Title: Tendinitis and Bursitis
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2Bursitis ???
3- ?????????????????????????????,?????????????,?????,
?????????????,?????????????????????????????????,??
?????,???????????,?????????????????????????? - Bursae are sacs lined with a membrane similar to
synovium they usually are located about joints
or where skin, tendon, or muscle moves over a
bony prominence. - may or may not communicate with a joint.
- Function reduce friction, protect delicate
structures from pressure.
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5- Bursae are similar to tendon sheaths and the
synovial membranes of joints and are subject to
the same disturbances (1) acute or chronic
trauma, (2) acute or chronic pyogenic???
infection, and (3) low-grade inflammatory
conditions such as gout, syphilis, tuberculosis,
or rheumatoid arthritis. - Two types of bursae normally present (as over
the patella and olecranon) and adventitious ones
(such as develop over a bunion???, an
osteochondroma????, or kyphosis?? of the spine).
Adventitious bursae are produced by repeated
trauma or constant friction?? or pressure.
6- ???????????????????,???????????????????(?????),??
???,???(?????)?????????????,?????????????,????????
??,?????????????????????????
7- Treatment---the cause of the bursitis
- Systemic causes, such as gout?? or syphilis??,
and local trauma or irritants should be
eliminated, and, when necessary, the patient's
occupation or posture should be changed. One or
more of the following local measures usually are
helpful Rest, hot wet packs, elevation, and, if
necessary, immobilization of the affected part.
8- Surgical procedures useful in treating bursitis
are (1) aspiration and injection of an
appropriate drug, (2) incision and drainage when
an acute suppurative ???bursitis fails to respond
to nonsurgical treatment, (3) excision of
chronically infected and thickened bursae, and
(4) removal of an underlying bony prominence.
9Carpal Tunnel Syndrome?????
- (another name tardy median palsy) results from
compression of the median nerve within the carpal
tunnel. The syndrome consists predominantly of
tingling?? and numbness in the typical median
nerve distribution in the radial three and
one-half digits (thumb, index, long, radial side
of ring). Pain occurs diffusely in the hand and
radiates up the forearm. Thenar?? atrophy usually
is seen later in the course of the nerve
compression.
innervated
10- The syndrome frequently is associated with
nonspecific tenosynovial edema and rheumatoid
tenosynovitis, as are trigger finger and de
Quervain disease. Some studies reported biopsy
specimens of the flexor tendon synovium from 21
patients with idiopathic??? carpal tunnel
syndrome. The findings were similar in all and
were typical of a connective tissue????
undergoing degeneration under repeated mechanical
stress.
11Diagnosis
- Paresthesia???? over the sensory distribution of
the median nerve is the most frequent symptom it
occurs more often in women and frequently causes
the patient to awaken several hours after getting
to sleep with burning and numbness of the hand
that is relieved by exercise. The Tinel sign may
be demonstrated in most patients by percussing??
the median nerve at the wrist. Atrophy to some
degree of the median-innervated thenar muscles
has been reported in about half of the patients
treated by operation.
12- Acute flexion of the wrist for 60 seconds in some
but not all patients or strenuous use of the hand
increases the paresthesia. Application of a blood
pressure cuff on the upper arm sufficient to
produce venous distention may initiate the
symptoms. Some studies evaluated the clinical
usefulness of commonly administered provocative
tests, including wrist flexion, nerve percussion,
and the tourniquet test, in 67 hands with
electrical proof of carpal tunnel syndrome and in
50 control hands.
13Diagnosis
- The most sensitive test was the wrist flexion
test, whereas nerve percussion was the most
specific and the least sensitive. They also found
that with the wrist in neutral position, the mean
pressure within the carpal tunnel in patients
with carpal tunnel syndrome was 32 mm Hg. This
pressure increased to 99 mm Hg with 90 degrees of
wrist flexion and to 110 mm Hg with the wrist at
90 degrees of extension. The pressures in the
control subjects with the wrist in neutral
position were 25 mm Hg, 31 mm Hg with the wrist
in flexion, and 30 mm Hg with the wrist in
extension.
14- Sensibility testing in peripheral nerve
compression syndromes was investigated, found
that threshold tests of sensibility correlated
accurately with symptoms of nerve compression and
electrodiagnostic studies.
15- Electrodiagnostic??? studies are reliable
confirmatory tests. Ultrasonography???? has been
used to show the movement of the flexor tendons
within the carpal tunnel, but it does not clearly
show soft tissue planes. Early reports of
magnetic resonance imaging (MRI) in carpal tunnel
syndrome are promising. A major advantage of MRI
is its high soft tissue contrast, which gives
detailed images of both bones and soft tissues.
Care should be taken not to confuse this syndrome
with nerve compression caused by a cervical disc
herniation, thoracic outlet structures, and
median nerve compression proximally in the
forearm and at the elbow.
16Treatment
- If mild symptoms have been present and there is
no thenar muscle atrophy, the injection of
hydrocortisone into the carpal tunnel may afford
relief. Great care should be taken not to inject
directly into the nerve. Injection also can be
used as a diagnostic tool in patients without
bony or tumorous blocking of the canal
17- 65 of these cases probably are caused by a
nonspecific synovial edema, and these seem to
respond more favorably to injection. Injection
also helps to eliminate the possibility of other
syndromes, especially cervical disc or thoracic
outlet syndrome. Some patients prefer to receive
injections two or three times before a surgical
procedure is carried out. If the response is
positive and there is no muscle atrophy,
conservative treatment with splinting and
injection is reasonable.
18Treatment
- If signs and symptoms are persistent and
progressive, especially if they include thenar
atrophy, division of the deep transverse carpal
ligament is indicated. The results of surgery are
good in most instances, and benefits seem to last
in most patients.
19- Although thenar atrophy may disappear, it
resolves slowly, if at all. As noted earlier,
when symptoms of median nerve compression develop
during treatment of an acute Colles fracture, the
constricting bandages and cast should be loosened
and the wrist should be extended to neutral
position. When median nerve palsy develops after
a Colles fracture and has gone unrecognized for
several weeks, surgery is indicated without
further delay.
20Lateral epicondylitis??????
- Lateral epicondylitis (tennis elbow), a familiar
term used to described a myriad of symptoms about
the lateral aspect of the elbow, occurs more
frequently in nonathletes than athletes, with a
peak incidence in the early fifth decade and a
nearly equal gender incidence. - Activities that require repetitive supination and
pronation of the forearm with the elbow in near
full extension.
21- Tenderness is present over the lateral epicondyle
approximately 5 mm distal and anterior to the
midpoint of the condyle. Pain usually is
exacerbated by resisted wrist dorsiflexion and
forearm supination, and there is pain when
grasping objects. Plain roentgenograms usually
are negative occasionally calcific tendinitis
may be present. MRI demonstrates tendon
thickening with increased T1 and T2 signals but
generally is not indicated.
22- Regardless of the underlying cause, nonoperative
treatment is successful in 95 of patients with
tennis elbow. Initial nonoperative treatment
includes rest, ice, injections, and physical
therapy centered around treatment such as
ultrasound, electrical stimulation, manipulation,
soft tissue mobilization, friction massage,
stretching and strengthening exercises, and
counter-force bracing. - If prolonged (6 to 12 months), operative
treatment may be considered it is effective in
90 of properly selected patients.
23- Adhesive Capsulitis
- (frozen shoulder.)
- ????????
24- Frozen shoulders in patients who report no
inciting event and with no abnormality on
examination (other than loss of motion) or plain
roentgenograms were designated as "primary," and
those with precipitant traumatic injuries as
"secondary." This division helps in planning
treatment but does not necessarily predict
outcome.
25- No formal inclusion criteria. There are no
universally accepted criteria for the diagnosis
of frozen shoulder. internal rotation frequently
is lost initially, followed by loss of flexion
and external rotation.
26- The incidence of frozen shoulder in the general
population is approximately 2. (an increased
incidence associated with, including diabetes
mellitus (up to 5 times more), cervical disc
disease, hyperthyroidism, intrathoracic
disorders, and trauma). People between the ages
of 40 and 70 are more commonly affected. Common
to almost all patients is a period of immobility,
the etiologies of which are diverse
27Primary Frozen Shoulder
- Primary frozen shoulder is a vague entity that
only rarely recurs in the same shoulder. The
clinical course of primary (idiopathic) frozen
shoulder consists of three phases. - Phase IPain. Patients usually have a gradual
onset of diffuse shoulder pain, which is
progressive over weeks to months. The pain
usually is worse at night and is exacerbated by
lying on the affected side. As the patient uses
the arm less, pain leading to stiffness ensues.
28Primary Frozen Shoulder
- Phase IIStiffness. Patients seek pain relief by
restricting movement. This heralds the beginning
of the stiffness phase, which usually lasts 4 to
12 months. Patients describe difficulty with
activities of daily living men have trouble
getting to their wallets and women with fastening
brassieres. As stiffness progresses, a dull ache
is present nearly all the time (especially at
night), and this often is accompanied by sharp
pain during range of motion at or near the new
endpoints of motion.
29Primary Frozen Shoulder
- Phase IIIThawing. This phase lasts for weeks or
months, and as motion increases, pain diminishes.
Without treatment (other than benign neglect)
motion return is gradual in most but may never
objectively return to normal, although most
patients subjectively feel near normal, perhaps
as a result of compensation or adjustment in ways
of performing activities of daily living.
30Secondary Frozen Shoulder
- Unlike patients with idiopathic frozen shoulder,
patients with secondary frozen shoulder can
recall a specific precipitating event, possibly
related to overuse or injury. The three phases of
classic frozen shoulder may not all be present
and may not follow the previously outlined
chronology fortunately, treatment for the two
entities is similar.
31Diagnosis
- tests in patients with a frozen shoulder
(including plain film roentgenograms) usually are
normal, except in those with medical disorders
such as diabetes or thyroid disease. Bone scans
have been reported to be positive in some
patients. - Arthrograms characteristically show a reduced
joint volume with irregular margins. Clinical
improvement has been reported after arthrography
because of brisement of adhesions from forcefully
injecting fluid into the joint. A volume of less
than 10 ml and lack of filling of the axillary
fold currently are accepted arthrographic
findings indicative of a frozen shoulder.
32Treatment
- Traditionally, frozen shoulder has been
considered a self-limiting condition, lasting 12
to 18 months. - Approximately 10 of patients have long-term
problems. Patients seeking care earlier usually
recover more quickly. Dominant shoulder
involvement has been reported to be predictive of
a good result, whereas occupation and treatment
programs are not statistically significant.
Obviously, the best treatment of frozen shoulder
is prevention (secondary frozen shoulder), but
early intervention is of paramount importance a
good understanding of the pathological process by
the patient and the physician also is important.
33Treatment
- Initial treatment is nonoperative, with emphasis
placed on control of pain and inflammation. - passive and active range-of-motion exercises.
Abduction should be avoided initially to prevent
impingement until joint motion becomes more
supple.
34Treatment
- Although a frozen shoulder usually is
self-limiting and resolves in 12 to 18 months,
many patients do not wish to wait that long for
resolution of symptoms and request active
intervention long before 12 months. With
appropriate patient selection, significant
improvement can be obtained in approximately 70
of patients. - Closed manipulation under anesthesia
- Open release of contractures
35Treatment
- Arthroscopic release is an option when closed
manipulation fails or for patients who have had
prolonged, recalcitrant adhesive capsulitis.
36Stenosing Tenosynovitis??????
- more often in the hand and wrist than anywhere
else in the body. - A peritendinitis may affect these tendons,
causing pain, swelling, and crepitus??? .
37- When the long flexor tendons are involved,
trigger thumb, trigger finger, or snapping finger
occurs. The stenosis occurs at a point where the
direction of a tendon changes, for here a fibrous
sheath acts as a pulley?? , and friction is
maximal. Although the tenosynovium lubricates the
sheath, friction can cause a reaction when the
repetition of a particular movement is necessary,
as in winding a fine coil of wire?? or stacking
laundry.
38DE QUERVAIN DISEASE
- Stenosing tenosynovitis of the abductor pollicis
longus and extensor pollicis brevis tendons - When the extensor pollicis brevis and the
abductor pollicis longus tendons in the first
dorsal compartment are affected, the condition is
named after the Swiss physician, De Quervain, who
described his experience in 1895. - Women are affected 10 times more frequently than
men. The cause is almost always related to
overuse, either in the home or at work, or is
associated with rheumatoid arthritis. The
presenting symptoms usually are pain and
tenderness at the radial styloid. Sometimes a
thickening of the fibrous sheath is palpable.
39diagnosis
The Finkelstein test usually is positive "on
grasping the patient's thumb and quickly
abducting the hand ulnarward, the pain over the
styloid tip is excruciating." Although
Finkelstein states that this test is "probably
the most pathognomonic objective sign," it is not
diagnostic the patient's history and occupation,
the roentgenograms, and other physical findings
must also be considered.
40Treatment
- Conservative treatment, consisting of rest on a
splint and the injection of a steroid preparation
into the tendon sheath, is most successful within
the first 6 weeks after onset. - When pain persists, surgery is the treatment of
choice (complete relief ).
41TRIGGER FINGER AND THUMB???????
- Stenosing tenosynovitis, leading to inability to
extend the flexed digit ("triggering") usually is
seen after 45 years of age. - Patients may note a lump? or knot?? in the palm.
The lump may be the thickened area in the first
annular part of the flexor sheath, or a nodule or
fusiform??? swelling of the flexor tendon just
distal to it. The nodule can be palpated by the
examiner's fingertip and will move with the
tendon. The tendon nodule usually is at the entry
of the tendon into the proximal annulus at the
level of the metacarpophalangeal joint.
42- Treatment of trigger digits usually is
nonoperative in the uncomplicated patient who
presents a short time after onset of symptoms.
Nonoperative methods include stretching, night
splinting, and combinations of heat and ice.
Corticosteroid injection is effective after one
injection - Surgical release reliably relieves the problem
for most patients
43Osteonecrosis of Femoral head????????
- Osteonecrosis of the femoral head is a
progressive disease that generally affects
patients in the third though fifth decades of
life if left untreated, it leads to complete
deterioration of the hip joint. It is estimated
that as many as 20,000 new cases of osteonecrosis
are diagnosed each year in the United States.
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46Diagnosis
- Patients are typically asymptomatic early in the
course of osteonecrosis and eventually have groin
pain on ambulation. A thorough history and
physical examination should be done to discover
potential risk factors and determine the clinical
status of the patient. Plain roentgenograms
should be obtained including anteroposterior and
lateral views. Roentgenographic changes seen in
osteonecrosis depend on the stage of the disease.
Plain films may appear normal in the early
stages, but changes are noted as the disease
progresses, such as increased density or lucency
in the femoral head.
47- Advances in MRI have made earlier diagnosis of
osteonecrosis of the femoral head possible and
allow determination of the exact stage and extent
of the pathological process without use of
invasive methods.
48Treatment
- Core decompression
- Bone Grafting
- Vascularized Fibular Grafting
- Osteotomies of Proximal Femur
49- Resurfacing Hemiarthroplasty
- Total Hip Arthroplasty and Bipolar
Hemiarthroplasty. - Improved results recently have been reported with
modern cementing techniques and press-fit
cementless total hip arthroplasty in patients
with osteonecrosis. With new bearing surfaces
becoming available, such as ceramic on ceramic,
metal on metal, and highly cross-linked
polyethylene, results may improve even more. The
results of primary total joint replacement for
osteonecrosis are now approaching those reported
for osteoarthritis in aged-matched patients.
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52Epiphysitis of tibial tuberosity???????
- (Osgood-Schlatter disease) (Osteochondrol
disease of the tibial tubercle)
53EPIPHYSITIS OF TIBIAL TUBEROSITY
(OSGOOD-SCHLATTER DISEASE)
- The terms osteochondrosis and epiphysitis
designate disorders of actively growing
epiphyses. The disorder may be localized to a
single epiphysis or occasionally may involve two
or more epiphyses simultaneously or successively.
The cause generally is unknown, but evidence
indicates a lack of vascularity that may be the
result of trauma, infection, or congenital
malformation.
54Treatment
- Surgery rarely is indicated for Osgood-Schlatter
disease - the disorder usually becomes asymptomatic without
treatment or with simple conservative measures
such as the restriction of activities or cast
immobilization for 3 to 6 weeks. In a review of
the natural history of untreated Osgood-Schlatter
disease in 69 knees in 50 patients, found that
76 of patients believed they had no limitation
of activity, although only 60 could kneel without
discomfort.
55- In a prospective study of 17 patients with
Osgood-Schlatter disease and 12 adolescents
without anterior knee pain, Aparicio et al. noted
a strong association between Osgood-Schlatter
disease and patella alta. The increase in
patellar height may require an increase in the
force by the quadriceps to achieve full
extension, which could be responsible for the
apophyseal lesion. However, it can be argued that
the patella alta is the result of chronic
avulsion of the bony tuberosity.
56- Surgery may be considered if symptoms are
persistent and severely disabling. - Complications reported of Osgood-Schlatter
disease whether treated surgically or not,
including subluxations of the patella, patella
alta, nonunion of the bony fragment to the tibia,
and premature fusion of the anterior part of the
epiphysis with resulting genu recurvatum.
57Insertion of Bone Pegs
- Incise the periosteum longitudinally distal to
the tuberosity. With an electric saw cut two
matchstick pegs 4 cm long from the tibia make
the base of each peg larger than its tip. Then
drill two holes through the tibial tuberosityone
near but not in contact with the proximal tibial
physis and slanting proximally and laterally and
the other also distal to the physis and slanting
proximally and medially. Insert the pegs into
these holes and resect their projecting ends.
58- technique for insertion of bone pegs for
Osgood-Schlatter disease
- AFTERTREATMENT. A cast is applied from groin to
toes and is worn for 2 weeks. A cylinder walking
cast is then worn for 4 more weeks.
59Excision of Ununited Tibial Tuberosity
- TECHNIQUE Make a longitudinal incision centered
over the tibial tuberosity. Expose the patellar
tendon and incise it longitudinally. Elevate the
tendon laterally and medially and excise any
loose fragments of bone and enough tibial cortex,
cartilage, and cancellous bone to remove any bony
prominence completely. Do not disturb the
peripheral and distal margins of the insertion of
the patellar tendon. Close the wound. - AFTERTREATMENT. A cylinder walking cast is
applied and worn for 2 to 3 weeks. Exercises are
then begun.
60- excision of ununited tibial tuberosity. A, Tibial
tuberosity has been exposed. B, Bony prominence
has been excised.
61Legg-Calve-Perthes DISEASEPerthes?
- The cause
- The clinical sign
- Plain roentgenographic changes
- Bone scintigraphy
- MRI
- Treatment
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63- classified patients with this disease into groups
according to the amount of involvement of the
capital femoral epiphysis - group I, partial head or less than half head
involvement - groups II and III, more than half head
involvement and sequestrum formation - group IV, involvement of the entire epiphysis.
64- They noted certain roentgenographic signs
described as "head at risk" correlated positively
with poor results, especially in patients in
groups II, III, and IV. - These head-at-risk signs include
- Lateral subluxation of the femoral head from the
acetabulum, - Speckled calcification lateral to the capital
epiphysis, - Diffuse metaphyseal reaction (metaphyseal cysts),
- A horizontal physis,
- Gage sign, a radiolucent V-shaped defect in the
lateral epiphysis and adjacent metaphysis.
65- Containment by femoral varus derotational
osteotomy for older children in groups II, III,
and IV with head-at-risk signs. - Contraindications include an already malformed
femoral head and delay of treatment of more than
8 months from onset of symptoms. - Surgery is not recommended for any group I
children or any child without the head-at-risk
signs.
66- Salter and Thompson advocated determining the
extent of involvement by describing the extent of
a subchondral fracture in the superolateral
portion of the femoral head. If the extent of the
fracture (line) is less than 50 of the superior
dome of the femoral head, the involvement is
considered type A, and good results can be
expected. If the extent of the fracture is more
than 50 of the dome, the involvement is
considered type B, and fair or poor results can
be expected.
67- According to Salter and Thompson, this
subchondral fracture and its entire extent can be
observed roentgenographically earlier and more
readily than trying to determine the Catterall
classification. Furthermore, according to these
authors, if the femoral head is graded as type B,
then probably an operation such as an innominate
osteotomy should be carried out. After
statistical analysis of 116 hips affected with
Perthes disease, Mukherjee and Fabry concluded
that Salter and Thompson's classification is
simple and accurate and can be applied early in
the course of the disease to determine
management.
68- Conclusions
- 1. Most patients can be treated by noncontainment
methods and obtain good results (84). - 2. Satisfactory clinical results frequently can
be obtained at long-term follow-up despite an
unsatisfactory roentgenographic appearance. - 3. The Catterall classification is a valid
indicator of results but is not applicable as a
therapeutic guide. - 4. Head-at-risk signs added little to the
Catterall classification as a prognostic
indicator or therapeutic guide. - 5. All of the fair and poor results were in
patients with Catterall III or IV involvement and
onset of the disease at age 6 or later.
69Injury of Meniscus?????
- The menisci are crescents, roughly triangular in
cross section, that cover one half to two thirds
of the articular surface of the corresponding
tibial plateau
70TEARS OF MENISCI
- Traumatic lesions of the menisci are produced
most commonly by rotation as the flexed knee
moves toward an extended position. The medial
meniscus, being far less mobile on the tibia, can
become impaled between the condyles, and injury
can result. The most common location for injury
is the posterior horn of the meniscus, and
longitudinal tears are the most common type of
injury.
71- The length, depth, and position of the tear
depend on the position of the posterior horn in
relation to the femoral and tibial condyles at
the time of injury. Menisci with peripheral
cystic formation or menisci that have been
rendered less mobile from previous injury or
disease may sustain tears from less trauma.
72- Congenital anomalies of the menisci, especially
discoid lateral meniscus, may predispose to
either degeneration or traumatic laceration.
Likewise, areas of degeneration that develop as a
result of aging cannot withstand as much trauma
as healthy fibrocartilage. Abnormal mechanical
axes in a joint with incongruities or ligamentous
disruptions expose the menisci to abnormal
mechanics and thus can lead to a greater
incidence of injury.
73Classification
- Numerous classifications of tears of the menisci
have been proposed based on location or type of
tear, etiology, and other factors most of the
commonly used classifications are based on the
type of tear found at surgery. (1) longitudinal
tears(bucket handle tears), (2)body tears,
(3)anterior horn tears, (4)1/3 anterior tears,
(5)1/3 posterior tears, and (6) horizontal tears
74Four basic patterns of meniscal tears I,
longitudinal II, horizontal III, oblique and
IV, radial
75Horizontal tears BOblique tears C Radial tears D
76- Cysts of the menisci are frequently associated
with tears and are 9 times more common on the
lateral than on the medial side. The most common
cause is trauma that produces degeneration and
secondary mucinous and cystic changes in the
periphery of the meniscus
77- Discoid menisci are abnormal, and because of
hypermobility and the bulk of the tissue between
the articular surfaces, they are vulnerable to
compression and rotary stresses. Degeneration
within the discoid meniscus, as well as tears,
may develop. The diagnosis often is not made
until surgery, since the discoid meniscus may not
produce significant symptoms until some
derangement of the meniscus occurs.
78Diagnosis
- The diagnosis of internal derangement of the knee
caused by a meniscal tear can be difficult even
for an experienced orthopaedic surgeon. Using a
careful history and physical examination and
supplementing standard roentgenograms in specific
instances with special imaging techniques and
arthroscopy can keep errors in diagnosing tears
of the menisci to less than 5.
79- When a meniscus has been injured, capsular and
ligamentous structures, as well as the articular
surfaces, often have been injured also. - Disorders that can produce symptoms similar to
those of a torn meniscus must be kept in mind,
and to avoid error, a detailed, careful, systemic
history and physical examination supplemented
with appropriate imaging studies and arthroscopy
are indicated, especially if symptoms and
findings are not quite typical of a torn
meniscus.
80- A history of specific injury may not be obtained,
especially when tears of abnormal or degenerative
menisci have occurred. This scenario is noted
most often in a middle-aged person who sustains a
weight-bearing twist on the knee or who has pain
after squatting. Tears of normal menisci usually
are associated with more significant trauma or
injury but are produced by a similar mechanism,
as the meniscus is entrapped between the femoral
and tibial condyles in flexion, tearing as the
knee is extended.
81- Patients with tears in degenerative menisci may
recall symptoms of mild catching, snapping, or
clicking, as well as occasional pain and mild
swelling in the joint. Once the tear in the
meniscus becomes of significant size, more
obvious symptoms of giving way and locking may
develop.
82- The syndromes caused by tears of the menisci can
be divided into two groups those in which there
is locking and the diagnosis is clear and those
in which locking is absent and the diagnosis is
more difficult. The injured knee can be locked
and still extend to neutral position. Locking
usually occurs only with longitudinal tears and
is much more common with bucket handle tears,
usually of the medial meniscus.
83Locking of the knee
- May be caused by
- a bucket handle tear of a meniscus
- an intraarticular tumor
- an osteocartilaginous loose body
- other conditions
- Regardless of its cause, locking that is
unrelieved after aspiration of the hemarthrosis
and a period of conservative treatment may
require surgical treatment.
84- No locking
- A patient typically gives a history of several
episodes of trouble referable to the knee, often
resulting in effusion and a brief period of
disability but no definite locking. A sensation
of "giving way" or snaps, clicks, catches, or
jerks in the knee may be described, or the
history may be even more indefinite, with
recurrent episodes of pain and mild effusion in
the knee and tenderness in the anterior joint
space after excessive activity.
85- When well understood, the following clues can be
important in the differential diagnosis in this
second group a sensation of giving way,
effusion, atrophy of the quadriceps, tenderness
over the joint line (or the meniscus), and the
reproduction of a click by manipulative maneuvers
during the physical examination.
86Diagnostic Tests
- Clicks or snaps, either audible or detected by
palpation during flexion, extension, and rotary
motions of the joint, can be valuable for
diagnosis, and efforts should be made to
reproduce and accurately locate them. If these
noises are localized to the joint line, the
meniscus most likely contains a tear. Similar
noises originating from the patella, the
quadriceps mechanism, or the patellofemoral
groove must be differentiated.
87- Numerous manipulative tests have been described,
but the McMurray test and the Apley grinding test
probably are most commonly used. All basically
involve attempts to locate and reproduce
crepitation that results as the knee is
manipulated.
88- The McMurray test
- With the patient supine and the knee acutely and
forcibly flexed, the examiner can check the
medial meniscus by palpating the posteromedial
margin of the joint with one hand while grasping
the foot with the other hand. Keeping the knee
completely flexed, the leg is externally rotated
as far as possible and then the knee is slowly
extended. As the femur passes over a tear in the
meniscus, a click may be heard or felt. The
lateral meniscus is checked by palpating the
posterolateral margin of the joint, internally
rotating the leg as far as possible, and slowly
extending the knee while listening and feeling
for a click.
89- A click produced by the McMurray test usually is
caused by a posterior peripheral tear of the
meniscus and occurs between complete flexion of
the knee and 90 degrees. Popping, which occurs
with greater degrees of extension when definitely
localized to the joint line, suggests a tear of
the middle and anterior portions of the meniscus.
Thus the position of the knee when the click
occurs may help locate the lesion. A positive
McMurray click localized to the joint line is
additional evidence that the meniscus is torn a
negative McMurray test does not rule out a tear.
90Grinding test
- Described by Apley
- With the patient prone, the knee is flexed to
90 degrees and the anterior thigh is fixed
against the examining table. The foot and leg are
then pulled upward to distract the joint and
rotated to place rotational strain on the
ligaments when ligaments have been torn, this
part of the test usually is painful. Next, with
the knee in the same position, the foot and leg
are pressed downward and rotated as the joint is
slowly flexed and extended when a meniscus has
been torn, popping and pain localized to the
joint line may be noted. Although the McMurray,
Apley, and other tests cannot be considered
diagnostic, they are useful enough to be included
in the routine examination of the knee.
91Imaging Studies
- Roentgenograms. AP, lateral, and intercondylar
notch views with a tangential view of the
inferior surface of the patella should be
routine. Ordinary roentgenograms will not confirm
the diagnosis of a torn meniscus but are
essential to exclude osteocartilaginous loose
bodies, osteochondritis dissecans, and other
internal derangements that can mimic a torn
meniscus.
92Other Diagnostic Studies
- such as ultrasonography, scintigraphy, computed
tomography (CT), and magnetic resonance imaging
(MRI), have been shown to improve diagnostic
accuracy in many knee disorders. Their principal
attractiveness over arthrography or arthroscopy
is that they are noninvasive procedures. - in a prospective study comparing the accuracy of
MRI with arthroscopic findings, reported 98
accuracy for medial meniscal tears, 90 for
lateral meniscal tears
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94ARTHROSCOPY
- Proven meniscal tears usually are treated
surgically, by arthroscopy. - Arthroscopy has made the diagnosis of acute
meniscal injuries more precise, which aids in the
treatment planning. Incomplete tears or small
peripheral tears are difficult to confirm without
arthroscopy. - Many incomplete tears will not progress to
complete tears if the knee is stable. Small
stable peripheral tears have been observed to
heal after 3 to 6 weeks of protection.
95- Chronic tears with a superimposed acute injury
cannot be expected to heal with nonoperative
treatment. Thus an acute meniscal injury in a
patient with a history of symptomatic episodes
such as catching, locking, and giving way
probably does not qualify for nonoperative
management. - Nonoperative treatment is never appropriate in a
patient with a locked knee caused by a bucket
handle tear of the meniscus. Forceful
manipulation of such displaced tears is never
justified, and most will not heal without surgery
even if reduced.
96- Meniscal tears that cause infrequent and minimal
symptoms can be treated with rehabilitation and
restricted activity. Tears associated with
ligamentous instabilities can be treated
nonoperatively if the patient defers ligament
reconstruction or if reconstruction is
contraindicated. - Chronic tears even within the vascularized zone
will not heal without surgery. However, chronic
tears have been shown to heal when the synovial
bed of the meniscus has been freshened and the
torn edges have been apposed and sutured.
97- The most important aspect of nonoperative
treatment, once the acute pain and effusion have
subsided, is restoration of the power of the
muscles about the injured knee to a level
comparable with that of the opposite knee. As
much motion of the joint as possible should be
encouraged. This can be accomplished through a
regular program of progressive exercises, not
only for the quadriceps and hamstrings but also
for the hip flexors and abductors.
98OPERATIVE MANAGEMENT
- The indications and surgical techniques for
excision of torn menisci have been controversial
noted orthopaedic surgeons have advocated total
excision of the torn meniscus, whereas others
have proposed subtotal excision. Justification
for total excision often was based on short-term,
functional recovery criteria. When longer
follow-up was studied, increasing degenerative
changes were noted, especially after total
meniscectomy was performed. Degenerative changes
probably caused by biomechanical changes were
directly proportional to the amount of meniscus
excised. In vitro that removal of even one third
of the meniscus increased the joint contact
forces by up to 350.
99- The greatest degenerative changes in animals
occurred after total rather than subtotal
meniscectomy. These changes also have been
observed arthroscopically in human knees. After
subtotal excision of the meniscus, less articular
cartilage degeneration was found, and it was
localized principally to the area previously
covered by the meniscus. The amount of
degenerative change in the articular cartilage
was directly proportional to the amount of
meniscus removed. - If a significant portion of the peripheral rim
can be retained by subtotal meniscal excision,
the long-term result is improved.
100- Complete removal of the meniscus is justified
only when it is irreparably torn, and the
meniscal rim should be preserved if at all
possible. Total meniscectomy is no longer
considered the treatment of choice in young
athletes or other people whose daily activities
require vigorous use of the knee.
101- Excision of only the torn portion of the
meniscus, either by open arthrotomy or by
arthroscopic technique, has sufficient support
and clinical results to indicate its routine use.
Subtotal excision of a torn meniscus by open
arthrotomy can be a difficult procedure and can
be accomplished more easily by arthroscopic
techniques.
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103Late Changes after Meniscectomy(????????????)
- The knee can function well without the meniscus,
sometimes for the rest of a patient's life, but
late degenerative changes within the joint
sometimes occur, and the loss of the meniscus
undoubtedly plays some part in producing these
changes. In addition to the condition of the
meniscus, numerous other factors can influence
long-term function, such as joint alignment,
laxity of the capsular or ligamentous structures,
and incomplete rehabilitation of the musculature
about the knee.
104- ????!
- Thank you very much for your attention!