mini group case discussion during COVID19

1. Gashaye T.
Case discussion 10

2. Q28
 A 19 year old man
participates in a
football match at an
elite level.
 He dislocates his left
shoulder during a
match 4 weeks back.
 This was his first
dislocation.
 It was reduced at
EOPD and regained
full ROM but his
shoulder feels
unstable.

3. Questions
 Describe the x ray?
 Left shoulder AP x ray
 Empty glinoid with
dislocated head
seems anteriorly
 No

4. How would you reduce in the EOPD?
 Needs analgesic and need sedation
 There are different techniques of reduction
 The commonly used is the traction counter traction
technique
 optimal technique should be quick, effective, simple to
perform and should require minimal force, analgesia
and assistance
 Option
 simple traction–countertraction
 Stimson technique
 Scapular manipulation technique
 Kocher maneuver
 Milch technique

5. simple traction–countertraction
 Hippocrates
 Sitting or supine
 Arm 45° of abduction
 elbow flexed to 90
degrees
 Gentle sustained
traction in abd and ER
position with
progressive internal
rotation and adduction
 High success rate

6. Stimson technique Milch technique
 Prone
 Manual traction
 5Ib weight
 15 to 20 min
 traction injury to a
nerve
 relies on
shoulder
position than
traction
 supine or
prone
 abducted and
externally
rotated to
overhead
 90/90 ABD/ER
 Thumb
pressure to
humeral head

7. Kocher
Scapular manipulation
technique
 Traction
 ER, Adduction
 arm is internally rotated
 If failed IR +ADD
 Complication high
 Prone position or
sitting
 Traction
 Weight
 manually
 Fix superior and
medial scapula
 push inferior tip
scapula medially
 Glenoid face
inferiorly

8.  Reduction can be checked with ROM
 Return of dugas test negative
 Post op x ray
 Immobilization with arm silng for 2 to 3wks

9. What type of instability is he most
likely to have?
 There are different
types of instability
 Anterior instability

10. Anterior posterior

11. How do you further investigate him to
describe the lesion he is having?
 This patient is young active with dislocation most likely having
bony leseion
 CT scan
 useful in defining humeral head or glenoid impression fractures
 loose bodies
 anterior labral bony injuries (bony Bankart lesion).
 Preop planning
 MRI
 identify rotator cuff, capsular, and glenoid labral Bankart lesion)
pathologic processes.
 Sub acute and chronic instablity
 Capsuloligamentous structure
 Single- or double-contrast arthrography may be utilized to
evaluate rotator cuff pathologic processes

12. What surgical option do you offer for
his instability?
 Based on the CT scan finding different surgical
option is there for shoulder instablity
 Indications for surgery include:
 First-time dislocation in young active men
….controversial
 Soft tissue interposition
 Displaced greater tuberosity fracture that remains
>5 mm superiorly displaced following joint reduction
 Glenoid rim fracture >5 mm in size

13.  Surgical option
 Closed
 Open
 involves arthroscopic ligamentous repair of the
anterior/inferior labrum (Bankart lesion).
Procedures such as capsular shift,
capsulorrhaphy, muscle or tendon transfers, and
bony transfers are reserved for refractory cases.

14. Arthroscopic Approach
 Most commonly used
 Posterior portal
 natural soft spot that exists
between the humeral head
and glenoid posteriorly –
typically around 1 to 2 cm
medial and 2 to 3 cm distal
to the posterolateral corner
of the acromion.
 Anterior portal
 the triangular space defined
by the long head of the
biceps tendon superiorly, the
upper border of the
subscapularis tendon
inferiorly, and the
anterosuperior glenoid and
labrum medially

15. Open surgery
 Anterior or posterior approach
based on type dislocation and
presence of lesion
 Anterior approach deltopectoreal
approach
 Land mark coracoid process and
anterior axillary line
 Three layer
 Clavipectoreal fascia
 Deltoid and pectoreal interval
…cephalic vein lateral
 Conjoined tendon take care of
musculocuat n. About 5cm from
origin
 Subscapularis muscle
 retract or cut from insertion about
1cm reppair latter
 Capsule –ruptured or incise in T
shape with horizontal limb based on
actual defect

16. Posterior approach
 Land mark
 PL acromion and
posterior axillary line
 Deltoid fascia
 Split or elivate posterior
origin of deltoid
 Use interval of infra
spinatous(bipanate and
wide ) and T.
minor(unipanate and
narrow) or release T
.minor from insertion
1cm
 Capsule incision T
shape

17. Option of management
 Soft tissue reconstruction
Glenoid labrum repair

18. Capsulorrhaphy
 Decreases capsular volume
 The capsular repair and shift are done with the
glenohumeral joint in 45 of abduction and external
rotation
 Even in patients with high functional demands, this
procedure has been associated with good to excellent
results in 92% to 96% of the patients, with recurrent
dislocation in only 0% to 4% of the patients

19. BONE RECONSTRUCTION
 Based on the degree of bone defect

20. Glenoid size defect measurement on
CT or arthroscopically

21. Treatment plan considering both
bony bankart and hill-sachs lesion

22. Post op
 Rehablitation may take years
 4-6 week
 Sling
 Flexion abdaction and ER STARTED PROGRESSIVLY
 BY 8-10 weeks
 Increase ROM and muscle strength
 Static strengthening exercises
 By 3 month
 Increase previous activities to functional and sporting level.
 Dynamic activities
 Patients are typically allowed full use of their shoulder by 6
months after the procedure.
 However, participation in high-demand activities and contact
sports may be delayed up to 9 month

23. Q 29
 This is the x ray of a
30 year old man who
present with
progressively
increasing painful
mass around his left
knee for past 5
months

24. Questions
 Describe the x ray
findings?
 AP and lat x ray of left
knee
 Perimitive bone
forming with hair on
end appearance of
periosteal reaction
disrupted cortex over
the meta diaphysis
area of the distal
femur
 No significant soft
tissue mass

25.  What do you think is the most likely diagnosis?
 osteosarcoma

26.  How do you investigate this lesion further?
 Routine IX
 CBC&ESR,CRP
 Serum lactate dehydrogenase
 MRI of the thigh
 CT scan of chest or x ray
 Bone scanning
 OFT

27. What are the principles of performing
open tumor biopsy?
 Purpose of the biopsy is to
confirm a suspected diagnosis
 The biopsy is not a substitute for
a thorough history, physical
exam, and laboratory
investigation
 prerequisites for a biopsy
 CBC, platelets, coagulation
studies
 cross-sectional imaging to
evaluate local anatomy
 treatment center performing
biopsy must be capable of
proper diagnosis and treatment
 Indications
 aggressive bone or soft tissue
lesions
 soft tissue lesions larger than
5cm, deep to fascia, or overlying
bone/neurovascular structures
 unclear diagnosis in a
symptomatic patient
 solitary bone lesions in a patient
with history of carcinoma
 not indicated
 asymptomatic latent bone lesions
or a symptomatic active bone
lesions which appear entirely
benign on imaging don't
necessarily need a biopsy
 soft tissue lesion which are
completely benign on MRI don't
necessarily need a biopsy (e.g.
lipoma, hemangioma)

28. Open biopsy principle
 aim is to obtain a representative sample of tissue
• to make or confirm a diagnosis &
• stage the lesion without compromising further treatment
• Musculoskeletal neoplasms should be evaluated completely before
biopsy is done
Principles
1. do not harm
2. last step in evaluation
3. performed by Rx surgeon and it’s a major procedure
4. biopsy better performed in treatment center than at referral center
5. ensure expert pathology facilities
6. tourniquet: no exsanguination, release before closure
7. should be done under GA
8. biopsy track should be considered contaminated with tumor cells

29. Cont.
 Avoid transverse incisions
 go through a single muscle
compartment during deep incision
 Major neurovascular structures should
be avoided
 sample the leading edge
 round or oval hole to minimize stress
concentration
 Frozen section should be sent
intraoperative
 drain should exit in line with the
incision
 wound should be closed tightly in

30. How do you stage him?
Staging
1. aid in planning the course of
treatment
2. provide insight into the
prognosis
3. assist in evaluating the
results of treatment
4. facilitate effective
interinstitutional
communication
5. contribute to continuing
investigation of human
malignancies
 Two staging system
 Enneking System
 AJCC Staging System
 Enneking system –
reliable & reproducible
 malignant lesions are
defined using Roman
numerals ( I, II, III)
 benign lesions are
defined using Arabic
numbers (1,2,3)

31. Compartment - inherent barriers to tumor
spread, including fascial planes and bone
structures

32. Outline your treatment options after
the lesion is identified and staged?
 Once early diagnosis staging done with biopsy
and imaging early treatment is needed
 Principle of treatment for osteosarcoma
 Neoadjuvant chemotherapy
 Surgery -wide margin
 Adjuvant chemotherapy

33. Cont.
 Neoadjuvant
chemotherapy role
 immediately treat
micrometases
 used to evaluate the effect
of each drug directly by
imaging
 provides a safety margin
for resection
 permit potentially less
resection of normal tissue
if there is a significant
response
 allows time for surgical
planning, manufacture
prostheses, and

35. Are you aware of any prognostic
indicators?
 With Only wide or radical amputation
 80% of pts died usually within 2yrs
 Multiple-agent chemotherapy +
Appropriate surgical Rx
 high-grade lesions without metastases long-term
survival of 60% -75%
 patients with low-grade lesions long survival rate is
90%

36. Factors affecting
prognosis
 Tumor stage
 Metastasis poor
prognosis
 Pulm met seen in 15%
of pt < 20% long-term
survival
 Extra pulm <5% long
term survival
 Grade of the lesion
 High grade poor
 Size of the primary
tumor
 Larger size poor
 Skeletal location
 Proximal poor
 Histologic sub type
 Histologic responsee
after neoadjuvant
 LDH and ALP
 Nature of osteosarcoma
 Secondary esp paget
and irradation poor
 Race
 Black worse than white

37. Is limb salvage surgery(LSS) feasible
in this patient?
 This patient is possibly stage IIB at least LLS less
likely
 LLS is indicated Enneking stage IA & IIA
 Ennekingstage IB & IIB
 Radical excision = Amputation / Disarticulation
 For metastasis
 operable resect both metastasis and amputation for
primary then chemo and radio
 For non operable
 Pallative Rx
 chemo

38. • What are the contraindications for LSS?
 major NV involvement
 Pathologic #
 Infection
 Extensive muscle involvement
 Inappropriate biopsy sites
 Skeletal immaturity

39. Q30
 This the x ray of a 40
year old carpenter
who sustained FDA
from a 20 meter
height building.
 He has no other site
injury.
Mechanism of calcaneal #

40. Questions
 What does this
radiograph show?
 Lt calcaneal fracture
with tongue type
displaced fracture

42. Can you classify this fracture?
 Classification systems are designed to facilitate
communication among surgeons, plan operative
procedures, and assist in determining outcomes
 Different classification
 Closed vs open
 Extra articular vs Intra articular
.

43.  Extra articular
 Anterior process
fractures
 Tuberosity fractures
 Medial process
fractures
 Sustentacular
fractures
 Body fractures
 Intra articular
 Essex- Lopresti
classification
 sanders classification

44. Essex- Lopresti based on x ray
 A tongue-type fracture,
where the articular
fragment remained
attached to a tuberosity
fragment
 Secondary fracture line
runs straight back to the
posterior border of the
tuberosity, from the
crucial angle of Gissane
 joint-depression–type
fracture, in which the
articular fragment was
separate from the
adjacent tuberosity

45. sanders classification
 Based on Posterior Facet
 After coronal CT

46. What are the principles of
management for this type of injury?
 Goal
 restore congruity of subtalar joint
 restore Böhler's angle and calcaneal height
 restore width
 correct varus malalignment
 Both non operative and operative

47. Non operative
 small extra-articular fracture (<1 cm) with intact
Achilles tendon and <2 mm displacement
 Sanders Type I (nondisplaced)
 near normal Böhler's angles (20-40°)
 anterior process fracture involving <25% of
calcaneocuboid joint
 comorbidities that preclude good surgical outcome
(smoker, diabetes, PVD)
 minimally displaced tuberosity fractures (<1 cm of
displacement) without threatened soft-tissue envelope
in elderly patients with reduced function or physical
capacity
 Stress fracture

48. How?
 placement of a bulky Jones dressing
 elevation
 supportive splint & short leg casting for 6wks
 Early subtalar and ankle joint ROM exercises
 non–weight-for approximately 10 to 12 weeks,
until radiographic union

49. Operative
 Displaced intra-articular fractures involving the
posterior facet
 Anterior process of the calcaneus fractures with
>25% involvement of the calcaneal–cuboid
articulation
 Displaced fractures of the calcaneal tuberosity, with
or without skin compromise
 Fracture-dislocations of the calcaneus
 Open fractures of the calcaneus
 Option
 Percutaneous reduction techniques
 Open reduction and internal fixation
 Primary arthrodesis.

50. closed reduction with
percutaneous pinning indications
 minimally displaced tongue-type fxs or those with
mild shortening
 large extra-articular fractures (>1 cm)
 early reduction prevents skin sloughing and need
for subsequent flap coverage
 ideal in patients with sever peripheral vascular
disease or severe soft-tissue compromise
 techniques
 lag screws from posterior superior tuberosity
directed inferior and distal

51.  ORIF indications
 displaced tongue-type fractures
 >1 cm displacement
 threatened soft tissue
 require urgent reduction and fixation to avoid skin necrosis (disastrous
consequence)
 open fractures
 open reduction allows for sufficient debridement of contaminated tissue
 inability to participate in closed treatment
 large extra-articular > 2 mm displacement
 Sanders Type II and III
 posterior facet displacement >2 to 3 mm, flattening of Bohler angle, or
varus malalignment of the tuberosity
 anterior process fracture with >25% involvement of
calcaneocuboid joint
 displaced sustentaculum fractures

52. Timing
 Emergency
 Open
 Vascular injury
 Comp sxx
 Urgently
 For calcaneal avulsion fracture displaced calc
tuberosity fracture with compromised posterior skin
 Other wise wait till blister subside 10 to 14 days
 No benefit from early fixation

53.  Potion
 Lag screw
 Plate
 Arthrodesis
 Approach
 Extensile lateral
or medial
 Sinus tarsi
approach
 Arthroscopically

54. What are the short- and long-term
consequences of calcaneal
fractures?
 surgical outcome correlates with the number of
intra-articular fragments and the quality of
articular reduction
 surgical treatment decreases the risk of post-
traumatic arthritis
 Use of proper surgical timing/technique/asepsis
can lead to good or excellent results in more than
90% of patients and avoiding the majority of the
complications

55. List the poor prognostic factors in
patients with calcaneal fractures?
 age > 50 (similar outcomes with surgical and nonsurgical
treatment)
 obesity
 initial Böhler's angle <0° (these injuries do poorly regardless of
treatment)
 lower Böhler angles suggest greater energy absorbed
 manual labor
 open fractures (significant soft tissue injury and engery
absorbed)
 workers comp
 smokers (poor wound healing)
 bilateral calcaneal fractures (significant gait problems following
bilateral injuries)
 multiple trauma
 vasculopathies
 men do worse with surgery than women

56. Are you aware of any literature showing a difference
between non-operative and operative management
of calcaneal fractures? Controversial

58.  Thank you!