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MEDICAL AND SURGICAL
PATIENT CARE
VARIOUS
FUNDRAISING AND HELP MEDICAL AND CHIRURGICAL
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Shoulder instability
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What does my doctor mean by Shoulder Instability?
- It means that the joint in the shoulder is loose and able to slide around too much in the socket. Sometimes, the shoulder actually slips out of the socket. This is called a dislocation. If not treated, instability can lead to arthritis of the shoulder, with impaired movement and pain.
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What parts of the shoulder are affected?
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The shoulder is made up of the bones of the shoulder blade (scapula), the upper arm (humerus) and the collarbone (clavicle). They are surrounded by a bundle of muscle tendons called the rotator cuff. This cuff connects the humerus to the scapula allowing movement of the arm at the shoulder joint and keeping the humerus tightly hold in the socket of the shoulder (glenoid). As this glenoid is very shallow and flat, there is a rim of soft tissue (labrum) surrounding its edge, and making the socket more like a cup. This way, the socket fits the head of the humerus better. All these structures are covered by a joint capsule made of ligaments, which holds fluids to lubricate the joint. This capsule is somewhat loose so that the shoulder can move freely. If the shoulder moves too far from the original position, though, the ligaments in the capsule become tight and stop it from going to far.
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When a force –either external, like running into a fielder; or internal, like pitching an extremely fast curve ball- overcomes the strength of the muscles in the rotator cuff and/or the ligaments of the shoulder, a dislocation of the shoulder joint can happen. Nearly all of them are anterior dislocations, meaning that the humerus slips out of the front of the glenoid socket. Only a very small percentage (around 3%) of dislocations are posterior dislocations, or out the back.
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Sometimes though, the shoulder does not come completely out of place. It does only partially, but then goes back to its normal position. This is what we call a subluxation.
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I had a shoulder dislocation in the past, and now my doctor says I have shoulder instability. Are they related in any way?
- Instability, although not always, often follows an injury that caused the shoulder to dislocate. This initial injury is usually fairly significant, and the shoulder must be positioned (reduced) back in its place by the doctor. This procedure might make it look as it the shoulder was normal again, but quiet often the ligaments and tendons in the joint remain unstable. They, along with the cartilage rim around socket, may have become stretched or torn. This makes them unable to keep the shoulder in place when it moves in certain positions. An unstable shoulder can result in repeated dislocations, even during normal activities.
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I’ve never had any problems in my shoulder, but now I have pain although I haven’t done anything different to what I usually do. Why is this?
- In some cases, the instability can happen without a previous apparent injury. People who do repeated shoulder motions may gradually stretch out the joint capsule. This is especially common in baseball pitchers, volleyball players, and swimmers. If the joint capsule gets stretched out and the shoulder muscles become weak, the ball of the humerus (the upper arm bone) begins to slip around too much within the shoulder. Eventually this can cause irritation and pain in the shoulder.
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Is there a genetic condition associated with this instability?
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Some people show a genetic problem with the connective tissues of their body (such as ligaments, tendons, cartilages, epidermis…) that can lead to ligaments that are too elastic. When these stretch too easily, they may not be able to hold the joints in place. All the joints of the body may be too loose. Some joints, such as the shoulder, may be easily dislocated.
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Is it a problem to have shoulder instability?
- Chronic instability causes several symptoms, like frequent subluxations of the shoulder. In this case, the shoulder may slip out of place (sublux) in certain positions or with certain movements. This commonly happens when the hand is raised above the head, for example while throwing a ball. It usually causes a quick feeling of pain, like something is slipping or pinching in the shoulder. Over time, people suffering from this stop using the shoulder in ways that cause subluxation.
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What are the consequences of having frequent dislocations of the shoulder?
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If the shoulder becomes so loose that it starts dislocating frequently, it can become a real problem, especially if you can't get it back in place and must go to the emergency room every time. A dislocation is usually very obvious: it is very painful, and the shoulder looks abnormal. Trying to move the shoulder in any way causes extreme pain. But the biggest problem is that a dislocated shoulder can damage the nerves around the joint.
If the nerves have been stretched, a numb spot may develop on the outside of the arm, just below the top point of the shoulder. Several of the shoulder muscles may become slightly weak until the nerve recovers. But the weakness is usually temporary.
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Can my doctor diagnose this condition even when the shoulder is not dislocated and looks normal?
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The diagnosis is done mainly through your medical history and physical exam. The doctor will ask you many questions about past shoulder injuries, pain, and how this is affecting your daily activities.
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During the physical exam, the doctor will feel and move your shoulder, checking it for strength and mobility. Your doctor will stress the shoulder to test the ligaments. When the shoulder is stretched in certain directions, you may get the feeling that the shoulder is going to dislocate. This is a very important sign of instability. It is called an “apprehension sign”. It will be uncomfortable, because you will think it’s going to dislocate, but it won’t: the doctor is not here to cause injuries, but to try to fix them!
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When you go to the doctor with a dislocated shoulder, X-rays are necessary to make sure therre is no fracture. They are usually done after the shoulder is put back into joint, allowing your doctor to make sure the joint is back in place. They can also help confirm that your shoulder was dislocated or injured in the past.
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Other test that might be used to diagnose this instability is an arthroscopy of the joint, done with general anesthesia.
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What treatment options are available?
- Nonsurgical:
- The initial goal of treatment is to reduce or control the pain, and this is usually done with rest and anti-inflammatory medication, such as aspirin or ibuprofen. Sometimes, if you are having trouble controlling your pain, the doctor may suggest a cortisone injection –a strong anti-inflammatory medication- directly into the joint.
- A physical or occupational therapist will direct your rehabilitation. At first, they will show you ways to avoid positions and activities that put the shoulder at further risk of injury or dislocation.
- The therapist may use heat or ice treatments to alleviate the pain and inflammation. Massages and active and passive exercises are used to improve the range of motion in your shoulder and nearby joints and muscles. Later on, strengthening exercises improve the strength and control of the shoulder. This, together with specific training of the shoulder, will improve its stability and help it move smoothly.
- Therapy lasts usually 6-8 weeks, time enough for most patients to get back to their activities with full use of their arm.
- Surgical:
- Sometimes therapy may not be enough to resolve the instability, and you may need surgery. Almost all the different types of shoulder operations attempt to tighten the loose ligaments. These ligaments are usually along the front or bottom part of the shoulder capsule.
- Bankart Repair:
- It’s the most common method for shoulders prone to anterior dislocations. It involves sewing or stapling ligaments, along with the labrum, on the front side of the joint back into their original position, drilling holes into the scapula in which these sutures will afterwards be anchored.
- This procedure can be done through an incision on the front of the shoulder or using an arthroscope, which requires smaller incisions, meaning less time in the hospital and less time to heal.
- Capsular Shift:
- An incision is made on the front of the joint capsule creating a flap, which is later pulled over the front of the capsule and sewn together, making it tighter.
- Thermal Capsular Shrinkage:
- Through an arthroscope, an electrode probe is slid inside the unstable shoulder. The electrode heats up, causing the capsule to shrink and tighten. One of the risks is that the capsule may get too tight, leading to restricted shoulder motion.
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What should I expect after treatment?
- Nonsurgical treatment:
- It usually requires a rehabilitation program, where the goal will be to strengthen the rotator cuff and shoulder blade muscles to make the shoulder more stable. At first the exercises are done with a therapist, eventually getting on a home program of exercise to keep the muscles strong and flexible. This should help avoid future problems.
- Surgical treatment:
- The rehabilitation program here is more complex. Usually, a sling is worn to support and protect the shoulder for 1-4 weeks. Depending on the type of surgery, therapy goes on for 2-4 months, generally achieving full recovery after 6 months.
- Initially, therapy focus on control of pain and swelling. The therapist might use ice and/or electrical stimulation, together with massage and other types of hands-on treatments to relieve the muscle spasm and pain.
- Therapy after open surgery has to be done with caution. Although exercises are started soon after the surgery is done, all the movements that stretch the front part of the capsule are done with great caution for the first 6-8 weeks. Gradually, therapy works into active stretching and strengthening of the muscles and other structuers of the shoulder.
- If the front shoulder muscles have been cut, therapy goes even. First we begin with passive movements, where the shoulder joint is moved, but the muscles stay relaxed. Gentle movement of the joint and gradual stretches are done by the therapist, who may eventually teach you how to do these passive exercises at home.
- Active therapy starts 3-4 weeks after surgery. You use your own muscle power, beginning with light strengthening exercises that work the muscles without straining the healing tissues.
- At about 6 weeks you start doing more active strengthening, focusing on improving the strength and control of the rotator cuff muscles and the muscles around the shoulder blade. This helps your shoulder move smoothly during all your activities.
- By about the 10th week, you will start even more active strengthening exercises of the rotator cuff muscles. These muscles will help hold the humerus tightly in the glenoid to improve shoulder stability.
- Some athletes, especially pitchers and quarterbacks start gradually in their sport activity about three months after surgery. They can usually return to competition within four to six months.
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Patella Instability
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What is patellar subluxation?
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The patella, or kneecap slides up and down a groove called the trochlea on the end of the thigh bone as the knee bends. The patella is designed to fit in the center of this trochlea, and slide evenly within it. In some people, the patella is pulled towards the outside of the knee. As this happens, the patella does not slide centrally within its groove. This improper tracking may not cause the patient any problems, or it may lead to dislocation of the patella (where the kneecap fully dislocates out of the groove). Most commonly, the tracking problem causes discomfort with activity, and pain around the sides of the kneecap. Patellar subluxation is a condition that usually affects adolescent, and sometimes younger children.
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What causes patellar subluxation?
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What else may be causing kneecap pain?
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The most common cause of kneecap pain is chondromalacia, or an irritation of the cartilage on the undersurface of the kneecap. Patellar subluxation and chondromalacia can go hand in hand, but they should be considered separate entities. That said, if chondromalacia is being caused by subluxation, then the instability of the kneecap must be addressed for treatment to be successful. Other causes of kneecap pain include osteoarthritis, patellar tendonitis (Jumper's knee), and plica syndrome.
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Is there any treatment for patellar subluxation?
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Treatment of the unstable patella is first to ensure that the patella is not dislocated. Your doctor can determine by examining your knee and obtaining x-rays, to see if the kneecap is outside of its groove. In patients with a kneecap dislocation, the kneecap may need to be repositioned, or "reduced."
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Treatment of patellar subluxation includes:
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Physical Therapy: traditionally, patients were sent to physical therapy to strengthen their VMO (part of the quadriceps muscle) to realign the pull on the kneecap. More recent research has shown that this is probably not the critical factor in eliminating kneecap problems. Focusing instead on strengthening of the hip abductors and hip flexors (so-called pelvic stabilization exercises) offers better control of the kneecap.
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Bracing and Taping: bracing and taping of the kneecap are also a conroversial topic in the rehabilitation of kneecap problems. These often provide symptomatic relief, but are certainly not a long-term solution. Caertianly if symptomatic relief is found with a brace or tape, it is certainly appropriate to continue with this as a treatment.
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Better Footwear: it contributes to the gait cycle. Motion control running shoes may help control your gait while running and decrease the pressure on the kneecap.
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Is surgery ever needed for patellar subluxation or dislocation?
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Some patients are not cured by conservative therapy, and it may be determined that surgery is needed, especially in patients who have significant pain or recurrent dislocation. By looking into the knee with an arthroscope, the surgeon can assess the mechanics of the knee joint to ascertain if there is an anatomic malalignment that could be corrected. One common malalignment is the result of too much lateral tension that pulls the kneecap out from its groove; this can place increased pressure on cartilage and lead to dislocation. For this problem, a procedure known as a lateral release can be performed. This procedure involves cutting the tight lateral ligaments to allow the patella to resume its normal position.
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What is a patellar dislocation?
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A dislocation of the patella occurs when the kneecap comes completely out of its groove, and rests on the outside of the knee joint. Kneecap dislocations usually occur as a significant injury the first time the injury occurs, but the kneecap may dislocate much more easily after the first injury.
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Why do kneecap dislocations become a recurrent problem?
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When the kneecap comes out of joint the first time, ligaments that were holding the kneecap in position are torn. The most commonly torn structure is called the medial patellofemoral ligament, or MPFL. This ligament secures the patella to the inside (medial) of the knee. When a kneecap dislocation occurs, something must fail to allow the kneecap out of the groove, and usually it is the MPFL.
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Once the MPFL is torn, it often does not heal with proper tension, and the kneecap can subsequently dislocate more easily.
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That is why recurrent dislocation of the kneecap occurs in a high percentage of patients who have this injury.
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What can be done to treat a kneecap dislocation?
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Traditionally, kneecap dislocations were treated by bracing a patient, and allowing the MPFL to heal. Unfortunately, bracing does not seem to be terribly effective, and no matter how long a brace is worn after a kneecap dislocation, the redislocation rate is still quite high.
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In patients who have recurrent (repeat) dislocations, there are surgical options. The usual treatment is to loosen the lateral (outside) ligaments that pull the kneecap; a so-called lateral release. At the same time, the muscle of the medial side of the knee (the VMO) is advanced to pull the kneecap more centrally.
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What about surgery after a first-time kneecap dislocation?
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Recent interest has developed in preventing these recurrent dislocations. Each time the kneecap dislocates, the cartilage can be injured, and the ligaments can become more stretched out. Some surgeons are trying to restore the normal anatomy by repairing the MPFL after a first-time dislocation. This surgery is controversial, because not all patients who dislocate their kneecap will have another dislocation. However, some patients would rather have the ligament repaired in an effort to lower the chance of having this become a repeat problem.
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Pelvic Osteotomy Surgery
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How long will my child be in the Hospital?
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How can I get a wheelchair, walker or crutches?
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A reclining pediatric wheelchair with leg extensions will be needed at home. Early in the hospitalization please speak to the hospital workers. They will help make arrangements for discharge. We will provide you with a prescription for the wheelchair, walker, or crutches. In some cases, a hospital bed will be ordered. We work closely with the hospital social workers to coordinate discharge planning and arranging for a nurse and physical therapist to make home visits.
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What type of activities will my child be able to do after the surgery?
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A hospital and/or home physical therapist will teach you how to transfer from (bed to chair) after surgery.
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Non-weight bearing - toe touch only on the affected side for transfers from bed to chair for 4 weeks after surgery.
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After 4 weeks, the physical therapist will teach you progressive weight bearing with crutches or a walker.
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No ambulation without an aid (i.e. walker, crutches) is allowed for 6 weeks after surgery.
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How do I take care of the surgical bandaging?
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How will my child be treated for pain?
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Your child will likely require an intravenous analgesia system. This special pump will allow the child to self medicate or receive a continuous controlled amount of medication for the first 24-48 hours post-operatively. On discharge, a prescription will be provided for oral pain medication. If your child requires a liquid solution for pain medication because they are unable to swallow pills, please have the discharge prescription filled at a pharmacy hear the hospital, as the solution form of the medicine may not be readily avaliable in your local pharmacy.
PATIENT CARE
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General Cast Care
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What is a cast?
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A cast is a rigid casing wrapped around a broken bone to keep it from moving while it heals. The cast must remain in place until the doctor removes it. If the cast is broken or damaged, the bone might not heal properly. Swelling sometimes occurs when a bone is broken; it can be helped by elevating the affected limb.
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How do I take care of the cast?
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Spica Cast Care
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What is a Spica cast?
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A cast which includes the trunk of the body and one or more limbs is called a Spica cast, just as a cast which includes the "trunk" of the arm and one or more fingers or the thumb is. For example, a shoulder spica includes the trunk of the body and one arm, usually to the wrist or hand. Shoulder spicas are almost never seen today, having been replaced with specialized splints and slings which allow early mobility of the injury so as to avoid joint stiffness after healing. A hip spica includes the trunk of the body and one or more legs. A hip spica which covers only one leg to the ankle or foot may be referred to as a single hip spica, while one which covers both legs is called a double hip spica. A one-and-a-half hip spica encases one leg to the ankle or foot and the other to just above the knee. The extent to which the hip spica covers the trunk depends greatly on the injury and the surgeon; the spica may extend only to the navel, allowing mobility of the spine and the possibility of walking with the aid of crutches, or may extend to the rib cage or even to the armpits in some rare cases. Hip spicas were formerly common in reducing femoral fractures, but today are rarely used except for congenital hip dislocations, and then mostly while the child is still an infant
- In some cases, a hip spica may only extend down one or more legs to above the knee. Such casts, called pantaloon casts, are occasionally seen to immobilize an injured lumbar spine or pelvis, in which case the trunk portion of the cast usually extends to the armpits.
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How do I take care of the spica cast?
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How do I prevent urine and stool from staining the cast?
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My child has some skin irritation. Can I use babypowder?
- For skin beakdown, a thin layer of Desitin may be used on diaper rash. Do not use babypowder under the cast.
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Clubfoot Cast Care
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My child has clubfeet. Why does he/she get casted?
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How often does the Clubfoot cast get changed?
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An appointment will be made every one to two weeks to check the correction of the foot/feet's position, and to apply a new cast(s). The parents need to remove the cast(s) before each appointment. Do this the morning of the appointment. Soak the cast(s) in warm water and vinegar. You'll often need two people to do this. It will take about an hour before the cast starts to unravel. Inspect the skin for any signs of redness or irritation. Tell the doctor if the skin is irritated. We may need to wait to put on the next cast.
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How do I make sure the Clubfoot cast is correctly applied?
- Check that all the toes are warm, with good color, and they move easily. If the infant can pull their foot/feet back up into the cast so that you cannot see the toes, soak the cast off, call the doctor and make an appointment. If the cast cracks or becomes soft, call the doctor, make an appointment and soak the cast off before the appointment.
VARIOUS
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Parents Helping Parents
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Are there other parents I could talk to?
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Yes. Parents Helping Parents is one our Quality of Life programs, matching families who have faced a similar experience. Learn from other parents how they handled what you are dealing with… casting or bracing, surgery, or missed school days. If you are seeking advice, or willing to share your experience, let one of our staff know you would like to participate in the Parents Helping Parents program.
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Parents Hosting Parents
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Do you offer housing for out-of-town families?
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Patient Success Stories
- We would love to share success stories with you. We know that success stories help parents visualize the best outcomes for their child.
- Visit our Patient Testimonials and Specialty Centers to read success stories that have been generously shared by children and their parents. Read our Newsletters to see a new story each issue.
- If you would like to share your story, let one of our staff know. By sharing your story, other parents will find hope.
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