This document discusses several orthopedic conditions including fractures, frozen shoulder, shoulder bursitis, rotator cuff injuries, infectious arthritis, and osteosarcoma. It provides details on the epidemiology, etiology, clinical presentation, diagnostics, management, and prognosis of each condition. Fractures are discontinuities of bone that can result from trauma or weakened bone. Frozen shoulder is a condition of shoulder stiffness and pain. Shoulder bursitis involves inflammation of bursae around the shoulder joint. Rotator cuff injuries commonly involve tears of the supraspinatus tendon and are a leading cause of shoulder pain. Infectious arthritis occurs when bacteria invade the synovium of joints. Oste

1. YL3 - SGD A1 Atienza, Baculna, Escobal, Malaluan, Moreno
Dx Description Epidemiology Etiology and
Pathophysiology
Clin. Manifestation Diagnostics Management Complication Prognosis
Fracture Discontinuity of the
bone cortex
W/ a degree of
damage to
surrounding tissues
LI: Shoulder
fractures
Types
1) Proximal
Humerus (ring
around anatomic
neck, greater
trochanter, lesser
trochanter)
2) Scapula (very
uncommon because
typically because of
high energy trauma
and associated with
other injuries)
3) Clavicle Fracture
(most common
~10% of all
fractures)
Accounts 4-6% in the
young and 1-3% in
elderly patients.
Increase in pediatric
px because they are
more active than
older patients.
Women after a
ground level fall
because of their
fragile bony
structure.
It can result from trauma,
mechanical force
Weakened bone
- (metastasis, bone
cyst) - pathologic
fractures
- Genetic
abnormalities
(osteogenesis
imperfecta) -
insufficiency
fractures
Chronic application of
abnormal stresses - fatigue
fractures
For younger patient HIGH
ENERGY TRAUMA
Popping sound
Severe fracture -
erythema of the sound
and pain
Holding on to elbow -
assessing their reaction to
certain movement
Bruises
Tenderness
Pain to touch
No to hilot as it may
worsen the condition and
lead to other diseases (e.g
bursitis)
Neurovascular status
important
Shoulder fractions have two
XRAYs:
- shoulder AP view
(glenohumeral joint is in
the natural anatomic
position and shows the
humeral head
superimposing glenoid of
scapula + displays the
entire clavicle, AC joint,
scapula, superior ribs, and
sternoclavicular joint, and
proximal humerus)
- lateral or scapular view
(profile view of scapula)
Protection - limited the use of injured part
(splint, cast, crutches)
Rest - prevent further injury
Ice
Compression
Elevating the injured limb above the heart
for the first two days
Medication: analgesic drugs for the pain
Acute
Bleeding, vascular injuries,
nerve injuries, fat
embolism (fracture of long
bones releases fat →
pulmonary embolism),
compartment syndrome
(pressure disrupts vascular
supply - increased in
pressure may come from
edema development),
infection
Long term
Instability, stiffness,
impaired ROM, non-union,
malunion (wrong
alignment), osteoarthritis,
and limb length
discrepancy
Healing time varies (different between
patients)
Most fractures - up to 18 months, in
adults - 3months
Frozen Shoulder
(adhesive
capsulitis)
Inflammatory
condition
characterized by
shoulder stiffness,
pain, and significant
loss of passive range
of motion. Intrinsic
shoulder disease is
often absent.
AAOS: a condition of
varying severity
characterized by the
gradual
development of
global limitation of
active and passive
shoulder motion
Prevalence ~2-5% in
the general
population
Mean age of onset:
65 years and above
Female
predominance 1.4:1
Nondominant hand
is usually affected
Comorbid conditions
that predispose:
thyroid disorder, DM
Classification
* secondary or primary
Primary
- Idiopathic but
associated with
comorbidities
SEcondary
- After trauma
- Common injuries -
rotator cuff tears,
fractures,
immobilization
-
Exact mechanism is
unknown
Predominant symptoms:
pain and limited ROM
Pain - inflammation and
fibrosis
ROM - fibrosis and
adhesions
Thickening of capsule,
inflammatory infiltrates
and fibrosis
Difficulty in abduction,
external rotation
Kinalawang - hinged
Criteria
I. slow onset shoulder pain
Ii. Localized discomfort
Iii. Inability to sleep on
affected side
Iv. Restricted gleno-humeral
elevation
V. Extensor rotation
Vi. Normal radiologic
appearance - sometimes,
osteopenia will be found
Diagnosed clinically - loss of
passive ROM
Systemic symptoms - MRI
Arthrography with contrast
material - if <15ml capacity
only
Conservative treatment - prednisone (know
if with DM); NSAID (if pt is not on
prednisone)
Physical therapy
Physician directed home therapy
Surgical treatment if conservative treatment
is not effective
Contrast material has therapeutic effects
Residual pain/stiffness
Manipulation may lead to
tendon rupture
Generally self-limiting
Typically resolves in 1-3 yrs
No reported diff. b/w pain and disability
in pts with DM
Long-term pain/stiffness after
treatment - 5% disability ; 7-15%
function loss; 40% persistent symptoms

2. Shoulder
Bursitis
Bursae - sacs
surrounding the
synovial fluid
0.4% of all primary
care visits
Gender prevalence is
equal in M & F
Older in individuals
it is because of years
of wears
Most common form
is the subacromial
bursitis often
accompanies rotator
cuff tendinitis
Caused by
● repetitive overhead
activities (Athletes,
factory workers,
manual laborers)
● Minor trauma or fall
● Long periods of
wear and tear
● Crystal deposition
● Subacromial
hemorrhage
● Autoimmune
disease
● Infection
● Impingement
syndrome
Can be multifactorial also
● Pain in the
anterolateral
● Usually does not
radiate but if
present, would
often point to
underlying
pathology
● Point tenderness
● Skin is warm but
no erythema
(rare)
●
History and PE
Lab tests are usually
unremarkable
Imaging - not really
necessary
Xray - to R/O other causes
of pain
Utz, MRI - excellent
imaging; associated tendon
lesions; eval thickness of
bursa
Ave shoulder: Thickness of
bursa ~0.25mm
W/ bursitis: ~1.27mm
Usually nonoperative
● Rest
● NSAIDs
● Physical therapy
● Corticosteroid injection
If conservative treatment is uneffective or
with recurrence
● Bursectomy or compression
● May also address problems with
rotator cuff
Rotator cuff damage Self-limiting condition
No long-term impact
Most improve with therapy
Worsens as pt gets older
Rotator Cuff
Injury
Suraspinatus is most
commonly affected
Infra- not involved
Associated with
Impingement
syndrome
Common cause of
pain in all age group
10% - children
30% - adults
62% - >80yo
RF
Age is most common factor
Smoking
Fam history
Poor posture - 50% more
likely
Trauma
Hypercholestorelimea
Occupational activities that
req significant overhead
activity
Partial tears factors
Size - small may remain
dormant
Symptoms - actively
enlarging tears
Location - anterior are more
likely to progress
Age - >60 develop tears that
progress
Macrotrauma - tear
Elderly - microtrauma -
degenerative tear
● Pain (acute; from
trauma)
● Difficulty w/ overhead
activities
● Pain can radiate to
deltoid muscle
● Tenderness on
insertion of 3 SITS
muscle
● Limited ROM
associated w/ pain
Xray - narrowing
Utz - eval of dynamic
movement
MRI - gold standard; can
show tear size, location,
atrophy, tendon and muscle
changes
History and PE
Depends on age , functional demands
● <40yo w/ complete tears - surgery w/
rehab
● Most traumatic injuries respond well
● Weak evidence against surgical therapy
● Physical therapy also works
5 categories
● Repair______
● Healthy pt, asymptomatic - repair
● Rotator cuff injury, symptomatic - surgcal
treatment
● Chronic massive tears -debridement and
reconstruction
● Painful pseudoparalysis w/ irreparable
tear - arthroplasty
Asymptomatic tear - nonoperative
management
Newly diagnosed tears - PT for muscle
strengthening
No clear advantage b/w surgical and non
surgical treatment
Algorithm
__________
Adhesive capsulitis
Weaker cuff strength
Infectious
arthritis
Mostly bacterial;
may also be fungal,
viral, etc
2-6 / 100,000
children> adults
Peaks b/w 2-3yo
M>f; 2:1
Mc. staph aureus
Streptococcus pneumoniae
Sexually abused - Neisseria
gonorheae
______
Systemic:Ill appearance,
fever, tachycardia,
Evaluation:
synovial fluid analysis:
culture, gram stain, crystal
analysis, WBC count
Can be caused by a plethora of causative
mcgs
● Antimicrobial therapy
Morbidity - ⅓ of pt
- Increase w/ age
- Joint disease

3. Orthopedic
emergency
Can cause
significant joint
damage and cause
death
RF for children
● Hemophilia
cs
● Immunoco
mpromised
(sickle cell,
HIV)
● Treated w/
chemo
RF for adults
● Starts at
80yo
● Comorbiditi
es (DM,
recent
surgery,
arthritis,
ulceration)
● HIV
● Sexual
activity (
gonococcal
infection)
Trauma
Abdominal infection
Might be due to punctured
wounds, intraarticular
injections, contiguous
spread, hematologic problem
(osteomyelitis)
Occur w/ bacterial invasion
of synovium - inflammatory
process
irritability, decreased
appetite
Most staph infections -
monoarticular
Neisseria - multiple joints
(polyarticular)
Group B Strep:
sternoclavicular, sacroiliac
joints
Joints affected with
prosthetics - drain sinus
(>50,000) with diff
(increased neutrophil)
Laboratory
CBC, ESR, CRP, blood
cultures
Imaging
Plain radiograph: widened
joint spaces, bulging of
some tissues or
subchondral bony changes
(normal radiograph does
not r/o IA)
MRI: sensitive for the early
detection of joint fluid and
delineates the extant of
cartilaginous involvement
Bone scan: not specific but
useful in evaluating
sacroiliac, and hip joint
- Empiric - done after aspiration;
anti-staph, anti-neisseria -
vancomycin; immunocompromized,
3rd gen ceph;
- Gram stain
● Joint fluid drainage
- If affected area is hip, shoulder or
prosthetic joint, inadequate
aspiration of fluid, no improvement
○ Daily needle aspiration
Complications:
- Osteomyelitis
- Chronic pain
- Osteonecrosis
- Discrepancy in leg
length
- Sepsis (leads to
death)
Osteosarcoma
Spindle cell
neoplasm that
produces osteoid.
Deadly form of msk
cancer. The common
cause of death of px
is pulmonary
metastatic disease.
Most arise as
solitary lesions with
the top 3 affected
areas: distal femur,
proximal tibia, and
humerus. Although
it could affect any
bone. Multifocal is
rare and occurs in px
younger than 10
years.
Classification
75% - classic
(composed of
obsteoblastic,
chondroblastic,
fibroblastic)
25% - variant (based
on the clinical,
morphological
Considered as the
most common
malignant bone
tumor
40% are
osteosarcoma
60% are in
children/adolescents
until 19 years old
10% are in the third
decade of life
In those in the 5th
decade are due to
radiation therapy
Bimodal age
distribution
(diagnosed at
2nd-3rd decade and
second peak at >65)
Males > females
(1.5-2x)
Black > white
Usually occurs in the
metaphysis of the
long bone
distal femur,
proximal tibia, and
proximal humerus
Unknown exact etiology and
pathophysiology
Risk Factors
1. Rapid bone growth
2. Genetic
predisposition (RB
gene is the
commonly mutated
+ radiation therapy
= increase in risk) Li
Fraumeni Syndrome
(p53), Roth
3. Environmental Risk
Factor - radiation
induced (secondary
cancer in mostly
elderly)
- May present for
weeks and
months before px
is diagnosed
- Most pressing
symptom: pain
w/ activity
- Often w history
of trauma
(unclear
contribution)
- Swelling is
dependent on
size and location
- Systemic
symptoms are
rare
- Findings are
limited in the site
of primary tumor
(palpable mass
may or may not
be present -
increased skin
vascularity,
pulsation or bruit
may be found)
- Decreased ROM
Laboratory Studies
- Relate to the use
of chemotherapy
(monitoring of
organ fxn)
- ALP and LPH are
the most impt test
- CBC
- Liver Function
(ALT, AST)
- Electrolyte level
(sodium
- Renal Function
Tests
Imaging Studies
Plain radiography (Xray)
- Elevation of
periosteum (new
bone formation)
CODMAN
TRIANGLE
- Sunburst
appearance
Bone Scanning
- 99 MPC/MDP/MPI
- Multifocal disease
(metastasis)
- Not always used
CT Scan
Chemotherapy
● Diet is not restricted
Excision
● Wide-resection; margins on all side
must contain normal tissue
Limb-sparing surgery
● Resection
● Reconstruction
○ Not required for
Non-weight bearing bones
○ 2 types: endoprosthetic
replacement and
biological reconstruction
Biological reconstruction
- Allograph, autograph,...
-
Depends on staging and using of
appropriate management for diff.
stages

4. characteristics, and
location
- Involvement is
obvious on PE
- Lymph node
involvement is
uncommon
- Obtained before
biopsy (less
ambiguity that
arise after
post-anaesthesia
atelectasis)
- Metastasis
MRI
- Best method of
assessing
intramedullary
disease, soft
tissues masses,
skip lesions
- MOST ACCURATE
for surgical system
- Enneking Staging
System
Histologic grade
Anatomic location
presence/absence
of metastasis
IA: low, intra
IB: low, extra
IIA: high, intra
IIB: high, extra
III: w/ metastases
Intracompartmental: any
individual bone, intra
articular space