Orthopaedic conditions


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A written report about various orthopedic conditions.
source: handbook of orthopeadic surgery by;Brashear

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Orthopaedic conditions

  1. 1. ORTHOPAEDIC CONDITIONS Congenital Talipes  Talipes equinovarus (congenital club foot) o o o o o o Etiology  Unknown; usually referred to as idiopathic club foot  Isolated lesions may be result of a neurologic d/o that is not immediately evident at the time of birth  Most widely accepted pathogenesis:  Arrested or anomalous development of this particular part of the embryo in the first trimester of pregnancy.  Inward rotation of the foot fails to occur at the 7th month of pregnancy.  Muscle imbalance Incidence  Occurs about once in every 1000 live births  Twice as common in boys as in girls  Slightly over half of the patients the disorder is bilateral  In Unilateral cases right and left sides are affected with equal frequency  Occasionally there is talipes equinivarus on one side with metatarsus varus or talipes calcaneovalgus on the other. Pathology  Achilles Tendon  shortened  Ant. And post. Tibial tendons  cx in proportion to the degree of varus deformity  Degenerative changes in fibers of certain ms. And anomalous insertion of tendons in the foot  At birth ligaments and joint capsules on the med. Side of the foot are cx.  Consistent deformity neck of talus shortened & dev. Med.  Most striking abnormality  talocalcaneonavicular jt.  Navicular bone  displaced med. Around the head of the talus.  Forepart of the foot follows the med. Displaced navicular  Subtalar surfaces  tilted into varus & equinus & med. Rot.  Calcaneous  slightly shortened & widened  As the child grows  talus  wedge shape with its post. Surface apposed to the tibia, calcaneous  points downward and rot. Med.  Structural changes may be found in all other bones but in lesser degree Clinical picture  Heel is drawn up, the entire foot below the talus is inverted, and the ant. Half of the foot is adducted.  Med. Border of the foot is concave, lat. Border is covex  (+) transverse crease across the sole @ the level of the mediotarsal joint  If not corrected before the infant starts to walk  suffers a serious handicap because of inability to WB N°  Ms.  Easily fatigued & (+) atrophy  Pain is developed only by Adult Pt. (arthritic changes) Diagnosis  Seen frequently in association with paralytic changes in the lower ex, in myelodysplasia, CP & poliomyelitis Prognosis  Range of severity and rigidity extends from a relatively flexible talipes equinvarus  responds to non-operative Rx; tight resistant clubfoot  requires surgical correction.
  2. 2.  o Foot  Cx med. & post. Tse. That make it resistant to gentle manual correction without surgical release of the contracted soft tse  POOR prognosis Treatment  Must start as the clubfoot is recognized  Correcting thoroughly all elements of the deformity, maintaining the correction until N° ms balance  developed; cont. until an over correction has been reached.  Goal of every Rx: Position of DF & Ev of the foot & Abd of the forefoot.  Functional result will be good if the final position can be obtained without the trauma of forceful manipulation & without radical surgery  interference with bone growth and by stiffness of the joints of the foot.  Rx starts: first week or two after birth should consist of gently manipulating the foot to improved position  holding the position by adhesive strapping or light plaster cast repeated 1/week  Key to success is reduction of the talonavicular joint  by gently stretching the med. Border of the foot by longitudinal traction on the forefoot with a force directing the navicular around the front of the head of talus; an everting and downward pull is exerted on the tiny heel to roll the calcaneous lat. From its inverted position beneath the talus.  When the full correction is achieved foot must be held in corrected position in a cast for 3-4 mo.; cast are changed 3-4 weeks, after child is fitted with clubfoot shoes attached to denis browne splint  Worn day and night except during ex. And bathing. If infant is ready to walk splints may be worn only at night & clubfoot shoes for day use.  Simplest and most frequently used operation is lengthening of Achilles tendon to lessen the equinus deformity; may be done early @ the age of 2/3 mo.  The correction of clubfoot in a child more than 10years old or in an adult requires operation on the tarsal bones. Congenital Abnormalities of fingers and toes  Syndactyly (webbed fingers/toes) o  Description  A common anomaly occurs twice as often in boys as in girls & more often in the hand than in the foot.  Ulnar side is more affected, & thumb is seldom involved.  Union between affected digits may consist only of skin and connective tissue  simple syndactyly; if union includes bone  complex o Treatment  Separation of involved fingers  dividing soft tissues/bony structures; done bet. 18 mo & 5 yrs., earlier when hand function is impaired. Macrodactyl o o  Overdevelpment of one or more fingers/toes Rx: amputation but occasionaly a plastic operation to effect a reduction in size is preferable Polydactyl o o o Supernumery digits; common & frequently inherited anomalies Often Bilateral; may be compined with syndactyly Amputation of the extra finger/ toe is indicated.
  3. 3. General Affectations of bones  Osteitis Deformans o Etiology  Causative agent is unkown o Pathology  Active stages  blood flow to bone greatly ↑  high output cardiac failure  Gross skeletal changes  developing thickening and bowing of the shafts of the long bones (tibia and femur) & generalized thickening of the cranium  Often affect only a single bone  Bones lose their ability to withstand N° stresses & ↑ degree of curvature  Spine (frequently involved)  partial collapse of one or more of the vertebral bodies  kyphosis  Later stage: bones matrix is laid down calcifies  thick, hard osseous structure o Clinical picture  Asymptomatic  Affects man more frequently than women and occasionally it occurs in families  40-60y.o when symptoms begin, may develop the ff:  Severe intractable pain  May complain of fatigue and aching in legs  h/a & backache  legs are becoming bowed, that the back is stooped or the head is becoming larger  moderately advanced stage: head appears massive an too large for the body; face is relatively small, head may droop forward, long dorsal kyphosis; chest is barrel shaped & lumbar spine flexed, legs are bowed outward & forward  no mental changes  may develop deafness and tinnitus and an impairment of vision o Treatment  Required no treatment  If with significant symptoms  drugs: Calcitonin. Bisphosphonates & mithramycin  ↓bone pain & control the activity of the dse.  Bracing for long bones and spine o Prognosis  Cardiovascular complication  MC cause of death  Length of life is good  Pathologic Fx is the MC complication (femur)  Ankylosing spondylitis (Strumpell –Marie Arthritis) o Characterized by ossification of the ligaments of the spine and by involvement of the hips & shoulders o Sacroiliac joints are affected early o Cause is unkown o 10x < men o Begins @ ages of 20-30 y.o o Familial o Pathology  Progressive ossification  capsular & intervertebral ligaments fusing lower and later the entire spine into a single mass.  Vertebral bodies seemed to be osteoporotic
  4. 4. o o   TUMORS Osteochonndroma o o o o o o o   (+) irregular spur formation & lipping of the vertebrae Clinical Picture  Onset: maybe assoc. with acute pain  Stiffness without pain may be the first symptom  Malaise and fatigability accompanied with wgt loss  Pain first appears @ hip, buttocks or lumbosacral region  LBP while pt. is recumbent in early morning hours  Pain & tenderness @ sacroiliac region when pelvic wings are pressed together /when hips are stressed in extremes of rot.  ↓spinal mobility & diminished chest expansion  Associated with other conditions: Plantar fasciitis, tendinitis of Achilles tendon, heel pain.  Pain lessens as the stiffness ↑  There is no involvement of the smaller joints Treatment  General measures  Rest & well- balanced diet  Control of pain o Regular dose of Aspirin o Saliciylates and other NSAIDs o Rare: steroid therapy  Local non-surgical measures  Bed rest (firm mattress/bed board should be use & rest without a pillow)  Hyperextension ex. Should be done & position of extension should be maintained  Wearing 3-point brace to prevent kyphosis  Breathing ex.  Surgical Rx  Osteotomy of the spine  Joint replacement  painful ankylosis of the hip MC benign tumors of bone They are hamartomas rather than true tumors First Dx with persons ages 10 – 25 y.o. & typically situated near the ends of long bones Symptoms  Swelling / lump is only pt’s complain  Discomfort to adjacent bones MC location: near the adjacent ends of the femur & tibia / upper end of the humerus; flat bones, scapula MC involved Treatment:  Operation is not always necessary  Any large osteochondroma in location that is prone to trauma must be removed Postpubertal enlargement and pain suggest malignant change. Osteogenic sarcoma (Osteosarcoma) o MC malignant primary bone tumor
  5. 5. o o o o o o  Typically develops in the metaphysis of a long bone in late childhood or early adult life (bet. 10 & 20 y.o.) Aggressive tumor  rapid growth, early pulmonary metastases, No definite cause Pathology  MC sites  Upper tibia, lower femur, & upper humerus  Hallmark: Osteoid matrix produced by the tumor cells Clinical Picture  MC in children & young adults  Males>females  Occasionally occurs In later adult years, but usually 2° to a pre-existing lesions such as paget’s dse.  Dull, constant, aching pain first symptom  Hard bony enlargement that is slightly tender and typically located above/below the knee or near the sho.  Discomfort  limping  Rapidly growing tumors  distention of the superficial veins and ↑ of skin temp. Treatment and prognosis  Classical methods of amputation or disarticulation well above the lesion  Chemotherapy FRACTURE o Any break in the continuity of the bone.  Open Fx  A fx where there is a communication bet. The bone and outside  Complicated by infection. Osteomyelitis, delayed union & even nonunion  Close Fx – there is no such communication  Pathologic Fx- occurs in bones weakened by pre-existing dse such as tumor, cysts, osteomyelitis or osteoporosis.  Stress Fx – result of bone fatigue from repeated unaccostumed loading & inadequate muscular support. o Described as;  Transverse – caused by simple angulatory forces  Oblique – unstable  Spiral- result from torsion ; unstable  Comminuted - the bone is broken into 3/more fragments; unstable o FX Rx 3 basic objectives:  Reduction / replacement of the bone fragments to as near anatomic position as possible.  Manipulation  Traction  Open surgery  Maintenance of reduction until healing is sufficient to & tendonsprevent displacement  External fixation (cast/splint)  Traction o Skin traction  Buck’s extension  Russell’s traction o Skeletal traction  Steinmann pin  Kirschner wire
  6. 6.  o o Internal Fixation o Transfixion screw o Bone plate o Intramedullary rod or nail  Preservation and restoration of function of ms. Joints Fx in children  Greenstick Fx - An incomplete Fx in which the angulating force bends the cortex on the compression side and breaks it on the distraction side  Torus Fx- Frequently seen in the distal fourth of the radius, where mild angulation casues buckling or buldging of the cortex on the compression side. Fx healing  Fx heal by physiologic process similar to the repair of wounds of soft tissues, conditioned by factors such as:  Rigidity of bone  Tendency of the Fx fragments to displace o Spiral fx heals more rapidly than transverse fx.  Length of time required for newly formed bone to restore strong union of fragments. o Humerus & FA – 3 mo o Femur & tibia – 4-6 mo.  3 late bony complications of Fx  Delayed union – fx healing is abnormally slow o (+) if tibia close fx does not become clinically firm in 20 weeks, humerus in 10 weeks 7 femur in 20 weeks  Causes of delay  Inaccurate reduction  Inadequate/ interrupted immobilization  Severe local traumatization  Impairment of bone circulation  Infection  Loss of bone substance  Distraction or separation of fragmentd o Rx  Early, accurate and gentle reduction and immobilization  Maintenance of function  Abstention from repeated trauma  Sound judgement and technique in the us of Internal Fixation  Non-union – healing stops short of firm union o NO Fx should be considerd ununited until @ least 6 mo. After the date of injury  Factors  Malnutrition  Generalized illness  Extensive tissue damage  Impairment of bone blood supply  Infection o Rx  Acceptance of the defect  Use of simple brace  Electrical stimulation
  7. 7.    Bone grafts  Autogenous bone – taken from the patient  Homogenous bone – taken from other person Malunion- healing takes place in unsatisfactory alignments AMPUTATION o May be a result of congenital limb deficiencies or may be acquired o Indications/ common reason  Vascular disease/accident  Trauma  Tumor  Infection  Thermal, chemical or electrical injury  Congenital anomaly o Types of surgical amputation  Disarticulation – amputation preforemed through a joint  Open amputation – surface of the wound is left unclosed  Closed amputation – a final or definitive amputation  stump  Minor amputations amputations through th or distal to the metacarpus or the metatarsus  Major amputations – all amputations proximal to the metacarpal or metatarsal bones. o amputation levels
  8. 8.  SCOLIOSIS o Scoliosis is a lateral deviation of the vertebral column. o MC found in the thoracic region and may be caused by muscular or vertebral defects. o Scoliosis is a deformity rather than a disease, and its causes are many often, scoliosis is compensatory and may be caused by a short leg or hip disease. o Classification and Etiology  Non-structural Scoliosis (Functional)  Not accompanied by rotational or asymmetric changes in the individual structures of the spine.  The curve is not fixed, in that in the bending in the opposite direction is not restricted, and the patient can actively and completely correct the deformity by sitting erect.  It may result from poor posture or leg length discrepancies and usually poses no major therapeutic problem.  It may also be caused by nerve root irritation such as sciatic scoliosis seen in acute lumbar disk herniation.  Functional scoliosis can become structural if untreated.  Structural Scoliosis  A fixed curvature of the spine associated with vertebral rotation and asymmetry of the ligamentous supporting structures.  It can be caused by deformity of the vertebral bodies and may be: o Congenital – defect in embryologic development of the vertebrae or ribs (e.g., wedge vertebrae, fused ribs or vertebrae, hemivertebrae) o Musculoskeletal (e.g., osteoporosis, spinal tuberculosis, rheumatoid arthritis) o Neuromuscular – associated with a great variety of paralytic disorders that causeasymmetric paralysis of the trunk muscles. (e.g., cerebral palsy, polio, myelomeningocele, muscular dystrophy) o Idiopathic (MC) – Scoliosis with unknown pathogenesis o Pathology  All the structures of the concave side are compressed or shortened; those in the convex side may remain normal or become lengthened.  The apical vertebrae, situated at the middle of the curve, shows the greatest curve, shows the greatest change, being wedge shaped and most rotated.  The vertebrae above and below it undergo similar but less pronounced changes. It always turns toward the convex side of the curve, and spinous process toward the concavity.  The IVD are compressed on the opposite side as a result of the pressure; nucleus pulposus migrates toward the convex side.  The anterior longitudinal ligament is thickened on the concave side and thinned on the convex side. o Age of onset: from birth onward  infantile (0 to 3 years)  juvenile (ages 3 to 10)  adolescent (age 10 until bone maturity at between 18 and 20 years of age)  adult (after skeletal maturation) o Clinical manifestations
  9. 9.   o o Curvatures of < 20 degrees rarely cause significant problems. Back most prominent features:  Spinal curvature  Asymmetric flank folds  unLevel pelvis  Prominence of the scapula and shoulder   Severe untreated scoliosis (> 60 degrees) may produce  pulmonary insufficiency  reduced lung capacity  back pain  degenerative spinal arthritis  disk disease  vertebral subluxation  sciatica  The adult with scoliosis  back pain d/t:  muscle fatigue  trunk imbalance  facet arthropathy  spinal stenosis  degenerative disk disease  Curves are designated as right or left depending on the convexity  Two primary curvatures may exist  rib hump (gibbus) tests and Measures  Diagnosis by clinical examination:  Forward bend  Scoliometer  Plumb line test  Leg length discrepancy  neurologic examination to rule out an underlying neurologic disorder  Cobb method  Risser-Ferguson method  Nash-moe scale Treatment  Conservative care  Exercise o Cotrel o Klapp’s  electrical stimulation  Observation and monitoring  spinal orthoses  Milwaukee  Boston  Wilmington  Charleston Bending brace  Surgeries for curvatures greater than 45 degrees have been recommended.  adult with scoliosis:  conservative nonoperative course of physical therapy  Non-narcotic analgesics
  10. 10.      o nutritional counselling smoking (or tobacco-use) cessation and nerve root blocks facet injections epidural steroid injections before surgery is considered Prognosis  Postural curvatures resolve as the primary problem is treated.  Structural curvatures are not eliminated but rather increase during periods of rapid skeletal growth.  If the curvature is <40 degrees at skeletal maturity, the risk of progression is small.  In curvatures >50 degrees, the spine is biomechanically unstable, and the curvature will likely continue to progress at a rate of 1 degree/yr throughout life.  Poor seating can contribute to this progression.  In severe kyphoscoliosis, pain and comfortable positioning can complicate care, and pulmonary compromise can lead to death.   AFFECTATIONS OF THE HIP Coxa vara and coxa valga o Coxa vara  Abnormality of the upper end of the femur, consisting of a decrease in the neck-shaft angle (angle of inclination)  shortening of the limb Limits abduction of the hips.  May be congenital or acquired (MC) o Coxa valga  Increase of the neck – shaft angle  N° in infants before WB, persist in children who are unable to stand because of chronic disability & seen as a secondary deformity in congenital dislocation of the hip.   AFFECTATIONS OF THE KNEE Cruciate ligaments injuries o ALC tear (MC)- hyper / force pushing the femur backward on the tibia o PCL tear – force applied to the front of the tibia push the tibia backward on the femur. o MCL tear – a valgus / abduction force sometimes associated with rotation or hyper / o LCL tear – a varus / Adduction force o LL< common than ML o Clinical picture  Usually accompanied by hemarthrosis  @ time of injury pt. will often note a definite “pop”  ACL  associated with abnormal forward movement of the tibia on the femur; (+) Lachman test  PCL  Abnormal forward or backward displacement of tibia on femur; (+) posterior drawer sign  MCL pain & swelling, tenderness on med. Side which may be localized just above or below the joint line; (+) valgus stress test; <5mm min., 5-10 mm mod., >10mm severe injury  LCL  swelling 7 tenderness on lat. Side; (+) Varus stress test o Classification of ligamentous injury  Mild/grade I – (-) instability & tear is only partial/interstitial  Mod./ grade II – mild instability, secondary supporting structures are intact  Severe/grade III – complete rupture of the ligaments and gross instability of the joint. o Rx
  11. 11.      Grade I  Short period of immobilization in soft splint  Early movement of the knee (pain and swelling subsides)  Grade II  Immobilization in plaster cast for 6-8 weeks  Early movement  Exercises for the quads & hamstrings  Ex. Involving Terminal ext. of knee should be avoided in ACL injuries  Grade III  Require surgical repair  Close Rx with cast immobilization  Brace that allow limited ROM  Exercises Patellar tendinitis (Jumper’s knee) o A common affectation of athletes o Characterized by pain & tenderness over the patellar tendon & pain on forceful / of the knee o Rx  Rest & restriction of forceful knee /  Use of splints/cast  Surgical debridement (rare) AFFECTATIONS OF ANKLE AND FOOT Foot strain o Common overuse condition characterized by pain & tenderness  Longitudinal arch d/t excessive & unaccustomed standing & walking. o Clinical Picture  Acute foot strain  Manifested by pain & tenderness  longitudinal arch  antalgic gait  Chronic foot strain  Complains of fatigue & aching in the feet  Discomfort  longitudinal arch  calves  Symptoms is worst @ the end of the day, by evening feet may feel tight and swollen  M.I. finding  localized tenderness under the NAVICULAR bone @ the apex of long. Arch. o Rx  Local Rx  Hot soaks/contrast baths = relieve discomfort  Chronic strain  felt / sponge rubber arch pad  shoe with a long counter & firm shank will give inc. support  Thomas heel  give support to navicular bone  Weight reduction. Hallux Valgus o Lat. Angulation of the great toe @ its MTP joint. o Etiology & Pathology  Frequently familial  Women>men  Med. Deviation of the 1st metatarsal is accompanied by lat. Deviation of the great toe  Ant part of foot is widened & metatarsal arch depressed  Cx of FHL &EHL is associated with a lat. Displacement of extensor tendons
  12. 12. o Rx & prognosis  Mild cases  properly fitting shoes & repeated overcorrection by stretching  If accompanied by diabling pain  surgery  removal of exostosis & bursa  Silver operation  EHL tendon is sectioned/ lengthened  Keller/ Schanz operation  resection of the proximal half of the first phalanx (for severe deformity)  Arthodesis of MTP joints  Osteotomy of Proximal or distal portions of 1st metatarsals / proximal phalanx  After operation:  Splint/cast/soft cushion pad placed bet. 1st & 2nd toe  Warm soaks & corrective foot ex.  Hallux Varus o Medial angulation of the great toe @ the MTP joint o May be congenital in origin o Casuse: Trauma, infection, ms. Imbalance, paralysis of Add Hallucis & bunion operation o Rx:  Mild cases corrected by surgically relaeasing Cx structures on the med. Side of the toe & placating the lat. Part of the joint capsule  Severe  osteotomy of the metatarsal head & use of sectioned EHB in a tenodesis to maintain the corrected alignment.   AFFECTATION OF NECK & SHOULDER TORTICOLLIS (WYRNECK) o A deformity of the neck  rotation & flexion o 1 SCM is shortened  tilting of the head towards the affected side & rot. Of chin to the opposite side; shoulder of affected side is elevated o Congenital torticollis (muscular torticollis)  Cause: unknown  Seen with relative frequency after difficult deliveries, with breech presentation & primiparas o Clinical picture:  Girls>boys  facial asymmetry develop within the first 3 months (affected: on the side which the head is tilted) o Prognosis  Proper Rx = complete cure  Incomplete surgical correction  recurrence  Corrected before 3 / 4 y.o.  facial asymmetry msy completely disappear o Rx  Non-surgical  Passive stretching of the neck in overcorrected position  Proper positioning of the head during sleep  If old enough  active exercises to strtch the short SCM  Surgical  Section of SCM  Maintenance of overcorrection of the deformity  plaster cast, brace/ traction  Program of ex. For securing ms. Balance to maintain the correction permanently
  13. 13.  o   Operation MC used  open resection of 1 cm segmentof SCM near its origin from sternum & clavicle; platysma miss also included  After operation: corrective ex for 6 mo. Acquired torticollis  Accompanied by pain & stiffness as well as bizarre deformities of the neck  Types  Acute traumatic/inflammatory  caused by cervical injuries, atlantoaxial rotary subluxation or inflammation of the ms/lymph nodes  Chronic infectious/ neoplastic caused by osteomyelitis, tuberculosis, or tumors of the spine.spinal cord  Arthritic  caused by RA, ankylosing spondylitis or OA  Cicatricial  Cx of scar tse after burn  Paralytic  assymetric flaccid/spastic paralysis of neck ms.  Hysterical  Psychogenic inability of the pt. to control neck ms.  Spasmodic  CNS/ cervical root lesion & manifested by involuntary rhythmic Contraction of the neck ms.  Rx  Is that of its 1° cause  Helps treating the symptoms o Hot application o Gentle massage o Horizontal/vertical neck traction o Cervical orthoses AFFECTATIONS OF THE SHOULDER Adhesive Capsulitis (frozen shoulder) o A chronic affectation characterized by pain and LOM (sho) that becomes worse over a period of 3-12 mo. o Frequently seen in pt.’s over 40y/o o Women> men o A.k.a. Periarthritis, obliterative bursitis & diffuse rotator cuff tendinitis o Pathology  Changes in jt. Capsule  Edema, Fibrosis, round cell infiltration (indicating low-grade inflammatory process)  Synovial recesses  adherent  LOM  Periarticular tse  lose elasticity, become shortened & fibrotic  fixing the head in the glenoid cavity  (+) ms. Atrophy  Cx CHL & subscapularis tendon  prevent ER of humerus  Articular surface  uninvolved o Clinical picture  May have an insidious onset  Frequently follows supraspinatus tendinitis, subacromial bursitis & tenosynovitis of the long head of biceps  May result from AC arthritis . play a part in shoulder-hand syndrome  Arm is kept in AdIr  (+) pain  ExAbEr  Night time pain  loss of sleep  emotionally upset
  14. 14.  ↓ Active & passive mobility in SH joint  restriction: ExAb  o Conservative tx  HMP  Gravity free ex. Within painless arcs of motion  Analgesic & anti-inflammatory drugs  Antigravity ex. (later part) e.g. finger ladder  Procaine blocks of the suprascapular nn.  relieve pain temporarily  Adhesive Tx Late stage: Acromioplasty or resection of the acromioclavicular jt. Rx    AFFECTATIONS OF THE ELBOW Pulled elbow o Common in children bet. 2-5 y/o o Locking of FA in pronation / neutral rot. When a segment of annular ligament is pilled over the edge of the radial head o A.k.a nursemaid’s elbow o MOI: sudden direct pull on the elevated limb with the elbow / and FA pronated o Clinical Picture  Child refuses to use the arm & the elbow is held slightly flexed  All N° ROM except supination  Attempts to supinate causes pain & a sensation of mechanical blocking o Rx  Brief manipulation without anesthesia  elbow flex to a right angle  FA supinated quickly while pressure is everted to the radial head.  a click is felt, if not carried out  spontaneous reduction.   AFFECTAIONS OF THE WRIST AND HAND Rupture of the central extensor slip o Rupture: near the insertion into the base of the mid phalanx  flexion deformity of the PIP jt. o A.k.a boutonniere (buttonhole) o Rx: suturing the central slip if possible, repositioning the lat. Bands & releasing them distally Avulsion of the Flexor Profundus Tendon o MOI: d/t forced / of firmly flexed fingers o MC in young athletes, usually involved the ring finger o (+) loss of active flexion of the distal joint & tenderness & swelling on the volar aspect of the finger o Rx: surgical reattachment of the avulsed tendon Mallet Finger (baseball/dropped finger) o MOI: sudden forcible flexion of the distal phalanx may cause an avulsion of the extensor tendon @ its insertion o Common: athletes o (+) inability to / actively the distal phalanx o (+) swelling and tenderness o Rx: DIP is held constantly in hyper / for 6 weeks done with a plaster splint/ small metal/plastic splint o Late cases: suture of the tendon/ bone fragment to the phalanx = unsatisfactory o Disability : very slight Dupuytren’s Cx o A slow progressive Cx of the palmar fascia   
  15. 15. o o o o o o o o o Men > women Between ages 55 -75 y/o When it occurs in women  younger group Changes involves:Ring finger, Little finger or both Usually Bilat. ; when unilat.  right MC Pathology  Chronic inflammation of the palmar fascia  progressive fibrosis  Cx of Palamar aponeurosis  Advance cases: skin is involved Etiology: unkown Clinical picture  (+) small nodular painless thickening in the palmar fascia overlying a flexor tendon in the region of MCP jt. often associated with dimpling of the skin.  Thickened longitudinal band is formed  flexion Cx of finger ↑  MCP & adjacent IP joints become flexed  DIP jt.  remains N° Rx  Earliest cases  frequent passive stretching  Limited/Partial Fasciectomy  Post-op:/ splint + ex.  Active and passive motion must begin as the healing of the skin permits