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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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