Below the Elbow, Below the Knee Orthopedics. Ted Parks, MD

Transcription

1 Below the Elbow, Below the Knee Orthopedics Ted Parks, MD

2 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.

3 Carpal Tunnel Syndrome Trigger Finger DeQuervaine s Syndrome Thumb basal joint arthritis (1 st CMC OA) Morton s Neuroma Plantar Fasciitis Bunions and Hammertoes Ankle Sprains and Fractures

4 Carpal Tunnel Syndrome

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9 Tendons High content of: -collagen fibers -connective tissue matrix Low content of: -cells -blood vessels -nerves Low metabolic rate

10 Nerve Axons Schwann cells (myelin) Complex micro vascular system High metabolic rate

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12 Carpal Tunnel Symptoms Pain Numbness Tingling In the Median Nerve Distribution!

13 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)

14 Tinel s Test

15 Phalen s Test

16 Thenar Muscle Atrophy

17 Etiology Trauma Ergonomics Arthritis Pregnancy Thyroid dysfunction

18 Treatment Eliminate the source of swelling NSAIDs Braces Cortisone injections

19 Treatment Eliminate the source of swelling NSAIDs Braces Cortisone injections

20 Treatment Eliminate the source of swelling NSAIDs Braces Cortisone injections

21 Treatment Eliminate the source of swelling NSAIDs Braces Cortisone injections

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26 Injection Site: Midline, 2cm distal to the distal wrist crease

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30 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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32 Surgery

33 Surgery

34 Surgery

35 Trigger Finger

36 Trigger Finger Finger locks in the flexed position Painful flexor tendon nodule

37 Finger Anatomy

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39 Finger Anatomy

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41 Finger Anatomy

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44 Treatment Options Extension splint NSAIDs Cortisone Injection

45 Cortisone Injection Technique: Inject midline, 2cm proximal to the MCP joint crease

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47 Surgery Safe Simple Effective

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49 Surgery

50 THUMB PAIN De Quervain s tendonitis vs 1 st CMC joint arthritis

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52 Finklestein s Test

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56 Arthritis at the Base of the Thumb AKA: Basal joint arthritis, 1 st CMC arthritis, Trapezio-metacarpal joint arthritis

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62 Surgery

63 Common Foot and Ankle problems Morton s Neuroma Plantar Fasciitis Bunions and Hammertoes Ankle Sprains and Fractures

64 Anatomy

65 Anatomy

66 Anatomy

67 Anatomy

68 Anatomy

69 Anatomy

70 Anatomy

71 Morton s Neuroma

72 Morton s Neuroma: Symptoms Pain: - may radiate to toes - feels like a pebble - worse with high heeled shoes Numbness Most = 3 rd webspace

73 Morton s Neuroma

74 Morton s Neuroma: Symptoms Pain: - may radiate to toes - feels like a pebble - worse with high heeled shoes Numbness Most = 3 rd webspace

75 Morton s Neuroma: Exam Splayed toes, fullness Palpable plantar mass Metatarsal shift test Loss of sensation

76 Morton s Neuroma: other tests X-rays EMGs, NCS MRI

77 Treatment: Conservative Shoe modification Wide Soft Low heel Metatarsal supports Cortisone injections

78 Treatment: Conservative Shoe modification Wide Soft Low heel Metatarsal supports Cortisone injections

79 Cortisone Injection

80 Inject from dorsal side Cortisone Injection 1.5 cm proximal to web Between the metatarsal heads Go about 1cm deep 1cc steroid, 1cc lidocaine

81 Treatment: Surgery

82 Plantar Fasciitis

83 History Most common ages More common in men than women Running/Impact sports Plantar heel pain Symptoms Often worse in AM

84 Physical Exam Tender to palpation plantar heel r/o calcaneal stress fracture with squeeze test

85 X-rays: The Bone Spur

86 Bone Spur

87 NSAIDs Treatment

88 Calf stretches Treatment

89 Heel pads Treatment

90 Plantar massage Treatment

91 Night splints Treatment

92 Treatment: Conservative Short leg walking cast

93 Treatment (controversial) Cowboy boots

94 Treatment (controversial) E.S.W.T. (extracorporal shock wave treatment)

95 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! Cortisone Injection

96 Surgery

97 Achilles Tendonitis

98 Treatment Calf stretches Night splints NSAIDS Casting Cortisone injections are NOT recommended Surgical debridement (rare) Not associated with tendon rupture (unless injected)

99 Bunions, Hammertoes and Corns

100 Bunions

101 Hammertoes

102 Corns

103 Corns

104 Bunions and Hammertoes Very common Often asymptomatic Only need to treat if: - pain - skin breakdown

105 Conservative Treatment: Devices Stick on pads (bunions and hammertoes) Toe spacers Medial bunion pad Abduction braces

106 Conservative Treatment Orthopedic Shoes Wide, roomy toe box Soft Low heels Usually ugly

107 Surgery Pain Skin breakdown

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109 Ankle Injuries: Sprains vs Fractures

110 Ankle Injuries: Sprains vs Fractures

111 Sprain vs Fracture?

112 Ankle Sprain

113 Ankle Sprain

114 Ankle Sprain Inversion Sprain (most common)

115 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

116 Ankle Sprain

117 Frank C, Woo S.L. et al, Am J Sports Med Nov-Dec;11(6): Created ligament injuries in mice Compared immobilization to motion

118 Motion Immobilization

119 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

120 When sprains don t get better Calcaneus anterior process fracture

121 When sprains don t get better Chondral injury of the talus

122 When sprains don t get better Inversion stress x-ray showing failure of lateral ligaments to heal

123 Ankle Fractures

124 Ankle Fracture

125 Ankle Fracture

126 Ankle Fracture

127 Sprain vs Fracture Should we get an x-ray?

128 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:

129 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