ORTHOPAEDICS: RED FLAG EMERGENCIES

SEPTIC JOINT Aetiology: o Trauma/bites/wounds/haematogenous spread (most common) o Usually Staph. Aureus but must suspect Neisseria gonorrheae in sexually active adults Presentation: o Localised progressive joint pain, elicited on both active and passive ROM o Difficulties moving/weight bearing o Monoarthropathy o Erythema, warmth, swelling o Examine for lymphangitis, lymphadenopathy, any other affected joints (e.g. proximal spread) Search for foci of infection Investigations: o Plain X-ray: exclude traumatic cause and fracture o Joint aspiration with aseptic technique Shoulder: posterior approach, 2cm medial and 2cm inferior to lateral tip of acromion, aiming towards coracoids Knee: superolateral approach, aim towards hallux Wrist: dorsal approach over 3rd extensor compartment Hip: under USS guidance or in operating theatre Elbow: anconeus approach with forearm supinated, feel radial head, olecranon and lateral epicondyle and mark centre of structures. Pronate forearm and flex elbow to 90, aim for mark Ankle: anterior, just medial to tibialis anterior Aspirate: WBC >80,000 with >90% neutrophils, protein >4.4 mg/dL; glucose <BCL, no crystals, positive gram stain Management: o IV antibiotics: after aspirate Gonoccocal empirical therapy: ceftriaxone Non gonococcal, no MRSA RF empirical therapy: flucloxacillin, clindamycin or cefazolin Non gonococcal, MRSA empirical therapy: vancomycin o Small joints: needle aspiration, serial if necessary o Large joints: surgical lavage Septic prosthesis o Medical therapy and retention of prosthesis only in patients with clinical symptoms <3 weeks o Rifampicin and flucloxacillin (or other culture proven sensitivity) Hip prosthesis: 3 months; knee prosthesis: 6 months o May need debridement with retention o Chronic prophylactic antibiotics may be necessary

OSTEOMYELITIS Either acute haematogenous osteomyelitis (usually in immunocompromised patients or children) or direct/contiguous inoculation osteomyelitis usually. But can also have chronic osteomyelitis or osteomyelitis secondary to peripheral vascular disease Aetiology: o Acute haematogenous osteomyelitis: Staph aureus, H. Influenzae and Enterobacter (in children)

Staph aureus, Enterobacter and Streptococcus (in adults) From direct seeding from blood, predisposed in children due to slower/sluding of blood flow in distal metaphysic and high vascularity of growing bones o Direct osteomyelitis General: S. Aureus, Enterobacter, Pseudamonas Puncture wound: S. Aureus, Pseudomonas Sickle cell disease: S. Aureus, Salmonellae From direct contact of the tissue and bacteria during trauma or surgery, tend to involve multiple organisms Clinical manifestations o Haematogenous osteomyelitis with slower insidious symptoms; direct osteomyelitis with more localised, prominent signs and symptoms o History Abrupt onset high fever Fatigue, irritability, malaise (H) Restriction of movement + pseudoparalysis of limb in neonates Local oedema, erythema, tenderness Recent bacteraemic episode Chronic osteomyelitis: non healing ulcer, sinus tract drainage, chronic fatigue, malaise, poor vascularity o Physical examination Fever Edema, warmth, fluctuance Tenderness to palpation Reduced ROM Sinus tract drainage Investigations o Blood cultures, aspirate cultures o CBE: leukocytosis; raised ESR; raised CRP (earlier sign) o Plain film X-ray: Soft-tissue oedema at 3-5 days Periosteal elevation at 14-21 days Lytic bone destruction and cortical or medullary lucencies following o MRI: most sensitive/specific, especially in early change o Bone scan with WBC tag shows increased uptake Diagnosis: 2 of 4 criteria o Purulent material on aspirate o Positive finding of bone or blood culture o Localised classic physical finding sof bony tenderness, with overlying soft-tissue erythema or oedema o Positive imaging Management o IV empirical antibiotic therapy: clindamycin or flucloxacillin, then targeted therapy o Surgery if MRI suggests abscess or if patient does not improve after 36 hours on IVAB

COMPARTMENT SYNDROME Occurs most commonly in the lower limb but can occur in any limb or even in the abdomen; usually secondary to trauma Increased interstitial pressure in an anatomical compartment where muscle and tissue are bounded by fascia and bone (cannot expand) o Interstitial pressure exceeds capillary perfusion pressure leading to muscle necrosis (in 4-6 hours) and nerve necrosis (8 hours) Aetiology

Intracompartmental: fracture (particularly tibial fractures, pediatric supracondylar fractures and forearm fractures), crush injury, revacsularisation Usually high impact injury, penetrating wounds or long bone fractures o Extracompartmental: constrictive dressing (e.g. circumferential hard cast), circumferential burn Pathophysiology o pressure from blood and intracompartmental swelling venous draingage and impaired lymphatic drainage intracompartmental pressure greater than perfusion pressure muscle and nerve anoxia muscle and nerve necrosis cytokine release and leaky basement membranes transudation into tissue surrounding compartment pressure from blood and intracompartmental swelling Anatomy o Thigh: 3 compartments Anterior (extensor): femoral nerve; Medial (adductor): obturator nerve; Posterior (flexor): sciatic nerve o Lower leg: 4 compartments Anterior (dorsiflexor and invertor): deep peroneal nerve; Lateral (everter and plantar flexor): superficial peroneal nerve; Deep posterior (invertor and plantar flexor): tibial nerve; Superficial posterior (plantar flexor): medial sural cutaneous nerve o Forearm: 3 compartments Mobile wad (extensor, supinators): radial nerve; Dorsal (extensor): posterior interosseous nerve; Volar (flexor, pronator): median and ulnar nerves [most common compartment, results in Volkmanns contracture if untreated] o Foot: 9 compartments Clinical manifestation o Cardinally: pain out of proportion for injury and exacerbated immensely by slight passive stretch o Paresthesia, pallor and pulselessness (late finding) Investigation o Usually unnecessary as is a clinical diagnosis, but where clinical exam is unreliable, compartment pressure monitoring and urgent treatment necessary when pressure >30mmHg or within 30mmHg of diastolic BP Treatment o Remove constrictive dressing o Elevate limb o Fasciotomy to release compartments Note after fasciotomy, due to sudden release of all toxins and cellular debris, predisposes to rhabdomyolysis and renal failure o

CAUDA EQUINA SYNDROME Simultaneous compression of multiple lumbosacral nerve roots below the conus medullaris neuromuscular and urogenital symptoms Aetiology: narrowing of spinal canal between T12 and L2 o Trauma, disc herniation, spinal stenosis, neoplasms, schwannomas, ependymomas, inflammatory conditions, infections, iatrogenic cause Clinical manifestation o Low back pain, unilateral or bilateral sciatica: local or radicular o Saddle and perineal hypaesthesia or anaesthesia o Bowel and bladder dysfunction (retention then incontinence) o Lower limb weakness and sensory deficit; reduced or absent lower limb reflexes o Loss of anal tone (must do DRE) Investigations o Usually clinical diagnosis o MRI where necessary Management o Medical management can be useful in certain patients e.g. anti-inflammatories with ankylosing spondylitis

Emergency surgical decompression of the spinal canal is necessary within 48 hours after the onset of symptoms Laminectomy if disc herniation Prognosis o Worse if bilateral sciatica o Complete perineal anesthesia more likely result with permanent paralysis of the bladder o Females and patients with bowel dysfunction have worse outcomes o

OPEN FRACTURES Fractured bone in communication with the environment Need to swab wound for cultures and need emergent washouts with physiological solution Debridement of foreign material, devitalised tissue and old blood Establish patient tetanus status o If unsure, may need tetanus toxoid, tetanus immunoglobulin and penicillin Gustilo-Anderson classification: o I: open wound <1cm with minimal contamination and soft tissue injury; simple or minimally comminuted fracture First gen cephalosporin (cefazolin) for 48 hours/clindamycin o II: high energy, wound 1-10cm with moderate contamination, some soft tissue injury and fracture comminution Gram negative (gentamicin) coverage for 72 hours o III: high energy, wound >10cm with extensive soft tissue damage and gross contamination A: adequate soft tissue coverage of bone despite extensive lacerations/flaps/trauma B: extensive soft tissue injury with periosteal stripping and bone exposure with massive contamination Plastics input C: arterial injury severe enough to require repair Vascular and plastics input o NB: Any high energy injury, comminuted fracture, shotgun blast, soil contamination or fracture >8hrs is classified Grade III Soil contamination needs penicillin to provide prophylaxis against Clostridium perfringens Management o Reduction of fracture/dislocation to more anatomical position after lavage Cover wound with antiseptic or vac dressing o Debridement within 24 hours to decrease risk of infection I&D continued ever 24-48 hours until a clean surgical wound ensured o Photograph the lesion o Fast patient and pre operative work up

NEUROVASCULAR COMPROMISE Fracture/dislocation that injures nerves/vessels and needs to be managed emergently to prevent permanent impairment Specific injuries: o Knee dislocation injured popliteal artery o Proximal tibial injury deep peroneal nerve injury (winds around fibular neck) o Femoral shaft # femoral neurovascular bundle, profunda femoral artery o Ankle fracture/dislocation anterior/posterior tibial artery injury o Shoulder dislocation/humeral neck # axillary nerve injury o Humeral shaft # radial nerve injury o Distal radius # median nerve injury

o Elbow #/dislocation all upper limb nerves/vessels Usually high energy trauma and may be associated with multiple injurys, spinal injuries or life threatening injuries

UNSTABLE PELVIC FRACTURE Stabilising ligaments: posterior iliosacral, anterior iliosacral, sacrospinous, sacrotuberous, symphyseal Fractures o Compression #: bleeding but not too much (not fatal) o Open book fractures worse with bleeding due to tearing of anterior vein and causing continuous bleed Common caused by AP force o Vertical shear fracture after falling from great height o Pelvic rami fractures: lateral compression injury until proven otherwise Causes a windswept effect, pushes and displaces (transference of force through bone) o Anterior pelvic # - with posterior # until proven otherwise Imaging o Inlet view: down tilt to pelvis o Outlet view: uptilt to pelvis, through obturator foramen o Judet view: 45 oblique view: views acetabulum best Posterior or anterior column, either straight down ilium or along rami; obturator foramen in view with ilium side on o CT: better deines posterior injury o Look at sacroilar joints for congruency o Pelvic xray is disproportionate to reality, take distances and shadows in to account AO Classification o Type A: Anterior injury with minimal posterior involvement o Type B: Rotationally unstable, vertically stable o Type C: Rotationally and vertically unstable Management o Assess genitourinary injury (rectal exam/vaginal exam mandatory) o External or internal fixation of all fractures o Fracture-dislocations most mobile within 24-48 hours and allow the best reduction with closed techniques Complications o Haemorrhage: iliolumbar artery, superior gluteal artery, lateral sacral artery, internal iliac artery, internal pudendal artery (common) o ARDS o Fat embolism, pulmonary embolism o Bladder/bowel injury o Obstetrical difficulties in future o Neurological damage: L5 and S1 most common, but can be from L2-S4 o Persistent SI joint pain o Post-traumatic arthritis of the hip with acetabular fractures

HIP DISLOCATION Hip dislocations ideally need to be reduced within 6 hours to reduce risk of avascular necrosis of femoral head Usually occur secondary to high impact trauma as hip is such a stable joint (e.g. MVA) Posterior dislocation o Mainly secondary to MVAs as force is transmitted ot the flexed hip from the knees striking dashboard or the leg from the floorboard o Presents with shortened, adducted and internally rotated limb o Treatment: Closed reducation under GA or ORIF if unstable

Or traction 4-6 weeks Anterior dislocation o Rare presentation but caused by hyperextension force against an abducted leg or anterior force against the posterior femoral neck Central hip dislocation o Traumatic injury where femoral head is pushed through acetabulum toward pelvic cavity; lateral force against an adducted femur Complications of hip dislocation o Avascular necrosis: Head of femur supplied by artery of ligamentum teres, but very minimally; and epiphyseal system of medial circumflex femoral artery (blood supply lost when communication disrupted) Risk factors: steroid use, chronic alcohol use, post-traumatic #/dislocation, septic arthritis, sickle cell disease X-Ray features of AVN: reactive sclerosis of adjacent bone, subchondral fracture, flattening of weightbearing zones with eventual collapse MRI more sensitive o Fracture of femoral shaft or neck o Post-traumatic arthritis o Sciatic nerve palsy in 25% o Damage to femoral head

ORTHOPAEDICS: FRACTURES
GENERAL Anatomy: Identify bone Integrity of skin/soft tissue o Closed o Open: laceration, fracture exposed to outside environment, continuous bleeding Location o Intra-articular or extra-articular o Epiphysela, metaphyseal, diaphyseal (proximal, middle, distal) Displacement o Distraction or impaction o Rotation o Tilt Dislocation (complete) or subluxation (partial incongruity between articulation of joints) Fracture pattern o Transverse: perpendicular low load force o Oblique o Butterfly: mid load with force from above, below and perpendicular; slight comminution at fracture site which looks largely like a butterfly o Segmental o Spiral: rotational force, low energe o Comminuted: high load crush force o Greenstick: incomplete gracture of one cortex often in children o Pathologic: related to malignancy

WRIST Colles Fracture o FOOSH twisting force causing excessive supination of forearm and compression force that acts vertically through carpus to radius Occurs at any age but especially osteoporotic/osteopaenic bone o Transverse distal radius fracture 2-4cm proximal to radiocarpal joint with dorsal displacement and ulnar styloid fracture Ulnar styloid fracture due to triangular fibrocartilage complex attachment stretched o Plain film findings Dorsal tilt Radial shortening Ulnar styloid process fracture Radial displacement Dorsal displacement of distal fragment o Management Restore radial height, radial inclination and volar tilt Closed reduction If unsuccessful, ORIF o Complications Compression/contusion of medial and/or ulnar nerves Acute carpal tunnel syndrome Flexor tendons may be injured by the bony fragments Ulnar styloid fracture often has delayed or non union Smiths Fracture o Volar displacement of distal radius due to fall on flexed wrists or blow to the dorsum of the wrist whilst in pronation o Plain film findings: Distal fracture fragment displaced volarly Usually fractured entire thickness of distal radius, 1-2cm above the wrist Scaphoid Fracture o Common in young men from FOOSH transverse fracture through middle of scaphoid wrist pain and tenderness in anatomical snuffbox o # may not be radiologically evident up to 2 weeks after acute injury, so is often a clinical diagnosis and treated o If non-displaced: long arm thumb cast x 4 weeks then short arm cast until radiographic evidence of healing (2-3 months) o If displaced, need open/percutaneous screw fixation o Complications Delayed union or non-union AVN of proximal fragment (scaphoid has distal to proximal blood supply) Osteoarthritis Complications of wrist fractures o Wrist may have radial shortening from malunion o Pain due to ulnar prominence o Arthritis o Carpal tunnel syndrome o Reflex sympathetic dystrophy: paresthesia, pain, stiffness, change in skin temperature and colour

FOREARM Nightstick Fracture

Isolated fracture of ulna midshaft usually after sustaining a direct blow to forearm (held in protection across the face) o Management Non-displaced: below elbow cast 1 week followed by forearm brace ~8 weeks Displaced: ORIF if >50% shaft displacement or >10 angulation Monteggia Fracture o Fracture of proximal ulna (usually proximal 1/3) with dislocation of radial head (often anterior) o Caused by direct blow on posterior aspect of forearm, fall on hyperextended elbow or hyperpronation o Clinically Decreased rotation of forearm, palpable lump at radial head Ulna angled apex anterior and radial head dislocated anteriorly o Complications Compartment syndrome Radial/posterior interosseous nerve injury Non/malunion and decreased range of movement o Management ORIF of ulna with indirect radius reduction 90 elbow flexion, cast for 6 weeks Galeazzi Fracture (much more common than Monteggia) o Fracture of distal radial shaft (usually distal 1/3) with dislocation of distal radioulnar joint (DRUJ) o Fall on hand o Plain film findings: DRUJ pathology: Shortening of radius by 5mm # base of ulnar styloid Widening of DRUJ space by 2mm Subluxation of DRUJ Dislocation of radius with respect to ulna on true lateral o Management ORIF with 90 flexion and forearm pronation splint and early mobilisation if DRUJ stable o

TIBIA Tibial Plateau Fracture o Mechanism Axial loading (fall from height); femoral condyles driven into proximal tibia Minor trauma only in osteoporotics Lateral more common than medial o Imaging X-rays: AP, lateral, skyling Schatzker classification o Mobilisation Depression on x-ray <3mm: straight leg immobilisation x 4-6 weeks Depression on x-ray >3mm: ORIF requiring bone grafting to elevate depressed fragment o Complications Ligamentous injuries, meniscal lesions Delayed union, AVN Infection Post-traumatic arthritis Decreased knee mobility/stiffness Tibia-Fibula Fracture o Mechanism Low-energy injury (ground level falls and athletics)

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High-energy injury (MVA, gunshot wounds) Maisonneuve fractures involve fracture of proximal dibula in association with fractured medial malleolus Tibia-fibula stress fracture Management Open fractures require immediate debridement and irrigation in operating room Continuous compartment pressure monitoring only when compartment syndrome is suspected or risked Immobilise knee May need reduction and internal fixation

ANKLE FRACTURE Anatomy o Tibiotalar joint movement: plantarflexion and dorsiflexion o Subtalar joint: inversion and eversion Mechanism o Ipsilateral ligamentous tears or transverse bony avulsion o Contralateral shear fractures (oblique or spiral) o Usually due to excessive inversion stress, due to: Medial malleolus is shorter than lateral malleolus, therefore talus can invert more than evert Deltoid ligament on medial aspect of ankle joint more supportive than thinner lateral ligaments o Posterior malleolar fractures are usually associated with other fractures and/or ligamentous disruption associated with fibular fracture and often unstable o Transverse malleolar fracture represent avulsion-type injury o Vertical malleolar fracture result from talar impaction Danis-Weber Classification o Based on level of fibular fracture relative to syndesmosis Type A: infra-syndesmotic Pure inversion injury Avulsion of lateral malleolus below plafond or torn calcenofibular ligament Type B: trans-syndesmosis (most common) External rotation and eversion Avulsion of medial malleolus or rupture of deltoid ligament Spiral fracture of lateral malleolus starting at plafond Type C: supra-syndesmotic Pure external rotation Avulsion of medial malleolus or torn deltoid ligament Fibbular fracture above plafond Frequently tears syndesmosis Investigations o X-ray: AP, lateral, mortise views Management o Undisplaced: non-weight bearing blow knee cast o Indications for ORIF All fracture-dislocations, all Type C fractures Trimalleolar (medial, posterior, lateral) fractures Talar tile >10 Open fracture/open joint injury Post-traumatic arthritis common

HIP FRACTURE

Femoral head fracture (rare usually associated hip dislocation) o Superior fracture + anterior dislocation Extremity abducted and externally rotated o Inferior fracture + posterior dislocation Extremity adducted and internally rotated o More common in younger population secondary to major trauma o Type 1: Single fragment fracture Reduce fragment as soon as possible to avoid avascular necrosis Closed reduction first, then open reduction and internal fixation is next treatment of choice o Type 2: Comminuted fracture Early orthopaedic consultation and arthroplasty is recommended Femoral neck (subcapital) fracture o Intracapsular fracture of femoral neck o Usually occurring in younger population from high impact injury, or older, with simple fall onto hip due to osteoporosis o Clinical manifestation Acute onset of hip pain, unable to weight bear Shortened, externally rotated leg, painful ROM o Garden classification of hip fracture Type 1: stress fracture or incomplete fracture Valgus alignment, trabeculae is malaligned Type 2: impacted fracture but non displaced and complete Neutral alignment, trabeculae is aligned Type 3: partially (<50%) displaced fractures and complete Varus alignment, malaligned trabeculae Type 4: completely displaced or comminuted fractures and complete Varus alignment, aligned trabeculae o Management Swift management to prevent AVN Undisplaced: internal fixation and DHS Displaced: depends on patient age and function, Austin-Moore or hemiarthroplasty in older patient o Complications AVN of femoral head Noneunion o DVT (enoxaparin 30mg SC BID, >12 hours before surgery) Extracapsular fracture o including the greater and lesser trochanters and transitional bone between the neck and shaft o Mechanism: direct or indirect force transmitted to the intertrochanteric area o Clinical manifestation Acute onset hip pain, unable to weight bear Shortened, externally rotated leg; ecchymosis at back of upper thigh o Classification Stable vs. Unstable Stable: intact posteromedial cortex Unstable: non-intact posteromedial cortex fractures o Management DVT prophylaxis Obtain a closed reduction under fluoroscopy After reduction, DHS o Complications Varus displacement of proximal fragment Malrotation deformity Non-union Failure of fixation device

Subtrochanteric fracture o Fracture at or below the lesser trochanter and involves the proximal femoral shaft o Occurs in the young with high energy trauma, or in the old with osteopenic bone o Presents similar to intertrochanteric fracture o Reduce and internally fixate with intramedullary nail or plating

ELBOW FRACTURE Supracondylar fracture o Most common in paediatric population o Anterior interosseous nerve injury commonly associated with extension o Mechanism: FOOSH o Management Cast in flexion for 3 weeks Requires percutaneous pinning followed by limb cast with elbow flexed >90 o Complications Joint stiffness, brachial artery injury, median or ulnar nerve, compartment syndrome Radial head fracture o terrible triad: radial head fracture, coronoid fracture, elbow dislocation o FOOSH o Mason classification and treatment of radial head fractures

FACIAL FRACTURE Blowout fracture o Fracture of walls or floor of orbit o Commonly caused by blunt trauma of the head o Intraorbital material may be pushed out into one of the paranasal sinuses (usually maxillary) o Complications Entrapment of inferior rectus muscle (gaze turned up and out) Orbital emphysema from communication with maxillary sinus Orbital haemorrhage with risk of compressive optic neuropathy Globe can be ruptured Zygoma fracture o Depressed malar eminence with tenderness, oedema o Pain in cheek on movement of jaw o Trismus or difficulty opening mouth from impingement of temporalis muscle Examine CN V Nasoorbitoethmoid complex o Confluence of frontal sinus, ethmoid sinus, anterior cranial fossa, orbits, frontal bone and nasal bones o Present with: Nasal and forehead swelling or lacerations Eye, forehead, and nose pain Diplopia, telecanthus CSF rhinorrhoea Le Fort fractures o I: horizontal: injury directed low on maxillary alveolar rim in a downward direction o II: pyramidal: blow to lower or mid maxilla, usually involving inferior orbital rim o III: transverse: craniofacial dissociation, involving zygomatic arch

ORTHOPAEDICS: SHOULDER PATHOLOGY

SHOULDER DISLOCATION Most common dislocation and mainly anterior Recurrence rate high, especially in young Complications o Tuberosity #, glenoid rim fracture o Rotator cuff tear, shoulder stiffness o Injury to axillary nerve/artery, brachial plexus injury o Recurrent/unreduced dislocation Anterior shoulder dislocation o Most common (>90%) o Mechanism: extreme abduction, external rotation, extension and posterior directed force against the humerus o Clinical manifestations Pain, arm held in slight abduction, external rotation; internal rotation is blocked Squared off shoulder Positive apprehension test: Apprehension with shoulder abduction and external rotation to 90 o Neurovascular: axillary and musculocutaneous o Investigations X-ray findings: AP, trans-scapular, axillary Dislocation: axillary view shows humeral head anterior Hill-Sachs lesion: divot in posterior superior humeral head due to forceful impaction of an anteriorly dislocated humeral head against the glenoid rim Bankart lesion: avulsion of anterior glenoid labrum from glenoid rim (accompanied by Hill-Sachs) o Management Closed reduction and sling x 3 weeks Posterior shoulder dislocation o Mechanism: axial load applied to adducted and internally rotated arm flexed arm; often occurs with epileptic seizure, EtOH, electrocution; blow to anterior shoulder o Clinically manifestation Arm in held in adduction and internal rotation; external rotation Anterior shoulder flattening, prominent coracoids, positive jerk test o Investigations: X-ray findings: AP view: partial vacancy of glenoid fossa and >6mm space between anterior glenoid rim and humeral head Axillary view: humeral head posterior o Management Closed reduction: inferior traction on a flexed elbow with pressure on back of humeral head then sling x 3 weeks

ROTATOR CUFF DISEASE Impingement syndrome o Clinical manifestation Pain is most common symptom Anterolaterally and superior pain referred to level of deltoid insertion

Aggravated with abduction and forward flexion Weakness, limitation, clicking, catching, stiffness, creptus o Etiology: narrow subacromial space Glenohumeral muscle weakness leading to abnormal motion of humeral head Scapular muscle weakness leading to abnormal motion of acromion Acromial abnormalities such as congenital narrow space or osteophyte formation o Classification of impingement syndrome Stage I edema and haemorrhage, affect persons younger than 25 year Stage II fibrosis and tendonitis, affect persons 25-40 year Stage III tears of cuff, affecting persons older than 50 o Investigation X-rays: AP view may show high riding humerus relative to glenoid, evidence of chronic tendonitis US: large cuff tears Frozen shoulder o Disorder characterised by progressive pain and stiffness of shoulder resolving spontaneously after 18 months o Mechanism: Primary: idiopathic, associated with diabetes mellitus Secondary: due to prolonged immobilisation, shoulder-hand syndrome; following myocardial infarction, stroke, shoulder trauma