OrthoConnecticut

By Dr. Jerome Barton, MD

Nursemaid’s elbow is a common injury occurring in preschool children usually between the ages of one and four. It is a partial dislocation (subluxation) of the upper end of the major forearm bone (radial head) when it slips partially out of the annular ligament which holds it in place.

It is frequently caused by an adult pulling on the child’s extended arm. The child is most often offering no resistance to the pull. The radial head is pulled downward out of its usual position where it is held by the annular ligament.

The child experiences pain and may later be relateively comfortable but will resist elbow motion. He or she will refuse to use the arm and will hold the arm against the body with the palm facing downward. It is usually evident that there has been an injury but it is sometimes hard to judge exactly where. There is usually no swelling associated with Nursemaid’s elbow.

A careful history including the pulling incident, the absence of a history of trauma, the absence of swelling and a gentle examination will usually make the diagnosis evident. X-rays are usually not necessary unless fracture is suspected.

The subluxation is reduced by the doctor by completely supinating the forearm by turning the palm upward. A click at the elbow can be felt as the radial head slips into place. After reduction the child is comfortable and returns to using the arm. No further treatment is necessary. If reduction was difficult or required several attempts or recurs, the elbow can be immobilized in a splint for a short time.

Nursemaid’s elbow may recur and parents should be careful to avoid traction on the arm and should so instruct other caregivers. It is very rare to have any residual problems from Nursemaid’s elbow even after recurrent episodes.

Nursemaid’s elbow is a relatively common problem in preschool children. It responds to gentle reduction, may recur but will respond to repeat reduction. It will stabilize with growth and usually has no long term effects.

 
 

By Dr. Jerome Barton

Injuries to the acromioclavicular joint are also known as shoulder separation injuries. They are distinct from shoulder dislocations which take place at the shoulder joint itself, the gleno-humeral joint. Shoulder separations occur at at the small joint at the top of the shoulder where the outer end of the clavicle ( collar bone ) meets the acromion, the superior outermost portion of the scapula

Injury to the acromioclavicular joint (AC joint) usually occurs from a fall on to the outer portion of the shoulder and usually with the arm at the side. It is characterized by varying degrees of pain and swelling dependent upon the extent of the injury to the supporting ligaments. The patient will point directly to the top of the shoulder as the painful injured area.

The AC joint is held together and stabilized by the acromioclavicular ligaments that surround the joint and by the very strong coracoclavicular ligaments that hold the clavicle at its mid portion to the coracoid, another adjacent part of the scapula.

The extent of injury to the AC joint is determined by the degree of trauma sustained and is measured by the extent of injury to both the AC (acromio-clavicular ) and CC ( coraco-clavicular ) ligaments.

Injuries to the acromioclavicular joint may be classified into three major groups.

Grade 1 injuries are a sprain or partial tearing of the AC ligaments and capsule that surround the AC joint and do not give rise to any clavicular instability.The coracoclavicular ligaments remain intact.

Grade 2 injuries involve a complete rupture of the AC ligaments and capsule and allow some displacement ( subluxation ) of the clavicle from its normal relationship to the acromion. The patient presents with pain and swelling about the AC joint and possibly some limited prominence of the distal end of the clavicle.

In both Grade1 and Grade 2 injuries the coracoclavicular ligaments remain intact.

Grade 3 injuries involve complete tearing of both the AC and CC ligaments and those injuries allow significant upward and posterior dislocation of the clavicle in relation to the acromion. The patient presents with considerable pain and swelling and obvious upward displacement of the clavicle.

Treatment of these injuries varies, of course, with the extent of injury.
Grade 1 injuries are treated with ice for swelling, possibly anti-inflamatories and analgesics as needed and a sling for support. As the acute symptoms subside a self-administered or formal therapy program is used to help regain motion and function and when appropriate the shoulder is guided back to a full activity schedule. The results are almost always good.

Grade 2 injuries are treated in a similar conservative manner. They take longer to resolve but results are usually good as is the return of function of the A-C joint. On occassion Grade 2 injuries may result in late symptoms related to the AC joint Attention to the joint at a later date will usually yield good results.

Grade 3 injuries are also mostly treated conservativly and on occassion with support to bring the clavicle down to more normal position. There are further subclassifications of the Grade 3 injury depending on the degree of soft tissue damage. Grade 3 injuries are frequently considered for surgical repair. Surgical repair involves operative fixation and repair of both the CC ligaments and the AC joint and the other injured soft tissue structures. Results are usually good but both the extent of injury and surgery lead to a more prolonged recovery and rehabilitation period.

Rehabilitation is an important part of the recovery process and becomes more important and prolonged with the more severe Grade 2 and 3 injuries. The patient must be guided through a program designed to recover range of motion, strength and neuromuscular control of the shoulder.

Results of treatment for AC injuries are generally quite good for the less extensive injuries but results may be compromised to some degree in the more extensive injury. Patient perception of outcomes will vary with age and functional demands of the shoulder.

In summary – Acromioclavicular separation is usually caused by a fall on the outer aspect of the shoulder. The degree of injury is related to the extent of injury to the acromioclavicular and coracoclavicular ligaments and varies from the more simple sprain to complete rupture of all noted ligaments and dislocation of the clavicle. Treatment is usually conservative but the more extensive injuries may require a more aggresive surgical approach.

 
 

By Dr. Paul A. Markey

Every day, people come to orthopaedic surgeons because of “hip pain”.  But often, what they are calling hip pain is not true hip pain.  How can this be?  It is because what most people call the hip is not the hip joint.  The hip joint is a ball and socket, and it is located in the groin.   The place that most people call the hip is on the side, at or below the belt line, where they put their hands when they stand with their hands “on their hips”, where a mother carries a baby on her “hip”, where the hip pockets of pants are, or where a policeman carries his pistol in a “hip holster”.  If you ask people to point to their hip joint, many will point to that area on the side, not to the groin.  We can speak of hip pain, therefore, as being either “true” hip pain—that is, coming from the hip joint itself—or “false” hip pain—that is, coming from another source.

True Hip Pain

True hip pain is most commonly felt in the groin, because that is where the hip joint is.  Sometimes it is felt also in the thigh or knee because of what is called referred pain, which is pain felt in a place other than at the source of the pain.  True hip pain is often accompanied by limping and decreased motion of the hip joint, causing the patient to have difficulty reaching his or her foot to cut toenails or tie shoes.

The most common cause of true hip pain is osteoarthritis, which is the most common joint disorder in the world, affecting more than 50% of people by age 65, and 80% by age 75.  It most often occurs in knees, hips and hand joints, and less often in other joints.  It causes destruction of joint cartilage, which is the smooth, slippery surface covering the ends of the bones.  You can see joint cartilage on the ends of a chicken bone.  As long as it stays smooth and slippery, joint motion is full and comfortable.  Osteoarthritis causes the cartilage to become soft and rough and to disintegrate, causing the joint to get painful and stiff.  If the pain is not too bad, it can be managed with over-the-counter or prescription pain relievers and a cane.  In some cases, a relatively new, minimally invasive operation called hip arthroscopy can help by recontouring and rounding the bones of the ball and socket if they have started to become deformed as part of the osteoarthritic process.  If the pain becomes too severe for the patient to tolerate, which is a common scenario, total hip replacement can be done.  Total hip replacement is one of the most common operations in the world, and one of the most successful, achieving in the great majority of cases complete relief of pain and restoration of normal walking and daily activities.

Another relatively common cause of true hip pain is a torn acetabular labrum.  The acetabular labrum is the rubbery cartilage rim of the hip socket, and it can become torn in slightly aging athletes doing vigorous sports, resulting in sharp groin pain with certain motions of the hip joint.  If it gets bad enough, that pain can often be greatly relieved by hip arthroscopy to repair or remove the torn cartilage.

Other causes of true hip pain include other kinds of arthritis, such as rheumatoid arthritis, and other conditions such as avascular necrosis and infection.  Avascular necrosis of the hip is death of the femoral head (the “ball” of the ball and socket hip joint) from loss of blood supply.  It can occur in people who have taken steroid medication for a long time, alcoholics, and after a femoral neck fracture or hip dislocation.  Rarely, it occurs spontaneously in young children, in which case it is called Perthes’ disease.  Infection in the hip joint can occur at any age, but is most common in infants and very young children, and causes fever and extreme pain. In young adolescents, a somewhat uncommon condition called slipped capital femoral epiphysis occurs, causing true hip pain and limping.  As a rule, sometimes with the exception of Perthes disease, these conditions will require surgery.  Occasionally, runners will develop a stress fracture of the femoral neck, resulting in groin pain and limping.  These stress fractures usually heal by themselves with time and rest from running.

False Hip Pain

The most common cause of false hip pain, which is felt in the side or back of the “hip” region, is referred pain from the lumbar spine (the lower back part of the spine), and it is more common than true hip pain.  The most frequent causes of  this pain originating in the lumbar spine are disc degeneration resulting in bulging or herniation of discs—either acute or chronic—and arthritic changes in the small spinal joints called facet joints.  These spinal conditions usually cause low back pain, and very often cause pain in the “hip”, groin, buttock, and thigh or farther down the leg.  This pain in these areas other than the lower back occurs either because of referred pain or because of radicular pain (sciatica) caused by pressure on a spinal nerve root from a herniated disc or the bone spurs of an arthritic facet joint.

The good news about pain coming from the lumbar spine, including false hip pain, is that it usually goes away, either by itself or with help from doctors and physical therapists consisting of advice about posture and body mechanics, pain-relieving exercises and sometimes medications.  Many patients have gone to see an orthopaedic surgeon complaining of severe “hip” pain, fearing that they might be heading for a hip replacement, and have been greatly relieved to find out that the culprit is not the hip joint but the lumbar spine, and that relief can be expected.

Another, less common, cause of false hip pain is trochanteric bursitis, which causes pain and tenderness over the bony prominence on the side of the hip region, often because of prolonged sitting which puts pressure on that spot.  It is commonly very long-lasting but not permanent, and can usually be relieved by changing one’s sitting posture and the type of chair one uses, by physical therapy, and/or by a cortisone injection.

An even less common cause of false hip pain is polymyalgia rheumatica, which can cause vague and diffuse pain and stiffness around the hip and shoulder regions, among other symptoms.  It is a vascular inflammatory disease, which can be very effectively treated with oral steroids.

Severe or persistent “hip” pain is a good reason to see a primary care doctor or orthopaedic surgeon.  By means of a history and physical examination, and sometimes x-rays and other tests, the doctor can diagnose and treat the problem with a high likelihood of success.

 
 

By Dr. T. Jay Kleeman

All of us, at some time or another, have twisted an ankle, on uneven ground, or have come down awkwardly, while playing a sport, such as tennis or basketball. What often results is a painful ankle sprain, a tearing of the fibrous ligaments that stabilize our joints. Ankle sprains are some of the most common injuries seen in an orthopedic practice, with about 25,000 people, in the US, each day, seeking treatment for an ankle sprain.

Over 90% of ankle sprains involve an inversion, where the bottom of the foot turns inward, and the structures on the outer side of ankle are put on stretch. Sprains are often graded from I to III, where a grade I sprain is a mild stretch injury, a grade II is a more significant partial ligament tear, and a grade III sprain is a complete rupture of one or more ligaments. Generally, there will be more bruising, swelling, and pain as the severity of the sprain increases.

When a patient first presents to the office after a sprain, the orthopedist will determine whether an x-ray is necessary, in order to rule-out a fracture or dislocation. Patients are relieved when they hear that there is no fracture, however, even severe sprains may not be visible on x-ray. A severe sprain may have a longer recovery and lead to more long-term problems then some simple fractures.

Regardless of the grade of sprain, most, if treated properly, will heal without residual pain or instability. The initial treatment involves the well-known mnemonic, RICE (Rest, Ice, Compression, and Elevation). Depending on the severity, the orthopedist may prescribe a brace, a walking boot, crutches, or physical therapy. Exercises to strengthen the surrounding muscles and tendons are essential to restore flexibility and stability.

Additional studies, such as MRI or CT scan, are usually not necessary immediately after an ankle sprain, as the results of these expensive and time-consuming studies rarely affect the initial management of the sprain. However, if pain persists for 6 to 8 weeks or more, and does not seem to be improving, these additional studies may be required to make a proper diagnosis.

One problem that may lead to long-term dysfunction and pain after an ankle sprain is instability. Patients may feel loose or say that their ankle is giving way without the ligaments actually being stretched. If laxity of the ligaments cannot be determined on the physical exam, the orthopedist may do a “stress x-ray”, where he or she manipulates the ankle while an x-ray is being taken. This is a quick and usually painless procedure that may give even more information than an MRI. Patients, who are found to be unstable, and remain functionally unstable, despite bracing and therapy, may be candidates for surgical reconstruction of their ligaments.

If the stress x-rays are normal, an MRI may be ordered to look for other sources of pain. These sources could include residual scar tissue from the sprain, subtle injuries to bone or cartilage, at the joint surface, as well as tears or instability of the tendons that surround the joint. If these issues remain symptomatic, despite conservative treatment, many can be treated with minimally invasive surgery using arthroscopy. These arthroscopic procedures are usually done with local anesthesia and light sedation. Tiny incisions are made around the ankle through which narrow instruments and a fiberoptic camera can be inserted. The procedures take less than an hour, and patients return home the same day. Crutches are often required for only a week or two.

Although many minor sprains are treated at home, without patients ever requiring medical attention, consultation with an orthopedic surgeon should be sought if there is significant bruising or swelling about the ankle, if there is pain and swelling above the ankle joint, or there is an inability to walk more than a few feet, without significant pain. Patients with poor sensation in their feet, such as diabetics, have to be especially cautious so as not to overlook more serious injuries. Many long-term problems, after an ankle sprain, can be prevented if a prompt diagnosis is made and treatment is instituted soon after the injury.

 
 

By Jerome Barton, M.D.

Injuries to the acromioclavicular joint are also known as shoulder separation injuries. They are distinct from shoulder dislocations, which take place at the shoulder joint itself, the gleno-humeral joint. Shoulder separations occur at the small joint at the top of the shoulder where the outer end of the clavicle ( collar bone ) meets the acromion, the superior outermost portion of the scapula.

Injury to the acromioclavicular joint (AC joint) usually occurs from a fall on to the outer portion of the shoulder and usually with the arm at the side. It is characterized by varying degrees of pain and swelling dependent upon the extent of the injury to the supporting ligaments. The patient will point directly to the top of the shoulder as the painful injured area.

The extent of injury to the AC joint is determined by the degree of trauma sustained and is measured by the extent of injury to the shoulder ligaments. Treatment of these injuries varies, of course, with the extent of injury.

Some injuries are treated with ice for swelling, possibly anti-inflammatory medication and analgesics as needed and a sling for support. As the acute symptoms subside a self-administered or formal therapy program is used to help regain motion and function and when appropriate the shoulder is guided back to a full activity schedule. The results are almost always good.

More severe injuries are frequently considered for surgical repair. Surgical repair involves operative fixation and repair of both the CC ligaments and the AC joint and the other injured soft tissue structures. Results are usually good but both the extent of injury and surgery lead to a more prolonged recovery and rehabilitation period.

Rehabilitation is an important part of the recovery process and becomes more important and prolonged with more severe injuries. The patient must be guided through a program designed to recover range of motion, strength and neuromuscular control of the shoulder.

Results of treatment for AC injuries are generally quite good for the less extensive injuries but results may be compromised to some degree in the more extensive injury. Patient perception of outcomes will vary with age and functional demands of the shoulder.