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Orthopaedic Surgery Sports Medicine. Ryan Dobbs, MD Orthopaedic Sports Fellow November 15 th , 2005. Introduction. Orthopaedic Surgery Sports Medicine Team Coverage Athletic Injuries Surgery of the Shoulder Surgery of the Knee Elbow, hip and ankle arthroscopy. Purpose of this talk.

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orthopaedic surgery sports medicine

Orthopaedic Surgery Sports Medicine

Ryan Dobbs, MD

Orthopaedic Sports Fellow

November 15th, 2005

introduction
Introduction
  • Orthopaedic Surgery Sports Medicine
    • Team Coverage
    • Athletic Injuries
    • Surgery of the Shoulder
    • Surgery of the Knee
    • Elbow, hip and ankle arthroscopy
purpose of this talk
Purpose of this talk
  • Exposure to orthopaedic sports medicine
  • OrthopAedics – We have to get an A in everything.
  • Three questions
    • The questions and the answers are found in this talk.
acl injuries epidemiology
ACL Injuries: Epidemiology
  • ≈ 100,000 injuries/year
  • ≈ 1 in 3,000 people in America
  • > 50,000 ACL reconstructions/year
  • Majority occur in 15-45 year old group
    • 1 in 1750 in this age group
  • 70% occur during sports involvement
acl injuries cost
ACL Injuries: Cost
  • ≈ 50,000 reconstruction/year
  • $17,000 per procedure
  • ≈ $850 Million
    • Does not account for
      • Initial care
      • Conservative care and rehab of nonoperative management
      • Long term impact of traumatic DJD whether reconstructed or not
anatomy acl1
Anatomy: ACL
  • Originates lateral aspect of medial tibial spine
anatomy acl2
Anatomy: ACL
  • Inserts posteriorly on medial aspect of lateral femoral condyle
  • Passes through the intercondylar notch in a proximal/post/lateral direction
acl function
ACL Function
  • Limits anterior displacement of tibia on femur
  • Works in concert with the PCL
    • To provide anterior and posterior balance to the knee
    • Balance of femoral translation and roll back with flexion
  • ACL and PCL are intracapsular and extrasynovial structures
mechanism of injury
Mechanism of Injury
  • 70% noncontact
  • 30% contact
    • Valgus force most common
mechanism of injury1
Mechanism of Injury
  • 1. Sharp deceleration during or prior to a change in direction (cutting)
mechanism of injury2
Mechanism of Injury
  • 2. Single leg landing off-balance, near full extension, slight valgus, with maximally contracted rectus
presentation of acl rupture
Presentation of ACL Rupture
  • Hemarthrosis
  • Heard or felt a ‘pop’
  • Knee ‘gave out’
  • Instability since
physical exam1
Physical Exam
  • Lachman’s exam
physical exam2
Physical Exam
  • Varus/valgus
    • Full extension
    • 30 deg flexion
physical exam3
Physical Exam
  • Posterior Drawer/Sag
  • Anterior Drawer
physical exam4
Physical Exam
  • Pivot-shift
imaging mri
Imaging: MRI

Normal!

NOT!

imaging mri1
Imaging: MRI

Empty Wall Sign

Bone Bruising

acl rupture management
ACL Rupture: Management
  • 1/3 of patients are able to do normal activities without modification
  • 1/3 of patients modify activities and are able to cope
  • 1/3 are unable to cope: unstable with daily activities
treatment acl reconstruction
Treatment!ACL Reconstruction
  • Anatomical reconstruction of ACL by creation of bone tunnels and recreation of stabilizing soft tissue structure
  • Performed arthroscopically, with a tourniquet, varying techniques
knee question
Knee Question
  • The most sensitive physical exam test for anterior cruciate deficiency is:
    • A) Anterior drawer
    • B) Posterior drawer
    • C) Lachman’s test
    • D) Pivot shift test
    • E) Wallet biopsy
treatment acl reconstruction1
Treatment!ACL Reconstruction

Options include bone-tendon-bone and hamstring autografts among others

treatment acl reconstruction4
Treatment!ACL Reconstruction
  • Place and stabilize the graft
treatment acl reconstruction5
Treatment!ACL Reconstruction
  • Different methods of fixation utilized
knee question1
Knee Question
  • The anterior cruciate ligament:
    • A) Limits posterior translation of the tibia relative to the femur
    • B) Limits anterior translation of the tibia relative to the femur
    • C) Limits anterior translation of the tibia relative to the fibula
    • D) Limits anterior translation of the femur relative to the tibia
physical exam5
Physical Exam
  • Inspection
  • Palpation
  • Sensation
    • A/R/U/M
  • Range of Motion
  • Impingement
  • Motor function
    • Deltoid, Biceps, Triceps, WF, WE, IO, Opponens
    • Internal rotation, external rotation, forward flexion
    • Suprapinatus, Infraspinatus, Subscapularis
physical examination
Physical Examination

Neer Sign

Hawkins’ Sign

physical examination1
Physical Examination

Lift-off test - Subscapularis

Belly Press - Subscapularis

physical exam6
Physical Exam

Abduction/Internal Rotation –

Supraspinatus

External Rotation - Infraspinatus

shoulder question
Shoulder Question
  • The four muscles of the rotator cuff are:
    • A) Supraspinatus, Infraspinatus, Teres Minor, Subscapularis
    • B) Supraspinatus, Infraspinatus, Teres Major, Subscapularis
    • C) Supraspinatus, Infraspinatus, Teres Major, Subspinatus
    • D) Supraspinatus, Infraspinatus, Teres Minor, Subspinatus
subscapularis
Subscapularis

Origin: Subscapular fossa

Insertion: Lesser tuberosity of the humerus

Innervation: Upper and lower subscapular nn.

supraspinatus
Supraspinatus

Origin: Supraspinatus fossa of scapula

Insertion: Superior facet on greater tuberosity of humerus

Innervation: Suprascapular nerve

infraspinatus
Infraspinatus

Origin: Infraspinatus fossa of scapula

Insertion: Middle facet on greater tuberosity of humerus

Innervation: Suprascapular nerve

teres minor
Teres Minor

Origin: Superior part of lateral border of scapula

Insertion: Inferior facet on greater tuberosity

Innervation: Axillary nerve

rotator cuff question
Rotator Cuff Question
  • Name the only rotator cuff muscle not innervated by the suprascapular nerve:
    • Supraspinatus
    • Infraspinatus
    • Teres Major
    • Subscapularis
rehabilitation
Rehabilitation
  • Immobilization
    • 2-6 weeks depending on size of tear and strength of the repair
  • Passive range of motion
    • Forward flexion and external rotation
  • Active assisted/active range of motion
    • Once full range of motion is achieved
  • Strengthening
    • Isometrics
    • Bands with increasing resistance