orthopedics and rheumatology

complete loss of contact b/w the articular surfaces of a joint

incomplete dislocation, results in nonconcentric joint surface

a maneuver whereby a fracture or dislocation is returned to anatomic alignment

• failure of the bony edges to unite
• (hypertrophic, atrophic)

healing of the bony fragments in a faulty position --> causing an imperfect alignment, deformity or rotation

normal bone + abnormal force = traumatic fracture

abnormal bone + normal force = pathological fracture

normal bone + repetitive force = stress fracture

• 1. location
• 2. fracture pattern (may be more than 1)
• 3. open vs. closed
• 4. displacement
• 5. angulation

• 1. generalized bone disease (paget, metabolic - osteoporosis - hyper PTH - osteomalacia, EtOH, poor diet
• 2. local disease (cyst, chronic infection)
• 3. malignancy (met, sarcoma, multiple myeloma)

• breast
• lung
• prostate
• kidney
• thyroid

• minimum 2 views
• joints above and below
• before and after reduction

• obtain reduction
• maintain reduction
• early mobilization
• pain management

• compartment syndrome
• soft tissue/skin injury
• pressure sores
• chaffing/pruritus
• swelling
• muscle atrophy

• serum Calcium, phosphate, alk phos, PTH, TSH, T3/T4
• serum protein electrophoresis
• bone density
• bone scan
• bone biopsy

• ***pain out of proportion to the injury
• loss of muscle function followed by pain with passive stretch
• use intracompartmental pressure readings for obtunded pts
• pulselessness, paresthesia, pallor, paralysis, pain are LATE signs

• avoidance of the painful activity (immobilization if pain present at rest)
• surgical treat in rare cases (nonunion, fracture propagation...)

• SITS
• subscapularis
• infraspinatus
• teres minor
• supraspinatus

• sterno-clavicular
• acromio - clavicular
• gleno - humeral
• scapulothoracic

• poorly localized
• full ROM w/o pain

• remove gross debris
• splint extremity
• start Abx
• check Tetanus status
• NPO, prep for OR

• neurovascular compromise
• intra-articular fracture
• salter harris II-V
• non-union obtained
• compartment syndrome

• fractures - clavicle, humerus, scapula
• dislocation - AC joint, GH joint

• frozen shoulder (adhesive capsulitis)
• GH arthritis (OA, RA, crystalline)
• GH instability
• SLAP lesion (injury to the glenoid labrum - Superior Labral tear from Anterior to Posterior)

• AC arthritis
• rotator cuff injury (impingement, tendiopathy, tear)
• biceps tendinopathy/rupture
• subacromial bursitis

• neurologic - disc herniation/stenosis, brachial plexus injury
• abdo - splenic injury, hepatobiliary
• thoracic - apical lung tumour, upper lobe pneumonia
• cardiac - MI (left shoulder only)

85% are anterior - abduction and external rotation of th earm or hyperextension (usually traumatic)

• 15% are posterior - high energy force when an arm in adduction and internal rotation
• associated with the Es (epilepsy, EtOH, electrical shock, encephalitis)

• "squared off shoulder"
• arm held in abduction/internal rotation
• humeral head may be palpable
• may/not be nerve injury

• flattening of anterior shoulder
• prominent coracoid
• arm held in adduction/internal rotation
• limited abduction/external rotation

proximal and middle fractures: sling 2-3 wks, rehab to increase ROM, strengthening

distal third - if unstable may need ORIF

• (not common)
• usually from rotator cuff tendinopathy or referred pain from the cervical spine

• compression of the rotator cuff tendons (and the subacromial bursa) between the acromion and the humeral head
• related to narrowing of supraspinatus outlet or muscular dysfunction/capsular tightness

• shoulder pain with overhead activities
• painful arc (60' to 120')
• positive impingement tests - Neer, Hawkins
• atrophy of muscles around the joint if chronic

• acromial morphology
• rotator cuff dysfunction
• repetitive overhead activities

• NSAIDs
• physio
• subacromial decompression

• pain along lateral deltoid with over head activity (reaching, pulling)
• positive painful arc test
• increased pain when sleeping on the affected side

• NSAIDs
• steroid injection

• anterolateral pain
• night pain
• shoulder weakness (unable to reach overhead)
• popping/catching of shoulder with movement
• positive drop arm test if tear is complete

• acutely:
• heat
• exercise
• local anesthetic injection

• after 3 weeks:
• young/active --> surgical repair
• elderly/sedentary --> conservative tx

tear of labrum at the point of biceps tendon attachment leading to labrum and biceps tendon tear

• rotator cuff injury (most common)
• DM
• use of sling
• stroke
• axillary surgery

• stiffness
• decrease ROM (external rotation > abduction > internal rotation)
• unable to reach up/put on clothes
• may have pain w mov't or direct pressure
• predictable stages (freezing, frozen, thawing)

• NSAIDs
• local heat
• PT to increase ROM and prevent further stiffening (NOT in freezing stage)
• may use injection of local anesthetic/corticosteroids
• arthroscopic release prn

grinding/popping sensation when reaching overhead or across the chest

chronic and progressively worsening stiffness and pain (esp w abduction and external rotation)

• NSAIDs
• PT to increase ROM
• steroid injections
• shoulder replacement prn