General Processes General Processes Common Clinical Adult Common - PDF document

8/11/2010 General Processes General Processes Common Clinical Adult Common Clinical Adult � Tendonitis (tendonosis) Orthopedic Problems Orthopedic Problems � Sprains and ligament tears � Nerve impingemnts � Nerve impingemnts Tendonitis Tendonitis Sprains, Strains Sprains, Strains � Over use phenomenon � Soft tissue injury heals with scar and remodeling � Natural reaction to stress increased fluid and lubrication � R I C E and then early functional mobilization mobilization � Increased blood supply and inflammatory � I d bl d l d i fl t cells prostaglandin mediated inflammation � NSAIDS for symptomatic treatment � Rest, Ice , Gentle active motions and some � Early return to non stressed ROM mild stretching � Collagen takes 6 - 12 weeks to regain � OT/PT modalities strength and remodeling up to one year � NSAIDS and activity modifications Shoulder Shoulder AC JOINT PROBLEMS AC JOINT PROBLEMS � AC JOINT � AC joint arthrosis - young as well as old � SUBACROMIAL REGION � AC joint separation- traumatic -------- 1 2 3rd degree 1,2,3rd degree � GLENOHUMERAL PROBLEMS � GLENOHUMERAL PROBLEMS 1

8/11/2010 AC Joint Arthrosis AC Joint Arthrosis Treatment Treatment � Weight lifter � INJECTION FOR DIAGNOSIS AND � traumatic TREATMENT � presents as bursitis p � NSAIDS � mass effect over � MRI to R/O other shoulder associated R/C � impinges on rotator pathology cuff � Surgical excision of the distal clavicle AC joint Separation AC joint Separation Treatment Treatment � traumatic in origin � Pain meds and symptomatic tx. � 1-2-3 degree of initially separation � Careful of skin � Not a functional overlying area problem usually � May need surgical � No hurry on definitive repair of ligaments treatment and distal clavicular resection Impingement and Bursitis Impingement and Bursitis Impingement and Bursitis Impingement and Bursitis � Compression of the � Positive impingement bursa and cuff sign � Weak or unstable � MRI to look for shoulder rotator cuff pathology � Night pain � X-rays for spur or arthritis � Cannot reach overhead � Cannot throw without pain 2

8/11/2010 Treatment Treatment Gleno Gleno- -Humeral Instability Humeral Instability � NSAIDS, heat, ROM � Usually anterior � Physical tx. strengthen dislocation or subluxation with labral rotator cuff pathology h l � Steroid injection into bursa � Usually traumatic � Arm externally rotated � Arthroscopic bursectomy and and abducted removal of � Tears ant. capsule etc. impingement Dislocated Shoulder Dislocated Shoulder Treatment Treatment � Anterior most � Dependent on age common � older patient = � Reduce under some decreased chance of anesthesia if required recurrence � MRI to look for other pathology � Abduction and traction with gentle terminal internal rotation � “Kocher maneuver” Adhesive Capsulitis Adhesive Capsulitis Treatment Treatment � Usually female ,40’s � Physical therapy � PAIN, Restriction of stellate blocks motion over time sometimes � Can hide underlying � Can hide underlying � Closed /arthroscopic other pathology such manipulation as tumor or shoulder � Investigation for disease underlying disease � PAIN -PAIN -PAIN (lung and breast CA) 3

8/11/2010 Rotator Cuff Tears Rotator Cuff Tears Rotator Cuff Tears Rotator Cuff Tears � All types and all � Cephalad humeral causes head � May present as � Discontinuity of the y impingement or p g bursitis supraspinatus � Need MRI/arthrogram to evaluate � Physical exam pain on resisted RC muscles Cubital Tunnel Syndrome Cubital Tunnel Syndrome Treatment Treatment � Compression of the � Splint , elbow pad, ulnar nerve at the activity evaluation elbow � NSAIDS � Tingling in ulnar � Injection nerve distribution � EMG/NCV’s � Happens at night and � Release during hyperflexion � sub muscular, sub fascial, epicondylectomy Lateral Epicondylits Lateral Epicondylits Treatment Treatment � Tendonitis of the � Counterforce brace extensor wad at the � Ice , NSAIDS , elbow usually ultrasound ECRB/L ECRB/L � Injection, � Tennis elbow, Iontophoresis carpenters elbow etc � STRETCH!!!!!!!! � Can be incapacitating � Counseling because of the pain � SURGERY IS LAST! 4

8/11/2010 Surgical Repair Surgical Repair De Quervains disease De Quervains disease � Removal of “damaged � Radial long thumb tendon” and repair extensors multiple � “Venting the EVIL � Tendonitis HUMORS!” � Positive Finklestein’s test � ICE –NSAIDS-- SPLINTAGE � Injection Carpal Tunnel Syndrome Carpal Tunnel Syndrome Open Release Open Release � Nerve compression � Gold Standard and loss of blood � Needs workup with supply EMG/NCV's � Splints NSAIDS � Failure of conservative activity evaluation treatment � Systemic causes � Dependable results � Traumatic, arthritic with the right group of patients CMC Arthroplasty CMC Arthroplasty 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 5

8/11/2010 Scaphoid Fracture Scaphoid Fracture Dupuytren’s Disease Dupuytren’s Disease � Poorly vascularised � Cellular change bone amongst the � High rates of non- fibroblasts union � Contractile bands, Contractile bands, � Typical history of MP,PIP neglected trauma � Involves nerves and � Cast usually vessels � May need ORIF if � Operate when unable displaced to passively extend � Operative trends PIP joint Trigger Digit Trigger Digit Mallet Finger Mallet Finger � Thumb, ring � Traumatic usually � Stenosing � Needs x-ray tenosynovitis � Splint for 8-12- p � NSAIDs splintage weeks! injections � Can pin closed and � Release, open or can operate to repair if percutaneous too much articular � Common in Diabetics surface is displaced Cervical Arthritis and Cervical Arthritis and Disc Rupture Disc Rupture Radiculopathy Radiculopathy � Facet joint arthrosis � Protruding disc material � Cx pain with radiculopathy and DTR changes 6

8/11/2010 Epidural Epidural Pattern of discomfort Pattern of discomfort � Can be radicular � Can be posterior shoulder and masquerade as shoulder pathology � Relieved by traction or distraction Scoliosis Scoliosis Surgery Surgery � Not first order of TX � OK TO WATCH � Traction NSAIDs DEPENDING ON Collar AGE AND � Physical therapy Physical therapy SEVERITY OF SEVERITY OF � Injections CURVE ! � Risser sign � Idiopathic vs. leg length inequality etc Can correct anything!!! Can correct anything!!! Hip Bursitis Hip Bursitis � Timing is key as well � Greater Trochanteric as guidelines for Bursa watching them � Impinges on Iliotibial � Fluid field and band changing guidelines!! � Mimics sciatica � Point tender � + Ober test � Injection test/treatment 7

8/11/2010 Avascular Necrosis Avascular Necrosis Fractured Hip Fractured Hip � Hip and Humerus � Intertroch, Neck,Subtroch � End bone circulation � Pelvis sup/inf rami � Stages for treatment g � Need ORIF or � Crutches to total joint replacement � NSAIDs crutches depending on pattern synovitis � Metabolic state of � Drilling ,grafting, patient replacements 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 8

8/11/2010 Torn Meniscus Torn Meniscus Osteochondritis Dissecans Osteochondritis Dissecans � Mechanical symptoms � Usually growing or “locked” knee children � MRI � Can see in adult as result of AVN � Arthroscopic TX � Make the knee mechanically sound Grades of OCD Grades of OCD Ankle Sprain Ankle Sprain � Mechanically sound � X-rays and get it to heal � intact mortise � Or remove it � 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? 9

8/11/2010 Stretching Stretching Plantar Fasciitis Plantar Fasciitis � Stretch plantar fascia � Post tibial nerve calcaneal branch � Tarsal tunnel � Lithotripsy?? � Injection?? � Stretch stretch stretch!! Mortons Neuroma Mortons Neuroma Ingrown Toenail Ingrown Toenail � Shoe wear mods � Cut nails too short on lateral folds � Inject � Nail tries to grow thru � Metatarsal Pad lateral fold creates � Surgery infection � SOAKS --pushing nail fold away until nail grows out � Shoe wear and cleanliness Gout Gout Surgical Solutions Surgical Solutions � Hyperuricemia � Podagra � usually 1st metatarsal- y phalangeal joint � VERY TENDER past what you would expect clinically 10

8/11/2010 Any other conditions that you Any other conditions that you Xray and Clinical of Gout Xray and Clinical of Gout want us to talk about? want us to talk about? 11