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60 Cards in this Set

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Osteochondrosis
disease causing degenerative change to epiphyseal ossification centers of long bones
AKA "aseptic necrosis, ischemic necrosis, avascular necrosis"
Disease Examples of Osteochondrosis
Legg-Calve-Perthes - hip
Osgood-Schlatter's - tib tub
Kohler's - navicular
Panner's - capitellum
Freiberg's - 1st MTP
Scheuermann's - Spine
Kienbock's - Lunate
Osteochondrosis Etiology and Predisposing Factors
-idiopathic
-may have genetically determined vascular configuration causing susceptibility
-may be related to trauma
-m>f; 3-10 y.o.
Osteochondrosis - Phase 1
"necrosis phase"
-dec. blood supply
-osteocyte/marrow die
-negative xray
- QUIET phase
Osteochondrosis - Phase 2
"revasularization"
-symptoms become evident
-inc. blood supply
-"head within a head" xray
-biological plasticity
-path fx to subchondral bone of original ossification ctr.
-synovial thickening, px, ROM loss
-rx: splinting
Osteochondrosis - Phase 3
"bone healing"
-bone resorption stops
-deposition continues
-biological plasticity remains
Osteochondrosis - Phase 4
"residual deformity"
-bone healing complete
-epiphysis shape fixed
-jt fxn remains due to healthy articular cartilage
-DJD likely to result from wt bearing and deformity of bone underlying articular cartilage
Legg-Calve-Perthes Disease

"AKA"
coxa plana
pseudocoxalgia
osteochondritis deformans coxae juvenalis
Legg-Calve-Perthes Disease Etiology
-avascular necrosis of the femoral head in boys>girls age 3-11.
-caused by synovial effusion which may have inflammatory disease or traumatic origin
-hereditary predisposition to susceptible vascular arrangement and possibly thrombophilia
Coxa Plana Complications
-subchondral fx
-hip jt incongruity leading to instability/sublux, dec. ROM (ABD/IR) and eventual DJD
-leg length discrepancy
-disuse atrophy to calf and upper thigh
Legg-Calve-Perthes Disease Treatment and Prognosis
-bracing, bed rest and avoid compensation
-good prognosis if found <5 y.o.
-fair between 5-7 y.o.
-poor >7 y.o.
Chandler's Disease
-affects adults
-non-traumatic associated with alcoholism, systemic adrenocorticosteroids, path fx, fat emboli and thrombophilia
-may be long span and never heal, art. cart destroyed
-poor prognosis, requires surgery
Panner's Disease
Osteochondrosis of the capitellum
-px/swell at elbow
-deformity unlikely 2* non-wt bearing
Freiberg's Disease
Osteochondrosis of the MTP (1st or 2nd)
-girls>boys
-forefoot px in wt bearing activity
-synovial thickening, tender, pxful dec MTP ROM
Scheuermann's Disease
Osteochondrosis of the Spine
-adolescent onset of kyphotic posture
-moderate back px, local tender
-excess l-spine lordosis, tight hamstrings
Kohler's Disease
Osteochondrosis of the Navicular
-midfoot px
-limp during movement analysis
Kienbock's Disease
Osteochondrosis of the Lunate
-wrist px and tender local to the lunate
-dec wrist ROM, weak grip
Calve's Disease
Osteochondrosis of 1 Vertebral Body
-children 2-8 y.o.
-mild back px
-slight kyphosis, muscle spasm may be present
Cyriax Capsular Pattern of the Hip
"FAME"
Flexion
Abduction
Medial Rotation
Extension
+slight lateral rotation
Kaltenborn Capsular Pattern of the Hip
"MEAL"
Medial Rotation
Extension
Abduction
fLexion
+slight lateral rotation
Trochanteric Bursitis Etiology
-gradual, insidious onset
-lat hip/thigh px, may refer to knee
-presents similarly to L5 nerve root lesion->check for LS px
-px with run, stairs, squatting, pressure during sidelying
Trochanteric Bursitis Examination Findings
- + palp tend over bursa*
- + palp cond over bursa*
- + MSTT str/px with ABD&IR
- + CPROM px w/ IR, ADD
- + CAROM px w/ ABD
Trochanteric Bursitis Rx
pa - cryo, heat
pr - same or none
co - rx SOURCE of irritation (gluts, IT band, leg length) non-thermal US, pt education -> cross legs, sleep pattern, leg pillow w/ sleep, AD for gait
Su - rest, try corrective rx at home
Trochanteric Fx Clinical Features
-extracapsular fx, ecchymosis, swelling, LE rests in ER and appears shorter at first
-most common in elderly osteoporotic females
-TWIST -> then FX -> then FALL
Trochanteric Fx Radiographic Features
-often severely comminuted
-abudant blood flow, so nearly all fx unite
Trochanteric Fx Rx
-ORIF most common, THA better for severe osteoporosis
-ok for pt to move in bed s/p ORIF, usually seated w/in few days
-WB defer until fx healed for more active pts
Femoral Neck Fx Clinical Features
-intracapsular, hemarthrosis = no observable swelling
-LE in ER and appears short
-most common in elderly osteoporotic females
-TWIST -> then FX -> then FALL
Femoral Neck Fx Radiographic Features
-distal fragment ER and shifted proximal=>neck appears short
-vertical fx line = poor prognosis
Femoral Neck Fx Rx
ORIF, hemiarthroplasty if severe osteoporosis
Femoral Neck Fx Complications
-long lever arm distal to fx site increases instability of fx
-possible DJD, avascular necrosis, and jt adhesions 2* to effusion
Trochanteric Fx Complications
-few 2* to extracapsular fx
-may develop non-union fx => coxa vara
Posterior Hip Fx-Dislocation Clinical Features
mechanism = excess FL, ADD, IR as in car accidents
-may involve acetabular fx
-may involve post labral tear (50%)
Posterior Hip Fx-Dislocation Complications
-sciatic n. dmg
-potential blood supply dmg and subsequent avascular necrosis of femoral head and eventual DJD
Posterior Hip Fx-Dislocation Rx
CRIF w/o fx
ORIF if fx present
Anterior Hip Fx-Dislocation Clinical Features
Uncommon
mechanism = violent EXT, ABD, ER
-possible acetabular fx
Anterior Hip Fx-Dislocation Rx
closed reduction
-hip spica to limit FL, IR, ADD
Anterior Hip Fx-Dislocation Complications
-possible femoral triangle dmg
-less chance of avascular necrosis than posterior fx-disl.
-may contribute to DJD if residual deformity develops
Developmental Dysplasia of the Hip
-abnormal changes/growth resulting in shallow acetabulum or femoral deformation
Developmental Dysplasia of the Hip Clinical Features
-8X more common in Females
-birth to 10 mo old
-dislocation or subluxations of the hip
-may see ADD/IR contractures or hypertrophy
Developmental Dysplasia of the Hip Rx
Splinting!!
-3rd world countries may use multiple diapers to support hip
Developmental Dysplasia of the Hip Complications
-early DJD changes
-antalgic gait=>limp, shortened stride/step length,
-femoral anteversion
Developmental Dysplasia of the Hip Special Tests
Ortolani's Sign - dislocation present
Barlow's Test - instability
Galeazzi's Sign - unilateral
Shiba Shoe Inserts
polymeric foam rubber best material, reduces shock absorption of LE by 11%
Hip OA/DJD Etiology
Pt is usually 60 y.o. or older, pain, dysfunction, limited ROM
-review 10 causes of 2ndary DJD
Hip OA/DJD Examination Findings
- + Scouring/Quadrant Test
- + FABER test (patrick's)
- pt Hx =>px post activity, inc morning px/stiffness
- Movement Analysis => pt may have difficulty with fxnal activity such as sit-stand; also ABD/antalgic gait
- dec ACCPROM in capsular pattern
Early Hip OA/DJD Rx
-long axis distraction
-encourage high rep low load exercise strengthening
-address contributing factors such as obesity or leg length discrepancey
Moderate/Advanced Hip OA/DJD Rx
-treat capsular tightness
-suggest AD, inserts to reduce jt compression during WB activity, raised toilet seat
-low load CKC exercise
Hip Joint Forces and the Gait Cycle
-capsular tightness leads to premature force increase at HO, adding to the already high force
-force increases after HS, then decreases at MS
5 Complications of THA that may necessitate a Revision
-Loosening of one or both components
-Fatigue fracture of metallic stem
-Dislocation*
-Wear of plastic acetabulum
-Infection*
-Blood clots*(acute phlebitis/DVT)
*= acute concerns
Cemented THA and WB precautions
with methyl methacrylate – liquidy powder, thicker; WBAT/PWB 50% of body weight, elderly
Uncemented THA and WB precautions
press fit or biological fixation - allows growth of bone into porous coated prosthesis; NWB to TDWB with only the wt of the leg (about 20 pounds), younger
Patient Instructions S/P THA
-No bending forward
-sit only on raised commodes
-No leg/ankle crossing
-No twisting on operated leg in standing or sitting
-Keep pillow between knees (sleep)
-Sit for short periods only on elevated chair
Benefits of Minimally Invasive THA
-less invasive
-dec hospital stay by 1 1/2 days
-less anesthesia -> less disorientation during PT
-dec surgery time-> dec blood loss
-less muscle dmg
-10cm incision vs 24 cm
S/P THA HEP
-ankle pumps/ circles
-Quad/Glut Sets
-SAQ/TKE
-heel slides
-hip abd/add (neutral to 15-20)
-LAQ
-AROM full ER to neutral
S/P THA ADL Restriction Timeline
All 8 weeks except:
-Left driving an automatic 4-6
-Right drive automatic 8-10
-Stick 10-12
-F stop using commode 3-4 mo
-stationery bike 6-8
-bike 8-10
-swim 6 weeks
Anterolateral THA
Prob: BV and Sup. Gluteal N
Adv: almost bloodless, quick
CI: EXT, ADD, ER
Anterior THA
Adv: good view of acetabulum
CI: EXT ABD ER
Transtrochanteric THA
Adv: old favorite, good femur and acetabular view
Prob: trochanteric non-union
Posterior THA
Advantage: good view of femur, well known to orthopods
Problem: sciatic nerve exposed
Contraind: FL, ADD, IR (~8-12 weeks)
Posterolateral THA
Gaining popularity with surgeons
Contraind: EXT, ADD, ER, active ABD