Orthopaedics 101 for Workers’ Compensation Claims CONFIDENTIAL 12/25/2017 Orthopaedics 101 for Workers’ Compensation Claims MASI Annual Conference September 30, 2016 Chad Hosemann, M.D. Capital Orthopaedic and Sports Medicine Center Flowood & Madison, MS www.drhosemann.com Knee Creations, LLC 1

Review common orthopaedic injuries in Workers’ Compensation claims Objectives Review common orthopaedic injuries in Workers’ Compensation claims Focus on Shoulder, Elbow, and Knee Develop a better understanding of the workup, treatment, and expected outcomes for these injuries Give some insight into particular problem areas contributing to prolonged cases

Upper Extremity: Shoulder & Elbow Rotator Cuff Tendonitis v. Tear AC Joint Sprains Dislocation (Labral/Bankart tear) The dreaded “SLAP tear” Myofascial, scapular, or neck pain Elbow Biceps tears Tendon issues, fractures

“Partial cuff tear” = Conservative measures Rotator Cuff Tears “Partial cuff tear” = Conservative measures Rest NSAIDs PT (6 weeks regimented) Cortisone Shot True acute ruptures usually require surgery “70% success rate”

Rotator Cuff Tear Surgery: Arthroscopic RCR in conjunction with acromioplasty (SAD) and bursectomy 6 weeks in a sling Extensive PT (3+ months) Average MMI around 5-8 months Difficult surgery to return from in a manual laborer!

Usually do not require surgery AC Joint Sprains Aka: “shoulder separation” Often result from fall 3-4 weeks in a sling PT Usually do not require surgery Footnote: Distal clavicle excision (DCE) often added for degenerative changes My Goal: Leave no pain generator to chance NEVER COME BACK!!!

Always results in a anterior labral or “Bankart tear” Dislocation Bankart tear Rare in work comp Always results in a anterior labral or “Bankart tear” First time dislocators >25 years old should be fine with rest/PT Surgery: Bankart repair, reserved for recurrent instability, very successful

SLAP Tear Superior Labrum Anterior Posterior Tear Commonly a “thrower’s injury” Often a “red herring” in work comp cases May be incidental finding, chronic issue One of the most abused reasons for surgery Patients will fixate on it, google it etc. and expect surgery despite the fact that it may not be causing their symptoms Back to the basics (H&P!) Surgical outcomes reasonable SLAP repair v. Biceps tenodesis

Myofascial/Scapular/Neck Pain Myofascial Pain: Hypersensitive to touch Again: H&P is critical Fibromyalgia, trigger points, “hurts all over!”etc. Physiatrist or Pain Management Referral Cuff tears are usually not tender to palpation Scapulothoracic pain is very difficult to treat Cervical radiculopathy could be causing symptoms Let us get C-spine MRI if we request it! Footnote: all of the above are BAD for you and me!!!

“Long head” biceps rupture: shoulder Biceps Pathology “Long head” biceps rupture: shoulder Usually nonoperative treatment “Popeye deformity” but no strength deficit Often a sign of other pathology Distal biceps rupture: elbow Immediate surgical repair Excellent outcomes MMI 4-6 months

Elbow Tendonitis/Bursitis Lateral Epicondylitis, aka “tennis elbow” Due to “repetitive microtrauma” Can resolve but requires rest (ice, PT, shot) Surgery rarely warranted Olecranon Bursitis Results from trauma Often a cosmetic nuisance Aspirate/Inject Can easily become infected

Elbow Fractures Radial head/neck Olecranon fracture Elbow Dislocation Common with falls Usually nonoperative Early ROM Olecranon fracture Usually operative injury Elbow Dislocation Usually nonoperative injury 3-4 weeks immobilization PT: prevent loss of motion

Knee Injuries Fractures Tendon ruptures Ligament Injuries Meniscal tears The dreaded “exacerbation of osteoarthritis”

Fractures Stress fractures (bone bruises on MRI): 6-12 week recovery, limited weight bearing True fractures of the femur, tibia, or patella should be expedited! Bone heals in 6 weeks, total recovery 3-4 months “working out the kinks”

Quadriceps and Patellar tendon Automatic surgery: Expedited case! Tendon Ruptures Quadriceps and Patellar tendon Automatic surgery: Expedited case! 6 weeks bracing, 3 months PT, most recover fully Quad Rupture

ACL: the most important knee ligament Ligament Injuries ACL: the most important knee ligament Usually requires reconstruction in young patient 2-3 months off, 6 month recovery MCL: usually nonoperative Hinged knee brace for 3-4 weeks LCL/posterolateral corner: bad! Almost always in conjunction with ACL Has to be fixed PCL: rare, usually ok with bracing and PT

Meniscus Tears The “shock absorber” of the knee, medial and lateral Very common diagnosis Start with conservative measures NSAID’s, rest, PT, knee sleeves, +/- Cortisone shot At least 6 weeks conservative treatment “Locked bucket handle tear” requires immediate intervention Most common orthopaedic surgery in America Arthroscopic: Easy, safe, fast, cheap, and it works!!! Expect 4-6 weeks return to work, 3-4 months MMI (unless they have arthritis!!!)

“Exacerbation of OA” Get ready, this may take a while! Rest, NSAIDS, bracing, Cortisone or Visco Shot Often go on to scope debridement Somewhat helpful as long as not bone on bone Realistic expectations: This may be “the straw that broke the camel’s back” Call your lawyer, most common litigated case I see… Often results in settlement followed by TKA

“Bone on Bone”

Foot Note “Baker’s Cyst” Often a result of a meniscus tear Another “red herring” A sign of a problem, not actually a problem Have been shown to be asymptomatic Patients will fixate on it, despite the facts

Prevention Most injuries due to “overuse” or “over exposure” Many injuries are present but exacerbated by work Age plays a role (especially in recovery) If caught early, most of these problems will resolve with appropriate conservative care

My Approach Everyone is a “VIP” The patient is always right Listening to them can do wonders Communication and availability are key Give them options and let them decide!!! Be conservative initially, but know when to call it a loss and go to surgery See things through to the end, and get them the best possible result!

Galatians 3:28: “for ye are all one in Christ Jesus” Why I’m Different Galatians 3:28: “for ye are all one in Christ Jesus” Workers’ Compensation cases can be frustrating and require patience and empathy Assume that everyone is trying to get better and get back to work because almost all of them are! Take extra time to explain the diagnosis and treatment options (I see less patients so I can do this!) Let the patient participate in the decision making process

About Me and My Practice Focus on Shoulder, Elbow, and Knee Still “see it all” The only “Andrews Fellow” in Jackson performing upper extremity surgery John Smoltz, Hope Solo, Terrell Owens, Mathew Stafford, Cam Newton, Allen Iverson, Mark Ingram, Davis Love III Professionalism: Suit and Tie Every Day Capital Orthopaedic takes pride in it’s smaller, more personable environment All fellowship trained surgeons Sports med, foot and ankle, hand/wrist, total joints

www.drhosemann.com

Thank you!