Introduction:

The hemiarthroplasty of the shoulder, is a partial replacement of the shoulder joint (ball and socket mechanism). During this procedure the humeral head (ball) is replaced with a metallic ball in an attempt to restore (a) smoothness of the surface (b) sphericity of the humeral head.

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Indications:

A hemiarthroplasty is commonly used in the following clinical scenarios

• Arthritis of the shoulder in a young patient, <60-65 years old, with high levels of activity
• Proximal humeral fractures – fractured ball in many pieces that is not amendable to fixation using screws and plates
• Revision surgery of prior failed shoulder replacement
• Avascular necrosis of the ball – humeral head, usually seen in younger patients
• When there is insufficient bone left in the socket – glenoid of the shoulder – and a total shoulder replacement cannot be done because the socket cannot support an implant.

Technique: A simulation of the replaced shoulder with a hemiarthroplasty is demonstrated in the video below. This was done using the software OrthoMesh3D that I developed and use for preoperative planning.

Rehabilitation: The rehabilitation after hemiarthroplasty requires immobilization of the shoulder in a sling for 6 weeks. This is necessary to allow the muscles of the shoulder to heal as those are separated and then repaired after implantation of the prosthesis. It is crucial to avoid forceful internal or external rotation of the shoulder- such as opening or closing doors with the arm. During those 6 weeks the sling can be removed for therapy and passive range of motion of the shoulder. After 6 weeks the sling is discontinued and light strengthening is started with progressive supine bench pressing, as well as scapular muscle and deltoid muscle strengthening. Patients experience the full benefit of surgery between 6-12 months from surgery.

Results: The results of hemiarthroplasty in terms of relief of pain are inferior to those of a total shoulder replacement – replacing the ball and socket of the shoulder. However, the benefit of the hemiarthroplasty is that it does not require any limitation in activity. After 6 months patients are allowed to do anything they wish to do. With the total shoulder replacement heavy activity is not permitted as this level of activity will result in early failure of the implant. The relief in pain from a hemiarthroplasty can be full, however most of the time is partial. The main reasons for a revision of a hemiarthroplasty is stiffness, erosion of the socket – glenoid of the shoulder- from the metallic ball, infection, or hardware complications such as loosening. Stiffness can be managed sometimes with gentle manipulation under conscious sedation. The frequency of those complications is somewhere between 4-10%.

Introduction:

Distal radius fractures are the most common fractures of the arm. The radius is the larger of the two bones of the forearm. The end toward the wrist is called the distal end. A fracture of the distal radius occurs when the area of the radius near the wrist breaks. Distal radius fractures are very common. In fact, the radius is the most commonly broken bone in the arm.

1. Intra-articular fracture. A fracture that extends into the wrist joint. ("Articular" means "joint.")
2. Extra-articular fracture. A fracture that does not extend into the joint is called an extra-articular fracture.
3. Open fracture. When a fractured bone breaks the skin, it is called an open fracture. These types of fractures require immediate medical attention because of the risk for infection.
4. Comminuted fracture. When a bone is broken into more than two pieces, it is called a comminuted fracture.

The most common cause of a distal radius fracture is a fall onto an outstretched arm. Osteoporosis (a disorder in which bones become very fragile and more likely to break) can make a relatively minor fall result in a broken wrist. Many distal radius fractures in people older than 60 years of age are caused by a fall from a standing position. A broken wrist can happen even in healthy bones, if the force of the trauma is severe enough. For example, a car accident or a fall off a bike may generate enough force to break a wrist. Good bone health remains an important prevention option. Wrist guards may help to prevent some fractures, but they will not prevent them all.

Treatment

The treatment of this fracture depends on the displaced, angulation of the fracture, deformity, activity level of the patient, patient’s age and occupation, presence or absence of osteoporosis. The treatment options are bracing, casting or surgery. Whether surgical treatment is required will depend of patient’s preference and most importantly the doctor’s recommendation. During surgery metallic implants – plates and screws – are used for fixation of the fracture. Below you will see xrays prior and after surgery and fixation of the fracture with a plate and screws.

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Xrays below show a malunion – united bone in a displaced position – which required an osteotomy, braking the bone again and fixing it.

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The animation below shows the planning for the osteotomy using custom drilling and cutting guides.

Recovery

Because the kinds of distal radius fractures are so varied and the treatment options are so broad, recovery is different for each individual. Talk to your doctor for specific information about your recovery program and return to daily activities.

Pain Management

Most fractures hurt moderately for a few days to a couple of weeks. Many patients find that using ice, elevation (holding their arm up above their heart), and simple, non-prescription medications for pain relief are all that are needed to relieve pain. Your doctor may recommend combining ibuprofen and acetaminophen to relieve pain and inflammation. The combination of both medications is much more effective than either one alone. If pain is severe, your doctor may suggest a prescription-strength medication, such as an opioid, for a few days. Be aware that although opioids help relieve pain after surgery, they are a narcotic and can be addictive.  It is important to use opioids only as directed by your doctor. As soon as your pain begins to improve, stop taking opioids. Talk to your doctor if your pain has not begun to improve within a few days of your surgery.

Cast and Wound Care

In some cases, original casts will be replaced because swelling has gone down so much that the cast becomes loose. The last cast is usually removed after about 6 weeks. During healing, casts and splints must be kept dry. A plastic bag over the arm while showering should help. If the cast does become wet, it will not dry very easily. A hair dryer on the cool setting may be helpful. Most surgical incisions must be kept clean and dry for 5 days or until the sutures (stitches) are removed, whichever occurs later.

Potential Complications

After surgery or casting, it is important that you achieve full motion of your fingers as soon as possible. If you are not able to fully move your fingers within 24 hours due to pain and/or swelling, contact your doctor for evaluation. Your doctor may loosen your cast or surgical dressing. In some cases, working with a physical or occupational therapist will be required to regain full motion. Unrelenting pain may be a sign of Complex Regional Pain Syndrome (Reflex Sympathetic Dystrophy) which must be treated aggressively with medication or nerve blocks.

Rehabilitation and Return to Activity

Most people do return to all their former activities after a distal radius fracture. The nature of the injury, the kind of treatment received, and the body's response to the treatment all have an impact, so the answer is different for each individual. Almost all patients will have some stiffness in the wrist. This will generally lessen in the month or two after the cast is taken off or after surgery, and continue to improve for at least 2 years. If your doctor thinks it is needed, you will start physical therapy within a few days to weeks after surgery, or right after the last cast is taken off. Most patients will be able to resume light activities, such as swimming or exercising the lower body in the gym, within 1 to 2 months after the cast is removed or within 1 to 2 months after surgery. Vigorous activities, such as skiing or football, may be resumed between 3 and 6 months after the injury.

Long-Term Outcomes

Recovery should be expected to take at least a year. Some pain with vigorous activities may be expected for the first year. Some residual stiffness or ache is to be expected for 2 years or possibly permanently, especially for high-energy injuries (such as motorcycle crashes), in patients older than 50 years of age, or in patients who have some osteoarthritis. However, the stiffness is usually minor and may not affect the overall function of the arm. Finally, osteoporosis is a factor in many wrist fractures. It has been suggested that people who have a wrist fracture should be tested for bone weakness, especially if they have other risk factors for osteoporosis. Ask your doctor about osteoporosis testing.

Research

I have been the author or co-author of several studies on the subject of distal radius fractures and I have classified 2500 xrays of the fractures of the distal radius for research purposes during my study of those injuries. A sample of publications on the subject is shown below.

1. Ruch DS, Wray WH 3rd, Papadonikolakis A, Richard MJ, Leversedge FJ, Goldner RD. Corrective osteotomy for isolated malunion of the palmar lunate facet in distal radius fractures. J Hand Surg Am. 2010 Nov;35(11):1779-86. doi: 10.1016/j.jhsa.2010.07.036. Epub 2010 Oct 20. PubMed PMID: 20961709.
2. Lucado AM, Li Z, Russell GB, Papadonikolakis A, Ruch DS. Changes in impairment and function after static progressive splinting for stiffness after distal radius fracture. J Hand Ther. 2008 Oct-Dec;21(4):319-25. doi: 10.1197/j.jht.2008.01.002. PubMed PMID: 19006757.
3. Chloros GD, Papadonikolakis A, Ginn S, Wiesler ER. Pronator quadratus space and compartment syndrome after low-energy fracture of the distal radius: a case report. J Surg Orthop Adv. 2008 Summer;17(2):102-6. PubMed PMID: 18549742.
4. Ruch DS, Papadonikolakis A. Volar versus dorsal plating in the management of intra-articular distal radius fractures. J Hand Surg Am. 2006 Jan;31(1):9-16. PubMed PMID: 16443097.
5. Shen J, Papadonikolakis A, Garrett JP, Davis SM, Ruch DS. Ulnar-positive variance as a predictor of distal radioulnar joint ligament disruption. J Hand Surg Am. 2005 Nov;30(6):1172-7. PubMed PMID: 16344174.
6. Ruch DS, Lumsden BC, Papadonikolakis A. Distal radius fractures: a comparison of tension band wiring versus ulnar outrigger external fixation for the management of distal radioulnar instability. J Hand Surg Am. 2005 Sep;30(5):969-77. PubMed PMID: 16182053.
7. Papadonikolakis A, Ruch DS. Internal distraction plating of distal radius fractures. Tech Hand Up Extrem Surg. 2005 Mar;9(1):2-6. Review. PubMed PMID: 16092812.
8. Papadonikolakis A, Shen J, Garrett JP, Davis SM, Ruch DS. The effect of increasing distraction on digital motion after external fixation of the wrist. J Hand Surg Am. 2005 Jul;30(4):773-9. PubMed PMID: 16039371.

Introduction:

Trauma to the elbow is quite common. It may be a result of an isolated injury or combined with other injuries of the arm. Taking into account age and the mechanism of injury is crucial, particularly because of the risk of accompanying nerve or vascular injury.

For an understanding of the elbow anatomy and fractures please see the animation below:

Summary of anatomy:

The elbow consists of portions of all three bones: The distal humerus is the lower end of humerus. It forms the upper part of the elbow and is the spool around which the forearm bends and straightens. The radial head is the knobby end of the radius where it meets the elbow. It glides up and down the front of the distal humerus when you bend your arm and rotates around the ulna when you turn your wrist up or down. The olecranon is the part of the ulna that "cups" the lower end of the humerus, creating a hinge for elbow movement. The bony "point" of the olecranon can be easily felt beneath the skin because it is covered by just a thin layer of tissue. The elbow is held together by its bony architecture, as well as ligaments, tendons, and muscles. Three major nerves cross the elbow joint.

Mechanism of injury

There are a variety of possible injuries because of the presence of three bones and the range of mechanisms of injury.

Radial head and neck fractures

Mechanism of injury

These are most commonly caused by a fall on to an outstretched arm. Radial head fracture is the most common fracture around the elbow joint in adults, whereas radial neck fractures occur more commonly in children.

Clinical features

• The patient presents with swelling over the lateral elbow with limited range of motion, particularly forearm rotation and elbow extension ± elbow effusion and bruising. Pain is increased with passive rotation.
• The most reliable clinical sign is point tenderness over the radial head.
• Needs careful assessment for nerve and vascular involvement, especially with brachial artery, median and ulnar nerves.
• It is important to detect crepitation or a mechanical blockage of motion from displaced fracture fragments. This often requires aspiration of a haemarthrosis – blood within elbow joint - with the instillation of local anaesthetic for pain relief.
• If there is significant wrist pain and/or central forearm pain, there may be acute longitudinal radioulnar dissociation with disruption of the distal radioulnar joint.

Investigations

• AP and lateral X-ray views of the elbow are usually sufficient.

Treatment

Doctors classify fractures according to the degree of displacement (how far out of normal position the bones are). Treatment is determined by the type of fracture, according to the classification below.

Type I Fractures

Type I fractures are generally small, like cracks, and the bone pieces remain fitted together.

• The fracture may not be visible on initial x-rays, but can usually be seen if the x-ray is taken 3 weeks after the injury.
• Nonsurgical treatment involves using a splint or sling for a few days, followed by an early and gradual increase in elbow and wrist movement (depending on the level of pain).
• If too much motion is attempted too quickly, the bones may shift and become displaced.

Type II Fractures

Type II fractures are slightly displaced and involve a larger piece of bone.

• If displacement is minimal, a sling or splint may be used for 1 to 2 weeks, followed by range-of-motion exercises.
• Small fragments of broken bone may be surgically removed if they prevent normal elbow movement or could cause long-term problems with the elbow.
• If a fragment is large and out of place enough, the orthopaedic surgeon will first attempt to hold the bones together with screws, or a plate and screws. If this is not possible, the surgeon will remove the broken pieces of the radial head.
• The surgeon will also correct any other soft-tissue injury, such as a torn ligament.

Type III Fractures

Type III fractures have multiple broken pieces of bone which cannot be put back together for healing.

• In most Type III radial head fractures, there is also significant damage to the elbow joint and the ligaments that surround the elbow.
• Surgery is always required to either fix or remove the broken pieces of bone and repair the soft-tissue damage. If the damage is severe, the entire radial head may need to be removed. In some cases, an artificial radial head may be placed to improve long-term function.
• Early movement to stretch and bend the elbow is necessary to avoid stiffness.

Even the simplest of fractures may result in some loss of movement in the elbow. Regardless of the type of fracture or the treatment used, exercises to restore movement and strength will be needed before resuming full activities.

Olecranon fractures

Mechanism of injury

These are low-energy fractures which occur most commonly in the elderly and result from indirect trauma caused by a sudden pull of the triceps and brachioradialis muscles.

However, in younger patients, olecranon fractures usually follow a direct blow to the point of the elbow and are often comminuted, and there may be an associated ulnar shaft fracture.

Clinical features

• The patient presents with swelling and tenderness over the olecranon with haemarthrosis and limited range of motion.
• There is an inability to extend the elbow against gravity, indicating dysfunction of the triceps lever.
• There is a need to check for ulnar nerve damage and examine distal pulses.

Investigations

• True lateral X-ray of the elbow should reveal the fracture.

Management

While you are in the emergency room, your doctor will apply a splint (like a cast) to your elbow, and give you a sling to help keep the elbow in position. Immediate treatment may also include:

• Applying ice to reduce pain and swelling
• Medications to relieve pain
• Whether or not your fracture requires surgery will be determined. Not all olecranon fractures will require surgery.
• Nonsurgical Treatment
• If the pieces of bone are not out of place (displaced), a fracture can sometimes be treated with a splint to hold the elbow in place during healing. During the healing process, your doctor will take frequent x-rays to make sure the bone has not shifted out of place.
• Splints are typically worn for 6 weeks before gentle motion is started. If the fracture shifts in position during this time, you may need surgery to put the bones back together.

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Surgical treatment

Surgery is usually required for olecranon fractures in which:

1. The bones have moved out of place (displaced fracture)
2. Pieces of bone have punctured the skin (open fracture)

Surgery for olecranon fractures typically involves putting the broken pieces of bone back into position and preventing them from moving out of place until they are healed.

Because of the increased risk of infection, open fractures are scheduled for surgery as soon as possible, usually within hours. Patients are given antibiotics by vein (intravenous) in the emergency room, and may receive a tetanus shot. During surgery, the cuts from the injury and the surfaces of the broken bone are thoroughly cleaned out. The bone will typically be repaired during the same surgery.

Surgical Procedures

Open reduction and internal fixation. This is the procedure most often used to treat olecranon fractures. During the procedure, the bone fragments are first repositioned (reduced) into their normal alignment. The pieces of bone are then held in place with screws, wires, pins, or metal plates attached to the outside of the bone.

 Bone graft. If some of the bone has been lost through the wound or is crushed, the fracture may require bone graft to fill the gaps. Bone graft can be taken from a donor (allograft) or from another bone in your own body (autograft)—most often the hip. In some cases, an artificial material can be used.

Removal of the fracture fragment. If the broken bone fragment is too small to repair, it is sometimes removed. When this is done, the triceps tendon, which is attached to the fragment, is reattached to the remaining portion of the ulna.

Complications of surgery

There are risks associated with all surgery. If your doctor recommends surgery, he or she thinks that the possible benefits outweigh the risks.

Potential complications include:

• Infection. There is a risk of infection with any surgery. Your doctor will take specific measures to help prevent infection.
• Hardware irritation. A small percentage of patients may experience irritation from the metal implants used to repair the fracture.
• Damage to nerves and blood vessels. There is a minor risk of damage to nerves and blood vessels around the elbow. This is an unusual side effect.
• Nonunion. Sometimes, a fracture does not heal. The fracture may pull apart and the screws, plates, or wires may shift or break. This can occur for a number of reasons, including:
  • The patient does not follow directions after surgery.
  • The patient has a health problem, such as diabetes, that slows healing. Smoking or using other tobacco products also slows healing.
  • If the fracture was associated with a cut in the skin (open fracture), healing is often slower.
  • Infections can also slow or prevent healing.
• If the fracture fails to heal, further surgery may be needed.

Recovery

Pain Management

Most fractures hurt moderately for a few days to a couple of weeks. Many patients find that using ice, elevation (holding their arm up above their heart), and simple, non-prescription medications for pain relief are all that are needed to relieve pain.

If your pain is severe, your doctor may suggest a prescription-strength medication, such as an opioid, for a few days.

Be aware that although opioids help relieve pain after surgery, opioid dependency and overdose has become a critical public health issue. For this reason, opioids are typically prescribed for a short period of time. It is important to use opioids only as directed by your doctor. As soon as your pain begins to improve, stop taking opioids.

Rehabilitation

Whether your treatment is surgical or nonsurgical, full recovery from an olecranon fracture requires a good effort at rehabilitation.

Nonsurgical Treatment

Because nonsurgical treatment can sometimes require long periods of splinting or casting, your elbow may become very stiff. For this reason, you may need a longer period of physical therapy to regain motion.

During rehabilitation, your doctor or a physical therapist will provide you with exercises to help:

1. Improve range of motion
2. Decrease stiffness
3. Strengthen the muscles within the elbow

You will not be allowed to lift, push, or pull anything with your injured arm for a few weeks. Your doctor will talk with you about specific restrictions.

Surgical Treatmen

Depending on the complexity of the fracture and the stability of the repair, your elbow may be splinted or casted for a short period of time after surgery.

Physical therapy. Patients will usually begin exercises to improve motion in the elbow and forearm shortly after surgery, sometimes as early as the next day. It is extremely important to perform the exercises as often as directed. The exercises will only make a difference if they are done regularly.

Restrictions. You will not be allowed to lift heavy objects with your injured arm for at least 6 weeks. You will also be restricted from pushing and pulling activities, such as opening doors or pushing up while rising from a chair. You may be allowed to use your arm for bathing, dressing, and feeding activities. Your doctor will give you specific instructions. He or she will also let you know when it is safe to drive a car.

Complications of Olecranon Fractures

Even with successful treatment, some patients with olecranon fractures may experience long-term complications.

Loss of Motion

In some cases, a patient may not be able to regain full motion in the affected elbow. In most of these cases, the patient cannot fully extend or straighten his or her arm. Fortunately, the loss of a few degrees of straightening does not usually affect the overall function of the arm. Patients who have significant loss of motion may require intensive physical therapy, special bracing, or further surgery. This is uncommon for olecranon fractures.

Posttraumatic Arthritis

Posttraumatic arthritis is a type of arthritis that develops in a joint after an injury. Even when your bones heal normally, the cartilage lining the joint surfaces can be damaged, leading to pain and stiffness over time. Posttraumatic arthritis is a relatively common complication of olecranon fractures. It can occur shortly after the fracture occurs or can take years to develop. Some patients with posttraumatic arthritis may need further surgery to relieve their symptoms. However, for many patients, there is little pain and no need for further treatment.

Outcomes

Most patients can return to their normal activities within about 4 months, although full healing can take more than a year. Recovering strength in your arm often takes longer than might be expected. Although x-rays may show that the fracture has healed completely, some patients report that they still have limitations in movement. These patients will usually continue to improve over time.

Fractures of the coronoid process

Mechanism of injury

The mechanism of injury is as for elbow dislocation and such fractures are associated with elbow dislocation in about 40% of cases.

Clinical features

• Patients present with tenderness over the antecubital fossa and swelling about the elbow.
• Check strength of the radial pulse with the elbow at 90°.

Investigations

• Lateral X-ray of the elbow should demonstrate a coronoid fracture.

Management

• Non-displaced fractures should be immobilised in a long arm posterior splint with the elbow at 90° and the forearm in full supination. After three weeks, start active range of movement exercises using a sling for comfort.
• Displaced fractures or those involving >50% of process need surgical repair.

Fractures of the distal humerus

Mechanism of injury

• Supracondylar/transcondylar - most are extension-type injuries from a fall on to an outstretched arm.
• Transcondylar fractures are more common in the elderly.
• Supracondylar fractures are more common in children.

Clinical features

• The patient usually presents with elbow swelling and pain.
• Undertake careful examination for neural or vascular involvement due to risk of damage to the brachial artery and nerve.
• Marked swelling of the forearm or palpable induration of forearm flexors, with pain on passive extension of the fingers, suggests acute volar compartment syndrome requiring emergency fasciotomy.
• Up to 18% of humeral shaft fractures have an associated radial nerve palsy.

Investigations

• AP and lateral X-rays of the elbow.

Management

• All but non-displaced or minimally displaced fractures without neural or vascular involvement should be referred for surgical repair - although a Cochrane review found a lack of consensus on best surgical management.
• Immobilise the elbow in a long arm posterior splint with the elbow at 90° to the forearm in neutral rotation.
• Check distal pulses after the splint has been applied and, if absent, extend the elbow to the point where pulses return.
• Frequent checking of neural and vascular function is essential during the first 7-10 days, and ice and elevation are important in reducing swelling.
• Re-examine within 24-48 hours.
• After two weeks, patients should remove the splint and perform gentle exercises, continuing to use a splint for approximately six weeks, and then starting vigorous exercises.

Intercondylar fractures

These are T- or Y-shaped fractures with varying displacement between the condyles and the humerus.

Mechanism of injury

Commonly caused by a direct or indirect blow to the elbow. The olecranon is forced as a wedge between the two condyles of the humerus.

Clinical features

• The patient usually presents with marked tissue swelling, holding their forearm in pronation.
• The injured forearm may appear shortened.
• Crepitus of movement may be felt when condyles are pressed together.

Investigations

• AP and lateral views should reveal the intercondylar fracture.

Management

• Most fractures require surgery because they are displaced[7].
• Refer for orthopaedic opinion.
• Rarely, non-displaced fractures can be treated similarly to non-displaced supracondylar fractures, as above.

Condylar fractures

Mechanism of injury

• Lateral condyle fractures are more common than medial.
• Lateral fractures are usually due to a sudden varus stress on an elbow in extension.
• Medial fractures are due either to impact to the olecranon with a flexed elbow or sudden valgus stress on an elbow in extension.

Clinical features

• Patients usually present with swelling, limited range of movement and tenderness over the injured condyle.
• Crepitus with motion is frequently present.

Investigations

• AP and lateral X-rays reveal a widened intercondylar distance and there may be displaced fracture fragments.

Management

• Aspiration of joint haemarthrosis relieves discomfort.
• Displaced fractures require surgical correction
• Undisplaced fractures can be treated with a long arm posterior splint with the elbow at 90°.

Capitellum fracture

Mechanism of injury

These fractures are usually caused by a fall on to the outstretched hand or by direct trauma

Clinical features

• These fractures involve the distal humeral articular surface.
• Present with anterior elbow pain and effusion.

Investigations

• Lateral and AP radiography usually reveals the fracture.

Management

• Undisplaced fractures may be splinted but more usually they are displaced and require surgical fixation.

Elbow dislocation

Elbow dislocation is the second most common major joint dislocation. The 'terrible triad of the elbow' refers to a combination of elbow dislocation and radial head and coronoid process fracture - it is notoriously difficult to manage although a systematic review found that whilst complications are common, functional outcomes are generally satisfactory.
A simple dislocation does not have any major bone injury.
A complex dislocation can have severe bone and ligament injuries.

Mechanism of injury

• Often due to a fall on to an extended elbow.
• Those without fracture are termed simple, whereas dislocations with fracture are termed complex.
• They are classified according to position of the ulna in relation to the humerus after injury.

Clinical features

• Often associated with injury to brachial artery and nerve, so undertake a full examination of distal pulses, and median and ulnar nerve function.
• The patient usually presents with severe pain, with the elbow flexed and swelling and deformity apparent.

Investigations

• AP and lateral X-rays of the elbow to confirm dislocation and exclude fractures.

Management

• Prompt reduction is essential. This is usually performed under IV sedation and with adequate analgesia.
• Posterior dislocation:
• First try countertraction on the humerus while applying longitudinal traction on the wrist and forearm.
• Continue distal traction as the elbow is flexed.
• May need downward pressure on the proximal forearm.
• If this fails, place the patient face down with the elbow hanging off the side of the table and place a small pillow under the humerus just proximal to the elbow joint; hang a 2.5-10 kg weight from the wrist or apply gentle longitudinal traction.
• Usually reduces within several minutes but may need forward pressure on the olecranon.
• Anterior dislocation:
• Basically the reverse of the above, applying posterior and downward pressure to the forearm whilst applying anterior pressure from behind to the distal humerus.
• After reduction, test joint mobility and stability and check neural and vascular function. Repeat X-ray and immobilise the elbow in a posterior splint with the elbow at 90°. 

Introduction:

The ream and run procedure is a hemiarthroplasty of the shoulder. It is a partial replacement of the shoulder joint (ball and socket mechanism). During this procedure the humeral head (ball) is replaced with a metallic ball in an attempt to restore (a) smoothness of the surface (b) sphericity of the humeral head.

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The procedure was pioneered by Dr Frederick Matsen at the University of Washington (UW) in Seattle for patients who want to maintain high levels of activity and are too young to have a full replacement of the shoulder. A full replacement of the shoulder for those individuals may lead to early failure of the implant on the socket side. During the ream and run procedure the glenoid is reamed and smoothened. This socket smoothening in conjuction with the replacement of the humeral head -ball of the shoulder, allows for smooth articulation of the joint. Patients are carefully selected for this procedure as it does require intense therapy and the recovery time is somewhere between 6-12 months. The most common problem seen with this type of surgery is stiffness of the shoulder which may require manipulation or conversion to a total shoulder replacement.

Individuals who want to maintain high levels of activity can contact me to find out if they are good candidates for this surgery. Generally, it is not offered to smokers, patients with multiple medical problems, females as they have a tendency to have less than an ideal outcome. Prior surgery to the shoulder is also a relative contra-indication for this type of surgery.

During my training at the UW I had the chance to participate in a large number of those surgeries and I am grateful for the experience I received there.

Indications:

A ream and run hemiarthroplasty is commonly used in the following clinical scenarios

• Arthritis of the shoulder in a young patient, <60-65 years old, with high levels of activity
• No prior surgery or injury to the shoulder.
• it is not offered to smokers, patients with multiple medical problems, females as they have a tendency to have less than an ideal outcome.

Technique: An arthroscope (camera) was placed in this shoulder as indicated below. The video shows the formation of fibrocartilage on the socket side after the ream and run operation. This patient had an arthroscopy in attempt to obtain culture specimens to evaluate for possible infection. On the top left corner of the screen you can see the prosthetic humeral head and on bottom the socket with the fibrocartilage formation.

The following animation shows how the implant is inserted in the humeral canal and press fitted.

Rehabilitation: The rehabilitation after the ream and run hemiarthroplasty requires immobilization of the shoulder in a sling for 6 weeks. During that time passive and assistive range of motion is permited. Like the conventional hemiarthroplasty, this is necessary to allow the muscles of the shoulder to heal as those are separated and then repaired after implantation of the prosthesis. It is crucial to avoid forceful internal or external rotation of the shoulder- such as opening or closing doors with the arm. During those 6 weeks the sling can be removed for therapy and passive range of motion of the shoulder. After 6 weeks the sling is discontinued and light strengthening is started with progressive supine bench pressing, as well as scapular muscle and deltoid muscle strengthening. Patients experience the full benefit of surgery between 6-12 months from surgery.

Results: The results of ream and run hemiarthroplasty in terms of relief of pain are less predictable but very close to those of a total shoulder replacement – replacing the ball and socket of the shoulder. However, the benefit of the ream and run hemiarthroplasty is that it does not require any limitation in activity. After 6 months patients are allowed to do anything they wish to do. With the total shoulder replacement heavy activity is not permitted as this level of activity will result in early failure of the implant. The relief in pain from a ream and run hemiarthroplasty can be full, however most of the time is partial. The main reasons for a revision of a ream and run hemiarthroplasty is stiffness, erosion of the socket – glenoid of the shoulder- from the metallic ball, infection, or hardware complications such as loosening. Stiffness can be managed sometimes with gentle manipulation under conscious sedation. The frequency of those complications is somewhere between 4-10%.

The hand conditions that may affect the quality of life of a patient are plenty. These are too numerous to describe them in a single document. For more information on certain conditions of the hand that may require surgery please follow the handcare patient education portal developed by the American Society for Surgery of the Hand.

Introduction:

The total shoulder replacement is a common procedure performed for glenohumeral joint arthritis. It is a full replacement of the shoulder joint (ball and socket mechanism). During this procedure the humeral head (ball) is replaced with a metallic ball in an attempt to restore (a) smoothness of the surface (b) sphericity of the humeral head. The socket is resurfaced and a polyethylene implant is implanted that allows articulation with the metallic ball. This articulation is much more efficient in decreasing friction within the glenohumeral joint as compared to the hemiarthoplasty – partial replacement, or ream and run procedure.

The metallic implant has a stem that is press fitted into the bone canal – humeral canal. The prosthetic metallic head is attached to the stem of the implant with a morse taper mechanism.

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Patients who want to maintain high levels of activity and are too young to have a full replacement of the shoulder are not good candidates for this procedure. A full replacement of the shoulder for those individuals may lead to early failure of the implant on the socket side. That happens because studies have shown that 5-10 years after surgery there is micromotion and loosening of the implant placed on the socket, there is also wear – linear and volumetric. Interestingly, not all shoulders that have loosening of the glenoid component – socket implant have pain

Patients are carefully selected for this procedure as it does require compliance with therapy and the recovery time is somewhere between 6-12 months. The most common problem seen with this type of surgery is progressive loosening of the glenoid component- socket implant.This may or may not require revision surgery in the distant future. The survivorship of this surgery is about 80-90% at 10 years after surgery.

Individuals who want to perform basic level of daily activity and have arthritis of the shoulder can contact me to find out if they are good candidates for this surgery. Generally, it is not offered to smokers, patients with multiple medical problems that prevent us from providing general anesthesia, chronic narcotic opioid use, loss of bone stock on the socket side of the shoulder, loss of the rotator cuff tendons, active or previous serious infection of the shoulder.

Generally good candidates for this surgery are patients who are of low demand and older than 65 years old who do not work a heavy duty job and do not perform heavy duty activity in general.

Indications:

A total shoulder replacement is commonly used in the following clinical scenarios

• Arthritis of the shoulder in a patient, >60-65 years old, with low levels of daily activity
• No prior infection to the shoulder.
• Patients who have less than ideal outcomes are: Smokers, patients with multiple medical problems, multiple prior surgeries to the shoulder, active infection to the shoulder, chronic opioid use, loss of cartilage to the shoulder due prior trauma or surgery to the shoulder.

Technique: This is an animation of computer planning of the anatomic total shoulder replacement. This was generated using my software called OrthoMesh3D which it is used for detailed 3D surgical planning. It is part of the online course used by students from 21 countries on how to plan such an operation.(Udemy Website)

The following animation shows how the implant is inserted in the humeral canal and press fitted.

Rehabilitation: The rehabilitation after the total shoulder replacement requires immobilization of the shoulder in a sling for 6 weeks. During that time passive and assistive range of motion is permitted. Like the conventional hemiarthroplasty, this is necessary to allow the muscles of the shoulder to heal as those are separated and then repaired after implantation of the prosthesis. It is crucial to avoid forceful internal or external rotation of the shoulder- such as opening or closing doors with the arm. During those 6 weeks the sling can be removed for therapy and passive range of motion of the shoulder. After 6 weeks the sling is discontinued and light strengthening is started with progressive supine bench pressing, as well as scapular muscle and deltoid muscle strengthening. Patients experience the full benefit of surgery between 6-12 months from surgery.

Results: The results of total shoulder replacment in terms of relief of pain are very good with complete or near complete relief of pain. After 6 months patients are allowed to do anything they wish to do as long as it is not heavy-duty activity that places a lot of stress on the operated shoulder. With the total shoulder replacement heavy activity is not permitted as this level of activity will result in early failure of the implant. The relief in pain from a total shoulder replacement can be full, however most of the time is near full. The main reasons for a revision of a total shoulder replacement loosening of the socket side implant, usually 5-10% at 10 years after surgery –Potential complications are: infection, or hardware complications such as loosening, fracture or stiffness. Stiffness can be managed sometimes with gentle manipulation under conscious sedation. The frequency of those complications is somewhere between 4-10%. Based on my collected data from the surgeries I performed between 2016-2019 my complication rate is 5%.

Carpal tunnel syndrome is a common condition that causes pain, numbness, and tingling in the hand and arm. The condition occurs when one of the major nerves to the hand — the median nerve — is squeezed or compressed as it travels through the wrist. 

In most patients, carpal tunnel syndrome gets worse over time, so early diagnosis and treatment are important. Early on, symptoms can often be relieved with simple measures like wearing a wrist splint or avoiding certain activities.

If pressure on the median nerve continues, however, it can lead to nerve damage and worsening symptoms. To prevent permanent damage, surgery to take pressure off the median nerve may be recommended for some patients.

Most cases of carpal tunnel syndrome are caused by a combination of factors. Studies show that women and older people are more likely to develop the condition.

Other risk factors for carpal tunnel syndrome include:

• Heredity. This is likely an important factor. The carpal tunnel may be smaller in some people or there may be anatomic differences that change the amount of space for the nerve—and these traits can run in families.
• Repetitive hand use. Repeating the same hand and wrist motions or activities over a prolonged period of time may aggravate the tendons in the wrist, causing swelling that puts pressure on the nerve.
• Hand and wrist position. Doing activities that involve extreme flexion or extension of the hand and wrist for a prolonged period of time can increase pressure on the nerve.
• Pregnancy. Hormonal changes during pregnancy can cause swelling.
• Health conditions. Diabetes, rheumatoid arthritis, and thyroid gland imbalance are conditions that are associated with carpal tunnel syndrome.

• Numbness, tingling, burning, and pain—primarily in the thumb and index, middle, and ring fingers.
• Occasional shock-like sensations that radiate to the thumb and index, middle, and ring fingers.
• Pain or tingling that may travel up the forearm toward the shoulder
• Weakness and clumsiness in the hand—this may make it difficult to perform fine movements such as buttoning your clothes.
• Dropping things—due to weakness, numbness, or a loss of proprioception (awareness of where your hand is in space).

In most cases, the symptoms of carpal tunnel syndrome begin gradually—without a specific injury. Many patients find that their symptoms come and go at first. However, as the condition worsens, symptoms may occur more frequently or may persist for longer periods of time.

Night-time symptoms are very common. Because many people sleep with their wrists bent, symptoms may awaken you from sleep. During the day, symptoms often occur when holding something for a prolonged period of time with the wrist bent forward or backward, such as when using a phone, driving, or reading a book.

Many patients find that moving or shaking their hands helps relieve their symptoms.

If this condition is left untreated for a long period of time, loss of muscle strength and bulk of the thenar – base of the thumb can happen, and this is an irreversible condition. See picture below

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During your evaluation, your doctor will talk to you about your general health and medical history and will ask about your symptoms.

He or she will carefully examine your hand and wrist and perform a number of physical tests. During these tests, your doctor will:

• Press down or tap along the median nerve at inside of your wrist to see if it causes any numbness or tingling in your fingers (Tinel sign).
• Bend and hold your wrists in a flexed position to test for numbness or tingling in your hands.
• Test sensitivity in your fingertips and hands by lightly touching them with a special instrument when your eyes are closed.
• Check for weakness in the muscles around the base of your thumb
• Look for atrophy in the muscles around the base of your thumb. In severe cases, these muscles may become visibly smaller.

Electrophysiological tests. These tests will help your doctor measure how well your median nerve is working and help determine whether there is too much pressure on the nerve. The tests will also help your doctor determine whether you have another nerve condition, such as neuropathy, or other sites of nerve compression that might be contributing to your symptoms.

Electrophysiological tests may include:

• Nerve conduction studies. These tests measure the signals travelling in the nerves of your hand and arm and can detect when a nerve is not conducting its signal effectively. Nerve conduction studies can help your doctor determine how severe your problem is and help to guide treatment.
• Electromyogram (EMG). An EMG measures the electrical activity in muscles. EMG results can show whether you have any nerve or muscle damage.
• Ultrasound. An ultrasound uses high-frequency sound waves to help create pictures of bone and tissue. Your doctor may recommend an ultrasound of your wrist to evaluate the median nerve for signs of compression.
• X-rays. X-rays provide images of dense structures, such as bone. If you have limited wrist motion or wrist pain, your doctor may order x-rays to exclude other causes for your symptoms, such as arthritis, ligament injury, or a fracture.
• Magnetic resonance imaging (MRI) scans. These studies provide better images of the body's soft tissues. Your doctor may order an MRI to help determine other causes for your symptoms or to look for abnormal tissues that could be impacting the median nerve. An MRI can also help your doctor determine if there are problems with the nerve itself—such as scarring from an injury or tumor.

Nonsurgical Treatment

If diagnosed and treated early, the symptoms of carpal tunnel syndrome can often be relieved without surgery. If your diagnosis is uncertain or if your symptoms are mild, your doctor will recommend nonsurgical treatment first.

Wearing a splint or brace reduces pressure on the median nerve by keeping your wrist straight.

Nonsurgical treatments may include:

• Bracing or splinting. Wearing a brace or splint at night will keep you from bending your wrist while you sleep. Keeping your wrist in a straight or neutral position reduces pressure on the nerve in the carpal tunnel. It may also help to wear a splint during the day when doing activities that aggravate your symptoms.
• Nonsteroidal anti-inflammatory drugs (NSAIDs). Medications such as ibuprofen and naproxen can help relieve pain and inflammation.
• Activity changes. Symptoms often occur when your hand and wrist are in the same position for too long—particularly when your wrist is flexed or extended.

If your job or recreational activities aggravate your symptoms, changing or modifying these activities can help slow or stop progression of the disease. In some cases, this may involve making changes to your work site or work station.

A steroid injection into the carpal tunnel may relieve symptoms for a period of time. Nerve gliding exercises. Some patients may benefit from exercises that help the median nerve move more freely within the confines of the carpal tunnel. Specific exercises may be recommended by your doctor or therapist.

Steroid injections. Corticosteroid, or cortisone, is a powerful anti-inflammatory agent that can be injected into the carpal tunnel. Although these injections often relieve painful symptoms or help to calm a flare up of symptoms, their effect is sometimes only temporary. A cortisone injection may also be used by your doctor to help diagnose your carpal tunnel syndrome.

Surgical Treatment

If nonsurgical treatment does not relieve your symptoms after a period of time, your doctor may recommend surgery.

The decision whether to have surgery is based on the severity of your symptoms—how much pain and numbness you are having in your hand. In long-standing cases with constant numbness and wasting of your thumb muscles, surgery may be recommended to prevent irreversible damage.

Surgical Procedure

The surgical procedure performed for carpal tunnel syndrome is called a "carpal tunnel release." There are two different surgical techniques for doing this, but the goal of both is to relieve pressure on your median nerve by cutting the ligament that forms the roof of the tunnel. This increases the size of the tunnel and decreases pressure on the median nerve. In most cases, carpal tunnel surgery is done on an outpatient basis. The surgery can be done under general anesthesia, which puts you to sleep, or under local anesthesia, which numbs just your hand and arm. In some cases, you will also be given a light sedative through an intravenous (IV) line inserted into a vein in your arm. Open carpal tunnel release. In open surgery, your doctor makes a small incision in the palm of your hand and views the inside of your hand and wrist through this incision. During the procedure, your doctor will divide the transverse carpal ligament (the roof of the carpal tunnel). This increases the size of the tunnel and decreases pressure on the median nerve.

After surgery, the ligament may gradually grow back together—but there will be more space in the carpal tunnel and pressure on the median nerve will be relieved.

Recovery

Immediately following surgery, you will be encouraged to elevate your hand above your heart and move your fingers to reduce swelling and prevent stiffness.

You should expect some pain, swelling, and stiffness after your procedure. Minor soreness in your palm may last for several weeks to several months.

Grip and pinch strength usually return by about 2 to 3 months after surgery. If the condition of your median nerve was poor before surgery, however, grip and pinch strength may not improve for about 6 to 12 months.

You may have to wear a splint or wrist brace for several weeks. You will, however, be allowed to use your hand for light activities, taking care to avoid significant discomfort. Driving, self-care activities, and light lifting and gripping may be permitted soon after surgery.

Complications

Although complications are possible with any surgery, your doctor will take steps to minimize the risks. The most common complications of carpal tunnel release surgery include:

1. Bleeding
2. Infection
3. Nerve aggravation or injury

Outcomes

For most patients, surgery will improve the symptoms of carpal tunnel syndrome. Recovery, however, may be gradual and complete recovery may take up to a year.

If you have significant pain and weakness for more than 2 months, your doctor may refer you to a hand therapist who can help you maximize your recovery.

If you have another condition that causes pain or stiffness in your hand or wrist, such as arthritis or tendonitis, it may slow your overall recovery. In long-standing cases of carpal tunnel syndrome with severe loss of feeling and/or muscle wasting around the base of the thumb, recovery will also be slower. For these patients, a complete recovery may not be possible.

Occasionally, carpal tunnel syndrome can recur, although this is rare. If this happens, you may need additional treatment or surgery.

Introduction:

Collarbone or clavicle fractures are common injuries. A broken clavicle is the result of direct blow to the bone. These injuries are seen in sports, falls from heights, motorcycle or automobile accidents or altercations.

Diagnosis:

The diagnosis is established using x-rays

Treatment

Nonsurgical Treatment

If the broken ends of the bones have not significantly shifted out of place, you may not need surgery. Most broken collarbones can heal without surgery.

Nonsurgical treatment may include:

• Arm support. A simple arm sling is usually used for comfort immediately after the break and to keep your arm and shoulder in position while the injury heals.
• Medication. Pain medication, including acetaminophen, can help relieve pain as the fracture heals.
• Physical therapy. Although there will be some pain, it is important to maintain arm motion to prevent stiffness. Often, patients will begin doing exercises for elbow motion immediately after the injury.


After a clavicle fracture, it is common to lose some shoulder and arm strength. Once the bone begins to heal, your pain will decrease and your doctor may start gentle shoulder exercises. These exercises will help prevent stiffness and weakness. More strenuous exercises will be started gradually once the fracture is completely healed.

Follow-up care. You will need to see your doctor regularly until your fracture heals. During these visits, he or will take x-rays to make sure the bone is healing in a good position. After the bone has healed, you will be able to gradually return to your normal activities.

Complications. In some cases, a clavicle fracture can move out of place before it heals. It is important to follow up with your doctor as scheduled to make sure the bone stays in position.

If the fracture fragments do move out of place and the bones heal in that position, it is called a "malunion." Treatment for this is determined by how far out of place the bones are and how much this affects your arm movement.

A large bump over the fracture site may develop as the fracture heals. This usually gets smaller over time, but a small bump may remain permanently.

Surgical Treatment

If the broken ends of the bones have significantly shifted out of place, your doctor may recommend surgery.

Surgery typically involves putting the broken pieces of bone back into position and preventing them from moving out of place until they are healed. This can improve shoulder strength when you have recovered.

Open reduction and internal fixation. This is the procedure most often used to treat clavicle fractures. During the procedure, the bone fragments are first repositioned (reduced) into their normal alignment. The pieces of bone are then held in place with special metal hardware.

Common methods of internal fixation include:

• Plates and screws. After being repositioned into their normal alignment, the bone fragments are held in place with special screws and metal plates attached to the outer surface of the bone.


After surgery, you may notice a small patch of numb skin below the incision. This numbness will become less noticeable with time. Because the clavicle lies directly under the skin, you may be able to feel the plate through your skin.


Plates and screws are not routinely removed after the bone has healed, unless they are causing discomfort. Problems with the hardware are not common, but some patients find that seatbelts and backpacks can irritate the collarbone area. If this happens, the hardware can be removed after the fracture has healed.

(Left) X-ray shows a displaced clavicle fracture (arrow). (Right) The pieces of bone have been realigned and held in place with plates and screws.

• Pins or screws. Pins or screws can also be used to hold the fracture in good position after the bone ends have been put back in place. The incisions for pin or screw placement are usually smaller than those used for plates.

• Pins or screws often irritate the skin where they have been inserted and are usually removed once the fracture has healed.

Pain management. After surgery, you will feel some pain.This is a natural part of the healing process. Many patients find that using ice and simple, non-prescription medications for pain relief are all that is needed to relieve pain.

If your pain is severe, your doctor may suggest a prescription-strength medication, such as an opioid, for a few days.

Be aware that although opioids help relieve pain after surgery, they are a narcotic and can be addictive. Opioid dependency and overdose has become a critical public health issue. For this reason, opioids are typically prescribed for a short period of time. It is important to use opioids only as directed by your doctor. As soon as your pain begins to improve, stop taking opioids.

Rehabilitation. Specific exercises will help restore movement and strengthen your shoulder. Your doctor may provide you with a home therapy plan or suggest that you work with a physical therapist.

Therapy programs typically start with gentle motion exercises. Your doctor will gradually add strengthening exercises to your program as your fracture heals.

Although it is a slow process, following your physical therapy plan is an important factor in returning to all the activities you enjoy.

Complications. There are risks associated with any type of surgery. These include:

• Infection
• Bleeding
• Problems with wound healing
• Pain
• Blood clots
• Damage to blood vessels or nerves
• Reaction to anesthesia

• Difficulty with bone healing
• Lung injury
• Hardware irritation

Patients who smoke or use tobacco products, have diabetes, or are elderly are at a higher risk for complications both during and after surgery. They are also more likely to have problems with wound and bone healing.

Before your surgery, your doctor will discuss each of the risks with you and will take specific measures to avoid complications.

Outcome

Whether your treatment involves surgery or not, it can take several months for your collarbone to heal. Healing may take longer in diabetics or in people who smoke or use tobacco products.

Most people return to their regular activities within 3 months of their injury. Your doctor will tell you when your injury is stable enough to do so. Returning to regular activities or lifting with your arm before your doctor advises may cause the fracture fragments to move or the hardware to break. This may require you to start your treatment from the beginning.

Once your fracture has completely healed, you can safely return to sports activities.

Introduction:

The rotator cuff problems are very common in the general population. They are usually seen in patients who older than 40-50 years of age. It is estimated that 3.5 billion dollars are spent each year in the US to treat the rotator cuff tears. There are 250000 rotator cuff repairs performed each year in the US. This has a very significant impact to the society, if we consider that the cost of fighting diabetes mellitus in the US is 45 billion dollars per year.

The rotator cuff is a group of muscles that control the motion of the shoulder. The role of the rotator cuff in the motion of the shoulder has been studied extensively. The main function of the rotator cuff is initiation of the shoulder motion.

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The video below illustrates the anatomy of the rotator cuff:

There are different types of tear. Partial thickness tear almost like a pair of blue jeans that has wear and tear but not complete tear and full thickness tear that involves the entire tendon- essentially the tendon is detached from the bone.

Those tears are further subdivided to acute and chronic tears. An acute tear is a tear that is less than 4-6 weeks old and it is the result of a specific traumatic event. Those tears need surgery urgently, - not emergently.

Chronic tears of the rotator cuff are either traumatic which are more than 4-6 weeks old or degenerative in nature which means wear and tear over the course of years.

Statistical analysis and epidemiologic studies have shown 50-60% chance of degenerative tears after the age of 65 and 30% chance of both shoulders involved.

While it is clear that a traumatic tear needs surgery, we currently do not know whether all degenerative tears need surgery. Some degenerative tears develop so slowly over the course of years that the patient does not have pain or has minimal pain and no loss of motion or strength to the shoulder. Those tears usually do not require surgery.

Introduction:

Since orthopedic surgeons began using a tiny TV camera called an arthroscope to diagnose and treat shoulder problems, they have discovered several conditions that no one knew existed. One of these conditions is an injury to a small structure in the shoulder called the labrum. A labral tear can cause pain and a catching sensation in the shoulder. Labral tears can be very difficult to diagnose.

This document will help you understand:

1. where and what the labrum is
2. what tests your doctor will run to diagnose the problem
3. what you can do to relieve your pain

Anatomy

What is the labrum?

The shoulder is made up of three bones: the scapula (shoulder blade), the humerus (upper arm bone), and the clavicle (collarbone).

A part of the scapula, called the glenoid, makes up the socket of the shoulder. The glenoid is very shallow and flat. The labrum is a rim of soft tissue that makes the socket more like a cup. The labrum turns the flat surface of the glenoid into a deeper socket that molds to fit the head of the humerus.

The rotator cuff connects the humerus to the scapula. The rotator cuff is formed by the tendons of four muscles: the supraspinatus, infraspinatus, teres minor, and subscapularis.

Tendons attach muscles to bones. Muscles move the bones by pulling on the tendons. The rotator cuff helps raise and rotate the arm. As the arm is raised, the rotator cuff also keeps the humerus tightly in the glenoid of the scapula.

The soft labral tissue can be caught between the glenoid and the humerus. When this happens, the labrum may start to tear. If the tear gets worse, it may become a flap of tissue that can move in and out of the joint, getting caught between the head of the humerus and the glenoid. The flap can cause pain and catching when you move your shoulder. Several tendons and ligaments attach to the labrum that help maintain the stability of the shoulder. So when the labrum tears, the shoulder often becomes much less stable.

Causes

What causes labral tears?

Labral tears are often caused by a direct injury to the shoulder, such as falling on an outstretched hand. The labrum can also become torn from the wear and tear of activity, a condition called overuse. An injured labrum can lead to shoulder instability. The extra motion of the humerus within the socket causes additional damage to the labrum. An extremely unstable shoulder may slip or dislocate. This can also cause the labrum to tear.

The biceps tendon attaches to the front part of the labrum. The biceps is the large muscle on the front of your upper arm. Sports can cause injuries to the labrum when the biceps tendon pulls sharply against the front of the labrum. Baseball pitchers are prone to labral tears because the action of throwing causes the biceps tendon to pull strongly against the top part of the labrum. Weightlifters can have similar problems when pressing weights overhead. Golfers may tear their labrum if their club strikes the ground during the golf swing.

Symptoms

What does a labral tear feel like?

The main symptom caused by a labral tear is a sharp pop or catching sensation in the shoulder during certain shoulder movements. This may be followed by a vague aching for several hours. At other times, the tear may not cause any pain. Shoulder instability from a damaged labrum may cause the shoulder to feel loose, as though it slips with certain movements.

Diagnosis

What tests will my doctor run?

Your doctor may suspect a labral tear based on your medical history. You will be asked questions about your pain and past injuries to your shoulder that may suggest labral damage.

In the physical examination, there are several shoulder movements that can bring on the symptoms. You may feel a catching sensation as your arm is raised, and there may be pain when the arm is held overhead. If your arm is held in front of your body, with the palm of the hand facing downward, you may feel pain when your doctor tries to push down on your arm.

Labral tears are difficult to see, even in a magnetic resonance imaging (MRI) scan. An MRI scan is a special imaging test that uses magnetic waves to show the tissues of the shoulder in slices. The MRI scan shows soft tissues such as tendons and ligaments as well as bones.

Labral tears may be seen using computed tomography (CT) scan and a special dye. A CT scan is an older test that uses computer-enhanced X-rays to show slices of the shoulder. The soft tissues do not show up in a CT scan, but the special dye does. The dye shows the outline of the labrum. If there is a tear, the dye may leak into it and show up on the CT scan.

However, MRI and CT scans are not very accurate in detecting labral tears. Confirming the diagnosis of a labral tear can be extremely difficult. A surgeon may need to look into your shoulder using an arthroscope. The arthroscope is a small TV camera that is inserted into the shoulder joint through a very small incision. The surgeon can then see pictures of the joint on a TV screen. This allows the surgeon to look directly at the labrum to see if it is torn.

Treatment

What treatment options are available?

Nonsurgical Treatment

Your doctor's first goal will be to control your pain and inflammation. Initial treatment for pain control is usually rest and anti-inflammatory medication, such as aspirin or ibuprofen. Your doctor may suggest a cortisone injection if you have trouble getting your pain under control. Cortisone is a strong anti-inflammatory medication. It can provide good relief, although its effects are temporary.

Your doctor will probably have a physical or occupational therapist direct your rehabilitation program. Your first therapy treatments will try to ease pain and inflammation by using such treatments as heat or ice. Hands-on treatment and various types of exercises are used to improve the range of motion in your shoulder and the nearby joints and muscles.

Later, you will do strengthening exercises to improve the strength and control of the rotator cuff and shoulder blade muscles. Your therapist will help you retrain these muscles to keep the ball of the humerus in the glenoid. This will improve the stability of your shoulder and help it move smoothly during all your activities.

You may need therapy treatments for four to six weeks. Most patients are able to get back to their activities with full use of their arm within this amount of time.

Surgery

If your symptoms don't go away, you may need surgery. Surgical treatment for this condition is still evolving. Surgeons have not known about the problem long enough to adequately evaluate the results of different treatments.

Labral Debridement
The arthroscope can be used to treat many labral tears. If the tear is small and is mostly getting caught as you move the shoulder, simply removing the frayed edges and any loose parts of the labrum may get rid of your symptoms. This is called labral debridement.

Labral Repair
If the tear is larger, the shoulder may also be unstable. If this is the case, the labral tear may need to be repaired, rather than simply removed. Several new techniques allow surgeons to place small staples or anchors into the labrum through an arthroscope. The staples/anchors attach the labrum to the bone of the glenoid.

Open Procedure
If the tear is too large to repair through the arthroscope, the surgeon will need to make an incision in the front of the shoulder. The main drawback of making the larger incision is that it will probably take you longer to recover from surgery.

Rehabilitation

What should I expect after treatment?

Nonsurgical Rehabilitation

Even nonsurgical treatment requires a rehabilitation program. Some evidence suggests that shoulder instability may eventually make labral tears worse. The goal of therapy will be to strengthen the rotator cuff muscles to make the shoulder more stable. At first you will do exercises with the therapist. Eventually you will be put on a home program of exercise to keep the muscles strong and flexible. This should help you avoid future problems.

After Surgery

Rehabilitation after surgery is more complex. You may need to wear a sling to support and protect the shoulder for a few days after surgery. A physical or occupational therapist will probably direct your recovery program. Depending on the surgical procedure, you will probably need to attend therapy sessions for one to two months, and you should expect full recovery to take up to three months.

Getting the shoulder moving as soon as possible is important. However, this must be balanced with the need to protect the healing tissues. The first few therapy treatments will focus on controlling the pain and swelling from surgery. Ice and electrical stimulation treatments may help. Your therapist may also use massage and other types of hands-on treatments to ease muscle spasm and pain.

Therapy proceeds quickly after a simple arthroscopic surgery to clean up the frayed edges or loose parts of the labrum. Sessions start with range-of-motion exercises and gradually work into active stretching and strengthening. Overhand athletes start their sports gradually within four to six weeks. They can usually return to competition within three months.

After surgery to repair the labrum, therapists usually begin with passive exercises. In passive exercises, the shoulder joint is moved, but your muscles stay relaxed. Your therapist gently moves your joint and gradually stretches your arm. You may also be taught how to do passive exercises at home.

Active therapy starts about six weeks after repair surgery. Active range-of-motion exercises help you regain shoulder movement using your own muscle power. Light isometric strengthening exercises are started about this time. These exercises work the muscles without straining the healing joint.

By about the tenth week, you will start more active strengthening. Exercises will focus on improving strength and control of the rotator cuff muscles. They help tighten the ball of the humerus in the glenoid socket and can improve the stability of the shoulder. A stronger and more stable shoulder helps keep the ball of the humerus centered in the socket during all your activities.

Some of the exercises you will do are designed get your shoulder working in ways that are similar to your work tasks and sport activities. Your therapist will help you find ways to do your tasks that don't put too much stress on your shoulder. Before your therapy sessions end, your therapist will teach you a number of ways to avoid future problems.

Introduction:

Malunions are conditions in which the fractured bone heals in non acceptable angulation that may compromise the function of the limb. These are conditions in which the patient seeks medical attention due to loss of motion, function, strength or development of pain.

Diagnosis:

The diagnosis is established with plain xrays, however it is not uncommon for a surgeon to order a CT scan and perform a 3D reconstruction of the bone in attempt to better understand the deformity. This process is crucial in complex conditions especially when surgery is planned.

I am the developer of an add on module for the animation software called Blender. This software allows for surgical planning in 3D and for better understanding of the condition. Based on the 3D bone models that are generated in the computer cutting guides can be produced that allow accurate corrections of the deformity, decrease operating room time and bleeding.

Below are some videos of the software used for this purpose

Introduction:

The reverse total shoulder replacement is a relatively new procedure approved by the FDA to be used in the US in 2004. Prior to that date and in the 1980s Paul Grammont in France designed and established the reverse total shoulder replacement that we use today. Several attempts were done before, starting in the 1970s but most of these early designs had catastrophic failures.

What is a reverse total shoulder replacement?

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During this procedure the humeral head (ball) is replaced with a socket that has a polyethylene component in it and the glenoid receives a metallic ball called the glenosphere in an attempt to (a) restore smoothness of the joint surface to address the arthritis (b) provide stability of the shoulder and (c) to move the center of rotation closer to the scapula and make the deltoid muscle effectively rotate the arm.

The metallic implant has a stem that is press fitted into the bone canal – humeral canal. The prosthetic socket is attached to the stem of the implant with a morse taper mechanism.

Indications:

A reverse total shoulder replacement is commonly used in the following clinical scenarios

• Arthritis of the shoulder in an elderly patient, >70 years old, with low levels of activity
• Patients who are older than 70 years old and have loss of the rotator cuff muscles that are not amendable to repair due to retraction poor tendon quality and quantity.
• Patient with the above problem in conjuction with arthritis of the shoulder – this condition is called rotator cuff arthropathy.
• It is not offered to patients with have frequent fall, patients with multiple medical problems, fracture of the shoulder blader, or injury to the deltoid muscle or its nerves.

Technique: An incision is made in the front of the shoulder, the muscles are separated and the bone is cut and replaced with metallic as indicated in the animation below.

Rehabilitation: After the reverse total shoulder replacement the shoulder is immobilized in a sling for 6 weeks. During that time passive and assistive range of motion is permitted to the elbow and wrist. Like the conventional anatomic arthroplasty, this is necessary to allow the muscles of the shoulder to heal as those are separated after implantation of the prosthesis. It is crucial to avoid forceful internal or external rotation of the shoulder- such as opening or closing doors with the arm, or pushing off a chair with the operated shoulder. During those 6 weeks the sling can be removed for therapy and passive range of motion of the elbow and wrist. After 6 weeks the sling is discontinued and light strengthening is started with progressive supine bench pressing, as well as scapular muscle and deltoid muscle strengthening. Patients experience the full benefit of surgery between 6-12 months from surgery.

Results: The results of reverse total shoulder replacement in terms of relief of pain are excellent and very close to those of a total shoulder replacement – replacing the ball and socket of the shoulder. However, the benefit of the reverse total shoulder replacement is that it does not require any extensive therapy. The limitation is that weight lifting of more than 20 pounds is not permitted for life. This is a salvage surgery to provide elevation of the arm and pain relief, it is not designed for high levels of activity. Heavy activity is not permitted as this level of activity will result in early failure of the implant. The relief in pain from a reverse total shoulder replacement can be full, and sometimes the elevation of the shoulder is full as well. However, most of the time is partial. The main reason for a revision of a reverse total shoulder replacement is instability which used to be 30%, however the last 4-5 years with the newer implants it is only 6% when the surgery is done for arthritis. Other complications are stiffness, infection, or hardware complications such as loosening or fracture of the bone. The frequency of all complications is somewhere between 4-10%.

Introduction:

Arthroscopy of the shoulder is a minimally invasive procedure that allows diagnosis and treatment of diseases of the shoulder or elbow joint. It is performed with a “telescope” – known as arthroscope. The arthroscope is a surgical instrument that has a small camera attached at the tip. By making a small incision about the size or half the size of the tip of the index finger we can insert the arthroscope in the joint and see inside the joint. Please see video below about the definition and technique of shoulder arthroscopy.

Benefits of shoulder arthroscopy:

When arthroscopy was introduced in surgery it was seen with criticism. Many orthopaedic surgeons believed that it is a “toy”. Now, arthroscopy is one of the major advances in the field of orthopaedic surgery as it is proven to be safe, it allows for faster recovery of the shoulder and more accurate diagnosis of shoulder conditions. Many procedures that were done in the past through large open incisions now they are done through small incisions. Examples of those are rotator cuff repair, repair of torn labrum, removal of loose bodies, decompression of nerves, etc.. Infection in shoulder arthroscopy is very rare, less than 1%

Below you can watch a presentation about fixation a fracture of the socket – glenoid of the shoulder though a small camera- arthroscope. This from the technique that I developed and published in the Journal of Arthroscopy. link

Benefits of elbow arthroscopy:

Using elbow arthroscopy we can treat a variety of joint diseases such as loose bodies, tennis elbow, smoothening of the elbow joint, release of scar tissue to improve range of motion and even resection of the bone. It is minimal invasive and allows the patient to move the elbow immediately with fast recovery which is 6-8 weeks depending the reason that the surgery is performed. There is very minimal risk of infection , around or less than 1%

What are the risks of arthroscopy of the elbow or shoulder:

The main risks of shoulder and elbow arthroscopy is nerve injury. It is very uncommon in shoulder arthroscopy less than 1%. During my 10-year practice I have never had one patient that I injured a nerve around the shoulder during arthroscopic shoulder surgery. In elbow arthroscopy it is about 4% for transient numbness to the arm that resolves over a few weeks and about 1% risk of major nerve damage. In a clinical study of 253 elbow arthroscopies in which I participated as a co-author there were only a few cases with permanent elbow nerve damage. Over a 10-year period, 253 elbow arthroscopies were performed at Wake Forest University Hospital. Minor and major nerve-related complications were recorded. There were 12 reported peripheral nerve injuries, 10 minor (4.4%) and 2 major complications (0.9%). link

What about bone spurs of the shoulder or "shoulder impingement"

For updated information on this condition follow this link.

How long does it take to heal from shoulder or elbow arthroscopy

The surgical wounds usually heal in 14 days. Rotator cuff repair that is done through the arthroscope has a healing rehab time of 6 months. By 6 weeks patients remove the sling that they were and they can drive. The same timeframe applies for labrum tears of the shoulder.

Elbow arthroscopy has healing times somewhere between 6-12 weeks. Usually the sling is removed within one week and the wounds on the skin heal in 14 days.

Other minor procedures of the elbow or shoulder such as removal of loose bodies cleaning of the shoulder or removal of bone spurs have shorter recovery times, usually 6 weeks.

How long does it take to perform elbow or shoulder arthroscopy

It depends on the experience of the shoulder or elbow surgeon and the complexity of the problem being treated. When I started practicing orthopaedic surgery in my early years an arthroscopic rotator cuff repair would take me 2 ½ hours now the fastest I have performed such a repair is 35 minutes. Elbow arthroscopy takes somewhere between 30-60 minutes to be performed.

What kind of anesthesia do patients have for shoulder or elbow arthroscopy

Depending on the preference of the patient surgeon and anesthesiologist elbow arthroscopy can be performed using local regional nerve block and/or general anesthesia. For the shoulder arthroscopy general anesthesia is required and the presence of a nerve block depends on the preference of the patient and anesthesiologist.

Introduction:

Most fractures of the proximal humerus can be treated without surgery if the bone fragments are not shifted out of position (displaced). If the fragments are shifted out of position, surgery is usually required. Surgery usually involves fixation of the fracture fragments with plates, screws, or pins or it involves shoulder replacement

How does the surgeon decide what treatment is best for me?

The treatment methods are:

1. immobilization in sling
2. fixation with plates and screws or nails
3. shoulder replacement

The most significant determining factors about the best option are

• age of the patient
• concurrent injuries
• activity level and profession of the patient
• health status
• balance problems
• controlled vs uncontrolled diabetes
• presence of a nerve injury around the shoulder
• prior history of shoulder arthritis
• configuration of the fracture, displacement, number of fragments etc
• presence of osteoporosis – soft bones

Immobization in a sling example link

Fixation with plates and screws examples link link link

Fixation with nails example link

Reverse Shoulder replacement example link

Partial shoulder replacement – Hemiarthroplasty example link