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Ears
Otoscopic examination
Evaluation of gross auditory acuity
Whisper test-1-2 feet, one is covered with palm
Tunning fork
Weber test-Forehead or head
Rinne test-auditory canal, or mastoid process
Audiometry-
Pure tone audiometry: musical tone, the louder it is perceived, the
greater the hearing loss
Speech audiometry: Spoken word used to determine the ability to
hear
-frequency:number of sound waves
-pitch: term to describe frequency
Tympanogram: for detecting middle ear disease by measuring the
middle ear muscle reflex, how the tympanic membrane reacts by
compensation of changing pressure in a sealed ear canal
Auditory brain stem response: detectable electrical potential from
cranial nerve VIII, eg. Tumor on cranial nerve VIII
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Electronystagmography: graphic recording of electrical potenitial
created by eye movement, assess vestibular and oculomotor
systems and their interaction: Menieres disease
Platform posturography: used to investigate postural control
capabilities
Sinusoidal harmonic acceleration: rotary chair, assess vestibule-
ocular system through eye movements in response to clockwise and
counterclockwise rotation
Middle ear endoscopy: performed by endosopist, used to evaluate
suspected perilymphatic fistula and new onset of conductive hearing
loss, anesthesized in the tympanic membrane topically for 10
minutes. taken With videos and photo
Hearing loss:
Occupational: carpentry, plumbing, coal mining- noise-inducedhearing loss
Conductive hearing loss: results from an external ear disorder,
impacted cerumen, middle ear disorder, otitis media, otosclerosis.
Sensorineural loss: involves damage to the cochlea or
vestibulocochlear nerve
Mixed hearing loss: both conductive and sensorineural loss
Functional: Psychogenic, emotional disturbances
Clinical manifestation: early sign: tinnitus
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speech deterioration, fatigue, indifference, social withdrawal,
insecurity
noise-induced hearing loss: lone exposure to noise
acoustic trauma: caused by single exposure to an extremely loud
noise, high frequency
Presbycusis: used to describe progressive hearing loss
CERUMEN IMPACTION
: normally accumulates in the external ear, causes otalgia: fullness of
pain in the ear with or without hearing loss
Mngmnt: irrigation, suctioning, instrumentation, warmed glycerin,
mineral oil, half strength hydrogen peroxide for 30 min. to soften it
before removal, DEBROX
Foreign bodies: insects, peas, beans, pebbles, beads, and toys
MGMT: irrigation, suctioning, instrumentation
EXTERNAL OTITIS(otitis externa): inflammation of the external ear
canal (swimmers ear): staphylococcus aureus and pseudomonas,
Aspergillus: most common
Pain, aural tenderness, fever, cellulitis, pruritus, hearing loss, feeling
of fullness, discharges maybe yellow or green discharges
MGMT: Burrows solution
Malignant external otitis: progressive: temporal bone osteomyelitis
FATAl, pseudomonas aeruginosa
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MGMT: antipseudomonal agent and aminoglucoside tx
Masses of external ear: Exostoses: are small, hard, bony
protrusions found in the lower posterior portion of the ear: surfers
ear
Surgical removal
Gapping earring puncture
: wearing heavy earrings for a long time
Surgical tx
MIDDLE EAR:
Tympanic membrane perforation: infection or trauma, otorrhea, or
rhinorrhea- clear watery drainage from ear or nose
MGMT:HEALS BY weeks or months, tympanoplasty: repair of
tympanic membrane
ACUTE OTITIS MEDIA:
Infection of the middle ear, 6 weeks, streptococcus pneumoniae,
harmophilus influenza, pain, otalgia,
MGMT:
Antibiotic mgmnt, myringotomy or tympanotomy, incision in the
tympanic membrane
Serous otitis media
-middle ear effusion, fluid with no infection, Eustachian tube
obstruction, children, concurrent respiratory infection or allergy,
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barotraumas, hearing loss, fullness in the ear, sensation of
congestion, air bubbles may be seen in the muddle ear
MGMT: Myringotomy, corticosteroids-barotrauma, vasalva
maneuver-worsens pain or perforation of the tympanic membrane
Chronic otitis media
-results of repeated episodes of acute otitis media, hearing loss may
be minimimal, persistent or intermittent, foul smelling otorrhea, pain-
acute mastoiditis
Cholesteatoma-ingrowth of the skin of the external layer of the
eardrum
MGMT
:antibiotic drops, tympanoplasty, ossiculoplasty, mastoidectomy
Otosclerosis
-involves the stapes, results from the formation of new, abnormal
spongy bone, common in women, hereditary, may be worsen by
pregnancy, progressive hearing loss, mixed hearing loss, florical
supplement, stapedectomy
MIDDLE EAR MASSES
-glomus, jugular tumor that arises from jugular bulb, Jacobsons
nerve
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Inner ear:
Motion sickness:
Disturbance of equilibrium caused by constant motion, sweating,pallor, nausea, and vomiting, vestibular overstimulation
MGMT: Dramamine, bonine
Menieres disease- abnormal inner ear fluid balance, blockage in
endolymphatic duct, inc pressure in the system or rupture of the
inner ear membranes, hearing loss, tinnitus, webers test
MGMT: ANTIVERT, DIAZEPAM, PROMETHAZINE,
HYDROCHLOROTHIAZIDE, BANANAS, TOMATOES, ORANGES,
ENDOLYMPHATIC SAC DECOMPRESSION, streptomycin,
gentamycin, VESTIBULAR nerve section
LABYRINTHITIS-inflammation of the inner ear, hearing loss, vertigo,
N and V, tinnitus, antibiotic
Benign paroxysmal position vertigo
-period of incapacitating vertigo, orith
MGMT; canalith repositioning procedures, epley procedure,
prochloperazine, dix hallpike test
Ototoxicity
-aspirin, quinine, tinnitus
Acoustic neuroma
-slow growing benign tumore of cranial nerve VIII,
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-Vestibular neuroma
MGMT: surgical removal, Labyrinthin
Low back pain
-L4, L5, S1
-disk protrusion can cause pressure on nerve roots, which results to
pain that radiates the nerve
-lasting more than 3 months without improvement and fatigue, pain
radiating down the leg (radiculopathy or sciatica), gait; spinal
mobility; reflexes; leg length; leg motor strength; sensory perception
are altered, paravertebral muscle spasm, possible spinal deformity
-back exam and neurologic (reflexes, sensory impairment, straight
leg raising, muscle strength, muscle atrophy), x-ray: fracture,
dislocation, osteroarthritis, scoliosis, bone scan and blood studies:
disclose infections, tumors, bone marrow abnormalities, CT scan:
soft tissue lesions and problems of vertebral disks, MRI; permitsvisualization of the nature and location, Electromyogram EMG and
nerve conduction studies: spinal nerve root disorders
MGMNT: 4 weeks for analgesics, acetaminophen, ibuprofen, heat or
cold therapy, traction, massage, diathermy, ultrasound, cutaneous
laser treatment, biofeedback, transcutaneous electrical nerve
stimulation, acupuncture, avoid twisting, bending, lifting, which
stresses the back are avoided, change positions freq, sitting should
be limited to 20-50 mins.,m based on level of comfort, bed rest for 1-
2days, max of 4 days if pain is severe, gradual return to activities,
conditioning of trunk muscles are begun after 2 weeks
Osteomyelitis
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-infection of the bone marrow
-Trauma, diabetes, Anemia, poorly nourished, elderly, or obese,
impaired immune systems, those with chronic illness
Deep sepsis after arthroplasty may be classified as follows:
Stage 1: acute fulminating, 3 months after orthopedic surgery, assoc.
with hematoma, drainage, or superficial infection
Stage 2: Delayed onset, 4-24 months after surgery
Stage 3: late onset: occurring 2 or more years after surgery,
hematogenous spread
Modes:
-EXTENSION of soft tissue infection (infected pressure, vascular,
incision infection)
-Direct bone contamination from bone surgery, open fracture, or
traumatic injury
-Hematogenous (bloodborne) spread from other sites of infection (
Infected tonsils, boils, infected teeth, upper respiratory infection)
-Staphylococcus aureus, proteus and pseudomonas, e.coli
:sequestrum )dead bone tissue, involcrum (new bone growth)
-Fever, chills, inflammation, rapid pulse, general malaise, infected
area becomes painful; swollen; extremely tender, pulsating pain with
movement
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Chronic: draining sinus, recurrent periods of pain, inflammation,
swelling, drainage, low grade infection
:x-ray: soft tissue swelling, for chronic dense bone formations are
seen on x-ray
Radiosotope bone scans, particularly the isotope labeled white blood
cell, MRI-definitive diagnosis
Blood studies: elevated leukocyte and sedimentation rate
-Pyogenic, Hematogenous, Chronic
Prevention: if there are infections surgery should be postponed,
prophylactic antibiotics are administered, urinary catheters and drains are
removed as soon as possible, treatment of focal infections (hematogenous
spread), Wound care, prompt management of soft tissue infection
MGMNT: antibiotic therapy, hydration, diet high in vitamins and
protein, correction of anemia, area of OS should be immobilized (fracture),
warm wet soaks for 20min., around the clock dosing (3-6 weeks for anti-b.therapy), orally administer from 3 months if controlled, anti-b. should not be
administered with food.
Surgical MNGMNT: Removal of necrotic material, irrigated with
Saline sol., sequestrectomy (removal of volucrum), Sauzerization (removal
of bone and cartilage, wound irrigation saline sol. 7-8 days,
Loose bodies
-occur in joints may occur as a result of articular cartilage wear and
bone erosion
-locks the joint, causes painful movement
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MGMNT: arthroscopy
Tendinitis, Bursitis, Rotator cuff impingement
B and T: are inflammatory conditions that commonly occur in theshoulder, bursae are fluid filled sacs that prevents friction between
joint structures during joint activity.
-painful when inflamed, restricts joints movement
MGMNT: rest of extremity, intermittent ice and heat to the joint,
NSAID, Arthroscopic synevectomy
I: Overuse may produce an impingement syndrome in the shoulder
-pain, tenderness, limited movement, muscle spasm, atrophy,
progress to rotator cuff tear
MGMNT: rest, NSAID, joint injections, physical treatment,
Artrhroscopic debridement
Carpal tunnel syndrome;
-Is an entrapment neuropathy that occurs when median nerve at
wrist is compressed by a thickened flexor tendon sheath, skeletal
encroachment, edema, soft tissue mass
-repetitive hand activities, arthritis, hypothyroidism, or pregnancy
-pain, numbness, paresthesia, possibly weakness along the mediannerve (thumb and first two fingers), night pain
-Tinels sign
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MGMNT: rest splints-prevent hyperextension, NSAIDs, Carpal canal
cortisone injection, yoga postures, relaxation, acupuncture, , endoscopic
laser surgical release of the transverse carpal ligament, hand splints,
assistance with ADLS, take several weeks or months
Septic Arthritis (infectious)
-joints that are infected through spread of infection from other body
parts
-Trauma, surgical instrumentation, coexisting arthritis, diminishedhost resistance, S.aureus, streptococci and gram neg., chondrolysis
(destruction of hyaline cartilage.
-diabetes mellitus, R.a, joint replacement
CM: systemic chills, fever, leukocytosis, warm, painful, swollen with
dec. range of motion joint
-Aspiration, culture of synovial fluid, computed tomography, MRI-
damage to joint lining, radioisotope scanning
MGMNT: Antibiotics IV., removal of excess joint fluid (promotes
comfort, decreases joint destruction), arthrotomy, arthroscopy: drain
and remove dead tissue), affected part is immobilized, codeine,
NSAIDs, fluid status is monitored, progressive range of motion
exercises, weight bearing and activity restrictions, safe use ofambulatory aids, assistive devices, wound care, ROM exercises after
infection subsides
Ganglion cyst
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-a ganglion, a collection of gelatinous material near the tendon
sheaths and joints, appears as a round, firm, cystic swelling, usually on the
dorsum of the wrist
-women, 50 yrs.
-tender, aching pain, weakness of the fingers
MGMNT: aspiration, corticosteroid injection, surgical excision,
compression dressing and splints are used after treatment
Dupuytrens disease
-is slowly progressive contracture of the palmar fascia which causes
flexion of the fourth and fifth fingers, and frequently the middle finger.
-men, 50 yrs.old, Scandinavian or celtic origin, arthritis, diabetes,
gout, and alcoholism
-start with a nodule of the palmar fascia-caused the contracture
-dull aching discomfort, morning numbness, cramping, and stiffness,
in the affected fingers, starts with one hand then eventually both
-finger stretching may prevent the contracture
MGMNT: palmar and digital fasciectomies are performed to improve
fx, finger exercises are performed after 1-2 days post-operatively
Plantar fascilitis
-an inflammation of the foot-supporting fascia
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-acute onset of heel pain, first steps of the morning, localized pain,
anterior medial aspects of the heel, diminished through gentle
stretching of the foot and Achilles tendon.
-MGMNT: stretching exercises, shoes with cushion for pain, orthotic
devices ( Heel cups, arch supports), NSAIDS, extracorporeal shock
wave theapy
-may resolved to fascial tears to heel spurs
Corn
-Area of hyperkeratosis (overgrowth of a horny layer of epidermis)caused by internal pressure, prominent bone caused by congenital
or aqured (arthritis) or external pressure (ill fitting shoes), fifth toe is
most frequently involved, any toe may be involved
-MGMNT: soaking and scraping off the horny layer by a podiatrist,
app. Of protective shield or pad, drying of the affected spaces and
separating the affected toes with limbs wool or gauze, wider shoe
Callus
-Thickened skin that has been exposed to persistent pressure or
friction, faulty foot mechanics
-MGMNT: eliminating the underlying causes and having the callus
treated with the podiatrist, keratolytic ointment, thin plastic cup worn
over the heel, felt padding with adhesive backing, orthostaticdevices, protuberance may be excised
Ingrown nails
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-Onchocryptosis is a condition in which the free edge of a nail plate
penetrated the surrounding skin either laterally or anteriorly, infection
or granulation may develop, caused by improper tx, external
pressure (tight shoes or stockings), internal pressure (deformed toes,
growth under the nail), trauma or infection
-prevent: cutting it straight across and filing the corners consistently
with the contour of the toe,
-MGMNT:washing the foot twice a day, app. Local anti.b, pain
mngmnt and dec. pressure of the nail plate on the surrounding soft
tissue, warm wet soaks (drains the infection), TOENAIL may be
excised by the podiatrist if there is infection
Hammer toe
-Is a flexion deformity of the interphalangeal joint, involves several
toes, acquired deformity, tight socks, corn develops on the top of the
toes and tender calluses develop under the metatarsal area
-prevent: wearing open toed sandals or shoes that conform to the
shape of the foot
-MGMNT: Osteotomy
Halux vagus
-BUNION, great toe deviates laterally, prominence of the medial
aspect of the first metatarsophalangeal joint, exostosis (enlargementof osseous) medial metatarsal head of the first met. Head, bursa
may form (Secondary to pressure and inflammation)
-reddened area, edema, tenderness
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-hereditary, ill-fitting shoes, gradual lengthening and widening
(aging), osteroarthritis
-MGMNT: tx depends on age, degree of deformity, conrorming
shape of shoe to the foot, corticosteroid injection, surgical removal of
bunion (Exostis) and osteomies, bunionectomy: Limited ROM,
paresthesisas, tendon injury, recurrence of deformity, intense
throbbing pain-opiod analgesics (morphine), foot elevated to level of
the heart, toe flexion and extension exercises are initiated to facilitate
walking
Pes cavus
-claw foot, abnormally high arch and a fixed equiinus deformity of the
forefoot, shortening of the foot and INC. pressure caused calluses at
met. Area and dorsum of the foot. Charcot Marie Tooth disease
(neuromuscular disease, familial degenerative disorder, diabetes,
tertiary syphilis
-MGMNT: exercises-manipulated forefoot into dorsiflexion and
relaxes the toes, orthotic devices-alleviates pain, Arthrodesis (fusion)
performed to reshape and stabilize foot
Mortons Neuroma
-plantar digital neuroma, neurofibroma, swelling of the third lateral
branch of the median plantar nerve, Third digital nerve loc. In the
third intermetatarsal web space, microscopically-cause an ischemia
of the nerve
-throbbing, burning pain in the foot relived when rested
-MGMNT: conservative tx, inserting innersoles and metatarsal pads
designed to spread the metatarsal heads and balance the foot
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posture, local injections of a corticosteroid, hydrocortisone
(ACTICORT), excision of the neuroma, pain relief and loss of
sensation are immediate and permanent
Flatfoot
-Common disorder, longitudinal arch of the foot is diminished,
congenital bone ligament injury, muscle and posture imbalances,
excess weight, muscle fatigue, poorly fitting shoes, arthritis
-burning sensation, fatigue, clumsy gait, edema, and pain
-MGMNT: exercises to strengthen the muscles and posture andwalking habits, foot orthoses
Osteoporosis
-Most prevalent bone disease, osteopenia-precursor to osteoporosis,
causes bone fracture, bone density, bone quality
-prevent: Inc. ca intake, regular exercises, diet modification
-secondary osteoporosis: medications, celiac disease,
hypogonadism ( Thyrotoxicosis, hyperparathyroidism,
hyperparathyroidism, anorexia nervosa, cushing syndrome, Inc.
cortisol, corticosteroids, anitseizures-bone loss, risk: small framed,
nonobese, genetics, asian, 30 yrs., men-low tostesterone,
menopause-women
ACCESS: alcoholism, corticosteroid, calcium, estrogen, smoking,
sedentary lifestyle,
-kyphosis (dowagers hump)
-loss of weight
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-DX:Bone densinometry, x-rays, DEXA (dual energy, x-ray,
absorptiometry), BMD testing (all women older than 65 yrs. Old,
older men 70 yrs.)
MGMNT: Calcitonin, estrogen, PTH, ca:1000-1200 mg, 800-1000 IU,
best source of ca and vit. D (fortified milk)
-regular weight bearing exercises (20-30 mins), 3 days/ more a week
-bisphonates (alendronate (fosamax):weekly, empty stomach, 2hrs.
prior ad., 30-60 mins ater first meal, up right pos. after taking, GI
disturbances, ca, vit d.
-calcitionin
Selective estrogen receptor modulators (relosifene, evista),
teriparatide (forteo)
Anabolic agent- cont. thromboembolism
Fracture MGMNT;
Joint replacement, closed/open reduction, c internal fixation,
percutaneous vertebroplasty/kyphoplasty
IV calcium-slow reg., tachycardia, hypotension, cardiac arrest,
dysrythmia, avoid food rich in zinc
Osteomalacia
-metabolic bone disease, charc. Inadequate mineralization of bone,
softening of the bone
-pain, tenderness, bowing of bones, pathologic fracutes, waddling/
limping gait
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-causes: Ca def., muscle weakness, unsteadiness, distal radius and
proximal femur: affected
-DX: X-ray studies, lab results: low serum calcium, hypomagnesemia
and phosphorus levels and inc. alkaline phosphatase concentration,
urine excretion of ca. and creatinine is low, bone biopsy-high osteoid,
pseudofracture, DXA-LOW BONE MASS, whole body scintigraphy-
demonstrates low bone uptake with foci or radiotracer accumulation
over mandible, ribs, and sternum, widening of the mandible, rachitic
rosary sign of ribs, tie sign of sternum, 24 hr urine ca and P-low ca
and high p: are high in patients with primary renal phosphate wasting
or Tancohs syndrome and oncologic osteomalacia, Bone biopsy andTetracycline labeling-reduced distance between tetracycline bands:
unmeneralized matrix appears (inc. osteoid scan)
MGMNT: pillows are used to support the body, Inc. vit d. c
supplemental ca, exposure to sunlight, adequate protein, inc. ca and
vit. D., calcitriol, calcium carbonate, cholecalciferol
Pagets disease
-osteitis deformans, disorder of localized rapid bone tunreover,
affecting the skull, femur, tibia, pelvic, bones, vertebrae, men
-skeletal deformity, sclerosic changes, bowing of the femur and tibia,
enlargement of the skull, deformity of pelvic bones, thickening of the
long bones, impaired hearing from cranial nerve compression and
dysfunction, thorax is compressed, tenderness, warmth over the
bones
-DX: inc. serum alkaline phosphatase, urinary hydroxypyroline
excretion, normal blood calcium level, x-ray- definitive dx, bone scan,
bone biopsy-severity
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MNGMNT: NSAIDS, calcitonin-polypeptide hormone, SQ inhalation
side effects: Flushing of face, Nausea, 3-6 months
Bisphonates-adequate daily intake of ca and vit. D is required during
therapy, Plicamycin (mithracin)-cytotoxic antibiotic
Traumatic injuries:
Contusion, Strains, and Sprains
C: Is a soft tissue injury produced by blunt force, ecchymosis,
bruising, swelling, pain, discoloration, hematoma COMP, 1-2 weeks
resolution
St: Muscle pull, overuse, overstreching or excessive stress, soreness
or sudden pain, local tenderness, muscle use and isometric
contraction
Sp: injury of the ligament, caused by wrenching or twisting motion,
swelling and bleeding causes the degree of disability and pain
-avulsion fracture: bone fragment is pulled away by a ligament or
tendon may be associated with sprain
-DX: X-ray
-MGMNT: PRICE: protection, rest, ice, elevation produces
vasoconstriction, which decreases bleeding, edema, and discomfort
Rest: promotes healing and prevents injury
Ice- Applied intermittently for 20-30 min. during first 24 to 48 hrs.
after injury
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:After the acute inflammatory stage (24-48 hrs.) heat may be applied
intermittently for 15-30 minutes to relieve muscle spasm and to
promote vasodilation, absorption, and repair
Elastic compression bandage controls bleeding, reduces edema, and
provides support for the injured tissues
Elevation controls the swelling.
-If sprain is severe (torn muscle fibers and disrupted ligaments:
Surgical repair or cast immobilization may be necessary so that the
joint will not lose its stability
:Severe sprain may may require 1-3 weeks of immobilization before
protected exercises are initiated; strains and sprains may take weeks
or months to heal
-prevent: splinting
Joint dislocation
-articular surfaces of the bones forming the joint are no longer in
anatomic contact, bones are literally out of joint
-subluxation is a partial dislocation of the articulating surfaces,
traumatic dislocation are orthopedic emergencies
-if dislocation is not treated promptly, avascular necrosis (tissue
death due to anoxia and diminished blood supply and nerve palsy
may occur
-May be congenital, present at birth (hip), spontaneous or pathologic
or disease of the periarticular structures or articular structure, or
traumatic: resulting from injury
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-pain, change in contour of the joint, change in the length of the
extremity, loss of normal mobility, and change in the axis of the
dislocated bones
-X-rays confirms the dx, and demonstrates associated fracture
-Affected joint is immobilized while the patient is transported to the
hospital, the dislocation is promptly reduced (displaced parts are
brought to into normal position) to preserve joint function, analgesia,
muscle relaxants, anesthesia are used to facilitate closed reduction,
joint is immobilized by bandages, splints, casts, or traction, and is
maintained in a stable position, neurovascular status is monitored, if
joint is stable, gentle, progressive, active and passive ROM
Exercises are done and restore strength.
Sports related injuries
-Acute: Sprain, Strain, dislocation, fractures
-Gradual: Chondromalacia patella, tendinitis, stress fracture
-Contusions results from direct falls or blows, initial dull pain
becomes greater, with edema and stiffness by the next day
-Sprains commonly occur in fingers, ankles, and knees. If ligament is
damage is major, the joint becomes unstable: surgical repair may be
required
-Strains manifest with a sharp, stabbing pain, caused by bleedingand immediate protective muscle contraction, Tennis (calf muscle
strains), Soccer players (quadriceps strains), Swimmers, Weight
lifters, Tennis players often suffer shoulder strains
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-Tendinitis: Inflammation of a tendon, caused by overuse and seen in
tennis players (epicondylar tendinitis or tennis blow), runners
(Achilles tendinitis), basketball players (infrapatellar tendinitis)
-Meniscal injuries or knee occur in excessive rotational stress
-dislocation are seen in sports that involve throwing or lifting
-fractures: Falls, skaters and bikers: Suffers colles fractures of the
wrist when they fall on outstretched arms, Ballet dancers and track
and field athletes (metatarsal fractures), stress fractures (occur with
repeated bone trauma from activities, jogging, gymnastics,
basketball, aerobics. Tibias, fibulas, and metatarsal are most
vulnerable
-treated with few days or longer than 6 weeks
-prevention: proper equipment use, effective training and
conditioning of the body, specific training needs to be tailored to the
person and the sports, warm up routines, walking or slow jogging for
5 minutes, followed by slow gradual stretching, stretch for 10
seconds before relaxing and repeating stretch, after exercise is cool
down to prevent cardiovascular problems such as hypotension,
syncope, and dysrhythmias, athlete needs to be taught to tune in to
body symptoms that indicate stress and to modify activities to
minimize injury and promote healing
Occupational Relation Injuries
-most common are sprains, strains, and tears,
Specific Musculoskeletal injuries
Tennis Elbow
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-Epicondylitis (tennis elbow), chronic painful condition caused by
excessive, repetitive activities results in inflammation (tendinitis) and
minor tears in the tendon, at the origin of the muscles on the medial
or lateral epicondyles
-casues: rackets sports, pitching, gymnastics, and repetitive uses of
a screwdriver
-pain radiates down to extensor (Dorsal) surface of the forearms,
weakened grasp, relief by rest and avoidance of activities
-app. Of ice (PRICE), admin. NSAIDS, COX-2 inhibitors,
immobilization,
Rupture of the achilles tendon
-during activities within the tendon sheath sudden contraction of calf
muscles with foot fixed firmly to the floor
-sharp pain, cannot plantar flex the foot
-6-8 weeks of cast
Lateral and medial collateral ligament injury
-occurs when foot is firmly planted and the knee is struck, either
medially, causing stretching, tearing injury to the lateral collateral
ligament, or laterally, causing stretching and tearing injury
-pain, joint instability, inability to walk w/o assistance
-Provide stability at the sides of the knee
-PRICE, Hemarthrosis (bleeding into the joint), joint fluid is aspirated,
treatment depends on the severity, limited weight bearing, elastic
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bandage or a brace, As pain subsides, ROM exercise are
encouraged, leg is immobilized and weight bearing is restricted for 6-
8 weeks, derotational brace
Anterior and posterior cruciate ligament injury
-ACL and PCL, stabilize forward and backward motion of the femur
and tibia. These ligaments cross in the center of the knee
-Occurs when foot is firmly planted, knee is hyperxtended and the
person twist the torso and femur, pt reports a pop or tearing
sensation with the twisting injury, usually ACL is torn, patient
experiences pain, joint instability, and pain with ambulation
-PRICE, Joint aspiration if hemarthrosis, BRACE, PT, avoidance of
jumping activities, Surgical ACL reconstruction, tendon repair with
grafting (Arthroscopic surgery) After surgery, the pt. is taught to
control pain with oral opiod anal, NSAID, COX-2 inhibitor,
cryotherapy (cooling pad incorporated in dressing). Pt is taught about
monitoring neuro. Status of the leg, Ankle pumps, Quadriceps sets,
and hamstring sets, knee braes, rehabilitation (6-12 months)
Fractures
Is a break in the continuity of bone, subjected to stress greater than it
can absorb
-Soft tissue edema, hemorrhage into the muscles, joint dislocation,
rupture tendons, severed nerves, damage blood vessels
Complete fractures: involves a break across the entire cross-section
of the bone (removed from normal position)
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Incomplete fracture: greenstick frac., break occurs through only a
part of the cross-section of the bone, one side of a bone is broken
and the other is bent
Comminuted fracture: Occurs only one part of the cross section of
the bone
Closed fracture: (simple fracture) one that does not cause a break in
the skin
Open fracture: Compound or complex, which skin is extended to the
fractured bone
Compression: A fracture in which bone has been compressed
Avulsion: A fracture in which a fragment of bone has been pulled
away by a tendon and its attachment
Depressed: A fracture in which fragments are driven inward (seen
freq.) in fractures of skull
Epiphyseal: A fracture thorugh epiphysis
Impacted: A fracture in which a bone fragment is driven into another
attachment
Oblique: A fracture occurring at an angle across the bone (less
stable than a transverse F.)
Pathologic: A fracture that occurs through an area of diseased bone
(osteoporosis, bone cyst, pagets disease, bony metastasis, tumor):
Can occur without trauma or fall
Simple: A fracture than remains contained with no disruption of the
skin integrity
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Spiral: A fracture that twist around the shaft of the bone
Stress: A fracture that results from repeated loading of bone and
muscle
Transversed: A fracture that is straight across the bone shaft
: Grade 1 is a clean wound less than 1cm long
Grade 2: Is a larger wound without excessive soft tissue damage
Grade 3: Highly contaminated has extensive soft tissue damage
-pain loss of fx, deformity, shortening of the extremity, CREPITUS-
grating sensation, local swelling, and dislocation
MGMNT: Immobilized, extremity is supported above and below the
fracture site to prevent rotation as well as angular motion, splinting,
Bandaging, clothes are gently removed, first from the uninjured side
of the body and then from the injured side, the clothing of the patient
may be cut away, the fractured extremity in moved a little as possible
to avoid more damage
Reduction: refers to restoration of the fracture fragments to anatomic
alignment and positioning, consent of the proc., analgesic is admin.,
injury of the extremity must be handled gently
Closed reduction: Through manipulation and manual traction, cast or
splints are app., anesthesia with percutaneous pinning, x-rays are
obtained to confirm the alignment, traction used to pt., 6-8 weeks
Open reduction: alignment of bone through surgical approach,
Internal Fixation devices are used: pins, wires, screws, plates, nails
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or rods. Risk for osteomyelitis, tetanus, and gas gangrene. Wound
irrigation and debridement, bone grafting is performed to fill the bone
defects, wound is usually left open for 5-7 days for intermittent
irrigation and cleansing, 4-8 weeks bone grafting may be necessary
to bridge bone defects and to stimulate bone healing
Factors enhancing healing:
Immobilization
Maximum bone fragment contact
Sufficient blood supply
Proper nutrition
Exercise: weight bearing for long bones
Hormones: growth hormone, thyroid, calcitonin, vit. D, anabolic
steroids
Electric potential across fracture
Inhibiting fractor:
Extensive local trauma
Bone loss
Weight bearing prior to approval
Malalignment of the fracture fragments
Inadequate immobilization
Space of tissue between bone fragments
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Infection
Local Malignancy
Metabolic bone disease (Pagets disease)
Irradiated bone (Radiation Necrosis)
Avascular Necrosis
Intra-Articular fracture (synovial fluid contains fibrolysins, which lyse
the initial clot and retard clot formation)
Age (Elderly)
Corticosteroids
Open: covered with a clean sterile dressing, splints are applied , no
attempt is made to reduce the fracture, even if one of the bone
fragments is protruding through the wound.
Comp:
Early comp:
Shock: Hypovolemic shock resulting from hemorrhage is more freq.
noted in trauma patients with pelvic fractures and displace or open
femoral fracture, femoral artery is torn by bone fragments, restore
blood vol. and circulation
Fat Embolism Syndrome
-After fracture or lone bones, Pelvic bone or crush injuries, in
younger tan 40 yrs. Of age in men, , may occlude the supply for
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lungs, brain, kidneys and other organ, onset is rapid 12-48 hrs. occur
in 10 days after injury
-Hypoxia, Tachypnea, Tachycardia, Pyrexia, Respiratory Distress,
Crackles, Wheezes, Precordial Chest pain, Tick white sputum, Chest
x-ray: Snow storm infiltrate, (ARDS, acute respiratory distress
syndrome), heart failure may develop- Manifested by change in
mental status from headache, mild agitation, delirium, and coma
Prevention and MNGMNT: Immobilization of fracture including early
surgical fixation, support during turning and positioning, respiratory
support, High flow oxygen, PEEP, vasopressor
Compartment syndrome
Area of the body encased by bone or fascia (fibrous membrane
separates muscles)
-deep throbbing pain, unrelenting pain, pain during the Passive ROMexercises, Too tight cast, Edema, hemorrhage, lower leg is mostly
involved
-6 ps: Pain, Paralysis, Paresthesias, Pallor, Pulselessness, and
Pressure
-Assess: Dorsiflex, Plantar flex of foot, flexion and extension of the
wrist, Motor weakness (nerve damage), Cyanotic nail beds, Edema,Doppler ultrasonography to verify the pulse, normal pressure is 8
Mmhg, prolonged pressure of more than 30,
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MNGMNT: Fasciotomy, wound is not sutured after, affected arm is
splinted in a functional position, ROM exercises for 4-6 hrs., In 3-6
days, wound is debride and closed, comp: AVN and infection
Comp:
Venous thromboemboli, DVT, PE-Reduced skeletal muscle
contractions and bed rest.
-Fractures of the lower extreme. And pelvis are prone to venous
thrombemboli
-PEs may cause death several days to weeks after injury
-DIC (disseminated Intravascular Coagulation is a systemic disorder-
Wide hemorrhage and microthrombosis with ischemia
: Bleeding after surgery, mucous membrane, venipuncture sites, and
gastro. And urinary tract
-watch out for infection tenderness, pain, redness, swelling, local
warmth, elev. Temp. and purulent drainage
Delayed Comp:
Delayed union-healing does not occur within the expected time
:assoc. with distraction (pulling apart) of bone fragments, nutrition,
comorbidity (DM, Autoimmune dis.)
Nonunion-failure of ends of a fractured bone to unite
Malunion-results from failure of the ends of fractured to unite in
normal alignment
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:Persistent discomfort, abnormal movement
-factors: infection, interposition, inadequate immobilization,
manipulation, excessive space between bone fragments, limited
bone contact, impaired blood supply result: AVN
NON: Pseudoarthrosis (false joint)
MGMNT: Internal fixation, bone grafting, elect. Bone stimulation,
Graft: Autograft: tissue from iliac crest, for his own use
Allograft: tissue harvested from a donor
:6-12 months or more
Comp: Graft infection, fracture of graft, nonunion
Autograft: limited quantity and pain for 2 yrs.
Avascular Necrosis
-occurs when the bone loses its blood supply and dies
-pain and limited movement
-x-ray: Loss of mineralized matrix
MGMNT: Bone grafts, prosthetic rep. or arthrodesis (joint fusion)
Rx to internal fixation
:removed when bony union takes place,
-pain and dec. fx,
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-mechanical failure: Inadequate insertion and stabilization, material
failure, Corrosion of the device: local inflammation, allergic response,
-the bone needs to be protected when removed to protect from
refracture r/t osteoporosis, altered bone structure, trauma
Complex regional pain syndrome
-CRPS: seen in upper extremity after trauma, common in women
-severe burning pain, local edema, hyperesthesia, stiffness,
discoloration, vasomotor skin changes (fluct. Warm, red, dry, cold,
sweaty, cyanotic.
-glossy, shiny skin, inc. hair and nail growth
-comp: Disuse muscle atrophy and bone deossification (osteoporosis
NM: Elevation of the exteme, ROM, pain relief, Nsaids,
Coriiticosteroids, muscle relaxants
Heterotopic ossification:
-Myositis ossificans is the abnormal formation, near bones or in
muscle, response to soft tissue trauma or fracture after blunt trauma
or total joint replacement
-painful muscle, limited contraction
-prevent: early mobilization, needs to be excised if symptoms persist
Necrosis
Amputation
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-used to relieve symptoms to improve function and most importantly
to save or improve function and pt. quality of life
-Gangrene, diabetes, burns, frostbite, osteomyelitis, malignant tumor
Assess: Circulation and functional usefulness: Physical exam,
Doppler flow studies and duplex ultrasound
-Levels of amp:
Syme amputation
-performed for extensive foot trauma and aims to produce a durable
extremity
Below knee amputation
-importance of the knee joint and the energy req. of waklings
Above knee amputation
-goal of preserving maximum fx length
Stage amputation
-Gangrene and infection exist, debrided and allowed to drain
Comp.: Hemorrhage, infection, phantom limb
-Pylon: temporary prosthetic extension
10-14 days for cast change
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