General Processes General Processes Common Clinical Adult Common - - PDF document

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Common Clinical Adult Common Clinical Adult Orthopedic Problems Orthopedic Problems General Processes General Processes

Tendonitis (tendonosis) Sprains and ligament tears Nerve impingemnts Nerve impingemnts

Tendonitis Tendonitis

Over use phenomenon Natural reaction to stress increased fluid

and lubrication

I

d bl d l d i fl t

Increased blood supply and inflammatory

cells prostaglandin mediated inflammation

Rest, Ice , Gentle active motions and some

mild stretching

OT/PT modalities NSAIDS and activity modifications

Sprains, Strains Sprains, Strains

Soft tissue injury heals with scar and

remodeling

R I C E and then early functional

mobilization mobilization

NSAIDS for symptomatic treatment Early return to non stressed ROM Collagen takes 6 - 12 weeks to regain

strength and remodeling up to one year

Shoulder Shoulder

AC JOINT SUBACROMIAL REGION GLENOHUMERAL PROBLEMS GLENOHUMERAL PROBLEMS

AC JOINT PROBLEMS AC JOINT PROBLEMS

AC joint arthrosis - young as well as old AC joint separation- traumatic --------

1 2 3rd degree 1,2,3rd degree

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AC Joint Arthrosis AC Joint Arthrosis

Weight lifter traumatic presents as bursitis

p

mass effect over

shoulder

impinges on rotator

cuff

Treatment Treatment

INJECTION FOR

DIAGNOSIS AND TREATMENT

NSAIDS MRI to R/O other

associated R/C pathology

Surgical excision of

the distal clavicle

AC joint Separation AC joint Separation

traumatic in origin 1-2-3 degree of

separation

Not a functional

problem usually

No hurry on definitive

treatment

Treatment Treatment

Pain meds and

symptomatic tx. initially

Careful of skin

• verlying area

May need surgical

repair of ligaments and distal clavicular resection

Impingement and Bursitis Impingement and Bursitis

Compression of the

bursa and cuff

Weak or unstable

shoulder

Night pain Cannot reach overhead Cannot throw without

pain

Impingement and Bursitis Impingement and Bursitis

Positive impingement

sign

MRI to look for

rotator cuff pathology

X-rays for spur or

arthritis

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Treatment Treatment

NSAIDS, heat, ROM Physical tx. strengthen

rotator cuff

Steroid injection into

bursa

Arthroscopic

bursectomy and removal of impingement

Gleno Gleno-

• Humeral Instability

Humeral Instability

Usually anterior

dislocation or subluxation with labral h l pathology

Usually traumatic Arm externally rotated

and abducted

Tears ant. capsule etc.

Dislocated Shoulder Dislocated Shoulder

Anterior most

common

Reduce under some

anesthesia if required

Abduction and traction

with gentle terminal internal rotation

“Kocher maneuver”

Treatment Treatment

Dependent on age

• lder patient =

decreased chance of recurrence

MRI to look for other pathology

Adhesive Capsulitis Adhesive Capsulitis

Usually female ,40’s PAIN, Restriction of

motion over time

Can hide underlying Can hide underlying

• ther pathology such

as tumor or shoulder disease

PAIN -PAIN -PAIN

Treatment Treatment

Physical therapy

stellate blocks sometimes

Closed /arthroscopic

manipulation

Investigation for

underlying disease (lung and breast CA)

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Rotator Cuff Tears Rotator Cuff Tears

All types and all

causes

May present as

impingement or p g bursitis

Need MRI/arthrogram

to evaluate

Physical exam pain on

resisted RC muscles

Rotator Cuff Tears Rotator Cuff Tears

Cephalad humeral

head

Discontinuity of the

y supraspinatus

Cubital Tunnel Syndrome Cubital Tunnel Syndrome

Compression of the

ulnar nerve at the elbow

Tingling in ulnar

nerve distribution

Happens at night and

during hyperflexion

Treatment Treatment

Splint , elbow pad,

activity evaluation

NSAIDS Injection EMG/NCV’s Release sub muscular, sub

fascial, epicondylectomy

Lateral Epicondylits Lateral Epicondylits

Tendonitis of the

extensor wad at the elbow usually ECRB/L ECRB/L

Tennis elbow,

carpenters elbow etc

Can be incapacitating

because of the pain

Treatment Treatment

Counterforce brace Ice , NSAIDS ,

ultrasound

Injection,

Iontophoresis

STRETCH!!!!!!!! Counseling SURGERY IS LAST!

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Surgical Repair Surgical Repair

Removal of “damaged

tendon” and repair

“Venting the EVIL

HUMORS!”

De Quervains disease De Quervains disease

Radial long thumb

extensors multiple

Tendonitis Positive Finklestein’s

test

ICE –NSAIDS--

SPLINTAGE

Injection

Carpal Tunnel Syndrome Carpal Tunnel Syndrome

Nerve compression

and loss of blood supply

Splints NSAIDS

activity evaluation

Systemic causes Traumatic, arthritic

Open Release Open Release

Gold Standard Needs workup with

EMG/NCV's

Failure of conservative

treatment

Dependable results

with the right group of patients

CMC Arthritis CMC Arthritis

Pain at base of thumb Goes along with other

arthritic conditions

Positive grind test and

positive x rays

Female , older NSAIDs, splintage,

restriction of activity

CMC Arthroplasty CMC Arthroplasty

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Scaphoid Fracture Scaphoid Fracture

Poorly vascularised

bone

High rates of non-

union

Typical history of

neglected trauma

Cast usually May need ORIF if

displaced

Operative trends

Dupuytren’s Disease Dupuytren’s Disease

Cellular change

amongst the fibroblasts

Contractile bands,

Contractile bands, MP,PIP

Involves nerves and

vessels

Operate when unable

to passively extend PIP joint

Trigger Digit Trigger Digit

Thumb, ring Stenosing

tenosynovitis

NSAIDs splintage

injections

Release, open or

percutaneous

Common in Diabetics

Mallet Finger Mallet Finger

Traumatic usually Needs x-ray Splint for 8-12-

p weeks!

Can pin closed and

can operate to repair if too much articular surface is displaced

Cervical Arthritis and Cervical Arthritis and Radiculopathy Radiculopathy

Facet joint arthrosis Protruding disc

material

Cx pain with

radiculopathy and DTR changes

Disc Rupture Disc Rupture

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Pattern of discomfort Pattern of discomfort

Can be radicular Can be posterior

shoulder and masquerade as shoulder pathology

Relieved by traction or

distraction

Epidural Epidural Surgery Surgery

Not first order of TX Traction NSAIDs

Collar

Physical therapy

Physical therapy

Injections

Scoliosis Scoliosis

OK TO WATCH

DEPENDING ON AGE AND SEVERITY OF SEVERITY OF CURVE !

Risser sign Idiopathic vs. leg

length inequality etc

Can correct anything!!! Can correct anything!!!

Timing is key as well

as guidelines for watching them

Fluid field and

changing guidelines!!

Hip Bursitis Hip Bursitis

Greater Trochanteric

Bursa

Impinges on Iliotibial

band

Mimics sciatica Point tender + Ober test Injection test/treatment

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Avascular Necrosis Avascular Necrosis

Hip and Humerus End bone circulation Stages for treatment

g

Crutches to total joint NSAIDs crutches

synovitis

Drilling ,grafting,

replacements

Fractured Hip Fractured Hip

Intertroch,

Neck,Subtroch

Pelvis sup/inf rami Need ORIF or

replacement depending on pattern

Metabolic state of

patient

Hip prostheses Hip prostheses Knee arthritis Knee arthritis

NSAIDS Injections steroid Injections visco-

j elastic?

Hyalgan, Synvisc Bracing for varus

knees

Valgus and Varus Knees Valgus and Varus Knees Patello femoral conditions Patello femoral conditions

Adolescent Females Valgus knees

g

Q-angle Track laterally

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Torn Meniscus Torn Meniscus

Mechanical symptoms

• r “locked” knee

MRI Arthroscopic TX

Osteochondritis Dissecans Osteochondritis Dissecans

Usually growing

children

Can see in adult as

result of AVN

Make the knee

mechanically sound

Grades of OCD Grades of OCD

Mechanically sound

and get it to heal

Or remove it

Ankle Sprain Ankle Sprain

X-rays intact mortise damage to articular

g surface

Anterior drawer ATFL Air cast elevation get

them moving!!!

Stretch heel cord

“SHOEWEAR PROBLEMS” “SHOEWEAR PROBLEMS” Bunions Bunions

Natural change to the

adult foot accelerated by some footwear

Shoe wear

modification

Operate only if painful

in bare feet

Gout?

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Plantar Fasciitis Plantar Fasciitis

Stretch plantar fascia Post tibial nerve

calcaneal branch

Tarsal tunnel Lithotripsy?? Injection?? Stretch stretch

stretch!!

Stretching Stretching Mortons Neuroma Mortons Neuroma

Shoe wear mods Inject Metatarsal Pad Surgery

Ingrown Toenail Ingrown Toenail

Cut nails too short on

lateral folds

Nail tries to grow thru

lateral fold creates infection

SOAKS --pushing nail

fold away until nail grows out

Shoe wear and

cleanliness

Surgical Solutions Surgical Solutions Gout Gout

Hyperuricemia Podagra usually 1st metatarsal-

y phalangeal joint

VERY TENDER past

what you would expect clinically

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Xray and Clinical of Gout Xray and Clinical of Gout Any other conditions that you Any other conditions that you want us to talk about? want us to talk about?