)
o then high risk of ON
- 10-20% incidence of ON
o MC complication
GT bursitis
- 60% respond to injection
Hip arthroscopy
- Anterolateral portal – superior gluteal nerve
- Posterolateral – sciatic n.
- Anterior LFC N > femoral N
Medial tibial stress sx
- Pain decreases w/ running
- Distal pronation
- Increased uptake in blood pool phase on bone
scan
Exertional compartment sx
- Anterior compartment most often affected
- May be ass w/ muscle hernia
- > 30 mm Hg 1 min after exercise
- resting > 15 mm Hg
popliteal artery entrapment sx
- medial head of gastroc aberration leads to
constriction of artery
- intermittent claudication, decreased pulses
- Tx: medial head of gastroc release
Saphenous neuritis
- Surfer’s neuropathy
Entrapment of superficial peroneal N.
- 12 cm prox to LM
- fascial defect
lateral plantar N. – baxter’s n.
- trapped in abd hallicus fascia
medial plantar N.
- arch support aggravates sx
Quadriceps contusion
- Immobilize in flexion
GCS
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Tennis leg – plantaris tendon
Tx w/ conservative management
Proximal hamstring avulsion
- Water skiing injury
- Avulsion off of ischial tuberosity
- Tx: early repair
Myositis ossificans
- Tx: active, not passive ROM
- Tx: rest
Peroneal tendon injuries
- Longitudinal tears usu involves brevis at
fibular groove
- Tx: debride/repair
FHL tendon injury
Sports Medicine
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Decreased great toe passive extension in
neutral (nl in PF)
Pain w/ resisted toe PF
Posteromedial pain
No pain w/ passive ankle plantar flexion
Tx: ice, NSAIDs
Achilles tendon injuries
- Tx: rest therapy w/ eccentric training later
phases
- In rupture, if defect > 5 cm, then FHL
transfer
- < 4 cm, then V-Y repair is appropriate
- Up to 50% Achilles can be detached before
detectable weakness
Os trigonum
- Surgical excision of lateral
- Pain w/ passive ankle plantar flexion
Os subfibulare
- Avulsion fx ATFL
- Ass w/ chronic ankle instab
Os peroneum – in peroneus longus tendon near 5th
MT base
- Proximal location = PL rupture
Ankle sprain
- OR – Brostrom procedure – for refractory
cases
Ankle arthroscopy
- Portals and dangers
o AL: peroneus tertius, superficial
peroneal n.
o AM: TA, saphenous vein
o PL: SSV/SN sural nerve
o Risks: synovial cut fistula, NV risk
Plantar fasciitis
- Can be treated w/ shock wave tx
Turf toe
- Incompetent plantar sesamoid complex
- Mechanism: hyperextension of MTP jt, axial
loading of post hindft
- Late sequela: hallux rigidus
o Tx: cheilectemy
Glenohumeral joint
- SGHL – inferior stability (arm adducted to
side)
- MGHL
o Ant stability 45 deg, shoulder ER
o Buford: variant
o Poorly defined in 40% of pt
- IGHLC
o Anterior band – stabilizer w/ ABD/ER
(cocking)
o Post band – stabilizer w/ 90 deg
flexion and IR
 static post stabilizer
o SLAP lesion doubles the strain in
IGHLC
- Labrum from 12 to 3 o’clock is nl variant of
“tears” or foramen
- When shoulder is neutral, restraint is
coracohumeral lig (ant-inf)
o 90 deg flexion/IR, then IGHL
o when in ER, then subscap M.
- RTC dyn jt compression force more imp for
stab than GH lig
- Scapular stabilizers position glenoid in
anteverted, sup position, dynamic coverage for
retroverted hum head
- Biceps tenson prov stab in ant and sup
direction
AC joint
- Coracoclavicular ligaments – vertical tether
- AC ligaments – horizontal tether
Throwing
- Wind-up
- Early cocking
- Late cocking
o Internal impingement
o Posterior glenoid tightness, partial cuff
tears, glenohumeral internal rotation
defects
- Acceleration
- Follow-through
o Stresses post capsule
o Ass w/ SLAP tears
o Highest torque across glenohumeral
joint
Sports Medicine
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shoulder most susc to injury during late
cocking and early acc phases
o tensile and compressive forces peak,
pathologic stresses on both areas
Throwers
o inc ER from inc humeral retroversion
(occurs through physis in little league)
or
o inc ant lig laxity
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Posterior shoulder dislocation
- Loss of external rotation
- Jerk test – jerks back in with cross-abduction
test
Subscap tear
- Excessive ER
- Lift off test
o Tests lower muscle (lower subscap N.)
C5-6)
- Abd compression test
o Tests upper muscle (upper subscap N.)
C5
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Humeral avulsion of glenohumeral ligament
- Older pt than Bankart
- MRI shows inferior extravasation of MRI
- Tx w/ open repair of lateral joint capsule
Anterior instability
- Bankart – avulsion of ant-inf capsulolabrum
from ant-inf glenoid rim
o West Point – reveal bony bankarts
- Stretching of ant-inf capsulolabrum
o in recurrent dislocaters, ant and inf
capsule elongated average 20%
- Throwers: shoulder slides out front during late
cocking phase
- 80-90% recurrence in young pt
o but still – standard of tx is conservative
management
- Tx: splint in external rotation (initial tx)
- Associated lesions
o Labral-Bankart tear
o Hill-Sachs defect
 Stryker notch view shows this
 80% ant instab have it
 play sign role if 30% of prox
hum art surf
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o GT fx
Older patients (> 40)
o RTC tear (need to repair this)
 MC cause of recurrent
instability
 40% in pt > 60 yo
o Nerve injury up to 50%
Arthroscopic contraindicated w/ glenoid
defects > 25% and engaging Hill-Sachs
Lesions
o higher recurrence rate
o inc ER compared to open
o engaging Hill-Sachs, inverted-pear
glenoid ass w/ high rates of instab after
arthro repair
 engages in abd and ER
Putti-platt
o Ties up subscap
o Wears out post glenoid
o Arthritis as complication
Bristow
o Coracoid to glenoid transfer
o Complication: nonunion
Complications
o Recurrence
o Unrepaired labral tear
o Subscap injury (from open shoulder
procedures)
o Axillary nerve injury
 Exploration if no recovery @
6-9 mo
o Overtightening
 Tx: z-lengthening of subscap
o Late arthritis
o Migrating hardware
MDI
o isometric M. act leads to off-center
hum head in MDI
 in traum instab – hum head
centers
o arthroscopic shrinkage in 27 shoulders
w/ MDI – success rate of 82%
poor results of revision: atraumatic causes of
failure, voluntary dislocations, multiple prior
stab attempts
Posterior instability
- Throwers: shoulder sx on follow-through
phase
Sports Medicine
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Subluxates w/ IR, cross-body
o reduction w/ further rotation
Hypermobility of joints
Need to address capsule
Seizures/shock
Exam: decreased ER
Can do open reduction for chronic reduction
even 3 mo after procedure
Address reversed hill sachs defect
o Need to fill w/ lesser tuberosity or
allograft
 Subscap and LT transfer for
young pt
 Defects 20-45% of head
 Disimpaction & BG is option
in injuries < 3 wks old
o Hemiarthroplasty if too big
Subluxation
o Offensive lineman, pitchers
o Tx: strengthen infraspinatus, avoid IR
in bracing
o If after 6 mo, fails, then tx:
 Posterior capsular shift
Problems w/ thermal shrinkage
o High recurrence rate w/ shoulder
instability (50% for MDI)
o Capsular necrosis/ablation
o Articular cartilage death
o Axillary nerve injury
o It breaks collagen cross-links, 65
degree C
Rotator Cuff Dz
- RTC purposes
o keep hum head center on glenoid by
counteracting sup vector of deltoid
o add strength and dyn stab to GH
motion
- Amount of retraction and not just transv
diameter – imp factor in fx def p RTC tear
- U/S can dx full-thickness, partial-thickness
tears
- no correlation b/w degn XX changes and fullthickness tears
- no ass b/w acromial pathology and RTC tears
- Throwers: part-thickness art-sided tear of
supra, and less so in infra
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Art cuff surf - less vascular, higher mod of
elast, higher ecc forces, less favorable stressstrain curve
o MC to have art-sided tears than bursal
RTC tear
o Leads to superior translation of
humeral head w/ 30 deg of abduction
Biceps tendon
o instab ass w/ subscap or ant interval
tears
o biceps tenotomy performed for
massive tears
Os acrominale
- Unfused secondary ossification center
- Incidence 3%
- Changes treatment
o May need to fuse the os before
decompression
o Excision can lead to deltoid
dysfunction
o May need aggressive acromioplasty
Subcoracoid impingement
- Impingement of LT and coracoid w/ flexion
and IR
- Local anesthetic will eliminate sx
- Nl coracohumeral distances
o Adducted: 8.7 mm
o Flexed: 6.8 mm
RTC repair
- Rehab: early PASSIVE ROM postop
- w/ advanced cuff arthropathy – then
hemiarthroplasty
o not improve function, just pain
- Tears easier to repair when smaller
- Higher recurrence rate w/ large tears
o repair predictable for pain relief, not
strength
- Chronic tears – M. atrophy, fatty degen
- Tear size most imp determinant of outcome in
active motion, strength, rating of result, pt
satisfaction
- Long-term outcome is good
- Success in fx outcome and pain relief does not
correlate w/ anatomic healing of RTC
- Ant-sup instability
Sports Medicine
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o massive tears, disruption of coracr
arch, ant deltoid dehisc
complications of operative tx
o lateral acromionectemy
o AC pain
o Deltoid detachment (open > miniopen)
Open repair w/ better strength, fx, outcome
scores, but pt satisfaction comp w
debridement
T-x of pec major for irreparable subscap tear
T-x latiss for post and sup cuff insuff
Calcific tendonitis
o Along supraspinatus tendon insertion
o Tx: pt/aspiration
o Surg evacuation of calcium deposits
MC organism of infx: propionbacterium acnes
RTC interval
o Can be injured during surgery (develop
ganglion)
o Dx: RTC interval contracture w/
limited ER @ side
o Tx: arthroscopic release
Suprascapular neuropathy
- SS notch entrapment
o Transverse scapular ligament
(hypertrophic) - underneath
o Affects supra and infraspinatus
o Decompress open
- Spinoglenoid notch entrapment
o Affects infraspinatus only
o Ass w/ post SLAP and cyst
o Traction injury in volleyball
- EMG/NCS is diagnostic
Quadrilateral space sx
- sx caused by compression of ax nerve
- Tx: open decompress of quad space
Thoracic outlet syndrome
- More common in females
- Tx: remove cervical rib, scalene muscle
Shoulder destruction
- Neuropathic joint
o Syringomyelia
o Hansen’s disease
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Axillary/subclavian A aneurysm – painful
ischemic hand in pitchers
Pec Major rupture
- Exclusively in males
- Weight lifters
- Axillary webbing
Subscap rupture
- Hyperabduction/ER mechanism
- Lift off test
- Biceps displaced medial
o Ass w/ disruption of transverse
ligament
- Need to stabilize biceps tenodesis along w/
subscap
SLAP tears
- I – fraying
- II – detachment of superior labrum from
glenoid
o peel-back phenomenon, contrib. to
post-sup instab
o anatomic repair shown to eliminate the
effect
- III – nl intact anchor w/ displaced labrum
- IV – displaced anchor
- Superior labrum withstands ER forces
- If 50% detachment of biceps, then tenodesis
of biceps tendon
- repair – 90% return to preinjury level
Glenohumeral internal rotation deficit
- Increased humeral retrovesion w/ scapula
stabilized
- > 20 deg loss IR is diagnostic
- Pitchers
- Tx: sleeper stretcher (internal rotation – push)
o Need 6 mo before operation – post
capsular release
Internal impingement
- Entrapment of post sup RTC/labrum during
late cocking/early acceleration
- Partial articular sided cuff tear at junction of
SS and IS
o b/c SS abrades against post superior
glenoid
- MRA w/ abd-ER rotation view
Sports Medicine
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o reveals post-sup labrum abn w/
“kissing lesion” of art-sided RTC
Tx: post capsular stretch/strengthen, or
arthroscopic debridement
o avoid hyperangulation – shoulder
extension beyond plane of scapula
during cocking phase
o arthroscopic tx focus on debridement
of RTC tear, post glenoid labral lesion
o last resort: humeral derotational
osteotomy
 goal: postop hum retrov of 30
deg
 compl rate high (hdwr)
Bennett Lesion
- Glenoid exostosis
- Ass w/ internal impingement (baseball
players)
Posterior SLAP tear
- Accentuated with ‘peel back’ w/ shoulder
abduction
- Posterior labral attachment
o Common in football lineman
o Tx: labral repair
Distal clavicle osteolysis
- MOI: weight lifters
- XX: cysts/osteopenia
- Tx: distal clav resection
AC arthritis
- Tx: activity modification, injection
- Distal clav resection
SC injury
- Serendipity view, or CT
- Anterior instability
o Chronic: IGNORE
o Acute: reduce
- Post instability: closed reduction
- Posterior capsular ligament
o Most important structure for A/P
stability
- Avoid pins/hdwr for fixation
Latissimus Dorsi Tear
- Weakness in extension
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Non-surgical tx
Adhesive capsulitis
- Pain w/ decreased ROM
- Ass w/ autoimmune dz
- Rehab, rehab, rehab for months
- MUA for late treatment
- Essential lesion
o Coracohumeral lig and rotator interval
capsule
Scapular winging
- Based on inferior border of scapula
o Medial: Compression of long thoracic
nerve
o Give 6 mo for nerve to come back
o Tx: pec transfer
- Lateral winging
o Trapezius, CN XI
o Tx: fuse scapula to thorax, or Eden
Lange Transfer: t-x medial scapular
muscles (levator and rhomboids)
laterally
Little leaguer’s shoulder
- Type I SH to proximal humerus
- XX: widened proximal physis
- Curve ball implicated
- Tx: rest for 12 wks
Clavicle Fx
- Operative indications
o Open fx
o Subclavian A injury
o Floating shoulder – clavicle & scapula
neck fx
o Type II distal fx
o Sx: nonunion
Concussion
- 3 in a year
o season is terminated
biceps tendon rupture
- MC injured NV structure: lateral antebrachial
cutaneous N.
- Synostosis is common complication, worse w/
approaches involving ulna
Sports Medicine
Distal radius physeal stress Sx
- Gymnasts
- Tx: 3-6 mo of rest
Elbow arthroscopy
- MC palsy: ulnar N. palsy
Elbow stability
- LCL resists both varus and ER stresses
- MCL divided 3 segm: ant bund, post bund,
transverse segm
o stab structure to valgus
o overhead throwers w/ MCL inj dev
posteromed olecranon impingement,
ulnohum arthritis with cont throwing
o 40% pt req MCL recon have ulnar N.
sx
o 70% throwers w/ MCL recon back to
sport
- Little Leaguer’s Elbow
o on medial side, medial epicondyle
growth plate is weaker, more susc to
trauma than MCL
OCD in elbow
- rep compression loads leads to focal ON of
capitellum or radial head
- OCD of capitellum seen in athletes 13-15 yo
Elbow arthroplasty
- Unconstrained elbow arthroplasty
o 10% w/ instability
- Distraction interposition ulnohumeral
arthroplasty
o Tx for pt w/ RA and posttraumatic OA
o And young pt who cannot have total
elbow, high-demand pt
- OA best tx w/ ulnohumeral arthroplasty
Erb’s palsy in baby
- Can resolve up to 2 yr after birth
Stress in elbow (in extension)
- 40% ulnohumeral
- 60% radiohumeral