orthopaedics 101
TRANSCRIPT
{ORTHOPAEDICS 101
Courtesy of Centenary College & Skylands Orthopaedics
Automobile owners manual Musculoskeletal
Neurovascular
Metabolic
Most pathology is caused by acute trauma (think MVA) or chronic overuse/repetitive trauma (think mileage)
Body Shop (OR) will fix most acute trauma
Mechanics will fix most chronic pathology
The exception to keep in mind in car vs our body is, most cosmetic car damage will still allow the car to function however due to pain and inhibition our function will be dramatically altered.
Relation of Orthopaedics to Biomechanics & Function
Internal Medicine Infectious Disease Primary Care Podiatry Ob/Gyn Plastics Emergency Room Oncologist Pediatrics Etc…There is a long list, and many Doctors will
specialize even further (Pediatric Orthopaedic for example)
Compared to Other forms of Medicine
This is where the typical Orthopaedic MD spends their day
Appointments - New patients, follow-ups, reductions, certain injection procedures, wound care, evaluation/examination, diagnosis, referrals, IMEs…the list goes on…
Main objective is to develop a plan to “fix” the patient.
Rx
Sx
PT
Then follow it through.
Most patients are seen every 2-5 weeks however this varies greatly!
The Exam Room
A thorough understanding of anatomy is necessary.
Knowing what structures lie in, under and around the vicinity of symptoms is the first step to identifying the underlying cause of dis-comfort (dis-ease).
The Following is a very brief section for anatomical familiarization.
ANATOMY: The Key to Orthopaedic Medicine
Anatomical Reference Points
AnteriorPosterior
Superior Inferior
Medial Lateral
DorsalPalmer/Plantar
ProximalDistal
CranialCaudal
Coronal Plane
Sagittal Plane
Transverse Plane
Osteology
C/T/L
12 ribs5 floating
8 carpal bones –2 rows
7 Tarsal bones
LigamentsCartilageBursaeRetinaculi
Articular Surfaces
Intent of Design
Myology
MMT
Neurology
Myotomes – DTR’s
Biceps – C5Brachioradialis – C6Triceps – C7Patellar – L4Achillies – S1
MMT
Dermatomes
Angiology
Pulse strength –occlusion.
Capillary Refill
Location & Identification of vessels vital to surgery.
Blood Work can identify if a problem which presents as orthopaedic is in fact metabolic (pathway disturbances)
Exam RoomOrthopaedics in Action
A “brief” synopsis of some of the more common ailments seen at SkylandsOrthopaedics. Upper Extremity
Low Back & Hip
Lower Extremity
The Doctors work as detectives to pinpoint the cause. History
Observation
Palpation
Evaluation
Shoulder ROM – Active ROM – Passive ROM ABD – Deltoid, Supraspinatus - 150°
ADD – Lat. Dor., Pec. Maj., Teres Maj.
FLX – Biceps (LH) Ant. Delt - 180°
EXT – Post. Deltiod, Triceps – 45-60°
EXT ROT – Infraspinatus – Apley’s Scratch ≈90°
INT ROT – Subscap, Teres Maj., Deltoid, Pec. Maj. - Apley’s≈70-90°
Shoulder Luxations - AC joint is separated, GH is Dislocated Older population less likely to have a 2nd/Chronic Dislocations
of GH joint but have a higher chance of decreased ROM b/c soft tissue scars down easier
Shoulder Pathology
Shoulder - GH joint
O’Brien Test
GH joint is flexed to 90° & horizontally adducted 15° from the sagittal plane. Humerus in full internal rotation and forearm pronated.
Examiner applies downward force. Patient is to resist this force.
Pain experienced while arm is internally rotated but pain decreases with external rotation/supination.
SLAP lesion
The inability to lower the arm in a controlled manner.
Humerus fully abducted and extrotated/forearm supinated
Falls uncontrollably from approx 90°
Indicative of lesions to the rotator cuff, especially supraspinatus.
Drop Arm
SLAC wrist: (scaphoid – lunate advanced collapse) Capitate collapses through lunate/scaphoid.
FOOSH mechanism – extreme hyperextension of wrist.
Wrist & Hand
Sawed through 15% of distal phalanx of 1st digit.
Stable fracture
Sutured & Monitored for infection.
Distal Phalanx & Band Saw
May be congenital.
Middle & Ring fingers most common.
Nodule forms in tendon sheath.
Flexor Tendon.
C/O:
Finger hurts when flexing hand.
Hears popping
Operative Release common.
Trigger Finger
DeQuervain’s Syndrome
Finklestein’s Test
Tendonopathy
Extensor Pollicis Brevis
Adductor PollicisLongus
Tinnel’s sign
Median n. compressed in the carpal tunnel.
Paresthesia over sensory distribution of median n. (palmer surface of first, 2nd, 3rd & ½ of 4th)
Sx release of transverse carpal ligament.
Carpal Tunnel Syndrome
Arthritis – head of femur/acetabulum –Joint space Arthroplasty
GT Bursitis Snapping hip syndrome Test hip ROM Low back pain typically muscular Can be referred from neurological mechanical pressure – down leg or buttock
Low Back & Hip
Arthritis – head of femur/acetabulum –Joint space Arthroplasty
GT Bursitis Snapping hip syndrome Test hip ROM Low back pain typically muscular Can be referred from neurological mechanical pressure – down leg or buttock
Low Back & Hip
Spinal Stenosis
Spondylolysis – Spondylolisthesis
Disc herniation
Disc Pathology
Spinal Stenosis
The Knee
Knee in MRI – Sagittal View
Meniscus Bucket Handle Tear
Traumatic impact
Loss of cartilage over Medial Femoral condyle
Point Tenderness mimics medial meniscus tear
Arthritis develops from exposed bone.
Bony Contusion of Knee
PF Osteochondritis
Gracillus
Sartorius
Semitendinosus
Femoral n.
Obterator n.
Tibial n.
Pes Anserine Bursitis
Foot, Ankle & Lower Leg
Fractures typically take 6-8 weeks to heal.
Sx depends on severity of the fracture.
Some fractures need to be reduced and fixed.
Fractures, Casts/Splints/ORIF/EF
Injection Procedures
Supartz/Synvisc One Injection
Alleviates osteoarthritic knee pain
Sodium Hyaluronate solution (Hyaluronic Acid)
Mimics synovial fluid
Like changing oil
Lubricates & cushions the knee joint
Allows for more fluid motion and reduces bone on bone pounding/contact
Supartz: Over the course of 5 injections patients are symptom free
Synvisc one: One inj for 6 months pain relief.
Supartz/Synvisc One
2-2-2, 1-1-1
Bupivacaine – HCl 0.5% 5 mg/mL
Lidocaine – HCl – 2% 20 mg/mL
Kenalog 40 – 400 mg/mL
Acute gouty arthritis
Acute and subacute bursitis
Acute nonspecific tenosynovitis
Epicondylitis
Rheumatoid arthritis
Synovitis
Osteoarthritis
Has diagnostic ability as well Hypertrophic Synovitis vs Internal derrangement
Steriod Flare – Hurts tremendously then feels better than others who dont get the flare!
Steroid Shot
Surgical Procedures
ACL Reconstruction
ACL Reconstruction
ACL Reconstruction
Mucous Cyst/Bone Spur-”Ectomy”
SupraspinatusTear
Full thickness tear involving anterior aspect of supra c mild retraction.
Mild tendopathy in infraspinatus.
SupraspinatusTear
Pull retracted m. back to insertion if new injury (arthroscopic or small incision)
Marginal convergence for supraspinatus
Arthoplasty – reverse shoulder.
Full thickness RC tear surgery options
Total Medial Knee Repair
MCL
MPFL
Med Ret
Jt. Capsule
Partial Chondroplasty
ACL extensive debridement
Meniscus loose body removal
Manipulation under anethesia
Cartilage formed 3 weeks since injury.
Cut down to where tissue is undamaged to use as anatomical land marking
Patella did not scar down
Patellar’smedial structures repaired first:
MPFLJt. CapsuleRetinaculum
Then
MCL anchored to femur –pulled up b/c intact distally on tibia
OsteoRaptor2.9mm doubleloadedpunch/pound in anchor
Tie sutures down
Now that the medial sturctures are fixed knee is flexed & scoped
Debrided intercondylarnotch, interarticularsurfaces, ACL & PCL
THANK YOU!