Surgery

Orthopedics – Sports Pediatrics

Dr. Joe Bair Alonto,MD, FPOA
Aug 2020

OUTLINE - Superior Labrum and Biceps tendon

- Impingement Syndromes
PRETEST ......................................................................................................1 - Acromioclavicular joint
SPORTS MEDICINE ......................................................................................1 - Shoulder, knee, and hip
Arthroscope ...........................................................................................................................1
Shoulder .................................................................................................................................1
Knee ........................................................................................................................................3 Rotator Cuff
PEDIATRIC ORTHOPEDICS .........................................................................4 - Forceful or repeated overhead and pulling movements
Birth Injuries...........................................................................................................................4 - SITS – shoulder movement and glenohumeral joint stability
Pediatric Fractures................................................................................................................5 - Arthroscopic repair
Developmental Dysplasia of the Hip ...................................................................................6
Lower Extremity Rational Abnormalities ...........................................................................7

PRETEST
1) True or false. Use of arthroscopy is the standard of surgical
treatment for sports injuries
2) Name of the rotator cuff muscles
3) Name 1 major stabilizer of the knee
4) T or F. Brachial plexus injuries involving the hand have the best
prognosis.
5) T or F. The growth plate can be mistaken for fractures in X-ray.

SPORTS MEDICINE
- Deals with the prevention and treatment of injuries related to
sports and exercise
- Treats a broad spectrum of patients, ranging from children who
have just started participating in their first sports to the specialized
care of professional athletes Figure 2. Arthroscope picture inside shoulder joint. G: glenoid, H: humeral head.
- Steady increase pre-covid Dotted lines show some separation & fraying of the ligaments.
o Due to multiple factors:
▪ Some athletes tend to participate in more than one
sports all-year round
▪ Weekend warriors participating in sporting activities
only in a few days in a month
▪ Always an increase expectation for higher performance
- Also has to consider the patient’s attempted return to his or her
previous level of activity
- Rehabilitation plays a major role

Arthroscope
- Basic surgical intervention for ligament and cartilage injuries in
sports medicine patients
- Shoulder, knee, and hip
Figure 3. U shaped or ligamentous gap, close it with sutures under arthroscopic
repair.

Shoulder Instability
- Most common etiology is related to trauma, especially shoulder
dislocation
- Stability is provided by the following:
o Dynamically: rotator cuff
o Statically: shoulder capsule and ligaments
Figure 1. Shoulder and knee with small portals (arthroscope)
- Repeat dislocations
- Xray shoulder:
Notes: Arthroscope is putting a viewing camera inside of joints and a o AP view
device and just use a TV camera, this is very minimally invasive o glenoid (axillary) view
o “Y” view
Shoulder - Tx: reduction
o Repair of capsulolabral structures
- Rotator cuff
o Stabilization procedures
- Shoulder instability
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Figure 4. First, axillary view. Mid, Y view. Last, do bankart repair (repair
of the capsule & labrum)

Notes: Younger patients are susceptible

Superior Labrum & Biceps Tendon (SLAP Lesion)

- Labrum: stabilizer, attachment (of many muscles particularly Biceps
long head)
- SLAP (superior labrum, anterior and posterior) lesion
o A & P to biceps tendon
o Trauma or by group repetitive shoulder motion, such as in
throwing athletes
o Characteristics: Shoulder pain, discomfort
- Diagnostics:
o Xray to evaluate bony changes
o MRI coronal view
- Tx:
o Conservative (Physical therapy, NSAIDS) specially if type I,
even injections
o Surgical repair

Figure 6. Left. Bursa is inflamed because of chronic impingement. Tx: excise by

bursectomy or acromioplasty. Right. Impingement pointed by the arrow,
(subacromial space). TX: resectomy & subacromial decompression.

Acromioclavicular Joint
- Gliding synovial joint comprises of the lateral end of clavicle and
medial facet of acromion
- 3 ligaments:
o the superior acromioclavicular ligament
o the inferior acromioclavicular ligament
o the coracoclavicular ligament
- Due to: lateral blow to the shoulder
- Xrays: Bilateral AP views
- Rockwood classification (6) – measures displacement and
reducibility
Figure 5.Left: Note the difference in various types especially Type IV. Note some o 1 & 2: treated conservatively (arm sling, PT)
fraying already present, in type IV, the superior labrum has already come down to
o 3: Surgery if high demand (needs to use upper extremity for
the fraying part in the biceps tendon. Right:. MRI coronal view - SLAP lesion
showing fraying work) → surgery is needed
o 4, 5 ,6: ORIF with ligament reconstruction
Impingement Syndrome
- Subacromial space
- Range from simple bursitis to tendonitis (tear of the longhead of
the biceps / suprasinatus tendon)
- Usually the impingement occurs on maximum arm abduction and
external rotation during the cocking early ______ of throwing
- Dx: MRI, ultrasound
- Tx:
o Conservative
▪ Steroid injection – dx and therapeutic
o Surgery is recommended if conservative treatment doesn’t
relieve pain
▪ Bursectomy and subacromial decompression via
acromioplasty

Figure 7. Note the relationship of clavicle to acromion (Right clav: normal)

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Figure 9. Whole meniscus with large tear (center) crossing

Figure 8. Rock wood classification Collateral Ligaments

- Most frequently injured knee ligament → particularly MCL
Knee
- Valgus stress (lateral blow)
- Largest joint in the body - Patients would complain of a “pop”
- Axial, torsional, sheer forces - Unhappy triad:
- Major Stabilizers: o MCL injury
o ACL, MCL o Meniscus injury
- Helps in the stability: o ACL tear
o Menisci, PLC, PCL, patellofemoral joint - Dx:
o Valgus stress test in 30deg flexion
o MRI → shows disruption of the MCL
- Hughston classification: (classified depending on the end-point of
the stress test)
o I: mild, no joint laxity
o II: moderate, tenderness, mild laxity, firm endpoint on stress
test
o III: Severe, no endpoint on stress test
- Sx: repair, reconstruction

Figure 9. Knee

Menisci Injuries
- Crescent shaped Fibrocartilage
- Provides joint stability, shock absorption, low distribution and
propioception to the knee Figure 10. MRI, disruption of the MCL
- Direct contact, twisting injuries
- Pain, swelling, stiffness, catching, and lock of the knee Cruciate Ligament
- Xrays to rule out bone involvement - Providing anteriorposterior and rotational stability of the knee
- MRI → see tear on the meniscus - ACL is most commonly injured
- Tx: o Happens with twisting injury
o Small peripheral tears → conservative o Common sports injury involving stopping and cutting sports
o Large tear → Meniscal repair o Alters the knee biomechanics and kinematics
▪ Meniscal excision if tear is too big - PCL is less common
- Patients w/ACL would develop early degenerative changes if it’s not
addressed
- Pain and swelling, instability, loss of ROM, joint line tenderness and
discomfort while walking (if there is an associated meniscus
injury)
- Giving way walking down stairs
- Lachman’s test – Most sensitive test
- MRI → complete tear of ACL + bone bruising
- IMPORTANT:
o Do not heal on its own
o Sx: for the young and active (ACL reconstruction with
tendon graft)

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o Internal rotation
- MRI, CT scan → shows some acetabular overgrowth
- Surgical
o Open surgery with acetabuloplasty
o Arthroscopic → removal of the bumps
o Combined

Figure 13. CAM- offset of the femoral head-neck junction; PINCER- normal
acetabular version, excess bone coverage on a tenuous causing the
impingement

Figure 11. (arrow)- tear

Posterolateral Corner
- LCL, popliteus tendon, and popliteofibular ligament
- Contributes to the statis and dynamic stability of the knee
- Usually in combination with ACL, other ligament injuries
- Altered knee biomechanics and subsequently increases the stress
on surrounding stabilizing structures
- MRI → separation & some edema
- High grade injury requires surgery
- Sx: repair, reconstruction

PEDIATRIC ORTHOPEDICS
- Birth Injuries
o Brachial Plexus Injuries
o Cerebral palsy
- Pediatric fractures
- Developmental Disease
o Developmental disease of the HIP (DDH)
o Legg-Calve-Perthes disease
o Slipped Capital femoral epiphysis
o Lower extremity Rotational abnormalities
o Clubfoot/Congenital talipes equinovarus
o Osgood-Schlatter disease

Figure 12. MRI Birth Injuries

Brachial Plexus Injuries
HIP Femoroacetabular Impingement (FAI) - Occur in 2 births in every 1000
- Impingement of the anterior femoral head-neck junction against - Large birth weight, forcep delivery, breech presentation, and
the anterosuperior acetabular labrum prolonged second stage of labor with shoulder dystocia
o There is excess head-neck bone causing pain - Stretch injury of upper or lower plexus
- Divided into: - Upper plexus injuries (Erb-Duchenne)
o CAM o Weakness of shoulder abductors and external rotators as well
o Pincer lesion as the elbow flexors
- Can lead to labral tears, cartilage delamination, and if untreated, - The hand is not involved
osteoarthritis - Good prognosis!!!
- Groin pain worse with hip flexion - Horner’s Syndrome → indicates a preganglionic injury of the
- Impingement test: FAddIR limitations cervical sympathetic nerve
o Flexion o If this occurs with BP injury → poor prognosis
o Adduction - Tx: Passive range-of motion exercises

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o Ask the parents to move the exremities
o target: 3 mos of age!
▪ Might need Neurolysis, nerve transfer or nerve grafts

Figure 15. SALTER mnemonic

Diaphyseal Fractures
- More angulation, shortening is tolerated compared to adults
- Extensive remodeling (high potential)
Figure 14. BP injury- "waiter's tip" - Treatment is usually closed reduction in a cast, splint, brace (d/t
remodeling potential
Cerebral Palsy
o Older children lesser remodeling potential
- Injury to the brain, which may be associated with mental impairment o Thus, adolescents will need some sort of surgery
- Might happen during pregnancy birth procedures or post natal - Forearm fractures: 10 deg angulation, rotation → acceptible
- Presentations: o Elastic nail
o Spastic (most common and most amenable to operative - Femur fractures: tx depending on age
treatment) o **important to note: if there is incidence before walking age →
o Athetotic = constant succession of slow writhing and voluntary consider child abuse
movements o <6mos: Pavlik harness
o Ataxic = inability to coordinate muscle movements → o 6mos to 5 yrs: spica cast
imbalance and wide-base gait o 5-10yr: elastic nail, plate
o mixed o 11+: interlocked nail
- There’s also anatomic classification:
o Quadriplegic - total body involvement
o Diplegic - mostly the legs
o Hemiplegic - one side of the body
- Most common: spastic, hyperreflexia with increased muscle tone
- Important: early intervention with PT
o Aim: to prevent contractures
- Surgical treatment for contractures & Soft tissue releases
- Watch out for Hip dislocation or subluxation
o If present → Hip flexors, adductor release, osteotomies if older
- Knee flexion contractures: hamstring lengthening, knee brace
- Foot deformities: Shoe wear could address the problem Figure 16a. Primary fracture and elastic nails (2nd pic) b. Pavlik harness/Spica
o Equinovalgus: tendon releases cast (6 mos to 5 yrs) c. Elastic nail inserted, can use plate for bigger patients)

Pediatric Fractures
Pediatric Skeleton
- Less dense and more porous
- Lower bending strength and mineral content
- Periosteum is very thick → Incompletely ossified
- Presence of growth plate (Physis) – reserve zone, zone of
proliferation, hypertrophic zone
o Physis = Weak point
▪ If fractured → Growth arrest, angular deformity
- Ends of long bones are nonossified cartilage
- Tendon may be stronger than bone insertion sites (adolescents)
- !! Dx: xray of contralateral limb (if in doubt)

Growth Plate Injuries

- SALTeR Harris Calssification
- Xray: Contralateral limb
- Tx: Figure 17. Mid: Plastic deformation (there's no break) - Surgery is needed Right-
most: Insertion of the nail
o Anatomic reduction of the fragments
o Sx: Smooth wires
Pediatric Hip:
- Complications:
- High energy trauma, weak bone
o Leg length discrepancy
- Spica cast
o Angular deformities
- Complication: Avascular necrosis (if physis is involved)

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Pediatric Ankle:
- Salter -Harris Classification
- Tilaux fx: type 3, Fracture of the anteroalateral tibial epiphysis
- Triplate fx- complex
- Tx

Figure 19a. Barlow and Otolani b. Galeazzi Test

Pediatric Elbow:
- Complex
- Lateral condyle
- Medial epicondyle, supracondylar
- Tx: use smooth pins or wires

Figure 20. X-rays of older partient particularly 4 months old

Figure 18a. Supracondylar Fracture b. Treatment

Developmental Dysplasia of the Hip

- Dysplasia, subluxation, dislocation
- Firstborn females with a positive family history or with breech birth
- Hip instability with the first 72 hours of life
o Barlow, Ortolani
o Galleazi test
- Hip ultrasound
- Tx: To achieves stable concentratic reduction of the hip
o Neonate to 6 months: Pavlik harness
o 6mos to 18 mos: spica cast
o >18mos: open reduction, capsulorraphy
▪ Femoral, acetabular osteotomies

Figure 21. Pavlik Harness and Spina cast

Figure 22. Femoral Osteotomy

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Legg-Calve-Perthes Disease Lower Extremity Rational Abnormalities
- Idiopathic Osteonecrosis of the proximal femoral epiphysis Intoeing - Femoral anteversion, tibial torsion, and
- Between 4 and 8 years of age, males metatarsus adductus
- Common in family history, low birth weight, abnormal birth - Normal 3 to 5 years of age, usually correct
presentation, Asian Inuits, and Central European decent by age 8
- Groin or knee pain, decreased hip motion and a limp Femoral - Intoeing gait in early childhood, W sitting
- Xrays: AP and frog leg AP views anteversion - Resolves spontaneously by age 8-10;
- <6 years at presentation is most important good prognostic indicator rarely need surgery
- Goals of tx: Pain relief, range of motion, containment of the hip - Tibial torsion
- Most common causer in toddler
- Resolves spontaneously by age 4; rarely
needs surgery
Metatarsus Adduction of forefoot (at tarsometatarsal joint)
adductus with normal hindfoot alignment

Figure 23. at the left, there is osteonecrosis at the femoral epiphysis

Slipped Capital Femoral Epiphysis

- Condition of the proximal femoral physis that leads to slippage of
the metaphysis relative to the epiphysis
- Slippage through the hypertrophic zone
- Adolescent obsess males
- Endocrine disorders, Down syndrome
- Groin, thigh pain, limp, sometimes knee pain
- Dx: rays, MRI (if not evident)
- Tx: Percutaneous IN-SITU fixation
o Osteochondroplasty, proximal femur osteotomies

Figure 24. Slippage of the metaphysis

Figure 26a. Tibial Torsion b. Metatarsus Adductus

Congenital Talipes Equinovarus (CLUBFOOT)

- Equinus, varus, cavus and adduction position (CAVE)
- Idiopathic
- Genetics suggested
- Rarely needs Xray (Usually in residual)
- Tx:
o Ponseti – serial casting and manipulation ffd by tenotomy and
denis-brown brace
Figure 25. IN SITU fixation o Sx: Posteromedial release and tendon lengthening
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Figure 27. Ponseti treatment

Figure 28. Tenotomy with denise-brown brace

Osgood-Schlatter Disease
- Traction apophysitis of tibial tubercle
- Adolescent boys, jumping and sprinting sports
- Pain on anterior knee, kneeling
- Activity restriction and anti-inflammatory drugs
- Cast immobilization
- Ossicle excision (Skeletally mature px)

Figure 29. Ossification (below pointer) there is constant pull from the tibial
tubercle causing pain

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