Orthopedic tx 400 -- Fracture. Tendinitis

Question 1

fx causes

Answer 1

Direct Violence - Fracture occurs at the site of trauma and sudden force.

Indirect Violence - Fracture occurs proximal to applied force, torque or twist.

Muscular Contraction - Sudden, violent.

Overuse - Repeated wear causing cracks.

Pathologies - Osteoporosis, tumor, local infection, cyst..

Question 2

Symptomatic Picture

Answer 2

Unnatural mobility, deformity at the site.

Shock, P, Bleeding, inflammation, Edema.

Local erythema, bruising, MM spasms and splinting.

Loss of function, fatigue, weakness.

(SHARP)

Question 3

complicated fracture

Answer 3

Complicated fracture – structures surrounding the fracture are injured. There may be damage to the veins, arteries or nerves, and there may also be injury to the lining of the bone (the periosteum).

E.g.
lungs
(Complicated: Broken bone has injured an internal organ.)

Question 4

Dupuytren’s fx

Answer 4

Dupuytren’s- Similar/Same as Pott’s? Talus pushed superiorly.

Question 5

complications of fx

Answer 5

May develop early or late

Possible increase in P levels, edema, bruising, paresthesia, heat local to the fracture etc.

Question 6

early complications fx

Answer 6

Early – torn MM, Tendons, Ligament damage, compartment syndrome, NV injury, Vascular injury, Joint hemarthrosis, infections, DVT, ill fitting casting.

Question 7

late complications

Answer 7

Late – Delayed/non/mal union, myositis ossificans, NV compression or entrapment, bone necrosis, Volkmann’s ischemic contracture, joint stiffness, disuse atrophy.

Question 8

During immobilization

Answer 8

Local and possible distal P

Tissue repair and bony callus formation occur

Adhesions develop around the injury

<Circulation, edema, atrophy, contractures

<Cartilage health

HT and TP’s in compensatory

Complications can occur: Compartment syndrome, periferal nerve compression, infection, plaster sores, non-union.

Question 9

After immobilization

Answer 9

Site is remodeling

<tissue health under casting: fragile, <tone

Adhesions have matured, contractures may be present

Initial P and stiffness may be present, loss of proprioception, scarring if open fracture

HT, TP’s, MM weakness and disuse atrophy

Occasionally a pocket of chronic inflammation can remain locally

Long term complications may occur.

Question 10

note terms

Answer 10

—> (ALL ARE RSI/OVERUSE —> TENDINOPATHY (general category encompassing various types))

tendinitis

tendinopathy (term we will be concerned with – general term encompassing various types)

tendinosis (term that pathology class is concerned with)

calcific tendinitis (only consider as a possibility that you warn pt about)

tenosynovitis (paratendinitis)

Question 11

with tendinitis (tendinopathy) — is there an acute or subacute stage?

Answer 11

there is no acute phase, no subacute phase — ALL considered CHRONIC

Question 12

heat and tendinitis

Answer 12

heat makes it feel better

E.g.
—> Hot shower

Question 13

4 stages / types of tendinitis

Answer 13

1) only discomfort after activity

2) discomfort before, that fades during activity, and returns after activity

3) discomfort before, during, and after activity

4) discomfort in general during ADLs (not just the specific activity/sport)

Question 14

impingemnet syndrome

Answer 14

Impingement Syndrome is inflammation, pain, and edema in the tissues within the coracoacromail arch and between the acromiaoclavicular and glenohumeral joints. Painful compression of the tendons, especially supraspinatus. There are three progressive stages of impingement:

Stage 1 – there is edema and hemorrhage of the subacromial bursa. (reversible)

Stage 2 – tendinitis and fibrosis are present. (reversible)

Stage 3 – incomplete tears or complete rupture occurs. (surgery indicated)

Question 15

Repetitive Strain Injury (RSI):

Answer 15

Repetitive movements and poor posture lead to mm fatigue and damage to the mm, tendons, and nerves of the shoulders, neck, and arms. Pain, numbness, and weakness are experienced. Tendonitis, tenosynovitis, trigger points, myalgia, and nerve entrapments – including TOS and carpal tunnel syndrome – are some of the diagnosed conditions.

Question 16

Calcific Tendonitis/Tendonopathy

Answer 16

is a late-occurring stage of rotator cuff tendonitis, usually developing in the supraspinatus tendon. Pressure on the tendon causes the fibrocytes to change to chondrocytes, collagen disintegrates and calcific deposits accumulate within the cells

Question 17

Tendonitis: Symptomatic Picture

Answer 17

Acute: Gradual onset, with local tenderness one or two days after activity. Initially pain diminishes with renewed activity. It progresses to pain during activity as severity increases Inflammation, heat, and swelling present. Crepitus may develop with tenosynovitis and paratendonitis. There is decreased ROM of the affected mm.

Chronic: Pain during and after activity. Chronic inflammation, fibrosis, and adhesions are present. Chronic thickening may be observable if the tendon is superficial (achilles tendon). Crepitus may be present, decreased ROM and strength. Flare-ups to the acute stage may occur with repeated overuse. The tendon can rupture if allowed to degenerate.

Question 18

History q

Answer 18

What activities or movements cause the pain?

How much is required to produce symptoms?

Where is the pain?

Present symptoms? How long?

First time?

New activities?

Previous injuries?

Question 19

Observations

Answer 19

Acute: Antalgic posture/gait. Swelling and redness.

Chronic: MM imbalance. Thickening of the tendon. MM wasting and disuse atrophy occur with complete tears.

Question 20

Palpation

Answer 20

Acute: Point tenderness, heat, swelling, HT, TP’s.

Chronic: Local pain, swelling, adhesions, granular feeling tendon or hard at the adhesion site. HT, TP’s, crepitus, a snapping sensation may be felt due to tight tendons that snap over a bony prominence or bursa.

Question 21

Testing

Answer 21

AROM is usually painless.

PROM may reveal pain with full stretch.

RROM/Isometric testing is painful, especially when applied in a fully lengthened position. The pain increases with the force of contraction. You may have to test isometrically in different positions. If this fails, the client puts the limb in the position that causes pain and isometric resistance is applied. Weakness may be present. This is called the tendonitis differentiation test.

(P with palp, stretch, and RROM with no initial trauma…)

Question 22

Tendonitis Treatment

Answer 22

Acute: Reduce inflammation with cold hydro. Reduce edema with MLD, nodal pumping. Reduce HT and TP’s(prox). Maintain ROM with PROM. Mobilize hypomobile joints. Modify symptomatic movements or volume if possible.

Chronic: Deep moist heat to soften adhesions and increase circulation (short duration). Reduce restrictions and edema with MFR and contrast hydro. Decrease HT and TP’s. To reduce adhesions skin rolling and separations are used generously before Frictions are applied. Isometrics or carefully dosed loading.

Question 23

Homecare

Answer 23

Pt education is key! Discussions about pain vs progress, tendon response timing, and loading options to self manage

Symptomatic control:
1) Hydro: contrasts with chronic, ice with acute flare ups.

2) Stretch shortened MM.

3) Alter activities to put less strain on affected MM.

4) Self massage!!!! (separations, skin rolling)

Long term:
Increase capacity of tendon with loading

Modify loads for controlled rehab

Optimize movement patterns without introducing fear avoidance

Question 24

BURSITIS

Answer 24

Bursitis is inflammation of a bursa.

Question 25

bursa

Answer 25

A bursa is a small, flat sac lined with synovium. The word bursa means “purse”. A bursa reduces friction, usually between tendons and bones. Since it is flat, a bursa is not palpable unless inflamed.

Question 26

bursa can…

Answer 26

A bursa can regrow in 6-24 months if surgically removed

Question 27

bursitis is via

Answer 27

Bursitis is caused from overuse of structures surrounding the bursa, leading to excessive friction and inflammation of the bursal walls.

It is usually secondary to other conditions such as tendonitis.

Question 28

bursitis contributing factors

Answer 28

Contributing factors include mm imbalance, poor biomechanics, & postural dysfunction such as scoliosis, other (?)

Question 29

less common causes & risk factors for bursitis

Answer 29

Less common causes include

acute trauma,
infection,
osteoarthritis,
gout,
rheumatoid arthritis.

Question 30

Common bursitis locations

Answer 30

Subscapular

Subacromial Aka Subdeltoid

Olecranon

Trochanteric

Iliopectineal

Ischial aka “bench warmers bursitis”

Pes anserine

Infrapatellar

Prepatellar

Retrocalcaneal

Subcutaneous calcaneal

Question 31

Subscapular bursitis

Answer 31

lies between the scapula and subscapularis mm. It is not easily palpated.

Question 32

subacromial bursa

Answer 32

lies between the acromion and supraspinatus tendon with a portion between the deltoid mm and humerus.

Question 33

olecranon bursa

Answer 33

lies between the olecranon and the subcutaneous fascia (superficial) and is quite swollen and obvious when inflamed. It is irritated by repetitive weight bearing or trauma such as dragging the elbow across a surface.

Question 34

Trochanteric bursa

Answer 34

There are two main bursa:

One lies between the gluteus maximus tendon and the trochanter,

the other between the gluteus medius tendon and the trochanter.

Pain is local to the lateral hip. The patient will not be able to sleep on that side.

Pain is worse on climbing stairs and getting out of a car.

Question 35

Iliopectineal bursa

Answer 35

lies between the iliopsoas mm and the iliofemoral ligament.

Question 36

Ischial Bursa

(“bench warmers bursitis”)

Answer 36

lies between glut max and the ischial tuberosity. It is palpated through glut max.

Pain is localized over the ischial tuberosity.

There may be referred pain down the posterior leg, and can appear like sciatic pain.

Pain can be alleviated when pressing the brake when driving the ischial tuberosity is rotated away from the seat.

Question 37

pes anserine bursa

Answer 37

between the tendons of sartorius, gracilis, and semitendonosis, and the medial tibia.

Question 38

Infrapatellar bursa

Answer 38

lies between the patellar ligament and the tibia.

Question 39

Prepatellar

Answer 39

between the distal half of the patella, the patellar ligament, and the skin. It is easily palpated when inflamed. Pain is local.

Question 40

up to how many bursae in knee

Answer 40

There are up to 11 bursae at the knee 

Question 41

Retrocalcaneal bursa

Answer 41

lies between the achilles tendon and the calcaneus. The bursa is palpated on either side of the tendon. Local pain when inflamed.

Question 42

subcutaneous calcneal bursa

Answer 42

between the subcutaneous facia and achilles tendon (superficial)

Question 43

Other similar (?) injuries

Answer 43

..

Question 44

Baker’s cyst

Answer 44

is a synovial cyst that usually appears at the lateral side of the popliteal space. Can appear in children and adults. They tend to spontaneously resolve. With surgical removal, they usually reoccur within seven months.

Question 45

Bunion

Answer 45

occurs at the first metatarsophalangeal joint capsule. Formed by excessive bone growth (exostosis), a callus, and inflamed thickened bursa developing over the joint.