Orthopedic Impairment Physical Disabilities Lec.5 PDF

Orthopedic Impairment Physical Disabilities Lec.5 Dr.Sarkawt S.Kakai KHCMS(Ortho. & Trauma) Almost inevitable developments for most individuals. Routine activities of daily living stress the musculoskeletal system. In the geriatric population, osteoporotic weakening of bones becomes increasingly evi...

Orthopedic Impairment Physical Disabilities Lec.5 Dr.Sarkawt S.Kakai KHCMS(Ortho. & Trauma) Almost inevitable developments for most individuals. Routine activities of daily living stress the musculoskeletal system. In the geriatric population, osteoporotic weakening of bones becomes increasingly evident. Degenerative changes accumulate in joints over time. These forces may affect even the healthiest members of the adult population. Environmental and lifestyle factors may influence this process. Acute traumatic events can suddenly create an orthopedic problem. Osteoarthritis also known as degenerative joint disease (DJD), is the most common form of arthritis. It can be classified into two categories: primary osteoarthritis and secondary osteoarthritis. OA usually presents with joint pain and loss of function; however, the disease is clinically very variable and can present merely as an asymptomatic incidental finding to a devastating, permanently disabling disorder. OA Is common, affecting ~25% of adults. The prevalence increases with age. In the age group below 50 years, men are more often affected, while in the older population the disease is more common in women. Modifiable articular trauma occupation, repetitive knee bending muscle weakness large body mass metabolic syndrome Risk factors Non-modifiable gender females >males increased age genetics race African American males are the least likely Primary Osteoarthritis: absence of an antecedent insult. A strong genetic component with the disease primarily affecting middle-aged women Secondary Osteoarthritis: Involves a specific trigger that exacerbates cartilage breakdown. Common triggers for secondary OA include Injury: Bone fractures increase a person’s chance of developing OA and can bring about the disease earlier. Abnormal mechanical forces (e.g. occupational stress, obesity Inactivity Inflammatory Diseases: Perthes' disease, and all chronic forms of arthritis (e.g., costochondritis, gout, and rheumatoid arthritis) History of certain conditions eg Diabetes, Marfan Syndrome, Joint infection and Congenital disorders of joints Grading Inspection Physical exam & Imaging body habitus gait antalgic gait associated with knee arthritis compensatory toe walking limb alignment effusion skin (e.g. scars) Range of motion Ligament integrity Radiographs recommended views: weight-bearing views of affected joint Fracture A fracture is a discontinuity in a bone (or cartilage) resulting from mechanical forces that exceed the bone's ability to withstand them. Fractures can occur in a variety of methods: A normal bone subjected to acute overwhelming force, usually in the setting of trauma Weakened bone from a focal lesion (e.g. metastasis, or bone cyst), known as pathological fractures. Weakened bone due to metabolic abnormalities (e.g. osteoporosis) or less frequently, genetic abnormalities (e.g. osteogenesis imperfecta). Resulting in insufficiency fractures. Chronic application of abnormal stresses (e.g. running), resulting in microfractures and eventually, macroscopic failure (fatigue fractures). Must consider the location and severity of the injury. Fracture management Fortunately at least some fractures are relatively stable and can be treated symptomatically. Uncomplicated fractures of ribs or distal phalanges of the toes are often in this category. Other fractures are moderately unstable. Manipulation of the bone fragments may yield adequate positioning. (When done without surgery this is a closed reduction.) Maintaining alignment may require controlling the joint above and below Traditional plaster casting techniques been augmented by use of fiberglass material. The use of special braces for fracture care allows faster mobilization in some cases. Some fractures will be quite unstable without operative intervention Physical therapy program after immobilization Problem solving approach Strengthening exc. for weak muscles Stretching exc. For tight structures Mobilizing exc. For limited ROM in certain joints Balance exc. And co-ordination exc.s Gait training with and without assistive devices Orthosis and prostheses KNEE JOINT E X A M I NAT I O N Dr.Sarkawt S.K akai Motor knee flexion - sciatic nerve knee extension - femoral nerve Sensory N E U R O VA S C U L A R medial thigh - obturator nerve anterior thigh - femoral nerve posterolateral leg - sciatic nerve Pulses Popliteal, dorsal pedis, posterior tibial Reflexes: patellar (L4) Flexion 125-135 deg ROM Extension 0-10 deg hyperexension Rotation (stabilize femur) 10-15 deg internal and external tibial rotation ANT ERIOR CRUCIAT E LIGAMENT Anterior Drawer test Lachman test Pivot shift test ANT ERIOR CRUCIAT E LIGAMENT Posterior drawer flex knee to 90 deg, posteriorly directed force on tibia PCL Posterior sag place the patient supine, hip at 45 deg, and knee at 90 deg View the knee from the lateral position Quadriceps active C O L L AT E R A L L I GA M E N T S Valgus stress Medial force to knee at 0 and 30 deg Varus stress Lateral force to knee at 0 and 30 deg Joint line tenderness most sensitive test for meniscal tear when pain is present MENISCUS McMurray's test Place knee into flexion, and internal rotation, then extend the knee Pain or pop sensation indicates lateral meniscus tear Place knee into flexion, and external rotation, then extend the knee Pain or pop sensation indicates medial meniscus tear JOINT EFFUSION Mild Bulge test Moderate Patellar tab Sever Ballottement test PAT E L L O F E M O R A L JOINT Patella displacement translate patella medially or laterally divide patella into 4 quadrants patella should translate 2 quadrants in both directions Ankle joint examination Dr.Sarkawt S.Kakai ANKLE JOINT OSTEOLOGY tibial plafond medial malleolus lateral malleolus talus ANKLE LIGAMENT INTRODUCTION Medial Lateral Deltoid ligament Syndesmosis (includes AITFL, PITFL, TTFL, IOL, ITL) Calcaneonavicular ligament (Spring Ligament) Anterior talofibular ligament (ATFL) Posterior talofibular ligament (PTFL) Calcaneal fibular ligament (CFL) Lateral talocalcaneal ligament (LTCL) History Common reasons Pain Swelling Deformity Stiffness Instability Abnormal gait Steps in examination Consent Feel Exposure Gait analysis Look Move NV assessment Special tests Exposure Both shoes and socks off At least rolled up to the knees Preferably down to underwear Gait analysis Begins first Concentrate on sequence of movement Heel strike, stance, push off and finally swing Antalgic gait Equinus (tiptoe) gait Equinovarus (walking in outer border) Steppage gait Look Feel Move Syndesmosis injury External rotation test Gently rotate the foot externally while holding the leg still. Any tenderness would be positive for a syndesmosis damage. Squeeze test Squeeze the tibia and the fibula together to elicit tenderness. If present, this indicates a syndesmosis damage. ANTERIOR TALOFIBULAR LIGAMENT (ATFL) Anterior drawer in 20° of plantar flexion This is a provocative test done to check for the integrity of the ATFL. One hand holds the leg down, while the other hand pulls the foot upwards and anteriorly. It is important to compare one side with the other. The presence of tenderness or laxity on one side only indicates an ATFL rupture. CALCANEAL FIBULAR LIGAMENT (CFL) Forced Inversion (supination) This is a provocative test done to check for the integrity of the CFL. Forcefully invert the foot while keeping the leg still with the other hand. Make sure to compare side to side. Again, tenderness or laxity on one side indicate a CFL lesion. Achilles Tendon Rupture Squeeze Test or Thompson’s Test To confirm a suspected Achilles tendon rupture, have the patient lying prone and then squeeze the calf while observing the foot. If there is plantar flexion of the foot, this means that the tendon is intact. Otherwise, a reduced or absent plantar flexion, when compared with the other side, is indicative of a tendon rupture.