Below the Elbow, Below the Knee Orthopedics
Transcript of Below the Elbow, Below the Knee Orthopedics
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Below the Elbow, Below the Knee Orthopedics
Ted Parks, MD
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Disclosure of Financial Relationships
Ted Parks, MD
Has no relationships with any entity producing, marketing, or re-selling, or distributing health
care goods or services consumed by, or used on, patients.
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• Carpal Tunnel Syndrome • Trigger Finger • DeQuervaine’s Syndrome • Thumb basal joint arthritis (1st CMC OA) -------------------------------------------------------------------- • Morton’s Neuroma • Plantar Fasciitis • Bunions and Hammertoes • Ankle Sprains and Fractures
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Carpal Tunnel Syndrome
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Tendons • High content of: -collagen fibers -connective tissue matrix • Low content of: -cells -blood vessels -nerves • Low metabolic rate
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Nerve • Axons • Schwann cells (myelin) • Complex micro vascular system
• High metabolic rate
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Carpal Tunnel Symptoms
Pain Numbness Tingling
In the Median Nerve
Distribution!
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Carpal Tunnel Syndrome is Not: • Wrist pain (tendonitis, arthritis) • Glove like distribution of symptoms (peripheral
neuropathy) • Symptoms on the dorsal side of the hand (radial
nerve pathology) • Symptoms in the small and ring finger (ulnar
nerve pathology) • Symptoms that radiate up the arm (cervical
radiculopathy)
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Tinel’s Test
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Phalen’s Test
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Thenar Muscle Atrophy
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Etiology
• Trauma • Ergonomics • Arthritis • Pregnancy • Thyroid dysfunction
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Treatment
• Eliminate the source of swelling • NSAIDs • Braces • Cortisone injections
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Treatment
• Eliminate the source of swelling • NSAIDs • Braces • Cortisone injections
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Treatment
• Eliminate the source of swelling • NSAIDs • Braces • Cortisone injections
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Treatment
• Eliminate the source of swelling • NSAIDs • Braces • Cortisone injections
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Injection Site: Midline, 2cm distal to the distal wrist crease
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Possible Results of Injection:
• Patient is permanently better
• Patient gets no relief at all • Patient gets better, but symptoms return in
more than 4 months surgery • Patient gets better, but symptoms return in
less than 4 months Surgery vs. re-inject
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Surgery
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Surgery
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Surgery
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Trigger Finger
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Trigger Finger • Finger locks in the
flexed position
• Painful flexor tendon nodule
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Finger Anatomy
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Finger Anatomy
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Finger Anatomy
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Treatment Options
• Extension splint • NSAIDs • Cortisone Injection
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Cortisone Injection Technique: Inject midline, 2cm proximal to the MCP joint
crease
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Surgery
• Safe • Simple • Effective
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Surgery
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THUMB PAIN
De Quervain’s tendonitis vs
1st CMC joint arthritis
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Finklestein’s Test
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Arthritis at the Base of the Thumb
AKA: Basal joint arthritis, 1st CMC arthritis, Trapezio-metacarpal joint arthritis
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Surgery
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Common Foot and Ankle problems
• Morton’s Neuroma • Plantar Fasciitis • Bunions and Hammertoes • Ankle Sprains and Fractures
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Anatomy
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Anatomy
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Anatomy
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Anatomy
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Anatomy
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Anatomy
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Anatomy
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Morton’s Neuroma
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Morton’s Neuroma: Symptoms
• Pain: - may radiate to toes - “feels like a pebble” - worse with high heeled shoes • Numbness • Most = 3rd webspace
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Morton’s Neuroma
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Morton’s Neuroma: Symptoms
• Pain: - may radiate to toes - “feels like a pebble” - worse with high heeled shoes • Numbness • Most = 3rd webspace
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Morton’s Neuroma: Exam
• Splayed toes, fullness • Palpable plantar mass • Metatarsal shift test • Loss of sensation
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Morton’s Neuroma: other tests
• X-rays
• EMGs, NCS
• MRI
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Treatment: Conservative
Shoe modification •Wide
•Soft
•Low heel
Metatarsal supports
Cortisone injections
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Treatment: Conservative
Shoe modification •Wide
•Soft
•Low heel
Metatarsal supports
Cortisone injections
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Cortisone Injection
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Cortisone Injection
• Inject from dorsal side
• 1.5 cm proximal to web
• Between the metatarsal heads
• Go about 1cm deep
• 1cc steroid, 1cc lidocaine
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Treatment: Surgery
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Plantar Fasciitis
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History
• Most common ages 40 – 70 • More common in men than women • Running/Impact sports
Symptoms • Plantar heel pain • Often worse in AM
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Physical Exam
• Tender to palpation plantar heel
• r/o calcaneal stress fracture with “squeeze test”
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X-rays: The Bone Spur
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Bone Spur
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Treatment
NSAIDs
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Treatment
Calf stretches
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Treatment
Heel pads
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Treatment
Plantar massage
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Treatment
Night splints
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Treatment: Conservative
Short leg walking cast
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Treatment (controversial)
Cowboy boots
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Treatment (controversial)
E.S.W.T. (extracorporal shock wave
treatment)
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Cortisone Injection • Don’t inject the bottom of the foot
• Go medial, aim for the front edge of the calacneus, touch the bone
• 1cc steroid, 1cc lidocaine
• This shot hurts!
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Surgery
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Achilles Tendonitis
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Treatment • Calf stretches • Night splints • NSAIDS • Casting • Cortisone injections are NOT recommended • Surgical debridement (rare)
• Not associated with tendon rupture (unless injected)
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Bunions, Hammertoes and Corns
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Bunions
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Hammertoes
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Corns
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Corns
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Bunions and Hammertoes
• Very common • Often asymptomatic • Only need to treat if: - pain - skin breakdown
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Conservative Treatment: Devices
Stick on pads
(bunions and hammertoes) Toe spacers
Abduction braces Medial bunion pad
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Conservative Treatment
Orthopedic Shoes
• Wide, roomy toe box
• Soft
• Low heels
• Usually ugly
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Surgery
• Pain • Skin breakdown
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Ankle Injuries:
Sprains vs Fractures
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Ankle Injuries: Sprains vs Fractures
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Sprain vs Fracture?
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Ankle Sprain
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Ankle Sprain
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Ankle Sprain
Inversion Sprain (most common)
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Ankle Sprain
Treatment • R.I.C.E. (rest, ice, compression, elevation)
• Air cast (full time 4 weeks, sports 4 weeks) • Crutches (if needed for comfort) • Cast (3-6 weeks for severe cases)
• Wt bearing as tolerated
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Ankle Sprain
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Frank C, Woo S.L. et al, Am J Sports Med. 1983 Nov-Dec;11(6):379-89.
• Created ligament injuries in mice
• Compared immobilization to motion
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Motion Immobilization
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When sprains don’t get better…
• Expect some degree of pain, stiffness and swelling for 6 - 12 weeks
• If symptoms persist, consider: - calcaneus anterior process fracture - chondral injury to talus - failure of the ligaments to heal
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When sprains don’t get better…
Calcaneus anterior process fracture
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When sprains don’t get better…
Chondral injury of the talus
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When sprains don’t get better…
Inversion stress x-ray showing failure of lateral ligaments
to heal
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Ankle Fractures
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Ankle Fracture
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Ankle Fracture
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Ankle Fracture
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Sprain vs Fracture Should we get an x-ray?
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The Ottawa Rules
• Hx of trauma and malleolar ankle pain
and any one of: • Age greater than 55 • Inability to bear weight • Tender over posterior 6cm of medial or lateral malleolus
Stiell et al, Ann Emerg Med 1992; 21:384-390
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Ankle Injury
Ottawa Rules
Positive for fracture
Non wt bearing
Negative for fracture
Cast Surgery
R.I.C.E
Air cast
Crutches (PRN)
Cast (PRN)
Wt bearing as tolerated