Exam Finals notes

7/24/2019 Exam Finals notes

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Ears

Otoscopic examination

Evaluation of gross auditory acuity

Whisper test-1-2 feet, one is covered with palm

Tunning fork

Weber test-Forehead or head

Rinne test-auditory canal, or mastoid process

Audiometry-

Pure tone audiometry: musical tone, the louder it is perceived, the

greater the hearing loss

Speech audiometry: Spoken word used to determine the ability to

hear

-frequency:number of sound waves

-pitch: term to describe frequency

Tympanogram: for detecting middle ear disease by measuring the

middle ear muscle reflex, how the tympanic membrane reacts by

compensation of changing pressure in a sealed ear canal

Auditory brain stem response: detectable electrical potential from

cranial nerve VIII, eg. Tumor on cranial nerve VIII


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Electronystagmography: graphic recording of electrical potenitial

created by eye movement, assess vestibular and oculomotor

systems and their interaction: Menieres disease

Platform posturography: used to investigate postural control

capabilities

Sinusoidal harmonic acceleration: rotary chair, assess vestibule-

ocular system through eye movements in response to clockwise and

counterclockwise rotation

Middle ear endoscopy: performed by endosopist, used to evaluate

suspected perilymphatic fistula and new onset of conductive hearing

loss, anesthesized in the tympanic membrane topically for 10

minutes. taken With videos and photo

Hearing loss:

Occupational: carpentry, plumbing, coal mining- noise-inducedhearing loss

Conductive hearing loss: results from an external ear disorder,

impacted cerumen, middle ear disorder, otitis media, otosclerosis.

Sensorineural loss: involves damage to the cochlea or

vestibulocochlear nerve

Mixed hearing loss: both conductive and sensorineural loss

Functional: Psychogenic, emotional disturbances

Clinical manifestation: early sign: tinnitus


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speech deterioration, fatigue, indifference, social withdrawal,

insecurity

noise-induced hearing loss: lone exposure to noise

acoustic trauma: caused by single exposure to an extremely loud

noise, high frequency

Presbycusis: used to describe progressive hearing loss

CERUMEN IMPACTION

: normally accumulates in the external ear, causes otalgia: fullness of

pain in the ear with or without hearing loss

Mngmnt: irrigation, suctioning, instrumentation, warmed glycerin,

mineral oil, half strength hydrogen peroxide for 30 min. to soften it

before removal, DEBROX

Foreign bodies: insects, peas, beans, pebbles, beads, and toys

MGMT: irrigation, suctioning, instrumentation

EXTERNAL OTITIS(otitis externa): inflammation of the external ear

canal (swimmers ear): staphylococcus aureus and pseudomonas,

Aspergillus: most common

Pain, aural tenderness, fever, cellulitis, pruritus, hearing loss, feeling

of fullness, discharges maybe yellow or green discharges

MGMT: Burrows solution

Malignant external otitis: progressive: temporal bone osteomyelitis

FATAl, pseudomonas aeruginosa


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MGMT: antipseudomonal agent and aminoglucoside tx

Masses of external ear: Exostoses: are small, hard, bony

protrusions found in the lower posterior portion of the ear: surfers

ear

Surgical removal

Gapping earring puncture

: wearing heavy earrings for a long time

Surgical tx

MIDDLE EAR:

Tympanic membrane perforation: infection or trauma, otorrhea, or

rhinorrhea- clear watery drainage from ear or nose

MGMT:HEALS BY weeks or months, tympanoplasty: repair of

tympanic membrane

ACUTE OTITIS MEDIA:

Infection of the middle ear, 6 weeks, streptococcus pneumoniae,

harmophilus influenza, pain, otalgia,

MGMT:

Antibiotic mgmnt, myringotomy or tympanotomy, incision in the

tympanic membrane

Serous otitis media

-middle ear effusion, fluid with no infection, Eustachian tube

obstruction, children, concurrent respiratory infection or allergy,


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barotraumas, hearing loss, fullness in the ear, sensation of

congestion, air bubbles may be seen in the muddle ear

MGMT: Myringotomy, corticosteroids-barotrauma, vasalva

maneuver-worsens pain or perforation of the tympanic membrane

Chronic otitis media

-results of repeated episodes of acute otitis media, hearing loss may

be minimimal, persistent or intermittent, foul smelling otorrhea, pain-

acute mastoiditis

Cholesteatoma-ingrowth of the skin of the external layer of the

eardrum

MGMT

:antibiotic drops, tympanoplasty, ossiculoplasty, mastoidectomy

Otosclerosis

-involves the stapes, results from the formation of new, abnormal

spongy bone, common in women, hereditary, may be worsen by

pregnancy, progressive hearing loss, mixed hearing loss, florical

supplement, stapedectomy

MIDDLE EAR MASSES

-glomus, jugular tumor that arises from jugular bulb, Jacobsons

nerve


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Inner ear:

Motion sickness:

Disturbance of equilibrium caused by constant motion, sweating,pallor, nausea, and vomiting, vestibular overstimulation

MGMT: Dramamine, bonine

Menieres disease- abnormal inner ear fluid balance, blockage in

endolymphatic duct, inc pressure in the system or rupture of the

inner ear membranes, hearing loss, tinnitus, webers test

MGMT: ANTIVERT, DIAZEPAM, PROMETHAZINE,

HYDROCHLOROTHIAZIDE, BANANAS, TOMATOES, ORANGES,

ENDOLYMPHATIC SAC DECOMPRESSION, streptomycin,

gentamycin, VESTIBULAR nerve section

LABYRINTHITIS-inflammation of the inner ear, hearing loss, vertigo,

N and V, tinnitus, antibiotic

Benign paroxysmal position vertigo

-period of incapacitating vertigo, orith

MGMT; canalith repositioning procedures, epley procedure,

prochloperazine, dix hallpike test

Ototoxicity

-aspirin, quinine, tinnitus

Acoustic neuroma

-slow growing benign tumore of cranial nerve VIII,


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-Vestibular neuroma

MGMT: surgical removal, Labyrinthin

Low back pain

-L4, L5, S1

-disk protrusion can cause pressure on nerve roots, which results to

pain that radiates the nerve

-lasting more than 3 months without improvement and fatigue, pain

radiating down the leg (radiculopathy or sciatica), gait; spinal

mobility; reflexes; leg length; leg motor strength; sensory perception

are altered, paravertebral muscle spasm, possible spinal deformity

-back exam and neurologic (reflexes, sensory impairment, straight

leg raising, muscle strength, muscle atrophy), x-ray: fracture,

dislocation, osteroarthritis, scoliosis, bone scan and blood studies:

disclose infections, tumors, bone marrow abnormalities, CT scan:

soft tissue lesions and problems of vertebral disks, MRI; permitsvisualization of the nature and location, Electromyogram EMG and

nerve conduction studies: spinal nerve root disorders

MGMNT: 4 weeks for analgesics, acetaminophen, ibuprofen, heat or

cold therapy, traction, massage, diathermy, ultrasound, cutaneous

laser treatment, biofeedback, transcutaneous electrical nerve

stimulation, acupuncture, avoid twisting, bending, lifting, which

stresses the back are avoided, change positions freq, sitting should

be limited to 20-50 mins.,m based on level of comfort, bed rest for 1-

2days, max of 4 days if pain is severe, gradual return to activities,

conditioning of trunk muscles are begun after 2 weeks

Osteomyelitis


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-infection of the bone marrow

-Trauma, diabetes, Anemia, poorly nourished, elderly, or obese,

impaired immune systems, those with chronic illness

Deep sepsis after arthroplasty may be classified as follows:

Stage 1: acute fulminating, 3 months after orthopedic surgery, assoc.

with hematoma, drainage, or superficial infection

Stage 2: Delayed onset, 4-24 months after surgery

Stage 3: late onset: occurring 2 or more years after surgery,

hematogenous spread

Modes:

-EXTENSION of soft tissue infection (infected pressure, vascular,

incision infection)

-Direct bone contamination from bone surgery, open fracture, or

traumatic injury

-Hematogenous (bloodborne) spread from other sites of infection (

Infected tonsils, boils, infected teeth, upper respiratory infection)

-Staphylococcus aureus, proteus and pseudomonas, e.coli

:sequestrum )dead bone tissue, involcrum (new bone growth)

-Fever, chills, inflammation, rapid pulse, general malaise, infected

area becomes painful; swollen; extremely tender, pulsating pain with

movement


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Chronic: draining sinus, recurrent periods of pain, inflammation,

swelling, drainage, low grade infection

:x-ray: soft tissue swelling, for chronic dense bone formations are

seen on x-ray

Radiosotope bone scans, particularly the isotope labeled white blood

cell, MRI-definitive diagnosis

Blood studies: elevated leukocyte and sedimentation rate

-Pyogenic, Hematogenous, Chronic

Prevention: if there are infections surgery should be postponed,

prophylactic antibiotics are administered, urinary catheters and drains are

removed as soon as possible, treatment of focal infections (hematogenous

spread), Wound care, prompt management of soft tissue infection

MGMNT: antibiotic therapy, hydration, diet high in vitamins and

protein, correction of anemia, area of OS should be immobilized (fracture),

warm wet soaks for 20min., around the clock dosing (3-6 weeks for anti-b.therapy), orally administer from 3 months if controlled, anti-b. should not be

administered with food.

Surgical MNGMNT: Removal of necrotic material, irrigated with

Saline sol., sequestrectomy (removal of volucrum), Sauzerization (removal

of bone and cartilage, wound irrigation saline sol. 7-8 days,

Loose bodies

-occur in joints may occur as a result of articular cartilage wear and

bone erosion

-locks the joint, causes painful movement


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MGMNT: arthroscopy

Tendinitis, Bursitis, Rotator cuff impingement

B and T: are inflammatory conditions that commonly occur in theshoulder, bursae are fluid filled sacs that prevents friction between

joint structures during joint activity.

-painful when inflamed, restricts joints movement

MGMNT: rest of extremity, intermittent ice and heat to the joint,

NSAID, Arthroscopic synevectomy

I: Overuse may produce an impingement syndrome in the shoulder

-pain, tenderness, limited movement, muscle spasm, atrophy,

progress to rotator cuff tear

MGMNT: rest, NSAID, joint injections, physical treatment,

Artrhroscopic debridement

Carpal tunnel syndrome;

-Is an entrapment neuropathy that occurs when median nerve at

wrist is compressed by a thickened flexor tendon sheath, skeletal

encroachment, edema, soft tissue mass

-repetitive hand activities, arthritis, hypothyroidism, or pregnancy

-pain, numbness, paresthesia, possibly weakness along the mediannerve (thumb and first two fingers), night pain

-Tinels sign


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MGMNT: rest splints-prevent hyperextension, NSAIDs, Carpal canal

cortisone injection, yoga postures, relaxation, acupuncture, , endoscopic

laser surgical release of the transverse carpal ligament, hand splints,

assistance with ADLS, take several weeks or months

Septic Arthritis (infectious)

-joints that are infected through spread of infection from other body

parts

-Trauma, surgical instrumentation, coexisting arthritis, diminishedhost resistance, S.aureus, streptococci and gram neg., chondrolysis

(destruction of hyaline cartilage.

-diabetes mellitus, R.a, joint replacement

CM: systemic chills, fever, leukocytosis, warm, painful, swollen with

dec. range of motion joint

-Aspiration, culture of synovial fluid, computed tomography, MRI-

damage to joint lining, radioisotope scanning

MGMNT: Antibiotics IV., removal of excess joint fluid (promotes

comfort, decreases joint destruction), arthrotomy, arthroscopy: drain

and remove dead tissue), affected part is immobilized, codeine,

NSAIDs, fluid status is monitored, progressive range of motion

exercises, weight bearing and activity restrictions, safe use ofambulatory aids, assistive devices, wound care, ROM exercises after

infection subsides

Ganglion cyst


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-a ganglion, a collection of gelatinous material near the tendon

sheaths and joints, appears as a round, firm, cystic swelling, usually on the

dorsum of the wrist

-women, 50 yrs.

-tender, aching pain, weakness of the fingers

MGMNT: aspiration, corticosteroid injection, surgical excision,

compression dressing and splints are used after treatment

Dupuytrens disease

-is slowly progressive contracture of the palmar fascia which causes

flexion of the fourth and fifth fingers, and frequently the middle finger.

-men, 50 yrs.old, Scandinavian or celtic origin, arthritis, diabetes,

gout, and alcoholism

-start with a nodule of the palmar fascia-caused the contracture

-dull aching discomfort, morning numbness, cramping, and stiffness,

in the affected fingers, starts with one hand then eventually both

-finger stretching may prevent the contracture

MGMNT: palmar and digital fasciectomies are performed to improve

fx, finger exercises are performed after 1-2 days post-operatively

Plantar fascilitis

-an inflammation of the foot-supporting fascia


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-acute onset of heel pain, first steps of the morning, localized pain,

anterior medial aspects of the heel, diminished through gentle

stretching of the foot and Achilles tendon.

-MGMNT: stretching exercises, shoes with cushion for pain, orthotic

devices ( Heel cups, arch supports), NSAIDS, extracorporeal shock

wave theapy

-may resolved to fascial tears to heel spurs

Corn

-Area of hyperkeratosis (overgrowth of a horny layer of epidermis)caused by internal pressure, prominent bone caused by congenital

or aqured (arthritis) or external pressure (ill fitting shoes), fifth toe is

most frequently involved, any toe may be involved

-MGMNT: soaking and scraping off the horny layer by a podiatrist,

app. Of protective shield or pad, drying of the affected spaces and

separating the affected toes with limbs wool or gauze, wider shoe

Callus

-Thickened skin that has been exposed to persistent pressure or

friction, faulty foot mechanics

-MGMNT: eliminating the underlying causes and having the callus

treated with the podiatrist, keratolytic ointment, thin plastic cup worn

over the heel, felt padding with adhesive backing, orthostaticdevices, protuberance may be excised

Ingrown nails


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-Onchocryptosis is a condition in which the free edge of a nail plate

penetrated the surrounding skin either laterally or anteriorly, infection

or granulation may develop, caused by improper tx, external

pressure (tight shoes or stockings), internal pressure (deformed toes,

growth under the nail), trauma or infection

-prevent: cutting it straight across and filing the corners consistently

with the contour of the toe,

-MGMNT:washing the foot twice a day, app. Local anti.b, pain

mngmnt and dec. pressure of the nail plate on the surrounding soft

tissue, warm wet soaks (drains the infection), TOENAIL may be

excised by the podiatrist if there is infection

Hammer toe

-Is a flexion deformity of the interphalangeal joint, involves several

toes, acquired deformity, tight socks, corn develops on the top of the

toes and tender calluses develop under the metatarsal area

-prevent: wearing open toed sandals or shoes that conform to the

shape of the foot

-MGMNT: Osteotomy

Halux vagus

-BUNION, great toe deviates laterally, prominence of the medial

aspect of the first metatarsophalangeal joint, exostosis (enlargementof osseous) medial metatarsal head of the first met. Head, bursa

may form (Secondary to pressure and inflammation)

-reddened area, edema, tenderness


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-hereditary, ill-fitting shoes, gradual lengthening and widening

(aging), osteroarthritis

-MGMNT: tx depends on age, degree of deformity, conrorming

shape of shoe to the foot, corticosteroid injection, surgical removal of

bunion (Exostis) and osteomies, bunionectomy: Limited ROM,

paresthesisas, tendon injury, recurrence of deformity, intense

throbbing pain-opiod analgesics (morphine), foot elevated to level of

the heart, toe flexion and extension exercises are initiated to facilitate

walking

Pes cavus

-claw foot, abnormally high arch and a fixed equiinus deformity of the

forefoot, shortening of the foot and INC. pressure caused calluses at

met. Area and dorsum of the foot. Charcot Marie Tooth disease

(neuromuscular disease, familial degenerative disorder, diabetes,

tertiary syphilis

-MGMNT: exercises-manipulated forefoot into dorsiflexion and

relaxes the toes, orthotic devices-alleviates pain, Arthrodesis (fusion)

performed to reshape and stabilize foot

Mortons Neuroma

-plantar digital neuroma, neurofibroma, swelling of the third lateral

branch of the median plantar nerve, Third digital nerve loc. In the

third intermetatarsal web space, microscopically-cause an ischemia

of the nerve

-throbbing, burning pain in the foot relived when rested

-MGMNT: conservative tx, inserting innersoles and metatarsal pads

designed to spread the metatarsal heads and balance the foot


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posture, local injections of a corticosteroid, hydrocortisone

(ACTICORT), excision of the neuroma, pain relief and loss of

sensation are immediate and permanent

Flatfoot

-Common disorder, longitudinal arch of the foot is diminished,

congenital bone ligament injury, muscle and posture imbalances,

excess weight, muscle fatigue, poorly fitting shoes, arthritis

-burning sensation, fatigue, clumsy gait, edema, and pain

-MGMNT: exercises to strengthen the muscles and posture andwalking habits, foot orthoses

Osteoporosis

-Most prevalent bone disease, osteopenia-precursor to osteoporosis,

causes bone fracture, bone density, bone quality

-prevent: Inc. ca intake, regular exercises, diet modification

-secondary osteoporosis: medications, celiac disease,

hypogonadism ( Thyrotoxicosis, hyperparathyroidism,

hyperparathyroidism, anorexia nervosa, cushing syndrome, Inc.

cortisol, corticosteroids, anitseizures-bone loss, risk: small framed,

nonobese, genetics, asian, 30 yrs., men-low tostesterone,

menopause-women

ACCESS: alcoholism, corticosteroid, calcium, estrogen, smoking,

sedentary lifestyle,

-kyphosis (dowagers hump)

-loss of weight


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-DX:Bone densinometry, x-rays, DEXA (dual energy, x-ray,

absorptiometry), BMD testing (all women older than 65 yrs. Old,

older men 70 yrs.)

MGMNT: Calcitonin, estrogen, PTH, ca:1000-1200 mg, 800-1000 IU,

best source of ca and vit. D (fortified milk)

-regular weight bearing exercises (20-30 mins), 3 days/ more a week

-bisphonates (alendronate (fosamax):weekly, empty stomach, 2hrs.

prior ad., 30-60 mins ater first meal, up right pos. after taking, GI

disturbances, ca, vit d.

-calcitionin

Selective estrogen receptor modulators (relosifene, evista),

teriparatide (forteo)

Anabolic agent- cont. thromboembolism

Fracture MGMNT;

Joint replacement, closed/open reduction, c internal fixation,

percutaneous vertebroplasty/kyphoplasty

IV calcium-slow reg., tachycardia, hypotension, cardiac arrest,

dysrythmia, avoid food rich in zinc

Osteomalacia

-metabolic bone disease, charc. Inadequate mineralization of bone,

softening of the bone

-pain, tenderness, bowing of bones, pathologic fracutes, waddling/

limping gait


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-causes: Ca def., muscle weakness, unsteadiness, distal radius and

proximal femur: affected

-DX: X-ray studies, lab results: low serum calcium, hypomagnesemia

and phosphorus levels and inc. alkaline phosphatase concentration,

urine excretion of ca. and creatinine is low, bone biopsy-high osteoid,

pseudofracture, DXA-LOW BONE MASS, whole body scintigraphy-

demonstrates low bone uptake with foci or radiotracer accumulation

over mandible, ribs, and sternum, widening of the mandible, rachitic

rosary sign of ribs, tie sign of sternum, 24 hr urine ca and P-low ca

and high p: are high in patients with primary renal phosphate wasting

or Tancohs syndrome and oncologic osteomalacia, Bone biopsy andTetracycline labeling-reduced distance between tetracycline bands:

unmeneralized matrix appears (inc. osteoid scan)

MGMNT: pillows are used to support the body, Inc. vit d. c

supplemental ca, exposure to sunlight, adequate protein, inc. ca and

vit. D., calcitriol, calcium carbonate, cholecalciferol

Pagets disease

-osteitis deformans, disorder of localized rapid bone tunreover,

affecting the skull, femur, tibia, pelvic, bones, vertebrae, men

-skeletal deformity, sclerosic changes, bowing of the femur and tibia,

enlargement of the skull, deformity of pelvic bones, thickening of the

long bones, impaired hearing from cranial nerve compression and

dysfunction, thorax is compressed, tenderness, warmth over the

bones

-DX: inc. serum alkaline phosphatase, urinary hydroxypyroline

excretion, normal blood calcium level, x-ray- definitive dx, bone scan,

bone biopsy-severity


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MNGMNT: NSAIDS, calcitonin-polypeptide hormone, SQ inhalation

side effects: Flushing of face, Nausea, 3-6 months

Bisphonates-adequate daily intake of ca and vit. D is required during

therapy, Plicamycin (mithracin)-cytotoxic antibiotic

Traumatic injuries:

Contusion, Strains, and Sprains

C: Is a soft tissue injury produced by blunt force, ecchymosis,

bruising, swelling, pain, discoloration, hematoma COMP, 1-2 weeks

resolution

St: Muscle pull, overuse, overstreching or excessive stress, soreness

or sudden pain, local tenderness, muscle use and isometric

contraction

Sp: injury of the ligament, caused by wrenching or twisting motion,

swelling and bleeding causes the degree of disability and pain

-avulsion fracture: bone fragment is pulled away by a ligament or

tendon may be associated with sprain

-DX: X-ray

-MGMNT: PRICE: protection, rest, ice, elevation produces

vasoconstriction, which decreases bleeding, edema, and discomfort

Rest: promotes healing and prevents injury

Ice- Applied intermittently for 20-30 min. during first 24 to 48 hrs.

after injury


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:After the acute inflammatory stage (24-48 hrs.) heat may be applied

intermittently for 15-30 minutes to relieve muscle spasm and to

promote vasodilation, absorption, and repair

Elastic compression bandage controls bleeding, reduces edema, and

provides support for the injured tissues

Elevation controls the swelling.

-If sprain is severe (torn muscle fibers and disrupted ligaments:

Surgical repair or cast immobilization may be necessary so that the

joint will not lose its stability

:Severe sprain may may require 1-3 weeks of immobilization before

protected exercises are initiated; strains and sprains may take weeks

or months to heal

-prevent: splinting

Joint dislocation

-articular surfaces of the bones forming the joint are no longer in

anatomic contact, bones are literally out of joint

-subluxation is a partial dislocation of the articulating surfaces,

traumatic dislocation are orthopedic emergencies

-if dislocation is not treated promptly, avascular necrosis (tissue

death due to anoxia and diminished blood supply and nerve palsy

may occur

-May be congenital, present at birth (hip), spontaneous or pathologic

or disease of the periarticular structures or articular structure, or

traumatic: resulting from injury


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-pain, change in contour of the joint, change in the length of the

extremity, loss of normal mobility, and change in the axis of the

dislocated bones

-X-rays confirms the dx, and demonstrates associated fracture

-Affected joint is immobilized while the patient is transported to the

hospital, the dislocation is promptly reduced (displaced parts are

brought to into normal position) to preserve joint function, analgesia,

muscle relaxants, anesthesia are used to facilitate closed reduction,

joint is immobilized by bandages, splints, casts, or traction, and is

maintained in a stable position, neurovascular status is monitored, if

joint is stable, gentle, progressive, active and passive ROM

Exercises are done and restore strength.

Sports related injuries

-Acute: Sprain, Strain, dislocation, fractures

-Gradual: Chondromalacia patella, tendinitis, stress fracture

-Contusions results from direct falls or blows, initial dull pain

becomes greater, with edema and stiffness by the next day

-Sprains commonly occur in fingers, ankles, and knees. If ligament is

damage is major, the joint becomes unstable: surgical repair may be

required

-Strains manifest with a sharp, stabbing pain, caused by bleedingand immediate protective muscle contraction, Tennis (calf muscle

strains), Soccer players (quadriceps strains), Swimmers, Weight

lifters, Tennis players often suffer shoulder strains


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-Tendinitis: Inflammation of a tendon, caused by overuse and seen in

tennis players (epicondylar tendinitis or tennis blow), runners

(Achilles tendinitis), basketball players (infrapatellar tendinitis)

-Meniscal injuries or knee occur in excessive rotational stress

-dislocation are seen in sports that involve throwing or lifting

-fractures: Falls, skaters and bikers: Suffers colles fractures of the

wrist when they fall on outstretched arms, Ballet dancers and track

and field athletes (metatarsal fractures), stress fractures (occur with

repeated bone trauma from activities, jogging, gymnastics,

basketball, aerobics. Tibias, fibulas, and metatarsal are most

vulnerable

-treated with few days or longer than 6 weeks

-prevention: proper equipment use, effective training and

conditioning of the body, specific training needs to be tailored to the

person and the sports, warm up routines, walking or slow jogging for

5 minutes, followed by slow gradual stretching, stretch for 10

seconds before relaxing and repeating stretch, after exercise is cool

down to prevent cardiovascular problems such as hypotension,

syncope, and dysrhythmias, athlete needs to be taught to tune in to

body symptoms that indicate stress and to modify activities to

minimize injury and promote healing

Occupational Relation Injuries

-most common are sprains, strains, and tears,

Specific Musculoskeletal injuries

Tennis Elbow


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-Epicondylitis (tennis elbow), chronic painful condition caused by

excessive, repetitive activities results in inflammation (tendinitis) and

minor tears in the tendon, at the origin of the muscles on the medial

or lateral epicondyles

-casues: rackets sports, pitching, gymnastics, and repetitive uses of

a screwdriver

-pain radiates down to extensor (Dorsal) surface of the forearms,

weakened grasp, relief by rest and avoidance of activities

-app. Of ice (PRICE), admin. NSAIDS, COX-2 inhibitors,

immobilization,

Rupture of the achilles tendon

-during activities within the tendon sheath sudden contraction of calf

muscles with foot fixed firmly to the floor

-sharp pain, cannot plantar flex the foot

-6-8 weeks of cast

Lateral and medial collateral ligament injury

-occurs when foot is firmly planted and the knee is struck, either

medially, causing stretching, tearing injury to the lateral collateral

ligament, or laterally, causing stretching and tearing injury

-pain, joint instability, inability to walk w/o assistance

-Provide stability at the sides of the knee

-PRICE, Hemarthrosis (bleeding into the joint), joint fluid is aspirated,

treatment depends on the severity, limited weight bearing, elastic


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bandage or a brace, As pain subsides, ROM exercise are

encouraged, leg is immobilized and weight bearing is restricted for 6-

8 weeks, derotational brace

Anterior and posterior cruciate ligament injury

-ACL and PCL, stabilize forward and backward motion of the femur

and tibia. These ligaments cross in the center of the knee

-Occurs when foot is firmly planted, knee is hyperxtended and the

person twist the torso and femur, pt reports a pop or tearing

sensation with the twisting injury, usually ACL is torn, patient

experiences pain, joint instability, and pain with ambulation

-PRICE, Joint aspiration if hemarthrosis, BRACE, PT, avoidance of

jumping activities, Surgical ACL reconstruction, tendon repair with

grafting (Arthroscopic surgery) After surgery, the pt. is taught to

control pain with oral opiod anal, NSAID, COX-2 inhibitor,

cryotherapy (cooling pad incorporated in dressing). Pt is taught about

monitoring neuro. Status of the leg, Ankle pumps, Quadriceps sets,

and hamstring sets, knee braes, rehabilitation (6-12 months)

Fractures

Is a break in the continuity of bone, subjected to stress greater than it

can absorb

-Soft tissue edema, hemorrhage into the muscles, joint dislocation,

rupture tendons, severed nerves, damage blood vessels

Complete fractures: involves a break across the entire cross-section

of the bone (removed from normal position)


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Incomplete fracture: greenstick frac., break occurs through only a

part of the cross-section of the bone, one side of a bone is broken

and the other is bent

Comminuted fracture: Occurs only one part of the cross section of

the bone

Closed fracture: (simple fracture) one that does not cause a break in

the skin

Open fracture: Compound or complex, which skin is extended to the

fractured bone

Compression: A fracture in which bone has been compressed

Avulsion: A fracture in which a fragment of bone has been pulled

away by a tendon and its attachment

Depressed: A fracture in which fragments are driven inward (seen

freq.) in fractures of skull

Epiphyseal: A fracture thorugh epiphysis

Impacted: A fracture in which a bone fragment is driven into another

attachment

Oblique: A fracture occurring at an angle across the bone (less

stable than a transverse F.)

Pathologic: A fracture that occurs through an area of diseased bone

(osteoporosis, bone cyst, pagets disease, bony metastasis, tumor):

Can occur without trauma or fall

Simple: A fracture than remains contained with no disruption of the

skin integrity


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Spiral: A fracture that twist around the shaft of the bone

Stress: A fracture that results from repeated loading of bone and

muscle

Transversed: A fracture that is straight across the bone shaft

: Grade 1 is a clean wound less than 1cm long

Grade 2: Is a larger wound without excessive soft tissue damage

Grade 3: Highly contaminated has extensive soft tissue damage

-pain loss of fx, deformity, shortening of the extremity, CREPITUS-

grating sensation, local swelling, and dislocation

MGMNT: Immobilized, extremity is supported above and below the

fracture site to prevent rotation as well as angular motion, splinting,

Bandaging, clothes are gently removed, first from the uninjured side

of the body and then from the injured side, the clothing of the patient

may be cut away, the fractured extremity in moved a little as possible

to avoid more damage

Reduction: refers to restoration of the fracture fragments to anatomic

alignment and positioning, consent of the proc., analgesic is admin.,

injury of the extremity must be handled gently

Closed reduction: Through manipulation and manual traction, cast or

splints are app., anesthesia with percutaneous pinning, x-rays are

obtained to confirm the alignment, traction used to pt., 6-8 weeks

Open reduction: alignment of bone through surgical approach,

Internal Fixation devices are used: pins, wires, screws, plates, nails


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or rods. Risk for osteomyelitis, tetanus, and gas gangrene. Wound

irrigation and debridement, bone grafting is performed to fill the bone

defects, wound is usually left open for 5-7 days for intermittent

irrigation and cleansing, 4-8 weeks bone grafting may be necessary

to bridge bone defects and to stimulate bone healing

Factors enhancing healing:

Immobilization

Maximum bone fragment contact

Sufficient blood supply

Proper nutrition

Exercise: weight bearing for long bones

Hormones: growth hormone, thyroid, calcitonin, vit. D, anabolic

steroids

Electric potential across fracture

Inhibiting fractor:

Extensive local trauma

Bone loss

Weight bearing prior to approval

Malalignment of the fracture fragments

Inadequate immobilization

Space of tissue between bone fragments


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Infection

Local Malignancy

Metabolic bone disease (Pagets disease)

Irradiated bone (Radiation Necrosis)

Avascular Necrosis

Intra-Articular fracture (synovial fluid contains fibrolysins, which lyse

the initial clot and retard clot formation)

Age (Elderly)

Corticosteroids

Open: covered with a clean sterile dressing, splints are applied , no

attempt is made to reduce the fracture, even if one of the bone

fragments is protruding through the wound.

Comp:

Early comp:

Shock: Hypovolemic shock resulting from hemorrhage is more freq.

noted in trauma patients with pelvic fractures and displace or open

femoral fracture, femoral artery is torn by bone fragments, restore

blood vol. and circulation

Fat Embolism Syndrome

-After fracture or lone bones, Pelvic bone or crush injuries, in

younger tan 40 yrs. Of age in men, , may occlude the supply for


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lungs, brain, kidneys and other organ, onset is rapid 12-48 hrs. occur

in 10 days after injury

-Hypoxia, Tachypnea, Tachycardia, Pyrexia, Respiratory Distress,

Crackles, Wheezes, Precordial Chest pain, Tick white sputum, Chest

x-ray: Snow storm infiltrate, (ARDS, acute respiratory distress

syndrome), heart failure may develop- Manifested by change in

mental status from headache, mild agitation, delirium, and coma

Prevention and MNGMNT: Immobilization of fracture including early

surgical fixation, support during turning and positioning, respiratory

support, High flow oxygen, PEEP, vasopressor

Compartment syndrome

Area of the body encased by bone or fascia (fibrous membrane

separates muscles)

-deep throbbing pain, unrelenting pain, pain during the Passive ROMexercises, Too tight cast, Edema, hemorrhage, lower leg is mostly

involved

-6 ps: Pain, Paralysis, Paresthesias, Pallor, Pulselessness, and

Pressure

-Assess: Dorsiflex, Plantar flex of foot, flexion and extension of the

wrist, Motor weakness (nerve damage), Cyanotic nail beds, Edema,Doppler ultrasonography to verify the pulse, normal pressure is 8

Mmhg, prolonged pressure of more than 30,


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MNGMNT: Fasciotomy, wound is not sutured after, affected arm is

splinted in a functional position, ROM exercises for 4-6 hrs., In 3-6

days, wound is debride and closed, comp: AVN and infection

Comp:

Venous thromboemboli, DVT, PE-Reduced skeletal muscle

contractions and bed rest.

-Fractures of the lower extreme. And pelvis are prone to venous

thrombemboli

-PEs may cause death several days to weeks after injury

-DIC (disseminated Intravascular Coagulation is a systemic disorder-

Wide hemorrhage and microthrombosis with ischemia

: Bleeding after surgery, mucous membrane, venipuncture sites, and

gastro. And urinary tract

-watch out for infection tenderness, pain, redness, swelling, local

warmth, elev. Temp. and purulent drainage

Delayed Comp:

Delayed union-healing does not occur within the expected time

:assoc. with distraction (pulling apart) of bone fragments, nutrition,

comorbidity (DM, Autoimmune dis.)

Nonunion-failure of ends of a fractured bone to unite

Malunion-results from failure of the ends of fractured to unite in

normal alignment


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:Persistent discomfort, abnormal movement

-factors: infection, interposition, inadequate immobilization,

manipulation, excessive space between bone fragments, limited

bone contact, impaired blood supply result: AVN

NON: Pseudoarthrosis (false joint)

MGMNT: Internal fixation, bone grafting, elect. Bone stimulation,

Graft: Autograft: tissue from iliac crest, for his own use

Allograft: tissue harvested from a donor

:6-12 months or more

Comp: Graft infection, fracture of graft, nonunion

Autograft: limited quantity and pain for 2 yrs.

Avascular Necrosis

-occurs when the bone loses its blood supply and dies

-pain and limited movement

-x-ray: Loss of mineralized matrix

MGMNT: Bone grafts, prosthetic rep. or arthrodesis (joint fusion)

Rx to internal fixation

:removed when bony union takes place,

-pain and dec. fx,


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-mechanical failure: Inadequate insertion and stabilization, material

failure, Corrosion of the device: local inflammation, allergic response,

-the bone needs to be protected when removed to protect from

refracture r/t osteoporosis, altered bone structure, trauma

Complex regional pain syndrome

-CRPS: seen in upper extremity after trauma, common in women

-severe burning pain, local edema, hyperesthesia, stiffness,

discoloration, vasomotor skin changes (fluct. Warm, red, dry, cold,

sweaty, cyanotic.

-glossy, shiny skin, inc. hair and nail growth

-comp: Disuse muscle atrophy and bone deossification (osteoporosis

NM: Elevation of the exteme, ROM, pain relief, Nsaids,

Coriiticosteroids, muscle relaxants

Heterotopic ossification:

-Myositis ossificans is the abnormal formation, near bones or in

muscle, response to soft tissue trauma or fracture after blunt trauma

or total joint replacement

-painful muscle, limited contraction

-prevent: early mobilization, needs to be excised if symptoms persist

Necrosis

Amputation


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-used to relieve symptoms to improve function and most importantly

to save or improve function and pt. quality of life

-Gangrene, diabetes, burns, frostbite, osteomyelitis, malignant tumor

Assess: Circulation and functional usefulness: Physical exam,

Doppler flow studies and duplex ultrasound

-Levels of amp:

Syme amputation

-performed for extensive foot trauma and aims to produce a durable

extremity

Below knee amputation

-importance of the knee joint and the energy req. of waklings

Above knee amputation

-goal of preserving maximum fx length

Stage amputation

-Gangrene and infection exist, debrided and allowed to drain

Comp.: Hemorrhage, infection, phantom limb

-Pylon: temporary prosthetic extension

10-14 days for cast change

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