11/14 Flashcards
Thenar Compartment
1. Abductor Pollicis Brevis- O: scaphoid and trapezium I: proximal 1st phalanx A: abducts thumb N: recurrent branch of median
2. Flexor pollicis brevis- more medial to abductor O: scaphoid and trapezium I: proximal 1st phalanx A: flex thumb N: recurrent branch of median
3. Opponens pollicis- deep to abductor O: scaphoid and trapezium I: proximal 1st phalanx A: thumb opposition N: recurrent branch of median
Hypothenar Compartment
1. Abductor digiti minimi- O: pisiform I: proximal 5th phalanx A: abduct pinky N: deep branch of ulnar
2. Flexor digiti minimi- O: hamate I: proximal phalanx of 5th digit A: flex pinky N: deep branch of ulnar
3. Opponens digiti minimi- deep to abductor O: pisiform I: proximal phalanx of 5th digit A: pinky opposition N: deep branch of ulnar
Adductor Compartment
1. Adductor pollicis-
O: Transverse head- 3rd metacarpal
Oblique head- base of 2-3 metacarpal
I: base of proximal 1st phalanx
A: adducts thumb
N: deep branch of ulnarCentral Compartment
1. Lumbrical muscles (4)-
O: tendons of Flexor digitorum profundus
I: extensor expansions
A: flex MCP and extend IP joints of digits 2-5
N: Lumbricals 1-2: median
Lumbricals 3-4: deep ulnar
Flexor tendons
Superficial palmar arch and digital vessels
Interosseous Compartment
1. Dorsal interossei (1-4)- O: adjacent metacarpals I: base of proximal phalanages A:abduct digits 2-4, help Lumbricals with MCP flexion and IP extension N: deep branch of ulnar
2. Palmar interossei (1-3)- O: adjacent metacarpals I: bases of proximal phalanges A: adduct digits 2-5, help Lumbricals with MCP flexion and IP extension N: deep branch of ulnar
Carpal Tunnel
- Tendons of-
Flexor Digitorum Profundus (4)
Flexor Digitorum Superficialis (4)
Flexor Pollicis Longus (1) - Median Nerve
Tendon Disorders
- Tendinitis- tendon inflammation
Partial tendon tears and the associated healing process
Inflammatory cells, fibroblasts, evolving hematoma, and granulation tissue
- Tendinosis- tendon degradation
More common than tendinitis and increases with age
Collagen fiber disorganization, increased mucous appearance, neovascularization, focal areas of necrosis, inflammatory cells not present
- Tenosynovitis- inflammation of the synovial sheath surrounding a tendon
Aseptic or related to infection, numerous inflammatory cells invading the synovial lining
- Tendon Rupture- eccentric loading beyond the capacity of the tendon
More common to have pre-existing degenerative change that predisposes to tendon rupture
Tendon Healing
- Inflammatory: 3-5 days, fibrin clot produced
- Fibroblastic: 1-6 weeks, production of collagen and matrix to form a disorganized tendon “callus”
- Remodeling: 6 weeks-9 months, reorganization of collagen into cross-linked pattern
Rehab following injury: joints immobilized during inflammatory phase and early remodeling to allow new collagen production and prevent injury of repair tissue, load progressively increased as remodeling proceeds
Ligament Injuries and Healing
A: Injuries-
Extra-articular ligament injuries have high healing capacity
Intra-articular ligament injuries have reduced healing capacity due to the fibrolytic and anti-coagulative environment in the joint, need surgery to heal
B: Healing- larger/bulkier but weaker than before
4 Steps of extra-articular ligament healing:
- Inflammatory response
- Cell proliferation
- Remodeling
- Scar maturation
Muscle Injury
Direct injury: laceration or contusion to the muscle
Indirect injury: acute or delayed onset, when muscle is loaded eccentrically, muscles that cross two joints are especially prone to injury
NSAIDS work, normally low cell turnover but higher for repair
Myositis Ossificans: calcification occurs within muscle tissue, generally associated with trauma
Muscle Repair Stages-
1. Degenerative: necrosis of muscle fibers, invasion of inflammatory cells (neutrophils and then macrophages)
- Regenerative: myogenic Cells move into area, enlarge, and fuse to form new fibers, regenerated fibers are smaller in caliber and have central nuclei
Osteomyelitis
Infection of bone and medullary space
80% caused by Staph Aureus, MRSA causes some too
Infants have Group B strep, S pyogenes in children
Erythrosedimentation above 70, may need bone biopsy
Tortuous venous sinusoids in metaphysis is site of bacterial seeding in hematogenous osteomyelitis
Mainly in children
Also: trauma, IV drug use, diabetes, immunocompromised
Treatment: surgical debridement of underlying bone
Native Joint Infection
Risk factors: diabetes, IV drug use, immunocompromised
Despite treatment 50% lose function
Pain with micromotion
Septic arthritis by bacteria in synovial space, neutrophils do inflammatory reaction that causes destruction of cartilage and loss of function
Evaluation:
Elevated ESR and CRP with no systemic WBC
Synovial fluid aspiration: look at WBC count, gram stain, crystals
WBC above 75k with 90% neutrophils
Usually hematogenous spread, but also direct inoculation and contiguous spread
Usually Staph aureus
Medical emergency: surgical debridement and antibiotics for 6-8 weeks
Prosthetic Joint Infection
Interaction between host, implant, and microbe
60% direct inoculation, others hematogenous
Staph aureus is common, form biofilm on prosthesis
Still need joint aspiration and ESR/WBC
Hematogenous seeding common
Coagulation Negative Staph and Staph aureus common but no one large group
Treatment: depend if acute or chronic, may need to amputate
Add spacer and do antibiotics then redo joint
Diabetic Infections
Neuropathy most common factor, also poor vascularity and poor nutritional status
Mortality rates increase with time after amputation
New approaches: revascularization with bypass grafting is effective and involves drainage of pedal sepsis, recombinant GCSF needs more trials, hyperbaric oxygen is not proven well
6 Elements of Chronic Care Model
- Community: services besides doctor like nutrition counseling
- Health system: changes that improve chronic illnesses care through leadership and health incentives
- Self-management support: patients learn effective self management skills
- Delivery system design: coordinate multiple care givers to improve clinical outcomes
- Decision support: integrate evidence-based guidelines
- Clinical Info Systems: help doctors deliver preventive care and remind patients of recommended care
