Orthopaedic Surgery - Supracondylar Elbow Fracture

Basics

A supracondylar humerus fracture occurs through the:

Distal humeral metaphysis

just proximal to the:

Elbow joint.

The fracture commonly passes through the relatively thin region of bone surrounding the:

Olecranon fossa.

Age-Related Injury Pattern

The same hyperextension mechanism produces different injury patterns according to age.

In:

Children

it commonly produces a:

Supracondylar humerus fracture.

In:

Toddlers

injury may instead involve the:

Distal humeral physis.

In:

Adults

a comparable mechanism more commonly results in:

Elbow dislocation

or other distal humeral fracture patterns.

Classification by Mechanism

Supracondylar fractures are classified as:

Extension type

or

Flexion type.

Extension-Type Fracture

Approximately:

95%

are extension-type injuries.

They typically occur after a:

Fall on an outstretched hand

with the elbow forced into:

Hyperextension.

Flexion-Type Fracture

Flexion-type fractures are:

Uncommon.

They usually result from a direct fall onto a:

Flexed elbow.

Gartland Classification

The:

Gartland classification

is the most commonly used system for extension-type supracondylar fractures.

Gartland Type I

Type I fractures are:

Nondisplaced.

Overall alignment is maintained, although an occult fracture may be suggested by:

Elbow effusion or posterior fat-pad sign.

Gartland Type II

Type II fractures are:

Displaced but retain some cortical continuity.

A posterior cortical hinge is typically preserved.

Gartland Type III

Type III fractures are:

Completely displaced

with no meaningful cortical contact between the:

Proximal and distal fragments.

These injuries have a substantially greater risk of:

Neurovascular complications.

Gartland Type IV

Type IV fractures are unstable in both:

Flexion

and

Extension.

This multidirectional instability usually reflects:

Complete periosteal disruption.

Synonym

A broader term is:

Distal humerus fracture

although this includes several other fracture patterns besides supracondylar injuries.

Epidemiology

Supracondylar humerus fracture is one of the most common:

Elbow fractures in children.

Age

The mean age at injury is approximately:

6 years.

Most occur in children between approximately:

5 and 7 years of age.

Sex

The injury occurs in both sexes with an approximately:

Equal distribution.

Adults

True supracondylar fractures are:

Uncommon in adults.

Adult distal humeral fractures overall have historically occurred at rates around:

5–6 per 100,000 persons per year.

Risk Factors

The principal risk factor is:

Fall on an outstretched upper extremity.

Participation in activities associated with falls, such as:

Playground activity

Sports

and

Cycling

may increase exposure to the typical mechanism.

Etiology

The classic mechanism is:

Fall on an outstretched hand

with the elbow driven into:

Hyperextension.

Extension Mechanism

During hyperextension, the:

Olecranon

acts as a fulcrum against the:

Olecranon fossa.

This concentrates force through the thin distal humeral metaphysis and produces:

Fracture.

Flexion Mechanism

Rarely, a direct fall onto a:

Flexed elbow

drives the distal fragment:

Anteriorly

and produces a:

Flexion-type supracondylar fracture.

Associated Conditions and Injuries

Important associated injuries include:

Ipsilateral forearm fracture

Brachial artery injury

and injuries to the:

Median

Anterior interosseous

Radial

or

Ulnar nerves.

Floating Elbow

A supracondylar fracture associated with an ipsilateral:

Forearm fracture

is sometimes called a:

Floating elbow.

This combination requires particularly careful monitoring for:

Compartment syndrome.

Diagnosis

Diagnosis is based on:

Trauma history

Physical examination

and

Radiographs.

Signs and Symptoms

Patients usually present after an acute injury with:

Severe elbow pain

Swelling

and refusal or inability to:

Move the arm.

Deformity

Displaced fractures may produce obvious:

Elbow deformity.

Ecchymosis

Bruising may develop in the:

Antecubital fossa

within several hours after injury.

Nerve Injury

Neurologic injury may present as inability to perform normal:

Finger

Thumb

or

Wrist movements.

Arterial Injury

Brachial artery compromise may produce:

Absent pulse

Pallor

Coolness

Delayed capillary refill

and, in severe ischemia,

Loss of motor function.

Physical Examination

The examination should be systematic and include:

Inspection

Palpation

Motor testing

Sensory testing

and careful:

Vascular assessment.

Swelling

Substantial swelling around the:

Elbow

is common.

Rapidly increasing swelling requires concern for:

Vascular injury or compartment syndrome.

Type III Deformity

A completely displaced fracture may create an:

S-shaped appearance

around the elbow and can sometimes resemble:

Elbow dislocation.

Skin Assessment

Inspect for:

Skin puckering

Tenting

Open injury

or threatened:

Skin viability.

Neurovascular Examination

A thorough neurovascular examination should be performed:

Before and after any reduction.

Documentation is essential because nerve and vascular injury are relatively:

Common.

Motor Examination

Motor testing should include the:

Median nerve

Anterior interosseous nerve

Radial nerve

and

Ulnar nerve.

Anterior Interosseous Nerve

The anterior interosseous nerve can be tested by asking the patient to make an:

“OK” sign

using the:

Thumb and index finger.

Weakness may produce a flattened:

Pinch posture.

Median Nerve

Median nerve motor function can be assessed by:

Thumb opposition

or finger flexion, depending on the child’s cooperation.

Radial Nerve

Ask the patient to:

Extend the wrist or fingers.

Ulnar Nerve

Ask the patient to:

Abduct or adduct the fingers

when cooperation permits.

Sensory Examination

Sensation should be tested in the:

Median

Radial

and

Ulnar nerve distributions.

Vascular Examination

Assess:

Radial pulse

Skin color

Temperature

and

Capillary refill.

Pulseless Hand

A child may have a:

Pulseless but well-perfused hand

after supracondylar fracture.

This situation requires urgent orthopaedic evaluation and careful reassessment after:

Reduction.

Poorly Perfused Hand

A pulseless hand that is:

Pale

Cool

or has poor capillary refill represents a:

Vascular emergency.

Compartment Syndrome

Severe pain with passive stretch of the:

Fingers

may indicate evolving:

Forearm compartment syndrome.

Other concerning findings include:

Increasing analgesic requirement

Tense swelling

and worsening:

Neurovascular status.

Imaging

Plain Radiographs

Standard:

AP

and

Lateral radiographs

of the distal humerus and elbow are usually sufficient.

Imaging Technique

Because the injured child may be unable to fully extend the elbow, imaging should be centered carefully on the:

Distal humerus.

Posterior Fat-Pad Sign

In an occult nondisplaced fracture, the only radiographic clue may be a:

Posterior fat-pad sign.

Visualization of a posterior fat pad after trauma strongly suggests:

Intra-articular fracture.

Anterior Humeral Line

On the lateral radiograph, the:

Anterior humeral line

should normally pass through the middle portion of the:

Capitellum.

Posterior displacement of the distal fragment may cause the line to pass anterior to the:

Capitellum.

Baumann Angle

The:

Baumann angle

on the AP radiograph can help assess:

Coronal alignment

and risk of:

Varus malunion.

Differential Diagnosis

Important alternative diagnoses include:

Elbow dislocation

Lateral condyle fracture

Medial condyle fracture

Intercondylar or bicondylar distal humerus fracture

and, in toddlers,

Distal humeral physeal injury.

Treatment

Treatment depends on:

Fracture displacement

Stability

Neurovascular status

and

Soft-tissue condition.

Initial Stabilization

Until definitive orthopaedic assessment, the elbow should be immobilized in a:

Well-padded splint

with the elbow in modest flexion.

Flexion During Initial Splinting

Approximately:

20–30° of elbow flexion

may be used when swelling or vascular status is concerning.

The goal is to avoid additional:

Displacement

and

Neurovascular compromise.

Excessive Flexion

Elbow flexion beyond approximately:

90°

can increase:

Forearm compartment pressure

and potentially compromise:

Brachial artery flow.

Therefore, excessive flexion should be avoided, particularly in:

Swollen displaced fractures.

Gartland Type I Treatment

Type I injuries are generally treated with:

Immobilization.

A long-arm splint or cast is typically used for approximately:

3 weeks

depending on healing and symptoms.

Gartland Type II Treatment

Type II injuries may be treated with:

Closed reduction

followed by:

Casting

or

Percutaneous pin fixation

depending on:

Alignment

Rotational stability

Swelling

and reliability of:

Cast position.

Gartland Type III Treatment

Type III injuries generally require:

Closed reduction and percutaneous pinning.

Gartland Type IV Treatment

Type IV fractures are multidirectionally unstable and typically require:

Operative reduction and pin fixation.

Analgesia

Pain control may include:

Acetaminophen

and, when necessary,

Short-term opioid analgesia.

Physical Therapy

Formal physical therapy is generally:

Not routinely required in children.

Most children recover elbow motion spontaneously after:

Fracture healing and cast removal.

Adult Rehabilitation

In adults, structured physical therapy is more commonly used because elbow stiffness is:

More problematic.

Surgery

Closed reduction should be attempted under appropriate:

Sedation or anesthesia

for displaced unstable fractures.

Reduction Goals

The goals are to restore:

Sagittal alignment

Coronal alignment

Rotation

and normal relationship of the:

Distal humeral fragments.

Open Reduction

Open reduction may be required when:

Closed reduction fails

or when there is concern for:

Entrapped soft tissue

Open fracture

Persistent vascular compromise

or another mechanical block.

Timing of Surgery

In a child with a well-perfused limb and no urgent complication, fixation can often be performed:

Urgently but not necessarily immediately overnight.

A delay of less than approximately:

24 hours

has not consistently been associated with worse outcomes when:

Neurovascular status is stable.

Percutaneous Pinning

Unstable fractures are commonly stabilized with:

Kirschner wires.

Lateral Pinning

Two or three:

Lateral-entry pins

can provide stable fixation while avoiding direct risk to the:

Ulnar nerve.

Crossed Pinning

Crossed medial and lateral pins may provide excellent:

Mechanical stability

but placement of a medial pin increases the risk of:

Iatrogenic ulnar nerve injury.

Pin Selection

The configuration is chosen according to:

Fracture pattern

Stability after reduction

and surgeon:

Preference.

Flexion-Type Fractures

Flexion-type supracondylar fractures are generally treated with:

Reduction and pin fixation

when significantly displaced.

Postoperative Immobilization

After fixation, the elbow is usually immobilized for approximately:

3–4 weeks.

Pin Removal

Percutaneous pins are commonly removed around:

3–4 weeks

once adequate healing is present, although timing may vary according to:

Fracture pattern

and

Radiographic healing.

Vascular Injury

After reduction and fixation, perfusion should be reassessed by examining:

Pulse

Capillary refill

Color

and

Temperature.

Persistent Poor Perfusion

If the hand remains:

Pulseless and poorly perfused

after reduction, urgent:

Vascular exploration

may be necessary.

Compartment Syndrome

Prompt recognition of vascular compromise and excessive swelling helps reduce the risk of:

Compartment syndrome.

If established compartment syndrome develops, urgent:

Fasciotomy

is required.

Follow-Up

Children require clinical and radiographic follow-up to verify:

Maintenance of reduction

and

Fracture healing.

Early Monitoring

Early follow-up should reassess:

Neurovascular status

Cast or splint condition

and

Alignment.

After Healing

Following fracture union, the patient should be assessed for:

Elbow motion

Carrying angle

and residual:

Deformity.

Prognosis

The prognosis is generally:

Excellent

when alignment and neurovascular status are restored promptly.

Motion Recovery

Most children gradually regain near-normal:

Elbow range of motion

without formal therapy.

Malunion

Poor alignment during healing may cause:

Angular deformity.

The most characteristic is:

Cubitus varus.

Complications

Nerve Injury

Transient nerve injuries are relatively common.

The:

Anterior interosseous branch of the median nerve

is frequently affected in extension-type injuries.

The:

Radial nerve

and

Ulnar nerve

may also be injured depending on:

Fracture displacement and type.

Nerve Recovery

Most traumatic neurapraxias recover spontaneously over:

Weeks to months.

Persistent deficits require further:

Evaluation.

Brachial Artery Injury

The:

Brachial artery

may be stretched, kinked, trapped, or injured by displaced fracture fragments.

Compartment Syndrome

Compromised arterial flow or severe swelling may lead to:

Forearm compartment syndrome.

Volkmann Ischemic Contracture

Untreated compartment syndrome can result in:

Volkmann ischemic contracture

with permanent:

Muscle fibrosis

Joint contracture

and

Neurologic dysfunction.

Cubitus Varus

Malunion can produce:

Cubitus varus

or a:

Gunstock deformity.

This is primarily caused by:

Coronal and rotational malalignment

rather than growth disturbance.

Elbow Stiffness

Temporary stiffness is common after immobilization, but persistent stiffness is relatively:

Uncommon in children

when the fracture heals in good alignment.

Trochlear Osteonecrosis

Rarely, vascular disturbance of the trochlea may produce:

Osteonecrosis

and a late:

Fishtail deformity.

Iatrogenic Ulnar Nerve Injury

Medial pin placement can injure the:

Ulnar nerve.

This risk is reduced when fixation can be achieved using:

Lateral-entry pins alone.

Patient Monitoring

Patients should be monitored for:

Pain

Swelling

Neurovascular status

Alignment

Fracture healing

and recovery of:

Elbow motion.

Key Principle

Supracondylar humerus fracture is a common pediatric elbow injury occurring through the distal humeral metaphysis, usually after a fall on an outstretched hand with hyperextension.

The most widely used classification is the:

Gartland system, ranging from Type I nondisplaced fractures to Type IV multidirectionally unstable injuries.

The most important early concern is:

Neurovascular injury, particularly involving the brachial artery and anterior interosseous, median, radial, or ulnar nerves.

Type I fractures are usually treated with:

Immobilization, whereas displaced unstable Type II, Type III, and Type IV fractures commonly require:

Closed reduction and percutaneous pin fixation.

Major complications include:

Nerve palsy, vascular compromise, compartment syndrome, Volkmann ischemic contracture, cubitus varus, and rare trochlear osteonecrosis.

Orthopaedic Surgery - Subungual Hematoma

Basics

A subungual hematoma is a:

Collection of blood beneath the nail plate

and above the:

Nail bed

of a finger or toe.

It usually follows:

Blunt trauma

that injures the underlying nail-bed soft tissues while the nail plate remains:

Intact or largely intact.

Pain Mechanism

Blood trapped beneath the rigid nail plate creates:

Pressure

against the sensitive:

Nail bed and distal phalanx.

This can produce:

Severe throbbing pain.

Nail-Bed Injury Patterns

Underlying nail-bed injury may consist of:

Simple linear laceration

Stellate laceration

or

Crush injury.

Epidemiology

Subungual hematoma is one of the most common:

Distal digit injuries

seen in:

Emergency departments

and

Outpatient practice.

Age

The injury commonly affects:

Older children

Adolescents

and

Young adults

although it can occur at:

Any age.

Most Commonly Injured Digit

The:

Middle finger

is commonly injured because it projects farther than the adjacent digits and is frequently exposed to:

Crush trauma.

Etiology

The usual cause is:

Blunt trauma to the distal phalanx.

Common Mechanisms

Typical mechanisms include:

Finger caught in a door

Crushing between two objects

Impact from a heavy object

and injuries involving:

Tools or machinery.

Associated Conditions

The most important associated injury is:

Distal phalanx fracture.

Nail-bed laceration may also coexist with:

Crush injury

or

Open fracture.

Diagnosis

Diagnosis is usually based on:

History

and

Physical examination.

Signs and Symptoms

Patients typically present shortly after injury with:

Localized distal finger or toe pain

and a clear history of:

Trauma.

Pain

Pain is often:

Throbbing

and may be disproportionately severe because of:

Pressure beneath the nail plate.

Visible Hematoma

Inspection reveals a:

Dark red

Purple

or

Black discoloration

visible beneath the:

Nail plate.

Nail Deformity

A nail deformity is usually a:

Late finding

and may indicate a previously unrecognized:

Nail-bed injury

or disruption of the:

Nail matrix.

Physical Examination

The examination should evaluate:

Nail integrity

Nail-fold disruption

Extent of hematoma

Tenderness

Swelling

and

Neurovascular status.

Nail Plate

Determine whether the nail plate is:

Intact

Split

Displaced

or detached from the:

Nail folds.

Nail Folds

Inspect the:

Eponychial fold

and

Lateral nail folds

for:

Laceration

or disruption.

Distal Phalanx

Diffuse swelling and marked bony tenderness raise concern for:

Associated distal phalanx fracture.

Neurovascular Examination

Document:

Sensation

Capillary refill

and distal:

Perfusion.

Imaging

Plain Radiographs

Radiographs should be considered when there is concern for:

Distal phalanx fracture

based on mechanism, tenderness, deformity, or substantial crush injury.

Recommended Views

Typical imaging includes:

AP

Lateral

and

Oblique views

of the affected digit.

Differential Diagnosis

Important alternatives include:

Distal phalanx contusion

Distal phalanx fracture without subungual bleeding

Subungual melanoma

and

Pyogenic granuloma.

Subungual Melanoma

A dark lesion under the nail without a convincing history of:

Trauma

or one that persists and evolves should raise concern for:

Melanocytic pathology.

Pyogenic Granuloma

A pyogenic granuloma may develop near the:

Nail fold

and can bleed easily.

It may follow:

Minor penetrating trauma

or manipulation of the:

Cuticle.

Treatment

Management depends on:

Pain

Nail integrity

Associated fracture

and evidence of:

Nail-bed disruption.

General Measures

A painful acute subungual hematoma beneath an intact nail can usually be treated with:

Trephination.

The purpose is to:

Decompress the hematoma

and rapidly reduce:

Pain.

Trephination

Trephination creates one or more small openings in the:

Nail plate

allowing trapped blood to:

Drain.

Modern Size Considerations

Historically, hematomas involving more than approximately:

50% of the nail surface

were treated with nail removal and nail-bed repair.

Modern practice is less dependent on:

Hematoma size alone.

If the nail plate and nail folds are intact and there is no displaced fracture or obvious nail-bed disruption, even a:

Large hematoma

may often be managed successfully with:

Simple trephination.

Indications for Trephination

Trephination is most useful when the hematoma is:

Acute

Painful

and the nail plate remains:

Intact.

Timing

Trephination is most effective during the:

First 24–48 hours

before the blood becomes extensively:

Clotted.

Preparation

The digit and nail should be cleaned using:

Sterile or clean antiseptic technique.

Anesthesia

A digital nerve block is usually:

Not required

for uncomplicated trephination because the nail plate itself is:

Insensitive.

Trephination Methods

The nail may be decompressed using:

Electrocautery

or a carefully rotated:

Large-bore needle.

Electrocautery

A battery-powered cautery device can rapidly create a hole through the:

Nail plate.

The operator stops as soon as blood begins to:

Drain.

Needle Technique

A needle may be rotated gently through the nail plate until the:

Hematoma cavity

is reached.

Care should be taken to avoid injuring the underlying:

Nail bed.

Number of Holes

Usually:

One or two openings

are sufficient for drainage.

Additional openings may be created if drainage remains:

Incomplete.

Pain Relief

Successful decompression typically produces:

Rapid and substantial pain relief.

When Nail Removal Is Appropriate

Nail removal and direct nail-bed inspection may be indicated when there is:

Nail avulsion

Nail-fold disruption

Major nail-plate laceration

Displaced distal phalanx fracture

or obvious:

Nail-bed injury requiring repair.

Associated Fracture

A nondisplaced distal phalanx fracture may be treated with:

Protective splinting

in addition to management of the:

Nail injury.

Displaced Fracture

A displaced fracture may require:

Reduction

and occasionally:

Operative fixation.

Activity

Activity may continue:

As tolerated

provided the injured digit is adequately:

Protected.

Protective Splinting

Patients with associated fracture or substantial fingertip tenderness may benefit from a:

Tip protector

or

Distal phalanx splint.

Physical Therapy

Formal therapy is rarely needed for an uncomplicated:

Subungual hematoma.

Hand Therapy

A hand therapist may provide a custom:

Fingertip protector

when hypersensitivity interferes with:

Work or activity.

Medication

Pain control may include:

Acetaminophen

or

NSAIDs

when medically appropriate.

Antibiotics

Routine prophylactic antibiotics are generally:

Not necessary

after uncomplicated trephination or a clean closed injury.

They may be considered when there is:

Open contamination

Significant soft-tissue injury

or another specific infection-related indication.

Nail-Bed Repair

When a significant nail-bed laceration requires repair, the nail plate may need to be:

Removed.

Anesthesia for Repair

A:

Digital nerve block

provides adequate regional anesthesia for most:

Nail-bed repairs.

Nail Removal

The distal nail edge is gently elevated and separated from the:

Nail bed

and

Eponychial fold

while minimizing additional:

Tissue trauma.

Irrigation

The wound should be thoroughly:

Irrigated

before repair.

Nail-Bed Suturing

Nail-bed lacerations are typically repaired using:

Fine absorbable sutures

such as approximately:

6-0 or 7-0 material.

Nail-Fold Splinting

After nail removal, maintaining the space beneath the:

Proximal nail fold

can help prevent adhesions and later:

Nail deformity.

Nail Replacement

The original nail plate may sometimes be replaced as a:

Biologic splint

if sufficiently intact.

Alternative Splint

If the native nail cannot be used, an appropriate sterile substitute may be placed beneath the:

Eponychial fold.

Dressing

The nail bed should be covered with a:

Nonadherent dressing

followed by protective:

Gauze or fingertip dressing.

Follow-Up

Follow-up depends on the:

Severity of injury.

After Simple Trephination

Patients treated by trephination alone often require only:

As-needed follow-up

if symptoms rapidly improve.

After Nail-Bed Repair

Patients undergoing nail-bed repair should generally be reviewed within approximately:

1 week.

Wound Care

Patients should keep the digit:

Clean

and monitor for:

Increasing redness

Drainage

Swelling

or

Fever.

Prognosis

The prognosis is generally:

Excellent

when associated nail-bed and bony injuries are identified and treated appropriately.

Nail Regrowth

A fingernail may require several:

Months

to grow completely.

Toenails generally take:

Longer.

Complications

Nail Deformity

Damage to the nail bed or matrix may lead to:

Ridging

Fissuring

Splitting

or abnormal:

Nail growth.

Eponychial Adhesions

Failure to preserve the space beneath the:

Eponychial fold

after nail removal may result in:

Adhesion formation

and subsequent:

Nail deformity.

Split Nail

A poorly healed nail-bed laceration may cause a:

Split nail

or a nail that does not adhere normally to the:

Nail bed.

Infection

Infection is uncommon with proper:

Wound care.

However, contaminated injuries or improper drainage can occasionally lead to:

Soft-tissue infection

or

Osteomyelitis.

Persistent Pain

Persistent pain after decompression should raise concern for:

Associated fracture

Incomplete drainage

or another:

Underlying injury.

Patient Monitoring

Patients should be monitored for:

Pain relief

Wound healing

Infection

and normal:

Nail regrowth.

Key Principle

A subungual hematoma is a collection of blood beneath the nail plate following trauma to the nail bed, often producing:

Severe throbbing pain from pressure within the confined nail space.

For an acute painful hematoma with an intact nail and nail folds, treatment usually consists of:

Simple nail trephination, which provides rapid decompression and pain relief.

The historical rule that hematomas involving more than:

50% of the nail

require nail removal is no longer applied rigidly; management depends more on:

Nail integrity, nail-fold injury, associated fracture, and evidence of significant nail-bed disruption.

Nail removal and repair are reserved for injuries with:

Avulsion, major nail disruption, displaced fracture, or a clearly repairable nail-bed laceration.

The overall prognosis is:

Excellent, although inadequately treated nail-bed injuries may lead to:

Permanent nail deformity.

Orthopaedic Surgery - Subtrochanteric Fracture

⸻

Basics

A subtrochanteric fracture is a fracture of the proximal femur occurring between the:

Lesser trochanter

and a point approximately:

5 cm distal to it.

This region is subjected to very high:

Compressive

and

Tensile forces

during normal weight bearing.

⸻

Classification

Numerous classification systems have been described.

From a practical and prognostic standpoint, one of the most important characteristics is:

Fracture stability.

⸻

Stable Versus Unstable Fracture

Stability depends largely on preservation of the:

Medial

and

Posteromedial cortices.

These regions normally resist substantial:

Compressive loading.

⸻

Unstable Fracture

Comminution of the:

Medial or posteromedial cortex

removes an important structural buttress and makes the fracture:

Mechanically unstable.

This increases the risk of:

Varus collapse

Loss of fixation

and

Nonunion.

⸻

General Prevention

Preventive measures include:

Fall prevention in older adults

and

Seat-belt use in motor vehicles.

⸻

Bone Health

Because many low-energy subtrochanteric fractures occur in patients with weakened bone, appropriate evaluation and treatment of:

Osteoporosis

and other metabolic bone disorders can reduce future:

Fragility fracture risk.

⸻

Epidemiology

Subtrochanteric fractures demonstrate a:

Bimodal age distribution.

⸻

Younger Patients

Approximately:

One-third

occur in patients younger than or equal to:

50 years.

These injuries are typically caused by:

High-energy trauma.

⸻

Older Patients

In geriatric patients, subtrochanteric fractures more commonly follow:

Low-energy trauma

such as a:

Fall from standing height.

⸻

Incidence

Historical series report that subtrochanteric fractures account for approximately:

10–34% of proximal femoral or hip fractures.

Reported percentages vary according to how the:

Subtrochanteric region

is defined.

⸻

Risk Factors

Any disorder that decreases:

Bone strength

may predispose to subtrochanteric fracture.

⸻

Generalized Bone Weakness

Examples include:

Osteoporosis

Osteomalacia

and other:

Metabolic bone diseases.

⸻

Focal Bone Weakness

Local structural weakening may occur with:

Metastatic disease

Primary bone tumor

Fibrous dysplasia

or other focal:

Bone lesions.

⸻

Etiology

The injury mechanism differs according to:

Age

and

Bone quality.

⸻

High-Energy Trauma

In young patients with normal bone, common mechanisms include:

Motor vehicle collisions

Falls from significant height

and

Gunshot wounds.

⸻

Low-Energy Trauma

In older patients with osteoporotic bone, a minor fall may generate sufficient force to produce a:

Subtrochanteric fracture.

⸻

Pathological Fracture

A pathological fracture may occur when structurally abnormal bone can no longer tolerate:

Normal physiologic loading.

Potential causes include:

Metastatic carcinoma

Multiple myeloma

Primary bone tumor

and

Metabolic bone disease.

⸻

Biomechanics

The subtrochanteric region experiences some of the highest mechanical forces in the:

Femur.

This contributes to both:

Fracture instability

and the risk of:

Fixation failure.

⸻

Associated Injuries

High-energy subtrochanteric fractures may occur with injuries involving:

The ipsilateral femur

Hip

Pelvis

Spine

Head

or other body regions.

⸻

Trauma Evaluation

Patients with a high-energy mechanism require a:

Complete trauma assessment.

⸻

Hemorrhage

Femoral fractures can be associated with substantial:

Blood loss.

Patients should be monitored for:

Hemodynamic instability

and

Hypovolemic shock.

⸻

Thigh Compartment Syndrome

Compartment syndrome of the thigh is:

Rare

but possible after severe trauma.

Increasing pain, tense swelling, and neurologic abnormalities should prompt:

Urgent evaluation.

⸻

Suspicion for Pathological Fracture

An underlying neoplasm or bone disorder should be considered when the fracture occurs after:

Minimal trauma

or when the patient reports preceding:

Thigh pain

Hip pain

or

Limp.

⸻

Biopsy

If a pathological lesion is suspected, the diagnostic plan should be established before definitive fixation.

In selected cases, this may include:

Biopsy

performed in a manner consistent with future:

Oncologic treatment.

⸻

Diagnosis

The clinical presentation often resembles a:

Femoral shaft

or

Intertrochanteric fracture.

⸻

Signs and Symptoms

Typical findings include:

Severe proximal thigh or hip pain

Swelling

Deformity

and inability to:

Bear weight.

⸻

Nondisplaced Fractures

Some fractures may initially be:

Nondisplaced

and therefore produce less obvious:

Deformity.

⸻

History

The usual history includes:

Trauma

or

Fall.

In pathological fractures, trauma may be:

Minimal or absent.

⸻

Physical Examination

The injured extremity often appears:

Shortened

and the thigh may be:

Swollen.

⸻

Deformity

Varus and rotational deformity may be apparent because of the powerful:

Muscle forces

acting across the fracture.

⸻

Neurovascular Examination

A complete neurovascular examination should document:

Motor function

Sensation

Peripheral pulses

and

Capillary refill.

⸻

Open Fracture

The skin should be examined carefully to exclude:

Open injury.

Even a small wound may communicate with the:

Fracture.

⸻

Laboratory Tests

⸻

Complete Blood Count

A CBC is useful to evaluate:

Hemoglobin

and

Hematocrit

because significant blood loss may accompany:

Femoral fractures.

⸻

Preoperative Testing

Patients likely to undergo surgery should receive appropriate:

Preoperative laboratory evaluation

based on age and:

Medical comorbidity.

⸻

Multiple Myeloma Evaluation

When a pathological fracture is suspected, selected testing may include:

Serum protein electrophoresis

and

Urine protein electrophoresis

to evaluate for:

Plasma-cell disorders.

⸻

Imaging

⸻

Plain Radiographs

Imaging should include:

AP pelvis

AP hip

Lateral hip

and

Full-length AP and lateral femur radiographs.

⸻

Entire Femur Imaging

The entire femur should be visualized because associated fractures may occur and because definitive fixation often requires knowledge of:

Femoral anatomy.

⸻

Femoral Neck

The femoral neck should be assessed carefully for an associated:

Ipsilateral femoral neck fracture.

This is particularly important after:

High-energy trauma.

⸻

Cross-Table Lateral

A:

Cross-table lateral hip view

is preferred in the acute setting.

A frog-leg lateral should generally be avoided because positioning can cause:

Pain

and potentially worsen:

Fracture displacement.

⸻

CT

CT may be useful in selected complex injuries to define:

Fracture morphology

or associated:

Pelvic or proximal femoral injury.

⸻

Pathophysiology of Deformity

Characteristic deformity occurs because the proximal and distal fragments are pulled in different directions by:

Muscle forces.

⸻

Proximal Fragment

The proximal femoral fragment is typically pulled into:

Flexion

Abduction

and

External rotation.

⸻

Flexion

The:

Iliopsoas

pulls the proximal fragment into:

Flexion.

⸻

Abduction

The:

Gluteus medius and minimus

contribute to proximal fragment:

Abduction.

⸻

External Rotation

The short external rotators contribute to:

External rotation

of the proximal fragment.

⸻

Distal Fragment

The distal fragment is pulled:

Proximally

and often into:

Adduction and varus.

⸻

Shortening

Muscular pull across the fracture produces:

Femoral shortening.

⸻

Varus Deformity

Loss of medial support and muscular forces predispose the fracture to:

Varus malalignment.

Recognition of these predictable deforming forces is important during:

Fracture reduction.

⸻

Differential Diagnosis

The major distinction is between:

Traumatic fracture

and

Pathological fracture.

⸻

Additional Differential Considerations

Other proximal femoral injuries include:

Intertrochanteric fracture

Femoral neck fracture

and

Proximal femoral shaft fracture.

⸻

Treatment

⸻

General Measures

Initial management follows standard principles of:

Trauma stabilization.

⸻

ATLS

For patients with major trauma, evaluation should follow:

ATLS principles

with treatment of immediately life-threatening conditions before definitive:

Fracture fixation.

⸻

Temporary Stabilization

Temporary immobilization may help reduce:

Pain

Bleeding

and further:

Soft-tissue injury.

⸻

Traction

Skeletal traction was historically used when definitive fixation was delayed or when nonoperative treatment was planned.

Modern practice generally favors:

Early surgical fixation

when medically feasible.

⸻

Nonoperative Treatment

Nonoperative management is uncommon and is usually reserved for:

Patients who cannot tolerate surgery

or other exceptional situations.

⸻

Limitations of Nonoperative Care

Traction or cast bracing frequently leads to:

Shortening

Rotational deformity

Varus malunion

Delayed union

or

Nonunion.

⸻

Medical Optimization

Important perioperative issues include:

Fluid and blood-volume management

Venous thromboembolism prophylaxis

Pain control

and treatment of:

Pre-existing medical conditions.

⸻

Venous Thromboembolism Prevention

Appropriate prophylaxis should be planned while considering the timing of:

Definitive surgery.

⸻

Activity

Before definitive stabilization, the patient is generally:

Non-weight-bearing.

⸻

Postoperative Weight Bearing

Weight-bearing recommendations depend on:

Fracture stability

Quality of reduction

Fixation construct

and

Bone quality.

⸻

Younger Patients

Historically, younger patients were often started with:

Toe-touch or protected weight bearing

using:

Crutches

or

A walker

during the early postoperative period.

Progression toward full weight bearing was guided by:

Clinical and radiographic healing.

⸻

Older Patients

Older patients are often allowed:

Weight bearing as tolerated

after stable fixation because prolonged restriction may be difficult and can increase:

Medical complications.

⸻

Physical Therapy

Rehabilitation should begin early after stabilization.

⸻

Range of Motion

Patients can usually begin:

Hip

and

Knee range-of-motion exercises

during the early postoperative period.

⸻

Strengthening

Progressive strengthening emphasizes:

Hip abductors

Quadriceps

and overall:

Lower-extremity function.

⸻

Gait Training

Physical therapy also includes:

Transfer training

Walking with assistive devices

and progression toward:

Independent mobility.

⸻

Medication

Significant acute pain often requires:

Short-term opioid analgesia.

⸻

Multimodal Pain Control

Whenever possible, pain treatment should use:

Multimodal analgesia

including:

Acetaminophen

and other appropriate adjuncts to reduce reliance on:

Opioids.

⸻

Surgery

Operative fixation is the treatment of choice for most:

Subtrochanteric fractures.

⸻

Goals of Surgery

The major objectives are to restore:

Femoral length

Rotational alignment

and

Coronal alignment

while preserving the:

Hip abductor lever arm.

⸻

Varus Prevention

Avoidance of:

Varus malreduction

is particularly important because varus increases mechanical stress across:

The fracture

and

Implant.

⸻

Intramedullary Fixation

Modern treatment most commonly uses a:

Cephalomedullary intramedullary nail.

This fixation method places the implant closer to the mechanical axis of the:

Femur

and is advantageous for many:

Unstable fracture patterns.

⸻

Cephalomedullary Nail

A cephalomedullary nail usually includes:

Proximal fixation into the femoral head and neck

and

Distal locking screws.

⸻

Posteromedial Comminution

Cephalomedullary fixation is particularly useful when there is:

Loss of posteromedial cortical support.

⸻

Interlocking Nail

Static interlocking nails may be used in selected patterns when the:

Proximal trochanteric anatomy

permits stable fixation.

⸻

Plate Fixation

A:

95° angled blade plate

is a historical and still occasionally useful option for selected complex fractures or:

Revision procedures.

⸻

Mechanical Environment

Because the subtrochanteric femur experiences high:

Tensile

and

Compressive forces

implant fatigue is a major concern when reduction is poor or healing is:

Delayed.

⸻

Reduction Quality

Successful fixation depends heavily on obtaining:

Near-anatomic alignment

especially restoration of the:

Medial cortex

and avoidance of:

Varus.

⸻

Pediatric Considerations

Subtrochanteric femur fractures are relatively uncommon in:

Children.

⸻

Mechanism in Children

Unless bone is weakened by disorders such as:

Simple bone cyst

Fibrous dysplasia

or

Osteoporosis

these fractures generally result from:

High-energy trauma.

⸻

Femoral Head Blood Supply

Unlike femoral neck fractures, typical pediatric subtrochanteric fractures do not directly endanger the:

Femoral head blood supply.

⸻

Leg-Length Discrepancy

Children may develop:

Leg-length discrepancy

even when no obvious physeal injury is present.

⸻

Rotational Alignment

Attention to:

Leg length

and

Femoral rotation

is especially important during pediatric treatment.

⸻

Pediatric Treatment Options

Treatment may include:

Closed reduction with spica casting

External fixation

or

Internal fixation

depending on:

Age

Fracture pattern

and

Body size.

⸻

Pediatric Intramedullary Nailing

In skeletally immature patients, traditional piriformis-entry rigid nails may endanger the:

Femoral head blood supply.

Alternative entry points or fixation methods are therefore preferred when the:

Proximal femoral physis remains open.

⸻

Follow-Up

Patients should be reviewed soon after:

Surgical fixation.

⸻

Early Review

An initial follow-up around:

1–2 weeks

may assess:

Wound healing

Alignment

and

Implant position.

⸻

Serial Follow-Up

Subsequent visits monitor:

Pain

Weight-bearing progression

Fracture callus

and evidence of:

Union.

⸻

Radiographic Monitoring

Radiographs are typically repeated at regular intervals until:

Solid healing

is demonstrated.

⸻

Prognosis

With appropriate reduction and stable fixation, many patients can return toward their:

Preinjury level of activity.

⸻

Older Patients

In frail geriatric patients, prognosis is also strongly influenced by:

Age

Comorbidities

and

Prefracture mobility.

Historical series of low-energy fractures have demonstrated substantial:

One-year mortality

and loss of:

Independence.

⸻

Historical Outcomes

One older series of patients treated with cephalomedullary nails reported approximately:

34.5% mortality at 1 year.

Among survivors, increased use of:

Walking aids

and greater:

Social dependence

were common.

These values reflect a frail historical population and should not be interpreted as a universal prognosis for every patient.

⸻

Residual Pain

Some survivors continue to experience:

Hip discomfort

although severe disabling pain is less common.

⸻

Reoperation

Historical data have reported reoperation in approximately:

9%

of patients in some geriatric cohorts.

⸻

Nonunion

Nonunion is uncommon with appropriate fixation but remains an important complication because of the high mechanical stresses in this region.

Historical reports have described rates around:

2%

in some modern nail series.

⸻

Complications

The principal complications include:

Nonunion

Malunion

Shortening

and

Implant failure.

⸻

Nonunion

Nonunion should be suspected when there is persistent:

Pain

Tenderness

and lack of radiographic progression toward healing over:

Several months.

⸻

Timing

Persistent symptoms and absent healing at approximately:

3–6 months

may raise concern for:

Delayed union or nonunion.

⸻

Risk Factors for Nonunion

Important factors include:

Varus malreduction

Medial cortical deficiency

Poor fixation

Smoking

Poor bone biology

and premature:

Excessive loading.

⸻

Malunion

Malunion may result in:

Limp

Rotational deformity

Varus alignment

and

Leg-length discrepancy.

⸻

Shortening

Loss of fracture alignment may produce:

Femoral shortening

and compromise:

Gait mechanics.

⸻

Implant Failure

Hardware failure is more likely when the fracture remains:

Unstable

or develops:

Nonunion.

⸻

Plate Failure

Plate constructs may fail through:

Screw pullout

especially in:

Osteoporotic bone.

Revision may require conversion to an:

Intramedullary device

with restoration of:

Alignment and biology.

⸻

Intramedullary Nail Failure

Potential causes include:

Inadequate distal locking

Undersized nail

Poor reduction

and

Fracture extension near the entry site.

⸻

Distal Cortical Penetration

An intramedullary nail may occasionally penetrate the:

Anterior distal femoral cortex

particularly when there is a mismatch between the:

Femoral bow

and

Implant geometry.

⸻

Revision Surgery

Symptomatic nonunion or malunion may require:

Revision fixation

Bone grafting

and occasionally:

Corrective valgus osteotomy.

⸻

Osteotomy

A valgus-producing osteotomy may improve mechanical loading by converting excessive:

Shear forces

into more favorable:

Compressive forces.

⸻

Pediatric Osteonecrosis

Osteonecrosis of the femoral head is uncommon in the fracture itself but may occur in a child if a rigid intramedullary nail is introduced through the:

Piriformis fossa

while the proximal femoral blood supply remains vulnerable.

⸻

Patient Monitoring

Follow-up should assess:

Pain

Wound healing

Neurovascular status

Alignment

Leg length

Rotation

Weight-bearing ability

and progression toward:

Fracture union.

⸻

Key Principle

A subtrochanteric fracture is a proximal femoral fracture extending from the lesser trochanter to approximately 5 cm distally.

The region experiences very high:

Mechanical forces, and loss of the medial or posteromedial cortex makes the fracture particularly:

Unstable.

Young patients usually sustain these injuries through:

High-energy trauma, whereas older patients typically sustain them after:

Low-energy falls in osteoporotic bone.

Most fractures are treated surgically, commonly with a:

Cephalomedullary intramedullary nail, with the goals of restoring:

Femoral length, rotation, and alignment while avoiding varus deformity.

Important complications include:

Nonunion, malunion, shortening, implant failure, and persistent functional impairment.

Orthopaedic Surgery - Subacromial Injection

Basics

Subacromial injection is a commonly used office-based procedure designed to:

Reduce pain and inflammation

within the:

Subacromial space.

By improving pain and shoulder motion, the injection may allow patients to participate more effectively in:

Physical therapy

and regain:

Strength and function.

Role of Exercise

Injection therapy is generally more effective when combined with:

Exercise-based rehabilitation.

Physical therapy helps address:

Rotator cuff weakness

Scapular dyskinesis

and limitations in:

Range of motion.

Common Uses

Subacromial injection is commonly used for:

Rotator cuff tendinopathy

Calcific tendinopathy

Subacromial bursitis

Subacromial impingement

and selected cases of:

Adhesive capsulitis.

Diagnostic and Therapeutic Uses

The injection may be used as:

A therapeutic treatment

or

A diagnostic test.

Therapeutic Injection

Therapeutic injections usually include:

Corticosteroid

with or without:

Local anesthetic.

The primary goal is reduction of:

Pain and inflammation.

Diagnostic Injection

A local anesthetic such as:

Lidocaine

may be used to determine whether the patient’s symptoms originate from the:

Subacromial space.

Marked short-term pain relief after injection supports the diagnosis of a:

Subacromial pain generator.

Emerging Injectates

Other agents such as:

Platelet-rich plasma

and

Hyaluronic acid

have been investigated for shoulder disorders.

Their role in routine subacromial treatment remains:

Less established than corticosteroid injection.

Multimodal Treatment

Subacromial injection is usually used after or together with:

Physical therapy

NSAIDs

Activity modification

and other:

Nonoperative measures.

Injection Approaches

Common approaches include:

Posterior

Lateral

and

Anterior approaches.

Posterior and lateral approaches are particularly common and generally demonstrate:

Similar clinical effectiveness.

Ultrasound Guidance

Ultrasound may be used to improve confidence that the needle enters the:

Subacromial-subdeltoid bursa.

Landmark-guided injections can also be effective when performed by an:

Experienced clinician.

Indications

Potential indications include:

Subacromial bursitis

Rotator cuff tendinopathy

Partial rotator cuff tears

Subacromial impingement

Painful os acromiale

and selected cases of:

Calcific tendinopathy.

Adhesive Capsulitis

Subacromial injection may occasionally be used in patients with:

Adhesive capsulitis.

However, because the primary pathology is within the:

Glenohumeral capsule

an:

Intra-articular glenohumeral injection

may be more directly beneficial.

Rotator Cuff Tears

Subacromial injection can reduce associated:

Bursal inflammation

and

Pain.

However, it does not repair the underlying:

Tendon tear.

Treatment

General Measures

Nonoperative treatment is usually attempted before surgery.

A typical program includes:

Activity modification

Physical therapy

NSAIDs

and, when appropriate,

Subacromial corticosteroid injection.

Physical Therapy Focus

Rehabilitation commonly emphasizes:

Periscapular stabilization

Rotator cuff strengthening

and restoration of:

Shoulder motion.

Diagnostic Value of Injection

The patient’s shoulder should ideally be examined:

Before

and

After injection.

This helps determine which symptoms improve after the anesthetic takes effect.

Persistent Weakness After Injection

If pain improves but:

Objective weakness persists

a structural lesion such as a:

Rotator cuff tear

should be considered.

Inflammation

Inflammation after tissue injury involves:

Increased blood flow

Capillary permeability

and recruitment of:

Inflammatory cells.

This contributes to:

Edema

Pain

and local tissue irritation.

Corticosteroid Mechanism

Corticosteroids suppress multiple components of the:

Inflammatory response.

They reduce:

Capillary dilation

Inflammatory-cell recruitment

and release of various:

Inflammatory mediators and enzymes.

Common Corticosteroids

Agents commonly used include:

Methylprednisolone acetate

Triamcinolone acetonide

and

Dexamethasone.

Local Anesthetics

Common local anesthetics include:

Lidocaine

and

Bupivacaine.

These provide:

Short-term analgesia

and can assist with the:

Diagnostic response.

Physical Therapy

Injection should usually serve as an adjunct to:

Rehabilitation

rather than a replacement for it.

Combining injection with therapy may improve:

Pain

Motion

and

Functional recovery.

Medication

A variety of corticosteroid and local anesthetic combinations may be used.

Choice depends on:

Clinician preference

Patient factors

and institutional:

Practice.

Procedure

Subacromial injection should be performed using:

Sterile technique.

Required Equipment

Typical equipment includes:

Sterile gloves

Skin antiseptic

Syringe

Appropriate-gauge needle

Corticosteroid

and optionally:

Local anesthetic.

Skin Preparation

The skin may be prepared with agents such as:

Chlorhexidine

Povidone-iodine

or

Alcohol.

Consent

Before the procedure, informed consent should address:

Expected benefits

Alternatives

and potential:

Risks and complications.

Local Skin Anesthesia

A cooling spray or small amount of:

Local anesthetic

may be used before the main injection.

When local anesthetic is infiltrated into the skin, a small wheal can be raised with a:

Fine needle.

Patient Position

The patient is usually:

Seated upright

with the arm relaxed and hanging at the:

Side.

This position facilitates access to the:

Subacromial space.

Landmark Identification

The border of the:

Acromion

is palpated.

For posterior or lateral injections, the needle is introduced just:

Inferior to the acromial margin.

Posterior Approach

In the posterior approach, the needle is directed into the:

Subacromial space

from the posterolateral aspect of the shoulder.

Lateral Approach

In the lateral approach, the needle is passed beneath the:

Lateral edge of the acromion

toward the:

Subacromial bursa.

Ultrasound-Guided Technique

Ultrasound can visualize:

Needle position

and

Bursal distention

during injection.

It may be particularly useful in patients with:

Altered anatomy

or after an unsuccessful landmark-guided:

Procedure.

Aspiration Before Injection

Before injecting, the clinician should:

Aspirate gently

to reduce the chance of injecting directly into a:

Blood vessel.

Injection Resistance

A correctly positioned needle should generally encounter:

Minimal resistance.

If marked resistance is felt, the needle should be:

Withdrawn slightly and repositioned.

Injection Volume

Historical techniques commonly use a combined injectate volume of approximately:

6–10 mL

including:

Local anesthetic and corticosteroid.

Actual volume varies according to the:

Medication and technique.

Completion

After injection, the needle is removed and the site is covered with a:

Small dressing.

Postinjection Examination

The shoulder may be reassessed approximately:

5–10 minutes later

once the local anesthetic has taken effect.

Interpretation of Immediate Response

Improved:

Pain

Range of motion

or

Strength limited previously by pain

supports a:

Subacromial pain source.

Persistent Weakness

Persistent true weakness despite adequate analgesia may suggest:

Rotator cuff tearing

or another:

Neuromuscular abnormality.

Follow-Up

The patient’s subsequent response should be assessed over:

Days to weeks.

Pain Journal

Patients may record:

Pain intensity

Duration of relief

and improvement in:

Activity and sleep

after the injection.

Prognosis

Outcome depends on the:

Underlying diagnosis.

Subacromial Impingement

For subacromial pain syndromes, corticosteroid injection alone or combined with:

Physical therapy

can provide substantial improvement in many patients.

Benefits are often greatest for:

Short-term pain relief

and facilitation of:

Rehabilitation.

Long-Term Effect

Long-term outcome is influenced more by:

Underlying pathology

Exercise adherence

and correction of:

Biomechanical factors

than by the injection alone.

Complications

Complications are generally:

Uncommon.

Infection

Iatrogenic infection is rare but potentially serious.

Strict:

Sterile technique

is therefore essential.

Hematoma

Patients taking:

Anticoagulants

or those with a:

Bleeding disorder

may have an increased risk of:

Bruising or hematoma.

Skin Hypopigmentation

Corticosteroid injection may cause localized:

Skin depigmentation

particularly when medication is deposited too:

Superficially.

Subcutaneous Fat Atrophy

Local corticosteroid exposure may also cause:

Subcutaneous fat atrophy

near the injection site.

Tendon Effects

Repeated corticosteroid exposure may adversely affect:

Rotator cuff tendon quality.

Experimental and clinical data suggest possible reduction in:

Tendon strength

and impaired:

Healing potential.

Surgical Considerations

Recent corticosteroid injection may also be relevant when planning:

Rotator cuff repair

or

Shoulder arthroplasty

because timing may influence:

Infection risk

and

Tendon healing.

Hyperglycemia

Corticosteroids may cause a transient rise in:

Blood glucose.

Patients with:

Diabetes mellitus

should be warned about this possibility and may require closer:

Glucose monitoring.

Contraindications and Precautions

Local Skin Infection

Injection should not be performed through an area of:

Cellulitis

Open wound

or

Skin breakdown.

Unstable Coagulopathy

Significant uncontrolled bleeding abnormalities are a:

Contraindication

until appropriately:

Corrected.

Diabetes

Injection should be used cautiously in patients with:

Diabetes

because of the risk of:

Transient hyperglycemia.

Medication adjustment may occasionally be necessary.

Immunocompromised Patients

Extra caution is appropriate in:

Immunocompromised patients

because of potentially increased:

Infection risk.

Shoulder Arthroplasty

Patients with a:

Shoulder prosthesis

should generally not undergo periarticular injection without consultation with the treating:

Orthopaedic surgeon.

Repeated Injections

Repeated corticosteroid injections are:

Controversial.

Potential concerns include:

Tendon degeneration

Reduced bone quality

and possibly increased risk of:

Infection or impaired surgical healing.

Frequency

There is no universally appropriate fixed number of:

Repeat injections.

The decision should be individualized according to:

Diagnosis

Response

Comorbidities

and future:

Surgical plans.

Patient Monitoring

Immediate monitoring should assess:

Pain relief

Strength

and

Range of motion.

Short-Term Monitoring

Patients should also watch for:

Increasing redness

Fever

Severe swelling

or escalating:

Pain

which may suggest:

Infection or another complication.

Diabetic Monitoring

Patients with diabetes should monitor:

Blood glucose

more closely for a short period after:

Corticosteroid injection.

Key Principle

Subacromial injection is a diagnostic and therapeutic procedure used primarily for painful conditions arising from the subacromial space, including:

Bursitis, rotator cuff tendinopathy, partial cuff tears, and impingement-type pain.

Local anesthetic can help determine whether symptoms originate from the:

Subacromial space, while corticosteroid may provide:

Short-term reduction in pain and inflammation.

The greatest benefit usually occurs when injection is combined with:

Physical therapy, rotator cuff and scapular strengthening, activity modification, and restoration of motion.

Important precautions include:

Diabetes, immunosuppression, bleeding risk, skin infection, prosthetic shoulder joints, and repeated corticosteroid exposure.

Orthopaedic Surgery - Stress Fracture

Basics

A stress fracture develops when:

Repetitive mechanical loading exceeds the ability of bone to remodel and repair itself.

With continued loading, microscopic damage accumulates until the bone develops a:

Structural fracture.

Fatigue Fracture

A fatigue-type stress fracture occurs when:

Abnormally repetitive or suddenly increased forces

are applied to otherwise:

Normal bone.

A classic example is a:

Metatarsal stress fracture

in a military recruit who suddenly begins prolonged marching without adequate:

Conditioning.

Insufficiency Fracture

An insufficiency fracture is related but occurs when:

Normal physiologic loads

are applied to:

Weak or osteopenic bone.

An example is a:

Femoral neck insufficiency fracture

in an older patient with:

Low bone density.

Common Sites

Stress fractures occur most frequently in:

Weight-bearing bones of the lower extremity.

Common locations include:

Metatarsals

Calcaneus

Tibia

Fibula

and

Femoral neck.

Synonyms

Other terms include:

Fatigue fracture

and

March fracture.

MRI/Radiographic Grading

Stress injuries may be classified according to:

Radiographic and MRI findings.

Grade I

Grade I injury demonstrates:

Normal radiographs

with abnormal signal on:

STIR MRI sequences.

This represents an early:

Bone stress reaction.

Grade II

Grade II injury demonstrates:

Normal radiographs

with abnormalities on:

STIR

and

T2-weighted MRI.

Grade III

Grade III injury may show:

Periosteal reaction on radiographs

with abnormalities on:

T1

T2

and

STIR MRI

but without a definite:

Cortical fracture line.

Grade IV

Grade IV injury demonstrates a definite:

Fracture line

on radiographs or MRI.

MRI abnormalities are seen on:

T1

and

T2-weighted sequences.

General Prevention

Prevention focuses on avoiding sudden increases in:

Training load.

Training Progression

Athletes should increase:

Running distance

Intensity

and

Impact loading

gradually.

Abrupt changes in training are a major risk factor for:

Bone stress injury.

Running Mileage

A commonly used training principle is to avoid increasing weekly running mileage by more than approximately:

10% per week.

This is not an absolute biological threshold, but it provides a practical framework for gradual:

Load progression.

Pain Awareness

Athletes should reduce or stop training when they develop:

New focal pain during activity.

Continuing through pain can convert an early stress reaction into a:

Complete fracture.

Bone Health

Prevention also requires optimization of:

Energy availability

Calcium intake

Vitamin D status

and overall:

Bone health.

Epidemiology

Stress fractures can occur at:

Any age.

Younger Patients

Patients younger than approximately:

60 years

usually develop fatigue-type fractures after:

Repeated or sustained physical activity.

Older Patients

Older adults are more likely to develop:

Insufficiency fractures

when normal activity is applied to:

Osteopenic or otherwise weakened bone.

Sex

Stress and insufficiency fractures occur more commonly in:

Females

than in males.

Athletic Populations

They are particularly common in:

Runners

Jumping athletes

Military recruits

and athletes exposed to repetitive:

Impact loading.

Military Recruits

Historical studies have reported stress fractures in approximately:

5% of military recruits.

Elite Athletes

Rates vary according to sport and training exposure.

Historical data from elite tennis players have reported rates around:

12%.

Femoral Stress Fractures

Femoral stress fractures have been reported at approximately:

20 per 100,000 person-years.

About half involve the:

Femoral neck.

Risk Factors

Important risk factors include:

Female sex

Low bone mineral density

Smoking

Sudden increase in training

High running mileage

Low aerobic fitness

Excessive alcohol intake

Low vitamin D

Poor recovery time

and

Abnormal biomechanics.

Relative Energy Deficiency

A major risk factor is:

Low energy availability

with or without:

Disordered eating.

This may be associated with:

Menstrual dysfunction

and

Reduced bone mineral density.

Historically, this constellation was called the:

Female athlete triad.

A broader modern concept is:

Relative Energy Deficiency in Sport, or RED-S.

Female Athlete Triad

The classic triad consists of:

Low energy availability

Menstrual dysfunction

and

Low bone density.

Any component can increase the risk of:

Stress fracture.

Smoking

Smoking adversely affects:

Bone health

and may increase susceptibility to:

Stress injury.

Alcohol

Higher alcohol consumption, historically more than approximately:

10 drinks per week

has been associated with increased:

Stress fracture risk.

Low Vitamin D

Low serum:

25-hydroxyvitamin D

is associated with impaired:

Bone mineralization

and increased risk of:

Bone stress injury.

Running Volume

Recreational running above approximately:

25 miles per week

has historically been associated with increased risk, particularly when combined with:

Rapid progression

or inadequate recovery.

Skeletal Alignment

Biomechanical factors may increase local stress.

Examples include:

Pes planus

Pes cavus

and excessive:

Hip external rotation.

Muscle Fatigue

Muscles normally absorb part of the:

Impact load.

As they fatigue, less shock is absorbed and more force is transmitted directly to:

Bone.

This is particularly relevant in:

Long-distance running.

Etiology

The fundamental mechanism is:

Repeated loading that exceeds bone adaptation.

Younger Individuals

In younger people, the typical cause is a:

Sudden increase in strenuous activity

applied to otherwise normal:

Bone.

Older Individuals

In older patients, fractures may occur under relatively normal loads because of:

Osteoporosis

Osteopenia

or other:

Metabolic bone disease.

Associated Conditions

Stress fractures may be associated with:

Osteopenia

Osteoporosis

Metabolic bone disease

Female athlete triad

and

RED-S.

Diagnosis

Diagnosis depends on:

History

Physical examination

and appropriate:

Imaging.

Early recognition is important to prevent progression to:

Complete fracture.

Signs and Symptoms

The typical presentation begins with:

Gradual activity-related pain.

Early Symptoms

Patients often describe approximately:

2–3 weeks

of a vague:

Dull ache

during:

Exercise or impact loading.

Progression

As the injury progresses, pain becomes:

Sharper

More localized

and begins:

Earlier during activity.

Advanced Injury

With increasing severity, pain may persist after exercise and eventually occur:

At rest.

Rest pain suggests a more advanced:

Bone stress injury.

Complete Fracture

If a stress injury progresses to a complete fracture, pain may become:

Sudden

Severe

and associated with major:

Functional limitation.

Physical Examination

The examination should identify:

Focal bone tenderness

and assess the patient’s ability to:

Bear weight.

Gait

An:

Antalgic gait

may be present.

Point Tenderness

One of the most characteristic findings is:

Localized tenderness directly over the involved bone.

Diffuse tenderness is less typical of a discrete:

Stress fracture.

Swelling

There may be:

Soft-tissue swelling

or localized thickening over the:

Affected site.

Hop or Impact Pain

Pain reproduced with:

Impact loading

may support the diagnosis but should be used cautiously when a high-risk fracture is suspected.

Femoral Neck Stress Injury

Femoral neck lesions may produce:

Groin pain

or

Anterior thigh pain.

Pain may be reproduced with:

Hip rotation

or resisted:

Straight-leg raise.

Stinchfield Test

Pain with resisted active straight-leg raise, sometimes called a:

Stinchfield sign

may occur with:

Femoral neck or intra-articular hip pathology.

It is not specific to stress fracture.

Laboratory Tests

Routine laboratory testing is not necessary for every stress fracture.

Metabolic Bone Evaluation

Laboratory workup should be considered in patients with:

Recurrent stress fractures

Older age

Low bone density

RED-S

Menstrual abnormalities

or suspected:

Metabolic bone disease.

Possible Laboratory Studies

Depending on the clinical setting, testing may include:

25-hydroxyvitamin D

Calcium

Phosphate

Parathyroid hormone

Renal function

and selected endocrine:

Studies.

Imaging

Plain Radiographs

Initial imaging usually includes:

AP and lateral radiographs.

Early Radiographs

Radiographs are frequently:

Normal during the first 1–2 weeks

after symptoms begin.

A normal early radiograph therefore does not exclude:

Stress fracture.

Later Radiographic Findings

With healing or progression, radiographs may show:

Periosteal reaction

Sclerosis

Cortical thickening

or a visible:

Fracture line.

Bone Scan

Bone scintigraphy is:

Highly sensitive

for increased bone turnover.

Bone-Scan Limitations

It is less specific than:

MRI

because many disorders produce increased:

Tracer uptake.

Delayed Positivity in Older Adults

In elderly patients with insufficiency fractures, scintigraphic abnormalities may occasionally be delayed for:

48–72 hours.

MRI

MRI is the preferred advanced imaging technique for most suspected:

Stress injuries.

MRI Advantages

MRI is:

Highly sensitive

and generally more:

Specific

than bone scintigraphy.

It can detect:

Bone marrow edema

before a fracture line becomes visible.

MRI Prognostic Value

MRI can classify severity and help estimate:

Time to return to activity.

Soft-Tissue Evaluation

MRI can also identify alternative causes of pain such as:

Tendon injury

Muscle injury

or

Joint pathology.

CT

CT may be useful for selected lesions when detailed evaluation of:

Cortical bone

or fracture healing is required.

It is particularly helpful in some:

Navicular

or

Anterior tibial cortex lesions.

Differential Diagnosis

Important alternatives include:

Acute fracture

Infection

Tumor

Soft-tissue injury

Exertional compartment syndrome

and, for tibial pain,

Medial tibial stress syndrome.

Medial Tibial Stress Syndrome

Shin splints generally produce:

Diffuse posteromedial tibial tenderness

rather than the focal tenderness characteristic of a:

Stress fracture.

Treatment

Treatment depends primarily on:

Fracture location

Risk category

Symptoms

and evidence of:

Fracture progression.

General Measures

The basic treatment principle is:

Reduce loading below the threshold that produces pain.

Walking Pain

If walking is painful, patients should use:

Crutches

or another method of:

Protected weight bearing.

Rest Pain

If pain occurs at:

Rest

or with minor motion, more complete protection may be needed using:

A boot

Splint

or

Cast.

Low-Risk Stress Fractures

Most low-risk fractures are treated with:

Activity modification

and progressive:

Protected loading.

Examples commonly include many:

Metatarsal shaft

Fibular

and

Posteromedial tibial stress fractures.

High-Risk Stress Fractures

High-risk injuries require more aggressive treatment because they have an increased risk of:

Displacement

Delayed union

Nonunion

or catastrophic:

Complications.

Activity Progression

Once symptoms have resolved, activity should be resumed:

Gradually.

Low-Impact Training

The patient may first begin:

Cycling

Swimming

Pool running

or other:

Low-impact conditioning.

Return to Running

Running should resume only when the patient can perform normal daily activities and impact testing without:

Pain.

Mileage should then increase:

Slowly and progressively.

Physical Therapy

Rehabilitation should identify the factor that caused the:

Stress injury.

Training Errors

Common issues include:

Sudden mileage increases

Excessive intensity

Insufficient rest

and repeated training on:

Hard surfaces.

Biomechanical Assessment

Therapy may evaluate:

Foot alignment

Running mechanics

Hip strength

and

Muscle imbalance.

Strengthening

Rehabilitation commonly includes:

Core strengthening

Hip strengthening

and progressive lower-extremity:

Conditioning.

Medication

Acetaminophen

Acetaminophen is generally preferred for:

Pain control.

NSAIDs

NSAIDs may decrease pain, but their use in stress fracture is:

Controversial

because prostaglandin inhibition may theoretically impair:

Bone healing.

If used, prolonged or high-dose treatment is generally avoided when bone healing is a major concern.

Surgery

Surgery is primarily considered for:

High-risk stress fractures

or injuries that progress despite adequate:

Nonoperative treatment.

Femoral Neck Stress Fracture

Certain femoral neck stress fractures require:

Urgent surgical treatment.

Tension-Side Femoral Neck Lesions

Stress fractures along the:

Superolateral or tension side

of the femoral neck have a high risk of:

Completion and displacement.

These lesions often require:

Internal fixation.

Displaced Femoral Neck Fracture

A complete displaced femoral neck stress fracture is an:

Orthopaedic emergency

because displacement can disrupt blood supply to the:

Femoral head

and cause:

Avascular necrosis.

Other High-Risk Locations

Stress fractures associated with a greater risk of delayed union or nonunion include:

Anterior tibial cortex

Patella

Medial malleolus

Talus

Tarsal navicular

and

Proximal fifth metatarsal.

Anterior Tibial Stress Fracture

Anterior tibial stress fractures are tension-sided injuries and may show the classic:

Dreaded black line

on radiographs.

They have a greater risk of:

Delayed union and nonunion.

Tarsal Navicular

Navicular stress fractures are high risk because of:

Limited central blood supply

and substantial mechanical:

Loading.

Fifth Metatarsal

Proximal fifth-metatarsal stress fractures may heal slowly because of the:

Watershed blood supply.

Some athletes benefit from:

Early surgical fixation.

Referral

Orthopaedic or sports-medicine referral is appropriate for:

High-risk fracture sites

Persistent pain

Uncertain diagnosis

and suspected:

Metabolic bone disease.

Metabolic Referral

Patients with:

RED-S

Eating disorder

Menstrual dysfunction

Recurrent fractures

or unexplained low bone density may require multidisciplinary evaluation involving:

Sports medicine

Endocrinology

Nutrition

and other specialists.

Follow-Up

Clinical follow-up assesses:

Pain

Tenderness

Weight-bearing tolerance

and progression back to:

Activity.

Radiographic Monitoring

Repeat radiographs may be obtained approximately every:

4–6 weeks

when radiographic healing needs to be documented.

MRI Follow-Up

Routine repeat MRI is not required for every patient.

It may be useful when symptoms fail to improve or in selected:

High-risk injuries.

Prognosis

Most stress fractures in:

Young healthy individuals

have an excellent prognosis.

Older Patients

Patients with:

Osteoporosis

or other metabolic bone disease are more likely to develop subsequent:

Insufficiency fractures.

Reversible Bone Disorders

When an underlying problem such as:

Low energy availability

Vitamin D deficiency

or another treatable bone-health abnormality is corrected, the risk of future:

Stress injury

may decrease.

Return-to-Activity Time by MRI Grade

Historical estimates suggest progressively longer recovery with increasing:

MRI grade.

Grade I

Return to full activity may require approximately:

3 weeks or longer.

Grade II

Recovery may require approximately:

5 weeks or longer.

Grade III

Recovery may require approximately:

11 weeks or longer.

Grade IV

Recovery may require approximately:

14 weeks or longer.

These intervals are approximate and depend heavily on:

Fracture location

Symptoms

Bone health

and

Individual healing.

Complications

Completion of the Fracture

The most important complication is progression from a stress reaction or incomplete fracture to a:

Complete fracture.

This can substantially prolong:

Healing time

and may require:

Surgical fixation.

Displacement

Displacement is particularly dangerous at sites such as the:

Femoral neck.

It may result in:

Avascular necrosis

or major:

Functional loss.

Delayed Union and Nonunion

High-risk lesions may develop:

Delayed union

or

Nonunion.

This is particularly important in:

Anterior tibial

Navicular

and

Proximal fifth-metatarsal fractures.

Persistent Pain

Some patients continue to experience:

Pain

after radiographic fracture healing.

Persistent symptoms should prompt reassessment for:

Incomplete healing

Biomechanical abnormalities

or another diagnosis.

Recurrent Stress Injury

Failure to address:

Training errors

RED-S

Low bone density

or other risk factors may lead to:

Recurrent stress fractures.

Patient Monitoring

Patients should be monitored for:

Resolution of focal tenderness

Pain-free walking

Progressive load tolerance

and evidence of:

Fracture healing.

Return-to-Sport Criteria

Return to unrestricted activity is safest when the patient has:

No pain with daily activity

No focal tenderness

Pain-free impact loading

Restored strength

and correction of important:

Training or metabolic risk factors.

Key Principle

A stress fracture is a bone injury caused when repetitive mechanical loading exceeds the rate at which bone can remodel and repair itself.

In younger patients, this usually represents a:

Fatigue fracture of normal bone, whereas older or osteopenic patients may sustain an:

Insufficiency fracture from normal loading.

Early radiographs may be normal, while:

MRI is highly sensitive and is generally the preferred advanced imaging study.

Treatment centers on:

Reducing load below the pain threshold, protected weight bearing when needed, correcting training and biomechanical factors, and gradually returning to activity.

High-risk fractures, particularly involving the:

Femoral neck, anterior tibia, navicular, medial malleolus, talus, patella, or proximal fifth metatarsal

require more aggressive management because of the risk of:

Displacement, delayed union, nonunion, or avascular necrosis.

Orthopaedic Surgery - Sternoclavicular Joint Dislocation

Basics

Sternoclavicular joint dislocation occurs when the:

Medial end of the clavicle

loses its normal articulation with the:

Sternum.

The dislocation may be:

Anterior

or

Posterior.

Clinical Importance

Anterior dislocations are more common and often remain somewhat:

Unstable or prominent

even after reduction.

Despite this, they usually produce relatively little long-term:

Functional impairment.

Posterior dislocations are much more dangerous because the displaced clavicle may compress or injure:

Mediastinal structures.

Posterior Dislocation

A posterior sternoclavicular dislocation may compromise:

Major blood vessels

Trachea

Esophagus

or nearby:

Nerves.

For this reason, posterior dislocation generally requires:

Urgent reduction.

Epidemiology

Sternoclavicular dislocation is:

Rare.

It accounts for approximately:

1% of all joint dislocations

and about:

3% of shoulder-girdle injuries.

Mechanism Distribution

Historical series have attributed approximately:

40%

to:

Motor vehicle trauma

and approximately:

21%

to:

Sports-related injuries.

Direction

Approximately:

63%

of sternoclavicular dislocations are:

Anterior.

Anatomy and Pathophysiology

The sternoclavicular joint is a:

Diarthrodial joint

between the medial clavicle and the:

Manubrium.

Ligamentous Stability

The principal restraints to anterior-posterior translation are the:

Anterior and posterior sternoclavicular capsular ligaments.

Additional support is provided by the:

Costoclavicular ligament

and

Intra-articular disc ligament.

Structures Posterior to the Joint

Several critical structures lie immediately behind the:

Sternoclavicular joint.

These include the:

Brachiocephalic vessels

Trachea

Esophagus

Vagus nerve

Phrenic nerve

and other:

Mediastinal vascular structures.

Importance of Posterior Displacement

Posterior displacement of the medial clavicle can produce:

Compression

Laceration

or

Obstruction

of these structures.

This explains why posterior dislocation is considered a potentially:

Life-threatening injury.

Medial Clavicular Physis

The medial clavicular growth plate is the last major physis in the body to:

Fuse.

Closure commonly occurs around:

23–25 years of age.

Physeal Injury in Young Patients

In patients younger than approximately:

25 years

an apparent sternoclavicular dislocation may actually represent a:

Medial clavicular physeal fracture-dislocation.

These injuries can mimic a true:

SC joint dislocation.

Prognosis of Physeal Injury

Medial clavicular physeal fractures generally have a better healing potential than true:

Sternoclavicular dislocations.

Etiology

The injury usually follows:

High-energy trauma

such as:

Motor vehicle collision

or

Contact sports.

Direct Mechanism

A direct blow to the:

Medial clavicle

typically drives it:

Posteriorly.

Indirect Mechanism

A force applied laterally across the shoulder girdle may produce sternoclavicular dislocation through:

Compression of the shoulder.

Examples include:

Football pileups

and

Side-impact motor vehicle collisions.

Associated Injuries

Because these injuries often occur after:

High-energy trauma

patients should be evaluated for additional:

Thoracic

Spinal

and

Extremity injuries.

Trauma Assessment

A complete trauma assessment using standard:

ATLS principles

is appropriate when the mechanism is substantial.

Diagnosis

Diagnosis depends on:

Mechanism

Physical examination

and especially:

CT imaging.

Signs and Symptoms

Patients usually report:

Severe pain around the sternoclavicular joint

that worsens with:

Arm movement.

Shoulder Compression

Pain may increase when the shoulders are:

Compressed toward each other.

Arm Support

Patients frequently support the injured arm using the:

Opposite hand

to reduce:

Shoulder movement and pain.

History

Important questions include the presence of:

Upper-extremity numbness

Weakness

Shortness of breath

Voice change

Difficulty speaking

or

Difficulty swallowing.

These symptoms raise concern for:

Posterior displacement.

Respiratory Symptoms

Dyspnea, stridor, or difficulty speaking may indicate compression of the:

Trachea

or other mediastinal structures.

Swallowing Difficulty

Dysphagia may result from compression of the:

Esophagus.

Neurologic Symptoms

Arm weakness, numbness, or paresthesia may indicate involvement of the:

Brachial plexus

or nearby neurovascular structures.

Physical Examination

The examination should include:

Inspection

Palpation

Neurovascular assessment

and evaluation for:

Thoracic compromise.

Anterior Dislocation

In an anterior dislocation, the medial clavicle is typically:

Prominent and palpable

compared with the opposite side.

Posterior Dislocation

In posterior dislocation, the medial clavicle may be:

Difficult to palpate

and there may be a:

Visible or palpable depression

over the sternoclavicular joint.

Shoulder Position

The affected shoulder may appear:

Shortened

and displaced:

Forward.

Neurologic Examination

A careful neurologic examination of both upper extremities should assess:

Motor function

Sensation

and possible:

Brachial plexus involvement.

Vascular Examination

Compare:

Radial pulses

between both arms.

Also evaluate:

Capillary refill

and overall:

Limb perfusion.

Venous Congestion

Look for:

Neck swelling

Upper-extremity swelling

or visible venous distention.

These may indicate obstruction of:

Central venous structures.

Imaging

Plain Radiographs

The sternoclavicular joint is difficult to evaluate accurately on:

Routine radiographs.

A chest radiograph may suggest asymmetry but is often:

Nondiagnostic.

Specialized Views

Specialized sternoclavicular projections have historically been used, but they can be:

Technically difficult

and difficult to:

Interpret.

CT

CT is the:

Imaging study of choice

when sternoclavicular dislocation is suspected.

CT Advantages

CT demonstrates:

Direction of displacement

Associated fractures

and the relationship of the medial clavicle to:

Mediastinal structures.

Posterior Dislocation

In posterior dislocation, CT can show whether the clavicle is compressing:

Great vessels

Trachea

or

Esophagus.

CT Angiography

When posterior displacement or vascular injury is suspected, consider:

CT angiography.

This can define the relationship between the clavicle and:

Major thoracic vessels.

Differential Diagnosis

Important alternatives include:

Sternoclavicular sprain

Medial clavicular physeal fracture

and other forms of:

Thoracic trauma.

Sternoclavicular Sprain

A sprain may cause pain and tenderness without true:

Dislocation.

These injuries are typically treated:

Symptomatically.

Pneumothorax and Thoracic Injury

Shortness of breath may be caused by associated:

Pneumothorax

Hemothorax

or other thoracic injury rather than the sternoclavicular dislocation itself.

A complete trauma assessment is therefore essential.

Treatment

Initial Stabilization

Posterior sternoclavicular dislocations require:

Urgent reduction.

Anterior dislocations are also commonly reduced, although they frequently become:

Recurrently prominent.

Posterior Dislocation

Because of the risk of injury to mediastinal structures, posterior dislocation should generally be reduced in a:

Controlled operative environment.

Analgesia and Sedation

Closed reduction often requires:

Deep sedation

or

General anesthesia

because of:

Pain

and

Muscle spasm.

Anterior Dislocation Reduction

The patient is positioned:

Supine

with a firm bolster approximately:

3–4 inches

thick between the:

Scapulae.

Positioning

The affected shoulder is typically placed in approximately:

90° of abduction

and about:

15° of extension.

Traction

An assistant applies:

Longitudinal traction

to the affected arm.

Direct Pressure

Posteriorly directed pressure is then applied to the:

Prominent medial clavicle

to guide it back into:

Alignment.

Postreduction Immobilization

After reduction, the arm may be placed in a:

Sling and swathe

or

Figure-8 dressing.

Posterior Dislocation Reduction

Posterior reduction should be undertaken with:

Thoracic or cardiothoracic surgical backup

because releasing the clavicle may unmask injury to:

Great vessels

or

Lung structures.

Operative Environment

Reduction is usually performed in the:

Operating room

with:

Sterile preparation

and appropriate emergency resources available.

Abduction-Traction Technique

One closed technique involves:

Abducting and extending the arm

and applying:

Longitudinal traction.

Shoulder Pressure

Downward pressure may be applied over the:

Glenohumeral joint

while the medial clavicle is pulled:

Anteriorly.

Direct Clavicular Manipulation

The medial clavicle may be grasped with the:

Fingers

and drawn anteriorly.

If this fails, a sterile:

Towel clamp

may sometimes be used in a controlled operative setting.

Reduction Sign

Successful reduction may produce an audible or palpable:

Pop.

Adduction-Traction Technique

Another technique uses the arm in:

Adduction

with:

Lateral traction.

Pressure is applied over the shoulder while the medial clavicle is guided:

Anteriorly.

Immobilization After Posterior Reduction

After successful reduction, the arm is placed in a:

Sling and swathe

or

Figure-8 dressing.

Activity

After reduction, the affected arm is generally immobilized for approximately:

4–6 weeks.

Sleeping Position

Patients may be more comfortable sleeping:

Upright

or in a:

Recliner

during the early period.

Nursing and Acute Care

Patients should have:

Intravenous access

and appropriate:

Analgesia.

Before definitive reduction, they may be more comfortable sitting:

Upright

with the arm supported in a:

Sling.

Physical Therapy

During immobilization, exercises for the:

Hand

Wrist

and

Elbow

can begin immediately.

Shoulder Motion

Shoulder range-of-motion exercises are usually delayed until approximately:

4–6 weeks

depending on stability and:

Pain.

Medication

Analgesic treatment may include:

Acetaminophen

NSAIDs

and, in the acute setting,

Short-term opioid medication.

Surgery

Surgery is indicated when a posterior dislocation cannot be:

Reduced closed

or remains:

Unstable.

Open Reduction

Failed closed reduction requires:

Open reduction

in the:

Operating room.

Thoracic Surgical Backup

A thoracic or cardiothoracic surgeon should be available because major vessel or lung injury may be:

Unmasked during reduction.

Stability Assessment

After open reduction, the sternoclavicular joint is assessed for:

Residual instability.

Many posterior dislocations become stable once:

Reduced.

Reconstruction

Persistently unstable joints may require:

Soft-tissue reconstruction

using:

Sutures

or

Tendon grafts.

Hardware Contraindication

Fixation with:

Kirschner wires

or

Steinmann pins

is contraindicated.

These implants can migrate into the:

Mediastinum

and cause catastrophic:

Cardiac or vascular injury.

Delayed Posterior Dislocation

Posterior dislocations untreated for more than approximately:

7–10 days

may become difficult to reduce closed because of:

Retrosternal adhesions and scarring.

Open reduction is more likely to be required.

Chronic Anterior Instability

Persistent anterior subluxation or dislocation is often treated:

Nonoperatively.

Functional Effect of Anterior Instability

Although the prominence may be visible, most patients have:

Minimal functional impairment.

Symptomatic Anterior Instability

Surgery may be considered when there is persistent:

Pain

Recurrent instability

or substantial:

Functional limitation.

Treatment generally involves:

Open reduction and stabilization.

Follow-Up

All patients with sternoclavicular dislocation should have follow-up with an:

Orthopaedic surgeon.

Immobilization

For a stable reduction, immobilization is commonly continued for:

4–6 weeks.

Range of Motion

Gentle shoulder range-of-motion exercises may usually begin after approximately:

4–6 weeks.

Unstable Anterior Dislocation

When persistent anterior instability is treated nonoperatively, the sling can be continued until:

Pain decreases.

Prognosis

Posterior dislocations are generally:

Stable after successful reduction.

Anterior Dislocations

Anterior dislocations are more likely to remain:

Unstable

or visibly:

Prominent.

Despite this, they usually cause relatively little:

Functional disability.

Cosmetic Deformity

Chronic anterior instability may leave a persistent:

Prominence over the medial clavicle.

This is primarily a:

Cosmetic issue

for many patients.

Complications

The most serious complications occur with:

Posterior dislocations.

Great-Vessel Injury

The medial clavicle may compress or lacerate:

Brachiocephalic vessels

or other major:

Thoracic vessels.

This can lead to:

Life-threatening hemorrhage.

Tracheal Compression

Posterior displacement may compress the:

Trachea

and produce:

Respiratory distress.

Esophageal Compression

Compression of the esophagus can cause:

Dysphagia.

Brachial Plexopathy

Posterior displacement may injure the:

Brachial plexus

producing:

Weakness

Numbness

or

Paresthesia.

Thoracic Outlet Syndrome

Chronic compression may rarely contribute to:

Thoracic outlet syndrome.

Anterior Dislocation Complications

Anterior dislocations are generally more benign but may produce:

Cosmetic deformity

Degenerative joint changes

Recurrent instability

and

Activity-related pain.

Patient Monitoring

Follow-up should continue until:

Pain has resolved

Range of motion is restored

and

Normal or near-normal function returns.

Key Principle

Sternoclavicular joint dislocation is displacement of the medial clavicle from the sternum and may be anterior or posterior.

Anterior dislocations are more common and often remain:

Prominent or unstable, but usually cause relatively little functional impairment.

Posterior dislocations are potentially:

Life-threatening because the displaced clavicle may compress or injure the:

Great vessels, trachea, esophagus, or brachial plexus.

CT is the:

Imaging study of choice, with CT angiography considered when posterior displacement threatens vascular structures.

Posterior dislocations require:

Urgent reduction in a controlled setting with thoracic surgical backup, while chronic anterior instability is often treated:

Nonoperatively unless symptoms are substantial.

Orthopaedic Surgery - Sprains

Basics

A sprain is an injury to a:

Ligament

caused by:

Excessive stretching or tearing of ligament fibers.

Ligament injuries are among the most common musculoskeletal problems encountered in:

Primary care

Sports medicine

and

Orthopaedic practice.

Sprains can occur in:

Any synovial or movable joint.

Synonyms

Other terms include:

Ligament injury

and

Torn ligament.

Classification

Sprains are commonly classified into:

Grade I

Grade II

and

Grade III injuries.

Grade I Sprain

A Grade I sprain represents a:

Mild ligament injury

with microscopic fiber damage but preservation of:

Overall ligament continuity.

There is typically:

Pain

Tenderness

and possibly mild:

Swelling

without clinically significant instability.

Grade II Sprain

A Grade II sprain is a:

Partial ligament tear.

Some fibers remain intact, so overall continuity is:

Preserved.

There may be:

Mild to moderate laxity

on stress testing, but the joint generally does not demonstrate gross:

Instability.

Grade III Sprain

A Grade III sprain represents:

Complete ligament disruption.

The involved joint may demonstrate:

Marked laxity

or

Gross instability.

Prevention

Appropriate preparation before exercise or sport may reduce the risk of:

Ligament injury.

Warm-Up

A proper warm-up should include:

Gradual cardiovascular activity

Dynamic movement

and sport-specific:

Preparation.

This allows muscles and periarticular tissues to adapt to increasing:

Mechanical load.

Epidemiology

Sprains are:

Very common injuries.

They may occur at essentially:

Any age.

Sex

Both:

Males

and

Females

are affected.

There is no consistent overall:

Sex predominance.

Risk Factors

Factors that may increase the risk of a sprain include:

Intermittent or poorly conditioned athletic participation

Running sports

Throwing sports

Jumping sports

Inadequate warm-up

Fatigue

and prior:

Ligament injury.

Recreational Athletes

So-called:

Weekend athletes

may be at increased risk when strenuous activity is performed without adequate:

Conditioning

or

Preparation.

Anabolic Steroids

Anabolic steroid use has historically been associated with increased risk of some:

Musculotendinous injuries

and may contribute indirectly to abnormal loading across:

Ligaments and joints.

Etiology