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Evaluation of impairment, disabilty, and workers’ compensation

1 Distinguish between impairment, disability, and handicap. An impairment is the “deviation of an anatomic structure, physiologic function, intellectual capability, or emotional status from that which the individual possessed prior to an alteration in those structures or functions or from that expected from population norms.” (1) A disability is the “inability to complete a specific task successfully that the individual was previously capable of completing or…

Evaluation of spinal deformities

1 What is a spinal deformity? A spinal deformity is an abnormality of the alignment, formation, or shape of the spinal column. Traditionally, spinal deformities have been classified into those that predominantly affect the coronal plane (e.g., idiopathic scoliosis) and the sagittal plane (e.g., Scheuermann kyphosis). In reality, spinal deformities are complex and simultaneously affect the sagittal, coronal, and axial plane alignment of the spinal column,…

Evaluation of thoracic and lumbar spine disorders

Thoracic spine examination 1 What are the most common reasons for referral to evaluate the thoracic spinal region? Pain and spinal deformity. The differential diagnosis of thoracic pain is extensive and includes both spinal and nonspinal etiologies. Spinal deformities (e.g., scoliosis, kyphosis) are generally painless in children but may become symptomatic in adult life. 2 What are some common causes of thoracic pain which are intrinsic…

Evaluation of cervical spine disorders

1 How does the evaluation of a patient with a spine complaint begin? A complete history and physical examination are performed. The purpose of the history and physical examination is to make a provisional diagnosis that is confirmed by subsequent testing as medically indicated. 2 What are some of the key elements to assess in the history of any spine problem? Chief complaint: pain, numbness, weakness,…

Clinically relevant anatomy of the lumbar and sacral region

Osteology 1 Describe a typical lumbar vertebra. The vertebral bodies are kidney shaped with the transverse diameter exceeding the anteroposterior diameter ( Fig. 3.1 ). The vertebral body may be divided by an imaginary line passing beneath the pedicles into an upper and lower half. Six posterior elements attach to each lumbar vertebral body. Three structures lie above this imaginary line (superior articular process, transverse process,…

Clinically relevant anatomy of the thoracic region

Osteology 1 Describe a typical thoracic vertebra. T1 and T10 through T12 possess unique anatomic features due to their transitional location between the cervicothoracic and thoracolumbar spinal regions, respectively. Thoracic vertebra two through nine are termed typical thoracic vertebra because they share common structural features ( Fig. 2.1 ): Vertebral body: Heart shaped in cross-section. Posterior vertebral height exceeds anterior vertebral height, resulting in a wedged…

Clinically relevant anatomy of the cervical region

Osteology 1 Describe the bony landmarks of the occiput. The occiput forms the posterior osseous covering for the cerebellum. The foramen magnum is the opening through which the spinal cord joins the brainstem. The anterior border of the foramen magnum is termed the basion (clivus), and the posterior border is termed the opisthion . The inion or external occipital protuberance is the midline region of the…

Technique Spotlight: Intramedullary Fixation for Midshaft Humerus Fractures

Indications Most humeral shaft fractures can be effectively managed without surgery utilizing functional bracing. However, displaced or comminuted humeral shaft fractures, fractures with extension into the proximal humerus, and patients following polytrauma with multiple extremity fractures may benefit from surgical fixation. Intramedullary fixation for midshaft humerus fractures can be a valuable option for the management of complex, comminuted, and segmental fractures. This method of fixation should…

Technique Spotlight: Minimally Invasive Plate Osteosynthesis in Humeral Shaft Fractures

Indications Surgical treatment of humeral shaft fractures is indicated after inadequate closed reduction, polytrauma, open fractures, bilateral injuries, and ipsilateral forearm fractures requiring surgical intervention. Excessive body mass index (BMI) or habitus forces the humerus into an unacceptable varus posture in a patient who otherwise would be best treated initially in a functional brace (i.e., smoker, diabetes). It should be noted that the majority of humeral…

Technique Spotlight: Nonoperative Management of Humeral Shaft Fractures

Indications The majority of isolated humeral shaft fractures can be managed nonoperatively. It is widely accepted that acute, closed, isolated fractures in a cooperative, ambulatory patient will achieve union with nonoperative management without a significant angular deformity or any functional limitations. However, while indications for nonoperative management of humeral shaft fractures are a continual debate, it is widely accepted that the humerus can tolerate 15–20 degrees…

Humeral Shaft Fractures

Introduction Fractures of the humeral shaft represent 1% to 3% of all fractures and have an annual incidence of 4.5 per 100,000 patients. The distribution of fractures follows a bimodal distribution with peaks occurring in the seventh and third decades of life commonly due to ground-level falls in elderly females and high-energy trauma in young males, respectively. The nonoperative management of humeral shaft fractures has historically…

Technique Spotlight: Endosteal Allograft for Complex Proximal Humerus Fracture Reconstruction

Indications Proximal humerus fractures are common injuries, and in certain patients, surgical fixation can restore anatomy, provide stability, improve pain, and restore function. Mitigating the risk of postoperative complications is critical for optimizing patient outcomes, and multiple studies have demonstrated reoperation rates of 14%–24%, with preoperative varus deformity in particular having high rates of postoperative failure. Reduction and support of the medial calcar improve maintenance of…

Technique Spotlight: RSA for Fracture

For a patient sustaining a proximal humerus fracture, the goal of treatment is to maximize functional outcome and patient satisfaction. While no clear consensus exists as to the optimal management of these injuries, and the results of closed treatment are frequently adequate in this patient population, certain fracture patterns and patient characteristics may help direct surgeons in selecting an appropriate plan of care. , Current practice…

Technique Spotlight: ORIF Proximal Humerus Fracture with IMN

Intramedullary Fixation for Proximal Humerus Fractures Indications Proximal humeral fractures continue to increase in frequency with projected rates of emergency visits in the United States alone annually to exceed 275,000 by 2030 and well over a million visits worldwide. Although many fractures can be treated nonoperatively, significantly displaced or angulated fractures in certain patients may benefit from surgical intervention. Intramedullary nail fixation has gained interest in…

Technique Spotlight: ORIF Proximal Humerus Fracture with Deltopectoral Approach

Indications Several options exist for the management of proximal humerus fractures including nonoperative care, closed reduction and percutaneous pinning, open reduction and internal fixation (ORIF) with a plate and screw construct, intramedullary nailing, and arthroplasty. The majority of these injuries are nondisplaced or minimally displaced and may be managed nonoperatively with positive functional outcomes. , However, a subset of patients presenting with displaced proximal humerus fractures…

Treatment Algorithm for Proximal Humerus Fractures

Introduction Proximal humeral fractures (PHFs) account for nearly 6% of all fractures. They have an overall incidence of 40 in 100,000 patients. This number is predicted to triple by 2030 with a growing elderly population leading to an increase in age-related osteoporosis. As such, management of these fractures will continue to pose challenges on many fronts. From fracture characterization to treatment options and personalized treatment decisions,…

Technique Spotlight: Open Reduction and Bone Grafting of Reverse Hill-Sachs Lesions

Conflicts of Interest: The position of PCN at the Steadman Philippon Research Institute is supported by Arthrex. PJM is a consultant for and receives royalties from Arthrex, Medbridge, and Springer; owns stock in VuMedi; receives support from the Steadman Philippon Research Institute and Vail Valley Medical Center; and has corporate sponsorship from the Steadman Philippon Research Institute, Smith & Nephew, Arthrex, Siemens, and Össur. BPE reports…

Posterior Shoulder Instability

Introduction Posterior shoulder dislocations are uncommon and potentially challenging traumatic injuries. Their incidence is around 1.1 per 100,000 population per year, which accounts for about 2% to 5% of all shoulder dislocations. Traumatic injuries such as falls, motor vehicle accidents, or sports injuries, followed by seizures, are the most common causes of posterior shoulder dislocation, and, more rarely, electrocution can be also implicated. , Some historical series…