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OFFICE ORTHOPAEDICS

Ramirez, Bryan Paul G.

Upper Limb Anatomy

Bicipital Tendinitis
• • An inflammatory process of the long head of the biceps tendon An overuse syndrome caused by repetitive overload of the biceps tendon from elbow flexion and supination Often occurs with impingement syndrome Presents as anterior shoulder pain Point tenderness with long head tendon at bicipital groove

• •

Symptoms
• achy anterior shoulder pain, exacerbated by lifting or elevated pushing or pulling • pain with overhead activity or with lifting heavy objects • may be localized in a vertical line along the anterior humerus, which worsens with movement • location of the pain may be vague, and symptoms may improve with rest. •(-) acute traumatic injury • Individuals with rupture of the long head of the biceps tendon may report a sudden and painful popping sensation.

Signs
• Local tenderness is usually present over the bicipital groove •The tenderness may be localized best with the arm in 10 º of external rotation. • Flexion of the elbow against resistance aggravates the patient's pain.

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

• Speed Test
•Weakness with resisted forward flexion and supination indicates pathology of the long head of biceps muscle

Special Tests

Special Tests
• Yergason Test
•Elbow flexed at 90 degrees with forearm in pronation with active resistance against supination

• Ludington’s Test
•Patient’s hands behind head with interlocking fingers, flexing biceps muscles

Bicipital tendinitis
• Imaging
– Radiographs are typically negative – MRI should be considered in athletes or with those having persistent pain to evaluate for anteroposterior lesions or rotator cuff tear – Ultrasound has a 100% specificity and 96% sensitivity for diagnosis of subluxation or dislocation

• Differential Diagnosis
– – – – – Bicipital bursitis Biceps tendon rupture Brachialis muscle tear Anterior capsule tear Lateral antebrachial cutaneous nerve compression syndrome

Bicipital tendinitis
• Treatment
– – – – – Rest Ice NSAIDs Activity modification Good prognosis with patient adherence to treatment

LATERAL EPICONDYLITIS
(TENNIS ELBOW)

• Inflammation at the origin of the extensor groups • Inflammation of the lateral epicondyle • (+) strectching of the extensor and whole area becomes inflamed causing tenderness

Etiology
• Related to overuse of elbow and hand • Activities like repeated forced grasping and pronation-supination • Trauma like
– Radiohumeral bursitis – Radiohumeral synovitis

Pathology
• Lesion = partial rupture of the extensor tendons near the origin from the lateral epicondyle • Extensor carpi radialis brevis is involved

Epidemiology
• 4th decade of life • Most common among tennis player, carpenter, butcher, policemen due to repetitive wrist extensor tendons

Manifestations
• Discomfort after continued overuse of the hand and wrist • Pain felt at the lateral aspect of the elbow • PE = small area of tenderness over lateral epicondyle of humerus and radiohumeral joint • (+) weak grip

Signs
• Cozen’s Sign
– Patient elbow is stabilized by examiner’s thumb. – Patient is asked to make a fist, pronate the forearm – (+) = sudden severe pain

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

Imaging
– AP/L radiographs of the elbow may show calcification in extensor origin – MRI is helpful to rule out associated ligamentous injury

Treatment
• Temporary immobilization with sling, adhesive dressing or plaster • Application of a dorsiflexion splint at the wrist with Procaine or Hydrocortisone

MEDIAL EPICONDYLITIS
(GOLFER’S ELBOW)

• Tenderness over the medial epicondyle • Rupture involving the flexor tendons arising from the medial epicondyle • Painful due to repetitive use of the superficial muscles of the anterior aspect of the forearm

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.

Signs
• pain with resisted wrist flexion • palpable tenderness over the medial epicondyle • Pain is also frequently found with resisted forearm pronation. • The Tinel sign should be checked over the ulnar nerve

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

Treatment
 Non-operative  NSAIDs  Activity modification  Icing  Wrist splint  Physical therapy  Synthetic corticosteroids
 Operative  Release of flexor pronator origin with debridement and repair (TOC)  Concurrent cubital tunnel release with or without ulnar nerve trasnposition  Period of immobilization and early ROM therapy 4-6 weeks after

CARPAL TUNNEL SYNDROME
• Results from any lesion that significantly reduce the 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

Etiology

 Any space occupying lesion (SOL) of carpal tunnel can cause carpal tunnel syndrome  Inflammatory causes:
 Rheumatoid arthritis  Wrist osteoarthritis

 Post-traumatic causes:
 Colle’s fracture

 Endocrine causes:
 Myxoedema  Acromegaly

 Idiopathic

Etiology

 Carpal Tunnel Syndrome as Occupational Disease  Causes:
           repetitive hand motions awkward hand positions strong gripping mechanical stress on the palm vibration Cashiers Hairdressers Knitters Farmers (milking cow) Office workers (keyboarding) Painter, etc.

 Common occupations:

Carpal Tunnel
 Is the passageway deep to the flexor retinaculum between the tubercles of the scaphoid and trapezoid bones on the lateral side and pisiform and hook of hamate on medial side.

Carpal bones

Median nerve Flexor pollicis longus

Carpal Tunnel

Flexor digitorum superficialis

Flexor digitorum profundus
A total of nine flexor tendons (not the muscles themselves) pass through the carpal tunnel: 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 of flexor digitorum profundus and flexor digitorum superficialis

Intermittent numbness of thumb, index, long and radial half of ring finger
Pain in hands or wrists and loss of grip strength Numbness and paresthesias in median nerve distribution

• •

Weakness and atrophy of the thenar muscles

SYMPTOMS

SIGNS
Special Tests

• Phalen’s maneuver
•Bend the patient’s wrists downwards as shown in the figure •This position should be held for about 1 minute. •Positive test : numbness or tingling along the median nerve distribution

SIGNS
Special Tests

• Tinel’s sign
•With the palm up, tap over the carpal tunnel area of the wrist 5 or 6 times •Positive test : tingling or paresthesia in the median nerve distribution

SIGNS
Special Tests

• Durkan test
•Press thumb over carpal tunnel and hold pressure for 30 seconds. •Positive test: Onset of pain or paresthesia in the median nerve distribution

Electromyogram (EMG) – nerve conduction study, GOLD STANDARD

OBJECTIVE TEST

Carpal tunnel syndrome
 Treatment

 Splinting (immobilizing braces)  Corticosteroid injection  Cortisone injection  Activity modification  Physiotherapy  Regular massage therapy treatments  Surgical release of transverse carpal ligament

DE QUERVAIN’S SYNDROME
(STENOSING TENOSYNOVITIS) (Washerman’s 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 of the styloid process of the radius.

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 thickening of 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.

Presentation
• Prominence of radial styloid • Pain, tenderness, soft tissue swelling • Palpable hard, tender nodule over the styloid process of radius

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

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

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)

Stenosing tenosynovitis
 Diagnosis  Treatment
  Corticosteroid injection effective over weeks to months Surgical release of sheath restricting tendon

 Almost exclusively by history and PE  Usually affects thumb, middle, or ring finger but may affect more than 1 finger at a time  Triggering more pronounced in morning or while gripping an object firmly

CHONDROMALACIA PATELLAE (patellofemoral syndrome, runner’s 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 strength and swelling of knee area

Chondromalacia patellae
 Associated with structural aberrations such as Patella Alta, recurrent sublaxation  Affects young adults and women especially soccer players, 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 of patella

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"

Signs
• patella clicks against the femur

• Clarke’s sign
– Examiner presses down slightly proximal to the upper pole or base of the patella with the web of the hand as the patient relaxes – (+) = Retropatellar pain – Patient can’t hold toe contraction

Signs
• Waldron’s Test
– Examiner palpate the patella while patient performs slow knee bends

• Zohler’s test
– Patient lies supine with knee extended – Examiners pulls patella distally – (+) = pain

Signs
• Frund’s Test
– Patient in sitting position while examiner percusses the patella – (+) = pain

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

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.

•intense sharp heel pain with the first couple of steps in the morning • primarily at the anterior aspect of the calcaneus, 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

SYMPTOMS

•Palpation over the medial tubercle of the calcaneus usually reproduces the pain of plantar fasciitis. In more severe 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 passive dorsiflexion of the toes, or having the athlete stand on the tiptoes and toewalk.

SIGNS

•Off-the-shelf insoles •Custom-made insoles •Stretching 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.

TREATMENT

Spondylosis degenerative osteoarthritis of the joints between the center of the spinal vertebrae and/or neural foraminae
• Dx: pain while coughing with neck in hyperextended position • Spurling’s test

Spondylolisthesis the anterior or posterior displacement of a vertebra or the vertebral column in relation to the vertebrae below.
• Hangman’s fracture: C2 vertebra is displaced anteriorly relative to the C3 vertebra due to fractures of the C2 vertebra'spedicles

Spondylitis
• an inflammation of the vertebra. It is a form of spondylopathy. In many cases, spondylitis involves 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 in activities such as tennis, diving, martial arts and gymnastics

LOW BACK PAIN
epidemiology etiology
treatment
• Usually healthy young males • May radiate if nerve is pinched

• Inflammatory disease = tender SI joints, flattening of the back, decreased motion • Degenerative disease = muscle pain, abnormal strength, reflex, SLR

• Spondylitis – rest, anti-inflammatory • Degenerative joint disease – rest, anti-inflammatory, analgesia • Strain – rest, analgesics, muscle relaxants

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

• Inflammatory disease – ankylosing spondylitis • Degenerative disease – disc degeneration • Low back strain – acute muscle spasm related to bonding • Functional pain

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