non-operative management of orthopaedic issues reza omid, m.d. assistant professor orthopaedic...
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Non-Operative Management of
Orthopaedic IssuesReza Omid, M.D.
Assistant Professor Orthopaedic Surgery
Shoulder & Elbow Reconstruction
Sports Medicine
Keck School of Medicine of USC
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
X-rays
•Consider x-ray for any patient with injury
•Fracture/Dislocation/Infection/Tumor
General Orthopaedics
• Shoulder/Elbow Reconstruction• Trauma• Pediatrics• Hand/Wrist• Foot/Ankle• Hip/Knee Reconstruction• Tumor• Sports Medicine• Spine
Shoulder Pain
Differential Dx
»Rotator Cuff Disease»Frozen shoulder»Fracture»Calcific Tendonitis»Labral Tears»Biceps Pathology
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!
Shoulder PainRotator Cuff Disorders
–17 million individuals in US at risk
–600,000 surgeries / year
–Most common source WC shoulder pain
Rotator Cuff Disease
Rotator Cuff Anatomy
•Supraspinatus• Infraspinatus•Tere Minor•Subscapularis
Rotator Cuff DiseaseIntrinsic Factors
–Age related degeneration
Extrinsic Factors–Acromial shape–Mechanical pressure on cuff–Activity
ConclusionsDemographics
–Unilateral tear in young–Bilateral tear in older–Tears rare before 50 yo.–>50% in pt over 66 yo.
Radiographs
Always obtain first
AP (scapular plane)
Axillary lateral
Supraspinatus outlet
History–Pain (especially night pain)
»Radiates around deltoid»Never below elbow
–Weakness–Difficulty reaching overhead or behind–Cannot sleep on affected side
Physical Examination
–Cervical spine–Shoulder ROM (active/passive) symmetric?
Physical Examination
Rotator cuff tests–TDA (supraspinatus)–ER at side (infraspinatus)–ER 90° abd (teres minor)–Lift-off (subscapularis)
Physical Examination
Physical Examination
Normal Motion–Elevation – 160–Abduction ER – 90
–ER @ side -60–IR/Ext – T7
Adjuvant Imaging Modalities
MRI
Ultrasound
CT Arthrogram
MRI Reads
• Labral tears• AC arthritis• Partial
thickness RC tears
• Full thickness RC tears
MRI Results
Arthritis: •Labral tears•AC arthritis•Partial thickness tears•Tendinosis
Rotator Cuff Dz:•Full thickness tears•High grade partial thickness tears
MRI Read
No RC Tear
Labral tear seen
AC joint arthritis seen
Dx: Shoulder arthritis
Partial Rotator Cuff Tears
• Can initially treat conservatively
• If fails conservative treatment then surgery
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
Rotator Cuff TearRisks - Chronic Changes
– retraction with adhesion– tendon morphology– muscle atrophy– fatty degeneration– degenerative changes
Conservative Treatment
»Rest, Activity modification
»NSAIDS»ROM stretching»Cuff/Periscapular strengthening
»Corticosteroid Injections
Cuff Strengthening
Conservative TreatmentInjections
–Elderly (>65yo)–Partial tears
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
Proximal Biceps Rupture
• Suspect RC Tear
Shoulder Dislocation
• If anyone >40 years dislocates get an MRI
• If full thickness tear seen with healthy muscle bellies then surgery is indicated
Frozen Shoulder“Adhesive Capsulitis”
Frozen Shoulder–Global and significant loss of both active and passive ROM in gradual fashion
–Absence of radiographic findings other than osteopenia
Clinical Presentation
–Age: late middle age (40-60)
–Male < Female
–Diabetic and Hypothyroid
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”)
Late Frozen Shoulder
–Significant loss of ROM»active and passive
Physical Exam–Passive ROM restricted
»ER early»global late
–ER < 50% unaffected side (pathognomic)
–Pain with extremes of ER
Treatment
Conservative–NSAID’s–Physical Therapy
Fluoro-Guided Intraarticular Fluoro-Guided Intraarticular Steroid Injection!Steroid Injection!
Accuracy of glenohumeral joint
injections: comparing approach and
experience of provider.Tobola JSES 2011:1147
• Posterior: 50%• Anterior: 42%
Arthroscopic Release
–Surgical release of contractures–Remove scar tissue–Complete motion
Elbow Pain
Differential Dx
Lateral Epicondylitis
Instability
Biceps Pathology
Medial Epicondylitis
Olecranon Bursitis
Fracture
Lateral Epicondylitis“Tennis Elbow”
Presentation
• Lateral elbow pain with grip
• Especially in extension• TTP at lateral
epicondyle
Conservative Treatment
• NSAIDs• Activity modification• Physical therapy• Counterforce brace• Iontophoresis• Injections
Conservative Treatment
Iontophoresis
Injections
Corticosteroids
Platelet Rich Plasma
Botulinum Toxin A
ONLY 1 INJECTION!
POSTEROLATERAL ROTATORY INSTABILITY OF THE ELBOW
IN ASSOCIATION WITH LATERAL EPICONDYLITIS. A REPORT OF THREE CASES.
Kalainov JBJSAm 2005: 1120
Physical Therapy
•Modalities•Eccentric exercises
Medial Epicondylitis“Golfers Elbow”
-Medial elbow pain with grip
-Much less common
-TTP at FP mass
-Similar treatment
Olecranon Bursitis
• Most resolve with symptomatic treatment
• Avoid aspiration unless you suspect infection
• Surgery has high complication rate!
Distal Biceps Tears
• Anterior elbow pain with associated “pop”
• Treated surgically as opposed to proximal biceps ruptures
Hand/Wrist Pain
Carpal Tunnel
Treament
•Brace•NSAIDs•Vit B6 (50 mg PO tid) may help some of patients
•Injections (nerve can be injured!)
DeQuervain’s Tenosynovitis
Other Causes of Radial Sided Wrist Pain
Scaphoid fracture
Wrist arthrits
Radial sensory nerve injury
“Crossover syndrome” (another sheath of
tendons)
Treatment
•Brace with thumb spica•NSAIDs•Corticosteroid injection into sheath
Hip Pain
Differential
Fracture
Stress Fracture
FAI
Arthritis
Stress Fracture
•Runners•Female•Rest•MRI (If Femoral neck fracture seen refer)
Stress Fractures
Femoroacetabular Impingement (FAI)
Treatment of FAI
RICE, NSAIDs
Physical Therapy
If MRI ordered get MR Arthrogram of
Affected Hip NOT Pelvis
Knee Pain
Differential Dx
Meniscus tear
Arthritis/OCD
Ligament Injury
Fracture
Knee Effusion
Ligament tear
Meniscus tear
Osteochondral fracture
Synovitis
Consider MRI
Anterior Knee Pain
Treatment
RICE
Weight loss (every pound lost is 7 pounds off the
knee)
Bracing
Physical Therapy
Meniscus Tears
Treatment
•RICE•Weight loss (every pound lost is 7 pounds off the knee)
•Bracing•Physical Therapy •Corticosteroid injection•Surgery is last option
ACL Injuries
Treatment of ACL
•If active and only mild arthritis orthopaedic referral.
•If degenerative and non-active treat non-operatively
•Age is irrelevant
Arthritis
•RICE•Glucosamine/Chondroitin•“Viscosupplement” Injections
•Corticosteroid Injections•Unloader Bracing•PT
Physical Therapy for Hip/Knee Injuries
•ROM•Quadriceps Strength•Hamstring Strength•Hip Abductor Strength•IT Band Stretching•Iliopsoas Stretching
Foot/Ankle Pain
Ankle Sprain
•Get x-rays!!•Most can be treated with CAM walker
•5th MT Fracture
Ottawa Ankle?
Achilles Tendon Injury
•If torn refer•If intact treat with RICE, NSAIDs, CAM boot, PT for eccentric exercises
Achilles Tendon Injury
• Tendinopathy vs insertional tendonitis
• Heel lift• NSAIDS
• PT (eccentric exercises)
Plantar Fascitis
•Inflammation of the plantar fascia
•Achilles stretching•RICE•Boot
Questions???
www.dromid.com
Reza Omid, M.D.Assistant Professor Orthopaedic SurgeryShoulder & Elbow ReconstructionSports MedicineKeck School of Medicine of USC