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Showing posts with label Musculoskeletal. Show all posts
Showing posts with label Musculoskeletal. Show all posts

Thursday, April 29, 2021

HUMERAL SHAFT FRACTURES

HUMERAL SHAFT FRACTURES


HUMERAL SHAFT FRACTURES
Injury To The Upper Arm
Whenever a patient presents with a possible humeral fracture, inspect the upper arm for swelling, ecchymosis, deformity, and open wounds. Palpate the area of maximal tenderness, and assess the joint above (shoulder) and below (elbow) for injury. Always perform a thorough distal neurovascular examination. After a fracture of the humeral shaft, the arm should be supported and immobilized.
When gross fracture angulation occurs, emergency care personnel should restore overall alignment of the arm by applying longitudinal traction. This is best accomplished with conscious sedation of the patient to avoid patient guarding and muscle spasm that may prevent adequate reduction of the fracture. Once the fracture is reduced, someone must maintain alignment of the fracture manually while a well-padded splint is applied to the arm to provide stability and maintain the reduction. For humeral shaft fractures, a coaptation splint typically works best. The entire injured limb can then be placed in a sling for added comfort.


HUMERAL SHAFT FRACTURES

Fracture Of Shaft Of Humerus
Fractures of the humeral shaft are generally due to direct trauma and can present as different fracture patterns, such as transverse, spiral or oblique, and comminuted. Nonsurgical treatment is acceptable in most instances, but the choice of treatment is based on the type and location of the fracture, concomitant injuries, and age and condition of the patient. For closed fractures, a coaptation splint or a collar and a lightweight, hanging arm cast may be placed initially. About 10 days after injury, when the initial swelling has subsided, the patient is fitted with a fracture brace, which allows the patient to exercise the hand, wrist, elbow, and shoulder while maintaining fracture alignment.
INJURY TO THE ELBOW

INJURY TO THE ELBOW


INJURY TO THE ELBOW
Injuries of the elbow range from nondisplaced fractures to complex fracture-dislocations. When a patient presents with an elbow injury, inspect the elbow and forearm for swelling, ecchymosis, deformity, and wounds such as abrasions or lacerations that could raise concern for an open injury. Palpate the area of maximal tenderness, and assess the joint above (shoulder) and below (wrist) for additional areas of tenderness that could suggest other injuries.
INJURY TO THE ELBOW

Palpation can also be utilized to detect for the presence of a joint effusion associated with the injury. An effusion is, again, most easily noted by palpation over the posterolateral “soft spot” of the elbow. Elbow range of motion may be limited after an acute injury owing to pain or because of the presence of a fracture or dislocation. A thorough distal neurovascular examination is mandatory to determine if damage has occurred to any neurovascular structures from the injury. After an elbow fracture, the elbow show be supported and immobilized with a well-padded posterior elbow splint incorporating both the upper arm and forearm. The entire injured limb can then be placed in a sling for added comfort.
FRACTURE OF DISTAL HUMERUS

FRACTURE OF DISTAL HUMERUS


FRACTURE OF DISTAL HUMERUS
In adults, fractures of the distal humerus often require surgical fixation because they are usually caused by a high-energy injury and frequently are comminuted and/or intra-articular in location. Fracture patterns include supracondylar, transcondylar, intercondylar (T or Y), lateral or medial condyle, or epicondyle and isolated capitellar or trochlear fractures. Intra-articular fractures may be difficult to adequately assess on plain radiographs; therefore, CT scans may be needed.
Surgical fixation can be with plates and screws, or screws alone, depending on the particular fracture pattern. Joint replacement has also become an option for distal humerus fractures that may be too comminuted to be stabilized with plates and screws.
FRACTURE OF DISTAL HUMERUS

Complex Intra-articular Fractures
Comminuted intra-articular fractures of the distal humerus are among the more challenging orthopedic injuries, and their reconstruction requires considerable surgical skill (see Plate 2-21). The major complications include restricted elbow motion and early degenerative joint disease.
FRACTURE OF HEAD AND NECK OF RADIUS

FRACTURE OF HEAD AND NECK OF RADIUS


FRACTURE OF HEAD AND NECK OF RADIUS
Fractures of the radial head occur primarily in adults, whereas fractures of the radial neck are more common in children. The usual causes of these injuries are indirect trauma, such as a fall on the outstretched hand, and, less commonly, a direct blow to the elbow. Radial head and neck fractures are generally classified into four groups. In type I fractures, the fracture is nondisplaced or minimally displaced. Type II fractures refer to displaced fractures of the joint margin or neck with a single fracture line. Type III fractures are comminuted fractures of the head or neck. Type IV fractures are associated with dislocation of the elbow.
RADIAL HEAD AND NECK FRACTURES

Diagnosis of a radial or neck head fracture may be difficult. Pain, effusion in the elbow, and tenderness to palpation directly over the radial head or neck are the typical manifestations. If the fracture is displaced, a “click” or crepitus over the radial head or neck is detected during forearm supination or pronation. Radiographic findings in nondisplaced fractures are minimal, and the radiograph often shows only swelling in the elbow with a fat pad sign. Any radiographic evidence of fat pad displacement accompanied by tenderness over the radial head or neck strongly suggests a fracture.
FRACTURE OF OLECRANON

FRACTURE OF OLECRANON


FRACTURE OF OLECRANON
Olecranon fractures are caused by a direct blow to the elbow or an indirect avulsion injury, such as a fall on an outstretched hand while the triceps is contracting. Nondisplaced fractures of the olecranon can be treated with posterior splinting or a cast, but displaced fractures are best stabilized with open reduction and internal fixation. 
FRACTURE OF OLECRANON

These fractures are typically intra-articular; therefore, care should be taken to appropriately reduce and align the joint surface during surgical fixation, regardless of technique utilized. Fixation with a tension band wire using screws or Kirschner wires is common in more simple fracture patterns. The tension band technique acts to convert the tensile forces through the fracture that are causing displacement into compressive forces that will allow fracture reduction and healing. If the fracture is too comminuted or too distal (extends to the coronoid or proximal ulnar shaft), a tension band technique is typically not adequate for fracture stability. Interfragmentary compression utilizing plate fixation is the preferred method of treatment in this situation. Precontoured plates that match the anatomy of the olecranon are now available and routinely used. The plate is positioned along the subcutaneous border of the ulna, however, and may require removal after fracture healing owing to its very superficial location.
DISLOCATION OF ELBOW JOINT

DISLOCATION OF ELBOW JOINT


DISLOCATION OF ELBOW JOINT
Dislocations of the elbow joint are the most common dislocations after those of the shoulder and finger joints. Swelling, pain, and pseudoparalysis of the arm are acute signs and symptoms of dislocation, and elbow deformity is visible on both clinical and radiographic examinations.
DISLOCATION OF ELBOW JOINT

Acute elbow dislocations are classified as anterior or posterior, with the direction determined by the position of the radius and ulna relative to the humerus. In addition to the anterior or posterior direction of dislocation, the forearm bones can also be displaced medially or laterally. Posterior elbow dislocations are by far the most common type and usually result from a fall on an outstretched hand. The rare, but extensively studied, anterior dislocation of the elbow is usually an open injury and may lacerate the brachial artery. Rarely, the radius and ulna dislocate in different directions, an injury called a “divergent” dislocation.

Monday, April 19, 2021

COMPLICATIONS OF FRACTURE

COMPLICATIONS OF FRACTURE


COMPLICATIONS OF FRACTURE
A major objective in the management of fractures and dislocations is to avoid as many complications as possible. The principles of fracture treatment direct the surgeon to reduce the fracture and immobilize it with a cast/splint or internal/external fixation devices, to allow natural healing to occur. A variety of complications, either as a consequence of the injury itself or as a consequence of treatment, can produce serious and permanent problems. Acute complications such as damage to nerves and blood vessels, adult respiratory distress syndrome, and infection usually arise from the injury itself. Complications also develop during the healing process and may lead to irreparable loss of function. Chronic complications include failure of union, deformities, osteoarthritis, joint stiffness, implant failure, and reflex sympathetic dystrophy.

COMPLICATIONS OF FRACTURE

Neurovascular Injury
Displacement of fracture fragments or bone ends at a dislocated joint often produces compression or laceration of adjacent vessels and nerves. Critical neurovascular structures (e.g., the brachial plexus) lie deep in the limb, close to the skeleton, which protects them from injuries. A fracture or dislocation makes nerves or vessels vulnerable to injury from sharp bone fragments or from entrapment in the fracture site.
ARTHRITIS

ARTHRITIS


ARTHRITIS
Primary osteoarthritis of the elbow is uncommon, unlike in the hip and knee; and the need for joint replacement in the elbow is much less common than the hip, knee, and shoulder. Elbow arthritis often develops in patients who repetitively load the joint, such as heavy laborers or athletes. It more commonly occurs in males and in the dominant extremity. Symptoms typically include pain and loss of motion. Pain typically occurs at the end ranges of motion, particularly terminal extension, from impingement due to osteophytes. Pain through the midrange of elbow motion is much less common but may develop if the articular cartilage loss is severe enough.
Other common causes of elbow arthritis include inflammatory conditions, most commonly rheumatoid arthritis, and trauma, most commonly after an intra-articular fracture. The elbow is a common site of involvement in rheumatoid arthritis, but the pharmacologic advances in treatment of this disease have made the progression of arthritis and symptoms much less severe. Although advances in implants have helped in the surgical treatment of intra-articular elbow fractures, post-traumatic arthritis can still occur.
Nonoperative management of elbow arthritis is the initial treatment and includes activity modification, range-of-motion exercises, use of braces and other support devices, intra-articular cortisone injections, and administration of nonsteroidal anti-inflammatory drugs or disease-modifying antirheumatic drugs.
IMAGING OF OPEN AND ARTHROSCOPIC ELBOW DEBRIDEMENT
IMAGING OF OPEN AND ARTHROSCOPIC ELBOW DEBRIDEMENT

Initial surgical treatments for elbow arthritis include open or arthroscopic debridement procedures (see Plate 2-33). These surgeries are done to improve pain and range of motion, and may include removal of loose bodies, osteophyte resection, capsular release or excision, and synovectomy. Recovery time can be shorter after an arthroscopic debridement, but there is a potential risk of neurovascular injury with this technique.
TENDON AND LIGAMENT DISORDERS AT THE ELBOW

TENDON AND LIGAMENT DISORDERS AT THE ELBOW


TENDON AND LIGAMENT DISORDERS AT THE ELBOW
Lateral Epicondylitis (Tennis Elbow)
Lateral epicondylitis, or “tennis elbow,” is due to degenerative changes or tendinosis at the origin of the common extensor tendons. The most commonly affected tendon is the extensor carpi radialis brevis (ECRB), but the other common extensor tendons may also be involved. The condition does not typically occur directly at the lateral epicondyle but just distal to this point at the tendon origin. The disease process is a degenerative rather than an inflammatory condition; therefore, tendinosis is a better descriptive term than epicondylitis. The condition most commonly affects patients age 30 to 60 years, and symptoms include chronic lateral elbow pain that is aggravated by wrist extension and/or forearm supination, particularly repetitive activities that involve these motions. Examination of the elbow demonstrates tenderness to palpa- tion just distal and posterior to the lateral epicondyle, at the origin of the ECRB and other common extensor tendons (see Plate 2-38). This pain is worsened by resisted wrist extension and/or resisted long finger extension (isolates the ECRB).
Nonoperative management consists of activity modification, nonsteroidal anti-inflammatory drugs, cortisone injections, physical therapy, and splinting for symptom relief. Therapy is focused on both strengthening and stretching of the affected muscles. Splinting can include a wrist splint to place the extensor tendons in a resting position or a counterforce strap to unload the area of tendinosis during lifting activities. Cortisone injections can be beneficial but if too frequent can cause tissue atrophy or even rupture of the common extensor or lateral collateral ligament origin. Surgery is indicated when nonoperative measures fail and involves debridement of the area of tendinosis to remove the degenerated tissue. Arthroscopic techniques are now being used in some instances for this procedure.
 
EPICONDYLITIS AND OLECRANON BURSITIS
EPICONDYLITIS AND OLECRANON BURSITIS
Medial Epicondylitis (Golfer’s Elbow)
Medial epicondylitis, or “golfer’s elbow,” is due to degenerative changes or tendinosis at the origin of the flexor-pronator mass. The pronator teres and flexor carpi radialis are the most commonly involved tendons. As with lateral epicondylitis, the disease process involves the tendon origin rather than the epicondyle directly and is a degenerative rather than an inflammatory condition. Therefore, tendinosis is a better description for the condition  than  epicondylitis. Symptoms  include chronic medial elbow pain that is aggravated by wrist flexion and/or forearm pronation. Examination of the elbow demonstrates tenderness to palpation just distal and anterior to the medial epicondyle, at the origin of the flexorpronator mass. Resisted wrist flexion and/or forearm pronation exacerbate the pain. Care must be taken to distinguish symptoms of medial epicondylitis from those that may be coming from the cubital tunnel, because both conditions may occur together. Treatment tis utilizes similar strategies as treatment for lateral epicondylitis. Surgical intervention may require addressing the ulnar nerve if symptoms of cubital tunnel syndrome are also present.

Sunday, April 11, 2021

OSTEOCHONDRITIS DISSECANS OF THE ELBOW

OSTEOCHONDRITIS DISSECANS OF THE ELBOW


Osteochondritis dissecans typically occurs in adolescent patients from repetitive high valgus stresses to the elbow, most commonly female gymnasts and male throwers. The repetitive valgus loads may create compressive forces across the lateral side of the elbow at the typical site of a pathologic process in the capitellum. It is thought that these forces cause repetitive micro-trauma and vascular insufficiency or injury to the capitellum that can lead to separation of the articular cartilage from the underlying subchondral bone. Genetic factors may also contribute in some cases. The condition occurs after the capitellum has almost completely ossified and involves both the articular cartilage and the underlying bone. If the articular cartilage becomes separated from the subchondral bone, it can become a loose body in the elbow joint.
OSTEOCHONDRITIS DISSECANS OF THE ELBOW

Symptoms include activity-related lateral elbow pain that may improve with rest from the offending activity. The pain may be dull and poorly localized. Mechanical symptoms, such as clicking or locking, may be present if a loose fragment develops. On examination, tenderness to palpation is noted over the capitellum and a joint effusion may be present. Range of motion of the elbow may produce crepitus, and patients commonly lack the terminal 10 to 30 degrees of elbow extension. Limitation of elbow flexion or of forearm pronation and supination may also occur but is less common. Plain radiographs can show lucency or fragmentation at the capitellum and a possible loose body if a fragment has broken off. If findings on plain radiographs are equivocal, advancing imaging (CT or MRI) can confirm the diagnosis. MRI is preferred and can delineate a stable versus unstable lesion by showing intervening fluid between the fragment and subchondral bone.
ROSIS OF THE ELBOW (PANNER DISEASE)

ROSIS OF THE ELBOW (PANNER DISEASE)


Panner disease also involves the capitellum and presents in a similar manner as a capitellar osteochondritis dissecans, but in a younger patient population and with a better long-term prognosis. Panner disease typically occurs in the dominant elbow of boys during the period of active ossification of the capitellar epiphysis at between 7 and 12 years of age, with a peak at age 9 years. 
ROSIS OF THE ELBOW (PANNER DISEASE)

The pathologic process is similar to that of Legg-Calvé-Perthes disease and is believed to be caused by interference in the blood supply to the growing epiphysis, which results in resorption and eventual repair and replacement of the ossification center. The exact cause of this avascular necrosis, or bone infarct, continues to be debated, with popular theories including chronic repetitive trauma, congenital and hereditary factors, embolism (particularly fat), and endocrine disturbances. Whatever factors are responsible, the end result is avascular necrosis. Signs and symptoms are similar to those seen with osteochondritis dissecans, including dull, aching lateral elbow pain that is aggravated by use and may improve with rest. Tenderness and swelling along the lateral side of the elbow with loss of terminal elbow extension are also common. Initial radiographic changes can appear similar to osteochondritis dissecans, with fragmentation of the capitellar epiphysis, but whereas lesions of osteochondritis dissecans can often progress to loose fragments, loose bodies are rare in Panner disease. Typically, the normal radiographic appearance of the capitellum will be reconstituted over time as growth progresses. Residual deformity of the capitellum is rare. MRI will demonstrate signal changes in the capitellar epiphysis but may be less useful than in osteochondritis dissecans owing to the lack of concern for an unstable lesion or a loose body.
CONGENITAL RADIOULNAR SYNOSTOSIS

CONGENITAL RADIOULNAR SYNOSTOSIS


CONGENITAL RADIOULNAR SYNOSTOSIS
Congenital radioulnar synostosis is an uncommon condition in which the proximal ends of the radius and ulna are joined, fixing the forearm in pronation. The deformity is due to a failure of the developing cartilaginous precursors of the forearm to separate during fetal development. Radioulnar synostosis is bilateral in 60% of patients and is frequently associated with other musculoskeletal abnormalities. Chromosomal abnormalities have been reported in some patients with bilateral involvement. Two types of synostosis are seen. In the first, called the headless type, the medullary canals of the radius and ulna are joined and the proximal radius is absent or malformed and fused to the ulna over a distance of several centimeters. The radius is anteriorly bowed and its diaphysis is larger and longer than that of the ulna. In the second type, the fused segment is shorter and the radius is formed normally but the radial head is dislocated anteriorly or posteriorly and fused to the diaphysis of the proximal ulna. The second type is often unilateral and sometimes associated with deformities such as syndactyly or supernumerary thumbs.
CONGENITAL RADIOULNAR SYNOSTOSIS

Radioulnar synostosis is present at birth but is usually not noticed until functional problems arise, most often in patients with bilateral involvement. Commonly, the only clinical finding is lack of rotation between the radius and the ulna, which fixes the forearm in a position of midpronation or hyperpronation. Range of motion in the elbow and wrist joints is usually normal or excessive, although some patients cannot completely extend the elbow. The degree of functional disability varies with the amount of fixed pronation and whether the condition is unilateral or bilateral. Unilateral deformity with less fixed pronation may be able to compensate with shoulder motion. However, in patients with bilateral involvement in which both hands are hyperpronated, many daily activities become problem- atic, such as turning a doorknob, buttoning clothing, drinking from a cup or eating, and personal hygiene.

Monday, March 8, 2021

TROCHANTERIC BURSITIS

TROCHANTERIC BURSITIS

TROCHANTERIC BURSITIS

Lateral (or trochanteric) hip pain is a very common presenting complaint. Patients often report the insidious onset of pain over the hip bone (trochanter). Occasionally, this can be caused by trauma or direct injury to the prominence. Complaints include activity-related increases in pain as well as occasionally pain at rest. Often there will be difficulty lying on the affected side for sleep. Pain is usually described as sharp and burning. It may radiate down the lateral aspect of the thigh along the course of the iliotibial band.

AVASCULAR NECROSIS

AVASCULAR NECROSIS

AVASCULAR NECROSIS

Avascular necrosis (AVN) of the femoral head is a debilitating disease that usually leads to osteoarthritis of the hip joint in relatively young adults (mean age at presentation, 38 years). The disease prevalence is unknown, but estimates indicate that 10,000 to 20,000 new cases are diagnosed in the United States per year, and up to 18% of total hip arthroplasties performed annually are for osteonecrosis of the femoral head.

FEMOROACETABULAR IMPINGEMENT/HIP LABRAL TEARS

FEMOROACETABULAR IMPINGEMENT/HIP LABRAL TEARS

FEMOROACETABULAR IMPINGEMENT/HIP LABRAL TEARS

The recognition and diagnosis of hip pain in the non-arthritic state has been an evolving process over the past 15 years. Patient complaints often include insidious onset of deep nonpalpable pain. This may be described as deep in the groin or, less commonly, in the buttock area. Activity-related hip pain is the norm, because this is believed to be a condition of the active population. The most common offending activities include but are not limited to running and sitting for long periods of time, with the common mechanism being hip flexion past 90 degrees with some rotation. Patients will often commonly complain of laterally based pain as well, making a true diagnosis difficult to make.

REHABILITATION AFTER TOTAL HIP REPLACEMENT

REHABILITATION AFTER TOTAL HIP REPLACEMENT

REHABILITATION AFTER TOTAL HIP REPLACEMENT

On the day of surgery, the patient performs deep-breathing and coughing exercises and isometric gluteus and quadriceps-setting exercises. Calf-pumping exercises are initiated to decrease the risk of thrombophlebitis. Lower limbs are maintained in position with an abduction splint. Active-assisted to mild resistive exercises are prescribed for unaffected joints and limbs. On the first postoperative day, the patient begins active-assisted range of motion of the affected hip and knee in all planes, with hip flexion limited to 80 degrees and extension limited to neutral. The patient is instructed in proper transfer techniques and is assisted in getting out of bed to stand for 15-minute periods.

ANATOMY PHYSIOLOGY

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