Common Orthopaedic Disorders ภาควิชาศัลยศาสตร์ออร์โธปิดิคส์และกายภาพบำบัด คณะแพทยศาสตร์ศิริราชพยาบาล Handout can be downlo...
Outlines <ul><li>Septic arthritis </li></ul><ul><li>Osteomyelitis </li></ul><ul><li>Ankle sprain </li></ul><ul><li>Achille...
Septic arthritis <ul><li>Acute suppurative (septic) arthritis </li></ul><ul><li>Tuberculous arthritis </li></ul>
Septic Arthritis <ul><li>Causal Organism </li></ul><ul><ul><li>Staph. Aureus </li></ul></ul><ul><ul><li>H. Influenzae in i...
Septic arthritis <ul><li>Pain around the joint </li></ul><ul><li>Malaise, fever and constitutional symptom </li></ul><ul><...
Septic Arthritis: Investigation <ul><li>WBC, ESR raising </li></ul><ul><li>Hemoculture may be positive </li></ul><ul><li>X...
Joint Fluid Analysis <ul><li>Characteristics & color </li></ul><ul><ul><li>purulent, may be clear </li></ul></ul><ul><li>W...
Septic arthritis of the hip <ul><li>Treatment </li></ul><ul><ul><li>Symptomatic treatment </li></ul></ul><ul><ul><ul><li>R...
Osteomyelitis
Acute Hematogenous Osteomyelitis <ul><li>Incidence </li></ul><ul><ul><li>Mostly in children </li></ul></ul><ul><ul><li>Adu...
Clinical Findings <ul><li>Limb pain </li></ul><ul><li>Fever, malaise, failure to thrive </li></ul><ul><li>Metaphyseal tend...
Diagnostic Images <ul><li>Plain X-ray </li></ul><ul><li>Ultrasound </li></ul><ul><li>Bone scan </li></ul><ul><li>MRI </li>...
Investigations <ul><li>CBC : Hb  , WBC  </li></ul><ul><li>C-reactive protein  </li></ul><ul><li>ESR :  usually remains </l...
Treatment of acute Osteomyelitis <ul><li>G eneral supportive treatment </li></ul><ul><ul><li>analgesia, IV fluid </li></ul...
Chronic Osteomyelitis <ul><li>Etiology  </li></ul><ul><ul><li>Sequel to acute hematogenous osteomyelitis </li></ul></ul><u...
Pathology <ul><li>Sequestrum </li></ul><ul><li>Involucrum </li></ul><ul><li>Clo a c ae </li></ul><ul><li>Sinus </li></ul>
Clinical Features <ul><li>R ecurrence of  pain, pyrexia, redness and tenderness </li></ul><ul><li>D ischarging sinus  </li...
COM : X-Ray Finding
COM : Investigation <ul><li>WBC  ESR  </li></ul><ul><ul><li>non diagnostic </li></ul></ul><ul><ul><li>helpful for monitori...
COM : Treatment <ul><li>Antibiotics </li></ul><ul><ul><li>depends on bact. Study </li></ul></ul><ul><ul><li>capable to pen...
Ankle sprain <ul><li>Lateral ankle sprain </li></ul><ul><li>Medial ankle sprain </li></ul><ul><li>Syndesmotic sprain (High...
Ankle sprain <ul><li>Correct diagnosis should be made </li></ul>
<ul><li>Anterior talofibular ligament (ATFL) </li></ul><ul><li>Calcaneofibular ligament (CFL) </li></ul>
Ankle sprain <ul><li>Grading </li></ul><ul><ul><li>Grade 1: no swelling, tenderness, microtear of ligament </li></ul></ul>...
General treatment <ul><li>RICE protocol </li></ul><ul><ul><li>Rest joint </li></ul></ul><ul><ul><li>Ice – applied for 20 m...
Treatment – lateral ankle sprains <ul><li>Grade 1 sprains </li></ul><ul><ul><li>Ambulate </li></ul></ul><ul><ul><li>Bandag...
Treatment – lateral ankle sprains <ul><li>Grade 2 sprains </li></ul><ul><ul><li>Brace, Support </li></ul></ul><ul><ul><li>...
Treatment – lateral ankle sprains <ul><li>Grade 3 sprains </li></ul><ul><ul><li>Casting to control pain and swelling (cont...
Ankle Sprain <ul><li>3 phase rehabilitation </li></ul><ul><ul><li>Inflammation: Medication, Short period immobilization </...
Early motion: ROM exercise, Gentle manipulation, modality?) <ul><li>Ankle motion </li></ul><ul><li>Subtalar motion </li></...
Ankle strengthening exercise <ul><li>Muscle power </li></ul><ul><li>Balance </li></ul><ul><li>Coordination </li></ul>
Muscle power <ul><li>Peroneal </li></ul><ul><li>Tibialis posterior </li></ul><ul><li>Tibialis anterior </li></ul><ul><li>T...
Balance and Coordination <ul><li>Core exercise </li></ul><ul><ul><li>Abdomen, Lateral body </li></ul></ul><ul><ul><li>Back...
Ankle sprain surgery <ul><li>Failed conservative treatment  (at least 3 months) </li></ul><ul><ul><li>Pain  </li></ul></ul...
Achilles tendon tear
Physical  Exam <ul><li>Tender in Achilles </li></ul><ul><li>Loss of profile, Gap </li></ul><ul><li>Thompson test +  </li><...
Achilles tear <ul><li>Casting VS Repair </li></ul><ul><li>Functional demand </li></ul><ul><li>Surgery </li></ul><ul><ul><l...
Achilles repair
Plantar fasciitis <ul><li>Most common plantar heel pain in adult </li></ul><ul><li>Plantar fascia inflammation/ tear </li>...
Risk Factors <ul><li>Middle age </li></ul><ul><li>Obesity, DM, Inflammatory joint disease  </li></ul><ul><li>Athletes  </l...
Diagnosis <ul><li>Location of pain </li></ul><ul><ul><li>Origin of plantar fascia from medial tubercle of the calcaneus </...
DDx <ul><li>Refer pain from spine </li></ul><ul><li>Nerve entrapment </li></ul><ul><ul><li>Tarsal tunnel syndrome  </li></...
Treatment <ul><li>Rest </li></ul><ul><li>NSAIDs </li></ul><ul><li>Stretching </li></ul><ul><li>Physical therapy </li></ul>...
Achilles stretching
PF Stretching <ul><li>More specific stretching of the plantar fascia employing the windlass mechanism may alleviate the ea...
Corticosteroid Injections <ul><li>Usually limited to 1-2 injections per heel </li></ul><ul><li>Temporary relief  </li></ul...
Surgery <ul><li>Reserved for cases resistant to conservative treatment </li></ul><ul><li>Subtotal plantar fascial release ...
Trigger finger <ul><li>Stenosing tenosynovitis of A1 pulley  </li></ul><ul><li>Snapping finger  </li></ul><ul><li>Digital ...
Trigger finger <ul><li>Pain </li></ul><ul><li>Tenderness </li></ul><ul><ul><li>A1 pulley </li></ul></ul><ul><ul><li>MCP le...
de Quervain <ul><li>Tenosynovitis of 1 st  extensor compartment </li></ul><ul><li>Abductor pollicis longus  </li></ul><ul>...
de Quervain <ul><li>Pain </li></ul><ul><li>Tenderness </li></ul><ul><li>Swelling </li></ul><ul><li>Finklestein test + </li...
Carpal tunnel syndrome (CTS) <ul><li>Median n. compression at wrist level </li></ul><ul><li>Symptom </li></ul><ul><ul><li>...
Carpal tunnel syndrome (CTS) <ul><li>Tinel sign </li></ul><ul><li>Phalen’s test </li></ul><ul><li>Check C-spine and proxim...
Trigger finger, de Quervain, CTS  <ul><li>Treatment </li></ul><ul><ul><li>Rest/ Modify activity </li></ul></ul><ul><ul><li...
Tennis elbow and Golfer elbow <ul><li>Lateral (tennis) and Medial (golfer) epicondylitis of humerus </li></ul><ul><li>Trea...
Summary <ul><li>Many orthopaedic problems can be treated conservatively </li></ul><ul><li>Aware of critical/ uncommon cond...
Thank you Any question? www.ortho.chuckpaiwong.com
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  • Statistically significant improvement in “worst pain” and pain c first steps in AM.
  • Davis et al reported the &lt;50% of patients with chronic heel pain were totally satisfied with the results of surgical intervention. Other’s have reported higher satisfaction rates, but with functional limitations.
  • ortho 06 common ortho dis 2 edited 12 mar 10

    1. 1. Common Orthopaedic Disorders ภาควิชาศัลยศาสตร์ออร์โธปิดิคส์และกายภาพบำบัด คณะแพทยศาสตร์ศิริราชพยาบาล Handout can be download at www.ortho.chuckpaiwong.com/presentation
    2. 2. Outlines <ul><li>Septic arthritis </li></ul><ul><li>Osteomyelitis </li></ul><ul><li>Ankle sprain </li></ul><ul><li>Achilles tendon tear </li></ul><ul><li>Plantar fasciitis </li></ul><ul><li>Trigger finger </li></ul><ul><li>De quarvain </li></ul><ul><li>Carpal Tunnel Syndrome (CTS) </li></ul>
    3. 3. Septic arthritis <ul><li>Acute suppurative (septic) arthritis </li></ul><ul><li>Tuberculous arthritis </li></ul>
    4. 4. Septic Arthritis <ul><li>Causal Organism </li></ul><ul><ul><li>Staph. Aureus </li></ul></ul><ul><ul><li>H. Influenzae in infant </li></ul></ul><ul><ul><li>Gonococcus in adults </li></ul></ul><ul><li>Predis p osing condition </li></ul><ul><ul><li>Rheumatoid arthritis </li></ul></ul><ul><ul><li>Chronic debilitating condition </li></ul></ul><ul><ul><li>IVDU, immunosup p ressive d rugs therapy </li></ul></ul><ul><ul><li>AIDS </li></ul></ul>
    5. 5. Septic arthritis <ul><li>Pain around the joint </li></ul><ul><li>Malaise, fever and constitutional symptom </li></ul><ul><li>Limit ROM due to pain </li></ul><ul><li>Flexion contracture </li></ul><ul><li>Refuse to walk (kids) </li></ul>
    6. 6. Septic Arthritis: Investigation <ul><li>WBC, ESR raising </li></ul><ul><li>Hemoculture may be positive </li></ul><ul><li>X-ray: widening of joint space </li></ul><ul><li>Ultrasound : joint effusion </li></ul><ul><li>Arthrocentesis & Joint fluid analysis </li></ul><ul><li>simple, quick, reliable </li></ul>
    7. 7. Joint Fluid Analysis <ul><li>Characteristics & color </li></ul><ul><ul><li>purulent, may be clear </li></ul></ul><ul><li>WBC count & differentiation </li></ul><ul><li>Gram stain & culture & sensitivity </li></ul>
    8. 8. Septic arthritis of the hip <ul><li>Treatment </li></ul><ul><ul><li>Symptomatic treatment </li></ul></ul><ul><ul><ul><li>Rest </li></ul></ul></ul><ul><ul><ul><li>Analgesia </li></ul></ul></ul><ul><ul><ul><li>Hydration/ Nutrition </li></ul></ul></ul><ul><ul><li>Drainage </li></ul></ul><ul><ul><ul><li>Aspiration </li></ul></ul></ul><ul><ul><ul><li>Open drainage </li></ul></ul></ul><ul><ul><ul><li>Arthroscopy </li></ul></ul></ul><ul><ul><li>Antibiotic 6-8 weeks </li></ul></ul><ul><ul><ul><li>IV </li></ul></ul></ul><ul><ul><ul><li>Oral </li></ul></ul></ul>
    9. 9. Osteomyelitis
    10. 10. Acute Hematogenous Osteomyelitis <ul><li>Incidence </li></ul><ul><ul><li>Mostly in children </li></ul></ul><ul><ul><li>Adults with immunocompromised </li></ul></ul><ul><li>Causative organism </li></ul><ul><ul><li>Staph. Aureus in all ages </li></ul></ul><ul><ul><li>H. Influenzae common in < 4 Y r . </li></ul></ul>
    11. 11. Clinical Findings <ul><li>Limb pain </li></ul><ul><li>Fever, malaise, failure to thrive </li></ul><ul><li>Metaphyseal tenderness </li></ul><ul><li>Painful, restricted joint motion </li></ul><ul><li>Local redness, swelling, warmth,edema </li></ul>
    12. 12. Diagnostic Images <ul><li>Plain X-ray </li></ul><ul><li>Ultrasound </li></ul><ul><li>Bone scan </li></ul><ul><li>MRI </li></ul>
    13. 13. Investigations <ul><li>CBC : Hb , WBC </li></ul><ul><li>C-reactive protein </li></ul><ul><li>ESR : usually remains </li></ul><ul><li>Hemoculture : 50% positive </li></ul><ul><li>Bone aspiration </li></ul>
    14. 14. Treatment of acute Osteomyelitis <ul><li>G eneral supportive treatment </li></ul><ul><ul><li>analgesia, IV fluid </li></ul></ul><ul><li>S plintage of the affected part </li></ul><ul><li>E ffective antibiotics therapy </li></ul><ul><ul><li>Older children & properly fit adults </li></ul></ul><ul><ul><ul><li>IV cloxacillin 1-2 wks + oral form 3-6 wks </li></ul></ul></ul><ul><ul><li>Children under 4 yo. </li></ul></ul><ul><ul><ul><li>cloxacillin + ampicillin </li></ul></ul></ul><ul><ul><ul><li>cephalolsporins (cefuroxime or cefotaxime) </li></ul></ul></ul><ul><ul><ul><li>co-amoxiclav. </li></ul></ul></ul><ul><ul><li>Immunocompromised host </li></ul></ul><ul><ul><ul><li>cloxacillin + gentamicin </li></ul></ul></ul><ul><ul><ul><li>cephalosporins ( ceftriaxone) </li></ul></ul></ul><ul><li>S urgical drainage </li></ul>
    15. 15. Chronic Osteomyelitis <ul><li>Etiology </li></ul><ul><ul><li>Sequel to acute hematogenous osteomyelitis </li></ul></ul><ul><ul><li>following open fracture </li></ul></ul><ul><ul><li>following operation </li></ul></ul><ul><li>Causative organisms </li></ul><ul><ul><li>Staph.aureus, E.coli, S.Pyogens, </li></ul></ul><ul><ul><li>Pro t eus, and Pseudomonas </li></ul></ul><ul><ul><li>Staph. Epidermidis </li></ul></ul><ul><ul><li>: common with implants </li></ul></ul>
    16. 16. Pathology <ul><li>Sequestrum </li></ul><ul><li>Involucrum </li></ul><ul><li>Clo a c ae </li></ul><ul><li>Sinus </li></ul>
    17. 17. Clinical Features <ul><li>R ecurrence of pain, pyrexia, redness and tenderness </li></ul><ul><li>D ischarging sinus </li></ul><ul><li>P athological fracture </li></ul><ul><li>N on-union </li></ul>
    18. 18. COM : X-Ray Finding
    19. 19. COM : Investigation <ul><li>WBC ESR </li></ul><ul><ul><li>non diagnostic </li></ul></ul><ul><ul><li>helpful for monitoring the progress of infection </li></ul></ul><ul><li>Culture & sensitivity of causative organism </li></ul><ul><ul><li>should be test repeatedly </li></ul></ul><ul><ul><li>often change and become resisted </li></ul></ul>
    20. 20. COM : Treatment <ul><li>Antibiotics </li></ul><ul><ul><li>depends on bact. Study </li></ul></ul><ul><ul><li>capable to penetrates sclerotic bone </li></ul></ul><ul><ul><li>non-toxic for long term use </li></ul></ul><ul><li>Surgery </li></ul><ul><ul><li>significant symptoms + clear evidence of sequestrum </li></ul></ul>
    21. 21. Ankle sprain <ul><li>Lateral ankle sprain </li></ul><ul><li>Medial ankle sprain </li></ul><ul><li>Syndesmotic sprain (High ankle sprain) </li></ul>
    22. 22. Ankle sprain <ul><li>Correct diagnosis should be made </li></ul>
    23. 23. <ul><li>Anterior talofibular ligament (ATFL) </li></ul><ul><li>Calcaneofibular ligament (CFL) </li></ul>
    24. 24. Ankle sprain <ul><li>Grading </li></ul><ul><ul><li>Grade 1: no swelling, tenderness, microtear of ligament </li></ul></ul><ul><ul><li>Grade 2: Mild to Mod swelling, tenderness, Patial tear of ligament </li></ul></ul><ul><ul><li>Grade 3: Severe swelling, marked tenderness, complete tear of ligament </li></ul></ul>
    25. 25. General treatment <ul><li>RICE protocol </li></ul><ul><ul><li>Rest joint </li></ul></ul><ul><ul><li>Ice – applied for 20 minutes every couple hours </li></ul></ul><ul><ul><li>Compression – elastic wrap </li></ul></ul><ul><ul><li>Elevate limb above heart </li></ul></ul>
    26. 26. Treatment – lateral ankle sprains <ul><li>Grade 1 sprains </li></ul><ul><ul><li>Ambulate </li></ul></ul><ul><ul><li>Bandage </li></ul></ul><ul><ul><li>Complete ligament healing in 2-3 weeks </li></ul></ul>
    27. 27. Treatment – lateral ankle sprains <ul><li>Grade 2 sprains </li></ul><ul><ul><li>Brace, Support </li></ul></ul><ul><ul><li>Complete healing within 6-8 weeks </li></ul></ul>
    28. 28. Treatment – lateral ankle sprains <ul><li>Grade 3 sprains </li></ul><ul><ul><li>Casting to control pain and swelling (controversial) </li></ul></ul><ul><ul><li>Complete healing 8 – 12 weeks </li></ul></ul>
    29. 29. Ankle Sprain <ul><li>3 phase rehabilitation </li></ul><ul><ul><li>Inflammation: Medication, Short period immobilization </li></ul></ul><ul><ul><li>Early motion: ROM exercise, Gentle manipulation, modality?) </li></ul></ul><ul><ul><li>Strengthening exercise </li></ul></ul>
    30. 30. Early motion: ROM exercise, Gentle manipulation, modality?) <ul><li>Ankle motion </li></ul><ul><li>Subtalar motion </li></ul>1-3 week
    31. 31. Ankle strengthening exercise <ul><li>Muscle power </li></ul><ul><li>Balance </li></ul><ul><li>Coordination </li></ul>
    32. 32. Muscle power <ul><li>Peroneal </li></ul><ul><li>Tibialis posterior </li></ul><ul><li>Tibialis anterior </li></ul><ul><li>Toe flexor/extensor </li></ul><ul><li>Intrinsic muscle </li></ul>
    33. 33. Balance and Coordination <ul><li>Core exercise </li></ul><ul><ul><li>Abdomen, Lateral body </li></ul></ul><ul><ul><li>Back (upper, lower) </li></ul></ul><ul><ul><li>Groin </li></ul></ul><ul><ul><li>Chest </li></ul></ul><ul><li>Body balance </li></ul><ul><ul><li>Single leg stance </li></ul></ul><ul><ul><li>Straight line walking </li></ul></ul><ul><ul><li>Balance board </li></ul></ul><ul><ul><li>Side walk </li></ul></ul>
    34. 34. Ankle sprain surgery <ul><li>Failed conservative treatment (at least 3 months) </li></ul><ul><ul><li>Pain </li></ul></ul><ul><ul><li>Instability </li></ul></ul><ul><li>Ankle arthroscopic debridement </li></ul><ul><li>Ankle ligament reconstruction (Mod Brostorm repair) </li></ul>
    35. 35. Achilles tendon tear
    36. 36. Physical Exam <ul><li>Tender in Achilles </li></ul><ul><li>Loss of profile, Gap </li></ul><ul><li>Thompson test + </li></ul><ul><li>Excessive DF </li></ul><ul><li>Weak PF </li></ul>
    37. 37. Achilles tear <ul><li>Casting VS Repair </li></ul><ul><li>Functional demand </li></ul><ul><li>Surgery </li></ul><ul><ul><li>Faster recovery </li></ul></ul><ul><ul><li>Better strength </li></ul></ul><ul><ul><li>Lower re rupture rate </li></ul></ul><ul><ul><li>Risk of surgery </li></ul></ul>
    38. 38. Achilles repair
    39. 39. Plantar fasciitis <ul><li>Most common plantar heel pain in adult </li></ul><ul><li>Plantar fascia inflammation/ tear </li></ul><ul><li>Pain </li></ul><ul><ul><li>Morning pain or after a period of rest. </li></ul></ul><ul><ul><li>Improve with activity </li></ul></ul><ul><ul><li>No rest and no night pain </li></ul></ul>
    40. 40. Risk Factors <ul><li>Middle age </li></ul><ul><li>Obesity, DM, Inflammatory joint disease </li></ul><ul><li>Athletes </li></ul><ul><li>Repetitive stress </li></ul><ul><li>Changes in activity </li></ul><ul><li>Abnormal foot biomechanics </li></ul><ul><ul><li>Pes cavus </li></ul></ul><ul><ul><li>Pes planus-TA tightness </li></ul></ul><ul><li>Bad shoes </li></ul>
    41. 41. Diagnosis <ul><li>Location of pain </li></ul><ul><ul><li>Origin of plantar fascia from medial tubercle of the calcaneus </li></ul></ul><ul><ul><li>May be aggravated by passive dorsiflexion of the toes </li></ul></ul><ul><ul><li>Pain may radiate distally along plantar fascia </li></ul></ul>www.your-feet.com
    42. 42. DDx <ul><li>Refer pain from spine </li></ul><ul><li>Nerve entrapment </li></ul><ul><ul><li>Tarsal tunnel syndrome </li></ul></ul><ul><li>Stress Fx, Calcaneal epiphysitis (Sever disease) </li></ul><ul><li>Tumor </li></ul><ul><li>Infection </li></ul><ul><li>Inflammatory disorder </li></ul><ul><li>Fat pad Disorder </li></ul><ul><li>Plantar fibromatosis </li></ul><ul><li>Achilles disorders, FHL tendinitis </li></ul>Not all heel pain is Plantar Fasciitis
    43. 43. Treatment <ul><li>Rest </li></ul><ul><li>NSAIDs </li></ul><ul><li>Stretching </li></ul><ul><li>Physical therapy </li></ul><ul><li>Shoe inserts </li></ul><ul><li>Orthotics </li></ul><ul><li>Night Splints </li></ul><ul><li>Casting </li></ul><ul><li>Corticosteroid injections </li></ul><ul><li>ESWT (Orthotripsy) </li></ul><ul><li>Surgery </li></ul><ul><li>Standard care is conservative but 10% still fail to respond </li></ul>
    44. 44. Achilles stretching
    45. 45. PF Stretching <ul><li>More specific stretching of the plantar fascia employing the windlass mechanism may alleviate the early morning pain better. </li></ul><ul><li>DiGiovanni, JBJS 85, 1270-7, 2003. </li></ul>
    46. 46. Corticosteroid Injections <ul><li>Usually limited to 1-2 injections per heel </li></ul><ul><li>Temporary relief </li></ul><ul><li>May predispose to </li></ul><ul><ul><li>fascial rupture </li></ul></ul><ul><ul><li>heel pad atrophy </li></ul></ul>Do not recommended !!!
    47. 47. Surgery <ul><li>Reserved for cases resistant to conservative treatment </li></ul><ul><li>Subtotal plantar fascial release </li></ul><ul><li>Preserve at least 50% of lateral fibers </li></ul><ul><li>May lead to decrease in arch stability </li></ul><ul><ul><li>Pfeffer GB, ICL, Vol 50, 2001 </li></ul></ul>cms.depuy.com
    48. 48. Trigger finger <ul><li>Stenosing tenosynovitis of A1 pulley </li></ul><ul><li>Snapping finger </li></ul><ul><li>Digital tendovaginitis stenosus </li></ul><ul><li>Chronic stenosing tendovaginitis </li></ul>
    49. 49. Trigger finger <ul><li>Pain </li></ul><ul><li>Tenderness </li></ul><ul><ul><li>A1 pulley </li></ul></ul><ul><ul><li>MCP level </li></ul></ul><ul><li>Swelling </li></ul><ul><li>Locking </li></ul>
    50. 50. de Quervain <ul><li>Tenosynovitis of 1 st extensor compartment </li></ul><ul><li>Abductor pollicis longus </li></ul><ul><li>Extensor pollicis brevis </li></ul>
    51. 51. de Quervain <ul><li>Pain </li></ul><ul><li>Tenderness </li></ul><ul><li>Swelling </li></ul><ul><li>Finklestein test + </li></ul>
    52. 52. Carpal tunnel syndrome (CTS) <ul><li>Median n. compression at wrist level </li></ul><ul><li>Symptom </li></ul><ul><ul><li>Pain </li></ul></ul><ul><ul><li>Numbness </li></ul></ul><ul><ul><li>Weakness, Thenar muscle atrophy </li></ul></ul><ul><li>Transverse carpal ligament (flexor retinaculum) : Thickening </li></ul>
    53. 53. Carpal tunnel syndrome (CTS) <ul><li>Tinel sign </li></ul><ul><li>Phalen’s test </li></ul><ul><li>Check C-spine and proximal nerve </li></ul>
    54. 54. Trigger finger, de Quervain, CTS <ul><li>Treatment </li></ul><ul><ul><li>Rest/ Modify activity </li></ul></ul><ul><ul><li>Medication </li></ul></ul><ul><ul><li>Physiotherapy </li></ul></ul><ul><ul><li>Cortisone injection </li></ul></ul><ul><ul><li>Decompression (Surgery) </li></ul></ul>
    55. 55. Tennis elbow and Golfer elbow <ul><li>Lateral (tennis) and Medial (golfer) epicondylitis of humerus </li></ul><ul><li>Treatment </li></ul><ul><ul><li>RICE </li></ul></ul><ul><ul><li>Activity modification </li></ul></ul><ul><ul><li>Immobilization </li></ul></ul><ul><ul><li>Medication </li></ul></ul><ul><ul><li>Exercise </li></ul></ul><ul><ul><li>Cortisone injection </li></ul></ul><ul><ul><li>Surgery </li></ul></ul>
    56. 56. Summary <ul><li>Many orthopaedic problems can be treated conservatively </li></ul><ul><li>Aware of critical/ uncommon condition </li></ul><ul><ul><li>Infection </li></ul></ul><ul><ul><li>Malignancy </li></ul></ul><ul><ul><li>NV damage </li></ul></ul><ul><li>Selectively refer case based on appropriate knowledge </li></ul>
    57. 57. Thank you Any question? www.ortho.chuckpaiwong.com

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