orthoAffections of the Soft Tissues.pptx

presentation about soft tissue affections

1. Affections of the Soft Tissues

2. ETIOLOGY : Idiopathic Trauma Increased frictional forces Repetitve microtrauma Inflammatory disease Biomechanical compression Increased volume states such as during pregnancy

3. DIAGNOSIS : Mainly clinically. X ray imaging only in presence of associated fracture.

4. TREATMENT : A) Conservative treatment : treatment of choice Rest Splinting NSAID’S Physiotherapy : ultrasound and IFT(interferential therapy) Corticosteroid injection Platelet rich plasma B) Surgery : if patient does not respond to any of the conservative treatment methods.

5. 1) BURSITIS : A fluid-filled sac or saclike cavity, especially one countering friction at a joint. coined from latin “purse”. Inflammation may occur in a normally situated bursa or in an adventitious bursa. It may arise from mechanical irritation or from bacterial infection .

6. Two types of bursitis: 1) Irritative bursitis: This is the commoner of the two types : It is caused by excessive pressure or friction , occasionally due to a gouty deposit. Inflammation of the bursa results in the effusion of a clear fluid within the bursal sac. With prolonged inflammation, the sac gets thickened and may cause pressure erosion on the adjacent bone.

7. Prepatellar bursitis Infrapatellar bursitis

8. Olecranon bursitis Weavers bottom

9. TREATMENT : A) Conservative treatment : treatment of choice Rest Splinting NSAID’S Physiotherapy : ultrasound and IFT(interferential therapy) Corticosteroid injection Platelet rich plasma B) Surgery : excision of the bursa .

10. 2) Infective bursitis: Uncommonly , a bursa may get infected by a pyogenic or tubercular infection. It occurs commonly in trochanteric bursa or prepatellar bursa. Treatment is by surgical drainage and antibacterial drugs.

11. 2) TENOSYNOVITIS Inflammation of the thin synovial lining of a tendon sheath is termed tenosynovitis . It may arise from mechanical irritation or from bacterial infection.

12. a) Irritative tenosynovitis commonly seen in the tendons of the hand and results in pain and swelling. Eg:DQTS

13. TREATMENT : A) Conservative treatment : treatment of choice Rest Splinting NSAID’S Physiotherapy : ultrasound and IFT(interferential therapy) Corticosteroid injection Platelet rich plasma B) Surgery : excision of the inflammed tendon sheath .

14. b) Infective tenosynovitis is an infection of the synovial lining of the tendon by pyogenic or tubercular bacteria. Pyogenic infection is common in the flexor tendons of the hand. Tubercular tenosynovitis of the sheaths of the flexor tendons of the forearm at the level of the wrist occurs commonly (compound palmar ganglion).

15. 3) TENNIS ELBOW (Lateral epicondylitis ) This is a condition characterised by pain and tenderness at the lateral epicondyle of the humerus . It is due to non-specific inflammation at the origin of the extensor muscles of the forearm (SPECIFICALLY ECRB) . Although , it is sometimes seen in tennis players, other activities such as squeezing clothes, carrying a suitcase etc. are frequently responsible.

16. CLINICAL FEATURES Tenderness localised to the lateral epicondyle of the humerus . Pain is aggravated by putting the extensor tendons to a stretch By palmar -flexing the wrist and fingers with the forearm pronated . ( COZEN TEST ) Elbow movements are normal . X-ray does not reveal any abnormality.

17. TREATMENT : A) Conservative treatment : treatment of choice Rest Splinting NSAID’S Physiotherapy : ultrasound and IFT(interferential therapy) Corticosteroid injection Platelet rich plasma B) Surgery : excision of the degenerated portion of ECRB .

18. 4) GOLFER'S ELBOW ( Medial epicondylitis ) This is a condition similar to tennis elbow where the inflammation is at the origin of the flexor tendons at the medial epicondyle of the humerus . FLEXOR PRONATOR GROUP, MOST COMMON –FCR,PRONATOR TERES.

19. TREATMENT : A) Conservative treatment : treatment of choice Rest Splinting NSAID’S Physiotherapy : ultrasound and IFT(interferential therapy) Corticosteroid injection Platelet rich plasma B) Surgery : excision of the degenerated portion of FCR AND PRONATOR TERES .

20. 5) de QUERVAIN'S TENOSYNOVITIS (DQTS) This is a condition characterised by pain and swelling over the radial styloid process . It results from inflammation of the common sheath of abductor pollicis longus and extensor pollicis brevis tendons .

21. On examination, the tenderness is localised to the radial styloid process . Pain is aggravated by adducting the thumb across the palm and forcing ulnar deviation and on asking the patient to perform radial deviation against resistance ( Finkelstein's test ). There may be a palpable thickening of the sheath.

22. TREATMENT : A) Conservative treatment : treatment of choice Rest Splinting NSAID’S Physiotherapy : ultrasound and IFT(interferential therapy) Corticosteroid injection Platelet rich plasma B) Surgery : slitting and excision of a part of the tendon sheath. Thumb spica splint

23. 6) TRIGGER FINGER/THUMB This is a condition resulting from the constriction of the fibrous digital sheath , so that free gliding of the contained flexor tendon does not occur.

24. CLINICAL FEATURES Initially, the only symptom is pain at the base of the affected finger. As the sheath further thickens, the contained tendon gets swollen proximal to it.

25. The swollen segment of the tendon does not enter the sheath when an attempt is made to straighten the finger from the flexed position. This is called ‘locking of finger’. This locking can be overcome either by a strong effort in which case the finger extends with a snap-like trigger of a pistol or by extending the finger passively with other hand .

26. TREATMENT : A) Conservative treatment : treatment of choice Rest Splinting NSAID’S Physiotherapy : ultrasound and IFT(interferential therapy) Corticosteroid injection Platelet rich plasma B) Surgery : splitting of the tight tendon sheath may be required . . Thumb spica splint

27. 7) CARPAL TUNNEL SYNDROME (TARDY MEDIAN NERVE PALSY) This is a syndrome characterised by the compression of the median nerve as it passes beneath the flexor retinaculum .

28. CAUSES Any space occupying lesion of the carpal tunnel may be responsible. PREGNANCY

29. CLINICAL FEATURES A middle aged woman complaining of tingling, numbness or discomfort in the lateral three and half fingers i.e ., in the median nerve distribution. Tingling is more prominent during sleep.

30. Features of low median nerve compression like : Weakness of grip or pinch Thenar muscle wasting Loss of opposition of thumb Ape thumb deformity Dystrophic nail changes.

31. TESTS FOR CTS Phalen’s test : Palmar flexion of wrist for 60 secs Positive : Paresthesia in median nerve distribution

32. Durkans test Direct compression over median nerve for 30secs Positive : Paresthesia in median nerve distribution TESTS FOR CTS

33. Tinel’s sign Tapping over median nerve distribution. Positive : Paresthesia in median nerve distribution TESTS FOR CTS

34. Investigations : Nerve conduction studies show delayed or absent conduction of impulses in the median nerve across the wrist. EMG

35. TREATMENT : A) Conservative treatment : treatment of choice Rest Splinting NSAID’S Physiotherapy : ultrasound and IFT(interferential therapy) Corticosteroid injection Platelet rich plasma B) Surgery : by dividing the flexor retinaculum , and thus decompressing the nerve.

36. 8) ‘FROZEN ’ SHOULDER ( Periarthritis shoulder)/adhesive capsulitis This is a disease of unknown aetiology where the gleno -humeral joint becomes painful and stiff because of the loss of flexibility of the joint capsule, possibly with adhesions between its folds . Often, there is a history of preceding trauma. The disease is commoner in diabetics.

37. CLINICAL FEATURES It produces pain and stiffness of the shoulder. In early stages , the pain is worst at night, and the stiffness limited to abduction and internal rotation of the shoulder . Later , the pain is present at all times and all the movements of the shoulder are severely limited.

38. TREATMENT : A) Conservative treatment : treatment of choice Rest NSAID’S Physiotherapy : ultrasound and IFT(interferential therapy) Corticosteroid injection Platelet rich plasma B) Surgery : arthroscopic adhesiolysis .

39. 9) PLANTAR FASCITIS This is a common cause of pain in the heel . It occurs as a result of inflammation of the plantar aponeurosis at its attachment on the tuberosity of the calcaneum . The pain is worst early in the morning, and often improves with activity.

40. On examination, there is marked tenderness over the medial aspect of the calcaneal tuberosity , at the site of attachment of the plantar fascia.

41. TREATMENT : A) Conservative treatment : treatment of choice Rest FOOT WEAR MODIFICATION NSAID’S Physiotherapy : ultrasound and IFT(interferential therapy) Corticosteroid injection Platelet rich plasma B) Surgery : In volves  releasing part of the plantar fascia to release the tension and relieve swelling.. MCP FOOTWEAR

42. 10) PAINFUL ARC SYNDROME This is a clinical syndrome in which there is pain in the shoulder and upper arm during the mid-range of gleno -humeral abduction .

43. Common causes : Supraspinatus tendon m inor tears. Supraspinatus tendinitis Supraspinatus tendon c alcification Subacromial bursitis Fracture of the greater tuberosity

44. In all these conditions, the space between the upper-end of the humerus and the acromion gets compromised , so that during mid-abduction the tendon of the rotator-cuff gets nipped between the greater tuberosity and acromion . X-ray of the shoulder may show calcific deposit, or a fracture of the greater tuberosity or acromion .

45. TREATMENT : A) Conservative treatment : treatment of choice Rest NSAID’S Physiotherapy : ultrasound and IFT(interferential therapy) Corticosteroid injection Platelet rich plasma B) Surgery : excision of the anterior, often prominent part of the acromion .

46. 11) GANGLION It is the commonest cystic swelling on the dorsum of the wrist. It results from mucoid degeneration of the tendon sheath or the joint capsule. Ordinarily, there are no symptoms other than the swelling itself . Sometimes , a mild discomfort or pain is experienced . Aspiration of the cyst is performed and an injection of hylase given. If the cyst recurs, excision may be required.

47. 12 ) MERALGIA PARAESTHETICA This is a feeling of tingling, burning, and numbness in the skin supplied by the lateral cutaneous nerve of the thigh as it gets entrapped in the fascia just medial to the anterior superior iliac spine .

48. TREATMENT : A) Conservative treatment : treatment of choice Rest NSAID’S Physiotherapy : ultrasound and IFT(interferential therapy) Corticosteroid injection Platelet rich plasma B) Surgery : decompression of the nerve.

49. 13) DUPUYTREN'S CONTRACTURE ( Contracture of the palmar aponeurosis ) This is a condition characterised by a flexion deformity of one or more fingers due to a thickening and shortening of the palmar aponeurosis .

50. Etiology Idiopathic Average age around 60yrs Diabetes mellitus Alcoholism Smoking Epilepsy Cirrhosis Men > women (10:1) Trauma,inflammatory response,ischaemia .

51. PATHOANATOMY Normally, the palmar aponeurosis is a thin but tough membrane, lying immediately beneath the skin of the palm. Proximally , it is in continuation with the palmaris longus tendon . Distally , it divides into slips, one for each finger.

52. In Dupuytren's contracture , the aponeurosis or a part of it becomes thickened and slowly contracts, drawing the fingers into flexion at the metacarpophalangeal and proximal inter- phalangeal joints. The ring finger is the one affected most commonly. The contracture is generally limited to the medial three fingers. Sometimes, it may be associated with a thickening of plantar fascia or that of the penile fascia ( Peyronie's disease).

53. CLINICAL FEATURES In early stages, thickening of the palmar aponeurosis is felt at the bases of ring and little fingers . Later, a flexion deformity of the fingers develops .

54. TREATMENT Surgery is the mainstay of treatment Percutaneous fasciotomy Fasciectomy Segmental aponeurectomy Total f asciectomy and digital z plasties Dermo fasciectomy * fasciectomy  is the surgical removal of part of the fascia. fasciotomy   is the cutting of the fascia to relieve tension or pressure (and treat the resulting loss of circulation by an area of tissue or muscle)

55. Salvage procedures : amputation(PIP joint flexion >70 degrees,recurrence of disease) dorsal wedge osteotomy of proximal phalanx,

56. arthrodesis of PIP joint, arthroplasty of PIP joint

57. Conservative : Those unwilling for surgery Physiotherapy (early disease) Calcium channel blockers (early disease) Collagenase for (advanced disease) Trypsin and hyaluronidase (enzymatic fasciotomy ) Steroid injection Local gamma interferon injections

58. Treatment of Orthopaedic Disorders: A General Review

59. Questions in exams Short wave diathermy Bone bank Subtrochantric osteotomy Bone graft Arthrodesis Ankylosis Arthroplasty Arthroscopy

60. Orthopaedic treatment can be broadly divided into NON-OPERATIVE AND OPERATIVE.

61. NON-OPERATIVE METHODS OF TREATMENT Rest Drugs Support Manipulation Radiotherapy Physiotherapy

62. A) REST : To the affected limb Since olden times, rest has been the mainstay of orthopaedic treatment. It helps in reducing inflammation and pain.

63. B) DRUGS a ) Analgesics anti-inflammatory : non-steroidal anti-inflammatory drugs (NSAIDs) and steroids . b) Antibacterial drugs : septic arthritis, acute osteomyelitis etc. c ) Hormones: The main drugs in this group are anabolic steroids, estrogens (for osteoporosis) and stilbesterol (for metastasis from prostate ).

64. Contd : d) Specific drugs: e.g., vitamin D for rickets, vitamin C for scurvy, etc. e) Cytotoxic drugs: These are used in the treatment of malignant bone tumours. f) Local injections of a depot preparation of hydrocortisone or methylprednisolone are used to control non-specific inflammation of a joint or an extra- articular lesion like tennis elbow.

65. C) SUPPORT : Temporary support with a splint made from Plaster of Paris or other splinting material .

66. orthosis : A limb or a joint not capable of functioning because of inadequate muscle power needs support (e.g., a polio limb). Prosthesis: A permanent or prolonged support, in the form of life time appliances (e.g., a amputated limb).

67. D) MANIPULATION passive movements of joints, bones or soft tissues are carried out with or without an anaesthetic , and often forcefully, as a deliberate step in treatment. ( i ) correction of deformity. eg ., CTEV

68. (ii) improving the range of movement of a stiff joint eg ,. Frozen shoulder (iii) relief of chronic pain in or about a joint. Eg,. tennis elbow ,low back ache.

69. E) RADIOTHERAPY a) Malignant tumours : Ewing's sarcoma is a highly radiosensitive malignant bone tumour. Radiotherapy is also used for other malignant tumours , either pre or post surgery. b) Benign tumours : Giant cell tumours of the bone which are unsuitable for excision can be irradiated . c) Other conditions: Recalcitrant ankylosing spondylitis .

70. F) PHYSIOTHERAPY : May be used as a primary treatment modality (e.g., for backache etc.) or secondary with other methods of treatment (e.g., post-operative physiotherapy).

71. Types : Ice therapy Heat therapy : surface heat deep heat Exercise Tractions Massage Hydrotherapy Occupational therapy ( i ) hot water bottle (rubber-bottle) (ii) warm bath (iii) hot soaks or compresses (iv) infra-red lamp (v) wax bath. ( i ) shortwave diathermy (ii) ultrasonic therapy (iii) microwave.

72. Ice therapy: beneficial during the first 24-72 hours after injury. causes relief in pain , reduces haematoma formation and reduces inflammation. Reduced blood flow Muscle spasm

73. Heat therapy: produces soothing effect by increasing the blood flow, and decreases joint stiffness, reduced pain and relieving muscle spasms . Heat must not be applied to insensitive or ischaemic skin, and if there is underlying acute infection or neoplastic tissue .

74. Heat therapy: Depending upon the depth of penetration of the heat, surface heat i.e., only the skin and subcutaneous tissues are heated deep heat i.e. deeper structures are heated

75. a) Surface heat: ( i ) hot water bottle (rubber-bottle ) ( ii) warm bath ( iii) hot soaks or compresses ( iv) infra-red lamp (v ) wax bath.

76. b) Deep heat: ( i ) shortwave diathermy (ii ) ultrasonic therapy ( iii) microwave.

77. Short wave Diathermy : ( dia - ‘through’ + thermon ‘heat ’.) it is a therapeutic modality most commonly used for rheumatoid arthritis and osteoarthritis. The term diathermy refers to the creation of heat using electrical pulses . In diathermy, a high-frequency electric current is delivered via shortwave, microwave, or ultrasound which is able to generate deep heat in body tissues. The heat can be used to improve circulation and/or to relieve pain. In addition, shortwave diathermy can be used for treating damaged tissues and relaxing muscles.

78. Exercise therapy: These are given for three purposes : ( i ) to mobilise joints ( ii) to strengthen muscles ( iii) to improve coordination and balance .

79. Tractions: traction is applied: ( i ) to separate joint surfaces while giving passive movements to a joint; ( ii) to obtain the relaxation of muscles which are in spasm (e.g., by giving cervical or lumbar traction) ( iii) to correct deformities by gentle continuous traction.

80. Massage: This is a systematic and scientific manipulation of the skin and the underlying soft tissues which gives rise to relief of pain and the relaxation of muscles . Myofascial release Muscle energy techniques

81. Hydrotherapy: The principles of buoyancy help to reduce pain by relaxation of the muscles, mobilisation of stiff joints, and thereby assist in the development of muscle power.

82. Occupational therapy: Occupational therapy aims at enabling the person to become as independent as possible, inspite of the disability he may have . a) Activities of daily living (ADL): self care, bathing, eating, wearing clothes etc. b) Work related activities: employment related and home management related activities . c) Leisure time activities: sports and social activities.

83. OPERATIVE METHODS OF TREATMENT Internal fixation/external fixation Osteotomy Arthrodesis Arthroplasty Arthroscopy Bone grafting Tendon transfer operations Excision of tumours Amputations Around joints

84. OPERATIVE METHODS OF TREATMENT INTERNAL FIXATION : for closed displaced fracture tibia intramedullary nailing or plating EXTERNAL FIXATION : for open displaced fracture tibia external fixation for tissue healing ILIZAROV FIXATION /LRS : for infected tibia non union

85. OSTEOTOMY : It means the cutting of a bone. Indications : To correct excessive angulation, bowing or rotation of long bone . To correct mal-alignment of a joint.

86. To permit elongation or shortening of a bone in cases of leg length inequality. Special indications e.g., McMurray's osteotomy for non union neck of femur.

87. ARTHRODESIS ( arthro – joint desis -fuse) In this operation, fusion is achieved between the bones forming a joint so as to eliminate any motion at the joint . An arthrodesis is used most often for a painful, stiff joint . It is also performed for grossly unstable joints in polio a stiff, painful ankle may be more disabling than an arthrodesed (fused) ankle (stiff but painless ).

88. Types of arthrodesis : intraarticular , extra-articular or combined In an intra-articular arthrodesis, the articulating surfaces are made raw and the joint immobilized in the position of optimum function until there is a bony union between the bones.

89. In an extra-articular arthrodesis , an extra-capsular bridge of bone is created between the articulating bones. This acts as a block to movement. Triple arthrodesis ( talocalcaneal, calcaneo -cuboid and talo -navicular) is one of the most commonly performed arthrodesis.

90. Position of arthrodesis of different joints: The best position of arthrodesis of a joint is the one that conforms to the requirements of the patient's work.

91. ARTHROPLASTY : ( arthro – joint plasty –moulding /formation of specified part) An arthroplasty is ‘construction’ of a new movable joint . Indications: used for painful joints where joint mobility is desirable. It is commonly performed for : ( i ) osteoarthritis of the hip and knee; (ii) ankylosis of the elbow; and ( iii) un-united femoral neck fracture.

92. Types of arthroplasty

93. a) Excision arthroplasty: In this type, one or both of the articular ends are excised so that a gap is created between them. The fibrous tissue that fills this gap, by virtue of its flexibility, provides movement at the joint. Commonly in hip and elbow.

94. b) Hemiarthroplasty or half joint replacement: In this type , only one of the articulating surfaces is removed and is replaced by a prosthesis of a similar type. The prosthesis is made of metal , silicon or rubber. Commonly , it is performed for fractures of the neck of the femur in elderly people (e.g., Austin-Moore hemiarthroplasty ).

95. Total replacement arthroplasty: Both the apposing articulating surfaces are excised and replaced by prosthetic components . Commonly , it is performed for hip osteoarthritis – Total hip replacement (THR).

96. BONE GRAFTING pieces of bone taken from some part of a patient's body are placed at another site. It is usually required for stimulating bone formation in a case of nonunion of a fracture, or for filling bone defects. A bone stimulating protein called bone morphogenic protein (BMP) is liberated from bone grafts. This helps in osteogenesis .

97. Indications: ( i ) non-union of fractures – to promote union; ( ii) arthrodesis of joints – to achieve fusion between joint surfaces; and ( iii) filling of bone defects or cavities in a bone .(traumatic bone loss or tumor excision)

98. Type of bone grafts: three types autograft (from the same person)  MOST COMMON allograft (from another person of the same species ) xenograft (from a different species ). Artificial bone graft substitutes muscle-pedicle bone graft free vascularized bone grafting

99. Autogenous grafting: This is the ‘gold standard’ technique. Cancellous bone grafts : When the graft is required for osteogenic purpose (as in non-union). Iliac crests are the commonest site and upper end of tibia. Cortical graft : When the graft is used for providing stability (as for filling bone gaps) Fibulae are the common source of cortical bone grafts.

100. Newer techniques of autogenous bone grafting : the vascularity of a graft is preserved while it is being placed on its receptor area . muscle-pedicle bone graft : bone graft is taken along with a pedicle of muscle. The muscle (with its intact blood supply) continues to supply blood to the graft For treating non-union of fracture of the neck of the femur .

101. free vascularized bone grafting : the bone (usually fibula) is taken along with the vessels supplying it. It is placed at the new site, and its vessels anastomosed to a nearby vascular bundle.

102. Allogenous grafting: when enough bone is not available from the host e.g., where a big defect is created following a tumour resection . Allogenous graft from live donors could be,for example, from the mother when larger amount of bone graft is required for a child.

103. Xenografting : Bone grafts from other species, usually bovine are now available off the shelf. These are available in tailor made sizes. Their use is not common yet.

104. Artificial bone: This is a material derived from corals. Coral , which closely resembles human bone in structure, has been among the most promising substitutes for bones. It is hydroxyapetite with porous structure. It is supposed to have osteo -conductive potential, and is being used in some countries.

105. BONE BANK Hospitals performing tumour excision surgery in a big way have a regular department procuring bones from patients and cadavers, processing it and storing it .

106. Why we need bone bank ….????? the use of tissues from musculoskeletal tissue banks has increased significantly within orthopedics over recent years. There are several reasons for this: 1 ) impossibility of obtaining large quantities of autologous bone; 2 )  morbidity  at the graft harvesting site; 3 ) increased numbers of revision procedures on  hip and knee arthroplasties and 4 ) development of new surgical techniques that depend on homologous bone.

107. TRAUMA : with the progressive increase in the numbers of cases of high-energy injuries and the growing rates of segmental bone loss and  pseudoarthrosis .

108. TUMORS : In cases of resection of bone segments because of malignant tumors, one of the options is to use massive homologous grafts for limb reconstruction.

109. ARTHRODESIS : including spinal arthrodesis, is a surgical procedure in which the volume of grafting material needed frequently leads to the use of homologous bone.

110. PEDIATRIC ORTHOPEDICS : in correction of scoliosis, arthrodesis on the foot and treatment for congenital pseudoarthrosis , among others.

111. It is a noble act of the highest order to donate one’s body for the greater good of humanity. Lakhs of patients get a new life every year thanks to bones and organs that are donated by such selfless individuals. However, the sad part is that India is currently going through a massive bone shortage. In 2013, India’s premier hospital All-India Institute of Medical Sciences (AIIMS) said that they have had only 12 or so cadaver donations in over a decade. A similar shortage is also seen at the Tata Memorial Hospital in Mumbai which is the country’s premier cancer research institution.

112. EXCISION OF TUMOURS ( i ) intra- lesional excision : The lesion is curetted from within , as done for a simple bone cyst ; ( ii) extra- lesional excision: The lesion is removed along with its wall ( iii) wide excision : The lesion is removed with a margin of normal tissue. ( iv) radical excision: The tumour is removed along with the whole compartment in which it lies .

113. TENDON TRANSFER OPERATIONS Insertion of the tendon of a functioning muscle is moved to a new site, so that the muscle, henceforth, has a different action. The transfer operation is planned in such a way that loss of the transferred muscle's original function does not cause problem.

114. Indications: ( i ) muscle paralysis – to restore or improve active control of a joint by utilising a healthy muscle to act in place of a paralysed one (e.g., in nerve palsy);

115. (ii) muscle imbalance – to restore the balance between opposite groups of muscles in case one is weaker than the other (e.g., in polio)

116. (iii)Traumatic rupture of a tendon – in cases where direct suture is not practicable.

117. Thank you