Office Orthopedics

8/4/2019 Office Orthopedics

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OFFICE ORTHOPAEDICS

Ramirez, Bryan

Paul G.


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Upper Limb Anatomy


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Bicipital

Tendinitis An inflammatory process of

the long head of the bicepstendon

An overuse syndrome causedby repetitive overload of the

biceps tendon from elbowflexion and supination

Often occurs withimpingement syndrome

Presents as anterior shoulderpain

Point tenderness with long

head tendon at bicipitalgroove


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Symptoms

achy anterior shoulder pain, exacerbated by lifting or elevatedpushing or pulling

pain with overhead activity or with lifting heavy objects

may be localized in a vertical line along the anterior humerus, whichworsens with movement

location of the pain may be vague, and symptoms may improve withrest.

(-) acute traumatic injury

Individuals with rupture of the long head of the biceps tendon may

report a sudden and painful popping sensation.


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Signs

Local tenderness is usually present over the bicipital groove

The tenderness may be localized best with the arm in 10 ofexternal rotation.

Flexion of the elbow against resistance aggravates the patient'spain.

Passive abduction of the arm in an arc maneuver may elicit painthat is typical of impingement syndrome.


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Special Tests

Speed Test

Weakness with resisted

forward flexion and

supination indicates

pathology of the long head

of biceps muscle


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Special Tests

Yergason TestElbow flexed at 90degrees with forearm inpronation with active

resistance againstsupination

Ludingtons TestPatients hands behindhead with interlockingfingers, flexing biceps

muscles


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Bicipital tendinitis

Imaging

Radiographs are typically

negative

MRI should be considered in

athletes or with those havingpersistent pain to evaluate for

anteroposterior lesions or

rotator cuff tear

Ultrasound has a 100%

specificity and 96% sensitivityfor diagnosis of subluxation or

dislocation

Differential Diagnosis

Bicipital bursitis

Biceps tendon rupture

Brachialis muscle tear

Anterior capsule tear

Lateral antebrachial

cutaneous nerve compression

syndrome


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Bicipital tendinitis

Treatment

Rest

Ice

NSAIDs

Activity modification

Good prognosis with patient

adherence to treatment


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LATERAL EPICONDYLITIS(TENNIS ELBOW)

Inflammation at the origin

of the extensor groups

Inflammation of thelateral epicondyle

(+) strectching of the

extensor and whole area

becomes inflamed causing

tenderness


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Etiology

Related to overuse of elbow and hand

Activities like repeated forced grasping and

pronation-supination

Trauma like

Radiohumeral bursitis

Radiohumeral synovitis


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Pathology

Lesion = partialrupture of theextensor tendons

near the originfrom the lateralepicondyle

Extensor carpiradialis brevis isinvolved


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Epidemiology

4th decade of life

Most common among tennis player, carpenter,

butcher, policemen due to repetitive wrist

extensor tendons


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Manifestations

Discomfort after continued

overuse of the hand and wrist

Pain felt at the lateral aspect ofthe elbow

PE = small area of tenderness

over lateral epicondyle of

humerus and radiohumeral

joint

(+) weak grip


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Signs

Cozens Sign

Patient elbow is stabilized by

examiners thumb.

Patient is asked to make a fist,

pronate the forearm

(+) = sudden severe pain


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Signs

While palpating the lateral epicondyle,

examiner pronates the forearm, flexes the

wrist fully and extends elbow. (+) = pain

Examiner resists extension of the 3rd digit of

the hand distal to the proximal

interphalangeal joint. (+) = pain


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Imaging

AP/L radiographs of

the elbow may show

calcification in

extensor origin

MRI is helpful to rule

out associated

ligamentous injury


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Treatment

Temporary immobilization with sling, adhesive

dressing or plaster

Application of a dorsiflexion splint at the wrist

with Procaine or Hydrocortisone


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MEDIAL EPICONDYLITIS(GOLFERS ELBOW)

Tenderness over the medialepicondyle

Rupture involving the flexortendons arising from themedial epicondyle

Painful due to repetitive use

of the superficial muscles ofthe anterior aspect of theforearm


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Symptoms

Athletes generally complain of aching pain

over the medial elbow. Patients who have

more chronic pain may also complain of grip

weakness.

Pain may be associated with the acceleration

phase of throwing.

Ulnar nerve symptoms are associated in up to

20% of athletes with medial epicondylitis.


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Signs

pain with resisted wrist

flexion

palpable tenderness over themedial epicondyle

Pain is also frequently found

with resisted forearmpronation.

The Tinel sign should be

checked over the ulnar nerve


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Imaging

Radiographs may reveal

calcification adjacent to

medial epicondyle

Rule out arthritis or

acute osseous injury

MRI may show

degenerative changes in

flexor pronator mass

Asses integrity of ulnar

collateral ligament


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Treatment

Non-operative

NSAIDs

Activity modification

Icing

Wrist splint Physical therapy

Syntheticcorticosteroids

Operative

Release of flexorpronator origin withdebridement and repair(TOC)

Concurrent cubitaltunnel release with orwithout ulnar nervetrasnposition

Period of immobilizationand early ROM therapy4-6 weeks after


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CARPAL TUNNEL

SYNDROME

Results from any lesion that significantly reducethe size of the carpal tunnel or increases the size

of some structure that pass through it

Result from the repetitive movements, trauma,

carpal tunnel stenosis, arthriditis, malunited

Colles fracture and DM

MEDIAN NERVE COMPRESSION

a space occupying lesion or anything that

decreases the volume in the tunnel


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Etiology

Any space occupying lesion (SOL) of carpal tunnel cancause carpal tunnel syndrome -

Inflammatory causes: Rheumatoid arthritis

Wrist osteoarthritis Post-traumatic causes:

Colles fracture

Endocrine causes: Myxoedema

Acromegaly

Idiopathic


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Etiology

Carpal Tunnel Syndrome as Occupational Disease

Causes: repetitive hand motions

awkward hand positions

strong gripping

mechanical stress on the palm vibration

Common occupations: Cashiers

Hairdressers

Knitters

Farmers (milking cow)

Office workers (keyboarding)

Painter, etc.


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Carpal Tunnel

Is the passagewaydeep to the flexorretinaculum between

the tubercles of thescaphoid andtrapezoid bones on

the lateral side andpisiform and hook ofhamate on medialside.


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Carpal bones


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Carpal Tunnel

A total of nine flexor tendons (not the muscles themselves) pass through the carpaltunnel:

1.-4.) flexor digitorum profundus (four tendons)5.-8.)flexor digitorum superficialis (four tendons)9.) flexor pollicis longus (one tendon)A single nerve passes through the tunnel: the 10.) median nerve between tendons offlexor digitorum profundus and flexor digitorum superficialis

Flexor pollicis longus

Median nerveFlexor digitorum superficialis

Flexor digitorumprofundus


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SYMPTOMS

Intermittent numbness ofthumb, index, long and

radial half of ring finger

Pain in hands or wristsand loss of grip strength

Numbness andparesthesias in median

nerve distribution

Weakness and atrophy ofthe thenar muscles


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Special Tests

Phalens maneuverBend the patientswrists downwards as

shown in the figure

This position shouldbe held for about 1minute.

Positive test :numbness or tinglingalong the mediannerve distribution

SIGNS


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Special Tests

Tinels signWith the palm up, tap

over the carpal tunnel

area of the wrist 5 or 6times

Positive test : tingling

or paresthesia in the

median nerve

distribution

SIGNS


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Special Tests

Durkan test

Press thumb over

carpal tunnel andhold pressure for

30 seconds.

Positive test:

Onset of pain or

paresthesia in themedian nerve

distribution

SIGNS


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OBJECTIVE TEST

Electromyogram (EMG) nerve conduction study, GOLD STANDARD


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Carpal tunnel syndrome

Treatment

Splinting (immobilizingbraces)

Corticosteroid injection

Cortisone injection Activity modification

Physiotherapy

Regular massage therapy

treatments Surgical release of

transverse carpalligament


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DE QUERVAINS SYNDROME(STENOSING TENOSYNOVITIS)

(Washermans sprain)

De Quervain tenosynovitis is an entrapment tendinitis of the

tendons contained within the first dorsal compartment at the

wrist; it causes pain during thumb motion.

De Quervain's is more common in women; the speculative

rationale for this is that women have a greater angle ofthe styloid process of the radius.


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Pathology

The tendons of the abductor pollicis

longus and the extensor pollicis

brevis are tightly secured against the

radial styloid by the overlying

extensor retinaculum. Any thickeningof the tendons from acute or

repetitive trauma restrains gliding of

the tendons through the sheath.

Efforts at thumb motion, especially

when combined with radial or ulnar

deviation of the wrist, cause pain and

perpetuate the inflammation and

swelling.


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Presentation

Prominence of radial

styloid

Pain, tenderness, softtissue swelling

Palpable hard, tender

nodule over the styloidprocess of radius


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Special Test

Finkelstein s test

Patient makes a fist with the

thumb inside the finger then

ulnar deviation of the wrist

(+) = sharp pain at the first

dorsal compartment


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Treatment

Splinting of the wrist and thumb using light

Plaster Cast

Injection of Hydrocortisone into tendon

sheath

Release of constriction by longitudinal incision

or by partial resection


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STENOSING TENOSYNOVITIS

(trigger finger) Usually a disorder of later adulthood characterized by catching, snapping

or locking of involved finger flexor tendon

Associated with dysfunction and pain

Caused by disparity in size between flexor tendon and retinacular pulley

system (level of 1st annular pulley)


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Stenosing tenosynovitis

Diagnosis

Almost exclusively by

history and PE

Usually affects thumb,

middle, or ring fingerbut may affect more

than 1 finger at a time

Triggering more

pronounced in morning

or while gripping anobject firmly

Treatment

Corticosteroid injection effective

over weeks to months

Surgical release of sheath restricting

tendon


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CHONDROMALACIA PATELLAE

(patellofemoral syndrome,

runners knee)

Most common cause of chronic knee pain

Abnormal softening of the cartilage under the

patella

Degeneration of cartilage due to poor

alignment of patella as it slides over lower end

of femur

Associated loss of quadriceps muscle strengthand swelling of knee area


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Chondromalacia patellae

Associated with structural aberrations such as PatellaAlta, recurrent sublaxation

Affects young adults and women especially soccerplayers, gymnasts, cyclists, rowers, tennis players, balle

t dancers, basketball players, horseback riders,volleyball players, and runners.

Early pathology = dull, soft, fibrillation and fissuring,cartilagenous tags

Advanced pathology = entire articular surface ofpatella


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Symptoms

(+) pain in knee under patella (worse by

climbing or descending stairs)

The pain of chondromalacia patellae is

typically felt after prolonged sitting, like for a

movie, and so is also called "movie sign" or

"theater sign"


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Signs

patella clicks against the femur

Clarkes sign

Examiner presses down slightlyproximal to the upper pole or

base of the patella with the web

of the hand as the patient relaxes

(+) = Retropatellar pain Patient cant hold toe contraction


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Signs

Waldrons Test

Examiner palpate the patella while

patient performs slow knee bends

Zohlers test

Patient lies supine with knee

extended Examiners pulls patella distally

(+) = pain


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Signs

Frunds Test

Patient in sitting position while

examiner percusses the patella

(+) = pain


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Treatment

Goal is to create straighter pathway for patella to follow

during quadriceps contraction

Avoid motions that irritate patella

Icing, NSAIDs

Strengthening of inner portion of quadriceps muscle

Surgical

Arthroscopically to remove damaged and heavily

inflamed cartilage and realign joint


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PLANTAR FASCIITIS

Plantar fasciitis is the pain caused by inflammation of the insertion of

the plantar fascia on the medial process of the calcaneal tuberosity.

Plantar fasciitis may cause significant heel pain, resulting in the

alteration of a person's activities. This condition sometimes is called "heel spurs" by the general public.

In actuality, many asymptomatic individuals have bony heel spurs,

whereas many patients with plantar fasciitis have no bony heel spur.


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SYMPTOMS

intense sharp heel pain with the first couple of

steps in the morning

primarily at the anterior aspect of thecalcaneus, but it may radiate proximally in more

severe cases

a dull ache in the heel at the end of the day,

especially after extensive walking or standing

During activity, the pain usually decreases as

the athlete warms up, but it generally returns

after activity.

The pain is aggravated particularly by sprinting.

Associated symptoms: In addition to pain,

athletes may complain of stiffness in the foot


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SIGNS

Palpation over the medial tubercle

of the calcaneus usually reproduces

the pain of plantar fasciitis. In moresevere cases, pain may also be

reproduced by palpation over the

proximal portion of the plantar fascia.

Windlass" test: reproduce the pain

of plantar fasciitis by passivedorsiflexion of the toes, or having the

athlete stand on the tiptoes and toe-

walk.


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TREATMENT

Off-the-shelf insoles

Custom-made insolesStretching of the plantar fascia is more effective than calf stretching and

should be recommended for all patients with pain.

Corticosteroid iontophoresis

Custom-made night splints

Extracorporeal shock wave therapy

walking cast should be considered for patients with plantar fasciitis who have

not responded to conservative measures.

Open or endoscopic surgery should be considered for patients with plantar

fasciitis in whom all conservative measures have failed.

Spondylosis


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Spondylosis

degenerative osteoarthritis of the joints between the center of the spinalvertebrae and/or neural foraminae

Dx: pain while coughing with neck in hyperextended position

Spurlings test

Spondylolisthesis

the anterior or posterior displacement of a vertebra or the vertebralcolumn in relation to the vertebrae below.

Hangmans fracture: C2 vertebra is displaced anteriorly relative to the C3 vertebra dueto fractures of the C2 vertebra'spedicles

Spondylitis

an inflammation of the vertebra. It is a form of spondylopathy. In many cases, spondylitisinvolves one or more vertebral joint as well, which itself is called spondylarthritis

Spondylolysis

caused by stress fracture of the bone, and is especially common in adolescents who overtrain inactivities such as tennis, diving, martial arts and gymnastics


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LOW BACK PAIN

Usually healthy young males

May radiate if nerve is pinchedepidemiology

Inflammatory disease = tender SI joints, flattening of the back, decreased

motion

Degenerative disease = muscle pain, abnormal strength, reflex, SLRetiology

Spondylitis rest, anti-inflammatory

Degenerative joint disease rest, anti-inflammatory, analgesia

Strain rest, analgesics, muscle relaxants

treatment

Inflammatory disease ankylosing spondylitis

Degenerative disease disc degeneration

Low back strain acute muscle spasm related to bonding

Functional pain

If with neck pain,ff have to be r/o


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Thank you

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