Common Orthopaedic Injuries

1. Common Orthopaedic Injuries Lutul D. Farrow, MD University Medical Center Human Motion Institute Assistant Professor, Clinical Orthopaedic Surgery University of Arizona College of Medicine Department of Orthopaedic Surgery

2. Disclosure • I have nothing to disclose

3. Objectives • After this presentation, the participant should be able to: • Diagnose common orthopaedic injuries • Understand nonoperative management of these injuries • List basic surgical treatment options for these injuries

4. Introduction • MSK injuries are common • 40% of complaints to PCP • Affects ADL’s • Lost work/wages

5. Overview • The Breakdown • Shoulder • Elbow • Hip • Knee

6. The Shoulder

7. The Shoulder Basics • Shoulder problems are simple • Three diagnoses • Impingement • Arthritis • Instability

8. The Shoulder • It gets simpler! • Less than 25 • Think instability • Over 40 years old • Impingement • Arthritis

9. The Shoulder • Impingement • Blanket term • Multiple pathologies • Tendinosis • Bursitis • Rotator cuff tears • Biceps tendinopathy

10. The Shoulder • Pain generators • AC joint • Bursa • Rotator cuff • Biceps tendon

11. The Shoulder • History • Pain – variable location • PAIN WITH OVERHEAD ACTIVITIES • +/- Trauma • Subjective weakness • Easily fatigued • NIGHT PAIN

12. The Shoulder • Exam • Palpation • Impingement tests • Strength tests • Cervical spine

13. The Shoulder • Nonoperative treatment • Activity modification • NSAID’s • Physical therapy • Injections

14. The Shoulder • Operative treatment • Rotator cuff • Decompression • Biceps • Distal Clavicle • Arthroscopy

15. The Shoulder • Instability • 45% of dislocations involve glenohumeral joint • 85% anterior • Incidence - 1.7% (anterior dislocation) • Male (78%) >> Female (22%) • Much Higher incidence in persons < 30 y.o.

16. The Shoulder • Mechanism of Injury • Abducted, externally rotated arm • Humeral head driven anterior • Common in contact sports and overhead athletes • Hi-end athletes • Pathoanatomy • Torn capsule/ligaments • Torn Labrum • Variable bony injury • BEWARE RTC INJURY!!!!

17. The Shoulder • History • Traumatic Episode • Direction? • Red Herrings • Electrocution • Seizures • Physical Examination • Apprehension test • Rotator cuff

18. The Shoulder • Treatment • 1st timers • Rehab • Rehab • Rehab • Athletes and repeat offenders • Consider surgery

19. The Shoulder • Bottoni et al AJSM 2002 • Nonoperative: 75% recurrence • Arthroscopic stabilization: 11% recurrence • Kirkley, Miniaci et al Arthroscopy 1999 • Nonoperative: 47% • Arthroscopic stabilization: 15.9% (p < .03) • Porcellini et al Arthroscopy 2002 • Acute arthroscopic stabilization: • 92% stable at 2 year follow-up

20. The Shoulder • Sachs et al JBJS 2007 • 57% shoulders remained stable • 20% requested surgical stabilization • Conclusion • Need for surgery in the acute period cannot be predicted • Copers and Non-Copers • 60:40 Rule • 80% won’t need surgery!

21. The Shoulder • Surgical Repair

22. The Shoulder • Arthritis • Shoulder less commonly affected • Typically > 50 yo • Typically “post-traumatic” • Genetic predisposition

23. The Shoulder • Symptoms • Activity pain • ↓ ROM • Stiffness • Grinding/catching • Can mimic impingement

24. The Shoulder • Exam • Decreased ROM • Strength • Imaging • Plain films • MRI: little utility

25. The Shoulder • Arthroscopic debridement • Resurfacing • Hemiarthroplasty • Total arthroplasty • Reverse arthroplasty

26. The Elbow

27. The Elbow • Still keepin’ it simple • Bursitis • Epicondylitis • Ulnar nerve compression

28. The Elbow • Epicondylitis • Tennis elbow • Golfer’s elbow • Overuse injury • Poor ergonomics • Not true inflammation

29. The Elbow • Exam • TTP at or near tendinous insertion • Provocative tests

30. The Elbow • Nonoperative treatment • Physical therapy • Bracing • Activity modification • NSAIDs

31. The Elbow • Corticosteroid • Autologous blood • Platelet-Rich Plasma (PRP)

32. The Elbow • Corticosteroid injection • Point of maximum tenderness • Triamcinolone: 40 mg • 1% lidocaine: 6 cc • Peppering technique • Inject deep to tendon • Avoid fat atrophy • Avoids skin discoloration • AVOID SERIAL INJECTIONS!

33. Conservative Management • Corticosteroid therapy • Hay et al • BMJ 1999 • RCT: 164 patients • Corticosteroid injection, Naproxen, Placebo tabs • Take home • Corticosteroids are effective in the short term • At one year, most patients are better regardless of treatment modality

34. The Elbow • Autologous Blood • Platelet Rich Plasma

35. Conservative Management • Platelets • 1st on scene • α granules • PDGF • TGF – β • FGF • EGF • VEGF • Plasma • IGF-1 • HGF

36. Conservative Management • IGF • Accelerate healing in muscle/tendon • Menetry et al JBJS-Br 2000 • Kurtz et al AJSM 1999 • PDGF • Induces synthesis of other GF’s • Molloy et al Sports Med 2003 • ↑ biomech strength of healing tendons • Hildebrand et al AJSM 1998 • ↑ MCL strength (73%) at 12 days (murine) • Letson et al Clin Ortho 1994 • FGF • ↑ angiogenesis • Efthimiadou et al BJSM 2006

37. Conservative Management • 2 options for delivery • Autologous blood • Platelet-rich Plasma

38. Conservative Management • Autologous blood • Draw 2 – 5 cc of patient’s blood • Identical technique to corticosteroid • Point of maximal tenderness • Peppering technique

39. Conservative Management • Autologous blood • Suresh et al • BJSM 2006 • Dry needling medial epicondylitis • US-guided injection • Significant decrease VAS at 10 months • Significant decrease modified Nirschl scores • Resolution of Ultrasound findings • Take home: • Dry needling and US-guided autologous blood effective for treatment of refractory medial epicondylitis

40. Conservative Management • 2 options for delivery • Autologous blood • Platelet-rich Plasma

41. Conservative Management • PRP injected into injured tissue • Aim to enhance wound healing • Delivery of growth factors • Optimize healing environment • Active secretion w/in 10 min • 95% presynthesized w/in 1 hour • Marx JOMFS 2004 • Viable for 7 days • “Depot style”

42. Conservative Management • Platelet-rich Plasma • 6 to 8 x concentration • Mishra et al AJSM 2006 • Sample of whole blood • 55 mL • Citrate dextrose A • Anticoagulant • Prevents PLT activation • Activated with Ca2+ and Thrombin

43. Conservative Management • Classic technique • Required 2 “spins” • Commercially available separators • Single Spin • RBC’s • PRP • Platelet poor plasma (PPP)

44. Conservative Management • PRP Technique • Obtain 3 – 5 mL of PRP • Point of maximal tenderness • Peppering technique • Benefits • Minimal risk • Disadvantages • Cost: ~ $350 • Not covered by insurance (YET) • Large volume of blood

45. Conservative Management • Platelet-rich plasma • Mishra and Pavelko • AJSM 2006 • Refractory epicondylitis • 15 patients PRP • 5 patients bupivicaine • 3 of 5 bupivicaine patients sought surgery • Take home • PRP effective in refractory epicondylitis

46. The Hip • Most common players • Bursitis • Arthritis • Impingement

47. The Hip • Trochanteric bursitis • Inflammation of bursa • Gluteus minimus/medius • IT band • LLD

48. The Hip • History • Insidious versus acute • LATERAL hip pain • Sometimes buttock • Night pain • Can’t lay on hip • Injury – rarely • RA

49. The Hip • Examination • Point TTP • Ober’s test • LLD • Minimal pain with ROM • Resisted hip abduction • No xrays necessary • MRI if refractory

50. The Hip • Treatment • NSAID’s • Patches • Activity modification • PT • IT band stretching • Corticosteroids • Long needle? • Surgery • Very rare • IT band lengthening • Arthroscopic • Open