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Orthopaedics > Tedinopathies and Compartment Syndrome > Flashcards

Tedinopathies and Compartment Syndrome Flashcards

1
Q

What is the function of a tendon?

A

Transmits force from muscle to achieve movement

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2
Q

Describe the structure of a tendon.

A

Parallel collagen fibrils with tenocytes
Sheathed by a paratendon sheath
Largely avascular, with nutrition supplied by the paratendon

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3
Q

What is a tendinopathy?

A

Chronic tendon injury of over use (repetitive loading)

  • degeneration, disorganisation of collagen fibres
  • increased cellularity as the body tries to stimulate healing
  • little inflammation
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4
Q

What are the risk factors for developing a tendinopathy?

A 
Age associated with activity levels
Chronic disease
Diabetes, RA
Adverse biomechanics
Repetitive exercise 
Recent increase in activity
Quinolone antibiotics
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5
Q

Describe the pathology of a tendinopathy.

A

Not inflammation (tendinopathy not teninitis)
Deranged collagen fibres associated with a scarcity of inflammatory cells
Increased vascularity around the tendon
Failed healing resposne to micro-tears
Inflammatory meditors released (IL-1, NO, PGs) cause apoptosis, pain and provoke degeneration through release of MMPs

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6
Q

Name some locations of common tendinopathies.

A 
Achilles tendinopathy
Rotator cuff tendonitis
Tennis elbow
Golfers elbow
Patella tendinopathy
Hamstring tendonitis
Adductor tendonitis
Plantar fasciits
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7
Q

What are the clinical features of a tendinopathy?

A

Pain
Swelling
Thickening
Tenderness

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8
Q

How are tendinopathies diagnosed?

A

X-Ray - rules out other causes
Ultrasound
MRI - best seen in T1

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9
Q

Describe some non-operative treatments of tendinopathies.

A 
NSAIDs
Activity modification
Physiotherapy 
GTN patches 
PRP injections 
Prolotherapy 
- irritant injection of dextrose
Extra Corporeal Shokwave therapy
- 3 weekly treatments 
Topaz 
- radiofrequency coblation 
Steriod injections
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10
Q

Describe the mechanism of action of GTN patches in tendinopathy treatment.

A

It is absorbed throught the skin, where it biotransforms into NO, which promotes
- extracellular collagen organisation
- collagen and protein synthesis
- vasodilations (to increase local perfusion)
Headaches are a common side effect

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11
Q

Describe the physiotherapy used in treatment for tendinopathies.

A

Eccentric loading
- contraction of the musculotendinous unit whilst it elongates
Beneficial in around 80% of patients

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12
Q

What are the operative treatments for tendinopathies?

A

Debridement
- excision of diseased tissue
- possible to remove 50% of the tendon without loss of function
Tendon transfers

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13
Q

Describe the prognosis of a tendinopathy.

A

Most will improve with activity modification
Most non-operative measures improve in symptoms in 70-80% over 1-2 years
Surgical treatments work in 80% of cases
- if non-operative methods fail

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14
Q

What is compartment syndrome?

A

An orthopaedic emergency
- can cause loss of function, limb or life
Elevated interstitial pressure within a close fascial compartment resulting in microvascular compromise

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15
Q

Where are the common sites for compartment syndrome to occur?

A

Leg
Forearm
Thigh

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16
Q

What are the general causes of compartment syndrome?

A 
Increased internal pressure
- bleeding
- swelling
- iatrogenic infiltration 
Increased external compression
- casts/bandages 
- full thickness burns 
Combination of any of the above
17
Q

Describe the pathophysiology of compartment syndrome.

A

Pressure within the compartment exceeds pressure within the capillaries
Muscles become ischaemic and develop oedema through increased endothelial permeability
Necrosis begins in the ischaemia muscles after 4 hours
Ischaemic nerves become neuropraxic
- this may recover if relieved early, permanent damage may result after just 4 hours
Compromise of the arterial blood supply.

18
Q

Describe the effects of ischaemia over time on nerves and muscles.

A

1 hour
- nerve conduction normal and muscle viable
4 hours
- neuropraxia in nerves (reversible)
- reversible muscle ischaemia
8 hours
- nerve axonotmesis and irreversible change
- irreversible muscle ischaemia and necrosis

19
Q

Describe the end stage of compartment syndrome.

A

Stiff fibrotic muscle compartments
Impaired nerve function
Clawing of limbs
Loss of function

20
Q

Name some specific causes of compartment syndrome.

A 
Internal pressure
- trauma (fractures, entrapment)
- muscle oedema/myositis
- intracompartmental administration of fluids/drugs 
- re-perfusion (vascular surgery)
External pressure 
- impaired consciousness/protective reflexes 
- positioning in theatre
- bandaging/casts
- full thickness burns
21
Q

What are the clinical features of compartment syndrome?

A

Pain - out of proportion to that expected from the injury
Pain on passive stretching of the compartment
Pallor
Parastesia - late stage
Paralysis - late stage
- deep nerves affected first
Pulselessness - late stage
Swelling
Shiny skin
Autonomic response - sweating and tachycardia
Seen on the hand, foot, leg, thigh and forearm

22
Q

How can a diagnosis of compartment syndrome be made?

A

Clinical signs and symptoms
Compartment pressure measurement
- normal 0-4mmHg (10mmHg with exercise)
- around 30mmHg means it is compartment syndrome

23
Q

What is the treatment for compartment syndrome?

A 
Open and constricting dressings and bandages 
Reassess
Surgical release
Later wound closure 
Skin grafting and plastic surgery input
24
Q

Describe the process of surgical release in compartment syndrome.

A

Full length decompression of all compartments
Excision of any dead muscles
Wounds left open for a while
Repeat debridement until pressure is down and all dead muscles excised
Wound closure and skin grafting

25
Q

Name the muscle compartments of the forearm.

A

Two fascial compartments

  • posterior compartment (containing the extensors of the hand)
  • anterior compartment (containing the flexors of the hand)
26
Q

Name the muscle compartments of the leg.

A

Four fascial compartments

  • anterior compartment
  • lateral compartment
  • deep posterior compartment
  • superficial posterior compartment
27
Q

Name the muscle compartments of the thigh.

A

Three fascial compartments

  • anterior compartment
  • medial compartment (contains the adductor muscles)
  • posterior compartment
28
Q

What peri-operative measures should be taken for someone who had compartment syndrome?

A

Adequate hydration
- due to fluid loss into the muscles and during surgery
Monitor and regulate electrolytes (postassium)
Correct acidosis
Myoglobinuria
Renal function

29
Q

What should be doe is compartment syndrome presents late?

A

Irreversible damage is already present
Fasciotomy will predispose them to infection
- non-operative treatment should be considered
Splint in position of function

Orthopaedics (13 decks)

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