Orthopaedic Surgery - Snapping Hip

Basics

Snapping hip, also called:

Coxa saltans

is a condition in which the patient feels or hears:

Snapping

Popping

or

Clicking

around the hip during movement.

Occasional painless snapping is common and often:

Clinically insignificant.

Patients generally seek treatment when the snapping becomes:

Frequent

Painful

or

Functionally limiting.

Synonyms

Common terms include:

Snapping hip

Popping hip

Coxa saltans

and, depending on the structure involved,

Tendinous snapping.

Classification

Snapping hip can be divided into:

Internal

External

and

Intra-articular

types.

The distinction is based on the structure producing the:

Snapping sensation.

Internal Snapping Hip

Internal snapping usually results from movement of the:

Iliopsoas tendon

over structures at the front of the hip.

Potential contact points include the:

Femoral head

Iliopectineal eminence

or

Superior pubic ramus.

External Snapping Hip

External snapping usually results from movement of the:

Iliotibial band

or anterior fibers of the:

Gluteus maximus

over the:

Greater trochanter.

Intra-Articular Snapping

Intra-articular causes include:

Acetabular labral tears

Loose bodies

Cartilage lesions

and other abnormalities within the:

Hip joint.

These may produce:

Clicking

Catching

or

Mechanical locking.

Prevention

Preventive measures include:

Adequate stretching before and after sports

and avoiding unnecessary repetitive activities that provoke:

Hip snapping.

Intramuscular Injections

Repeated intramuscular injections into the:

Gluteal region

may rarely lead to fibrosis and contracture of the:

Gluteal muscles

or

Iliotibial band.

Avoiding repeated injections into the same region may therefore reduce this uncommon risk.

Epidemiology

Snapping hip may occur at:

Any age

including in:

Older adults.

It is reported more often in:

Females

than in males.

Incidence

Clinically significant snapping hip is:

Uncommon.

Reliable population estimates of its true:

Incidence and prevalence

are not well established.

Risk Factors

Important risk factors include:

Coxa vara

Repetitive athletic activity

Rapid increases in training volume

and a history of repeated:

Gluteal intramuscular injections.

Coxa Vara

A decreased:

Femoral neck-shaft angle

makes the greater trochanter relatively more prominent.

This can increase friction between the:

Greater trochanter

and

Iliotibial band

and predispose to:

External snapping.

Athletic Activity

Athletes who dramatically increase their:

Training volume

or frequency of repetitive hip motion may develop symptomatic snapping because of:

Tendon irritation

and altered:

Muscle-tendon mechanics.

Genetics

There is no established:

Genetic predisposition

for snapping hip syndrome.

Etiology

The mechanism depends on whether the snapping is:

Internal

External

or

Intra-articular.

Internal Snapping

The iliopsoas tendon may move abruptly over the:

Anterior femoral head

Pelvic brim

or

Iliopectineal eminence

during hip motion.

This movement can produce an audible or palpable:

Snap.

Iliopsoas Mechanics

During hip:

Flexion and abduction

the iliopsoas tendon changes position relative to the pelvic brim.

As the hip moves toward:

Extension and adduction

the tendon may shift medially and snap over an underlying:

Bony prominence.

External Snapping

The iliotibial band or anterior fibers of the gluteus maximus may move from:

Posterior

to

Anterior

over the greater trochanter as the hip is:

Flexed and extended.

A tight or thickened tendon can produce a visible and palpable:

Snap.

Injection-Related Fibrosis

Repeated gluteal injections may cause:

Fibrosis

and

Contracture

of the gluteus maximus or iliotibial band.

This can accentuate abnormal movement over the:

Greater trochanter.

Intra-Articular Causes

Mechanical symptoms arising from inside the joint may result from:

Loose bodies

Labral tearing

Chondral injury

or other intra-articular abnormalities.

After Total Hip Arthroplasty

Rarely, snapping or painful mechanical symptoms may occur after:

Total hip arthroplasty.

Potential causes include:

Component malposition

Iliopsoas irritation

or

Implant loosening.

Associated Conditions

Most cases of snapping hip occur:

In isolation

and are not associated with a systemic disorder.

Diagnosis

The diagnosis depends on:

History

Localization of symptoms

Dynamic physical examination

and selective:

Imaging or diagnostic injection.

Signs and Symptoms

Patients commonly describe:

A tendon or muscle jumping

over the:

Front

or

Side of the hip.

Localization

The patient’s ability to point directly to the site of snapping is highly useful.

Snapping felt:

Anteriorly

suggests an:

Iliopsoas mechanism.

Snapping felt:

Laterally

suggests:

Iliotibial band or gluteus maximus involvement.

Functional Symptoms

Patients may have difficulty:

Entering or rising from a squat

or with activities requiring repeated:

Hip flexion and extension.

Reproducibility

The snapping can often be reproduced during:

Specific hip movements.

This is useful both diagnostically and for identifying the structure responsible.

History

Symptoms usually begin:

Gradually

and often without a discrete:

Traumatic event.

Athletic Association

Symptomatic snapping occurs more often in:

Athletes

than in the general population.

It commonly begins in:

Juvenile

or

Adolescent years.

Important History Questions

Ask:

What movement triggers the snapping?

Where is it felt?

How often does it occur?

Is it painful?

Is there catching or locking?

Was there any trauma?

Has there been prior hip surgery?

Physical Examination

Ask the patient to:

Point to the exact location of the snap

and, if possible,

Reproduce it.

Internal Versus External Location

An anterior snap favors:

Iliopsoas involvement.

A lateral snap over the greater trochanter favors:

Iliotibial band or gluteus maximus involvement.

Iliopsoas Provocation

A maneuver similar to a:

Figure-4 movement

may reproduce iliopsoas snapping.

The patient moves the hip from:

Extension

toward:

Flexion and abduction

and then back toward:

Extension and adduction.

Figure-4 Maneuver

The snapping may occur as the iliopsoas tendon shifts across the:

Pelvic brim

during the transition between these positions.

External Snapping Examination

To evaluate the iliotibial band, the patient may be placed:

Lying on the opposite side.

The affected hip is then repeatedly:

Flexed

and

Extended

with progressively greater:

Adduction.

Findings in External Snapping

Assess for:

Visible or palpable snapping

Reproduction of pain

and possible:

Abduction contracture.

Blocking the Tendon

The examiner may attempt to manually stabilize or block movement of the:

Iliopsoas tendon

or

Iliotibial band.

Reduction or elimination of the snap can help confirm the:

Responsible structure.

Imaging

Plain Radiographs

Plain radiographs of the pelvis and hip are useful primarily to exclude:

Bony abnormalities

or underlying joint pathology.

Bony Causes

Radiographs may identify:

Coxa vara

Exostosis

Hip dysplasia

Arthritis

or other structural abnormalities.

MRI

MRI may be useful when symptoms suggest:

Labral pathology

Bursal inflammation

Tendon abnormality

or another intra-articular condition.

MR Arthrography

MR arthrography may provide additional sensitivity for detecting:

Acetabular labral tears

in selected patients.

CT

CT may be useful when a structural bony abnormality is identified and more precise definition of:

Bone anatomy

is required.

Dynamic Ultrasound

Ultrasound is particularly useful because it can evaluate the hip:

Dynamically.

An experienced examiner may directly visualize:

Iliopsoas

or

Iliotibial band movement

during the snapping event.

Ultrasound-Guided Injection

Ultrasound can also guide diagnostic or therapeutic injection into the:

Iliopsoas bursa

or other symptomatic regions.

Iliopsoas Bursography

Historically, iliopsoas bursography has been performed under:

Fluoroscopy

with contrast injected into the:

Iliopsoas bursa.

The tendon may be seen to move abruptly during provocative hip motion.

Diagnostic Iliopsoas Injection

A combination of:

Local anesthetic

and sometimes:

Corticosteroid

may be injected around the iliopsoas tendon or bursa.

Marked temporary symptom relief supports the diagnosis of:

Internal snapping hip.

Trochanteric Injection

Injection around the:

Greater trochanteric bursa

may help confirm that lateral symptoms originate from the:

Peritrochanteric structures.

Hip Arthroscopy

Hip arthroscopy may be useful when an:

Intra-articular cause

is strongly suspected.

It can both confirm and treat:

Labral tears

Loose bodies

and selected:

Chondral lesions.

Pathological Findings

Internal Snapping

The iliopsoas unit travels across a relatively shallow region between the:

Iliopectineal eminence

and nearby anterior pelvic structures.

Snapping may occur as the tendon moves over:

Bone

Iliopsoas bursa

or neighboring tendon components.

External Snapping

The iliotibial band receives contributions from the:

Tensor fasciae latae

and

Gluteus maximus.

It remains under tension as the hip:

Flexes and extends

and moves over the:

Greater trochanter.

Trochanteric Bursa

Thickening or inflammation of the:

Trochanteric bursa

or increased tension within the iliotibial band may contribute to:

External snapping.

Differential Diagnosis

Important alternatives include:

Acetabular labral tear

Loose body

Hip subluxation

Exostosis

Greater trochanteric pain syndrome

Iliopsoas bursitis

and referred mechanical symptoms from the:

Knee.

Meniscal Snapping

A snapping meniscus may occasionally be mistaken for snapping hip because the:

Hip and knee often flex together

during movement.

Careful localization is therefore important.

Exostosis

A bony exostosis around the hip may mechanically interfere with:

Tendon excursion

and produce snapping.

Habitual Hip Subluxation

Habitual hip subluxation is an uncommon disorder in:

Children and adolescents

that may mimic snapping hip.

The sensation is generally deeper and associated with actual:

Joint translation.

Treatment

Treatment depends on:

Severity

Pain

and the underlying:

Cause.

Painless snapping generally requires:

No treatment.

General Measures

For symptomatic cases, initial treatment includes:

Activity modification

Stretching

Anti-inflammatory medication

and, when needed,

Diagnostic or therapeutic injection.

Activity Modification

Patients should temporarily reduce movements that repeatedly provoke symptoms, such as:

Running

Repeated hip flexion-extension

or

Adduction-based activities.

Incline Running

Running along the side of an incline may increase repetitive:

Adduction

and tension across the lateral hip.

Avoiding this activity may reduce:

External snapping.

Stretching

Stretching should target the involved structure.

For internal snapping, therapy may emphasize the:

Iliopsoas.

For external snapping, emphasis is placed on the:

Iliotibial band

and surrounding:

Hip musculature.

Injection Therapy

Injection may be used when conservative therapy alone is insufficient.

A mixture of:

Local anesthetic

and

Corticosteroid

may provide both:

Diagnostic confirmation

and

Symptomatic relief.

Repeat Injection

In selected persistent cases, corticosteroid injection may be repeated after an appropriate interval, historically around:

6 months

depending on response and clinical circumstances.

Physical Therapy

Physical therapy may focus on:

Iliopsoas stretching

Iliotibial band flexibility

Hip abductor strengthening

Core control

and correction of:

Movement patterns.

Medication

NSAIDs

NSAIDs may be used for:

Pain

and associated:

Inflammation.

Choice of agent and dosing should account for:

Age

Comorbidities

Renal function

and gastrointestinal:

Risk.

Gastrointestinal Risk

NSAIDs should be used cautiously in patients with a history of:

Peptic ulcer disease

or other significant:

Gastrointestinal disease.

Opioids

Opioid analgesics are generally:

Not indicated

for uncomplicated snapping hip.

Surgery

Surgery is reserved for:

Persistent, functionally limiting symptoms

that fail appropriate:

Nonoperative treatment.

External Snapping Surgery

When the iliotibial band is responsible, operative treatment may involve:

Lengthening

or

Release of the iliotibial band

over the:

Greater trochanter.

Iliopsoas Surgery

Persistent internal snapping may be treated by:

Iliopsoas tendon lengthening

or

Release.

This can be performed at different anatomical levels depending on the:

Specific technique.

Intra-Articular Surgery

Hip arthroscopy can treat:

Loose bodies

Labral tears

and other mechanical:

Intra-articular lesions.

Surgical Selection

Surgery should be used cautiously when no definite:

Structural cause

has been demonstrated because outcomes are less predictable.

Complications of Surgery

One possible complication after iliopsoas release or lengthening is:

Hip flexion weakness.

Rare neurologic complications, including:

Femoral nerve injury

may also occur.

Follow-Up

Because snapping hip is usually:

Benign

follow-up can often be:

As needed.

Patient Self-Monitoring

Patients may return for reassessment if symptoms become:

More painful

More frequent

or begin causing:

Functional limitation

Catching

or

Locking.

Prognosis

The prognosis is generally:

Good.

Most cases do not remain a major long-term problem.

Arthritis Risk

Isolated extra-articular snapping hip does not typically lead directly to:

Hip arthritis.

However, intra-articular pathology such as a labral tear may have its own long-term implications.

Complications

The most common difficulty is:

Persistent symptoms despite treatment.

Failed Conservative Treatment

Some patients continue to experience:

Snapping

or

Pain

despite stretching, activity modification, and injections.

These cases require reconsideration of the:

Diagnosis and underlying structure.

Key Principle

Snapping hip, or coxa saltans, describes a palpable or audible snap around the hip and may arise from:

Internal iliopsoas motion, external iliotibial-band or gluteus maximus motion, or intra-articular pathology such as a labral tear or loose body.

The diagnosis is usually made by:

Careful localization and reproduction of the snapping during physical examination, with dynamic ultrasound, MRI, or diagnostic injection used when necessary.

Most symptomatic cases improve with:

Activity modification, stretching, physical therapy, NSAIDs, and selective injection therapy.

Surgery is reserved for:

Persistent, functionally limiting cases with a clearly identified structural cause.

Orthopaedic Surgery - Slipped Capital Femoral Epiphysis

Basics

Slipped capital femoral epiphysis, or:

SCFE

is an adolescent hip disorder in which the:

Femoral head remains seated within the acetabulum

while the:

Femoral neck and metaphysis displace relative to the epiphysis through the proximal femoral physis.

Clinically, this produces:

External rotation of the lower extremity

and often a:

Limp.

Classification

SCFE can be classified according to:

Stability

Duration of symptoms

and

Degree of displacement.

Stable SCFE

A slip is considered:

Stable

when the patient can still bear some weight on the affected limb, with or without:

Crutches.

Stable slips have a substantially better prognosis.

Historical series report satisfactory results in approximately:

95% of appropriately treated stable cases.

Unstable SCFE

A slip is:

Unstable

when the patient is unable to bear weight, even with assistance.

This form carries a much higher risk of:

Avascular necrosis

and often represents a more severe:

Physeal injury.

Historical series have reported satisfactory outcomes in only about:

50% of unstable cases.

Chronologic Classification

SCFE may also be categorized by symptom duration.

Acute: symptoms present for less than approximately 3 weeks

Chronic: symptoms present for more than approximately 3 weeks

Some patients have an:

Acute-on-chronic presentation

with sudden worsening of longstanding symptoms.

Anatomic Severity

Displacement can be graded by the percentage of slip.

Grade 0 – Preslip: no visible displacement, but clinical or MRI evidence of impending physeal failure

Grade I – Mild: approximately 1–33% displacement

Grade II – Moderate: approximately 33–50% displacement

Grade III – Severe: more than 50% displacement

Epidemiology

SCFE occurs predominantly during the:

Adolescent growth spurt.

Approximately:

80% of cases

occur during adolescence.

Typical Age

The usual age range is approximately:

10–16 years in boys

and

9–14 years in girls.

Sex

Boys are affected more often than girls, historically at approximately a:

2.4:1 male-to-female ratio.

Incidence

The incidence in the general population has been reported at approximately:

2–10 cases per 100,000 persons per year.

Seasonal Variation

Historical studies have suggested seasonal variation, with higher incidence around:

September

and lower incidence around:

March.

Possible explanations have included:

Seasonal activity patterns

and potential effects of:

Vitamin D status, although the clinical significance remains uncertain.

Risk Factors

Important risk factors include:

Adolescence

Male sex

Obesity

Delayed skeletal maturation

and

Previous contralateral SCFE.

Obesity

Obesity is one of the strongest risk factors.

Approximately:

50–75% of patients

have historically had a BMI above the:

90th percentile.

Bilateral Disease

SCFE may affect both hips.

Approximately:

25%

have bilateral disease at initial presentation, and up to approximately:

50%

may eventually develop involvement of the:

Contralateral hip.

Race and Population Variation

Incidence differs among populations.

Historically, higher rates have been reported in:

Black adolescents

compared with some other groups.

Genetics

Familial clustering occurs more often than expected by chance.

Historical reports suggest SCFE in approximately:

5–7% of family members

of affected patients.

However, most cases do not follow a simple:

Mendelian inheritance pattern.

Etiology

SCFE is most likely:

Multifactorial.

The proximal femoral growth plate becomes susceptible when:

Physeal strength decreases

while

Shear forces increase.

Growth-Plate Vulnerability

During rapid growth, the proximal femoral physis becomes relatively:

Weaker

and more vulnerable to:

Shear stress.

Mechanical Stress

Increased mechanical stress may result from:

Obesity

Activity

Minor trauma

or altered:

Hip biomechanics.

Endocrine and Metabolic Causes

Less commonly, SCFE may be associated with disorders that weaken the:

Physis.

Examples include:

Hypothyroidism

Panhypopituitarism

Hypogonadism

Hyperparathyroidism

Renal osteodystrophy

and

Chronic renal failure.

Radiation

Previous:

Pelvic radiation therapy

may also weaken the proximal femoral physis and predispose to:

SCFE.

Associated Conditions

Important associated conditions include:

Hypothyroidism

Hyperparathyroidism

Chronic renal disease

Renal osteodystrophy

and

Previous pelvic irradiation.

Diagnosis

Diagnosis requires a high index of suspicion because symptoms are often:

Mild

Insidious

or referred away from the hip.

Signs and Symptoms

The most common symptom is:

Pain.

Pain Location

Pain may be located in the:

Groin

Medial thigh

or

Knee.

Referred Knee Pain

Some patients present almost entirely with:

Knee pain.

This is an important cause of delayed diagnosis.

A child or adolescent with unexplained knee pain should therefore have the:

Hip examined.

Limp

Common gait abnormalities include:

Antalgic gait

Trendelenburg gait

and

Externally rotated gait.

Antalgic Gait

The patient spends as little time as possible bearing weight on the:

Affected limb.

External Rotation

The affected lower extremity often rests in:

External rotation.

History

SCFE frequently develops without a major traumatic event.

The onset is often:

Spontaneous and gradual.

Trauma

Some patients report:

Minor trauma

but this is not required for diagnosis.

Delayed Presentation

Pain may be relatively mild, and patients may delay seeking medical attention.

Some report only:

Fatigue

Limping

or difficulty keeping up with peers.

Endocrine Symptoms

Features suggesting an associated endocrine disorder include:

Cold intolerance

Lethargy

Delayed skeletal maturity

Coarse hair

and abnormalities of:

Growth or puberty.

Physical Examination

Groin and Proximal Femur Tenderness

There may be mild tenderness over the:

Groin

or

Proximal femur.

Internal Rotation

Loss of:

Hip internal rotation

is one of the most characteristic examination findings.

Many patients have:

Little or no internal rotation.

Painful Motion

Pain is typically greatest with:

Internal rotation

and sometimes:

Abduction.

Obligatory External Rotation

A classic finding is:

Obligatory external rotation during hip flexion.

As the hip is flexed, the leg automatically rotates:

Externally.

This is sometimes called:

Drehmann sign.

Resting Position

The affected limb often rests in more:

External rotation

than the opposite side.

Endocrine Screening

History and examination should assess for evidence of:

Hypothyroidism

Pituitary disease

Hypogonadism

and

Renal osteodystrophy.

Laboratory Tests

Routine laboratory testing is not required in every patient.

Endocrine Evaluation

An endocrine workup is appropriate when there is:

Marked delay in skeletal maturity

Atypical age

Short stature

or symptoms suggesting:

Endocrine or metabolic disease.

Imaging

Plain Radiographs

Standard radiographs are usually sufficient to establish the diagnosis.

Typical views include:

AP pelvis

and

Lateral view of the affected hip.

Lateral View

The slip is often most apparent on the:

Lateral projection.

Frog-Leg Lateral

A frog-leg lateral may be useful in a:

Stable SCFE.

It should generally be avoided in an unstable slip because positioning may theoretically worsen:

Displacement.

A cross-table lateral can be used instead.

Radiographic Appearance

The epiphysis remains in the acetabulum while the metaphysis and femoral neck move:

Anteriorly and superiorly

relative to the head.

This produces the classic appearance of:

Ice cream slipping off its cone.

Kline Line

Kline line is drawn along the superior border of the:

Femoral neck.

Normally, this line should intersect part of the:

Femoral head epiphysis.

Loss or reduction of this intersection suggests:

SCFE.

Physeal Changes

Other radiographic findings include:

Widening of the physis

Physeal lucency

Physeal irregularity

and

Blurring of the growth plate.

Epiphyseal Height

There may be a relative decrease in:

Epiphyseal height

compared with the:

Contralateral hip.

Varus Relationship

The epiphysis may appear relatively:

Varus

with respect to the femoral neck.

Pistol-Grip Deformity

Chronic remodeling can produce a:

Pistol-grip deformity

from prominence of the:

Anterolateral femoral neck or metaphysis.

This can predispose to:

Femoroacetabular impingement.

MRI

MRI is useful when a:

Preslip

is suspected despite normal or equivocal radiographs.

Preslip MRI Findings

MRI may show:

Physeal widening

and

Bone marrow edema adjacent to the physis.

These findings can precede visible displacement.

CT

CT may define:

Severe deformity

or help with complex preoperative planning, but is not routinely required for straightforward diagnosis.

Differential Diagnosis

Important alternatives include:

Perthes disease

Proximal femoral fracture

Femoral neck stress fracture

Transient synovitis

Septic arthritis

and other causes of adolescent:

Hip or knee pain.

Perthes Disease

Perthes disease typically affects younger children, often approximately:

4–8 years old.

It may present with:

Limp

and relatively mild pain.

Radiographs distinguish it from:

SCFE.

Proximal Femoral Fracture

True proximal femoral fractures in children and adolescents are usually associated with:

High-energy trauma.

Femoral Neck Stress Fracture

Femoral neck stress fractures are more common near or after:

Skeletal maturity.

They occur more distally along the:

Femoral neck

rather than through the physis.

Treatment

General Principles

Once SCFE is suspected or diagnosed:

Weight bearing should stop immediately.

The central goal is to:

Prevent additional displacement.

Initial Management

The patient should be placed on:

Strict non-weight-bearing precautions

and referred urgently for:

Orthopaedic surgical management.

Admission

Many patients are admitted for:

Prompt operative stabilization.

In Situ Fixation

The standard treatment for most stable slips is:

Percutaneous in situ screw fixation.

Goal of Fixation

The purpose is to:

Prevent further slipping

and allow the:

Physis to close.

Surgical Technique

A guidewire is placed percutaneously from the:

Anterior or anterolateral femoral neck

into the center of the:

Femoral epiphysis.

Cannulated Screw

A cannulated screw, historically approximately:

6.5–7.3 mm

is advanced over the guidewire.

Screw Position

The screw should achieve secure fixation while avoiding penetration of the:

Subchondral articular surface.

Joint Penetration

Screw penetration into the:

Hip joint

can damage cartilage and increase the risk of:

Chondrolysis.

Number of Screws

For most stable SCFE cases, a:

Single centrally positioned screw

is typically sufficient.

Unstable or Severe SCFE

Management of unstable severe slips is more controversial because of the high risk of:

Osteonecrosis.

Reduction

Some surgeons use:

Gentle positioning

or cautious reduction.

Forceful manipulation should be avoided because it may further damage the:

Retinacular blood supply.

Modified Dunn Procedure

In selected severe slips, an open realignment procedure such as the:

Modified Dunn procedure

may be considered by experienced surgeons.

This permits correction while directly protecting the:

Femoral head blood supply.

Corrective Osteotomy

Residual severe deformity may sometimes be treated with:

Proximal femoral osteotomy

to improve:

Alignment

and

Hip mechanics.

Contralateral Prophylactic Fixation

Prophylactic fixation of the opposite hip remains:

Selective rather than routine.

Possible Indications

It may be considered in:

Very young patients

Endocrine or metabolic disorders

Renal disease

Marked skeletal immaturity

or situations in which reliable:

Follow-up is uncertain.

Screw Removal

Routine screw removal after successful fixation is generally:

Not recommended.

Physical Therapy

After surgery, patients require instruction in:

Crutch or walker use.

Weight Bearing

Patients with stable slips may progress to:

Partial weight bearing

according to the surgeon’s protocol and evidence of:

Healing and stability.

Rehabilitation

Physical therapy may address:

Gait

Hip motion

Strength

and safe progression of:

Weight bearing.

Late Degenerative Disease

Patients who later develop severe hip degeneration may require:

Reconstructive procedures.

Historically these have included:

Hip fusion in selected young patients

or

Total hip arthroplasty in adults.

Follow-Up

Long-term follow-up is important because of the risk of:

Contralateral SCFE

and later:

Hip degeneration.

Contralateral Hip Monitoring

The opposite hip should be monitored clinically and radiographically when appropriate, particularly in patients with:

High bilateral risk.

Prognosis

Outcome depends primarily on:

Slip severity

Stability

and presence of:

Complications.

Stable Slips

Stable slips generally have a:

Favorable prognosis

when treated promptly.

Unstable Slips

Unstable slips have a much worse prognosis because of the greater risk of:

Femoral head osteonecrosis.

Degenerative Joint Disease

Even without major early complications, altered proximal femoral shape may predispose to:

Early degenerative joint disease.

Weight Management

Weight reduction in patients with obesity may decrease:

Mechanical load

on the hip and improve long-term:

Joint health.

Metabolic Health

Patients with SCFE and obesity may also have increased risk of:

Type 2 diabetes

Hypertension

and other obesity-related conditions.

Complications

Osteonecrosis

Osteonecrosis is one of the most serious complications.

It results from loss of blood supply to the:

Femoral head.

Consequences of Osteonecrosis

The femoral head may:

Collapse

leading to:

Severe pain

Stiffness

and

Early degenerative arthritis.

Risk of Osteonecrosis

Risk is greatest in:

Unstable SCFE.

Historical estimates have reported rates approaching:

40% in unstable slips

compared with approximately:

5% in stable slips.

Chondrolysis

Chondrolysis is:

Rapid loss of articular cartilage

leading to:

Pain

Joint-space narrowing

and

Hip stiffness.

Causes of Chondrolysis

Potential contributors include:

Severe disease

Inflammation

and especially:

Intra-articular hardware penetration.

Femoroacetabular Impingement

After SCFE, the metaphysis may remain relatively prominent and anterior to the:

Femoral head.

During hip flexion and internal rotation, this prominence can contact the:

Acetabular rim.

Consequences of Impingement

This may produce:

Pain

Labral damage

Cartilage injury

and progressive:

Femoroacetabular impingement.

Treatment of Residual Impingement

Selected patients may be treated with:

Osteoplasty

or

Corrective osteotomy

depending on deformity severity.

Degenerative Joint Disease

Untreated or severely deformed SCFE may result in:

Early osteoarthritis

and can eventually lead to:

Total hip arthroplasty.

Patient Monitoring

Follow-up should assess:

Pain

Gait

Hip range of motion

Radiographic healing

Slip progression

and the status of the:

Contralateral hip.

Key Principle

Slipped capital femoral epiphysis is an adolescent disorder in which the femoral neck and metaphysis displace relative to the femoral head through a weakened proximal femoral growth plate.

The most important clinical clues are:

Limp, loss of internal rotation, obligatory external rotation with hip flexion, and groin, thigh, or referred knee pain.

Once suspected:

Weight bearing should stop immediately, and urgent orthopaedic assessment is required.

Most stable slips are treated with:

Percutaneous in situ screw fixation to prevent further displacement and promote physeal closure.

The most serious complications are:

Osteonecrosis, chondrolysis, femoroacetabular impingement, and premature degenerative arthritis, with unstable slips carrying the highest risk of poor outcome.

Orthopaedic Surgery - Skeletal Scintigraphy

Basics

Skeletal scintigraphy, commonly called a:

Bone scan

is a nuclear medicine technique used to evaluate abnormalities of:

Bone metabolism

Blood flow

and

Osteoblastic activity.

It is particularly sensitive for detecting areas of:

Increased bone turnover

often before abnormalities become visible on:

Plain radiographs.

Basic Principle

Bone-seeking radiopharmaceuticals accumulate preferentially in areas with:

Increased perfusion

and

Active new bone formation.

Therefore, regions undergoing:

Fracture healing

Tumor-associated bone reaction

Infection

or other processes that stimulate osteoblastic activity may demonstrate:

Increased tracer uptake.

Advantages

Major advantages include:

High sensitivity for early skeletal disease

and the ability to perform a:

Whole-body survey

during a single examination.

Disadvantage

The principal limitation is:

Low specificity.

Many unrelated disorders can produce increased tracer uptake, so scintigraphic findings must be interpreted together with:

Clinical history

Physical examination

and

Anatomic imaging.

Indications

Whole-body skeletal scintigraphy may be used to evaluate:

Primary bone tumors

Bone metastases

Osteomyelitis

Painful joint prostheses

Occult fractures

Stress fractures

Medial tibial stress syndrome

Spondylosis

Complex regional pain syndrome

Fracture nonunion

Avascular necrosis

Unexplained musculoskeletal pain

Heterotopic ossification

Paget disease

Fibrous dysplasia

Three-Phase Skeletal Scintigraphy

Three-phase skeletal scintigraphy, or:

TPSS

adds early vascular and soft-tissue imaging to delayed bone-phase imaging.

It is particularly useful in selected cases of:

Osteomyelitis

Stress fracture

Complex regional pain syndrome

and

Osteoid osteoma.

Radiopharmaceutical

The most commonly used radiopharmaceuticals are:

Technetium-99m-labeled diphosphonate compounds.

These agents bind to the mineral phase of bone, particularly in regions of:

Active remodeling

and

Osteoblastic response.

Technique

Whole-Body Skeletal Scintigraphy

A typical adult dose is approximately:

20–30 mCi of technetium-99m diphosphonate

administered by:

Intravenous injection.

Whole-body delayed images are generally obtained approximately:

2–4 hours later.

Three-Phase Study

TPSS uses the same radiopharmaceutical but acquires images during several distinct phases.

Phase 1 – Flow Phase

Immediately after intravenous bolus administration, rapid sequential images are obtained, typically every:

1–3 seconds

for approximately:

60 seconds.

This phase evaluates:

Regional blood flow.

Flow-Phase Interpretation

Increased activity during this phase suggests:

Hyperemia

or increased vascular delivery to the region of interest.

Phase 2 – Blood-Pool Phase

Immediately after the flow phase, higher-count images are obtained.

This phase reflects tracer distribution within:

Blood pool

and

Extracellular soft tissues.

Blood-Pool Interpretation

Increased uptake may indicate:

Soft-tissue inflammation

Hyperemia

or active:

Synovitis.

Phase 3 – Delayed Bone Phase

Delayed images are obtained approximately:

2–4 hours after injection.

These assess tracer incorporation into:

Bone.

Delayed Bone-Phase Interpretation

Focal increased uptake generally indicates increased:

Bone turnover

or

Osteoblastic activity.

Optional Phase 4 – Very Delayed Imaging

Additional images may be obtained approximately:

24 hours after injection.

These are sometimes useful when tracer delivery or clearance is delayed, such as in patients with:

Poor peripheral perfusion

Diabetes

Peripheral vascular disease

or

Renal dysfunction.

SPECT

Single-photon emission computed tomography:

SPECT

provides:

Three-dimensional cross-sectional imaging

and improves:

Lesion contrast

and anatomic localization compared with planar imaging.

SPECT/CT

When combined with CT, SPECT can provide both:

Functional information

and

Anatomic localization.

This can substantially improve characterization of:

Focal skeletal abnormalities.

Pathological Findings

Primary Malignant Bone Tumors

Primary malignant bone tumors may demonstrate:

Hyperemia on flow images

and

Intense delayed tracer uptake

corresponding to areas of:

Reactive bone formation.

The exact appearance varies with tumor type.

Primary Benign Bone Tumors

Tracer uptake in benign tumors is:

Variable.

Some lesions are very active, while others demonstrate little:

Radiopharmaceutical accumulation.

Osteoid Osteoma

Osteoid osteoma typically demonstrates:

Marked focal uptake

and is one of the most scintigraphically active:

Benign bone lesions.

Osteoid Osteoma Three-Phase Pattern

Findings may include:

Increased flow

Marked blood-pool activity

and

Intense focal delayed uptake.

This gives skeletal scintigraphy high sensitivity for lesion:

Detection and localization.

Radionuclide-Guided Surgery

Historically, radiopharmaceutical localization has also been used to assist:

Intraoperative identification

of small lesions such as:

Osteoid osteoma.

Osteomyelitis

Classic acute osteomyelitis may demonstrate a:

Three-phase positive bone scan.

Osteomyelitis – Flow Phase

There is:

Focal arterial hyperemia.

Osteomyelitis – Blood-Pool Phase

There is increased:

Regional soft-tissue and osseous activity.

Osteomyelitis – Delayed Phase

There is:

Focal increased bone uptake.

Cellulitis Without Osteomyelitis

Cellulitis usually produces increased:

Flow

and

Blood-pool activity

but lacks the corresponding focal increase in:

Delayed osseous uptake.

Cellulitis With Osteomyelitis

When both are present, early phases may show relatively:

Diffuse regional activity

while delayed images demonstrate more focal uptake within:

Bone.

Accuracy in Osteomyelitis

Three-phase bone scanning can be highly accurate in uncomplicated native bone.

Historical estimates approach approximately:

90% accuracy

when confounding factors are absent.

Factors Reducing Specificity

Specificity decreases substantially after:

Recent fracture

Recent surgery

Orthopaedic hardware placement

or other causes of active bone remodeling.

Importance of Clinical Correlation

Because many disorders produce a similar three-phase pattern, interpretation requires correlation with:

Clinical history

and

Plain radiographs.

Differential Diagnosis of a Three-Phase Positive Study

Conditions that may produce increased uptake during all three phases include:

Fracture

Gout

Osteoarthritis

Charcot arthropathy

Complex regional pain syndrome

Healing osteonecrosis

Primary malignant bone tumor

Recent osteotomy

and

Osteomyelitis.

False-Negative Osteomyelitis Studies

False-negative examinations may occur in:

Neonates

Very elderly patients

and individuals with markedly impaired:

Blood flow.

Poor Perfusion

Examples include patients with:

Diabetes mellitus

or

Peripheral vascular disease.

Reduced tracer delivery may limit uptake despite active:

Infection.

Antibiotic Therapy

Prior or ongoing:

Antibiotic treatment

may also reduce scintigraphic activity in some cases.

Septic Arthritis

Septic arthritis may also demonstrate a:

Three-phase positive pattern.

Septic Joint Appearance

Typical findings include increased tracer activity in:

Periarticular bone

and around the:

Joint space.

These findings are sensitive but not specific because inflammatory arthritis may produce similar:

Periarticular uptake.

Complementary Nuclear Medicine Studies

When infection remains uncertain, other nuclear medicine examinations may improve:

Specificity.

Radiolabeled Leukocyte Scintigraphy

Autologous leukocytes can be labeled with a radionuclide and reinjected.

The leukocytes migrate toward sites of:

Active inflammation and infection.

Limitation of Leukocyte Imaging

Leukocytes also normally localize within:

Bone marrow.

This can complicate interpretation, particularly around:

Prostheses

or areas where marrow distribution has been altered.

Leukocyte Plus Bone Marrow Imaging

Combined:

Radiolabeled leukocyte imaging

and

Bone marrow scintigraphy

can help differentiate true infection from normal or displaced:

Marrow activity.

Principle

A site showing increased labeled leukocyte uptake without corresponding uptake on the:

Sulfur colloid marrow scan

supports the diagnosis of:

Infection.

Accuracy

Historical reports have described diagnostic accuracy of approximately:

89–98%

for appropriately performed paired leukocyte/marrow studies.

Gallium-67 Imaging

Sequential:

Three-phase bone scanning

and

Gallium-67 scintigraphy

has historically been used in selected cases of suspected infection.

Interpretation

The studies are compared for:

Location

and

Relative intensity of uptake.

Gallium activity that is disproportionately greater than corresponding bone-scan activity may support:

Active infection.

Limitations of Gallium Combination Imaging

A substantial proportion of studies may be:

Equivocal

which limits:

Sensitivity

and practical usefulness.

Vertebral Osteomyelitis

Vertebral osteomyelitis often causes:

Intense uptake in adjacent vertebral bodies.

Sensitivity

Historical sensitivity of delayed bone scintigraphy for vertebral osteomyelitis has ranged from approximately:

86–100%.

Bone/Gallium Combination

Combining bone scintigraphy with:

Gallium imaging

can improve specificity in selected cases.

Leukocyte Imaging in Vertebral Osteomyelitis

Radiolabeled leukocyte imaging is less useful for:

Vertebral osteomyelitis

because false-negative studies are relatively common.

Historical false-negative rates have approached:

40–50%.

Diabetic Foot

Bone scintigraphy may be useful in evaluating suspected:

Diabetic foot osteomyelitis, although specificity is limited by neuropathic and postoperative changes.

Negative Predictive Value

A negative three-phase bone scan has a relatively high:

Negative predictive value

for osteomyelitis.

Forefoot Infection

When a forefoot TPSS study is:

Positive or equivocal

labeled leukocyte imaging may improve diagnostic accuracy.

Midfoot and Hindfoot

Interpretation is more difficult in the:

Midfoot

and

Hindfoot

because Charcot neuroarthropathy may produce intense uptake even without:

Infection.

Charcot Foot

Neuropathic bone and marrow remodeling may attract:

Radiolabeled leukocytes

without true osteomyelitis.

Therefore, paired:

Labeled leukocyte

and

Bone marrow scintigraphy

may be particularly useful.

Arthritis

Arthritis commonly produces:

Diffuse periarticular tracer uptake.

There may also be focal increased activity in:

Subchondral bone.

Occult Fractures

Bone scintigraphy is highly sensitive for fractures that are not yet visible on:

Plain radiographs.

Timing of Fracture Positivity

Historical data indicate that approximately:

80%

of fractures may be visible scintigraphically within:

24 hours

and approximately:

95% by 72 hours

in patients younger than:

65 years.

Older Patients

In patients older than approximately:

65 years

maximum sensitivity may not occur until around:

7 days after injury.

Return to Normal After Fracture

Tracer uptake may persist long after:

Clinical fracture healing.

Nondisplaced Fractures

Historical data suggest normalization in approximately:

60–80% by 1 year

and approximately:

95% by 3 years.

Displaced Fractures

Some displaced fractures may remain scintigraphically:

Positive indefinitely

because of persistent remodeling or deformity.

Athletic Injuries

Stress Fractures

Stress fractures often become positive on skeletal scintigraphy approximately:

1–2 weeks before radiographic abnormalities appear.

Stress-Fracture Pattern

Typical uptake is:

Intense

Focal

and often:

Oval or fusiform

at the fracture site.

Shin Splints

Medial tibial stress syndrome generally has a different scintigraphic pattern.

Shin-Splint Pattern

Flow and blood-pool phases are usually:

Normal.

Delayed images may demonstrate:

Mild to moderate linear uptake

along the:

Posteromedial tibial cortex.

Bilateral Tibial Involvement

The pattern is commonly:

Bilateral

and extends longitudinally rather than appearing as the focal intense uptake seen in:

Stress fracture.

Painful Prosthesis

Bone scintigraphy may demonstrate increased uptake around a:

Painful joint replacement

but is generally unable to reliably differentiate:

Aseptic loosening

from

Infection.

Typical Loosening Pattern

Around a hip prosthesis, increased uptake may occur near:

Greater trochanter

Lesser trochanter

and the:

Distal tip of the prosthesis.

Normal Postoperative Uptake

Increased bone-scan activity may persist for approximately:

1 year after cemented arthroplasty

and as long as:

2–3 years after uncemented arthroplasty.

Therefore, postoperative uptake alone does not establish:

Infection or loosening.

Prosthetic Joint Infection

Historically, combined:

Indium-111-labeled leukocyte

and

Technetium-99m sulfur colloid marrow imaging

has been one of the more accurate nuclear medicine strategies for distinguishing:

Infection

from noninfectious prosthetic changes.

Diagnostic Performance

Historical studies have reported sensitivity and specificity above approximately:

90%

in selected settings.

Marrow Displacement Pitfall

One cause of false-positive leukocyte imaging is:

Displaced or redistributed marrow.

The sulfur colloid marrow scan helps distinguish this from:

True infection.

Bone Grafts

Bone scintigraphy can sometimes evaluate the vascularity of:

Bone grafts

particularly during the early postoperative period.

Early Postoperative Assessment

Within approximately:

1 week after surgery

bone-seeking tracer uptake may provide information about:

Graft perfusion and viability.

Vascularized Graft

A viable vascularized graft may show:

Normal

or

Diffuse increased uptake

with focal uptake at the:

Osteotomy site.

Failed Graft

A failed or poorly perfused graft may appear as a:

Photopenic defect

with little or no tracer accumulation.

Graft Imaging Pitfalls

Interpretive problems include:

New bone formation on a nonviable graft

Postoperative changes

and

Osteoradionecrosis.

Metastatic Bone Disease

Skeletal scintigraphy is widely used to survey for:

Bone metastases.

Patterns of Metastatic Disease

Metastatic disease may appear as:

Multiple randomly distributed lesions

A solitary focus

Diffuse skeletal involvement

or occasionally:

Photopenic lesions.

Osteoblastic Metastases

The examination is particularly sensitive for tumors that induce substantial:

Osteoblastic activity.

Reduced Sensitivity

Sensitivity is lower for predominantly:

Lytic tumors

that provoke little osteoblastic response.

Examples include some metastases or lesions associated with:

Multiple myeloma

Renal cell carcinoma

Thyroid carcinoma

and

Lymphoma.

Multiple Myeloma

Conventional bone scintigraphy may underestimate disease in:

Multiple myeloma

because many lesions are predominantly:

Osteolytic

without substantial reactive bone formation.

Spinal Surgery

Following spinal surgery, increased uptake at operative sites is commonly:

Normal

because of:

Healing and new bone formation.

Nonunion and Pseudoarthrosis

Persistent:

Focal intense uptake

at a fusion or fracture site may suggest ongoing motion or:

Nonunion.

SPECT in Spinal Nonunion

SPECT or SPECT/CT can improve localization and sensitivity when evaluating suspected:

Pseudoarthrosis.

Pediatric Considerations

Young children may require:

Sedation

if they cannot remain still during prolonged imaging.

The need for sedation depends on:

Age

Developmental level

and examination duration.

Pregnancy Considerations

Technetium-99m bone scintigraphy exposes the fetus to a relatively:

Low radiation dose.

Historical estimates for most routine studies are below approximately:

0.5 rad.

Fetal Risk

Radiation-associated fetal risk is considered low at doses far below approximately:

5 rad.

Nevertheless, nuclear medicine imaging during pregnancy should be performed only when:

The expected diagnostic benefit outweighs the potential fetal radiation risk.

Follow-Up Applications

Serial skeletal scintigraphy may be used to evaluate:

Stability or progression of metastatic bone disease

Residual or recurrent primary bone tumor

Response to cancer therapy

Response to treatment of infection

and

Persistent fracture nonunion.

Limitations of Follow-Up

Persistent tracer uptake may reflect:

Healing

rather than active disease.

Therefore, interval changes must be interpreted in the context of:

Symptoms

Other imaging

and the expected time course of:

Bone remodeling.

Key Principle

Skeletal scintigraphy is a highly sensitive nuclear medicine technique for detecting abnormalities of bone perfusion and osteoblastic activity, but it has:

Limited specificity.

Technetium-99m-labeled diphosphonates accumulate in areas of:

Active bone remodeling, allowing detection of abnormalities such as:

Stress fractures, osteomyelitis, occult fractures, tumors, metastases, nonunion, and prosthesis-related bone changes.

Three-phase scintigraphy adds assessment of:

Blood flow, blood-pool activity, and delayed bone uptake, making it particularly useful for:

Infection and stress-related injuries.

Because many different disorders can produce similar uptake patterns, bone-scan findings should always be interpreted together with:

Clinical information, radiographs, and—when needed—MRI, CT, SPECT/CT, or complementary leukocyte-based nuclear imaging.

Orthopaedic Surgery - Shoulder/Proximal Humerus Fracture

Basics

Proximal humerus fractures are:

Common fractures of the shoulder region

and occur particularly frequently in:

Older adults

especially those with:

Osteoporosis.

They are especially common after the age of:

70 years.

Sex Distribution

Women are affected more often than men, historically at approximately a:

2:1 ratio.

This reflects, in part, the higher prevalence of:

Osteoporosis

and fragility fractures in older women.

Mechanism by Age

In older adults, proximal humerus fractures usually result from:

Low-energy falls

such as a fall from:

Standing height.

In younger patients, they are more commonly associated with:

High-energy trauma.

Neer Classification

The:

Neer classification

divides the proximal humerus into four major anatomical segments:

Humeral head / anatomic neck segment

Greater tuberosity

Lesser tuberosity

Surgical neck / shaft segment.

Definition of a Displaced Part

Traditionally, a fracture fragment is considered a separate displaced part when it has:

More than 1 cm of displacement

or

More than 45° of angulation.

Number of Parts

Fractures are consequently described as:

1-part

2-part

3-part

or

4-part fractures.

Other Important Fracture Patterns

Additional important patterns include:

Fracture-dislocations

and

Head-splitting fractures.

These injuries often have greater:

Articular damage

and risk of:

Humeral head ischemia.

Blood Supply

The proximal humerus receives blood from branches of the:

Anterior humeral circumflex artery

and

Posterior humeral circumflex artery.

Modern anatomic studies suggest that the posterior circumflex system provides a substantial portion of the:

Humeral head blood supply.

Medial Calcar

Preservation of the:

Medial calcar

and associated soft-tissue attachments improves the likelihood that:

Humeral head perfusion

will remain intact.

Disruption of the medial hinge and vascular attachments increases concern for:

Osteonecrosis.

Prevention

Prevention is particularly important in:

Older adults with fragility fractures.

Osteoporosis Screening

A proximal humerus fracture after a low-energy fall should prompt consideration of:

Osteoporosis assessment

and treatment.

This may reduce the risk of subsequent:

Hip

Wrist

Vertebral

or other fragility fractures.

Fall Prevention

Patients with recurrent falls or balance problems may benefit from:

Balance training

Assistive devices

Medication review

Vision assessment

and

Home-safety evaluation.

Epidemiology

Proximal humerus fractures are among the most common:

Fragility fractures in older adults.

They traditionally rank behind:

Hip

and

Distal radius fractures

when vertebral compression fractures are excluded.

Proportion of Humerus Fractures

Approximately:

Half of all humerus fractures

involve the:

Proximal humerus.

Female Predominance

Historical series report that approximately:

50–70%

occur in:

Women.

Incidence With Age

The incidence rises sharply after approximately:

50 years of age

and continues to increase with:

Advancing age.

Peak Incidence

Peak incidence has been reported between approximately:

85 and 90 years of age.

Historical combined rates in men and women have approached:

300 per 100,000 persons per year.

Older Adults

Historical U.S. incidence estimates in people older than:

70 years

have been approximately:

424 per 100,000 women

and

150 per 100,000 men.

Population Aging

Because the population is aging, the overall burden of proximal humerus fractures is expected to:

Increase substantially.

Older projections estimated approximately:

275,000 U.S. cases annually by 2030.

Risk Factors

Important risk factors include:

Advanced age

Osteoporosis

Female sex

Low bone mineral density

Previous fragility fracture

History of falls

Low dietary calcium intake

Early menopause

Diabetes mellitus

Certain anticonvulsant medications

Alcohol intoxication

Obesity

and conditions that increase:

Fall risk.

Protective Factors

Some historical observational data have associated:

Calcium supplementation

and

Menopausal hormone therapy

with lower fracture risk in selected populations.

These interventions should be individualized according to overall:

Bone-health and medical considerations.

Genetics

There is no single common genotype that causes most proximal humerus fractures.

However, inherited disorders that weaken bone may increase fracture susceptibility.

Examples include:

Osteogenesis-related connective-tissue disorders

Ehlers–Danlos syndromes

and

Fibrous dysplasia.

Etiology

The injury mechanism varies substantially with:

Patient age

and

Bone quality.

Younger Patients

Adolescents and young adults typically sustain these fractures after:

Motor vehicle collisions

Sports injuries

Falls from height

Penetrating trauma

or other:

High-energy mechanisms.

Older Patients

In older adults, the most common mechanism is a:

Low-energy fall from standing height.

Historical series attribute approximately:

88% of proximal humerus fractures

in this population to:

Falls.

Mechanical Injury

During trauma, the relatively softer proximal humeral bone may fail when the:

Humeral head

is driven against the harder:

Glenoid.

Associated Conditions and Injuries

Most proximal humerus fractures are:

Isolated injuries.

However, associated trauma must be considered, particularly in:

Younger high-energy patients.

Associated Injuries in High-Energy Trauma

Possible accompanying injuries include:

Cervical spine fractures

Rib fractures

Other extremity fractures

Shoulder dislocation

and

Thoracic injury.

Nerve Injury

Peripheral nerve injury may occur from:

Traction

Direct trauma

or displacement of fracture fragments.

The:

Axillary nerve

is particularly important to assess.

Vascular Injury

Major vascular injury is:

Uncommon

but may occur.

Distal circulation must therefore be documented carefully.

Rotator Cuff Dysfunction

Fracture displacement involving the:

Greater or lesser tuberosity

may alter normal rotator cuff:

Force coupling

and cause loss of:

Strength

or

Shoulder motion.

Rotator Cuff Avulsion

Acute rotator cuff avulsion or tearing may also accompany the fracture, although this can be difficult to recognize during the:

Initial painful phase.

Diagnosis

Diagnosis is based on:

History

Physical examination

and

Radiographic evaluation.

Signs and Symptoms

Typical symptoms include:

Severe shoulder pain

Swelling

Bruising

and inability or reluctance to:

Move the arm.

Ecchymosis

Bruising may extend distally toward the:

Elbow

during the first several days to weeks.

This can be dramatic but is common after:

Proximal humerus fracture.

Physical Examination

The examination should evaluate:

Skin integrity

Alignment

Neurovascular function

and evidence of other:

Traumatic injuries.

Inspection

Inspect for:

Open wounds

Skin tenting

Marked swelling

Expanding hematoma

Ecchymosis

and abnormal:

Extremity alignment.

Skin Tenting

Prominent fracture fragments beneath the skin may threaten:

Skin viability

and require urgent:

Orthopaedic assessment.

Neurovascular Examination

A careful neurovascular examination is essential.

Document:

Peripheral pulses

Capillary refill

Motor function

and

Sensation.

Motor Examination

Motor assessment should extend from the:

Shoulder

through the:

Elbow

Wrist

and

Fingers.

Sensory Examination

Sensory function should be documented in relevant peripheral nerve distributions, particularly the:

Axillary nerve

over the lateral shoulder.

Entire Extremity Examination

The entire upper extremity should be inspected and palpated because associated injuries may involve the:

Clavicle

Scapula

Humeral shaft

Elbow

or

Forearm.

Trauma Examination

Patients injured through a high-energy mechanism require a:

Complete trauma assessment.

Older Fall Patients

In older patients following a fall, evaluation should also consider:

Head injury

and

Cervical spine injury.

This is especially important in patients taking:

Anticoagulants

or those with recurrent:

Falls.

Imaging

Plain Radiographs

Initial shoulder imaging should include appropriate orthogonal views.

Commonly obtained views include:

AP or Grashey view

and

Scapular-Y view.

Axillary View

A standard:

Axillary view

may be difficult because of pain.

A:

Modified axillary

or

Velpeau view

can be used when conventional positioning is not tolerated.

Purpose of Axillary Imaging

Axillary or equivalent imaging helps determine:

Glenohumeral alignment

and identify associated:

Fracture-dislocation.

CT

CT is helpful for:

Complex fracture patterns

Articular involvement

Tuberosity displacement

Head-splitting fractures

and preoperative:

Planning.

MRI

MRI is generally:

Not routinely required in the acute setting.

It may be used later when concern persists for:

Rotator cuff injury

or other:

Soft-tissue pathology.

Pathological Fracture

Histopathological testing is not usually necessary unless there is concern for a:

Pathological fracture.

When to Suspect Pathological Fracture

Concern should increase with:

Minimal or unusual mechanism

Suspicious radiographic bone lesion

Known malignancy

or concerning systemic:

Cancer history.

Differential Diagnosis

Important alternative or associated diagnoses include:

Acromioclavicular separation

Subacromial bursitis

Clavicle fracture

Elbow fracture

Humeral shaft fracture

Rotator cuff tear

Scapular fracture

Shoulder dislocation

Treatment

General Principles

Treatment depends on:

Fracture displacement

Fracture pattern

Bone quality

Age

Functional demand

Medical comorbidity

and ability to participate in:

Rehabilitation.

Nonoperative Treatment

Most proximal humerus fractures are treated:

Nonoperatively.

Historical estimates suggest approximately:

Two-thirds

can be managed without surgery.

Minimally Displaced Fractures

Nondisplaced or minimally displaced fractures usually respond well to:

Sling immobilization

followed by:

Early progressive motion.

Fracture-Dislocation

A fracture-dislocation generally requires:

Urgent reduction.

Subsequent management depends on:

Fracture stability

Fragment displacement

Humeral head viability

and associated injuries.

Caution During Reduction

Forceful reduction should be avoided, especially when a fracture through the:

Surgical neck

is present.

Manipulation may further displace the fracture or compromise:

Humeral head blood supply.

Three- and Four-Part Fractures

Historically, many displaced:

3-part

and

4-part fractures

were treated surgically.

Current management is more individualized because some older or lower-demand patients may have similar functional outcomes with:

Nonoperative treatment.

Monitoring Nonoperative Fractures

Potentially unstable fractures treated without surgery should undergo:

Early repeat radiographs

to ensure that displacement has not:

Progressed.

Sleeping Position

During the acute period, many patients are more comfortable sleeping:

Semi-upright

in a chair or:

Recliner.

Activity

Sling Immobilization

A sling is commonly used for approximately:

2–4 weeks

depending on pain and fracture stability.

Early Distal Motion

Even while using the sling, patients should usually perform:

Elbow

Wrist

and

Hand range-of-motion exercises

several times daily.

Weight Bearing

The injured upper extremity is initially:

Non-weight-bearing

or restricted from lifting.

Shoulder Motion

For stable fractures, gentle passive or pendulum motion is often started:

Early

to reduce the risk of:

Posttraumatic stiffness.

Axillary Skin Care

The:

Axillary fold

should be kept:

Clean and dry

because prolonged sling use can lead to:

Skin irritation or maceration.

Preoperative Activity

Patients awaiting surgery are generally maintained in:

A sling

with lifting restrictions until definitive treatment.

Postoperative restrictions depend on:

Fixation stability

Implant type

and

Surgeon protocol.

Physical Therapy

Physical therapy should balance:

Fracture protection

with prevention of:

Shoulder stiffness.

Timing

For nonoperatively treated fractures, formal therapy often begins around:

2–4 weeks

although simple passive exercises may start earlier in stable patterns.

Pendulum Exercises

Early rehabilitation commonly begins with:

Pendulum exercises

and gentle:

Passive motion.

Progression

Motion may progress gradually to:

Pulleys

Passive forward elevation

and broader:

Passive range of motion.

Active-Assisted Motion

At approximately:

6 weeks

active-assisted and then active range-of-motion exercises may begin when:

Clinical and radiographic healing

are progressing appropriately.

Surgical Rehabilitation

After surgery, rehabilitation timing varies according to:

Fracture pattern

Fixation quality

Bone quality

and

Procedure performed.

The goal is to begin safe motion as early as possible to minimize:

Stiffness.

Medication

Acetaminophen

Acetaminophen is commonly used for:

Pain control.

NSAIDs

NSAIDs may also be used.

Some surgeons limit prolonged NSAID use because of theoretical concerns regarding:

Bone healing, although the clinical importance of this effect is uncertain.

Opioids

Short-term opioid medication may occasionally be necessary during the:

Acute painful period.

Prescribing should account for:

Age

Fall risk

Other medications

and overall:

Medical condition.

Tramadol

Tramadol may sometimes be used as an alternative analgesic, although similar precautions regarding:

Sedation

Falls

and drug interactions apply.

Surgery

Surgery is unnecessary for many proximal humerus fractures.

It may be considered when there is:

Major displacement

Unstable fracture configuration

Fracture-dislocation

Head-splitting fracture

or other circumstances in which acceptable function is unlikely with:

Nonoperative treatment.

Open Reduction and Internal Fixation

ORIF may use:

Plates

Screws

or other fixation devices.

The goals are to restore:

Alignment

Tuberosity position

and sufficient stability for:

Early rehabilitation.

Locking Plate Fixation

Locking plates are commonly used in:

Osteoporotic bone

because fixed-angle support can improve fixation of:

Proximal fragments.

Intramedullary Fixation

Selected fracture patterns may be treated using:

Intramedullary fixation.

Its suitability depends on:

Fracture anatomy

and

Tuberosity involvement.

Bone Grafting

Allograft or other structural bone graft may be used when there is:

Poor bone quality

Medial column deficiency

or substantial:

Bone loss.

Arthroplasty

Arthroplasty may be appropriate when reconstruction of the native humeral head is unlikely to succeed.

Reverse Shoulder Arthroplasty

Reverse shoulder arthroplasty has become increasingly common for:

Displaced complex fractures in older adults

particularly when there is:

Poor bone quality

Comminution

or unreliable:

Tuberosity healing.

Hemiarthroplasty

Hemiarthroplasty historically was used more frequently for:

Complex fracture patterns

but has become less common because reverse arthroplasty can provide more predictable function in many older patients.

Follow-Up

Patients require serial clinical and radiographic assessment to ensure:

Maintained alignment

and

Progressive healing.

Radiographic Monitoring

During the early postinjury or postoperative period, radiographs may be obtained every:

Few weeks

depending on fracture stability.

Later Imaging

Once alignment is stable, imaging may be repeated approximately every:

4–6 weeks

until sufficient:

Fracture healing

is demonstrated.

Prognosis

Most minimally displaced fractures treated nonoperatively have:

Satisfactory functional outcomes.

Recovery Time

Recovery can be:

Slow.

Patients should understand that improvement in pain and motion may continue for:

Many months.

Historical studies suggest that approximately:

8 months

may pass before some patients achieve near-maximal recovery.

Displaced Fractures

Displaced fractures treated nonoperatively generally have less predictable outcomes than:

Minimally displaced fractures.

Residual:

Stiffness

Weakness

or

Malunion

may occur.

Complications

Stiffness

Posttraumatic shoulder stiffness is:

Very common.

Many patients experience at least some temporary loss of:

Range of motion.

Malunion

Nonoperative healing in a displaced position can lead to:

Symptomatic malunion

with altered:

Shoulder mechanics.

Nonunion

Failure of fracture union is:

Uncommon

but may occur, particularly with:

Poor bone quality

Severe displacement

or compromised biological healing.

Osteonecrosis

Disruption of the humeral head blood supply may result in:

Osteonecrosis.

Risk is greatest with:

Complex fracture patterns

Anatomic neck fractures

Fracture-dislocations

and loss of the:

Medial hinge.

Rotator Cuff Dysfunction

Tuberosity malposition or associated tendon injury may cause:

Persistent weakness

and impaired:

Shoulder elevation or rotation.

Infection

Surgically treated fractures carry a risk of:

Deep or superficial infection.

Fixation Failure

Implant-related complications include:

Loss of fixation

Screw penetration

Plate failure

and

Secondary displacement.

These are more common in:

Osteoporotic bone

and highly comminuted fractures.

Posttraumatic Arthritis

Articular injury, malunion, or osteonecrosis may eventually lead to:

Posttraumatic glenohumeral arthritis.

Patient Monitoring

Follow-up should assess:

Pain

Neurovascular status

Range of motion

Fracture alignment

Radiographic healing

and development of:

Stiffness or other complications.

Bone Health Monitoring

Older patients with a fragility-type proximal humerus fracture should also be evaluated for:

Osteoporosis

and future:

Fall and fracture risk.

Key Principle

Proximal humerus fractures are common fragility injuries in older adults, particularly women with osteoporosis, while younger patients usually sustain them through high-energy trauma.

Most fractures are:

Nondisplaced or minimally displaced and can be treated nonoperatively with short-term sling immobilization followed by progressive range-of-motion exercises.

More complex fractures require individualized assessment based on:

Displacement, number of fracture parts, bone quality, tuberosity position, medial calcar integrity, vascular risk, patient age, and functional demand.

Surgical options include:

Open reduction and internal fixation, bone grafting, and shoulder arthroplasty, with reverse shoulder arthroplasty increasingly used for complex displaced fractures in older adults.

Important complications include:

Stiffness, malunion, nonunion, osteonecrosis, rotator cuff dysfunction, fixation failure, and posttraumatic arthritis.

Orthopaedic Surgery - Shoulder Instability

Basics

Shoulder instability describes:

Abnormal symptomatic translation of the humeral head relative to the glenoid

beyond the limits of normal physiologic motion.

It is common in:

Young

Active

and

Athletic patients.

Instability Versus Laxity

It is important to distinguish:

Instability

from

Laxity.

Instability is the patient’s subjective experience of:

Painful slipping

Subluxation

Apprehension

or

Dislocation.

Laxity is an objective finding of:

Excessive joint translation on examination.

A patient may have physiologic laxity without:

Symptoms or true instability.

Classification

Shoulder instability may be classified according to:

Direction

Cause

and

Severity.

Classification by Direction

Instability may be:

Anterior

Posterior

or

Multidirectional.

Classification by Etiology

It may be:

Traumatic

or

Atraumatic.

Classification by Degree

Instability events may consist of:

Subluxation

or complete:

Dislocation.

Multidirectional Instability

Multidirectional instability is defined as symptomatic abnormal translation in:

More than one direction.

It commonly has an element of:

Generalized ligamentous laxity

and may involve:

Both shoulders.

Anterior Instability

Traumatic anterior instability is the:

Most common pattern

and often follows a true:

Anterior shoulder dislocation.

Posterior Instability

Posterior instability may result from:

Trauma

such as seizures or electrical injury

or from repetitive loading in athletes such as:

Football linemen.

It may also occur without a single major traumatic event.

Epidemiology

Shoulder instability is common in:

Young athletic populations.

It is among the most frequent shoulder problems encountered in:

Sports medicine.

Posterior Instability

Posterior instability accounts for approximately:

10% of shoulder instability cases.

It is substantially less common than:

Anterior instability.

Incidence

Anterior shoulder dislocation requiring closed reduction has historically been reported at approximately:

24 per 100,000 persons per year.

Posterior instability has been estimated at approximately:

1.1 per 100,000 persons per year.

Age Distribution

Posterior instability peaks in:

Men aged approximately 20–49 years

and in:

Women older than approximately 70 years.

Multidirectional Instability

The exact incidence is unknown.

It is particularly common in athletes involved in:

Gymnastics

Swimming

Volleyball

and other activities requiring repeated:

Overhead motion.

It often becomes symptomatic during the:

Second or third decade of life.

Risk Factors

Important risk factors include:

Young age

Male sex

Contact or collision sports

Connective-tissue disorders

Generalized hyperlaxity

Previous contralateral instability

Seizure disorder

and selected:

Glenoid morphologies.

Glenoid Morphology

Posterior instability is associated particularly with:

Glenoid retroversion

and

Glenoid hypoplasia.

These abnormalities may reduce posterior containment of the:

Humeral head.

Athletic Risk

Certain sports place the shoulder repeatedly in positions that stress specific stabilizers.

Examples include:

Football

Gymnastics

Swimming

Volleyball

and other overhead activities.

Age

Patients younger than approximately:

20 years

have an increased risk of:

Recurrent instability.

Genetics

Historically, traumatic shoulder instability was not considered a primarily:

Genetic disorder

in patients without connective-tissue disease.

However, altered collagen biology may contribute in selected patients.

Reduced expression of:

COL5A1

has been reported in capsular tissue from some patients with recurrent instability.

Etiology

The shoulder has exceptional mobility but relatively limited inherent:

Bony stability.

Normal stability depends on both:

Static

and

Dynamic stabilizers.

Static Stabilizers

These include:

Glenoid morphology

Labrum

Capsule

Glenohumeral ligaments

and

Negative intra-articular pressure.

Dynamic Stabilizers

These include:

Rotator cuff muscles

Long head of the biceps

and

Periscapular musculature.

Anterior Instability Mechanism

The classic mechanism for traumatic anterior instability involves:

Abduction

External rotation

and often:

Extension

with a force that drives the humeral head:

Anteriorly.

Posterior Instability Mechanism

Posterior instability may result from:

Posteriorly directed force

or an axial load with the arm in:

Internal rotation

and

Adduction.

Multidirectional Instability Mechanism

Multidirectional instability is often produced by a combination of:

Biologic factors

such as ligamentous laxity

and

Environmental or activity-related factors

such as repetitive overhead sports.

Associated Conditions and Lesions

Shoulder instability may be associated with:

Bankart lesions

Bony Bankart lesions

HAGL lesions

ALPSA lesions

GLAD lesions

Labral tears

Hill-Sachs lesions

Reverse Hill-Sachs lesions

Rotator cuff tears

Tuberosity fractures

and

Generalized hyperlaxity.

ALPSA Lesion

An:

Anterior labroligamentous periosteal sleeve avulsion

occurs when the anteroinferior labrum and attached ligamentous structures are stripped medially from the:

Glenoid neck

while remaining attached to the:

Periosteum.

Bankart Lesion

A Bankart lesion involves injury to the:

Anteroinferior labrum and capsuloligamentous complex.

It may be:

Soft tissue

or

Bony.

HAGL Lesion

A:

Humeral avulsion of the glenohumeral ligament

occurs when the inferior glenohumeral ligament is avulsed from its:

Humeral attachment.

GLAD Lesion

A:

Glenolabral articular disruption

involves injury to the:

Labrum

and adjacent:

Glenoid cartilage.

Hill-Sachs Lesion

Anterior instability may produce a:

Posterolateral or posterosuperior humeral head compression defect.

This is known as a:

Hill-Sachs lesion.

Reverse Hill-Sachs Lesion

Posterior instability may produce an:

Anteromedial humeral head impaction defect

known as a:

Reverse Hill-Sachs lesion.

Posterior Instability Pathology

Posterior instability may be associated with:

Posterior labral tearing

Posterior cuff fraying

Posterior capsular injury

and

Glenoid retroversion or hypoplasia.

Diagnosis

Diagnosis depends on:

History

Physical examination

and

Imaging.

The clinician must determine whether observed laxity is:

Physiologic

or

Pathologic and symptomatic.

Signs and Symptoms

Patients may report:

Pain

Apprehension

Sensation of slipping

Recurrent subluxation

or

Frank dislocation.

Tenderness

Tenderness may be present around the:

Shoulder girdle

particularly after an acute instability event.

Range of Motion

Attempted motion may produce:

Pain

or a sense of:

Instability.

Abnormal Arm Position

During an acute dislocation, the arm may be held in a characteristic:

Abnormal posture

depending on the direction of displacement.

Physical Examination

A complete examination should include:

Inspection

Palpation

Range of motion

Rotator cuff strength

Instability testing

Hypermobility assessment

and

Neurovascular examination.

Sulcus Sign

The sulcus sign is produced by applying:

Downward traction

to the relaxed arm.

A visible depression below the acromion indicates:

Inferior humeral translation.

It is particularly useful in assessing:

Inferior laxity

and

Multidirectional instability.

Apprehension Test

The shoulder is placed in:

Abduction

and

External rotation.

A sensation of impending dislocation rather than pain alone suggests:

Anterior instability.

Relocation Test

Posteriorly directed pressure on the humeral head during the apprehension position that reduces:

Apprehension

supports the diagnosis of:

Anterior instability.

Acute Setting

Apprehension and relocation testing should not be performed aggressively during an:

Acute unreduced dislocation.

Beighton Score

The:

Beighton hypermobility score

can be used to assess:

Generalized ligamentous laxity.

This is especially relevant in patients suspected of having:

Multidirectional instability.

Load-and-Shift Test

The examiner stabilizes the scapula and translates the humeral head:

Anteriorly

and

Posteriorly.

Excessive translation or reproduction of symptoms suggests:

Instability.

Posterior Stress Testing

Posterior instability may be evaluated using:

Posterior load-and-shift

Posterior stress test

Jerk test

and

Kim test.

Jerk Test

The arm is elevated to approximately:

90°

with internal rotation and axial loading.

A painful:

Clunk

or sudden posterior translation suggests:

Posterior instability or posterior labral pathology.

Kim Test

The Kim test applies a:

Posteroinferiorly directed force

while elevating the arm.

Pain or a posterior clunk may indicate:

Posteroinferior labral injury.

Rotator Cuff Examination

Assess:

Supraspinatus

Infraspinatus

Teres minor

and

Subscapularis strength.

Cuff injury may coexist with:

Instability, especially in older patients.

Neurovascular Examination

Neurovascular status should be assessed:

Before and after reduction

when a dislocation is present.

Particular attention should be paid to the:

Axillary nerve.

Imaging

Plain Radiographs

A full conventional shoulder series is usually the initial study.

At minimum, obtain:

Anteroposterior

and

Axillary views.

Axillary View

The axillary view is essential for identifying:

Posterior dislocation

and determining the relationship between the:

Humeral head

and

Glenoid.

Posterior dislocations are commonly missed when this view is omitted.

Postreduction Imaging

Postreduction radiographs are necessary to:

Confirm concentric reduction

and identify associated:

Fractures

or

Bony defects.

CT

CT is useful for assessing:

Glenoid bone loss

Hill-Sachs defects

Reverse Hill-Sachs lesions

Fracture morphology

and abnormal:

Glenoid version.

MRI

MRI is useful for evaluating:

Labral tears

Capsular injury

Rotator cuff tears

HAGL lesions

and other:

Soft-tissue abnormalities.

MR Arthrography

MR arthrography can improve detection of:

Subtle labral

and

Capsuloligamentous lesions

in patients with chronic or recurrent instability.

Pathological Findings

Histopathological testing is:

Not routinely required.

The relevant pathology is usually defined by:

Clinical examination

and

Imaging.

Differential Diagnosis

Important alternative diagnoses include:

Acromioclavicular injury

Clavicle fracture

Proximal humerus fracture

Rotator cuff tear

and other causes of shoulder pain or apparent instability.

Treatment

General Principles

Treatment depends on:

Direction

Cause

Frequency

Structural damage

and whether instability is:

Traumatic or atraumatic.

Acute Dislocation

If a true dislocation is present, treatment begins with:

Urgent closed reduction.

The technique depends on the:

Direction of displacement.

Reduction

Reduction should be performed using:

Gentle controlled maneuvers

with appropriate:

Analgesia

and

Muscle relaxation.

Posterior dislocations require techniques different from:

Anterior dislocations.

Immobilization

After uncomplicated anterior dislocation, a sling or immobilizer may be used for approximately:

7–10 days

primarily for:

Pain control.

Posterior Dislocation Immobilization

After posterior dislocation, some patients are placed in an:

External rotation brace

to reduce recurrent posterior translation during healing.

Range of Motion

Gentle shoulder motion may begin after:

Acute pain improves.

The sling can be discontinued gradually as:

Comfort allows.

Return to Sport

Athletes may return when they have:

Full range of motion

Symmetric strength

Minimal pain

and sufficient:

Dynamic stability.

In-Season Return

Athletes returning during the same season may use an adjustable brace that limits:

Abduction

and

External rotation.

However, recurrent instability during in-season return is:

Common.

Historical data suggest that only a minority may complete the remainder of the season without another instability event.

Activity Modification

For:

Multidirectional instability

and

Subtle posterior instability

initial treatment centers on:

Activity modification

and

Rehabilitation.

Sport Cessation

Temporary cessation of the provocative sport may be necessary for:

Posterior

or

Multidirectional instability

when symptoms are driven by repetitive athletic loading.

Physical Therapy

Physical therapy is central to treatment, particularly for:

Atraumatic

Posterior

and

Multidirectional instability.

Anterior Instability Rehabilitation

After uncomplicated anterior dislocation, therapy can begin once:

Acute pain subsides.

If fractures or other injuries are present, rehabilitation may need to be:

Delayed.

Posterior Instability Rehabilitation

After posterior dislocation, strengthening may be delayed for several weeks, often approximately:

4–6 weeks

depending on associated injury and stability.

Multidirectional Instability Rehabilitation

Patients with multidirectional instability usually require a prolonged course of:

Dynamic stabilization exercises

often lasting approximately:

4–6 months.

Rehabilitation Goals

Therapy emphasizes:

Rotator cuff strengthening

Scapular stabilization

Proprioception

Neuromuscular control

and

Closed kinetic-chain exercises.

Medication

Symptomatic treatment may include:

NSAIDs

Acetaminophen

and

Ice.

A short course of opioid medication may occasionally be used after an acute dislocation, but prolonged use is generally avoided.

Surgery

Surgical treatment is selected according to the:

Underlying structural lesion.

First-Time Dislocation

Surgery after a first-time anterior dislocation remains:

Individualized.

Young athletes at high risk of recurrence may be considered for:

Early stabilization.

Bankart Repair

Soft-tissue Bankart lesions are commonly treated with:

Arthroscopic labral and capsular repair.

Bony Bankart Repair

Significant glenoid rim fractures may require:

Arthroscopic

or

Open fixation or reconstruction.

Hill-Sachs Lesions

Surgical treatment depends on:

Size

Location

Engagement

and the amount of associated:

Glenoid bone loss.

Bone Loss

Recurrent instability can progressively enlarge:

Glenoid

and

Humeral head bone defects.

Substantial glenoid bone loss may require a:

Bone-augmentation procedure

rather than isolated soft-tissue repair.

Tuberosity Fractures

Associated greater or lesser tuberosity fractures are treated according to:

Displacement

Patient function

and

Rotator cuff integrity.

Rotator Cuff Tears

Rotator cuff tears associated with dislocation, especially in patients older than approximately:

50 years

may require:

Surgical repair

when clinically significant.

Irreducible Dislocation

If the shoulder cannot be reduced by closed methods, urgent:

Open reduction

is indicated.

Posterior Instability Surgery

Procedures may include:

Posterior labral repair

Posterior capsular plication

or correction of substantial:

Bone deficiency or abnormal glenoid morphology.

Multidirectional Instability Surgery

Patients with persistent symptomatic multidirectional instability despite prolonged rehabilitation may undergo:

Capsular plication

or another capsular volume-reduction procedure.

Follow-Up

After a simple dislocation, patients are generally reviewed within approximately:

7–10 days.

Early Follow-Up

The clinician should reassess:

Pain

Neurovascular status

Rotator cuff function

Range of motion

and associated:

Fracture or soft-tissue injury.

Sling Weaning

Patients with uncomplicated dislocations should gradually:

Wean from the sling

as pain improves.

Multidirectional Instability Follow-Up

Patients undergoing nonoperative treatment for multidirectional instability should be seen periodically to evaluate:

Compliance

Strength

Scapular control

and

Response to therapy.

Posterior Instability Follow-Up

After posterior instability or dislocation, immobilization strategy and timing of:

Physical therapy

should be individualized according to:

Structural injury

and

Clinical stability.

Prognosis

Prognosis depends on:

Age

Direction of instability

Athletic demands

Degree of laxity

and associated:

Structural damage.

Recurrence in Young Patients

Recurrent instability is very common in:

Teenagers

and

Young adults.

Historical recurrence rates in teenagers have approached:

80%.

Age Effect

The younger the patient at the first instability event, the greater the likelihood of:

Recurrent episodes.

Structural Risk Factors

Recurrence is more likely when associated with:

Labral tears

Capsular injury

Bone loss

Rotator cuff tearing

or

Fracture.

Posterior Instability Outcomes

Football players treated with arthroscopic posterior labral repair often demonstrate a:

High rate of return to play.

Throwing athletes may have more difficulty returning to their:

Previous performance level.

Multidirectional Instability Outcomes

Many patients improve with:

Structured rehabilitation.

Younger athletes may have less predictable success with therapy alone.

Surgical capsular stabilization can produce:

Good functional outcomes

Low recurrence

and

High return-to-sport rates

in appropriately selected patients.

Complications

Recurrent Instability

The most common long-term complication is:

Recurrent subluxation or dislocation.

Glenohumeral Arthritis

Repeated instability episodes may contribute to:

Progressive cartilage damage

and eventually:

Glenohumeral osteoarthritis.

Nerve Injury

Transient:

Neurapraxia

occurs in a minority of patients.

The:

Axillary nerve

is most commonly involved.

Stiffness

Excessive immobilization or surgery may result in:

Loss of shoulder motion.

Vascular Injury

Vascular injury is:

Rare

but has been reported, particularly after traumatic dislocation.

Abnormal pulses or limb perfusion require:

Urgent assessment.

Patient Monitoring

Long-term follow-up should assess:

Recurrent episodes

Pain

Range of motion

Strength

Scapular control

Apprehension

and the effectiveness of:

Rehabilitation.

Key Principle

Shoulder instability is symptomatic abnormal motion of the humeral head relative to the glenoid and must be distinguished from asymptomatic physiologic laxity.

It may be:

Anterior, posterior, or multidirectional, and may arise from traumatic or atraumatic mechanisms.

Young patients, athletes, patients with:

Hyperlaxity

and those with:

Labral or bony defects

have the greatest risk of recurrence.

Treatment ranges from:

Urgent reduction and short-term immobilization after dislocation

to prolonged:

Rotator cuff and scapular stabilization therapy

for atraumatic or multidirectional disease.

Surgery is reserved for:

Recurrent instability, significant labral or capsular injury, substantial bone loss, persistent posterior instability, multidirectional instability that fails rehabilitation, or irreducible dislocation.

Orthopaedic Surgery - Shoulder Impingement Syndrome

Basics

Shoulder impingement syndrome is a common cause of:

Shoulder pain

particularly during:

Overhead activity.

The most common form is:

External or subacromial impingement.

Spectrum of Disease

Shoulder impingement has traditionally been viewed as a spectrum extending from:

Subacromial bursitis

to

Partial-thickness rotator cuff tearing

and eventually:

Full-thickness rotator cuff tearing.

However, the relationship between actual mechanical contact with the acromion and rotator cuff degeneration is complex.

Both:

Intrinsic tendon degeneration

and

Extrinsic mechanical factors

likely contribute.

Major Types

The two principal categories are:

External impingement

and

Internal impingement.

Less common forms include:

Subcoracoid impingement.

External Impingement

External or subacromial impingement is the:

Most common type.

It involves painful contact or compression of structures within the:

Subacromial space.

Subacromial Space

The subacromial space lies between the:

Acromion superiorly

and

Humeral head inferiorly.

Structures occupying or traversing this space include:

Supraspinatus tendon

Infraspinatus tendon

Long head of the biceps

Joint capsule

Subacromial-subdeltoid bursa

Coracoacromial ligament.

Mechanism of External Impingement

Compression of the rotator cuff against the:

Acromion

and

Coracoacromial arch

has historically been considered an important contributor to:

Rotator cuff disease.

The pathological spectrum may range from:

Inflamed and thickened bursal tissue

to

Bursal-sided partial-thickness cuff tearing.

Acromial Morphology

The acromion is commonly described as:

Flat

Curved

or

Hooked.

Hooked morphology has historically been associated with a higher prevalence of:

Rotator cuff tearing.

However, acromial shape should be interpreted as one factor among several rather than as the sole cause.

Structural Causes of Reduced Subacromial Space

Conditions that may decrease the available space include:

Subacromial osteophytes

Greater tuberosity exostosis

Acromial fracture

Os acromiale

Acromioclavicular osteophytes

Proximal humeral malunion.

Soft-Tissue Causes

The space can also effectively narrow because of enlargement or inflammation of:

Rotator cuff tissue

Subacromial bursa

or deposition of:

Calcium within a tendon.

Internal Impingement

Internal impingement occurs predominantly in:

Overhead throwing athletes.

It involves contact between the:

Articular surface of the posterosuperior rotator cuff

and

Posterosuperior glenoid or labrum.

Throwing Phase

Symptoms typically occur during the:

Late cocking

or

Early acceleration phase

of throwing, when the shoulder is in:

Abduction

and

Maximal external rotation.

Internal Impingement Pathology

Associated abnormalities may include:

Partial articular-sided supraspinatus tears

Posterior rotator cuff fraying

Posterior labral tears

Posterosuperior glenoid cartilage defects

and

Bennett lesions.

Bennett Lesion

A Bennett lesion is a:

Posteroinferior glenoid rim exostosis

or ossific change associated with chronic repetitive throwing.

Peel-Back Phenomenon

Extreme external rotation during throwing can place torsional force on the:

Posterosuperior labrum

through the long head of the biceps.

This may produce the:

Peel-back phenomenon

and contribute to:

Superior or posterosuperior labral tearing.

Contributing Factors in Internal Impingement

Internal impingement is often multifactorial.

Important contributors include:

Posterior capsular contracture

Glenohumeral internal rotation deficit

Scapular dyskinesis

Subtle anterior microinstability

Adaptive remodeling in throwing athletes.

Prevention

External impingement symptoms may be reduced by maintaining:

Rotator cuff strength

Scapular control

and

Shoulder flexibility.

Throwing Athletes

For overhead athletes, prevention emphasizes:

Appropriate throwing mechanics

Posterior shoulder flexibility

Scapular stabilization

and management of:

Training volume.

Epidemiology

Shoulder impingement is among the:

Most common causes of shoulder pain.

Its reported prevalence varies because the term has historically encompassed several overlapping:

Subacromial disorders.

Incidence

The exact incidence is difficult to determine because diagnostic definitions vary.

Nevertheless, subacromial pain and impingement-type symptoms represent a:

Very common source of shoulder dysfunction.

Risk Factors

Important risk factors include:

Increasing age

Repetitive overhead activity

Throwing sports

Swimming

Volleyball

Tennis

Gymnastics

Occupational overhead work.

Genetics

There is no established specific:

Genetic association

for shoulder impingement syndrome.

Etiology

Pain commonly occurs during:

Forward elevation

and

Internal rotation.

Multiple structural and functional abnormalities may contribute.

Proximal Humeral Malunion

Malunion involving the:

Greater tuberosity

or proximal humerus may mechanically narrow the:

Subacromial space.

Coracoacromial Ligament

Thickening of the:

Coracoacromial ligament

may contribute to subacromial contact.

Acromioclavicular Arthritis

Inferiorly projecting osteophytes from the:

AC joint

may reduce the space available for the:

Rotator cuff.

Rotator Cuff Weakness

Weakness or tearing of the rotator cuff may permit:

Superior migration of the humeral head

which can further decrease the:

Subacromial space.

Neurologic Weakness

Rarely, weakness from:

Cervical radiculopathy

or

Suprascapular neuropathy

may impair the supraspinatus and infraspinatus enough to alter shoulder mechanics.

Subacromial Bursitis

Inflammation and thickening of the:

Subacromial bursa

commonly accompany symptomatic external impingement.

Internal Impingement Etiology

Excessive repetitive external rotation in throwers may produce contact between the:

Posterior cuff

and

Posterior-superior glenoid.

Posterior Capsule Contracture

Tightness of the posterior capsule is a common finding and can contribute to:

Glenohumeral internal rotation deficit

and altered humeral translation.

Scapular Dyskinesis

Abnormal scapular motion may reduce:

Effective subacromial clearance

and disturb the normal:

Scapulohumeral rhythm.

Associated Conditions

Common associated abnormalities include:

Glenohumeral internal rotation deficit

Hooked acromion

Os acromiale

Posterior capsular contracture

Partial articular-sided supraspinatus tears

Rotator cuff tears

Scapular dyskinesis

Diagnosis

Diagnosis is primarily based on:

History

Physical examination

and selective:

Imaging.

Signs and Symptoms

Typical symptoms include:

Shoulder pain with overhead activity

Difficulty performing work or sport

and

Night pain or difficulty sleeping.

Activity-Related Pain

Pain commonly occurs during:

Reaching overhead

Throwing

Swimming

Lifting

or repetitive occupational use.

Physical Examination

A complete examination should assess:

Range of motion

Rotator cuff strength

Scapular mechanics

Impingement signs

and associated:

Labral or instability findings.

Neer Impingement Sign

The examiner passively forward elevates the arm.

Reproduction of shoulder pain, often above approximately:

90° of elevation

suggests:

Subacromial pain or impingement.

Neer Impingement Test

Historically, the Neer test refers to repeating the painful maneuver after:

Subacromial local anesthetic injection.

Relief of pain supports the subacromial space as the:

Pain generator.

Hawkins Test

With the shoulder and elbow flexed to:

90°

the examiner forcibly:

Internally rotates the shoulder.

Pain suggests:

Subacromial impingement or rotator cuff pathology.

Jobe Test

The arm is elevated in the:

Scapular plane

and internally rotated or pronated while resistance is applied.

Pain or weakness suggests:

Supraspinatus pathology.

Internal Impingement Examination

Internal impingement may produce posterior shoulder pain with:

Abduction

and

Maximal external rotation.

Range of Motion

Both shoulders should be compared for:

Internal rotation

External rotation

Forward elevation

and

Total rotational arc.

Contracture

Loss of motion may indicate:

Posterior capsular tightness

or another shoulder contracture contributing to symptoms.

Scapular Examination

Observe the scapula during:

Forward elevation

and

Abduction

for:

Winging

Asymmetric motion

or

Dyskinesis.

Imaging

Plain Radiographs

Conventional shoulder radiographs are useful for identifying:

Calcific tendinitis

Arthritis

Acromial abnormalities

Proximal humeral malunion

Os acromiale

and other bony causes of pain.

Acromiohumeral Distance

The distance between the acromion and humeral head can be assessed on radiographs.

A normal interval is generally around:

7–14 mm

depending on technique and patient factors.

Marked narrowing may suggest:

Chronic rotator cuff insufficiency.

Acromial Morphology

Radiographs may also demonstrate:

Flat

Curved

or

Hooked acromial morphology.

MRI

MRI is useful for evaluating:

Rotator cuff tendons

Subacromial bursitis

Labral pathology

Biceps abnormalities

and alternative diagnoses.

Internal Impingement Imaging

MRI or MR arthrography may demonstrate:

Articular-sided cuff tearing

Posterior labral injury

or other changes associated with:

Internal impingement.

Bennett Lesion Imaging

A Bennett lesion may be visible as a:

Posterior glenoid rim exostosis.

Pathological Findings

Possible pathological findings include:

Rotator cuff tendinosis

Interstitial cuff tearing

Partial-thickness tearing

Full-thickness tearing

Thickened inflamed bursa.

Differential Diagnosis

Important alternatives include:

Acromioclavicular arthritis

Biceps tendinopathy

Calcific tendinitis

Cervical radiculopathy

Adhesive capsulitis

Glenohumeral arthritis

Symptomatic os acromiale

Rotator cuff tear

Scapular winging

Scapular dyskinesis

Suprascapular neuropathy

Thoracic outlet syndrome

Treatment

General Principles

Initial treatment is typically:

Nonoperative.

The cornerstone of treatment is:

Physical therapy

combined with:

Activity modification

and symptomatic medication.

Activity Modification

Avoid or temporarily reduce activities that reproduce symptoms, particularly:

Repeated overhead motion

Heavy lifting

or

Throwing.

Throwing Athletes

Athletes with internal impingement should temporarily stop:

Throwing or painful overhead activity

and enter a structured:

Sport-specific rehabilitation program.

Physical Therapy

Rehabilitation should emphasize:

Rotator cuff strengthening

Periscapular strengthening

Scapular stabilization

Range-of-motion restoration

and correction of:

Scapular mechanics.

Rotator Cuff Strengthening

Improving cuff strength helps maintain the humeral head:

Centered within the glenoid

and may reduce abnormal superior translation.

Periscapular Strengthening

Strengthening the:

Trapezius

Serratus anterior

Rhomboids

and other scapular stabilizers can improve:

Scapulothoracic rhythm.

Range of Motion

Any limitation in:

Posterior shoulder flexibility

or

Internal rotation

should be addressed when clinically relevant.

Sleeper Stretch

The:

Sleeper stretch

may be used selectively in throwing athletes with:

Posterior shoulder tightness

or

Glenohumeral internal rotation deficit.

It should be performed carefully to avoid provoking symptoms.

Sport-Specific Rehabilitation

Internal impingement rehabilitation should ultimately address:

Throwing mechanics

Kinetic-chain function

Core strength

Scapular control

and progressive return to:

Overhead activity.

Medication

First Line

Symptomatic treatment may include:

NSAIDs

and

Acetaminophen.

Subacromial Corticosteroid Injection

A subacromial corticosteroid injection may provide:

Temporary pain relief

and can assist participation in:

Physical therapy.

It may also have diagnostic value.

Repeated injections should be used cautiously because of potential adverse effects on:

Tendon tissue.

Surgery

Surgery is reserved for patients with:

Persistent symptoms despite appropriate nonoperative treatment

or those with a specific structural lesion requiring correction.

Acromioplasty

Acromioplasty has historically been used to enlarge the:

Subacromial space

by reshaping the undersurface of the:

Acromion.

Its routine value for isolated subacromial pain without a clear structural indication remains:

Debated.

Distal Clavicle Excision

When symptomatic:

AC joint osteophytes or arthritis

contribute to pain, distal clavicle excision may be considered in selected patients.

Bursectomy

Inflamed:

Subacromial bursal tissue

may be removed arthroscopically when persistent symptoms accompany other surgically treated pathology.

Rotator Cuff Treatment

If a rotator cuff tear is identified, treatment may include:

Débridement

or

Repair

depending on:

Tear depth

Size

Location

and patient factors.

Internal Impingement Surgery

Surgical treatment may include:

Rotator cuff débridement or repair

Labral débridement or repair

and, in selected cases,

Posterior capsular release.

Follow-Up

Patients should be monitored throughout:

Rehabilitation

and after:

Injection or surgery.

Prognosis

Most patients improve with:

Nonoperative treatment.

Historical series suggest successful outcomes in approximately:

70–80%

with a combination of:

Physical therapy

and

Subacromial injection.

Factors Associated With Better Outcome

Historically reported favorable factors include:

Shorter duration of symptoms

Less prolonged work absence

and lack of substantial:

Acromioclavicular degeneration.

These associations should not be interpreted as deterministic for an individual patient.

Surgical Outcome

Patients who undergo surgery after unsuccessful conservative treatment may experience improvements in:

Pain

and

Shoulder function.

Long-Term Decompression Outcomes

Historical long-term follow-up after subacromial decompression has demonstrated acceptable results in many patients, although current practice places more emphasis on:

Rotator cuff pathology

Scapular mechanics

and avoiding unnecessary decompression.

Return to Sport in Internal Impingement

Return-to-play rates are generally favorable, but return to the same performance level depends on:

Extent of cuff injury

Labral involvement

and the athlete’s:

Throwing demands.

Complications

Potential complications of treatment include:

Acromial fracture

Skin discoloration after corticosteroid injection

Infection

Deltoid dysfunction

Neurovascular injury

Seroma

Hematoma

Complex regional pain syndrome

and general:

Medical complications.

Deltoid Dysfunction

Open decompression procedures can rarely injure the:

Deltoid attachment

and lead to impaired:

Shoulder elevation.

Corticosteroid Skin Changes

Subacromial corticosteroid injection may occasionally cause:

Skin depigmentation

or

Subcutaneous fat atrophy

near the injection site.

Patient Monitoring

Follow-up should assess:

Pain

Range of motion

Rotator cuff strength

Scapular control

and ability to resume:

Work or sport.

Internal Impingement Monitoring

In throwing athletes, rehabilitation goals include restoration of:

Full functional range of motion

Strength

Dynamic stability

Scapular mechanics

and

Neuromuscular control.

Return to throwing should occur through a:

Graduated sport-specific progression.

Key Principle

Shoulder impingement syndrome encompasses a group of subacromial and internal contact disorders that produce pain during shoulder elevation or overhead activity.

External impingement most commonly involves the:

Rotator cuff and subacromial bursa beneath the coracoacromial arch, whereas internal impingement primarily affects:

Overhead athletes through contact between the posterosuperior cuff and glenoid.

Treatment begins with:

Activity modification, rotator cuff and scapular rehabilitation, restoration of motion, analgesic therapy, and selective subacromial injection.

Surgery is reserved for:

Persistent symptoms or clearly defined structural pathology, and routine acromioplasty for nonspecific subacromial pain remains:

Controversial.

Orthopaedic Surgery - Shoulder Dislocation

Basics

The shoulder is the:

Most commonly dislocated major joint.

Its predisposition to dislocation reflects the combination of:

Extensive range of motion

and relatively limited inherent:

Bony stability.

The glenohumeral joint therefore relies heavily on:

Capsular

Labral

Ligamentous

and

Muscular restraints

to maintain stability.

Classification

Shoulder dislocations are primarily classified according to the:

Direction of displacement of the humeral head.

The major types are:

Anterior

Posterior

and

Inferior dislocation.

Anterior Dislocation

Anterior dislocations account for approximately:

95% of shoulder dislocations.

The humeral head typically moves:

Anterior and inferior to the glenoid.

Posterior Dislocation

Posterior shoulder dislocation is substantially less common but clinically important because it is:

Frequently missed.

Failure to obtain an adequate:

Axillary or equivalent lateral view

is a major reason the diagnosis is overlooked.

Arm Position

The position in which the patient holds the arm often reflects the:

Direction of dislocation.

Anterior and posterior dislocations typically produce different characteristic postures.

Spontaneous Reduction

Some shoulder dislocations:

Reduce spontaneously

at the time of injury or before medical evaluation.

In these patients, residual:

Pain

Instability

Labral injury

or

Fracture

may provide evidence that a dislocation occurred.

Age-Related Injury Pattern

Associated injuries vary considerably with:

Patient age.

Younger Patients

Patients approximately:

30 years or younger

are more likely to sustain injury to the:

Labrum

Capsule

or

Glenoid rim.

Older Patients

Patients older than approximately:

40–50 years

have a higher likelihood of associated:

Rotator cuff tear

Greater tuberosity fracture

and

Neurovascular injury.

Prevention

There is no completely effective method of preventing traumatic shoulder dislocation.

Avoidance of:

Contact and collision sports

may reduce exposure to a common mechanism in younger patients.

Epidemiology

Shoulder dislocation occurs most frequently in:

Young males

with another incidence peak occurring in:

Older adults.

Sex

Historical series report that males account for approximately:

74% of shoulder dislocations.

Age Distribution

The highest incidence occurs in:

Males younger than 20 years.

A second peak occurs in individuals older than approximately:

70 years.

This produces a:

Bimodal age distribution.

Incidence

The overall incidence in the United States has historically been estimated at approximately:

24 per 100,000 persons per year.

Geriatric Considerations

Approximately:

20% of shoulder dislocations

occur in patients older than:

60 years.

Older-Adult Associated Injuries

Compared with younger patients, older individuals have an increased incidence of:

Rotator cuff tears

Greater tuberosity fractures

and

Peripheral nerve injury.

Rotator Cuff Evaluation in Older Patients

Persistent weakness following reduction in an older patient should raise concern for:

Acute rotator cuff tear.

MRI or ultrasound may be appropriate when there is:

Significant weakness

or an abnormal examination after reduction.

Pediatric and Adolescent Considerations

The incidence is particularly high among:

Adolescent boys, especially around 14–16 years of age.

Recurrence following nonoperative treatment may be very high in this group and can resemble that seen in:

High-risk young adults.

Risk Factors

Important risk factors include:

Male sex

Contact sports

Collision sports

Generalized ligamentous laxity

Connective-tissue disorders

Previous shoulder dislocation

Risk Factors for Recurrent Instability

Recurrent dislocation is associated with:

Young age at first dislocation

Male sex

Hyperlaxity

Glenoid bone loss

Humeral head bone loss

Repeated instability episodes

and the amount of time and activity exposure after the:

Initial dislocation.

Early Age at First Dislocation

An initial dislocation before approximately:

20 years of age

is strongly associated with a higher likelihood of:

Recurrent instability.

Genetics

Traumatic shoulder instability has traditionally not been regarded as primarily:

Genetic.

However, alterations in collagen biology may contribute to susceptibility in some individuals with:

Recurrent instability

or underlying connective-tissue laxity.

Reduced expression of:

COL5A1

has been reported in capsular tissue from some patients with recurrent instability.

Etiology

The classic mechanism of an anterior shoulder dislocation is:

Abduction

External rotation

and

Extension

with a force directed so that the humeral head is driven:

Anteriorly.

Predisposing History

Important historical factors include:

Previous shoulder trauma

and

Prior dislocation or instability episodes.

Posterior Dislocation Mechanisms

Posterior dislocations may occur after:

Seizure

Electrical injury

or trauma that produces forceful:

Internal rotation and adduction.

Because the deformity may be subtle, these injuries require a:

High index of suspicion.

Associated Conditions and Injuries

The patient’s age helps predict the pattern of associated damage.

Patients Younger Than 40 Years

Younger patients commonly sustain injuries involving the:

Capsule

Glenoid

and

Labrum.

Bankart Lesion

A Bankart lesion involves injury to the:

Anteroinferior glenoid labrum and capsuloligamentous structures

after anterior dislocation.

Bony Bankart Lesion

When the anterior-inferior glenoid rim is fractured, the injury is termed a:

Bony Bankart lesion.

The lesion may therefore be:

Soft-tissue

Bony

or a combination of both.

Patients Older Than 40 Years

Older patients are more likely to sustain:

Rotator cuff tears

Greater tuberosity fractures

Lesser tuberosity fractures

Articular cartilage injuries

Coracoid fractures

and

Neurovascular injury.

Hill-Sachs Lesion

Anterior shoulder dislocation may create a:

Compression defect of the posterolateral or posterosuperior humeral head

when it impacts the:

Anterior glenoid rim.

This is known as a:

Hill-Sachs lesion.

Reverse Hill-Sachs Lesion

Posterior shoulder dislocation may produce an:

Anteromedial humeral head impaction defect

known as a:

Reverse Hill-Sachs lesion.

Diagnosis

Diagnosis is based on:

History

Physical examination

and

Radiographs.

Signs and Symptoms

Typical findings include:

Severe shoulder pain

Tenderness

Inability or unwillingness to move the shoulder

and visible alteration in:

Shoulder contour.

Arm Support

Patients frequently support the injured arm using the:

Opposite hand

to minimize painful motion.

Neurovascular Symptoms

Patients may develop:

Numbness

Weakness

or other evidence of:

Nerve injury.

The:

Axillary nerve

is the most commonly affected.

Axillary Nerve Findings

Axillary nerve dysfunction may cause:

Reduced sensation over the lateral shoulder

and

Deltoid weakness.

Physical Examination

A careful examination should be performed:

Before and after reduction.

Inspection

Inspect the shoulder girdle for:

Asymmetry

Loss of normal contour

Swelling

Ecchymosis

and deformity.

Anterior Dislocation Appearance

With anterior dislocation, the shoulder may appear:

Squared off

with a prominent:

Acromion

and loss of the normal rounded deltoid contour.

Palpation

The displaced humeral head may occasionally be palpable:

Anteriorly

or

Posteriorly

depending on the direction of dislocation.

Sulcus Sign

The sulcus sign demonstrates:

Inferior laxity

but is more relevant to chronic instability evaluation than to the immediate management of an acute dislocation.

Apprehension and Relocation Tests

These tests are useful after the acute injury has resolved to evaluate:

Anterior instability.

They should not be aggressively performed during the:

Acute dislocation episode.

Neurovascular Examination

Document before and after reduction:

Axillary nerve sensation

Deltoid function

Distal motor function

Peripheral pulses

Capillary refill

and overall:

Limb perfusion.

Range of Motion and Strength

Formal testing of:

Active motion

Passive motion

and

Shoulder girdle strength

should usually be deferred until after:

Reduction

and reduction of acute pain.

Imaging

Plain Radiographs

Conventional radiographs are generally sufficient to confirm the diagnosis.

At minimum, imaging should include:

Anteroposterior view

and

Axillary or equivalent orthogonal view.

Axillary View

The axillary view is particularly important for detecting:

Posterior shoulder dislocation.

If AP and scapular-Y views appear normal but clinical suspicion remains, an:

Axillary view

should be obtained whenever feasible.

Posterior Dislocation Pitfall

Posterior dislocation may be missed when only:

AP radiographs

are obtained.

This is one of the classic diagnostic pitfalls in shoulder trauma.

Scapular Y View

The scapular-Y view can help demonstrate the relationship between the:

Humeral head

and

Glenoid.

However, it does not completely replace the:

Axillary view.

Postreduction Radiographs

Radiographs should be obtained after reduction to:

Confirm concentric reduction

and evaluate for associated:

Fractures

Hill-Sachs lesions

or other bone injury.

CT

CT is useful for assessing:

Glenoid bone loss

Humeral head defects

Fracture configuration

and complex:

Bony instability lesions.

MRI

MRI is useful for evaluating:

Labral tears

Capsular injury

Rotator cuff tears

Biceps pathology

and other:

Soft-tissue injuries.

Pathological Findings

Histopathological testing is:

Not routinely required

for traumatic shoulder dislocation.

Differential Diagnosis

Important alternative or associated diagnoses include:

Acromioclavicular injury

Cervical spine injury

Clavicle fracture

Labral injury

Proximal humerus fracture

Rotator cuff tear

Treatment

General Principles

Acute shoulder dislocation requires:

Prompt closed reduction

after appropriate assessment and imaging.

The direction of the dislocation must be understood because it influences the:

Reduction technique.

Urgency

Reduction should be performed:

Urgently

to relieve pain, reduce neurovascular stretch, and minimize ongoing:

Cartilage and soft-tissue injury.

Analgesia and Sedation

Options include:

Intra-articular local anesthetic

Procedural sedation

Intravenous analgesia

or other appropriate pain-control strategies.

Muscle Spasm

Muscle spasm can prevent easy reduction.

Adequate:

Analgesia

Relaxation

and gentle technique reduce the risk of:

Iatrogenic fracture or soft-tissue injury.

Reduction Principles

Reduction should be:

Slow

Controlled

and

Gentle.

Forceful manipulation should be avoided.

Stimson Technique

The patient lies:

Prone

with the affected arm hanging over the side of the table.

Gentle downward traction, historically sometimes assisted by:

Weights

allows gradual muscle relaxation and reduction.

Traction-Countertraction

With the patient supine, gentle longitudinal traction is applied to the:

Affected arm

while countertraction is applied across the torso using:

A sheet or assistant.

Milch Technique

The arm is gradually:

Abducted

while the examiner controls the humeral head.

Once adequate abduction is achieved, gentle:

External rotation

may assist reduction.

FARES Technique

The:

FARES technique

uses gentle longitudinal traction while the arm is progressively abducted with small:

Vertical oscillations.

It is designed to provide:

Fast, atraumatic reduction

without abrupt force.

Posterior Dislocation Reduction

Posterior dislocations require special caution.

Forceful:

External rotation

should be avoided because it can cause:

Proximal humerus fracture

particularly when a reverse Hill-Sachs lesion is present.

Posterior Reduction Principle

Reduction generally involves:

Gentle traction

Controlled internal rotation

and carefully directed force on the:

Proximal humerus

to disengage the humeral head from the posterior glenoid.

Irreducible Dislocation

If closed reduction fails, the patient requires:

Urgent open reduction.

Failure may result from:

Interposed soft tissue

Fracture fragments

or an entrapped:

Humeral head defect.

Immobilization

After uncomplicated reduction, patients are typically placed in a:

Sling

or

Shoulder immobilizer.

Duration of Sling Use

A short period of approximately:

7–10 days

is often sufficient for pain control in simple dislocations.

The exact duration depends on:

Age

Associated injury

and

Comfort.

Early Motion

After acute pain subsides, patients should gradually begin:

Gentle range-of-motion exercises.

Prolonged immobilization should be avoided, especially in:

Older patients

because of the risk of:

Shoulder stiffness.

Return to Sport

Athletes may return when they have:

Full or near-full range of motion

Symmetric strength

Minimal or no pain

and sufficient:

Stability for sport-specific activity.

Bracing for Contact Sports

Some contact athletes use braces that limit:

External rotation

and

Abduction

during return to play.

However, recurrent instability after return to competition remains:

Common.

Physical Therapy

Physical therapy may begin after the:

Acute pain subsides.

Rehabilitation Goals

The goals are to restore:

Range of motion

Rotator cuff strength

Scapular control

and

Symmetric shoulder function.

Associated Injuries

If a patient has an associated:

Fracture

Rotator cuff tear

or other significant injury, rehabilitation may need to be:

Delayed or modified.

Need for Therapy

Not every uncomplicated dislocation requires formal:

Physical therapy.

A structured home program may be sufficient for some patients.

Medication

First-Line Analgesia

Pain may be treated with:

NSAIDs

and

Acetaminophen.

Opioids

A short course of opioid analgesia may occasionally be needed for:

Severe acute pain.

Routine prolonged opioid treatment should be avoided.

Surgery

Surgical treatment after a first-time shoulder dislocation is:

Individualized.