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Tendinitis and Bursitis

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... and median nerve compression proximally in the forearm and at the elbow. ... treatment such as ultrasound ... normal menisci usually are associated ... – PowerPoint PPT presentation

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Title: Tendinitis and Bursitis


1
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  • ???????1(??2)
  • ????????
  • ??????????
  • ?????
  • ?????????????
  • ???

2
Bursitis ???
  • ????????

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.

4
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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.

9
Carpal 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.

11
Diagnosis
  • 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.

13
Diagnosis
  • 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.

16
Treatment
  • 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.

18
Treatment
  • 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.

20
Lateral 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

27
Primary 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.

28
Primary 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.

29
Primary 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.

30
Secondary 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.

31
Diagnosis
  • 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.

32
Treatment
  • 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.

33
Treatment
  • 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.

34
Treatment
  • 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

35
Treatment
  • Arthroscopic release is an option when closed
    manipulation fails or for patients who have had
    prolonged, recalcitrant adhesive capsulitis.

36
Stenosing 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.

38
DE 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.

39
diagnosis
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.
40
Treatment
  • 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 ).

41
TRIGGER 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

43
Osteonecrosis 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.

44
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45
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46
Diagnosis
  • 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.

48
Treatment
  • 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.

50
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52
Epiphysitis of tibial tuberosity???????
  • (Osgood-Schlatter disease) (Osteochondrol
    disease of the tibial tubercle)

53
EPIPHYSITIS 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.

54
Treatment
  • 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.

57
Insertion 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.

59
Excision 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.

61
Legg-Calve-Perthes DISEASEPerthes?
  • The cause
  • The clinical sign
  • Plain roentgenographic changes
  • Bone scintigraphy
  • MRI
  • Treatment

62
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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.

69
Injury 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

70
TEARS 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.

73
Classification
  • 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

74
Four basic patterns of meniscal tears I,
longitudinal II, horizontal III, oblique and
IV, radial
75
Horizontal 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.

78
Diagnosis
  • 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.

83
Locking 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.

86
Diagnostic 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.

90
Grinding 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.

91
Imaging 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.

92
Other 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

93
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94
ARTHROSCOPY
  • 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.

98
OPERATIVE 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.

102
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103
Late 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
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