These postop x-rays show the femur fracture from the previous post, now fixed with a plate (red arrows) and screws (black arrows). ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ This was a midshaft periprosthetic femur fracture unfortunately located between a total hip replacement (blue arrow) and a total knee replacement (green arrow). The fracture has been aligned back into anatomic position (the orange arrows point to the fracture). ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ This specific injury poses quite a challenge because the metal replacements do not allow a minimally-invasive intramedullary rod to be used. Instead, a large incision must be made and a very long plate secured with many screws must be utilized. An additional challenge is to make sure there is enough robust fixation both above and below (proximal and distal) to the fracture to protect the bone from additional fracture(s) if this elderly patient were to fall again. That is why the plate is so long and why so many screws proximally and distally were utilized. ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ The second image shows identical lateral views of the femur and the orange arrow in these images points to the surgical staples used to close the incision at the end of surgery. ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ This patient did incredibly well after surgery and went on to completely heal her femur fracture. She returned to full, painless use of her left leg 💪🏽.
This delightful 89 year-old patient had a fall and broke her left femur (orange arrow). Usually this type of fracture in this anatomic location is best fixed with surgery where small incisions are made and a rod is placed within the the bone to stabilize the fracture. ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ Because this patient has both a total hip replacement (blue arrow) as well as a total knee replacement (green arrow), rodding this femoral shaft fracture is not an option. This is because the metal from the hip and knee replacements block the insertion points for a rod. This situation mandates that the fracture be fixed via a large incision with a plate and screws.
These X-rays show the patella fracture from the previous post, now surgically repaired. The fracture fragments were first pieced together and secured by screws and then the plate was applied to the anterior surface of the patella with a screw in each hole to further secure the fracture. ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ For added fixation, I then treaded a very strong suture circumferentially around the patella, running it through the quadriceps tendon, medial retinaculum, patellar tendon, and then the lateral retinaculum, tying it to itself for additional stabilization of the fracture. ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ The plate that I used is typically utilized in foot/ankle surgery but worked well for this patella. We started gentle limited range of motion right after surgery and will gradually work to full flexion over about 6 weeks. ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ The third X-ray shows the lateral with a green line demonstrating the congruity of the articular surface of the patella. The goal of surgery is to reposition the fracture fragments anatomically so that this surface is smooth. This will hopefully minimize posttraumatic arthritis of the patella articular cartilage.
This patient fell directly onto her knee, shattering her patella. The blue arrows point to the fracture fragments (three main fragments). The orange arrow points to a nondisplaced fracture line in one of the main fracture fragments. ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ If a patella breaks but the fracture fragments aren’t separated (this is termed “nondisplaced”), this can often be treated nonoperatively. In this case, however, the fracture fragments are significantly separated (“displaced”) and surgery is really the only option to treat this injury. ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀ Any thoughts on how this should be surgically repaired??
These are the loose bodies from the previous post. These pieces of bone were stuck within the biceps tendon sheath, abrading the tendon and causing mechanical pain. ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀ This delightful, active patient had severe shoulder osteoarthritis and underwent a total shoulder replacement surgery. As part of her surgery, I located and removed these pieces of bone and tenodesed her biceps tendon. The loose bodies within the biceps tendon sheath were a relatively unusual finding. ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ The goal of surgery is to treat everything completely the first (and hopefully the only) time. A close review of the MRI preoperatively allowed me to identify all shoulder pathology ahead of time so that I could address every possible source of her shoulder pain at the time of surgery.
Here’s yet another way for a biceps tendon to hurt. ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀ This is a coronal MRI slice showing a right shoulder. The orange arrow points to the long head of the biceps tendon. The red arrow points to loose bodies right next to the biceps tendon. ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ These loose bodies are made of bone and have wedges themselves into a tight space within the biceps tendon sheath. Note the bright white surrounding both the tendon and loose bodies; this is fluid and indicates that inflammation is present. When this patient moves her arm, the loose bodies grind against the tendon, causing gradual physical damage to the tendon and causing pain in the front of the shoulder. ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ Loose bodies can be made of bone or cartilage or a combination of the two. In this case, they were pieces of bone that had formed within the glenohumeral joint due to osteoarthritis.
This is the same biceps tendon from the previous post, released from its intraarticular insertion. ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ Now we’re seeing the tendon exteriorized immediately prior to performing a subpectoral biceps tenodesis. The split tears are quite evident (black arrows). Compare these to the more normal-appearing proximal tendon (blue arrow). ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ There is so much diseased tendon present that a subpectoral tenodesis really is the only viable surgical option and it happens to be an excellent one.
This is another example of a very unhappy biceps tendon. The shaver falls into a very large split tear. ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ This type of tearing is very painful and causes severe pain in the front of the shoulder. Injections and physical therapy sometimes help with symptoms but in a case like this, surgery really is the treatment of choice (in my practice, this would be a biceps tenodesis).
This is an intraoperative video showing a very unhappy long head of the biceps tendon. ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ The camera is in the back of the shoulder and the metal probe enters the shoulder from the front. ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ You can see how shredded the tendon appears. Also note how when the probe pushes on the tendon, the tendon snaps down. This is called biceps instability and causes a painful snapping sensation with certain movements, typically with rotation of the shoulder with reaching or with a throwing motion. ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ This patient has severe biceps tendinopathy as well as instability of the tendon. This combination of problems is incredibly common. If symptoms don’t respond to no operative treatments such as physical therapy and injection(s), then surgery is the next step.