Non-Operative Management of Orthopaedic Issues

1. Non-Operative Management of Orthopaedic Issues Reza Omid, M.D. Assistant Professor Orthopaedic Surgery Shoulder & Elbow Reconstruction Sports Medicine Keck School of Medicine of USC

2. Musculoskeletal Injuries • Common cause for doctor visists (ER and outpatient). • >1 in 4 Americans has a musculoskeletal condition requiring medical attention. • Most can be treated non-operatively

3. X-rays • Consider x-ray for any patient with injury • Fracture/Dislocation/Infection/Tumor

4. General Orthopaedics • Shoulder/Elbow Reconstruction • Trauma • Pediatrics • Hand/Wrist • Foot/Ankle • Hip/Knee Reconstruction • Tumor • Sports Medicine • Spine

5. Shoulder Pain

6. Differential Dx • Rotator Cuff Disease • Frozen shoulder • Fracture • Calcific Tendonitis • Labral Tears • Biceps Pathology

7. Shoulder Pain • Among the most common sources of pain • Ranks 2nd to lower back pain as a reason pt. seek medical attention • Approx. 40% of people over 65 yo have rotator cuff tears!

8. Shoulder Pain • Rotator Cuff Disorders • 17 million individuals in US at risk • 600,000 surgeries / year • Most common source WC shoulder pain

9. Rotator Cuff Disease

10. Rotator Cuff Anatomy • Supraspinatus • Infraspinatus • Tere Minor • Subscapularis

11. Rotator Cuff Disease • Intrinsic Factors • Age related degeneration • Extrinsic Factors • Acromial shape • Mechanical pressure on cuff • Activity

12. Conclusions • Demographics • Unilateral tear in young • Bilateral tear in older • Tears rare before 50 yo. • >50% in pt over 66 yo.

13. Radiographs • Always obtain first • AP (scapular plane) • Axillary lateral • Supraspinatus outlet

14. History • Pain (especially night pain) • Radiates around deltoid • Never below elbow • Weakness • Difficulty reaching overhead or behind • Cannot sleep on affected side

15. Physical Examination • Cervical spine • Shoulder ROM (active/passive) symmetric?

16. Physical Examination • Rotator cuff tests • TDA (supraspinatus) • ER at side (infraspinatus) • ER 90° abd (teres minor) • Lift-off (subscapularis)

17. Physical Examination

18. Physical Examination • Normal Motion • Elevation – 160 • Abduction ER – 90 • ER @ side -60 • IR/Ext – T7

19. Adjuvant Imaging Modalities • MRI • Ultrasound • CT Arthrogram

20. MRI Reads • Labral tears • AC arthritis • Partial thickness RC tears • Full thickness RC tears

21. MRI Results • Arthritis: • Labral tears • AC arthritis • Partial thickness tears • Tendinosis • Rotator Cuff Dz: • Full thickness tears • High grade partial thickness tears

22. MRI Read • No RC Tear • Labral tear seen • AC joint arthritis seen • Dx: Shoulder arthritis

23. Partial Rotator Cuff Tears • Can initially treat conservatively • If fails conservative treatment then surgery

24. Orthopaedic Referral • Full thickness tear in patients <60-65yo • Acute (<3month) traumatic full thickness tears in any age • Full thickness tear in patients >65 yrs who fail conservative treatment

25. Rotator Cuff Tear • Risks - Chronic Changes • retraction with adhesion • tendon morphology • muscle atrophy • fatty degeneration • degenerative changes

26. Conservative Treatment • Rest, Activity modification • NSAIDS • ROM stretching • Cuff/Periscapular strengthening • Corticosteroid Injections

27. Cuff Strengthening

28. Conservative TreatmentInjections • Elderly (>65yo) • Partial tears

29. Shoulder Injections • “The effect of corticosteroid on collagen expression in injured rotator cuff tendon” • Wei A, et al JBJSAm 2006: 1331-8 • LIMIT TO 1-2 INJECTION • GET MRI PRIOR

30. Proximal Biceps Rupture • Suspect RC Tear

31. Shoulder Dislocation • If anyone >40 years dislocates get an MRI • If full thickness tear seen with healthy muscle bellies then surgery is indicated

32. Frozen Shoulder“Adhesive Capsulitis”

33. Frozen Shoulder • Global and significant loss of both active and passive ROM in gradual fashion • Absence of radiographic findings other than osteopenia

34. Clinical Presentation • Age: late middle age (40-60) • Male < Female • Diabetic and Hypothyroid

35. Clinical Presentation • Significant pain - especially at night! • Insidious onset • No trauma • Minor trauma (“dog pulled me”, “I reached in the back seat of the car”)

36. Late Frozen Shoulder • Significant loss of ROM • active and passive

37. Physical Exam • Passive ROM restricted • ER early • global late • ER < 50% unaffected side (pathognomic) • Pain with extremes of ER

38. Treatment • Conservative • NSAID’s • Physical Therapy Fluoro-Guided Intraarticular Steroid Injection!

39. Accuracy of glenohumeral joint injections: comparing approach and experience of provider. • Tobola JSES 2011:1147 • Posterior: 50% • Anterior: 42%

40. Arthroscopic Release • Surgical release of contractures • Remove scar tissue • Complete motion

41. Elbow Pain

42. Differential Dx • Lateral Epicondylitis • Instability • Biceps Pathology • Medial Epicondylitis • Olecranon Bursitis • Fracture

43. Lateral Epicondylitis“Tennis Elbow”

44. Presentation • Lateral elbow pain with grip • Especially in extension • TTP at lateral epicondyle

45. Conservative Treatment • NSAIDs • Activity modification • Physical therapy • Counterforce brace • Iontophoresis • Injections

46. Conservative Treatment

47. Iontophoresis

48. Injections • Corticosteroids • Platelet Rich Plasma • Botulinum Toxin A

49. Only 1 INJECTION!

50. Posterolateral rotatory instability of the elbow in association with lateral epicondylitis. A report of three cases. Kalainov JBJSAm 2005: 1120