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Orthopaedics Presentation 1

Orthopaedics Presentation 1

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Orthopaedics

WHAT IS OCCUPATIONAL THERAPY?
‡ Occupational therapy is a profession concerned with promoting health and well being through occupation. ‡ The primary goal of occupational therapy is to enable people to participate in the activities of everyday life. ‡ Occupational therapists achieve this outcome by enabling people to do things that will enhance their ability to participate or by modifying the environment to better support participation.

What is physical therapy?
‡ It is defined as a system for assessing problems of function of musculoskeletal and neurophysiological origin including those of pain and of psychosomatic nature of dealing with and of preventing them or by natural methods based on manual therapy, movements and physical agencies.

Introduction
‡ Orthopaedics surgery is made up of physicians and other healthcare professionals who provide comprehensive orthopaedics services. ‡ Their expertise provides treatment and care of diseases, injuries, fractures, and pain. ‡ Orthopaedists also design rehabilitation programs for the physically disabled and participate in ongoing musculoskeletal research.

Definition of Orthopaedics
‡ It is the branch of medicine concerned with diseases, injuries, and conditions of the musculoskeletal system - relating to the body's muscles and skeleton, and including the joints, ligaments, tendons, and nerves.

Common Orthopaedic Disorders
‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Arthritis OA Rheumatoid Arthritis Osteoporosis Anklosing spondylitis Puget's disease of the bone Bursitis Elbow Pain and Problems Cubital Tunnel Syndrome

Common Orthopaedic Disorders
‡ Tennis Elbow (Lateral Epicondylitis) ‡ Golfer¶s or Baseball Elbow (Medical Epicondylitis) ‡ Fibromyalgia ‡ Foot Pain and Problems ‡ Fractures ‡ Low back pain

Common Orthopaedic Disorders
‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Hand pain and problems Carpal Tunnel Syndrome Knee Pain and problems Ligament Injuries to the knee Torn Meniscus Neck Pain and problems Scoliosis Shoulder pain and problem Soft tissue injuries

What is arthritis?
‡ Arthritis is inflammation of a joint - the point where two or more bones meet. ‡ In arthritis, inflammation occurs in the damaged area of a joint. ‡ Damage may be caused by any number of conditions, including trauma, infection, neurogenic disturbances, degenerative joint disease, metabolic disturbances, or for unknown reasons. ‡ Arthritis is usually chronic, which means that it rarely changes, or it progresses slowly.

Causes of Arthritis
‡ Specific causes for most forms of arthritis are not yet known.

Clinical feature of arthritis
‡ Pain ‡ Swelling ‡ Limited movement in joints and connective tissues in the body. ‡ Redness ‡ warmth.

What are the parts of a joint?
‡ Joints are the areas where two bones meet. ‡ Most joints are mobile, allowing the bones to move. Joints consist of the following: ‡ Cartilage ‡ Synovial membrane ‡ Ligaments ‡ Tendons, Bursas and Meniscus. ‡ Synovial fluid ‡ Femur - tibia - patella.

Cartilage
‡ Cartilage, is a smooth protective layer which allows the bones to glide smoothly upon each other, lines the bones inside the joint. In arthritis, this smooth lining becomes damaged.

Synovial membrane
‡ It is a tissue called the synovial membrane lines the joint and seals it into a joint capsule. ‡ The synovial membrane secretes synovial fluid (a clear, sticky fluid) around the joint to lubricate it.

Ligaments, tendons and bursas
‡ Ligaments - strong ligaments (tough, elastic bands of connective tissue) surround the joint to give support and limit the joint's movement. ‡ Tendons - tendons (another type of tough connective tissue) on each side of a joint attach to muscles that control movement of the joint. ‡ Bursas - fluid-filled sacs, called bursas, between bones, ligaments, or other adjacent structures help cushion the friction in a joint.

‡ Synovial fluid - a clear, sticky fluid secreted by the synovial membrane. ‡ Femur - the thighbone. ‡ Tibia - the shin bone. ‡ Patella - the kneecap. ‡ Meniscus - a curved part of cartilage in the knees and other joints.

What are the most common types of arthritis?

‡ The three most prevalent forms of arthritis include the following: ‡ OA ‡ fibromyalgia ‡ rheumatoid arthritis - an

Other forms of arthritis
o gout - a result of a defect in body chemistry (such as uric acid in the joint fluid), this painful condition most often attacks small joints, especially the big toe. It can usually be controlled with medication and changes in diet. o systemic lupus erythematosus (lupus) - a very serious, chronic, autoimmune disorder characterized by periodic episodes of inflammation of and damage to the joints, tendons, other connective tissues, and organs, including the heart, lungs, blood vessels, brain, kidneys, and skin.

How is arthritis diagnosed?
‡ In addition to a complete medical history and physical examination, diagnostic procedures for arthritis may include the following: ‡ X-rays or other imaging procedures (to show the extent of damage to the joint) ‡ Blood tests and other laboratory tests, including the following: 1. Antinuclear antibody (ANA) test - to check levels of antibodies in the blood. 2. Arthrocentesis or joint aspiration (to remove a sample of the synovial fluid to determine if crystals, bacteria, or viruses are present)

1. Complete blood count (to determine if white blood cell, red blood cell, and platelet levels are normal) 2. Creatinine (to monitor for underlying kidney disease) 3. Erythrocyte sedimentation rate (to detect inflammation). 4. Hematocrit (to measure the number of red blood cells) 5. Rheumatoid factor test (to determine if rheumatoid factor is present in the blood) 6. Urinalysis (to determine levels of protein, red blood cells, white blood cells, and casts) 7. White blood cell count (to determine level of white blood cells in the blood).

Osteoarthritis (OA)

What is OA?
‡ It is the most common form of arthritis in elderly people. ‡ It represent a major cause of morbidity, chronic pain and increases health care usage. ‡ It is a chronic, degenerative, joint disease that affects mostly middle-aged and older adults. ‡ It is characterized by the breakdown of joint cartilage and adjacent bone in the neck, lower back, knees, hips, and/or fingers. ‡ The disease is also known as degenerative arthritis or degenerative joint disease.

Causes of OA
‡ It can be classified as primary or secondary. ‡ Primary OA has an unknown cause ‡ secondary OA is caused by another disease, infection, injury, or deformity.

Causes of OA
‡ Several risk factors are associated with OA, including the following: ‡ Age. ‡ Heredity- slight joint defects or laxity of the joint and genetic defects may contribute to the development of OA. ‡ Obesity- excessive weight can put undue stress on such joints as the knees over time. ‡ Injury/overuse- significant injury to a joint, such as the knee, can later result in OA. ‡ Injury may also result from repeated overuse or misuse over a period of time.

Diagnoses of OA
‡ In addition to a complete medical history and physical examination, diagnostic procedures for OA may include the following: ‡ X-ray - a diagnostic test which uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film. ‡ Joint aspiration - involves a removal of fluid from the swollen bursa to exclude infection or gout as possible causes.

The goals of treatment
‡ The goals of treatment for OA are to reduce joint pain and stiffness, and improve joint movement.

Treatment for OA
Treatment may include:
‡ Specific treatment for OA will be determined by your physician based on: ‡ The age, overall health, and medical history. ‡ Exercise- aerobic exercise, and stretching and strengthening exercises may help reduce the symptoms of and pain associated with OA. ‡ Heat treatment help to reduce pain.

‡ Physical and occupational therapy may help to reduce joint pain, improve joint flexibility when performing daily activities, and reduce joint strain. ‡ Weight maintenance may help to prevent or reduce the symptoms of OA. ‡ Medication for specific symptoms may include pain relievers (in pill form or topical cream) and anti-inflammatory medications, if inflammation is present. ‡ Injections of thick liquids into the joints to maintain normal joint fluid. ‡ Joint surgery may be necessary to repair or replace a severely damaged joint.

Rheumatoid Arthritis

What is rheumatoid arthritis?
‡ It is a chronic, autoimmune disease, is the most crippling form of arthritis and affects approximately 2.1 million Americans. ‡ It is characterized by painful and stiff joints on both sides of the body that may become enlarged and deformed. ‡ It is affects more women than men (75 percent of persons with rheumatoid arthritis are women). ‡ The disease most often occurs between the ages of 20 and 45. ‡ Patients with rheumatoid arthritis often also have osteoporosis, a progressive deterioration of bone density.

Juvenile rheumatoid arthritis
‡ Juvenile rheumatoid arthritis (JRA) is a form of arthritis in children ages 16 or younger that causes inflammation and stiffness of joints for more than six weeks. ‡ Unlike adult rheumatoid arthritis, which is chronic and lasts a lifetime, children often outgrow juvenile rheumatoid arthritis. ‡ However, the disease can affect bone development in the growing child.

Causes of rheumatoid arthritis?
‡ The exact cause of rheumatoid arthritis is not known. ‡ It is an autoimmune disorder, which means the body's immune system attacks its own healthy cells and tissues. ‡ The response of the body causes inflammation in and around the joints, which then may lead to a destruction of the skeletal system. ‡ It is also may have devastating effects to other organs, such as the heart and lungs. ‡ Researchers believe certain factors, including heredity, may contribute to the onset of the disease.

Symptoms of rheumatoid arthritis
‡ The joints most commonly affected by rheumatoid arthritis are in the hands, wrists, feet, ankles, knees, shoulders, and elbows. ‡ The disease typically causes inflammation symmetrically in the body, meaning the same joints are affected on both sides of the body. ‡ Symptoms of rheumatoid arthritis may begin suddenly or gradually.

Common symptoms of rheumatoid arthritis.
‡ inflamed, painful joints ‡ stiff joints ‡ enlarged and/or deformed joints (such as fingers bent toward the little finger and/or swollen wrists) ‡ frozen joints (joints that freeze in one position) ‡ cysts behind the knees that may rupture, causing lower leg swelling and pain

Common symptoms of rheumatoid arthritis.
‡ Hard nodules (bumps) under the skin near affected joints. ‡ low-grade fever. ‡ Inflamed blood vessels (vasculitis) may occur occasionally, leading to nerve damage and leg sores. ‡ Inflamed membranes around the lungs (pleurisy), the sac around the heart (pericarditis), or inflammation and scarring of the lungs themselves, that may lead to chest pain, difficulty breathing, and abnormal heart function.

Common symptoms of rheumatoid arthritis.
Swollen lymph nodes. Sjgren's syndrome (dry eyes and mouth). Eye inflammation. Morning stiffness that lasts longer than one hour for at least six weeks. ‡ Three or more joints that are inflamed for at least six weeks. ‡ Presence of arthritis in the hand, wrist, or finger joints for at least six weeks. ‡ The symptoms of rheumatoid arthritis may resemble other medical conditions or problems, including acute rheumatic fever, Lymph disease, psoriatic arthritis, gout, osteoarthritis and ankylosing spondylitis. ‡ ‡ ‡ ‡

Diagnosis of rheumatoid arthritis
‡ Diagnosis of rheumatoid arthritis may be difficult in the early stages, because symptoms may be very subtle and go undetected on x-rays or blood tests. ‡ In addition to a complete medical history and physical examination, diagnostic procedures for rheumatoid arthritis may include the following: ‡ x-ray - a diagnostic test which uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film. ‡ joint aspiration - involves a removal of fluid from the swollen bursa to exclude infection or gout as possible causes.

Diagnosis of rheumatoid arthritis
‡ Biopsy (of nodules tissue) - a procedure in which tissue samples are removed (with a needle or during surgery) from the body for examination under a microscope; to determine if cancer or other abnormal cells are present. ‡ Blood tests (to detect certain antibodies, called rheumatoid factor, and other indicators for rheumatoid arthritis)

Introduction
‡ The anterior cruciate ligament) ACL) is probably the most commonly injured ligament of the knee. ‡ In most cases, the ligament is injured by people participating in athletic activity. ‡ As sports have become an increasingly important part of day-to-day life over the past few decades, the number of ACL injuries has steadily increased. ‡ This injury has received a great deal of attention from orthopedic surgeons over the past 15 years, and very successful operations to reconstruct the torn ACL have been invented.

ACL

Introduction
‡ The posterior cruciate ligament) PCL) is one of the less commonly injured ligaments of the knee. Understanding this injury and developing new treatments for it have lagged behind the other cruciate ligament in the knee, the anterior cruciate ligament) ACL), probably because there are far fewer PCL injuries than ACL injuries.

Anterior and Posterior Cruciate Ligament
‡ The normal posterior cruciate ligament (PCL (is easily viewed as a dark wavy line running from the femur to the tibia .

Torn anterior cruciate ligament (ACL)

(PCL tear (right slide

The case:
‡ A 57-year-old woman presented with left knee pain after falling off of a stool.

Answer to Radiologic Case Study Knee Dislocation

Figure 1 :Consecutive sagittal proton density MRI of the left knee shows a torn PCL (A,B) and ACL (C). Anterior translation of the tibia (D) Figure 2 :Consecutive coronal T2 MRI of the left knee shows an intact lateral collateral ligament (A). Tears of the MCL and lateral meniscus can be seen, as well as lateral translation of the tibia (B-D)

Foot Pain and Problems

Anatomy of the foot
‡ The foot is one of the most complex parts of the body, consisting of 38 bones connected by numerous joints, muscles, tendons, and ligaments. ‡ The foot is susceptible to many stresses. ‡ Foot pain and problems can cause pain, inflammation, or injury, resulting in limited movement and mobility.

What are the different types of foot problems?
‡ Foot pain is often caused by improper foot function. ‡ Improperly fitted shoes can worsen and, in some cases, cause foot problems. ‡ Shoes that fit properly and give good arch support can prevent irritation to the foot joints and skin. ‡ There are many types of foot problems that affect the heels, toes, nerves, tendons, ligaments, and joints of the foot. ‡ The symptoms of foot problems may resemble other medical conditions and problems.

What are heel spurs?
‡ A heel spur is a bone growth on the heel bone, particularly on the underside forepart of the heel bone where the bone connects to the plantar fascia. ‡ If the plantar fascia, a long band of connecting tissue running from the heel to the ball of the foot, is over-stretched, it can cause a bone growth, or spur, to develop. ‡ This connective tissue holds the arch together and acts as a shock absorber during activity. ‡ The pain results from the stress and inflammation of the plantar fascia pulling on the bone.

Ankle joint fractures
‡ These fractures may be serious and require immediate medical attention. ‡ Ankle fractures usually require a cast, and some may require surgery if the bones are too separated or misaligned.

metatarsal bone fractures
‡ Fractures of the metatarsal bones, located in the middle of the foot, often do not require a cast. ‡ A stiff-soled shoe may be all that is needed for support as the foot heals. ‡ Surgery sometimes is needed to correct misaligned bones or fractured segments.

Sesamoid bone fractures
‡ The Sesamoid bones are two small, round bones at the end of the metatarsal bone of the big toe. ‡ Usually, padded soles can help relieve pain. ‡ However, sometimes, the Sesamoid bone may have to be surgically removed.

Toe fractures
‡ Fractures of the middle toes can heal without a cast. ‡ Fractures of the big toe or little toe may require a cast and/or surgery.

What is foot pain?
‡ Foot pain can be debilitating to an active lifestyle. ‡ Foot pain can have many sources, from fractures and sprains to nerve damage. ‡ Listed below are three common areas of pain in the foot and their causes:

pain in the ball of the foot
‡ Pain in the ball of the foot, located on the bottom of the foot behind the toes, may be caused by nerve or joint damage in that area. ‡ In addition, a benign (non-cancerous) growth, such as Morton's neuroma, may cause the pain. ‡ Corticosteroid injections and wearing supportive shoe inserts may help relieve the pain. Sometimes, surgery is necessary.

plantar fasciitis
‡ Plantar fasciitis is characterized by severe pain in the heel of the foot, especially when standing up after resting. ‡ The condition is due to an overuse injury of the sole surface (plantar) of the foot and results in inflammation of the fascia, a tough, fibrous band of tissue that connects the heel bone to the base of the toes. ‡ Plantar fasciitis is more common in women, people who are overweight, people with occupations that require a lot of walking or standing on hard surfaces, people with flat feet, and people with high arches. Walking or running, especially with tight calf muscles, may also cause the condition.

Treatment
‡ Treatment may include: o rest o ice pack applications o nonsteroidal anti-inflammatory medications o stretching exercises of the Achilles tendons and plantar fascia

Achilles tendon injury
‡ The Achilles tendon is the largest tendon in the human body. However, this tendon is also the most common site of rupture or tendonitis, an inflammation of the tendon due to overuse. ‡ Achilles tendonitis is caused by overuse of the tendon and calf muscles. Symptoms may include mild pain after exercise that worsens gradually, stiffness that disappears after the tendon warms up, and swelling.

Treatment
o rest o nonsteroidal anti-inflammatory medications o supportive devices and/or bandages for the muscle and tendon o stretching o massage o ultrasound o strengthening exercises ‡ surgery

What is a fracture?
‡ A fracture is a partial or complete break in the bone. When a fracture occurs, it is classified as either open or closed: ‡ Open fracture (Also called simple fracture) - the bone exits and is visible through the skin, or a deep wound that exposes the bone through the skin. ‡ Closed fracture (Also called compound fracture) - the bone is broken, but the skin is intact.

Types of Fractures
‡ transverse - the break is in a straight line across the bone. ‡ spiral - the break spirals around the bone; common in a twisting injury. ‡ oblique - diagonal break across the bone. ‡ compression - the bone is crushed, causing the broken bone to be wider or flatter in appearance. ‡ comminuted - the break is in three or more pieces and fragments are present at the fracture site. ‡ segmental - the same bone is fractured in two places, so there is a "floating" segment of bone.

What causes a fracture?
‡ Fractures occur when there is more force applied to the bone than the bone can absorb. ‡ Bones are weakest when they are twisted. ‡ Breaks in bones can occur from falls, trauma, or as a result of a direct blow or kick to the body.

What are the symptoms of a fracture?
pain in the injured area. swelling in the injured area. obvious deformity in the injured area. difficulty using or moving the injured area in a normal manner. ‡ warmth, bruising, or redness in the injured area. ‡ ‡ ‡ ‡

Diagnosed OF fracture
‡ In addition to a complete medical history (including asking how the injury occurred) and physical examination, diagnostic procedures for a fracture may include the following: ‡ X-ray ‡ Magnetic resonance imaging (MRI) ‡ Computed tomography scan (Also called a CT or CAT scan.

Complication related to the fracture itself
‡ ‡ ‡ ‡ ‡ ‡ Infection Delayed union Non-union A vascular necrosis Mal-union Shortening

Causes of Non-union
Infection of the bone. Inadequate blood supply to one or both fragments. Excessive shearing movement between the fragments. Interposition of soft tissue between the fragments. Loss of apposition between the fragments (including overdistraction by traction apparatus. ‡ Dissolution of the fracture hematoma by synovial fluid (in fractures within joints). ‡ The presence of corroding metal in the immediate vicinity of the fracture. ‡ Destruction of the bone by a tumor (in pathological fracture). ‡ ‡ ‡ ‡ ‡

Types of bone grafts
‡ Autogenous grafts- obtained from another part of the patient¶s body. ‡ Allograft; homogenous graft- obtained from another human subject. ‡ Heterogeneous grafts- obtained from animals

Complications attributable to associated injury
‡ ‡ ‡ ‡ ‡ ‡ Injury to major blood vessels Injury to nerves Injury to viscera Injury to tendons Injuries and post-traumatic affections of joints Fat embolism

Treatment for a fracture
‡ Specific treatment for a fracture will be determined by your physician based on:
± your age, overall health, and medical history ± The goal of treatment is to control the pain, promote healing, prevent complications, and restore normal use of the fractured area.

Types of fractures

Fracture ulna and radius

Four fracture of the wrist

Rolando Fracture
‡ Comminuted ‡ Intra-articular ‡ Fracture through base of thumb ‡ Prognosis: worse than Bennett's fracture (difficult to reduce)

Bennett's Fracture
‡ Intra-articular fracture/dislocation of base of 1st metacarpal ‡ Small fragment of 1st metacarpal continues to articulate with trapezium ‡ Lateral retraction of 1st metacarpal shaft by abductor pollicis longus

Barton's Fracture
‡ Intra-articular fracture of the dorsal margin of the distal radius ‡ Extends into radiocarpal joint

Colles' Fracture
‡ Extra-articular fracture of the distal radius ‡ Does not extend into joint space ‡ Dorsal angulations with radial and dorsal displacement of distal fragment ‡ Frequently associated with fracture of ulnar styloid

Colle¶s fracture

Tibia fractures

Fracture Femur

Conversion of arthrodesis to THR

Arthrodesed hip 30 years previously

Typical Hip Fracture: Adult

Fracture Reconstruction and Hip Replacement

Surgical treatment

Revision hip replacement with bulk allografting

Profix Total Knee Replacement

Compression fracture

Normal vertebra

Compression fracture

Fracture Humorous

Anatomy of the carpal bone

Fracture of metacarpal bone

Fracture cervical vertebral

Left clavicle fracture

Fracture styloid

Fracture dislocation

Fracture skull

Fracture scaphoid

Fracture ankle

Shoulder Pain and Problems

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