Orthopedics for primary care - PowerPoint Presentation

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Orthopedics for primary carethe whirlwind tour

Michael Patney, DO, FAOAO

Coastal OrthopedicsSlide2

Location Based diagnosis and treatment

Shoulder

Fractures/trauma

Overuse injuriesagingElbowFractures/traumaOveruse injuriesAging Wrist/hand Fractures/traumaOveruse injuriesAging

Hip

Fractures/trauma

Overuse injuries

aging

Knee

Fractures/trauma

Overuse injuries

Aging

Ankle/foot

Fractures/trauma

Overuse injuries

AgingSlide3

Fractures in GeneralOpen – skin is broken over the fracture to any extent

Graded based on mechanism and location

Most open fractures are urgencies

should be handled within 8 hoursRequire wash out and stabilizationNot all treatment requires the surgical suiteFinger tip, toe and grade 1 fractures can be washed out in the ED or office with secondary follow upStabilization can be in many formsBrace, splint, cast, external fixation, plates & screws and rodsSlide4

Fractures in GeneralClosed – skin and soft tissue envelope remain closed around the fracture

Reduction

Depends on several factors

Patient comfortProvider comfortEase or availability of referralExperience and trainingImmobilizationTemporizing or definitive treatmentDepends on type of fracture and deformityBrace, splint, cast, surgical referralSlide5

Dislocations in General

Dislocations are urgencies

Rapid reduction improves outcomes

One of 5 general orthopedic urgency/emergencyCompartment syndromeDislocationOpen fractureAdvancing myelopathyPelvic fracture with hemodynamic compromiseOnce reduced is no longer an urgencyShould be immobilizedFollow up referral to assess for surgical stabilization is recommended.Slide6

Shoulder

Fracture

Humerus

Common fractures in the surgical neckMore common in the elderlyCan usually be treated with short immobilization and progressive PTX-ray utilized for diagnosis most commonlyClavicleVary in location along clavicleVary in age distributionFixation is more commonly recommendedCertain types and age groups still treated with immobilization

X-ray utilized for diagnosis most commonlySlide7

ShoulderFracture

Scapula

Associated with high energy injuries

Associated with pulmonary contusion and fractured ribsOccurs at all agesUsually treated conservativelyCT necessary to assess for type of fracture and associated injuriesOveruseSubacromial bursitisDiagnosed by clinical exam and x-rayConservative treatment Surgical treatmentTopical NSAID/oral NSAID arthroscopy

Corticosteroid injection open debridement

Physical TherapySlide8

ShoulderOveruse – continued

Rotator cuff strain

Diagnosed by clinical exam and x-ray

Treatment with rest, ice, NSAID and possible injectionNo surgical treatment for acute strain aloneBicep tendonitisDiagnosed by physical examNSAID and corticosteroid both effective in treatmentRotator cuff tearDiagnosed by physical exam and confirmed by MRIPhysical therapy will improve pain but not strengthSurgical repair of the cuff is recommended to avoid long term sequelaeSlide9

ShoulderAging

Arthritis becoming more prevalent with aging population.

Acromioclavicular arthritis

Can lead to rotator cuff tear in late stagesPain with cross chest testDiagnosed by physical exam and x-rayTreated with NSAIDs and injection initially, surgery in recalcitrant casesGleno - humeral arthrosisPain with ROM of shoulderDiagnosed by physical exam and x-rayTreated with NSAIDs and injection initially, surgery in recalcitrant casesSlide10

Elbow

Fractures

Humeral

Diagnosed with physical exam and x-rayShaft fractures usually treated with Sarmiento braceRod is also an option for early mobilizationDistal humeral fractures can be treated closed with immobilization if non-displaced; otherwise they almost always require surgical fixationRadial head fracturesDiagnosed with physical exam and x-rayImpacted fractures are treated with early ROMDisplaced fractures treated with surgical fixation or replacementSlide11

Elbow

Ulna

Usually olecranon fracture

Diagnosed with physical exam and x-rayDisplacement requires surgical fixationNon-displaced fractures can be treated with immobilizationOveruseMedial/lateral epicondylitisMedial = golfers elbowLateral = tennis elbowComes from straining of the tendon origin of the muscle wad at the elbowDiagnosed with physical exam and x-rayTreatment with RICE therapy, bracing, injection, therapy and surgerySlide12

Elbow

Olecranon bursitis

Comes from pressure placed on the elbow

Diagnosed with physical exam and x-rayTreatment includes activity modification, NSAIDs, elbow pads, aspiration +/- corticosteroid and surgical resectionUlnar nerve neuritis (Cubital tunnel syndrome)Compression neuropathy of the ulnar nervePositive tinels at the elbowDiagnosed by physical exam and confirmed by EMGTreatment includes bracing (especially at night), B-vitamins, NSAIDs and surgical release +/- transpositionSlide13

ElbowAging

Arthritis

Radial – Capitellar

Treat with NSAIDs, injections and radial head arthroplasty if necessaryUlnar – HumeralTreat with NSAIDs, injections and total elbow arthroplasty if necessary depending on functionFusion of the elbow is treatment in high demand individuals who fail conservative treatmentSlide14

Wrist and HandFractures

Radius

Extra-articular

Amenable to a trial of closed reductionRecheck at 2 weeks regardless of pattern to assure no loss of positionAny position changes then referIntra-articularLikely will need referral for definitive treatmentRecheck at 2 weeks regardless of pattern to assure no loss of positionAny position changes then referSlide15

Wrist and HandFractures

Ulna

Styloid fractures

Usually benignAssociated with other fracturesOften treated conservativelySplintEarly ROMShaftLook for additional injuryPay attention to elbow – any pain then refer!Slide16

Wrist and HandFracture

Carpals

Usually require referral for management

Displaced fractures require fixationLow index of suspicion for concomitant injuryScapho-lunate ligamentPerilunate dislocationAcute carpal tunnelMetacarpalsUsually treat with a splint if alignment is acceptableCan be pinned or plated if position is not acceptableSlide17

Wrist and HandFracture

Phalanges

Proximal and middle usually treatable with any form of stabilization for a short period with ROM

Distal simply require immobilizationOpen fractures of the fingertip need to be cleaned and oral antibiotics but are NOT emergenciesWatch for associated injuriesTendon lacerationNail bed lacerationJoint dislocationSlide18

Wrist and Hand

Overuse

Trigger finger

Stenosis of the A1 pulley to any digitTreat with NSAIDS and corticosteroid injection firstRelease when conservative treatment failsPercutaneousOpenDequervain’s tenosynovitisStenosis of the 1st dorsal compartment (thumb)Treat with NSAIDS and corticosteroid injection first

Release when conservative treatment failsSlide19

Wrist and Hand

Overuse

Carpal tunnel syndrome

Positive TinelsPositive Phalens at <1 minute+/- EMGTreat initially with wrist splintShould be at neutral not “cocked up”Use B-Complex supplements+/- NSAIDsCheck concomitant disease statesThyroid Myxedema Rheumatoid Heart failureDM Lupus Renal disease etc.Slide20

Wrist and HandOveruse

Carpal tunnel syndrome

Corticosteroid injection

May have limited benefitDifficult to ensure delivered correctlyDO NOT inject nerve!ReleaseOpen – traditional, reliable, no contraindications based on disease state.Limited open/percutaneous – more modern, contraindicated in many disease states.Slide21

Wrist and Hand

Aging

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st CMC arthritisBase of the thumbWomen > MenPositive grind testTreatment with topical NSAIDs, oral NSAIDs, injection, bracing and arthroplasty of the CMC jointArthritis of the carpalsThrough out the wrist/handTreatment with topical NSAIDs, oral NSAIDs, injection, bracingFusion (limited or full) is surgical treatment of choice except in extremely low demand patientsSlide22

Wrist and HandAging

MCP, PIP and DIP

Treatment

with topical NSAIDs, oral NSAIDs, injectionFusion as last resort for recalcitrant casesArthroplasty of the MCP and PIP are possible if low demand patientSlide23

The Half Way Point!Slide24

Hip

Fracture

Pelvis

Rami – usually not emergent but painfulTreat symptomaticallyEvaluate for osteoporosisAcetabulumNon-displaced treat non-weight bearingDisplaced require surgical evaluationFemurHead fractureNon-displaced treat non-weight bearingDisplaced require surgical evaluationSlide25

HipFractures

Femur

Neck

Usually require some form of fixation depending on the neckMobilization of the patient is keyArthroplasty recommended over 75 yo to allow full WBIntertrochanteric/SubtrochantericUsually treated with open reduction internal fixation (ORIF)Can be plate or rod fixationMobilization of the patient is keySlide26

HipOveruse

Trochanteric bursitis

Lateral hip pain from greater trochanter to the knee

Worse with pressureWakes from sleep or when patient rolls on their side.Treat with topical NSAIDs, oral NSAIDs, corticosteroid injection and physical therapyBursoscopy(Arthroscopy) and resection is restricted for recalcitrant casesSlide27

Hip

Overuse injuries

Hip pointer/Groin strain

Straining of the fibers attaching the muscle to boneMay result in an avulsion type fractureUsually diagnosed clinically after x-rays are negativeTreated with RICE therapy and gentle stretching with activity modification.Piriformis syndromeCan mimic sciaticaPosterior hip painAggravated by certain positions (driving)Treat with NSAIDs and a stretching program

Injection in recalcitrant casesSlide28

HIP

Aging

Hip arthritis

Limited ROM Groin or buttock painMorning stiffness or after periods of restDiagnosis confirmed by x-rayMRI of little value if arthritis is seen on x-rayTreatment with NSAIDs and/or injection of corticosteroidTotal hip for patients that have persistent symptomsVariety of approachesVariety of implantsVariety of venuesSlide29

KneeFractures

Femur

Condyles

Non-displaced fracture may be treated by non-weight bearingDisplaced fractures require surgical repairAvulsionFrom collateral attachmentMay render the knee unstableUsually treated conservatively unless a high level athleteRICE and ROM bracingSlide30

KneeFractures

Tibia

Plateau

Nondisplaced treated conservatively up to 5-10 mm displacementRICEImmobilizer or castingDisplaced fracture usually treated surgicallyTibial spineMay indicate an ACL tearMay be repairable and warrants urgent referralLimit activity and non-weight bearingSlide31

KneeFractures

Fibula

Common fracture with compression

Watch out for associated ankle painIf the patient has ankle pain in addition to the fibula fracture then refer for evaluationUsually treated conservativelyPatellaNon-displaced treated with immobilizationDisplaced require surgical interventionSlide32

Knee

Overuse

Patellar tendonitis

Runner’s kneePainful during and immediately following exerciseDiagnosed clinicallyTreated with PT, activity modification, NSAIDs, topical medications and bracingShould not be injected as this may lead to tendon rupturePes BursitisInflammation of the bursa medial inferior to kneeAggravated by repeat knee twistingTreat with NSAIDs, PT, bracing and injectionSlide33

KneeOveruse

Patellofemoral syndrome

Symptoms include pain beneath the patella, crepitus, feeling unstable, difficulty climbing stairs, pain when first rising from a seated position

Caused by motor imbalance in the extensor mechanism or mechanical problems in the patellofemoral articulationDiagnosed clinically but MRI may confirm severe casesTreated with therapy mostlyMay use NSAIDs and/or injection to alleviate severe symptomsSurgery may be needed of all conservative treatment failsSlide34

Knee

Overuse

Meniscal tear

Pain along joint lineInstabilityBucklingGiving wayDiagnosed clinically but confirmed on MRIHealing is age dependent with a higher probability in younger patientsAcute tears in younger patients should be operated quickly to preserve functionDegenerative tears often associated with arthritis and overloading of repair is commonSlide35

Knee

Aging

Arthritis

PatellofemoralSimilar to patellofemoral syndromeIsolated PF arthritis is rareTibiofemoralCan be from many causesOsteoarthritis (70%)Usually medial but can affect the entire kneeStiffness with first risingAchingLoss of ROM slow and insidiousTreat with NSAIDs, injection, bracing and surgery is always the last optionSlide36

Knee

Aging

Arthritis

Tibiofemoral OsteoarthritisSurgical optionsHigh tibial osteotomyUnicompartmental knee arthroplastyTotal knee arthroplastyTibiofibularThe forgotten joint of the kneeCan be painful either due to arthritis or impactDiagnosed clinically and confirmed on either CT or MRITreated with NSAID, topicals or injectionSlide37

Ankle and FootFracture

Tibia

Distal tibia

PlafondDifficult to treatUsually involve jointNondisplaced fractures treat closedDisplaced fractures require fixationMalleolusIsolated medial malleolar may be treated conservativelyDisplacement of > 5mm should be cause for surgical referralSlide38

Ankle and FootFracture

Fibula

Nondisplaced fracture can be treated with immobilization

Displaced fractures usually should be fixedBeware of medial pain as this can indicate instabilitySyndesmosisThis is a special case.Ligament that holds the fibula to the tibia giving the ankle its stabilityIf the ankle looks shifted in the least refer for surgical evaluationSlide39

Ankle and FootFracture

Talus

Poor blood supply

Fracture bears a bad prognosisShould be seen by orthoDiagnosed by CT as x-ray is usually difficult to seeCalcaneusCommon fracture with a fall landing on footExtent of fracture does not predict the outcome of the injuryEquivocal evidence that fixation is better than conservative treatmentLong term outcome of intra-articular fractures is usually fusionSlide40

Ankle and FootFracture

Remaining tarsals

Nondisplaced fractures can be treated conservatively

Beware of compartment syndromeUse CT to establish the extent of injuryThese are ALWAYS worse than the x-ray suggestsTreatment for displaced fracture is usually pinning but often leads to later fusionMetatarsalsSimilar to tarsalsCan treat most fractures conservatively as long as the foot remains planta gradeLarge angular deformities should be referredSlide41

Ankle and FootFracture

Phalanges

Usually treated with conservative management

Great to can be pinned or plated if displacedSlide42

Ankle and Foot

Overuse

Achilles tendonitis

Diagnosed clinicallyCan be confirmed and/or staged with MRITreat with NSAIDs, splinting (specifically at night), topicals and therapyActivity modification will be beneficial to prevent recurrence or rupturePlantar fascitisDiagnosed clinicallyX-ray usually shows calcaneal spurNOT the cause of painSlide43

Ankle and FootOveruse

Plantar fascitis

Calcaneal spur

Is a result of the traction of the fascia on the calcaneusTreat with NSAID, Injection, therapy and night splintsAgingArthritis in the ankle can be treated with arthroplasty in low demand patientsInitial treatment with NSAIDs, injection and topicalBracing may decrease symptomsSlide44

Ankle and FootAging

Definitive treatment of arthritis of the ankle and foot us usually by fusion of the painful joints

This results in a cascade of overload on the surrounding joints necessitating further surgery in timeSlide45

Thank YouSlide46

Orthopedics for primary carethe whirlwind tour

Michael Patney, DO, FAOAO

Coastal Orthopedics