Sports Medicine Miller Review



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

o ER asymmetry (Dial test)

▪ If dial at just 30, then PLC injury

▪ If dial at 30 and 90, then PLC and PCL injury

o Patella baja – associated w/ arthrofibrosis

o OCD – lateral aspect Medial femoral condyle

o Stress radiographs

▪ For PCL measurement

▪ If > 12 mm, then probably PCL and PLC injury

o ACL

▪ Bone bruise

• Lateral femoral condyle (mid 1/3)

• Lateral tibial plateau (post 1/3)

o Posterior horn MM tear

▪ AL and PM portals for best visualization

- Quad rupture > 40

- Patella rupture < 40

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

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

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

▪ 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 KT-1000 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)

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

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

- 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

- 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

- 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

- 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

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

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

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

- 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 full-thickness tears

- no ass b/w acromial pathology and RTC tears

- Throwers: part-thickness art-sided tear of supra, and less so in infra

- Art cuff surf - less vascular, higher mod of elast, higher ecc forces, less favorable stress-strain 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

o massive tears, disruption of coracr arch, ant deltoid dehisc

- complications of operative tx

o lateral acromionectemy

o AC pain

o Deltoid detachment (open > mini-open)

- 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

- 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

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

- 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

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

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