Lecture 9 - Lower Limb Soft Tissue And Bone Disorders Flashcards Preview

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Flashcards in Lecture 9 - Lower Limb Soft Tissue And Bone Disorders Deck (33):
1

Dysplasia of the hip: Pathophysiology

- during childbirth
- abnormality in size, shape, orientation or organization of the femoral head or acetabulum

RISK FACTORS: breech, female, Family Hx, Firstborne

2

Dysplasia of the hip: assessment

- ortolani and barlow maneuvers
- Galeazzi sign
- Hip abduction range

3

Dysplasia of the hip: management

- subluxation often corrects spontaneously
- if subluxation persists: Pavlik harness
- if dislocation persists: closed reduction and Hip Spica casting

4

Perthe's disease pathophysiology

- osteochondrosis of capital epiphysis of femoral head: disruption of blood supplu
- cessatin of endochondral ossification
- Vascular invasion of cartilage

- necrosis of marrow space and trabecular bone

5

Perthe's disease: Assessment

- low grade ache, male 4-10 yo
- Limited abduction and internal rotation upon physical exam
- XRAY: increased density and flattening of femoral capital epiphysis

6

Perthe's disease: Management

Rest
- exercise for range of motion
- Brace
- surgery

7

Avascular necrosis of the femoral head: pathophysiology

- damage to deep branch of medial femoral circumflex artery leading to necrosis of femoral head
- follows femoral fracture in high energy trauma
- can have non traumatic causes: anything that compromises blood supply in artery

8

Avascular necrosis of the femoral head: clinical assessment

- history of hip pain progressively worse over time
- located in groin, proximal thigh, buttock
- aggravates with weight bearing and eases with rest
- antalgic gait
- passive movement elicits pain
- limitation in motion in capsular pattern
- MRI

9

Avascular necrosis of the femoral head: management

- if non traumatic: non-weight bearing activities, alter risk factors
- older patient: hip replacement
- younger patient: reconstructive procedure

10

Osgood Schlatter's syndrome (aka: traction apophysitis)

- apophysis biomechanically weak during growth spurt: at danger in young athletes
- resultant traction causes irritation, inflammation, microtrauma

- Osgood Shlatters: tibial tuberosity
- Sinding Larsen Johansson: inferior angle of patella

11

What is an apophysis

Secondary ossification centre, attachment of tendons

12

Osgood Schlatters: clinical presentation

- in very active younf children aged 10-15 during growth spurt
- more often boys cause growth spurt later
- often unilateral
- inflammed, swollen and tender on palpation
- child may have poor lower limb alignment

13

Osgood Schlatters management

PRICEM
- gentle strecth of rectus femoris
- orthotics
- patellar tendon taping

14

Patellofemoral dislocation

- Patella moves laterally
- Predisposing factor: femoral anteversion, genu valgum, increased Q angle, Patella alta, ligament laxity, muscle weakness

15

Patellofemoral dislocation assessment

Physical exam: tenderness over medial patella, patellar apprehension test

16

Patellofemoral dislocation: management

- relocate and assess for fracture
- conservative
- surgery sometimes required

17

Patellofemoral pain syndrome

- 12-35 years
- activity dependent
- aching pain
- cause unknown

Contributing factors: abnormal biomechanics, tight structured, muscle imbalance, training/load

18

Patelofemoral pain syndrome diagnosis

- history : area of pain, aggrevating activities, crepitus
- Physical: alignment abnormalities, single leg step down (less pain if glide patella medially), isometric muscle test
- no imaging required

19

Management of Patellofemoral pain syndrome

Rest
- McConnell taping: increased activation of vastus medialis
- Address control and strength issues
- stretch tight structures
- orthotics
- NSAIDS in acute phase only

20

Achilles tendinosis

A degenerative mucoid condition characterised by an increase in ground substance and vascular tissue and an absence of inflammatory markers

21

Achilles tendinosis presentation

- pain localised to tendon
- gradual onset
- pain aggravated during or after activities
- pain can disappear after warm up and return when cooling down

22

Stage 1: reactive tendinopathy

- acute tensile stress or compressive overload
- tendon cells activated and proliferate
- proteoglycans produced
- tendon thickening
- short term reduction in stress

23

Stage 2 tendinopathies: tendon dysrepair

- worsening pathology with greater matrix breakdown
- tendon cells more prominant
- myofibroblasts appear
- increased production of proteoglycans and collagen
- collagen separation and disruption of matrix
- growth of vessels and nerves

24

Stage 3 tendinopathies: degenerative

- end stage of disease
- matrix and cell changes progress
- apoptosis
- large areas of disorganised matrix, little collagen, vessels

25

Pain in tendinopathy

Up to 65% of degenerative tendons which rupture were pain free

Where does pain originate:
- biochemical substances
- neurovascular in growth

26

Management of stage 1 early stage 2 tendinopathy

PHARMACOLOGY
- tenocyte inhibitor
- affrecan inhibitor

PHYSICAL
- load management

27

Late stage 2 or stage 3 tendinopathy management

PHARMACOLOGY
- prolotherapy
- aprotinin
- sclerosing therapy
- glyceryl trinitrate

PHYSICAL
- exercise with eccentric component
- Shock wave therapy, friction, ultrasound

28

Exercises for tendinopathies: effect

- increased collagen production in affected tendon
- improve tendon structure
- reduce tendon vessels
- reduce pain

29

Achilles tendinosis prsentation

- common in sports involving running and jumping
- tenderness and thickening in mid portion of achilles
- crepitus or nodules
- pain on heel rise test

30

Management of achilles tendinosis

Eccentric exercise protocol by Alfredson and cook

31

Plantar heel pain pathophysiology

Overuse of plantar ffascia at attachment of calcaneus
- collagen disarray in ABSENCE of inflammatory cells
- RISK FACTORS: pes planus/cavus, sports, excessive load

32

Plantar heel pain assessment

- pain with 1st step am, prolonged standing or running
- palation of medial calcaneal tuberosity is the definitive objective sign

33

Plantar heel pain: management

- offload the platar fascia: activity modification
- NSAIDS
- stretching
- self massage
- strengthening exercise
- taping
- corticosteroid injection