Ligament injuries
• Lateral collateral ligament
~ damage caused by impact to the inside of the knee
• Medial collateral ligament
~ damage caused by impact to outside of the knee
~ common injury in contact sports e.g. football, rugby
• Anterior cruciate ligament
~ damage caused by twisting the knee or impact to the side of the knee
• Posterior cruciate ligament
~ damage caused by hyperextension or bending the knee back the wrong way
Cartilage/meniscus injuries
• Lateral meniscus
~ damage caused by internally rotating the knee with the foot, over-bending the knee backwards or forwards, or from over use
• Medial meniscus
~ damage caused by twisting the knee, over flexing (bending) or over use
• Osteoarthritis
~ affects articular cartilage
Tendon injuries
• Damage can be in the form of inflammation (as a result of overuse), tear/rupture or avulsion.
Tendons most commonly affected include:
~ patella tendon (aka ‘jumper’s knee’)
~ quadriceps tendon
~ hamstring tendons
Dislocations
• Patella
~ pain, instability, dislocation and fracture all common
• Tibiofibular joint
~ occurs most commonly when one sustains an impact or falls with knee in a fully flexed position, with foot pointing inwards (inversion) and downwards
Other
• Bursitis
~ prepatellar or infrapatellar
• Iliotibial band syndrome
~ aka ‘runner’s knee’
~ caused by the iliotibial band rubbing against the lateral femur and becoming inflamed
• Fat pad impingement
~ the fat pad is soft tissue between the patella and the femoral condyle. It can get pinched, often as the result of a hyperextension of the knee resulting in knee pain
• Septic arthritis
Thursday, October 4, 2007
Wednesday, October 3, 2007
First aid and emergency management of a knee injury:
Rest
Use crutches, splinting, slings etc.
Prevents further damage
Reduces blood flow and oxygen demand which promotes clotting
Reduces pain, allows healing
Ice
Decreases bleeding, swelling and pain
Rules:
o Never apply directly to skin
o Leave on for no longer than 20 mins, then 20 mins off, 20 mins on etc.
o Check skin colour and distal pulses
o Apply as often as possible for 2-3 days
Compression
Reduces swelling and healing time
Use compression bandage
o Monitor circulation
Elevation
Above the level of the heart
Reduces bleeding and swelling
AVOID:
Heat
I.e. hot baths, heat packs, showers, saunas
Alcohol
Increases bleeding, swelling and delays healing
Running
Exercise will cause further damage
Massage
Increases bleeding and swelling
Medication:
NSAIDs are recommended for controlling the inflammatory response to speed the recovery process - either topical or oral
Paracetamol
Hemarthrosis:
· Aspiration (withdrawal of fluid) as necessary
Use crutches, splinting, slings etc.
Prevents further damage
Reduces blood flow and oxygen demand which promotes clotting
Reduces pain, allows healing
Ice
Decreases bleeding, swelling and pain
Rules:
o Never apply directly to skin
o Leave on for no longer than 20 mins, then 20 mins off, 20 mins on etc.
o Check skin colour and distal pulses
o Apply as often as possible for 2-3 days
Compression
Reduces swelling and healing time
Use compression bandage
o Monitor circulation
Elevation
Above the level of the heart
Reduces bleeding and swelling
AVOID:
Heat
I.e. hot baths, heat packs, showers, saunas
Alcohol
Increases bleeding, swelling and delays healing
Running
Exercise will cause further damage
Massage
Increases bleeding and swelling
Medication:
NSAIDs are recommended for controlling the inflammatory response to speed the recovery process - either topical or oral
Paracetamol
Hemarthrosis:
· Aspiration (withdrawal of fluid) as necessary
Thursday, September 20, 2007
Complications & Prognosis of Disk Prolapse
Complications and Prognosis of Disk Prolapse
Complications:
Can lead to pain on coughing, laughing, sneezing, urinating, or straining while defecating.
Intense pain radiating down leg (sciatica) due to disk compressing on spinal nerve
Can lead to pain on defecating or urinating if nerves to bowel and bladder are compressed.
Also weakness of the muscles of the genitourinary area. May lead to trouble urinating or erectile dysfunction.
Loss of sensation to buttocks, medial and posterior thigh.
Prognosis:
90% of patients usually fully recover within a month or two with only use of paracetamol or NSAIDs to manage pain
Modified activity to rest the site and physiotherapy will improve the chances of the disk healing back to its pre-prolapse state.
About 10% of patients will require surgery and the success rate depends on the extent of the damage.
Day procedure with two to four week recovery time.
Usually works but general risks of surgery apply.
Complications:
Can lead to pain on coughing, laughing, sneezing, urinating, or straining while defecating.
Intense pain radiating down leg (sciatica) due to disk compressing on spinal nerve
Can lead to pain on defecating or urinating if nerves to bowel and bladder are compressed.
Also weakness of the muscles of the genitourinary area. May lead to trouble urinating or erectile dysfunction.
Loss of sensation to buttocks, medial and posterior thigh.
Prognosis:
90% of patients usually fully recover within a month or two with only use of paracetamol or NSAIDs to manage pain
Modified activity to rest the site and physiotherapy will improve the chances of the disk healing back to its pre-prolapse state.
About 10% of patients will require surgery and the success rate depends on the extent of the damage.
Day procedure with two to four week recovery time.
Usually works but general risks of surgery apply.
Surgical Mx of Back Pain
Surgery is not always the best option for treatment of sciatica or back pain, as it can cause complications in some cases. Surgery is advised only for a selective group of people with back pain. The pain must present for at least four weeks, and must be so severe that it affects normal function. These are some of the types of surgeries that are performed for back pain and sciatica:
Laminectomy, the removal of the entire lamina or Laminotomy, removal of part of the lamina is a treatment method for back pain resulting from spinal stenosis, or spinal tumours. Part of the lamina is cut away to uncover the ligamentum flavum, which is then incised to enter the spinal canal. The cause of the compression (eg a herniated disk) can then be corrected.
Discectomy Is the treatment of a herniated disk (where the gel-like substance in the intervertebral disk breaks through the exterior). This is usually done with laminectomy. In a discectomy the gel substance which has broken through and is compressing the spinal nerve is removed. This returns the disk to its normal shape, and relieves the pressure on the spinal nerve.
Rhizotomy is a procedure whereby the sensory nerve roots are first separated from the motor ones and then cut. Identification of the nerve fibres to be cut is then made by means of electrical stimulation. The one(s) producing the pain or other problems are identified in this way, and then selectively cut.
Foraminotomy is the treatment for pinched nerves. The opening where the spinal nerve exits the spine (foramen or neuroforamen) is surgically enlarged. This relieves compression of spinal nerve.
Spinal fusion is when vertebrae are fused together because abnormal positioning of the vertebrae is putting pressure on the nerve. A bone graft may be used, or devices such as cages, plates, screws and rods, to fuse the vertebrae.
Most spinal surgeries are not an emergency, so it is possible to prepare for surgery. It is important to eat a balanced diet with adequate vitamin supply, to help wound healing and reduce risk of infection. Exercise (which is approved by doctor) can increase cardiovascular endurance and speed up recovery. More body weight strains the spine, slows healing process, and increases post operative pain. So losing some weight (if required) before surgery may be beneficial. Also, smokers are encouraged to quit, as it can increase the chance of complications.
Laminectomy, the removal of the entire lamina or Laminotomy, removal of part of the lamina is a treatment method for back pain resulting from spinal stenosis, or spinal tumours. Part of the lamina is cut away to uncover the ligamentum flavum, which is then incised to enter the spinal canal. The cause of the compression (eg a herniated disk) can then be corrected.
Discectomy Is the treatment of a herniated disk (where the gel-like substance in the intervertebral disk breaks through the exterior). This is usually done with laminectomy. In a discectomy the gel substance which has broken through and is compressing the spinal nerve is removed. This returns the disk to its normal shape, and relieves the pressure on the spinal nerve.
Rhizotomy is a procedure whereby the sensory nerve roots are first separated from the motor ones and then cut. Identification of the nerve fibres to be cut is then made by means of electrical stimulation. The one(s) producing the pain or other problems are identified in this way, and then selectively cut.
Foraminotomy is the treatment for pinched nerves. The opening where the spinal nerve exits the spine (foramen or neuroforamen) is surgically enlarged. This relieves compression of spinal nerve.
Spinal fusion is when vertebrae are fused together because abnormal positioning of the vertebrae is putting pressure on the nerve. A bone graft may be used, or devices such as cages, plates, screws and rods, to fuse the vertebrae.
Most spinal surgeries are not an emergency, so it is possible to prepare for surgery. It is important to eat a balanced diet with adequate vitamin supply, to help wound healing and reduce risk of infection. Exercise (which is approved by doctor) can increase cardiovascular endurance and speed up recovery. More body weight strains the spine, slows healing process, and increases post operative pain. So losing some weight (if required) before surgery may be beneficial. Also, smokers are encouraged to quit, as it can increase the chance of complications.
Sciatica and neoplasias of the spine
Like other forms of sciatica pain is caused when a neoplasia compresses the spinal roots. Patients present with typical symptoms of sciatica but may also have other symptoms including slight paralysis, spinal deformity (e.g. scoliosis, kyphosis), and fever. Sciatic pain can occur at rest, be worse at night, and may or may not be related to activity. Neoplasias need to be ruled out if sciatic pain does not resolve or if neurologic deficit is experienced (one of Murtagh’s ‘unmissables’).
There are three kinds of neoplasia that can affect the spin:
• Extradural (similar to epidural only does not have to be immediately outside the dura mater.
• Extramedullary (outside of any medulla oblongata)
• Intramedullary (within the bone or medullar oblongata)
Both extradural and extramedullary neoplasias can cause compression of the spinal cord. This generally takes weeks to months and typically present with root pain and sensory loss. Intramedullary tumours are rarer and typically progress over many years.
Neoplasias of the spine are typically secondary cancers formed by metastatic neoplasias of the bronchus, breast, prostate, lymphoid, thyroid or skin (melanomas), and so may often imply more serious implications.
There are three kinds of neoplasia that can affect the spin:
• Extradural (similar to epidural only does not have to be immediately outside the dura mater.
• Extramedullary (outside of any medulla oblongata)
• Intramedullary (within the bone or medullar oblongata)
Both extradural and extramedullary neoplasias can cause compression of the spinal cord. This generally takes weeks to months and typically present with root pain and sensory loss. Intramedullary tumours are rarer and typically progress over many years.
Neoplasias of the spine are typically secondary cancers formed by metastatic neoplasias of the bronchus, breast, prostate, lymphoid, thyroid or skin (melanomas), and so may often imply more serious implications.
Wednesday, September 19, 2007
Facet Joint Injections
Facet joints provide stability and give the spine the ability to bend and twist.
Facet joints are made up of the two surfaces of adjacent vertebrae, which are separated by a thin layer of cartilage. The joint is surrounded by a capsule containing synovial fluid.
Facet joints can become painful due to arthritis of the spine, a back injury, or mechanical stress of the back.
An injection of a steroid medication is given into the facet joint, which anaesthetises the joint and blocks the pain.
There are two reasons for having facet joint injections:
1) For diagnosis
2) For pain relief
To determine if the facet joint is the cause of the pain, a small amount of anaesthetic is injected into the facet joint. If this reduces or moves pain, it indicates that the facet joint is the source of the pain.
Once it’s known that the facet joint is the source of the pain, therapeutic injections (anaesthetic and anti-inflammatory, usually time-release cortisone) may give relief for longer periods of time. The pain relief from a facet joint injection is intended to help the patient better tolerate other forms of treatment (such as physiotherapy) to rehabilitate their back injury.
Extra info:
Where pain is felt due to facet joint problems depends on which facet joints are affected:
• Cervical facet joints: pain felt in the head, neck, shoulder and/or arm
• Thoracic facet joints: pain felt in upper back, chest and/or arm (rarely)
• Lumbar facet joints: pain felt in lower back, hip, buttock and/or leg
Facet joints are made up of the two surfaces of adjacent vertebrae, which are separated by a thin layer of cartilage. The joint is surrounded by a capsule containing synovial fluid.
Facet joints can become painful due to arthritis of the spine, a back injury, or mechanical stress of the back.
An injection of a steroid medication is given into the facet joint, which anaesthetises the joint and blocks the pain.
There are two reasons for having facet joint injections:
1) For diagnosis
2) For pain relief
To determine if the facet joint is the cause of the pain, a small amount of anaesthetic is injected into the facet joint. If this reduces or moves pain, it indicates that the facet joint is the source of the pain.
Once it’s known that the facet joint is the source of the pain, therapeutic injections (anaesthetic and anti-inflammatory, usually time-release cortisone) may give relief for longer periods of time. The pain relief from a facet joint injection is intended to help the patient better tolerate other forms of treatment (such as physiotherapy) to rehabilitate their back injury.
Extra info:
Where pain is felt due to facet joint problems depends on which facet joints are affected:
• Cervical facet joints: pain felt in the head, neck, shoulder and/or arm
• Thoracic facet joints: pain felt in upper back, chest and/or arm (rarely)
• Lumbar facet joints: pain felt in lower back, hip, buttock and/or leg
Thursday, September 13, 2007
Treatment of Osteoarhtirits-Surgery
Several surgical options:
•Total Hip replacement or arthroplasty
•Arthroscopic levage or debridement
Using a small camera (arthroscope)Lavage-using saline to flush out blood, fluid or loose debris inside your joint- or Debridement-which removes loose fragments of bone or cartilage inside your joint- are performed. These procedures may provide short-term pain relief and improved joint function for some people, not really for severe osteoarthritis
•Repositioning bones or osteotomy
Surgeons can also reposition your bones to help correct deformities
•Fusing bones or arthrodesis
Surgeons also can permanently fuse bones in a joint to increase stability and reduce pain. The fused joint, can then bear weight without pain, but has no flexibility.
Total Hip Replacement At A Glance
• The prosthesis for a total hip replacement can be inserted into the femur bone with or without cement.
• Chronic pain and impairment of daily function of patients with severe hip arthritis are reasons for considering treatment with total hip replacement. Age important (usually for 60+ yo patients).
• Complication and risks of total hip replacement surgery have been identified.
• Preoperative banking of the blood of patients planning total hip replacement is considered when possible.
• Physical therapy is an essential part of rehabilitation after a total hip replacement.
• Patients with artificial joints are recommended to take antibiotics before, during, and after any elective invasive procedures (including dental work).
What is a total hip replacement?
• the diseased cartilage and bone i.e. the diseased acetabulum and femur, are replaced with a metal ball and stem (“prosthesis”) inserted into the femur bone, and an artificial plastic cup socket.
• prosthesis inserted into the central core of the femur, then fixed with a bony cement called methylmethacrylate. Alternatively, a "cementless" prosthesis is used which has microscopic pores that allow bony in growth from the normal femur into the prosthesis stem. "cementless" hip is felt to have a longer duration esp. good for younger patients
Who is a candidate for total hip replacement?
• performed most commonly b/c of progressively severe arthritis( esp. O/A) in the hip joint
• Other conditions leading to total hip replacement include bony fractures, rheumatoid arthritis, aseptic necrosis-caused by fracture, drugs-alcohol, prednisone, prednisolone, diseases-systemic lupus erythematosus
• The progressively intense chronic pain together with impairment of daily function like walking, climbing stairs and rising from a sitting position, eventually become reasons to consider a total hip replacement.
• Because replaced hip joints can fail with time, whether and when to perform total hip replacement are not easy decisions, especially in younger patients. Replacement is generally considered after pain becomes so severe that it impedes normal function despite use of antiinflammatory and/or pain medications
• 60s are good age. Surgeons unlikely to undertake operation earlier (i.e at 55 yo) b/c of 20% chance that prosthesis will fail within 10-12yrs
• A total hip joint replacement is an elective procedure, a decision made with an understanding of the potential risks and benefits.
What are the risks of total hip replacement?
• The risks of total hip replacement include blood clots in the lower extremities (pulmonary embolism), difficulty with urination, local skin or joint infection, fracture of the bone during and after surgery, scarring and limitation of motion of the hip, and loosening of the prosthesis which eventually leads to prosthesis failure.
• Because total hip joint replacement requires anesthesia, the usual risks of anesthesia apply and include heart arrhythmias, liver toxicity, and pneumonia.
What does the preoperative evaluation entail?
• Total hip joint replacement can involve blood loss, so patients planning to undergo Rx often will donate their own (autologous) blood to be banked for transfusion during the surgery.
• The preoperative evaluation: a review of all medications being taken by the patient, complete blood counts, electrolytes (potassium, sodium, chloride, bicarbonate), blood tests for kidney and liver functions, urinalysis, chest x-ray, EKG, and a physical examination.
• Any indications of infection, severe heart or lung disease, or active metabolic disturbances such as uncontrolled diabetes, may postpone or defer total hip joint surgery.
What will it be like for the patient after surgery?
• A total hip joint replacement takes two to four hours of surgical time
• After surgery, taken to a recovery room for immediate observation-one to four hours. The lower extremities closely observed for both sensation and circulation.
• Upon stabilization, the patient is transferred to a hospital room.
• During the immediate recovery period, patients are given intravenous fluids, to maintain a patient's electrolytes as well as for administering antibiotics.
• Pain control medications are commonly given through a patient-controlled analgesia (PCA) pump whereby patients can actually administer their own dose of medications on demand. Pain medications occasionally can cause nausea and vomiting. Anti-nausea medications may then be given.
• Immediately after surgery, patients are encouraged to frequently perform deep breathing and coughing in order to avoid lung congestion and the collapse of tiny airways in the lungs.
What is involved in the rehabilitation process after total hip joint replacement?
• After total hip joint replacement surgery, patients often start physical therapy immediately! Eventually, rehabilitation incorporates stepping, walking, and climbing. Initially, supportive devices such as walker or crutches are used.
• Physical therapy is extremely important in the overall outcome of any joint replacement surgery. The goals of physical therapy are:
o to prevent contractures-resulting from scarring of tissues around joint, loss ROM
o improve patient education
o strengthen muscles around the hip joint through controlled exercises.
o given home exercise programs to strengthen muscles around the buttock and thigh.
• Most patients attend outpatient physical therapy for a period of time while incorporating home exercises regularly into their daily living.
•Total Hip replacement or arthroplasty
•Arthroscopic levage or debridement
Using a small camera (arthroscope)Lavage-using saline to flush out blood, fluid or loose debris inside your joint- or Debridement-which removes loose fragments of bone or cartilage inside your joint- are performed. These procedures may provide short-term pain relief and improved joint function for some people, not really for severe osteoarthritis
•Repositioning bones or osteotomy
Surgeons can also reposition your bones to help correct deformities
•Fusing bones or arthrodesis
Surgeons also can permanently fuse bones in a joint to increase stability and reduce pain. The fused joint, can then bear weight without pain, but has no flexibility.
Total Hip Replacement At A Glance
• The prosthesis for a total hip replacement can be inserted into the femur bone with or without cement.
• Chronic pain and impairment of daily function of patients with severe hip arthritis are reasons for considering treatment with total hip replacement. Age important (usually for 60+ yo patients).
• Complication and risks of total hip replacement surgery have been identified.
• Preoperative banking of the blood of patients planning total hip replacement is considered when possible.
• Physical therapy is an essential part of rehabilitation after a total hip replacement.
• Patients with artificial joints are recommended to take antibiotics before, during, and after any elective invasive procedures (including dental work).
What is a total hip replacement?
• the diseased cartilage and bone i.e. the diseased acetabulum and femur, are replaced with a metal ball and stem (“prosthesis”) inserted into the femur bone, and an artificial plastic cup socket.
• prosthesis inserted into the central core of the femur, then fixed with a bony cement called methylmethacrylate. Alternatively, a "cementless" prosthesis is used which has microscopic pores that allow bony in growth from the normal femur into the prosthesis stem. "cementless" hip is felt to have a longer duration esp. good for younger patients
Who is a candidate for total hip replacement?
• performed most commonly b/c of progressively severe arthritis( esp. O/A) in the hip joint
• Other conditions leading to total hip replacement include bony fractures, rheumatoid arthritis, aseptic necrosis-caused by fracture, drugs-alcohol, prednisone, prednisolone, diseases-systemic lupus erythematosus
• The progressively intense chronic pain together with impairment of daily function like walking, climbing stairs and rising from a sitting position, eventually become reasons to consider a total hip replacement.
• Because replaced hip joints can fail with time, whether and when to perform total hip replacement are not easy decisions, especially in younger patients. Replacement is generally considered after pain becomes so severe that it impedes normal function despite use of antiinflammatory and/or pain medications
• 60s are good age. Surgeons unlikely to undertake operation earlier (i.e at 55 yo) b/c of 20% chance that prosthesis will fail within 10-12yrs
• A total hip joint replacement is an elective procedure, a decision made with an understanding of the potential risks and benefits.
What are the risks of total hip replacement?
• The risks of total hip replacement include blood clots in the lower extremities (pulmonary embolism), difficulty with urination, local skin or joint infection, fracture of the bone during and after surgery, scarring and limitation of motion of the hip, and loosening of the prosthesis which eventually leads to prosthesis failure.
• Because total hip joint replacement requires anesthesia, the usual risks of anesthesia apply and include heart arrhythmias, liver toxicity, and pneumonia.
What does the preoperative evaluation entail?
• Total hip joint replacement can involve blood loss, so patients planning to undergo Rx often will donate their own (autologous) blood to be banked for transfusion during the surgery.
• The preoperative evaluation: a review of all medications being taken by the patient, complete blood counts, electrolytes (potassium, sodium, chloride, bicarbonate), blood tests for kidney and liver functions, urinalysis, chest x-ray, EKG, and a physical examination.
• Any indications of infection, severe heart or lung disease, or active metabolic disturbances such as uncontrolled diabetes, may postpone or defer total hip joint surgery.
What will it be like for the patient after surgery?
• A total hip joint replacement takes two to four hours of surgical time
• After surgery, taken to a recovery room for immediate observation-one to four hours. The lower extremities closely observed for both sensation and circulation.
• Upon stabilization, the patient is transferred to a hospital room.
• During the immediate recovery period, patients are given intravenous fluids, to maintain a patient's electrolytes as well as for administering antibiotics.
• Pain control medications are commonly given through a patient-controlled analgesia (PCA) pump whereby patients can actually administer their own dose of medications on demand. Pain medications occasionally can cause nausea and vomiting. Anti-nausea medications may then be given.
• Immediately after surgery, patients are encouraged to frequently perform deep breathing and coughing in order to avoid lung congestion and the collapse of tiny airways in the lungs.
What is involved in the rehabilitation process after total hip joint replacement?
• After total hip joint replacement surgery, patients often start physical therapy immediately! Eventually, rehabilitation incorporates stepping, walking, and climbing. Initially, supportive devices such as walker or crutches are used.
• Physical therapy is extremely important in the overall outcome of any joint replacement surgery. The goals of physical therapy are:
o to prevent contractures-resulting from scarring of tissues around joint, loss ROM
o improve patient education
o strengthen muscles around the hip joint through controlled exercises.
o given home exercise programs to strengthen muscles around the buttock and thigh.
• Most patients attend outpatient physical therapy for a period of time while incorporating home exercises regularly into their daily living.
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