Dr. Rami Abo Ali

1. ORTHOPEDIC SURGERY
Dr. Rami Abo Ali
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Dr.
Rami
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Ali
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2. INJURIES TO THE UPPER LIMB ( 1 )
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6. BRACHIAL PLEXUS LESIONS
 It is based on mechanism and level of injury and is as
follows:
 I Open (usually from stabbing)
 II Closed (usually from motorcycle accident)
 IIa Supraclavicular
 IIb Infraclavicular Lesion
 III Radiation induced
 IV Obstetric
 IVa Erb's (upper root)
 IVb Klumpke (lower root)
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Dr.
Rami
Abo
Ali

7. BRACHIAL PLEXUS LESIONS
 In general, supraclavicular area is most commonly
affected
 Roots and trunks get affected more compared to cords
and terminal branches
 Injury may be due to :
 Stretching of nerve at time of trauma
 Compression of hematoma
 Direct trauma by proximal humerus
 Entrapment of nerve (after reduction of dislocation)
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Ali

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9. BRACHIAL PLEXUS LESIONS
 Open injuries
 In the past, cavalrymen wielding sabres disabled the
enemy by cutting the upper cords of the brachial plexus of
opposing infantry.
 Today, open injuries still occur and are just as devastating but
they are more often caused by falling objects such as glass or
steel.
 Closed injuries
 Closed injuries can occur in two ways:
 1. By violent lateral flexion of the neck with depression of the
shoulder or forced abduction of the arm.
 2. At birth, although this is now rare in developed countries.
This is associated with obstructed or difficult deliveries
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Orthopedic
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Dr.
Rami
Abo
Ali

10. BRACHIAL PLEXUS LESIONS
 Supraclavicular lesions
 Blows to the shoulder and head cause violent lateral
flexion of the cervical spine and depression of the
shoulder.
 This tears the upper part of the brachial plexus.
 In the UK about 90% of these injuries occur in
motorcyclists landing on the head and shoulder
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Orthopedic
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Dr.
Rami
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Ali

11. BRACHIAL PLEXUS LESIONS
 Erb's (upper root) (typically C5-6).
 If the upper cords of the plexus are damaged at birth, the
supinator, deltoid, wrist extensors and elbow flexors will
be weak, causing a ‘waiter’s tip’ position of the arm
 It most commonly occurs as a result of a stretching injury
during a difficult vaginal delivery
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Dr.
Rami
Abo
Ali

12. BRACHIAL PLEXUS LESIONS
 Infraclavicular lesions
 Injuries in which the arm is violently abducted can
tear the lower part of the brachial plexus.
 The commonest mechanism is anterior dislocation of the shoulder,
but the lesion can also be caused by a fall from a height in which the
hand is caught so that the full weight is taken by the arm.
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Dr.
Rami
Abo
Ali

13. BRACHIAL PLEXUS LESIONS
 Klumpke (lower root) (C8-T1)
 The end result of damage to the lower cords of the brachial plexus at
birth is a Klumpke’s palsy, which consists of a weakness of the lumbrical
muscles, which normally act to flex the metacarpophalangeal joints
(MCPJs) and extend the interphalangeal joints (IPJs)
 The primary feature of Klumpke’s palsy is a clawed hand
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Abo
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15. BRACHIAL PLEXUS LESIONS
 Assessment
 The first step in management is to define the anatomy of the
lesion.
 Each lesion has a different prognosis and the site of the
lesion must be identified by a careful neurological
examination.
 In general terms, the more distal the lesion, the better the
prognosis.
 It is important to decide whether the lesion lies between the
spinal cord and the dorsal root ganglion (preganglionic) or
distal to the ganglion (postganglionic).
 Preganglionic lesions never recover, postganglionic lesions
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Dr.
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Abo
Ali

16. BRACHIAL PLEXUS LESIONS
 One way of determining the exact site of the lesion clinically is
to assess muscle function.
 The first branches to leave the brachial plexus are the motor
nerves to the rhomboids and levator scapulae.
 If the patient has power in these muscles and can elevate the
scapula, the lesion must be distal to the origin of these nerves
from the plexus and the prognosis will be better than for a
patient who cannot elevate
the scapula.
 A useful approach is to look at the activity of the autonomic
nervous system.
 If a Horner’s syndrome is present, the lesion must be close to
the cord and the prognosis is poor .
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

17. BRACHIAL PLEXUS LESIONS
 Investigations are less useful than clinical examination.
 The most useful investigation is the EMG, which can
identify accurately the roots involved.
 Radiculography will show if the roots are still attached
to the spinal cord and may demonstrate traumatic
meningocoeles along the roots, but reveals little else.
 CT scanning does not give much information about the
peripheral nerves, although MRI may prove helpful.
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Dr.
Rami
Abo
Ali

18. BRACHIAL PLEXUS LESIONS
 Management of brachial plexus lesions
 Identify the site of the lesion by careful neurological
examination and EMG.
 Decide if the lesion is preganglionic or postganglionic.
 Preganglionic lesions (Horner’s syndrome, absent axonal
reflex) cannot be repaired.
 Postganglionic lesions have a better prognosis: the more
distal, the better the outlook.
 Surgical repair or grafting is sometimes possible for
clean cuts and distal lesions
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

19. BRACHIAL PLEXUS LESIONS
 Management of brachial plexus lesions
 If the roots are torn out of the spinal cord, nothing can
be done to restore continuity.
 If the lesions are distal to the ganglion or there is a clean
cut across the nerve, microsurgical repair may be
possible.
 Cable grafting of defects in the supraclavicular part of
the plexus is practised but the results are unpredictable,
and a few patients eventually request amputation to rid
themselves of their heavy, useless arm.
 Artificial limbs are available but many patients find them
an encumbrance and do not wear them.
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Ali

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21. CLAVICLE FRACTURE
 Common fracture in all ages especially in children .
 It is 2 – 10% of all fractures .
 Mechanism of injury :
 Direct traumatic impact or fall on the shoulder (most common ).
 Direct impact to clavicle .
 Fall on outstretched.
 From fall on the side .
 Vigorous muscle contraction , seizures [rare] .
 Pathological fracture
 Classification : according to site of fracture :
 group 1: Fracture mostly occur in the middle one third of
clavicle 80%
 group 2: The fractures of lateral third is 15% ..
 group 3: fracture of medial third 5%
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Orthopedic
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Dr.
Rami
Abo
Ali

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23. CLAVICLE FRACTURE
 Clinical presentation :
 Pain and tenderness at site of injury .
 Obvious deformity and swelling sometimes occur .
 Patient come support his injured limb with other hand and head tilted
toward injured side .
 Local bruising .
 Diagnosis :
 Clinical picture examination .
 Investigation :
 x-ray [AP view ] :
 is usually in middle third, outer fragment below the inner(The
clavicular head of the sternocleidomastoid muscle arises from the
posterior edge of the inner third of the clavicle and displace it up) .
 CT scan : useful for non union assessment .
 arteriography : if vascular injury suspected .
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

24. CLAVICLE FRACTURE
 Treatment :
 The aim is to provide support for the weight of the arm .
 Fracture of clavicle unite with or without treatment .
 Healing occurs usually in 3-6 weeks .
 It may be : conservative or surgical .
 Conservative treatment :
 Support the arm in a sling until the pain subsides , usually 1-3
weeks .
 Figure of 8- bandage .
 Analgesics .
 Surgical treatment :
 Rarely indicated , except in :
 lateral one third fracture .
 presence of neurovascular injury .
 Severe displacement causing tenting of the skin with the risk of
puncture
 non union cases .
 Polytrauma (with multiple fractures): To expedite rehabilitation
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Orthopedic
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Dr.
Rami
Abo
Ali

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Ali

26. CLAVICLE FRACTURE
 Complications:
 Early :
 [subclavian or carotid artery injury ,pneumothorax and
hemothorax ,brachial plexus injury ]
 late :
 Malunion .
 Ununion : treated by internal fixation and bone grafting .
 Neurovascular injury [rare] . .
 Stiffness of shoulder in elderly .
 Ulnar neuropathy .
 Refracture .
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Orthopedic
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Dr.
Rami
Abo
Ali

27. STERNOCLAVICULAR JOINT
 Gliding joint with a disc that serves to anchor the shoulder girdle to the
chest wall
 Elevation of the arm from 0 to 90 degrees produces clavicular rotation
about its longitudinal axis and elevation at the sternoclavicular joint of 0
to 40 degrees.
 The posterior capsule is the primary restraint of excessive anterior and
posterior translation
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

28. STERNOCLAVICULAR JOINT
 Sternoclavicular joint dislocations
 traumatic dislocation
 anterior (more common)
 posterior (mediastinal structures at risk)
 important to distinguish from medial clavicle physeal fracture (physis doesn't
fuse until age 20-25)
 atraumatic subluxation
 occurs with overhead elevation of the arm
 affected patients are younger
 many demonstrate signs of generalized ligamentous laxity
 subluxation usually reduces with lowering the arm
 Treatment
 reassurance and local symptomatic treatment
 atraumatic subluxation
 chronic anterior dislocation (> 3 weeks old)
 closed reduction under general anesthesia +/- cardiothoracic surgery
 acute anterior or posterior dislocations (< 3 weeks old)
 open reduction and soft-tissue reconstruction with thoracic surgery
back-up
 posterior dislocation with failed closed reduction
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

29. ACROMIOCLAVICULAR JOINT INJURY
 acromioclavicular joint injury, otherwise known as a shoulder
separation, is a traumatic injury to the acromioclavicular (AC) joint
with disruption of the acromioclavicular ligaments and/or
coracoclavicular (CC) ligaments
 One of the most common injuries in athletes/ sports.
 9% of injuries affecting the shoulder girdle
 treatment is immobilzation or surgical reconstruction depending
on the degree of separation and ligament injury.
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

30. SHOULDER DISLOCATION
 Shoulder joint is the most common large joint which suffer from
dislocation ; due to many factors like shallow glenoid and its wide
range of movements .
 Types of shoulder dislocation :
1- anterior dislocation (the most common ) .
2-posterior dislocation (rare) .
3- inferior dislocation (Luxatio erecta) (rare) .
 Stability of the glenohumeral joint is dependent on four factors:
1. The suction cup effect of the glenoid labrum around the
humeral head
2. Negative gleno-humeral intra-articular pressure and limited
joint volume
3. Static stabilizers, including labrum, ligaments and joint
capsule
4. Dynamic stabilizers especially rotator cuff and biceps muscle
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

31. ANTERIOR DISLOCATION OF THE SHOULDER
 This is the most common type of shoulder dislocation, accounting for
more than 95% of cases and have a high recurrence rate that
correlates with age at dislocation
 It caused by fall on out stretched hand , the head of the humerus
driven foreword tearing the capsule or avulsing the glenoid labrum,
and settled under the clavicle in the infraclavicular fossa .
 Less in children as their epiphyseal plate is weaker and tends to
fracture before dislocating.
 Clinically : history of trauma , sever pain , the patient support his arm
with the opposite hand and resist any kind of examination .
 On examination : there is loss of normal contour of the affected
shoulder , visible or palpable boney mass below the clavicle .
 Neurovascular examination for axillary nerve and distal pulsation is
very important before any attempt of reduction for medicoleagal
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Ali

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Ali

33. ANTERIOR DISLOCATION OF THE SHOULDER
 X –ray :
 antero-posterior view show the head of the humerus out of the glenoid and
located usually below of the clavicle or the coracoid process .
 axillary view is very helpful also .
 Treatment : 3 methods of reduction :
 Kocher’s maneuver : most commonly used under general anesthesia , with the
assistant do counter traction, flexion of the elbow 90` and held close to the body
, no traction , slow
lateral rotation of the arm then adduction and medial rotation .
 Hippocratic’s method . Traction on the line of the limb with counter traction .
 stimson’s technique (gravity) .patient prone the arm hanged beside the bed for
15 – 20 minutes
 acute reduction, ± immobilization, followed by therapy
 risk factors for re-dislocation are
 age < 20 (highest risk)
 male
 contact sports
 hyperlaxity
 glenoid bone loss >20-25%
 Operative for recurrent dislocation
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Orthopedic
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Dr.
Rami
Abo
Ali

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Ali

35. ANTERIOR DISLOCATION OF THE SHOULDER
 Complications :
 Early :
 nerves injuries : axillary nerve is the most commonly injured ; the
patient is unable to do contraction of the deltoid muscle and there will
be small patch of anesthesia over the tip of the shoulder . The lesion is
usually neuropraxia and recovery will occur after few weeks
 vascular injuries : mainly the axillary vessels .
 rotator cuff tear : there will be difficulty in abduction of the shoulder
 associated fractures : fracture proximal humerus , fracture greater
tuberosity of humerus .
 Late :
 stiffness of the shoulder .
 recurrent dislocation . It occur due to avulsion of the labrum or sever
tear of the capsule . It should be treated by surgery.
 50 – 90% patients under 20
 5 to 10% of patients over age 40
 unreduced dislocation .(missed)
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Dr.
Rami
Abo
Ali

36. POSTERIOR SHOULDER DISLOCATION
 It is rare , less than 2% , it occur due
to marked internal rotation with
adduction ; it occur in convulsion or
with electrical shock .
 Clinically : the arm is held in medial
rotation and it locked in that
position .
 X-ray may show a 'lightbulb' sign
 Reduction : In most cases, acute
posterior dislocations have
spontaneously reduced prior to
imaging
 To reduce a posterior dislocation,
apply traction to the internally-
rotated and adducted arm in
conjunction with direct pressure on
the posterior aspect of humeral
head 36
Orthopedic
Surgery
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Dr.
Rami
Abo
Ali
With seizure activity, the internal
rotator muscles (teres
major and subscapularis )
overpower the external rotator
muscles (teres minor, infraspinatus)
to dislocate the head of humerus

37. LUXATIO ERECTA (INFERIOR DISLOCATION OF SHOULDER)
 In exceptional circumstances, the humeral head becomes jammed
below the glenoid with the arm pointing directly upwards,
presenting a spectacular appearance sometimes mistaken for
hysteria.
 This is a true inferior dislocation, in contrast to anterior dislocation
in which the head only slips downwards after it has dislocated
anteriorly. The humeral head lies against the vessels and can cause
ischaemia, and the rotator cuff is always damaged
 Treatment
 Reduction can be difficult but once achieved immobilization is not
required
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Orthopedic
Surgery
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Dr.
Rami
Abo
Ali

38. RUPTURE OF THE SUPRASPINATUS TENDON
 The supraspinatus tendon can be ruptured without
a fracture.
 This injury is comparatively common in older patients with
degenerate tendons and is usually seen in the orthopedic clinic
rather than an accident department, but sudden ruptures of the
supraspinatus can also occur in young people after a violent
injury.
 Clinically, there is both bruising and tenderness
around the supraspinatus muscle and weakness
of abduction.
 jobe’s test and drop arm test used to examine supraspinatus
tendon
 Treatment
Surgical repair is advisable in acute tears in young or active
patients. Rehabilitation is prolonged 38
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Ali

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Ali

40. ADHESIVE CAPSULITIS (FROZEN SHOULDER)
 Refers to a condition in which the shoulder capsule becomes
contracted and thickened; with no clear underlying cause
 patients note a dramatic decrease in shoulder ROM
 in many cases there is spontaneous resolution after 1-3 years and
motion is re-gained
 More common among women / ages 40-60 years
 Mechanism of injury
 primary, idiopathic form
 post-traumatic (following proximal humerus fracture or
immobilization for other upper extremity injury)
 post-surgical (following rotator cuff repair or axillary dissection for
malignancy)
 Pathoanatomy
 inflammatory process causing fibroblastic proliferation of joint
capsule leading to thickening, fibrosis, and adherence of the capsule
to itself and humerus
 Imaging
 Radiographs: disuse osteopenia
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Orthopedic
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Dr.
Rami
Abo
Ali

41. ADHESIVE CAPSULITIS (FROZEN SHOULDER)
 Treatment
 Non Operative Treatment:
 involves NSAIDS/steroids, intra-articular steroid injection, and physical
therapy
 Operative
 Manipulation under Anesthesia
 Arthrscopic Release
 Open Release
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Rami
Abo
Ali

42. FRACTURES OF SCAPULA
 Is a flat triangular bone that lies on the posterior thorax wall between
2-7 rib.
 It envelope by :
 supraspinatus muscle
 infraspinatus muscle
 subscapularis muscle
 Attached to clavicle at acromioclavicular joint ,secured by
acromioclavicular ligament .
 Articulate with humerus at glenohumeral joint .
 Attached to thorax in scapulothoraxic joint .
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Dr.
Rami
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Ali

43. FRACTURES OF SCAPULA
 Fractures of scapula are uncommon because of scapula location and
surrounding muscles whitchprotect it .
 Fractures of scapula
 are result of high energy trauma with high incidence of associated injuries
by 60-98 %
 Fractures of scapula are classified according to location :
 body fracture 50 % .
 neck fracture 5-30 % .
 glenoid fracture 10 % .
 Coracoid fracture 8 % .
 Acromion fracture 7 %
 Diagnosis : x-ray , CT scan
 Treatment
 Conservatively by analgesics and simple sling to rest shoulder for 2-3 weeks
 Fractures of neck and glenoid :
 sling for 2-3 weeks
 if there is displacement > shoulder spica after reduction .
 open reduction > indicated if there is isolated glenoid rim fractures associated
with dislocation or subluxation of shoulder .
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Orthopedic
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Dr.
Rami
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Ali

44. FRACTURES OF SCAPULA
 Complication :
 Malunion non union
(rare)
 Glenohumeral arthritis .
 Limitation in range of
motion .
 After surgery :
 local dyscomfort
 infection
 nerve injuries
 post traumatic arthritis
 rotator cuff dysfunction
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Orthopedic
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Dr.
Rami
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Ali
The term floating
shoulder describe
ipsilateral fractures of
the clavicle and
scapular neck

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Rami
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Ali