Orthopedics PDF

Orthopedics Primary roles: protect and support soft tissue, attachment site for muscles, store minerals, produce red blood cells in bone marrow Bone growth is influenced by nutrition (calcium, phosphorus, and vitamin D) and hormones (insulin growth like factor,...

Orthopedics Primary roles: protect and support soft tissue, attachment site for muscles, store minerals, produce red blood cells in bone marrow Bone growth is influenced by nutrition (calcium, phosphorus, and vitamin D) and hormones (insulin growth like factor, human growth hormone, thyroid hormones, and sex hormones to close epiphyseal plates) ○ Issues: too much hGH can lead to gigantism and too little hGH can cause a short stature Soft tissue basics ○ Atrophy: wasting away of muscles by disuse or denervation (muscle loses the nerve) ○ Hypertrophy: muscles increase in number and diameter ○ Skeletal muscle starts to convert to connective or adipose tissue starting at 30. With an increased age comes a slowing of reflexes, reduction of max strength, and flexibility Abnormal contractors ○ Spasm: involuntary contraction of single muscle(s) ○ Cramp: painful spasmodic contraction (because of a lack of potassium and/or water) ○ Tic: involuntary twitch of muscles (often in face or eyelid) ○ Tremor: Rhythmic, involuntary, purposeless co-contraction of contracting muscles ○ Fasciculation: involuntary twitch of multiple motor units that are visible beneath the skin (seen with ASL) ○ Fibrillation: involuntary twitch of a single motor unit that is NOT visible beneath the skin Abnormal Curves of the Spine ○ Kyphosis: anterior to posterior thoracic curvature (“hunchback) ○ Lordosis: extreme exaggeration with the lumbar curvature (pregnant women) ○ Scoliosis: s-shaped curve in the thoracic spine ○ Rotoscoliosis: torsion couple with curve Etiology: traumatic injuries, sports, falls (leading cause), rheumatic diseases, aging Orthopedic conditions Rickets CAUSE Lacking calcium/vitamin D in childhood SXS Soft bone, deformities of skull, legs, rib cage, pelvis and teeth, muscle cramps, stunted growth (epiphyseal plates close too soon) TREATME Calcium diet to correct deformities NT Genu valgum: knees are knocked Genu varum: bow legged Windswept deformity: both legs go laterally to one side Osteomalacia CAUSE Lacking calcium/vitamin D in adulthood SXS Soft bone, prone to fracture, bone pain in lower extremities, muscle weakness TREATME Increased vitamin D in diet (salmon) and increased sun exposure  NT Paget’s Disease CAUSE Unknown (may be viral); there is an issue with the recycling process and the bones are built faster than they should be SXS Excessive bone formation and breakdown, located in the spine, femur, or skull, very high ratio of spongy to compact bone TREATME Calcitonin and bisphosphonates NT Osteopenia CAUSE Unknown, genetic, malnourishment, associated conditions SXS Reversible weakening of bone TREATME Calcium enriched diet and supplements, weight bearing activities, and bone density screens NT Osteoporosis CAUSE Progressive osteopenia that is irreversible SXS Early on there is none; later there is pain, kyphosis, height loss, skeletal function TREATME none NT HIGH RISK Women, history of falls, quadriceps weakness, postural instability INCIDENC 1:2 women will have a fracture related to osteoporosis whereas 1:4 men will have. This is because when E women go through menopause there is decreased estrogen Heterotopic Ossification CAUSE Unknown, abnormal bone formation in soft tissues (there are bones in muscles); spontaneous onset but could also be because of trauma or surgery SXS Pain, warmth at joint, edema, redness, induration (changes to tissues beneath the surface), decreased range of motion with a bony end feel TREATMENT Iontophoresis, range of motion, pain management COMORBIDITI Neurological issues  ES PREVALENCE Elbow fracture: 90% chance Hip fracture: 50% chance Only ⅓ have functional limitations Spina Bifida CAUSE Birth defect due to incomplete closure of bone/membrane around the spinal cord. Happens prenatally SXS Myelomeningocele: leg weakness/paralysis, orthopedic issues, bladder/bowel issues, neurological issues Meningocele: small sac or gait immobility Occulta: may have no issues FRACTURES: trauma to a bone or joint Fracture classifications ○ Bone ends: displaced or nondisplaced ○ Complete or incomplete break ○ Linear or transverse break on the long axis ○ The bone goes through the skin its compound. If it simple then the bone does not break the skin Fracture types ○ Closed (simple): the bone does not go through the skin ○ Open (compound): the bone breaks the skin ○ Transverse: complete, occurs at a right angle of the bone ○ Comminuted: multiple bone fragments ○ Greenstick: incomplete, bend that causes the other side to break off ○ Stress: repetitive use ○ Hairline: incomplete, small ○ Spiral: from torsional force or twisting Symptoms: localized pain at site, deformity, edema (swelling), ecchymosis (discoloration, a few days after the incident) Incidence: falls are the leading cause of fractures in older adults, falls are the leading cause of nonfatal injuries, the most common fractures from falls are hip, wrist and humerus, vertebrae and pelvis (44% of all fractures involve a distal radius Hip Fractures A primary cause of disability and mortality in older adults (1 in 5 older adults die in the first year post hip fracture); there is a chance someone may not return to baseline An avulsion is a possibility (the muscle is pulled off the bone) CAUSE Fall and fracture proximal femur SXS Referred pain in knee, unable to bear weight on affected leg, leg-length discrepancy Extracapsular (involves trochanters) and intracapsular (involves femoral neck) TREATME Surgery: closed reduction and immobilization (does not cut open and can fix from the outside), open NT reduction and internal fixation (ORIF, cut open and fix things internally), hemiarthroplasty (replace the femoral neck and head with a metal prosthesis), total hip replacement (the acetabulum is replaced and resurfaced, replace the ball of the femur, lasts 10-25 years) *precautions: hip flexion should not be more than 90 degrees (can’t bring knee to chest OR chest to knee), hip rotation (no rotation at all), hip adduction (abduction is fine, replacement is on the lateral side so adduction would pull it in a bad way), sleep on back with pillow between legs, keep leg extended when going from sitting to standing. Humeral Fractures 20% have a loss of wrist extension or loss of feeling because of damage to the radial nerve, 70-90% gain function back after 4 months (both sensory and motor) CAUSE Osteoporosis, aging, injury SXS Humeral displacement and location, distal end: supracondylar fracture (elbow, can lead to HO), loss of wrist extension and dorsum hand sensation in around ⅕ cases TREATME Closed reduction (manual), open reduction and internal fixation (ORIF), sling, immobilization and NT mobilization schedule varies *Supracondylar fractures: humeral fracture that occurs above medial and lateral condyles and often affects muscles, nerves, and arteries. There is a high risk of malunion (no rejoining) and Volkmann’s deformity which is caused by severe trauma leading to damage to forearm muscles and lack of blood flow. Volkmann’s deformity is classified by pain, pallor, pulselessness, paralysis, and paresthesia. Distal Radius Fracture CAUSE Falling on outstretched hand SXS Loss of sensation, strength, and range of motion Classified based on articular and/or ulnar involvement, soft tissue involvement, and displacement TREATME Closed reduction (manual), open reduction and internal fixation (ORIF), splint or cast, immobilization NT and mobilization schedule varies based on physician Scaphoid Fracture CAUSE Wrist hyperextension is greater than 90 degrees and radial deviation, common in sports injuries SXS Pain and tenderness that intensifies when trying to pinch or grasp objects, vascular necrosis TREATME Non-displaced: non-surgical and requires a thumb spica splint for 10 weeks. If it is more proximal you NT could have to wear it for longer Displaced: surgical and requires bolts, screws and need a splint for 2-4 weeks. A person who gets surgery will be much stronger than a person who doesn’t Post-operative fracture considerations: edema, range of motion and tightness (tightness is because of swelling), nerve compression (numbness, tingling, decreased function), tendon rupture ○ Complex regional pain syndrome (CRPS): CNS and PNS are not working properly because there are issues in communication between limb, brain, and spinal cord Must be chronic (longer than 6 months) post-injury affecting ONE limb (if it is bilateral it is not CRPS) SXS: burning, throbbing, aching pain and changes in skin color, temperature, and swelling in the affected area CRPS-I: there is no confirmed nerve injury  CRPS- II: know there is nerve involvement Upper Extremity Orthopedics Basics of the shoulder joint: there is a decreased stability for increased mobility, it is a ball and socket joint Shoulder problems ○ Rotator cuff disorder: pain located in the upper lateral arm with possible weakness and dysfunction. This is the most common shoulder disorder Acute: possible tear Chronic: tear or inflammation, notice over months that you are losing function, range of motion, and strength Bursitis (inflammation of the bursa) A bursa is a cushion between bones and tissues to reduce friction CAUSE Excessive use SXS Inflammation of subacromial bursa (under the acromion) that is painful and swollen. This is often associated with rotator cuff tendonitis TREATME Activity modifications NT Tendonitis (inflammation of a tension) CAUSE overuse SXS Pain, inflammation. It is associated with bursitis Common in: rotator cuff and biceps tendon TYPES Acute: happens due to an accident Chronic: wear and tear from aging, degenerative issue like arthritis Tendon Tearing CAUSE Sudden injury, degenerative changes, long term use SXS Sharp pain audible pop, weakness, bruising, cramping, common in biceps, rotator cuff Partial: part of tendon is still intact Complete: tendon is pulled away from bony structure TREATME Non surgical: think that it will heal over time on its own, NSAIDs NT Surgical: have pain that doesn’t resolve Impingement  CAUSE Acromion puts pressure on underlying soft tissues when shoulder is abducted or flexed SXS Pain, decreased range of motion; could cause bursitis or tendonitis TREATME Soft tissue management, range of motion, joint mobilizations NT Instability CAUSE Sudden injury or repetitive use SXS Pain, frequent dislocation, feelings of shoulder “giving out” or “just hanging there”. Can be partial or complete (dislocation), there is a risk for developing arthritis TREATME Non-surgical: modifying activities, anti-inflammatories, therapies NT Surgical: often necessary, have to be immobilized afterward Fracture CAUSE Floor level falls, sports injuries, motor vehicle accident SXS Pain, swelling, bruising at should , deformity, grinding sensation TREATME Non-surgical: immobilization, NASIDs NT Surgical: compound or displaced fracture If not rehabbed appropriately, range of motion and strength can be affected Thoracic Outlet Syndrome CAUSE Trauma, repetitive use, pregnancy, anatomical differences, poor posture. The shoulder and chest muscles are weakened so the clavicle slips down which compresses the blood vessels and nerves in the superior thoracic outlet SXS Pain in shoulders and neck, numbness and tingling, and coldness in the fingers, weakened grip, thumb atrophy TREATME Non-surgical: rest, activity modification, OT/PT NT Surgical: anatomical difference, muscle is cutaway to make more space; could cause a brachial plexus injury ELBOW Medial Epicondylitis (Golfer’s elbow) CAUSE inflammation of medial tendon of elbow due to repetitive use of wrist and forearm  SXS Usually dominant hand, radiating pain from medial elbow down forearm, weakness, pain, stiffness TREATME NSAIDs, rest, ice, ROM, taping, OT/PT NT RISKS playing throwing sports, playing instrument, painting TRIGGERS shake hands, turn doorknob, pick up object with palm down Lateral Epicondylitis (Tennis elbow) CAUSE inflammation of lateral tendon of elbow due to repetitive use of wrist and forearm SXS Usually dominant hand, pain or burning on lateral side of elbow, weak grip strength TREATME NSAIDs, rest, ice, ROM, brace, steroid injections, OT/PT, don’t really do surgery because it can be NT treated conservatively RISKS plumbers, carpenters, painters, mechanics, chefs, butchers TRIGGERS shake hands, turn wrench, holding a racket/garden hose Ulnar Collateral Ligament (UCL) Rupture CAUSE repetitive use, fall on outstretched arm SXS pain at medial elbow, “pop” after throwing, point tenderness, swelling, inability to throw/perform activity, numbness in ring/pinky fingers TREATME Non-surgical: NSAIDs, ice, rest NT Surgical: Tommy John Surgery, take a tendon from somewhere else TYPES Partial or complete (pain in medial part of the elbow) Posterior Olecranon Osteophyte CAUSE formation of bone spurs on posterior olecranon SXS pain in elbow with no mechanism of injury, decreased ROM, catching or locking of elbow joint with movement TREATME Surgery to remove bone spurs and debridement of osteophytes, PT/OT NT RISKS manual labor jobs, athletes Elbow Dislocation CAUSE fall on outstretched arm SXS Partial - pain with ROM, “shifting”, tingling/numbness Complete - deformity, extreme pain, NO ROM (arm can’t flex or extend) TREATME Non-surgical - relocation and possible immobilization NT Surgical - repair ligaments, external hinge TYPES Partial - relocates on its own Complete - does not relocate on its own; has to be manually set Radial Head Fracture CAUSE fall on outstretched arm or in conjunction with elbow fx, damage to the bone itself SXS pain on lateral elbow, swelling, decreased ROM, decreased supination & pronation TREATME Type I: non-surgical rest + sling for days; be mindful of movement NT Type II: surgery to remove bone fragments + sling for weeks Type III: surgery to remove bone & repair ligaments + OT/PT Olecranon Bursitis CAUSE direct injury, prolonged pressure, infection, other medical problems (gout, RA) SXS painful elbow, edema, redness, warm skin TREATME Non-surgical: antibiotics for infection; suck out fluid; modify activities, NSAIDs NT Surgical: takes bursa out, use splint RISKS jobs or activities that require prolonged prop on elbows Elbow arthritis Elbow Arthritis Less likely to occur than knees because they don’t carry as much weight CAUSE breakdown of cartilage on articulating surfaces of bones SXS pain, decreased ROM, locking/grating sensation, edema TREATME Non-surgical - NSAIDs, OT/PT, corticosteroids NT Surgical - arthroscopy or joint replacement Ulnar Nerve Entrapment (cubital tunnel syndrome) CAUSE subluxed nerve, prolonged pressure, swelling, direct injury; ulnar nerve gets pinched/trapped  SXS pain, numbness in elbow, hand or wrist, weakened grip, atrophy of hand musculature, reduced FM coordination TREATME Non-surgical: special pillow, brace, NSAIDs NT Surgical: cubital tunnel release, transposition ulnar nerve, medial epicondylectomy WRIST Pediatric deformities: 1/20 kids are born with orthopedic differences in their hand ○ Syndactyly: some fingers/toes united; webbing ○ Thumb duplication: second complete or partial thumb ○ Hypoplastic thumb: thumb is underdeveloped ○ Radial club hand: wrist radial deviation; missing all or part of fingers ○ Failure of formation of upper limb Radiocarpal Joint Disorders Carpal Tunnel Syndrome CAUSE increased pressure or entrapment of the median nerve at wrist; genetics, pregnancy SXS numbness, tingling, and pain in fingers, hand and arm; gradual onset, often complaints at night, lose proprioception and can’t realize what their hand is doing ASSESS Positive Tinel Sign TREATME Non-surgical - NSAIDs, bracing/splinting, steroids, activity modifications, nerve glides NT Surgical - cut the ligament to create more space RISKS repetitive hand use, hand/wrist positioning, pregnancy, genes De Quervain's Tenosynovitis CAUSE overuse of wrist causes irritation of sheath around APL and EPB tendons to your thumb, or scar tissue; comorbid with rheumatoid arthritis SXS pain and swelling at base of thumb, deceased thumb movement, trouble grasping objects ASSESS Positive Finkelstein Test TREATME Non-surgical: NSAIDs, splint full time, steroids, activity modifications, ice/heat NT Surgical: cut sheath around tendon, then OT/PT RISKS child rearing (picking up the child), pregnancy, carpenter, mechanic Ganglion Cysts CAUSE Unknown SXS small lump, painless, noncancerous lump often by tendons/joints in wrist or hand, becomes painful when a nerve is compressed  ASSESS Positive Tinel Sign TREATME Non-surgical: typically resolves on its own NT Surgical: may need to be drained or removed MCP Joint Disorders Swan-Neck Deformity: MCP joint FLEXED, PIP joint EXTENDED, DIP joint FLEXED (not seen in the thumb because there aren’t three joints) CAUSE rheumatoid arthritis SXS mallet finger at DIP, limited mobility, pain TREATME Non-surgical: splinting, HEP, ROM, OT/PT, NSAIDs NT Surgical: soft tissue surgery or finger joint fusion for stability Boutonniere Deformity: MCP joint EXTENDED, PIP joint FLEXED, DIP joint EXTENDED (not seen in the thumb because there aren’t 3 joints) CAUSE forceful blow to dorsum of bent PIP or slicing of central slip tendon, arthritis SXS PIP can’t be straightened, DIP cannot be bent, swelling & pain at PIP TREATME Non-surgical - splinting, HEP NT Surgical - if there is a tendon that is severed or a compound fracture or splinting doesn’t work Dupuytren Contracture Progression is very slow Tender nodule develops in the palm → Superficial cord forms resulting in contractures in MCP and IP joints → Hand becomes arched → Fibrous thickening develops on PIP joints CAUSE unknown, but something triggers the fascia of the palm to thicken and it eventually tightens which reduces hand function SXS lumps, nodules, and cords which leads to contractures that pull fingers inward, toward the palm TREATME Non-surgical: splinting, steroids NT Surgical: fasciotomy or subtotal palmar fasciectomy RISKS diabetes, alcoholism, epilepsy Neck and Back Orthopedics Orthopedic disorders of the neck ○ Can be acute or chronic and can be due to injury or trauma, genetics, degenerative diseases, posture, position  ○ Acute neck pain is caused by sleeping in a weird position, sports injury, poor posture, repetitive movements, prolonged isometric contraction during activity, whiplash ○ Chronic neck pain (more than 3 months) is caused by Cervical Degenerative Disc Disease, Cervical herniated disc, Cervical osteoarthritis, Spinal stenosis, Foraminal stenosis Cervical Degenerative Disc Disease: wear and tear on cervical spine, discs become less hydrated which results in decreased cushioning and shock abortion, caused by aging because the discs are no longer able to be rehydrated long term symptoms are herniated disc, pinched nerve facet joints changes and arthritis Cervical Herniated Disc CAUSE Nucleus pulposus (inside of vertebral disc) leaks out through a tear in disc’s outer layer SXS none, pain & numbness in arm TREATMENT Non-surgical: NSAIDS, rest, modalities, exercises, OT/PT Surgical Cervical Osteoarthritis CAUSE Aging leads to increase stiffness in discs and abnormal growths for on bones of neck, break down of bone or cartilage SXS Pain, stiffness, decreased range of motion, headache (pain pattern because of stiff muscles), crepitus TREATMENT Non-surgical: rest breaks, activity modification (not worth it to do surgery) Spinal Stenosis CAUSE narrowing of spinal canal which compresses the spinal cord, most common in the cervical spine because of mobility SXS pain & numbness, possible myelopathy (weakness and decreased coordination in arms or legs), impaired bowel and bladder function TREATMENT Non-surgical: OT/PT, NSAIDs Surgical: cervical decompression (cut out the bone to give more space for the spinal cord) Spinal Stenosis CAUSE narrowing of spinal canal which compresses the spinal cord, most common in the cervical spine because of mobility SXS pain & numbness, possible myelopathy (weakness and decreased coordination in arms or legs), impaired bowel and bladder function TREATMENT Non-surgical: OT/PT, NSAIDs Surgical: cervical decompression (cut out the bone to give more space for the spinal cord) Foraminal Stenosis CAUSE Narrowing of cervical disc space at one nerve root on ONE side SXS Intermittent localized pain, weakness, numbness TREATMENT Non-surgical: modify activities but it’s not very helpful Surgical: traction (blocks foramen), decompression surgery Back Pain ○ Caused by inflammation, osteoarthritis, whiplash, herniated disc, compression fracture, scoliosis, stenosis, work-related injuries ○ Work related back injuries are caused by overstretching of ligaments and muscles in the back, ex: improper lifting, carrying, pulling or pushing, twisting, unexpected exertion, slips or falls Common injuries: Herniated discs, Muscle strains or sprains, Tension-Neck Syndrome (non specific pain in the neck, arm, or shoulder), Rotator Cuff Tendinitis, Shoulder Impingement Syndrome, Thoracic Outlet Syndrome Whiplash CAUSE sudden jerking forward and back of head results in trauma to muscles and ligaments in neck SXS neck pain, decreased mobility, spasms, vision changes, nausea, migraine headaches TREATMENT Non-surgical: NSAIDs, OT/PT Surgical: would only need surgery if muscles tear which would also probably result in trauma to the brain/spinal cord Thoracic or Lumbar Herniated Disc CAUSE Nucleus pulposus leaks out through a tear in disc’s outer layer SXS none, pain & numbness in buttocks, legs or feet TREATMENT Non-surgical: rest, NSAIDs, modalities, massage, exercise, steroids, OT/PT Surgical Compression Fracture CAUSE Structural collapse of vertebrae SXS Pain, widow’s hump TREATMENT Non-surgical: rest, heat (ideal) Surgical: there would be multiple vertebrae with compression fractures Lower Extremity Orthopedics KNEE Largest, most complex joint, at least 12 bursae which increases the risk for bursitis Ligaments ○ Extracapsular: ligamentum patellae, MCL, LCL, oblique popliteal, prevents hyperextension ○ Intracapsular: ACL, PCL, prevents anterior-posterior displacement Knee Injuries CAUSE lateral blows, excessive twisting STRUCTURES meniscus & ACL are most common AFFECTED EVALUATION Anterior Draw Sign → tibia can move forward from the femur (ACL damage) Posterior Draw Sign → tibia moves posteriorly and the femur stays fixed (PCL) TREATMENT Surgery (healing is very slow) Knee Bursitis CAUSE direct blow, fall on knee, chronic pressure SXS inflammation, swelling, warm, tender, increased fluid TREATMENT Non-infected: rest, ICE, NSAIDs, Infected: Antibiotics, aspiration, surgery RISKS prolonged kneeling, certain sports, obesity ANKLE Joint is the strongest in dorsiflexion and weakest in plantarflexion Plantarflexion and inversion are the cause of most ankle injuries (lateral ligaments) Ankle ligaments ○ Lateral ligament: anterior talofibular ligament, posterior talofibular ligament, calcaneofibular ligament, prevents inversion ○ Medial ligament: deltoid ligament, prevents eversion Ankle sprains ○ Most common injury: inversion sprains ○ Most common structures affected: calcaneofibular ligament, anterior talofibular ligament Arthritic Diseases Joint inflammation, overarching diagnosis for 100+ conditions Inflammatory vs. noninflammatory: the main difference is how it breaks down the synovium ○ Inflammatory: Chronic inflammation of synovium (otherwise healthy), Swelling, Redness, Warm + tender joints, Autoimmune response, ex: rheumatoid arthritis ○ Non-inflammatory: Chronic inflammation of synovium, Usually occurs later in life, Mechanical breakdown, ex: osteoarthritis  Juvenile Idiopathic Arthritis: must occur prior to 16 years old, group of diseases present for months to years, 5 total types, does not carry over into adulthood ○ SXS: arthritis, joint tissue swelling and stiffness, fever, rash, contracture and disfigurements ○ Male to female ratio - from 1:2 to 1:3, more common in Caucasian ○ Better prognosis overall, but increased likelihood of depression in childhood ○ Oligoarticular: involves one side of body, most common, 4 or less BIG joints, girls more affected ○ Polyarticular: involves both sides of body, 5 or more small joints, girls more affected ○ Psoriatic: red, flaky patchy rash, pain/swelling, involves multiple joints, girls more affected Rheumatoid Arthritis CAUSE untreated synovitis and tenosynovitis with the addition of an infection results in an inflammatory response which leads to an immune reaction (an autoimmune disorder) SXS swelling and warmth around joints, redness, presence of pannus (makes soft tissue self destruct), BILATERAL (will always be bilateral but not symmetrical), malaise, fever, weight loss (loss of muscle mass, decrease in bone density, not as much nutrient uptake, depression), symmetrical or asymmetrical, joint guarding, decreased ROM (because of swelling), abnormal gait, balance, worst first thing in the morning Common joints affected: MCP and proximal IP joints (effects smaller joints with less cartilage and more synovial fluid) CATEGORIES before 16 years OR 25-50 years old PREVALENCE 1% worldwide; no gender/race bias SKELETAL subchondral cysts, erosions of sinuses in joints, presence of osteophytes, severe periarticular FEATURES bone fragmentation, ulnar deviation of MCP joints (hallmark of RA in hands), traces in cartilage supporting bone tissues of MA joint, osseous ankylosis (stiffening), BILATERAL joint involvement TYPES Single joint: rare, bilateral elbows Polyarticular: most common, multiple surfaces, fatigue, and overall weakness Remit: flare ups then to baseline Progressive: steady deadline Seropositive: worse prognosis, have rheumatoid factor Seronegative: less chronic progressive, cremitive ASSESS physical examination, use of diagnostic criteria, blood work, synovial fluid testing, MRI/x-ray, tissue biopsy AGE OF ONSET 25-50 years old PROGNOSIS Gradual onset, 20% of people go into remission, varies a lot Remission: 2 consecutive months with 5 plus requirements (women are more common than men), can be spontaneous or because of drugs COMPLICATIONS contractures, subluxation, ankylosis, dislocation, adhesions  COMORBIDITIES Depression (17%) TREATMENT DMARDs: disease modifying anti-rheumatic drugs, first thing that is tried because it has the highest chance of remission, ex: methotrexate Biological agents: help suppress immune system, prevent joint damage and decrease joint inflammation, ex: TNF (humera) Steroids: “buffer” between drugs Surgery: less-invasive vs. more-invasive, remove synovial fluid, remove RA nodes, joint replacement GOALS Reduce pain + joint stiffness, Reduce edema, Preserve normal joint function + musculature, Minimize medication interactions, Promote normal growth + development, Maintain ADL independence DISEASE PROCESS Acute: fever, decreased range of motion and strength, stiffness, gel phenomenon, weight loss Subacute: mild fever, decreased range of motion and strength, morning stiffness, decreased endurance, gel phenomenon Chronic active: decreased range of motion, strength, poor endurance Chronic inactive: decreased range of motion, muscle atrophy, worse endurance, contractures Osteoarthritis CAUSE genetics and environmental, aging, chondropenia (lose cartilage faster than the body can replace it), noninflammatory SXS localized pain, palpable edema, point tenderness, stiffness, inflammation of bones and joints, ASYMMETRICAL involvement, weight bearing joints + hands most affected, crepitus during ROM, in bigger, weight bearing joints PREVALENCE 10-15% of worldwide ASSESS patient history, MRI/x-ray, leg length discrepancy, anatomical bony abnormalities ONSET Gradually over years TYPES Primary: general wear and tear, no known cause Secondary: external injury or disease PROGNOSIS “silent” or traumatic, joint location TREATMENT NSAIDs, CINODs, joint replacement surgeries RISKS Caucasian, women, obesity COMORBIDITIES depression, GI issues (comes from medication) Fibromyalgia CAUSE unknown SXS widespread CHRONIC severe pain, tender points, NO inflammation, headaches, malaise, poor sleep, abdominal cramps, mood disorder, from the waist up PREVALENCE 1-5% worldwide, women more affected than men (US is 3:1) ASSESS patient history, physical examination, no genetic or blood test can be done WPI: frequency and location of pain/point tenderness symptom severity scale (SSS): level of fatigue and cognitive drain The symptoms remain at these levels for 3+ months AND WPI score of 7+ and SSS 5+ OR WPI score of 3-6 and SSS 9+ ONSET Widespread or unilateral, can start unilateral then go bilateral TYPES unilateral or bilateral PROGNOSIS Unclear TREATMENT NSAIDs, opioids, antidepressants RISKS aging COMORBIDITIES OA, RA, depression Gout CAUSE crystallization and build up of uric acid in the joint (hyperuricemia) SXS rapid onset, joint specific pain, warmth, swelling, reddish discoloration, tenderness, “attacks” that last hours to days, intermittent, tophi PREVALENCE 1-4% worldwide 8.3 million in US ASSESS medical history, physical exam, blood work, MRI/x-ray/CT ONSET 30 - 50 years old TYPES Most common in big toe 1st metatarsal TREATMENT diet low in purines, NSAIDs, xanthine oxidase inhibitors (XOI), comprehensive planning (diet) RISKS Men, african american COMORBIDITIES Insulin resistance syndrome, hypertension, renal damage, depression Burns Skin anatomy: epidermis (thin, nonvascularized, epithelial cells, 25% of skin, top layer, body temperature regulation, erection of waste, makes vitamin D), dermis (75% of skin, blood vessels, hair follicles, sweat glands, nerve endings, barrier for bacteria, prevents moisture loss), subcutaneous tissue (fat, below dermis) Wound healing process 1. Hemostasis: stop bleeding (clot) 2. Inflammatory: cells come to clean up the wound 3. Proliferative: rebuilding of cells a. Connective tissue deposits b. Contraction (rebuild tissue) c. epithelia is rebuilt 4. Maturation: collagen reorganizes itself Primary factors for burns: temperature and time exposed Zones of burns (tells how much damage is done) ○ Coagulation: brunt of the heat, innermost, most damage, irreversible ○ Status: decreased perfusion, surrounding coagulation, moderate damage, can be saved but effort is needed ○ Hyperemia: decreased perfusion, outermost, minimal damage, has potential to survive Prognosis: the depth and surface area of the burn determines the healing rate and success Classifying burns by depth Superficial Burn DEGREE 1st LAYERS Epidermis only APPEARANCE Redness, dry, blanches, no blisters SXS Painful and very sensitive to air and light touch CAUSES Sunburn, flash from explosion, mild burn HEALING 3-4 days, no scarring COMPLICATIO none NS Superficial Partial-Thickness Burn DEGREE 2nd LAYERS Epidermis and papillary dermis (thinner) APPEARANCE Weeping (oozing), wet skin, blanches (turns white then red/skin color), clear blisters SXS Painful to touch  CAUSES Peeling sunburn HEALING 2-3 weeks, no scars but pigment changes COMPLICATI Local infection and fluid loss ONS Deep Partial-Thickness Burn DEGREE 2nd LAYERS Epidermis and entire dermis, the hair follicle is spared APPEARANCE White, no blanching, bloody blisters, moist skin SXS Very painful to touch because of the nerve endings that originate in the dermis CAUSES Heat, electricity, chemicals HEALING More than 3 weeks, scarring (at risk for contractures) COMPLICATI Local infection and scarring and contractures ONS Full- Thickness Burn DEGREE 3rd LAYERS Epidermis, entire epidermis, and subcutaneous tissue APPEARANCE Charred black, bright red, tan, or pearly white, fragile blisters, dry, leathery SXS Insensate but can feel deep pressure because the nerve endings are burned, high risk of contractures CAUSES heat , friction, electricity, chemicals HEALING Requires skin graft, months to years, body can’t heal on its own COMPLICATI Systemic infections, septus, pneumonia, organ failure, scarring and contractures ONS Deep Full-Thickness Burn DEGREE 4th LAYERS All skin layers and tendon, muscle, or bone APPEARANCE Charred or mummified, eschar (dead skin/tissue)  SXS Insensate, but can feel deep pressure, difficult to heal, possible loss of function, may require amputation, contractures CAUSES Heat, friction, electricity, chemicals HEALING Requires skin graft, months to years COMPLICATI Amputation, functional impairment and death ONS Additional issues: Burn shock, Hypermetabolism, Inhalation injury, Infection, Scars, Contractures ○ Burn shock: happens when more than 20% TBSA is burned, occurs within 48-72 hours of initial injury, due to loss of fluid or plasma in the blood (but not the blood itself) Body’s response: capillaries open to increase fluid into the interstitial fluid which causes swelling this results in decreased cardiac output, decreased intravascular volume inside the blood vessels, and an increased peripheral vascular resistance Less than 25% total body surface area burned: edema is localized to burned area More than 25% total body surface area burned: edema is not localized to burned area, affects the whole body ○ Infection: the body’s biggest protection against infection is compromised which means they are more prone to infection and more prone to death, the burn symptoms are very similar to the infection symptoms (high white blood cell count, tachycardia, fever), use burn specific indicators plus have 3 or more additional symptoms Infection indicators: Temperature, Progressive tachypnea (high respiratory rate), Progressive tachycardia, Thrombocytopenia (low platelet levels), Hyperglycemia (elevated blood sugar), Enteral feeding intolerance ○ Scars: formation begins when the wound begins to close (fibrous tissue replaces missing tissue) Hypertrophic: a lot of collagen, raised and red, stay within the borders of burn Keloid: raised and red, very tender and painful, have a lot of fibrous tissue, extend beyond the borders of the burn, can be hard to treat Increased scarring risks: Genetically predisposed, African ethnic origin, Burns located in mobile regions or at joints (trunk, wrist, knees) Contractures: occurs from tightening and shortening of the burn scar (webbing), greatly impacts function, the symptoms are painful, disfiguring, itchy, and do not stretch. Most commonly located over large joints like the elbow. 40% of burn scars become contractures Inhalation injuries SXS facial burns, singed nose hair, hoarse voice, wheezing, dark oral mucosa, hypoxia, cough ASSESS Fiberoptic bronchoscopy COMPLICATI CO toxicity: CO2 binds to red blood cells instead of oxygen ONS Cyanide toxicity: hydrogen cyanide releases when household products get hot, if inhaled it affects oxygen’s ability to bind to hemoglobin (no O2 leads to suffocation) 20% increase in mortality rate and increased risk of pneumonia if inhalation injury is comorbid with burn TREATMENT Primary goal is oxygenation, ideal oxygen is 100%  Interventions: bronchial hygiene therapy, chest PT, airway suctioning, early mobility, mechanical ventilation, escharotomy (slit in the burn to release pressure), toxicities, the earlier they get up and moving the better the outcome Hypermetabolism CAUSE Prolonged stress response SXS Increase of cytokines, insulin, and catecholamines in the body, an increase in hormones results in an increase in metabolism EFFECT Increased energy consumption/use increased protein turnover, causes a breakdown of muscle and fat *nutritional management: primary goal is to get the body calories, need increased calories to get adequate nutrition to decrease risk of infection or death, the interventions are NG tube (through the nose), G tube, TPN (IV fluid that is high in calories and can be used for a long period of time) Assessment ○ Lund-Browder Scale: manually adds areas of the body that are burned and is determined by age and weight, limited accuracy and time consuming ○ Rule of Nines: areas of 9%, user error and overestimates ○ Rule of Palms: that patient’s palm is 1% of the body’s surface area, user error and overestimates ○ Knowing the percentage helps determine treatment and how much fluid the patient needs ○ Assessments on the rise: Laser Doppler scanning, Histological assessments, Indocyanine green fluorescence ○ Additional assessments All injuries: Full blood count (look at everything in the blood, if hematocrit is greater than 55% the bloodstream is missing a lot), Urea and Electrolyte concentration (hyponatremia and hyperkalemia), Clotting screen (is there coagulation) Electrical injuries: 12 lead electrocardiogram (is there arrhythmia), Cardiac enzymes (tells myocardial injury) Inhalation injuries: Chest x-ray (aspiration, trauma, smoke in lungs), Arterial blood gas analysis (carbon monoxide) Treatment ○ Fluid Resuscitation: primary goal is to replace fluids loss from burn (keep the blood volume), secondary goal is to oxygenate tissues and organs, Crystalloid (lactated Ringer solution). Various formulas where the purpose is to determine how much fluid a patient needs and is calculated based on BURN SIZE + BODY WEIGHT Too much: fluid creep, fluid goes in places it isn’t wanted, increased edema, ARDS (limit lung expansion), compartment syndrome (could lead to amputation), multiorgan failure Not enough: hypoperfusion (blood doesn’t go where is needs to), shock (hypovolemia), renal failure ○ Debridement: Surgical removal of non-viable and non-adherent tissue, Prevent dermal ischemia, Inclusion of medication (sedatives, analgesics (pain management), anxiolytics) ○ Hydrotherapy: Use water to decontaminate and clean wound bed (whirlpool, showering), Time-limited, Temperature regulated (around 85 degrees) ○ Dressings  Burn Dressings: Should be non-adhering and absorbent (telfa pads), serve as barrier and help absorb fluids Topical Dressings: serve as barrier , facilitate gas exchange, increase comfort and retain moisture, “moist but not wet!” ○ Excision: remove bad tissue and close up tissue as soon as possible (24-48 hours after burn), reduce blood loss and decrease risk of infection ○ Grafting: graft areas are based on size, location, and function (hands take priority, face and ears take a long time to heal), use the epidermis and the dermis Autograft: “the real deal”, person’s own skin in unharmed area, permanent, results in wound at donor site Allograft: “skin substitute”, another living or deceased person, temporary, lasts 7-12 days (for an emergency), used until an autograft can be used Mesh graft: small holes throughout, expandable, custom sized, more bang for buck, snakelike, crosshatch appearance, large areas of the body, skin is run through a machine to stretch it out to cover more surface area Sheet graft: no holes, kept intact and laid directly over, more aesthetically pleasing, smooth, cosmetic appearance, doesn’t go far, used on the hand or face Skin grafts: Cultured epithelium (costly, fragile, prone to infection, >50% TBSA), Epidermal substitutes (only a few layers thick, it’s not put anywhere functional because they don’t have all human characteristics, Alloderm, Biobrane), Stem cells Treatment post-graft: Immobilize the grafted area in a functional position and wait until there is confirmed circulation, Elevate extremity to prevent edema, Begin ROM 4-6 days post-op (Varies by MD) Amputations Most common cause: diabetes and peripheral artery disease (lack of circulation). Most common amputation: leg above or below the knee Basics: removal of limb due to trauma, disease, or medical issues, can be corrective (trauma) or preventative, 1.8 million Americans Types: ○ Lower extremity: hemipelvectomy (entire half of the body, take out the pelvis), hip disarticulation (preserve pelvis), above the knee (lose the joint), knee disarticulation (entire femur is intact), below the knee, ankle disarticulation (keep ankle joint), partial foot amputation (big toe) ○ Upper extremity: shoulder disarticulation and forequarter amputation (whole arm, clavicle, and scapula), above the elbow (lose the elbow joint), elbow disarticulation (entire humerus is intact), below the elbow, wrist disarticulation, metacarpal amputation (wrist stays intact), partial hand amputation (digits) Reasons: circulatory disorders (diabetes, gangrene, peripheral artery disease), neoplasms (cancers, liposarcoma, osteosarcoma, chondrosarcoma, melanoma), infection (osteomyelitis, diabetes, frostbite), birth defects (deformities of digits/limbs, extra digits/limbs), trauma Preparation: requires spinal anesthesia or general anesthesia ○ Priority: remove unhealthy tissue while preserving healthy tissue as much as possible ○ Considerations for the limb: Pulse, Temperature, Sensation, Color Procedure: Remove unhealthy tissue and bone, Shave and smooth uneven bone, Cauterize blood vessels and nerves, Shape musculature of stump to promote prosthesis attachment Recovery: Closed (the goal, use existing skin to close it) vs. open (might have to go in later to remove more) amputation, Covered with sterile dressing (reduce infection), Use of drains,  traction or splinting, Dressing changes, Pain and infection management, Promote healing (4-8 weeks for healing) Complications: Joint deformity, Residual limb pain, Phantom limb issues, Hematoma, Infection, Wound opening, Tissue death, DVT, PE ○ Phantom limb: Sensation coming from a body part that is no longer there Originates in CNS due to issue with remapping (Damaged nerve endings, Scar tissue, Memories), Can improve over time or be incredibly debilitating Predictors: Premorbid pain, Residual limb pain, Poor-fitting prosthesis Phantom sensation: cold, warm, tingly, or itchy Phantom limb pain: shooting, stabbing, boring, squeezing, throbbing, or burning, feels it is in an uncomfortable position, often affects most distal portion of amputated limb (hand or foot), possibly triggered from pressure on intact part of limb, can be intermittent or constant Managing sensations: medication management (nerve pain medications, NSAIDs, opioids, depression medication), therapeutic exercise (make the limb feel engaged) acupuncture, guided meditation and imagery, massage, relaxation and deep breathing mirror therapy, TENS, virtual reality Therapy services: residual limb shrink/shape, desensitization, scar management, wound care, prosthesis training, TENS, strengthening and ROM, ADL/IADL retraining, assistive device/limb training, emotional support and adjustment Prosthetics ○ Fitting: Temporary prosthesis (4-6 weeks post-amputation, begins once swelling reduce and incision healed, complete trials with device on), Final prosthesis (3+ months post-amputation, additional prostheses long term) ○ Components: socket, strap or harness, sleeve or liner, mechanical components, terminal device Lifestyle changes: healthy eating, smoking cessation, weight loss, exercise regularly Pain Chronic pain: any pain lasting more than 12 weeks, may arise from initial injury or ongoing condition, incredibly subjective, can impact any part of the body Side effects: Decreased appetite (aren’t doing a lot so calories aren’t burned), Fatigue, Sleep disturbance, Mood changes, Decreased mobility (can lead to atrophy, blood clots, pressure ulcers, obesity, bone density, falls/fractures), Decreased strength, Decreased endurance Treatments: reduce pain and increase function, Medications, Acupuncture, Electrical stimulation/TENS, Nerve blocks, Surgery, Psychotherapy, Biofeedback, Behavior modification Medications ○ Nociceptive: NSAIDs, opioids ○ Neuropathic: AEDs, COX-2 inhibitors, tricyclic antidepressants (Zolof), SSRIs/SNRIs Self management of pain: Patient takes ACTIVE role in managing pain, understanding that patient needs help learning how to “think, feel and do better” to lead a productive life, encouraged to problem-solve, ask questions and make decisions regarding their pain management, empower person to be an advocate Nociceptive Pain CAUSE Damage to body tissues, nerve receptors in tissues send pain signals to the CNS DESCRIPTO Sharp, aching, or throbbing, crushing, constant, stabbing, dull, shooting, intermittent RS  TYPES radicular: the nerve root is irritated (the nerve root is a body tissue) Somatic: receptors in muscle or skin, mainly with movement, localized, (ex: headache, paper cut, cuts, bruises) visceral: inside, internal organs, vague SOURCE Torn muscles, benign pathology, cancer, tumor Neuropathic Pain CAUSE Damage to nerves, damage to the nerve itself causes typical pain symptoms DESCRIPTO Burning, numbness, tingly, heavy, crushing, constant, stabbing, dull, shooting, intermittent RS TYPES Paresthesia: specific, numb/tingling Allodynia: non painful stimuli become painful (ex: the wind hurts) Hyperalgesia: very sensitive SOURCE Spinal tumor, alcoholism, diabetes, SCI, ABI, chemotherapy, rheumatic diseases, HIV