Bursa, Wrist & Hand Surgery & Rehab Flashcards
What are bursae?
Flattened sacs of synovial membrane supported by dense, irregular connective tissue
Where do bursae occur?
Between tissue planes
- Subcutaneous (skin & bone)
- Submuscular (muscle planes)
- Subtendinous (tendon & muscle/muscle & bone/tendon & bony pulley/tendon & ligaments)
- May communicate with the joint
What are bursa problems often linked to?
Tendinopathy
What pathology is associated with bursae?
Acute inflammation/infection
Chronic
- Pathology in the stroma (supporting tissue)
- Biochemical (cytokines etc)
- Histo-anatomy (increased synovial hypertrophy, vascularisation, inter adipose septa)
What areas commonly get bursitis?
- Trochanteric
- Knee
- Iliopsoas
- Ischium
- Ankle
- Subacromial
- Cubital
- Olecranon
- Radio-humeral
What is the treatment for acute bursitis?
- Infective: Antibiotics
- Non-infective: NSAIDs, corticosteroid injection, ice, rest, treat underlying problem, behaviour modification
What is the treatment for chronic bursitis?
- Bursectomy
- Synovectomy
What does periodisation of the rehab program involve?
- Balancing protection of healing tissue with ROM and strength
What is associated with increase immobilisation period in the elbow and hand?
Increased risk of flexion contracture
Why is orthopaedic management required for hands?
Education
- Oedema management (elevation, compression, fist squeezing)
- Prevention of adhesions
- Maintenance of other joints
What is involved in a flexor tendon repair?
- Tendon ends located by extended incision to find where they have retracted
- Threaded back through the sheath/pulleys
- Repaired through window between the pulleys
- Maintaining relationship of FDP/FDS tendons
What must a flexor tendon repair ensure to allow early-active flexion rehab protocols?
- Secure knots
- Smooth junction of tendon ends at repair site
- Suture knots to minimise impingement
- Prevent gapping
- Maintain tendon vascularity
What are the 4 types of flexor tendon repair?
- Modified Kessler (2 strand)
- Double Kessler (4 strand)
- Savage (6 strand)
- Indiana (4 strand)
Approximately how long does it take a flexor tendon to regain enough tensile strength to avoid rupture with normal strong use of hand?
12 weeks after repair
What factors can affect rate of healing of flexor tendon repairs?
- Type of injury
- Status of tendon/sheath/vessels at time of repair
- Injury to surrounding structures
- Co-morbiditis
- Lifestyle factors
- Age
- Gender
- Long term steroid use
- Ability to comply with rehab program
Why is elevation used in the early phase after repair?
Other forms of oedema control are limited by continuous splinting
What does adhesion control involve?
- Passive flexion
- Active extension toa blocked point (splint)
- Passive localised full extension for single joints
Why can passive localised full extension not be used for composite joints (i.e. all 3 finger joints)?
It places an adverse stretch effect on the flexor tendon repair (can be tolerated at 4 weeks with wrist in flexion)
What does immediate passive flexion involve?
- MCP/PIP joints flexed, passively extending DIP
- DIP/MCP joints flexed, passively extending PIP
What are the indications for hand immobilisation?
- Young children for first 3-4 weeks
- Cognitive limitations
- Cast may be needed instead of removable splint
- Fracture/significant loss of skin graft
