Lecture 9 - Bone Pathology

after 40
12% US
<45 men, >45 women
Mutlifactoral, biomechanical, biochemical, previous injury, inherited

usually starts 1 side, hips, knees, spine, hands, feet
Brief arm stiffness that resolves with activity
stiffness with prolonged rest

no systemic signs

effusion infrequently low WBC, ESR mildly increased, -RA factor

First line intervention exercise, anti inflammatory medications

between 25-50
1-2% US
Women 3:1
Unknown autoimmune with prolific inflammatory response

systemic simultaneous joint involvement, small joints, greatest deformity seen in hands, feet, prolonged morning stiffness lasting 1 or more hours

constitutional signs, fever, weight loss, fatigue, malaise

Synovial fluid high WBC, ESR increased, +RA factor, elevated C reactive protein

First line treatment medications
disease modifiers
symptom mediatiors
Exercise and activity reduce symptoms

CMC joint of the thumb - Base of 1st metacarpal and trapezium (scaphoid trapazoid involvement in advanced stages)
HH
PIP (Bouchard) and DIP (Heberden) joints hand - might see nodules on fingers

history of shoulder injuries in the past, perhaps surgical interventions for shoulder conditions
history of current repetitive overhead sport or occupational activites
pain with reaching overhead and to side with some loss of mobility
pain sleeping on that side
may also report creptus

AC
RCRSP - measure muscle performance of Cuff + ST, no pain with load

If RTC integrity poor, poor candidate for surgical repair TSA, will need reverse TSA - make glenoid concave
fatty infiltrate - last resort is total joint replacement
Subscapularis repair critical for TSA recovery

genetic predisposition, seems to be gender bias
repetitive use of hands
tasks that involve repetitive gripping

tenosynovitis thumb

conservative care results in short term improvement in pain, stiffness, grip and quality of life but no long term influences

Education on condition, pain, activity modifications
Exercise - no specific consensus on type/form - whatever the pt likes to do
-early stability and pain modulation
-later strength
Manual therapy - no consensus, usually traction joint mob
Hand Orthoses (splints) hand OA
NSAID's only in presence of severe disability (pain not allowing them to exercise)
NO therapeutic ultrasound

reduce pain and maximize optimal movement, muscle balance around involved joints, restore function
build up to endurance, strength, and power

reduce pain, restore mobility of associated soft tissue and joint if applicable avoid glides
traction!
Can do thoracic for GH, manipulation at joint not involved in degeneration

improve ROM and reduce pain
Dosage: High volume low load
not bringing to fatigue
3-4 sets, 20-30 reps per set

high load lower reps
3-4 sets 8-12 reps each set
fatigue at the end - overload

10-20 reps per exercise
goal is mobility and pain relief

pain reduction and capsular extensibility

early pain modulation
Grade unload joint not stretch
If safe glides to restore motion may be used

indicated with articular wear and degeneration is now subcortical and pain limitations greatest, failed conservative management
Usually done in younger population as an alternative to TSA
Rehab is restoration fo functional ROM and strength
Early motion allowed pendulum, limited ER/IR due to tendon and capsule repair subscap protection indicated
often detach biceps tendon from labrum due to increased tendonopathy post op
Return to high level of activities is common in this population

indications are severe degeneration, loss of functional use of UE, pain limitations
Surgical procedures include complete removal of glenoid and humeral components of joint cemented/cementless still utilized
Capsule and RC repairs dependent upon presurgical condition
Rehab - goal is restoration of functinal ROM and strength
Prognosis - fatty infiltrate in rotator cuff poor prognostic indicator, post operative non healing or tendon rupture complication of TSA, age, level of pre-post surgical pain, premormid medical conditions
AVOID ext past neutral

Indicated in severe DJD with complete loss of RTC integrity, failed TSA previously
Surgical procedure involves replacement of glenoid with a convex component angles approx 15-20 deg ant/superiorly
rehab - done for restoration of functional ROM and strength
Avoid Ext Add IR for 10-12 weeks

indications - rheumatoid arthritis, non union of distal humeral fractures, post traumatic multi segment fractures
allows flex and ext

1 - Inflammatory
2 - repair
3 - remodeling

Pain at rest
swelling
Ecchymosis (bruising)
Muscular guarding

pain with motion/stress
minimal swelling
restricted motion from adaptive changes
muscle weakness/stiffness

FOOSH
most common head in older women, every 20th female over 65 will likely fracture

conservative relative rest, early mobility to prevent adhesions, sling as needed
AROM begun at 3 weeks
Risk for non union greatest in smokers

surgical management necessary if unable to align, no visual callous formation at 11 day or displacement greater than 3cm

If fracture of the Greater Tuberosity then prognosis for early AROM is limited secondary to attachment of RTC
They just take longer but evidence suggests as long as displacement not greater than 3mm will heal
OA if articular surface involved or if fracture above anatomical neck

FOOSH
young athlete
most common middle 3rd of clavicle

immobilization in sling or figure of 8
4-6 weeks in young adult
child or infant shorter and possibly no immobilization

can manage without surgery however cosmetic
surgery always if signs of neurovascular dysfunction in upper arm (brachial plexus)

full restoration of functional normal use of arm
visual deformity may be present if not surgically realigned

high impact fall or accident MVA
fall from a high area or glenoid fractures with loaded dislocation

immobilization with relative rest/sling as needed

surgery rare unless glenoid fracture is greater than 1/3 of glenoid and arm unstable

good for full restoratin of function unless dislocation of HH post fracture
then subsequent surgery likely
If glenoid, OA likely outcome

non operative
immobilized 5-7 days, collar cuff spling allowing flex and ext

operative techniques can include fragment excision, complete head excision, radial head athroplasty, ORIF (open reduction internal fixation)

sling immobilization
early AROM

tension wire or plate fixation

plate and screw preferred

plate and screw

tension wiring

ulna fracture
dislocate radius

fracture radius
dislocate ulna

HPI identifying onset and cause - irritability
Observation of posture and TOF if safe and willingness to move
Mobility Assessment if safe - ROM and Joint play
Muscle Performance if possible - Grip strength and ST strength

integumentary - visualization for bruising, discoloration or if surgury performed then wound healing
neurological - ensure that fracture or inflammation/immobilization during healing have not resulted in injury to peripheral nerves
vascular - ensure that fracture or inflammation/immobilization during healing have no resultured in injury to arterial or venous supply to arm

pulses in distal extremity
swelling/discoloration of extremity and nail beds
temperature of skin distal to fracture site

Reduction of pain - inflammatory or acute phase
Tissue healing - inflammatory/ repair subacute
Restoration of ROM: Inflammatory/ repair subacute if safe to move
Restoration of optimal motor performance strength and endurance: remodeling

Age
-children 4-8 weeks
-adolescents 6-8 weeks
-adults 10-18 weeks

Promote optimal stress for repair/ bone healing - compression/load
reduce pain
restore ROM
restore strength

3 weeks for fracture dislocation cornoid and radial heal

long term loss of ROM
Functional mobility of the elbow and forearm (functional arc)

pathological bone formation in non osseous tissue
Surgical excision necessary for restoration of mobility
early identification

fall on tip of shoulder with arm adducted
FOOSH

immobilize in sling 1-4 wks

Sprain

tear
clavicle unstable
wait on overhead movement (posterior rot of clavicle)