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Common Clinical Adult Common Clinical Adult Orthopedic ProblemsOrthopedic Problems

General ProcessesGeneral Processes

Tendonitis (tendonosis)Sprains and ligament tearsNerve impingemntsNerve impingemnts

TendonitisTendonitisOver use phenomenonNatural reaction to stress increased fluid and lubricationI d bl d l d i fl tIncreased blood supply and inflammatory cells prostaglandin mediated inflammationRest, Ice , Gentle active motions and some mild stretchingOT/PT modalitiesNSAIDS and activity modifications

Sprains, StrainsSprains, StrainsSoft tissue injury heals with scar and remodelingR I C E and then early functional mobilizationmobilizationNSAIDS for symptomatic treatmentEarly return to non stressed ROMCollagen takes 6 - 12 weeks to regain strength and remodeling up to one year

ShoulderShoulder

AC JOINTSUBACROMIAL REGIONGLENOHUMERAL PROBLEMSGLENOHUMERAL PROBLEMS

AC JOINT PROBLEMSAC JOINT PROBLEMS

AC joint arthrosis - young as well as oldAC joint separation- traumatic --------1 2 3rd degree1,2,3rd degree

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AC Joint ArthrosisAC Joint Arthrosis

Weight liftertraumaticpresents as bursitispmass effect over shoulderimpinges on rotator cuff

TreatmentTreatment

INJECTION FOR DIAGNOSIS AND TREATMENTNSAIDSMRI to R/O other associated R/C pathologySurgical excision of the distal clavicle

AC joint SeparationAC joint Separation

traumatic in origin1-2-3 degree of separationNot a functional problem usuallyNo hurry on definitive treatment

TreatmentTreatment

Pain meds and symptomatic tx. initiallyCareful of skin overlying areaMay need surgical repair of ligaments and distal clavicular resection

Impingement and BursitisImpingement and Bursitis

Compression of the bursa and cuffWeak or unstable shoulderNight painCannot reach overheadCannot throw without pain

Impingement and BursitisImpingement and Bursitis

Positive impingement signMRI to look for rotator cuff pathologyX-rays for spur or arthritis

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TreatmentTreatmentNSAIDS, heat, ROMPhysical tx. strengthen rotator cuffSteroid injection into bursaArthroscopic bursectomy and removal of impingement

GlenoGleno--Humeral InstabilityHumeral Instability

Usually anterior dislocation or subluxation with labral

h lpathologyUsually traumatic Arm externally rotated and abductedTears ant. capsule etc.

Dislocated ShoulderDislocated Shoulder

Anterior most commonReduce under some anesthesia if requiredAbduction and traction with gentle terminal internal rotation“Kocher maneuver”

TreatmentTreatment

Dependent on ageolder patient = decreased chance of recurrence

MRI to look for other pathology

Adhesive CapsulitisAdhesive CapsulitisUsually female ,40’sPAIN, Restriction of motion over timeCan hide underlyingCan hide underlying other pathology such as tumor or shoulder diseasePAIN -PAIN -PAIN

TreatmentTreatment

Physical therapy stellate blocks sometimesClosed /arthroscopic manipulationInvestigation for underlying disease (lung and breast CA)

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Rotator Cuff TearsRotator Cuff TearsAll types and all causesMay present as impingement or p gbursitisNeed MRI/arthrogram to evaluate Physical exam pain on resisted RC muscles

Rotator Cuff TearsRotator Cuff Tears

Cephalad humeral headDiscontinuity of the ysupraspinatus

Cubital Tunnel SyndromeCubital Tunnel Syndrome

Compression of the ulnar nerve at the elbowTingling in ulnar nerve distributionHappens at night and during hyperflexion

TreatmentTreatment

Splint , elbow pad, activity evaluationNSAIDSInjectionEMG/NCV’sReleasesub muscular, sub fascial, epicondylectomy

Lateral EpicondylitsLateral Epicondylits

Tendonitis of the extensor wad at the elbow usually ECRB/LECRB/LTennis elbow, carpenters elbow etcCan be incapacitating because of the pain

TreatmentTreatment

Counterforce braceIce , NSAIDS , ultrasoundInjection, IontophoresisSTRETCH!!!!!!!!CounselingSURGERY IS LAST!

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Surgical RepairSurgical Repair

Removal of “damaged tendon” and repair“Venting the EVIL HUMORS!”

De Quervains diseaseDe Quervains disease

Radial long thumb extensors multipleTendonitis Positive Finklestein’s testICE –NSAIDS--SPLINTAGEInjection

Carpal Tunnel SyndromeCarpal Tunnel Syndrome

Nerve compression and loss of blood supplySplints NSAIDS activity evaluationSystemic causes Traumatic, arthritic

Open ReleaseOpen Release

Gold StandardNeeds workup with EMG/NCV'sFailure of conservative treatmentDependable results with the right group of patients

CMC ArthritisCMC Arthritis

Pain at base of thumbGoes along with other arthritic conditionsPositive grind test and positive x raysFemale , olderNSAIDs, splintage, restriction of activity

CMC ArthroplastyCMC Arthroplasty

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Scaphoid FractureScaphoid FracturePoorly vascularised boneHigh rates of non-unionTypical history of neglected traumaCast usuallyMay need ORIF if displacedOperative trends

Dupuytren’s DiseaseDupuytren’s DiseaseCellular change amongst the fibroblastsContractile bands,Contractile bands, MP,PIP Involves nerves and vesselsOperate when unable to passively extend PIP joint

Trigger DigitTrigger DigitThumb, ringStenosing tenosynovitisNSAIDs splintage injectionsRelease, open or percutaneousCommon in Diabetics

Mallet FingerMallet Finger

Traumatic usuallyNeeds x-raySplint for 8-12-pweeks!Can pin closed and can operate to repair if too much articular surface is displaced

Cervical Arthritis and Cervical Arthritis and RadiculopathyRadiculopathy

Facet joint arthrosisProtruding disc materialCx pain with radiculopathy and DTR changes

Disc RuptureDisc Rupture

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Pattern of discomfortPattern of discomfort

Can be radicularCan be posterior shoulder and masquerade as shoulder pathologyRelieved by traction or distraction

EpiduralEpidural

Surgery Surgery Not first order of TXTraction NSAIDs Collar Physical therapyPhysical therapyInjections

ScoliosisScoliosis

OK TO WATCH DEPENDING ON AGE AND SEVERITY OFSEVERITY OF CURVE !Risser signIdiopathic vs. leg length inequality etc

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

Timing is key as well as guidelines for watching themFluid field and changing guidelines!!

Hip BursitisHip Bursitis

Greater Trochanteric BursaImpinges on Iliotibial bandMimics sciaticaPoint tender+ Ober testInjection test/treatment

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Avascular NecrosisAvascular Necrosis

Hip and HumerusEnd bone circulationStages for treatmentgCrutches to total jointNSAIDs crutches synovitisDrilling ,grafting, replacements

Fractured HipFractured Hip

Intertroch, Neck,SubtrochPelvis sup/inf ramiNeed ORIF or replacement depending on patternMetabolic state of patient

Hip prosthesesHip prosthesesKnee arthritisKnee arthritis

NSAIDSInjections steroidInjections visco-jelastic?Hyalgan, SynviscBracing for varus knees

Valgus and Varus KneesValgus and Varus KneesPatello femoral conditionsPatello femoral conditions

AdolescentFemalesValgus kneesgQ-angleTrack laterally

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Torn MeniscusTorn Meniscus

Mechanical symptoms or “locked” kneeMRIArthroscopic TX

Osteochondritis DissecansOsteochondritis Dissecans

Usually growing children Can see in adult as result of AVNMake the knee mechanically sound

Grades of OCDGrades of OCD

Mechanically sound and get it to healOr remove it

Ankle SprainAnkle Sprain

X-rays intact mortisedamage to articular gsurface Anterior drawerATFLAir cast elevation get them moving!!!Stretch heel cord

“SHOEWEAR PROBLEMS”“SHOEWEAR PROBLEMS” BunionsBunions

Natural change to the adult foot accelerated by some footwearShoe wear modificationOperate only if painful in bare feetGout?

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Plantar FasciitisPlantar Fasciitis

Stretch plantar fasciaPost tibial nerve calcaneal branchTarsal tunnelLithotripsy??Injection??Stretch stretch stretch!!

StretchingStretching

Mortons NeuromaMortons Neuroma

Shoe wear mods InjectMetatarsal PadSurgery

Ingrown ToenailIngrown Toenail

Cut nails too short on lateral foldsNail tries to grow thru lateral fold creates infectionSOAKS --pushing nail fold away until nail grows outShoe wear and cleanliness

Surgical SolutionsSurgical Solutions GoutGout

HyperuricemiaPodagrausually 1st metatarsal-yphalangeal jointVERY TENDER past what you would expect clinically

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