2/20/2018 DUPUYTREN S CONTRACTURE. Palmar fibrosis COMMON ORTHOPAEDIC CONDITIONS ENCOUNTERED IN PRIMARY CARE NO DISCLOSURES UPPER EXTREMITY

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1 COMMON ORTHOPAEDIC CONDITIONS ENCOUNTERED IN PRIMARY CARE NO DISCLOSURES Lori Bretschneider MSN,APRN,ONC DUPUYTREN S CONTRACTURE Palmar fibrosis UPPER EXTREMITY DUPUYTREN S CONTRACTURES Thickening and adhesion formation of the soft tissue within the palmar fascia See more in Scandinavian/Scottish decent Men to women, smokers alcoholics, repetitive mechanical shock, seizures and after distal radius fractures DUPUYTREN S CONTRACTURES 1

2 Splinting with OT Xiaflex Surgery for contractures greater than 30 XIAFLEX enzyme produced by bacterium clostridium histolyticum dismantles collagen Requires training Approved in 2010 for use in Dupuytrens GANGLION CYSTS GANGLION GANGLIONS GANGLIONS Acute vs chronic Functional vs cosmetic Volar vs Dorsal Dorsal ganglions arise from tendon or joints, most common Volar cysts can also arise from tendons of joints, but also be close to nerves and blood vessels 2

3 TRIGGER FINGERS NSAID Bracing Aspirate and inject (50% will return) Surgery Tendinitis of flexor tendon at the level of the A-1 pulley Causes finger to lock or trigger See in RA, gout and diabetes, repeated in strong grip activities TRIGGER FINGER Nsaid Hand therapy Splinting Injection CARPAL TUNNEL CARPAL TUNNEL Numbness and tingling in the median nerve distribution Usually worse at night See with pregnancy, some jobs, after fractures of the wrist,diabetes,thyroid disease 3

4 EVALUATION Tinel test, Allen test, Phalen test Thenar mass atrophy,weakness of thumb abduction NCS(nerve conduction study) CARPAL TUNNEL DEQUERVAINS TENDONITIS DEQUERVAIN S Tendonitis of first dorsal compartment DEQUERVAINS TENDONITIS DEQUERVAINS TENDONITIS EVALUATION Pain with turning wrist,grasping, or making a fist May feel snapping or squeaking sensation Swelling over tendons Overuse, pregnancy, RA, diabetes More common in women 4

5 DEQUERVAINS TENDONITIS DEQUERVAINS TENDONITIS BRACING NSAID Brace x one month Physical therapy Inject with steroids Surgery OLECRANON BURSITIS OLECRANON BURSITIS Inflammation of the bursa overlying the elbow OLECRANON BURSITIS Goose egg presentation Acute vs Chronic Find irritating factor Think gout or infection Aspirate for gram stain and culture and sensitivity Treat for inflammation Aspirate and inject with steroids Protect elbow 5

6 PEARL NEVER inject with cortisone if any chance of infection EPICONDYLITIS Inflammation of the tendons that join the muscles of the forearm to the elbow Medial vs Lateral EPICONDYLITIS LATERAL/MEDIAL EPICONDYLITIS From repetitive forceful gripping and lifting Sports such as tennis and golf Occupations such as plumbers, painters, carpenters and butchers EVALUATION EPICONDYLITIS Pain over epicondyle Swelling Pain with resistance against wrist extension, and forced supination Weakness Numbness, tingling Tennis elbow strap NSAID (oral or topical) Injection Physical therapy Surgery 6

7 ALTERNATIVE BRACING NSAIDS Oral Topical: Patches Compounding ointments NSAID NSAID Dosing: Once daily: Celebrex, Mobic, Piroxicam Price: Diclofenac 75mg,Ibuprofen 400,600,800mg, Indocin25mg,Naproxen 3l75,500mg,Meloxicam 7.5,15mg Dual: Duexis (Ibuprofen 800/famotidine 26.6mg) Vimvo (Naprosyn 375 or 500mg/ esomeprazole 20mg Use lowest effective dose for shortest effective duration NSAID CONSIDERATION Hx of anticoagulants, antiplatelet Kidney disease Cardiac disease Gastric bypass Reflux or hx ulcer, GI bleed TOPICAL NSAID Voltaren Gel 1%: 2-4gm QID Pennsaid: 2 pumps BID (only indication is OA knee) Ketoprofen Gel : ( compounding pharmacy) BID Compounding ointment (specialty pharmacy) 7

8 NSAID PATCH ROTATOR CUFF PATHOLOGY Flector patch 1.3% BID (Only indication is acute pain) Tendonitis Bursitis Impingement TENDONITIS ROTATOR CUFF 4 tendons that form the roof of the shoulder Supraspinatus Subscapularis Infraspinatus Teres Minor BURSITIS A bursa is a tiny fluid-filled sac that functions as a gliding surface to reduce friction between tissues of the body Pinching of rotator cuff between humerus and acromion Can be activity related or anatomical IMPINGEMENT 8

9 SYMPTOMS PEARL Pain with overhead activities Pain with ADL s (donning shirt, putting on bra, tucking in shirt, taking wallet out, combing hair Acute vs Chronic Night time pain think Rotator cuff pathology Crepitus with gentle ROM think OA Acute: NASID Sling Physical therapy SLING Chronic NSAID or injection Physical therapy MRI Surgery SHOULDER IMMOBILIZERS LOWER EXTREMITY 9

10 COMMON HIP COMPLAINTS TROCHANTERIC BURSITIS Where do you feel the pain OA of the hip usually presents with groin pain/ anterior thigh pain Patients that present with radicular pain think back as source Pain directly lateral, think trochanteric bursitis TROCHANTERIC BURSITIS Inflammation of the bursa over the trochanteric area of hip From falls,overuse,abnormal posture(scoliosis),previous surgery, bone spurs or calcium deposit in tendons More common in women Pain directly over lateral hip Pain with lying on it getting up, stairs NSAID (oral, topical or patch) Heating pad Physical therapy Injection Surgery DRY NEEDLING ACUTE KNEE INJURIES Assess mechanism of injury(mva,sports injury, stepped in hole) Meniscus: complain about catching, locking or something is slipping, comes and goes Ligament: gives out 10

11 ACUTE ACL INJURIES ACUTE KNEE INJURIES 3 Questions: Did you hear or feel a pop? Were you able to continue? Did your knee swell right away? Dx: initial exam may be limited,x-ray PEARL X-rays are STILL the gold standard of imaging RICE NSAID Crutches Bracing KNEE IMMOBILIZER OA KNEE 11

12 OA KNEE Wear and tear Previous meniscectomy Previous fracture or injury Obesity NSAIDS Injections Physical therapy Bracing Surgery Weight loss INJECTIONS ANKLE SPRAINS Cortisone: attacks inflammation Can be repeated every 3 months Ottawa Scale (to determine if x-rays are needed) order 3 views always 3 grades of ankle sprains Hyuronic acid injections: lubricate joint Can be repeated every 6 months Only indication is for OA of knee Always squeeze the proximal fibula (Maisonneuve fracture) ANKLE SPRAINS MAISONNEUVE FRACTURE WIDENED MORTISE 12

13 ANKLE SPRAINS INITIAL Rule of 3: 3 days of pure misery 3 weeks of misery 3 months to rehab NSAID Walking boot, 1-3 weeks Crutches or walker, start non weight bearing and progress Physical Therapy WALKING BOOT ASO ANKLE BRACE ASO ANKLE BRACE PLANTAR FASCIITIS Indications: ankle sprains, good to return to sports or work Script, Off the shelf, on line Comes in xxsm xx xl, universal Cost: $30-40 Inflammation of the tough fibrous band of tissue in the plantar aspect of the foot. Inserts in the calcaneus and goes out to the toes along the arch of the foot 13

14 PLANTAR FASCIITIS PLANTAR FASCIITIS See more in women, those overweight, jobs that require standing or walking on concrete, runners with tight calf muscles, those with flat feet or very high arches Heel pain that is worse with standing, 1 st thing in the morning and after periods of rest PEARL PLANTAR SPUR Heel spurs are the RESULT of chronic inflammation, NOT the cause of plantar fasciitis PLANTAR FASCIITIS PLANTAR FASCIITIS NIGHTTIME SPLINT TX: heel pads, heel cups,nsaids, rest, exercises stretching, taping, night time splints, walking cast, walking boot, custom orthotics, injections, surgery 14

15 PLANTAR FASCSIITIS HEEL PADS PLANTAR FASCIITIS HAMMERTOES Contracture of proximal phalanges(s) Flexible vs fixed contracture Ulcer can arise on top of the toe TX: hammertoe pads (dx: hammer toe () foot, single or double hammertoe pad), surgery HAMMERTOES HAMMERTOE PADS HAMMERTOE REPAIR 15

16 BUNIONS HALLUX VALGUS NIGHT TIME SPLINT Hallux valgus deformity of the base of the metatarsophalangeal joint See more in women, tight narrow shoes, familial tendency Tx: prevention, night time splint, spacer TOE SPACER MORTON S NEUROMA Thickening of the tissue that surrounds the digital nerve in the toe Most common is found between 3rd and 4th toes in the web space c/o of burning in the foot the is intensified with activity and shoe wear Dx: by history, squeeze test,mri MORTON S NEUROMA MORTON S NEUROMA Tx: change footwear, orthotics or pads, cortisone injection, surgery 16

17 MORTON S NEUROMA PAD PEARL Common things occur commonly QUESTIONS 17