Clean Intermittent Catheterization
- Recommended when children with spina bifida have problems with bladder continence
- Insertion of a small plastic tube into the bladder, through the urethra, at intervals to drain the urine, so that the bladder is emptied completely, preventing reflux of urine into the kidneys, which may then cause damage and infection of the kidneys
- May be combined with bladder irrigation and/or instillation which involves washing the bladder with antiseptic or antibiotic solution
- Irrigation: solution flows through the catheter into the bladder and held for one minute, Instillation: solution is left in the bladder
- Usually done every 3 to 4 hours during the day, or 4 to 6 times during a 24 hour day, with no longer than 8 hours between catheterizations at night
- Parents usually do this for children aged 5 and under, and after that the child may be taught how to do CIC, if still required
http://www.healthcare.uiowa.edu/cdd/patients/cic.asp#whylearn
http://www.spinabifidaassociation.org/site/c.liKWL7PLLrF/b.2664425/apps/s/content.asp?ct=3822599
Friday, October 17, 2008
Gait and functional issues relating to spina bifida
People with Spina Bifida have different degrees of muscle paralysis, spine and limb difficulties and thus need specialised treatments that address any deformity that interferes with the patient’s function ie. Accessibility, gait and independence.
Generally, muscular imbalance is present, which results in joint contractures and developmental problems such as hip dislocation and spinal deformities.
Initially, a general orthopaedic evaluation is performed, to detect any early changes that may require intervention. A gait analysis which looks at the patient's muscle innervation, strength, joint range of movement and coordination is also used to evaluate patients functionally.
Independent ambulation generally is a function of having an intact quadriceps muscle with good-plus or excellent-plus strength levels. Patients who do not have adequate quadriceps function may require bilateral Lofstrand crutches or may be primarily restricted to a wheelchair.
Functional ambulation generally is described according to the following levels:
• Community ambulator - Indoors or outdoors, crutches with or without braces
• Household ambulator - Only indoors, crutches with or without braces
• Nonfunctional ambulator - Wheelchair, crutches, and braces, in therapy
• Nonambulator - Wheelchair bound
In addition, patients should be monitored for appropriate development and be provided with prolonged physical therapy, gym resources, and adaptive training while in school. Subsequent efforts are necessary to encourage, develop, and maintain independence.
The goal of bracing is to allow patients to function at the maximum level permitted by their neurologic lesion and intelligence. Bracing also ensures a normal developmental progression, its aim being to enable patients to ambulate and to participate in appropriate age-related activities. Finally, orthotics should aid in minimizing energy expenditure to maintain mobility levels.
As long as flexion contractures and skeletal deformities are not severe, patients with no lower-extremity reflexes may, with determination and strong upper extremities, become ambulatory using bilateral Lofstrand or forearm crutches.
Generally, muscular imbalance is present, which results in joint contractures and developmental problems such as hip dislocation and spinal deformities.
Initially, a general orthopaedic evaluation is performed, to detect any early changes that may require intervention. A gait analysis which looks at the patient's muscle innervation, strength, joint range of movement and coordination is also used to evaluate patients functionally.
Independent ambulation generally is a function of having an intact quadriceps muscle with good-plus or excellent-plus strength levels. Patients who do not have adequate quadriceps function may require bilateral Lofstrand crutches or may be primarily restricted to a wheelchair.
Functional ambulation generally is described according to the following levels:
• Community ambulator - Indoors or outdoors, crutches with or without braces
• Household ambulator - Only indoors, crutches with or without braces
• Nonfunctional ambulator - Wheelchair, crutches, and braces, in therapy
• Nonambulator - Wheelchair bound
In addition, patients should be monitored for appropriate development and be provided with prolonged physical therapy, gym resources, and adaptive training while in school. Subsequent efforts are necessary to encourage, develop, and maintain independence.
The goal of bracing is to allow patients to function at the maximum level permitted by their neurologic lesion and intelligence. Bracing also ensures a normal developmental progression, its aim being to enable patients to ambulate and to participate in appropriate age-related activities. Finally, orthotics should aid in minimizing energy expenditure to maintain mobility levels.
As long as flexion contractures and skeletal deformities are not severe, patients with no lower-extremity reflexes may, with determination and strong upper extremities, become ambulatory using bilateral Lofstrand or forearm crutches.
Thursday, October 16, 2008
Complications with Ventriculoperitoneal shunt
Complications for ventriculoperitoneal shunting include standard complications involved with surgery and anesthetic (respiratory failure, medication reactions, bleeding, infection, death).
The shunt may malfunction, resulting in under/over-draining of CSF from the ventricles.
Also the shunt may need to be replaced after the growth of a baby (body increases in size, shunt doesn’t).
The shunt can also disconnect or become blocked – CSF fluid will accumulate and symptoms will occur and necessitate immediate medical attention.
Other complications include fever, vomiting, irritability, redness and swelling over the sites of tubing, or decreased alertness and lethargy.
The shunt may malfunction, resulting in under/over-draining of CSF from the ventricles.
Also the shunt may need to be replaced after the growth of a baby (body increases in size, shunt doesn’t).
The shunt can also disconnect or become blocked – CSF fluid will accumulate and symptoms will occur and necessitate immediate medical attention.
Other complications include fever, vomiting, irritability, redness and swelling over the sites of tubing, or decreased alertness and lethargy.
PCL 13- Peer teasing
Psychological effects that may result from Peer teasing
· Reasons why the child is discriminated against
o Physical appearance
o Incompetency
· Psychological impact (situation tends to improve before preadolescence)
o Depression
o Anxiety
o Loneliness
o Negative self-perceptions and on others
o Aggression and delinquent behavior
· Counseling
o School programs to reduce harassment
o Teaching victimized children to focus on positive social encounters
Reference
http://www.news-medical.net/?id=13266
http://cat.inist.fr/?aModele=afficheN&cpsidt=18424075
http://www.medicalnewstoday.com/articles/30644.php
Biological and psychological factors of dealing with a disease in a Rural area
Biological
Access would be a factor in the care of Janet. As said in the PCL the only medical care available is that of a GP, a paediatrician requires a visit to a larger town. Due to this lack of specialist treatment, Janet could possibly not receive the ongoing treatment she requires. As found in a report by Strong et al, the number of specialists per capita decreases markedly in rural areas compared to metropolitan areas.
Psychological
Living in a rural town could influence Janet’s psychological needs. As it is a small town there is unlikely to be any other children or adults who have Spina Bifida, this could affect both Janet and her mother, as there could be a lack of support groups. Also mental health in rural areas can be sadly lacking, for adults let alone children. In a US survey, 65% of adults were provided with mental health care treatment, by their primary provider, so getting no specialised services. Often
Sarah
Refernces
Mental Healthcare in Rural Communities:
The Once and Future Role of Primary Care
www.arhen.org.au/docs/gphmhci-rsa-summary.pdf
Access would be a factor in the care of Janet. As said in the PCL the only medical care available is that of a GP, a paediatrician requires a visit to a larger town. Due to this lack of specialist treatment, Janet could possibly not receive the ongoing treatment she requires. As found in a report by Strong et al, the number of specialists per capita decreases markedly in rural areas compared to metropolitan areas.
Psychological
Living in a rural town could influence Janet’s psychological needs. As it is a small town there is unlikely to be any other children or adults who have Spina Bifida, this could affect both Janet and her mother, as there could be a lack of support groups. Also mental health in rural areas can be sadly lacking, for adults let alone children. In a US survey, 65% of adults were provided with mental health care treatment, by their primary provider, so getting no specialised services. Often
Sarah
Refernces
Mental Healthcare in Rural Communities:
The Once and Future Role of Primary Care
www.arhen.org.au/docs/gphmhci-rsa-summary.pdf
Osteomyelitis
Definition
Osteomyelitis is the medical term for an infection in a bone. Infections can reach a bone by traveling through your bloodstream or spreading from nearby tissue. Infections can also begin in the bone itself if trauma exposes your bone to germs. Bone infections commonly affect the long bones of your body, such as your leg bones and upper arm bone, as well as your spine and pelvis.
Osteomyelitis often occurs in children as an acute condition. In adults, osteomyelitis may occur as either the acute and chronic form.
Once considered incurable, osteomyelitis can be successfully treated today. Still, osteomyelitis is a serious condition, requiring aggressive treatment to prevent spread of your infection and to save the affected bone.
Symptoms
Signs and symptoms of osteomyelitis depend on whether the condition is acute, lasting several months or less, or chronic, lasting several months to years.
Signs and symptoms of acute osteomyelitis include:
-Fever that may be abrupt
-Irritability or lethargy in young children
-Pain in the area of the infection
-Swelling, warmth and redness over the area of the infection
Signs and symptoms of chronic osteomyelitis include:
-Warmth, swelling and redness over the area of the infection
-Pain or tenderness in the affected area
-Chronic fatigue
-Drainage from an open wound near the area of the infection
-Fever, sometimes
Sometimes osteomyelitis causes no signs and symptoms or has signs and symptoms that are difficult to distinguish from other problems. For instance, osteomyelitis of the hip, spine or pelvis may have few signs and symptoms. Osteomyelitis that occurs after a broken bone (fracture) or deep wound may cause pain and swelling that you may attribute to your injury, not an infection.
Tests and Diagnosis
Your doctor conducts a physical exam to better understand your signs and symptoms if he or she suspects you may have osteomyelitis. Your doctor may feel the area around the affected bone for any tenderness, swelling or warmth.
Your doctor may order a combination of tests and procedures to diagnose osteomyelitis and to determine what type of infection you have, including:
-Blood tests.
Blood tests may reveal elevated levels of white blood cells and other factors that may indicate that your body is fighting an infection. If your osteomyelitis was caused by an infection in the blood, tests may reveal what germs are to blame. No blood test exists that tells your doctor whether you do or do not have osteomyelitis. However, blood tests do give clues about your diagnosis, which your doctor uses to decide what further tests and procedures you may need.
-X-rays.
X-rays can reveal damage to your bone. However, damage may not be visible until osteomyelitis has been present for several weeks. More-detailed imaging tests may be necessary if your osteomyelitis has developed more recently.
-Other imaging procedures.
fI your doctor can't get a clear picture of the affected bone using X-ray, he or she may order other imaging procedures, such as computerized tomography (CT), magnetic resonance imaging (MRI) or a bone scan.
-Bone biopsy.
During a biopsy, a surgeon removes a small piece of your infected bone for analysis in a laboratory. The laboratory determines what type of bacteria or other pathogen is infecting your bone. Your doctor uses that information to determine your treatment. A biopsy can be performed as an open biopsy, meaning that it requires anesthesia and surgery to access the bone. In some situations, a surgeon inserts a long needle into your skin and your bone to take a biopsy (fine-needle aspiration). This procedure requires local anesthetics to numb the area where the needle is inserted.
Treatment
Doctors treat chronic osteomyelitis with surgery and antibiotics. In acute osteomyelitis in children or vertebral osteomyelitis, surgery isn't always necessary.
Doctors treat chronic osteomyelitis with surgery and antibiotics. In acute osteomyelitis in children or vertebral osteomyelitis, surgery isn't always necessary.
Surgery
What type of surgery you undergo for osteomyelitis depends on what bone is infected. Surgery may include one or more of the following procedures:
-Drain the infected area.
Opening up the area around your infected bone allows your surgeon to drain any pus or fluid that has accumulated in response to the infection.
-Remove diseased bone and tissue.
In a procedure called debridement, the surgeon removes as much of the diseased bone as possible, taking a small margin of healthy bone to ensure that all the infected areas have been removed. Surrounding tissue that shows signs of infection also may be removed.
-Restore blood flow to the bone.
Your surgeon may fill any empty space left by the debridement procedure with a piece of bone or other tissue, such as skin or muscle, from another part of your body. Sometimes temporary fillers are placed in the pocket until you're healthy enough to undergo a bone graft or tissue graft. The graft helps your body repair damaged blood vessels and form new bone.
-Remove any foreign objects.
In some cases, foreign objects, such as surgical plates or screws placed during a previous surgery, may need to be removed.
In order to stabilize the affected bone and the new graft, you may need to have metal plates, rods or screws inserted into the bone. This procedure is sometimes performed later. Your doctor may use other devices to stabilize your affected bone, such as external fixators.
People who can't tolerate surgery
Surgery as an osteomyelitis treatment isn't available to everyone. People who are very ill may not be able to endure the extensive surgery and recovery. In these cases, doctors may use antibiotics for longer periods of time, sometimes for years, in an attempt to suppress the infection, though cure generally isn't possible with this approach. If the infection persists, amputation of all or part of an infected arm or leg may be necessary.
Antibiotics
If your doctor suspects you have chronic osteomyelitis, he or she works to determine exactly what microorganism is causing the infection before prescribing antibiotics. Your doctor uses a bone biopsy or a piece of bone removed during surgical treatment to determine what's causing the infection.
Once the bacterium or fungus causing your infection has been identified and you've undergone surgery, if necessary, your doctor selects the antibiotic most likely to be effective in fighting your particular type of infection. Antibiotics are administered most often through a vein in your arm (intravenously) or, in some cases, they can be taken orally. You typically take antibiotics for four to six weeks, or even longer. In some cases, you may need to take antibiotics for the rest of your life.
Antibiotics carry a risk of side effects, including nausea, vomiting and diarrhea. Allergic reactions also can occur.
www.mayoclinic.com
Osteomyelitis is the medical term for an infection in a bone. Infections can reach a bone by traveling through your bloodstream or spreading from nearby tissue. Infections can also begin in the bone itself if trauma exposes your bone to germs. Bone infections commonly affect the long bones of your body, such as your leg bones and upper arm bone, as well as your spine and pelvis.
Osteomyelitis often occurs in children as an acute condition. In adults, osteomyelitis may occur as either the acute and chronic form.
Once considered incurable, osteomyelitis can be successfully treated today. Still, osteomyelitis is a serious condition, requiring aggressive treatment to prevent spread of your infection and to save the affected bone.
Symptoms
Signs and symptoms of osteomyelitis depend on whether the condition is acute, lasting several months or less, or chronic, lasting several months to years.
Signs and symptoms of acute osteomyelitis include:
-Fever that may be abrupt
-Irritability or lethargy in young children
-Pain in the area of the infection
-Swelling, warmth and redness over the area of the infection
Signs and symptoms of chronic osteomyelitis include:
-Warmth, swelling and redness over the area of the infection
-Pain or tenderness in the affected area
-Chronic fatigue
-Drainage from an open wound near the area of the infection
-Fever, sometimes
Sometimes osteomyelitis causes no signs and symptoms or has signs and symptoms that are difficult to distinguish from other problems. For instance, osteomyelitis of the hip, spine or pelvis may have few signs and symptoms. Osteomyelitis that occurs after a broken bone (fracture) or deep wound may cause pain and swelling that you may attribute to your injury, not an infection.
Tests and Diagnosis
Your doctor conducts a physical exam to better understand your signs and symptoms if he or she suspects you may have osteomyelitis. Your doctor may feel the area around the affected bone for any tenderness, swelling or warmth.
Your doctor may order a combination of tests and procedures to diagnose osteomyelitis and to determine what type of infection you have, including:
-Blood tests.
Blood tests may reveal elevated levels of white blood cells and other factors that may indicate that your body is fighting an infection. If your osteomyelitis was caused by an infection in the blood, tests may reveal what germs are to blame. No blood test exists that tells your doctor whether you do or do not have osteomyelitis. However, blood tests do give clues about your diagnosis, which your doctor uses to decide what further tests and procedures you may need.
-X-rays.
X-rays can reveal damage to your bone. However, damage may not be visible until osteomyelitis has been present for several weeks. More-detailed imaging tests may be necessary if your osteomyelitis has developed more recently.
-Other imaging procedures.
fI your doctor can't get a clear picture of the affected bone using X-ray, he or she may order other imaging procedures, such as computerized tomography (CT), magnetic resonance imaging (MRI) or a bone scan.
-Bone biopsy.
During a biopsy, a surgeon removes a small piece of your infected bone for analysis in a laboratory. The laboratory determines what type of bacteria or other pathogen is infecting your bone. Your doctor uses that information to determine your treatment. A biopsy can be performed as an open biopsy, meaning that it requires anesthesia and surgery to access the bone. In some situations, a surgeon inserts a long needle into your skin and your bone to take a biopsy (fine-needle aspiration). This procedure requires local anesthetics to numb the area where the needle is inserted.
Treatment
Doctors treat chronic osteomyelitis with surgery and antibiotics. In acute osteomyelitis in children or vertebral osteomyelitis, surgery isn't always necessary.
Doctors treat chronic osteomyelitis with surgery and antibiotics. In acute osteomyelitis in children or vertebral osteomyelitis, surgery isn't always necessary.
Surgery
What type of surgery you undergo for osteomyelitis depends on what bone is infected. Surgery may include one or more of the following procedures:
-Drain the infected area.
Opening up the area around your infected bone allows your surgeon to drain any pus or fluid that has accumulated in response to the infection.
-Remove diseased bone and tissue.
In a procedure called debridement, the surgeon removes as much of the diseased bone as possible, taking a small margin of healthy bone to ensure that all the infected areas have been removed. Surrounding tissue that shows signs of infection also may be removed.
-Restore blood flow to the bone.
Your surgeon may fill any empty space left by the debridement procedure with a piece of bone or other tissue, such as skin or muscle, from another part of your body. Sometimes temporary fillers are placed in the pocket until you're healthy enough to undergo a bone graft or tissue graft. The graft helps your body repair damaged blood vessels and form new bone.
-Remove any foreign objects.
In some cases, foreign objects, such as surgical plates or screws placed during a previous surgery, may need to be removed.
In order to stabilize the affected bone and the new graft, you may need to have metal plates, rods or screws inserted into the bone. This procedure is sometimes performed later. Your doctor may use other devices to stabilize your affected bone, such as external fixators.
People who can't tolerate surgery
Surgery as an osteomyelitis treatment isn't available to everyone. People who are very ill may not be able to endure the extensive surgery and recovery. In these cases, doctors may use antibiotics for longer periods of time, sometimes for years, in an attempt to suppress the infection, though cure generally isn't possible with this approach. If the infection persists, amputation of all or part of an infected arm or leg may be necessary.
Antibiotics
If your doctor suspects you have chronic osteomyelitis, he or she works to determine exactly what microorganism is causing the infection before prescribing antibiotics. Your doctor uses a bone biopsy or a piece of bone removed during surgical treatment to determine what's causing the infection.
Once the bacterium or fungus causing your infection has been identified and you've undergone surgery, if necessary, your doctor selects the antibiotic most likely to be effective in fighting your particular type of infection. Antibiotics are administered most often through a vein in your arm (intravenously) or, in some cases, they can be taken orally. You typically take antibiotics for four to six weeks, or even longer. In some cases, you may need to take antibiotics for the rest of your life.
Antibiotics carry a risk of side effects, including nausea, vomiting and diarrhea. Allergic reactions also can occur.
www.mayoclinic.com
Sexuality and spina bifida
Males can have normal sexual function, but may be affected to some degree. Erections are possible, but there is no ejaculation.
Females less affected.
May have problems with positioning during intercourse due to orthopaedic problems.
Most males and females are fertile.
It is common for people with spina bifida to have latex allergies.
For more information there is a very informative piece at:
http://www.spinabifida-incontinence.info/pdfs/Sex.pdf
Females less affected.
May have problems with positioning during intercourse due to orthopaedic problems.
Most males and females are fertile.
It is common for people with spina bifida to have latex allergies.
For more information there is a very informative piece at:
http://www.spinabifida-incontinence.info/pdfs/Sex.pdf
Effects of Lack of Innervation
Bladder Continence
Bladder and bowel function are controlled by sacral nerves:
Usual bladder emptying: when the bladder is full receptors sense this and signal it to the brain; when a person is ready to urinate motor nerves coordinate the contraction of the bladder with the relaxation of the sphincters.
Spina Bifida: a person with spina bifida will usually have nerve damage impairing the bladder and/or sphincters. There are three situations which may occur:
Bowel Continence:
Nerve damage generally affects three areas of the bowel:
· the external anal sphincter
=> limited control over when the bowel will empty
· the sensory mechanism which tells the brain that the rectum is full
=> not knowing when it is time to go to the toilet
· the muscles which move the faeces along the colon and out of the body
=> constipation
Skin Innervation:
Damaged and improperly developed nerves in people with spina bifida mean they may have little or no sensation in some areas of the skin, usually the areas corresponding with a loss of movement.
- Pressure sores: skin is pressed between bones and a hard surface, depriving the tissue of blood, oxygen and nutrients, leading cells to die. If there is a problem with the supply of blood to an area, the brain usually sends a message to the body to change position so that the cells will once again receive a proper blood supply. A person with spina bifida has areas of skin which do not have any feeling and often have partial or complete paralysis, and so does not receive these messages.
- Burns: sunburn, wheelchair left in sun, holding hot food on your lap etc. People with spina bifida have poor circulation so the skin is often not as strong, and will burn more easily than usual
- Scrapes: will take longer to heal due to poor circulation and poor nerve supply
Bladder surgery
Surgical Bladder Repair
Repairs for weakened or damaged bladders are the norm for most incontinence problems. Surgeries are available to remove blockages, raise fallen bladders, and even implant artificial sphincters.
Bladder Surgery
(a) Description
(b) Possible Complications
1. Retropubic Suspension
(a) This surgery is specifically for women. The bladder and urethra are raised in the pelvic area, bringing them back into the correct position. This prevents the bladder from pushing down onto the urethra.
(b) Urinary tract infections.Infections in the surgical area.Recurrence of incontinence
2. Sling Procedure
(a) Usually performed on women. Either a synthetic material or abdominal tissue is used to help compress the urethral sphincter.
I(b) nfections.Urine retention.Gradual deterioration of the sling.
3. Bladder Stone Removal
(a) A bladder stone can cause urinary tract infections and contribute to incontinence by blocking normal urine flow. More common in men than women, stones can usually be crushed by inserting a cystoscope into the bladder or broken up with ultrasonic waves.
(b) Long term treatment to prevent recurrence is usually required.Enlarged prostates prevent stones from being flushed out. Prostate treatment may also be required.
4. Artificial Urinary Sphincter
(a) An artificial sphincter replaces the faulty urinary sphincter. This is usually a last resort.
(b) Infections.Deterioration of surrounding tissues, requiring removal of the mechanism.
Depending on the procedure, surgery can be performed while the patient is under general, regional, or local anesthesia. Most patients are discharged home on the same day of surgery.
After surgery, they can expect to return to a normal level of activity after 6 weeks
Repairs for weakened or damaged bladders are the norm for most incontinence problems. Surgeries are available to remove blockages, raise fallen bladders, and even implant artificial sphincters.
Bladder Surgery
(a) Description
(b) Possible Complications
1. Retropubic Suspension
(a) This surgery is specifically for women. The bladder and urethra are raised in the pelvic area, bringing them back into the correct position. This prevents the bladder from pushing down onto the urethra.
(b) Urinary tract infections.Infections in the surgical area.Recurrence of incontinence
2. Sling Procedure
(a) Usually performed on women. Either a synthetic material or abdominal tissue is used to help compress the urethral sphincter.
I(b) nfections.Urine retention.Gradual deterioration of the sling.
3. Bladder Stone Removal
(a) A bladder stone can cause urinary tract infections and contribute to incontinence by blocking normal urine flow. More common in men than women, stones can usually be crushed by inserting a cystoscope into the bladder or broken up with ultrasonic waves.
(b) Long term treatment to prevent recurrence is usually required.Enlarged prostates prevent stones from being flushed out. Prostate treatment may also be required.
4. Artificial Urinary Sphincter
(a) An artificial sphincter replaces the faulty urinary sphincter. This is usually a last resort.
(b) Infections.Deterioration of surrounding tissues, requiring removal of the mechanism.
Depending on the procedure, surgery can be performed while the patient is under general, regional, or local anesthesia. Most patients are discharged home on the same day of surgery.
After surgery, they can expect to return to a normal level of activity after 6 weeks
Tuesday, October 14, 2008
Learning issues involved with hydrocephalus
Hydrocephalus- accumulation of cerebrospinal fluid (CSF) which is caused by an imbalance in the production and drainage of fluid within the brain. It can be caused by a Arnold Chiari malformation, which occurs due to an abnormal position of the lower brain. This abnormal position is believed to lead to learning difficulties.
Issues:
Issues:
- a slowing of mental capacity is seen as one of the first signs in children
- can be confused with dementia in adults/elderly
- 10% lower IQ than population on average
- These difficulties might be in one or more of the following areas:
- attention
- language
- memory and learning
- visuo-motor integration skills
- planning
- organisational skills
Thursday, October 9, 2008
Complications of open fractures of the lower limb
Joint may become permanently stiff if the fracture is through or near the joint
Bone or bone marrow may be infected by bacteria or fungi. If this becomes chronic it is called osteomyelitis. Pus is produced within the bone, creating an abscess that stops the bone from getting its blood supply. In chronic osteomyelitis the bone dies due to the loss of blood (avascular necrosis).
Avascular necrosis may also occur if the bones refuse to join back up again or take a long time in doing so.
http://www.nhsdirect.nhs.uk/articles/article.aspx?articleId=166§ionId=6
http://www.nlm.nih.gov/medlineplus/ency/article/000437.htm
http://www.nlm.nih.gov/medlineplus/ency/article/000001.htm
Bone or bone marrow may be infected by bacteria or fungi. If this becomes chronic it is called osteomyelitis. Pus is produced within the bone, creating an abscess that stops the bone from getting its blood supply. In chronic osteomyelitis the bone dies due to the loss of blood (avascular necrosis).
Avascular necrosis may also occur if the bones refuse to join back up again or take a long time in doing so.
http://www.nhsdirect.nhs.uk/articles/article.aspx?articleId=166§ionId=6
http://www.nlm.nih.gov/medlineplus/ency/article/000437.htm
http://www.nlm.nih.gov/medlineplus/ency/article/000001.htm
PCL 12- Language and kinship
• Aboriginal language
o Complex grammar and vocabulary
o Can be split broadly into 2 types
Pama-Nyungan and non- Pama-Nyungan
More than 200 indigenous languages exist
20 of them are used more commonly
o Language changes depending on the situation:
Formal (during ceremonies), talking to relatives, talking about sacred matters
o Various form are present depending on age, status
o There are classes that teach indigenous languages, taught by aborigines
• Aboriginal kinship
o Based on classes or skins (eg: 2 groups), it’s the indigenous people’s way to maintain social structure
o Contains the norms, roles, institutions and cognitive processes in relationships
o Kinship dictates whom an aborigine can speak and not speak to (if communication is needed, a third party is required to pass messages)
This is regarded as an act of respect between certain classes of relatives
Sharing food or giving gifts to certain relatives can happen, but there are also those you can play tricks on or tease.
o Marriage
Cannot marry into your own skin group (like incest)
http://www.dnathan.com/VL/austLang.htm
http://indigenousaustralia.frogandtoad.com.au/language.html
http://acl.arts.usyd.edu.au/projects/wangkamaya/index.php?option=com_content&task=view&id=105&Itemid=144
http://indigenousaustralia.frogandtoad.com.au/social3.html
o Complex grammar and vocabulary
o Can be split broadly into 2 types
Pama-Nyungan and non- Pama-Nyungan
More than 200 indigenous languages exist
20 of them are used more commonly
o Language changes depending on the situation:
Formal (during ceremonies), talking to relatives, talking about sacred matters
o Various form are present depending on age, status
o There are classes that teach indigenous languages, taught by aborigines
• Aboriginal kinship
o Based on classes or skins (eg: 2 groups), it’s the indigenous people’s way to maintain social structure
o Contains the norms, roles, institutions and cognitive processes in relationships
o Kinship dictates whom an aborigine can speak and not speak to (if communication is needed, a third party is required to pass messages)
This is regarded as an act of respect between certain classes of relatives
Sharing food or giving gifts to certain relatives can happen, but there are also those you can play tricks on or tease.
o Marriage
Cannot marry into your own skin group (like incest)
http://www.dnathan.com/VL/austLang.htm
http://indigenousaustralia.frogandtoad.com.au/language.html
http://acl.arts.usyd.edu.au/projects/wangkamaya/index.php?option=com_content&task=view&id=105&Itemid=144
http://indigenousaustralia.frogandtoad.com.au/social3.html
Damage to Neurovascular supply
Damage to the neurovascular supply of the leg in a compound fracture
• Damage to popliteal region, with associated nerve, vein and artery injury, very serious. Damage is easily missed.
•Arteries that could be damaged in leg:
o Anterior tibial artery
o Fibular artery
• Nerves
o Common fibular nerve – often injured with tibia/fibula fractures
o Superficial fibular nerve
o Saphenous nerve
o Deep fibular nerve
o Sural nerve
• Peripheral nerves can be possibly damaged.
• Damage to popliteal region, with associated nerve, vein and artery injury, very serious. Damage is easily missed.
•Arteries that could be damaged in leg:
o Anterior tibial artery
o Fibular artery
• Nerves
o Common fibular nerve – often injured with tibia/fibula fractures
o Superficial fibular nerve
o Saphenous nerve
o Deep fibular nerve
o Sural nerve
• Peripheral nerves can be possibly damaged.
Wednesday, October 8, 2008
Fracture of the leg -- Surgical Management
Before the surgery, the patient is assessed under general anesthetic…
Open fracture: Tibial shaft fracture is associated with a break in the skin
For successful treatment of contaminated open tibial fractures, patient undergoes
1.Radical debridement of necrotic tissue (within 6 hours of injury)
2.Pulsed lavage of the area to remove bacteria
3.Prophylactic intravenous antibiotics (Often, Aminoglycosides + Cephalosporin. For low-grade open fractures, antibiotics such as first-generation cephalosporins are used. For higher-grade injuries with dirty wounds & infection, penicillin + aminoglycosides used)
Repeat debridements (every 24 h, as needed) are often used in
-Injuries with extensive soft tissue injury
-Severely contaminated wounds
-Wounds with vascular compromise in which additional necrotic tissue may present itself.
Soft tissue is usually covered (using sterile technique) within 1 week of injury
A splint should be used for stabilization. The splint usually remains intact until the patient is prepared in the operating room.
Intramedullary (IM) Rodding [Preferred treatment]
Intrameduallary rodding is a procedure to place a medal rod down the center of the tibia to hold the alignment ofthe bone. - A tibial rodding is a surgical procedure that lasts about an hour and half
- Usually done under general anaesthetic
1.Patients will have an incision over the knee joint, and small incisions below the knee and above the ankle. In addition, some fractures may require an incision near the fracture to realign the bones.
2.IM rods are secured within the bone by screws both above and below the fracture.
3.The metal screws and the rod can be removed if they cause problems, but can also be left in place for life.
Tibial rodding provides excellent fixation and alignment of the bones
-Most common risk of surgery is knee pain
-Most common complication is infection Infection of the rod may require removal of the rod in order to cure the infection
Plates and Screws
Plates and screws are less commonly used, but are helpful in some fracture types, especially those closer to the knee or ankle joints.
Most surgeons choose an IM rod for tibial shaft fractures unless the fracture is too close to the joint to allow for placement of the IM rod In fractures close to the joint surface, a plate and screws may be the ideal method of fixation.
External Fixator
External fixators tend to be used in more severe fractures, especially open fractures with associated lacerations and soft-tissue damage
-Placement of IM rods or plates may not be possible because of soft-tissue injury
-When there is significant soft-tissue injury, the external fixator may provide excellent immobilization while allowing monitoring and treatment of the surrounding soft tissues
Amputation
Amputation is uncommon but is sometimes indicated for severe tibial fractures, especially those with large soft tissue injury or those in patients with vascular compromise, such as in diabetic patients.
Amputation for grades I and II fractures is rare, but the rate of amputation is increased for grade III fractures. In fact, fractures requiring revascularization (type IIIc fractures) have a corresponding amputation rate of greater than 20%.
The Mangled Extremity Severity Score is a tool that has been developed to help the surgeon decide whether or not amputation is indicated, but it is only part of the equation. Surgical expertise and patient communication are of vital importance when making amputation decisions.
http://www.emedicine.com/orthoped/TOPIC340.HTM
http://www.emedicine.com/orthoped/topic336.htm
http://orthopedics.about.com/od/brokenbones/a/tibia.htm
Open fracture: Tibial shaft fracture is associated with a break in the skin
For successful treatment of contaminated open tibial fractures, patient undergoes
1.Radical debridement of necrotic tissue (within 6 hours of injury)
2.Pulsed lavage of the area to remove bacteria
3.Prophylactic intravenous antibiotics (Often, Aminoglycosides + Cephalosporin. For low-grade open fractures, antibiotics such as first-generation cephalosporins are used. For higher-grade injuries with dirty wounds & infection, penicillin + aminoglycosides used)
Repeat debridements (every 24 h, as needed) are often used in
-Injuries with extensive soft tissue injury
-Severely contaminated wounds
-Wounds with vascular compromise in which additional necrotic tissue may present itself.
Soft tissue is usually covered (using sterile technique) within 1 week of injury
A splint should be used for stabilization. The splint usually remains intact until the patient is prepared in the operating room.
Intramedullary (IM) Rodding [Preferred treatment]
Intrameduallary rodding is a procedure to place a medal rod down the center of the tibia to hold the alignment ofthe bone. - A tibial rodding is a surgical procedure that lasts about an hour and half
- Usually done under general anaesthetic
1.Patients will have an incision over the knee joint, and small incisions below the knee and above the ankle. In addition, some fractures may require an incision near the fracture to realign the bones.
2.IM rods are secured within the bone by screws both above and below the fracture.
3.The metal screws and the rod can be removed if they cause problems, but can also be left in place for life.
Tibial rodding provides excellent fixation and alignment of the bones
-Most common risk of surgery is knee pain
-Most common complication is infection Infection of the rod may require removal of the rod in order to cure the infection
Plates and Screws
Plates and screws are less commonly used, but are helpful in some fracture types, especially those closer to the knee or ankle joints.
Most surgeons choose an IM rod for tibial shaft fractures unless the fracture is too close to the joint to allow for placement of the IM rod In fractures close to the joint surface, a plate and screws may be the ideal method of fixation.
External Fixator
External fixators tend to be used in more severe fractures, especially open fractures with associated lacerations and soft-tissue damage
-Placement of IM rods or plates may not be possible because of soft-tissue injury
-When there is significant soft-tissue injury, the external fixator may provide excellent immobilization while allowing monitoring and treatment of the surrounding soft tissues
Amputation
Amputation is uncommon but is sometimes indicated for severe tibial fractures, especially those with large soft tissue injury or those in patients with vascular compromise, such as in diabetic patients.
Amputation for grades I and II fractures is rare, but the rate of amputation is increased for grade III fractures. In fact, fractures requiring revascularization (type IIIc fractures) have a corresponding amputation rate of greater than 20%.
The Mangled Extremity Severity Score is a tool that has been developed to help the surgeon decide whether or not amputation is indicated, but it is only part of the equation. Surgical expertise and patient communication are of vital importance when making amputation decisions.
http://www.emedicine.com/orthoped/TOPIC340.HTM
http://www.emedicine.com/orthoped/topic336.htm
http://orthopedics.about.com/od/brokenbones/a/tibia.htm
Definition - Tetanus + 'Tetanus-prone wound'
Tetanus is a medical condition characterized by an acute onset of hypertonia, painful muscle contractions (usually of the jaw and neck), and generalized muscle spasms without any other apparent medical causes. Symptoms are caused primarily by tetanospasmin, a neurotransmitter produced by the anaerobic bacterium ‘Clostridium tetani’.
A wound is classified as ‘tetanus-prone’ if it has one or more of the following characteristics.
1) Age of wound > 6hrs
2) Type of wound = Stellate (star shaped or radiating from central wound), abrasion, avulsion
3) Depth > 1cm
4) Mechanism of injury = Projectile, crush, burn, frostbite
5) Signs of infection present
6) Gross contamination (feces, saliva, grass, dirt) present
7) Ischemic tissue present
A wound is classified as ‘tetanus-prone’ if it has one or more of the following characteristics.
1) Age of wound > 6hrs
2) Type of wound = Stellate (star shaped or radiating from central wound), abrasion, avulsion
3) Depth > 1cm
4) Mechanism of injury = Projectile, crush, burn, frostbite
5) Signs of infection present
6) Gross contamination (feces, saliva, grass, dirt) present
7) Ischemic tissue present
General measures for treating tetanus prone wounds - Eunice
General measures for treating tetanus-prone wounds
Types of wounds likely to favour the growth of tetanus organisms:
- Compound fractures
- Deep penetrating wounds
- Wounds containing foreign bodies, especially wood splinters
- Wounds complicated by pyogenic infections
- Wounds with extensive tissue damage (e.g. contusions or burns)
- Any wound obviously contaminated with soil, dust or horse manure, especially if topical disinfection is delayed more than 4 hours
- Re-implantation of an avulsed tooth is also a tetanus-prone event, as minimal washing and cleaning of the tooth is conducted to increase the likelihood of successful re-implantation.
Management
- Wounds must be cleaned, disinfected and treated surgically if appropriate
- Recommended protocols for prophylactic vaccination
- The new Immunisation Schedule recommends that 10-yearly tetanus boosters are no long required up until the age of 50, provided that the primary series of 3 vaccinations plus 2 boosters have been given
- Instead, one Td (ADT) booster isrecommended ≥ 10 years of age, after completion of the childhood vaccination schedule, and another Td(ADT) booster is recommended at 50 years of age.
- If a person who is 50 years of age has had a Td (ADT) booster within 10 years, then this dose can be omitted.
- Every person should have had at least 5 routine doses of tetanus and diphtheria vaccines before 50 years of age, the first 3 doses 1-2 months apart, and the next 2 doses 10 years apart.
- A combination vaccine should be used in order to boost community protection against pertussis:
• < 8 years old DTPa-IPV (Infanrix-IPV®)
• > 8 years old dTpa (Boostrix®)
- A diphtheria/ tetanus toxoid vaccine (ADT® ) can be used if pertussis vaccination is contraindicated.
http://www.rch.org.au/clinicalguide/cpg.cfm?doc_id=5221
http://hsd.odgp.com.au/projects/immunisation/download_update_2006/Tetanus_Prophylaxis_for_Wound_Management.pdf
Types of wounds likely to favour the growth of tetanus organisms:
- Compound fractures
- Deep penetrating wounds
- Wounds containing foreign bodies, especially wood splinters
- Wounds complicated by pyogenic infections
- Wounds with extensive tissue damage (e.g. contusions or burns)
- Any wound obviously contaminated with soil, dust or horse manure, especially if topical disinfection is delayed more than 4 hours
- Re-implantation of an avulsed tooth is also a tetanus-prone event, as minimal washing and cleaning of the tooth is conducted to increase the likelihood of successful re-implantation.
Management
- Wounds must be cleaned, disinfected and treated surgically if appropriate
- Recommended protocols for prophylactic vaccination
- The new Immunisation Schedule recommends that 10-yearly tetanus boosters are no long required up until the age of 50, provided that the primary series of 3 vaccinations plus 2 boosters have been given
- Instead, one Td (ADT) booster isrecommended ≥ 10 years of age, after completion of the childhood vaccination schedule, and another Td(ADT) booster is recommended at 50 years of age.
- If a person who is 50 years of age has had a Td (ADT) booster within 10 years, then this dose can be omitted.
- Every person should have had at least 5 routine doses of tetanus and diphtheria vaccines before 50 years of age, the first 3 doses 1-2 months apart, and the next 2 doses 10 years apart.
- A combination vaccine should be used in order to boost community protection against pertussis:
• < 8 years old DTPa-IPV (Infanrix-IPV®)
• > 8 years old dTpa (Boostrix®)
- A diphtheria/ tetanus toxoid vaccine (ADT® ) can be used if pertussis vaccination is contraindicated.
http://www.rch.org.au/clinicalguide/cpg.cfm?doc_id=5221
http://hsd.odgp.com.au/projects/immunisation/download_update_2006/Tetanus_Prophylaxis_for_Wound_Management.pdf
Monday, October 6, 2008
Compartment Syndrome (PCL 12)
Compartment Syndrome - Penny and Ben
Definition: compression of nerves and blood vessels within a compartment of the body (confined space surrounded by fascia), which can lead to impaired blood flow, muscle damage and nerve damage.
Pathophysiology: since fascia does not expand, swelling within a compartment can lead to increased pressure in the compartment, causing compression of muscle, nerves and blood vessels. If the pressure is high enough, blood flow may be blocked and permanent damage may occur. If the pressure lasts long enough, the limb may die.
When the pressure in the compartment exceeds the pressue in the capillaries, the capillaries will collapse and can no longer deliver oxygen and nutrients to the muscles and nerves within the compartment, and they will start to die in a matter of hours.
Causes: compartment syndrome is caused by increased pressure in the compartment, which may be due to a) increased fluid content or b) decreased compartment size.
Signs and Symptoms
Severe pain, especially when the muscle is stretched, and out of proportion to the injury, which does not respond to pain medication.
Tingling or burning sensation in the muscle (parasthesia)
Muscle feeling tight or full
Paralysis = cell death has already begun
Diagnosis
References
http://www.emedicine.com/EMERG/topic739.htm
http://www.nlm.nih.gov/MEDLINEPLUS/ency/article/001224.htm
http://orthoinfo.aaos.org/topic.cfm?topic=a00204
Definition: compression of nerves and blood vessels within a compartment of the body (confined space surrounded by fascia), which can lead to impaired blood flow, muscle damage and nerve damage.
Pathophysiology: since fascia does not expand, swelling within a compartment can lead to increased pressure in the compartment, causing compression of muscle, nerves and blood vessels. If the pressure is high enough, blood flow may be blocked and permanent damage may occur. If the pressure lasts long enough, the limb may die.
When the pressure in the compartment exceeds the pressue in the capillaries, the capillaries will collapse and can no longer deliver oxygen and nutrients to the muscles and nerves within the compartment, and they will start to die in a matter of hours.
Causes: compartment syndrome is caused by increased pressure in the compartment, which may be due to a) increased fluid content or b) decreased compartment size.
- Swelling from a high-trauma injury such as a car crash or surgery
- Swelling from repetitive activities such as runing may cause chronic compartment syndrome
- Burns
- Fractures
- Hemorrhage
- Tight bandages or casts
- Use of creatinine monohydrate by athletes to build muscle
Signs and Symptoms
Severe pain, especially when the muscle is stretched, and out of proportion to the injury, which does not respond to pain medication.
Tingling or burning sensation in the muscle (parasthesia)
Muscle feeling tight or full
Paralysis = cell death has already begun
Diagnosis
- Measurement of compartment pressure ( >30 mm Hg suggests compartment syndrome)
- Lab Studies
- CT to look at the bones
- Vascular pathologies can be evaluated with arterial and venous Doppler ultrasonography
- Magnetic resonance imaging (MRI) to see muscle tears
- Physical rehabilitation that decreases activity or load acting on affected compartment
- Aquatic exercises can improve mobility and strength
- Massage and stretching exercises also have been shown to be effective
- For worse compartment syndromes, a fasciotomy is performed
- Irreversible tissue ischemia can develop in the acute setting → permanent muscle and nerve damage, along with chronic pain, may occur.
- Peroneal nerve palsy, in particular, may develop.
- Muscle contractures may be observed.
- Infection is a major issue after fasciotomy and in some cases becomes chronic. Patients, especially those with multiple traumatic injuries--> can lead to death through metabolic complications
- Calcific myonecrosis - latent formation of a dystrophic calcified mass occurring almost exclusively in the lower limb
References
http://www.emedicine.com/EMERG/topic739.htm
http://www.nlm.nih.gov/MEDLINEPLUS/ency/article/001224.htm
http://orthoinfo.aaos.org/topic.cfm?topic=a00204
Thursday, September 25, 2008
PCL 11 - LCL Injury Fern & Myat
Mechanism of Injury
- Force directed on anteromedial aspect of tibia with foot planted and knee in various degrees of flexion
- An LCL injury should not be confused with other overuse lateral knee injuries (eg, iliotibial band syndrome, biceps femoris tendinitis)
- Other problems:
Meniscal tear
Osteochondral fracture
Biceps femoris tendiniton
Examination
History
-Ask if there is any effusion within few hours of injury. One should not expect significant effusion unless there is cruciate ligament of meniscal tear.
-If the patient also felt or heard a pop it may suggest concomitant injury
Inquire about previous injuries, symptoms, surgeries to the knee
Physical
-Inspect – gross abnormalities, skin abrasions, swelling, redness, scars etc…
-Palpate – suprapatellar pouch for effusion, joint-line tenderness
-Move
With patient lying flat and leg extended, test for medial movement of the leg at the knee joint.
More than 5 to 10 degrees is abnormal
Varus stress occurs at 0 to 30 degrees of flexion
Investigations
-X – ray to rule out fractures, dislocations, acute traumatic injuries, degenerative joint disease
-MRI to confirm diagnosis
-Electromyogram (EMG) and nerve conduction velocity (NCV) tests may assess for peroneal nerve injury.
-Arteriogram – to check popliteal artery if multiple ligaments torn
-Grade the degree of the LCL injury according to the following:
Grade 1 – Interstitial injury without laxity is present, but there is pain with varus stress; only microscopic tearing has occurred.
Grade 2 – A 5-10 mm of joint-space opening with a distinct end point is noted; partial macroscopic tearing has occurred.
Grade 3 – Complete tearing (>10 mm joint-space opening) has occurred; complete macroscopic tearing is noted.
Treatment
Grade I and II:
-RICE
-Non-bearing restrictions with use of crutches
-NSAIDs
Grade III
-Surgical intervention
-Full weight-bearing gait should return in about 4 weeks
-Rehabilitation program
-Range of movement exercise e.g. cycling, quadriceps-strengthening exercises
Surgery
-Ligament Repair
Repair of a recently torn collateral ligament usually requires an incision through the skin over the area where the tear in the ligament has occurred. If the ligament has been pulled from its attachment on the bone, the ligament is reattached to the bone with either large sutures (strong stitches) or special staples called suture anchors. Tears of the middle areas of the ligament are usually repaired by sewing the ends together.
-Ligament Reconstruction
Chronic swelling or instability caused by a collateral ligament injury may require a surgical reconstruction. Reconstruction differs from repair of the ligaments, described earlier. A reconstruction operation usually works by either tightening up the loose ligament or replacing the loose ligament with a tendon graft.
-Ligament Tightening
In the tightening procedure, your surgeon will use the remaining ligament tissue and take up the slack (similar to taking in the waist on a pair of pants). This is usually done by detaching one end of the ligament from its place on the bone and moving it so that it becomes tighter. The ligament is then reattached to the bone in the new place and held with sutures or metal staples.
-Autograft Method
if a tendon graft is needed to replace the loose ligament, it is usually taken from somewhere else in the same knee. Taking tissue from your own body is called an autograft. A common autograft that is used is one of the hamstring tendons called the semitendinosus tendon. Studies have shown that this tendon can be removed without affecting the strength of the leg. This is because other bigger and stronger hamstring muscles can take over the function of the tendon that is removed. In this operation, your surgeon will use the tendon graft to replace the damaged collateral ligament. The ends of the tendon graft are attached to the bone using large sutures or metal staples.
-Allograft Method
Another way to replace a badly torn collateral ligament is with an allograft. For this procedure, the surgeon gets graft tissue from a tissue bank. This tissue is usually removed from an organ donor at the time of death and sent to a tissue bank. There the tissue is checked for infection, sterilized, and stored in a freezer. When needed, the tissue is ordered by the surgeon and used to replace the torn collateral ligament.
Complications
-Chronic pain
-Weakness
-Instability
-Peroneal nerve injury
Prognosis
Non-surgical rehabilitation
-Minor tears should get better in 4 to 6 weeks
-Moderate tears should rehabilitate in 2 months
-Severe tears 3 months, if longer à surgery
-LCL leave knee most unstable, patients without surgery don’t usually do well
After surgery rehabilitation
-Depends on type of surgery performed
-Continuous Passive Movement:
Machine that helps the joint to move and alleviate joint stiffness
-Patients are strongly advised to follow recommendations of how much weight and -pressure they place on leg while standing or walking (usually up to 12 weeks, no weight)
-Formal exercise therapy with physical therapist
ACL Tear - Mechanism of Injury, Examination & Complications & Prognosis of Surgery
Anterior Cruciate Ligament
- Mechanism of injury: usually occurs through a twisting force being applied to the knee whilst the foot is firmly planted on the ground or upon landing. A torn ACL can also result from a direct blow to the knee, usually the outside, as may occur during a football or rugby tackle. This injury is sometimes seen in combination with a medial meniscus tear and MCL injury, which is termed O’Donohue’s triad.
- Examination:
a) Lachman test: with patient’s knee bent 20-30 degrees, grasp limb over distal femur and proximal tibia. Tibia alternately pulled forward and pushed backward. Movement of 5mm or more than that in normal limb indicates rupture of ACL
b) Anterior drawer test: With patient lying on the table, hip flexed 45 degrees, knee 90 degrees. Examiner sits on patient’s foot to stabilise it, places hands on each side of upper calf and firmly pulls tibia forward. Movement of 5mm or more is positive result. Result is compared with normal limb which is tested first.
Surgery (involves reconstruction or repair of the ACL)
- Prognosis: About 60% of patients return to the full level of pre-injury activity. But 80 – 90% have favourable results (reduced pain, good knee function and stability, and return to normal levels of activity). Surgery is usually successful for cases of ACL avulsion, where the ligament has torn away from the femur or tibia. Between 3% and 10% of people who have ACL surgery still have knee pain and instability and may need another surgery (revision ACL reconstruction). Revision ACL reconstruction is generally not as successful as the initial ACL reconstruction.
- Complications:
• Problems related to the surgery itself: Numbness in the surgical scar area, infection in the surgical incisions, damage to structures, nerves (common peroneal and tibial), or blood vessels around and in the knee, blood clots in the leg and anaesthesia risks.
• Problems with the graft tendon (loosening, stretching, reinjury, or scar tissue). The screws that attach the graft to the leg bones may cause problems and require removal.
• Limited range of motion, usually at the extremes, e.g. not being to completely bend or straighten the leg. This is uncommon, and sometimes manipulation under anesthesia can help.
• Crepitus, as the patella moves against the lower end of the thighbone (femur), which may develop in people who did not have it before surgery. In rare cases, the kneecap may be fractured while the graft is being taken during surgery or from a fall onto the knee soon after surgery.
• Pain, when kneeling, at the site where the tendon graft was taken from the patellar tendon or at the site on the lower leg bone (tibia) where a hamstring or patellar tendon graft is attached.
• Repeat injury to the graft (just like the original ligament). Repeat surgery is more complicated and less successful than the first surgery.
http://www.webmd.com/a-to-z-guides/anterior-cruciate-ligament-acl-surgery
- Mechanism of injury: usually occurs through a twisting force being applied to the knee whilst the foot is firmly planted on the ground or upon landing. A torn ACL can also result from a direct blow to the knee, usually the outside, as may occur during a football or rugby tackle. This injury is sometimes seen in combination with a medial meniscus tear and MCL injury, which is termed O’Donohue’s triad.
- Examination:
a) Lachman test: with patient’s knee bent 20-30 degrees, grasp limb over distal femur and proximal tibia. Tibia alternately pulled forward and pushed backward. Movement of 5mm or more than that in normal limb indicates rupture of ACL
b) Anterior drawer test: With patient lying on the table, hip flexed 45 degrees, knee 90 degrees. Examiner sits on patient’s foot to stabilise it, places hands on each side of upper calf and firmly pulls tibia forward. Movement of 5mm or more is positive result. Result is compared with normal limb which is tested first.
Surgery (involves reconstruction or repair of the ACL)
- Prognosis: About 60% of patients return to the full level of pre-injury activity. But 80 – 90% have favourable results (reduced pain, good knee function and stability, and return to normal levels of activity). Surgery is usually successful for cases of ACL avulsion, where the ligament has torn away from the femur or tibia. Between 3% and 10% of people who have ACL surgery still have knee pain and instability and may need another surgery (revision ACL reconstruction). Revision ACL reconstruction is generally not as successful as the initial ACL reconstruction.
- Complications:
• Problems related to the surgery itself: Numbness in the surgical scar area, infection in the surgical incisions, damage to structures, nerves (common peroneal and tibial), or blood vessels around and in the knee, blood clots in the leg and anaesthesia risks.
• Problems with the graft tendon (loosening, stretching, reinjury, or scar tissue). The screws that attach the graft to the leg bones may cause problems and require removal.
• Limited range of motion, usually at the extremes, e.g. not being to completely bend or straighten the leg. This is uncommon, and sometimes manipulation under anesthesia can help.
• Crepitus, as the patella moves against the lower end of the thighbone (femur), which may develop in people who did not have it before surgery. In rare cases, the kneecap may be fractured while the graft is being taken during surgery or from a fall onto the knee soon after surgery.
• Pain, when kneeling, at the site where the tendon graft was taken from the patellar tendon or at the site on the lower leg bone (tibia) where a hamstring or patellar tendon graft is attached.
• Repeat injury to the graft (just like the original ligament). Repeat surgery is more complicated and less successful than the first surgery.
http://www.webmd.com/a-to-z-guides/anterior-cruciate-ligament-acl-surgery
Medial Meniscus - Sarah and Bryn
Task – Medial Meniscus
The medial meniscus is a fibrocartilage band that spans the medial knee, and lies on the head of the tibia.
Its anterior end is attached to the anterior intercondyloid fossa of the tibia, in front of the anterior cruciate ligament.
Its posterior end is fixed to the posterior intercondyloid fossa of the tibia, between the attachments of the lateral meniscus and the posterior cruciate ligament.
The medial meniscus separates the tibia and femur and serves as a shock absorber, to increase the contact area between the bones, reducing the peak contact force experienced. It also reduces friction between the two bones to allow smooth movement in the knee
Meniscus tear
There are three types of tear to the meniscus that can occur and these lead to another three types.
Longitudinal tear - Bucket handle tear
Radial tear - Parrot beak tear
Horizontal tear - Flap tear
The medial meniscus has a rich supply to its periphery, a tear there healing fast and usually quite well. However a deeper tear may not heal as well.
The neuroanatomy of the meniscus is not well described. But it is believe to be enervated in a similar manner to the arteries, more on the periphery less deeper, these nerve endings are believed to play a role in sensory feedback and proprioception.
Mechanism of Injury
• The meniscus both medial and lateral are often torn by a twisting injury, common in sporting injuries, which involve twisting and bending of the knee.
• Can also be damaged in the elderly as it becomes weaker, and more likely to tear.
Investigation
• When taking a history these things should be noted:
o Tears sometime related to significant trauma, but not always.
o The injury often results from twisting or bending of a weight bearing knee in various degrees of flexion and extension.
o Pain is often intermittent and results from synovitis or abnormal motion of the unstable meniscus fragment.
o The pain is usually localised at the joint line.
o Patients can complain of: clicking, scratching, catching, locking, pinching or the sensation of giving way.
o Swelling usually occurs as a delayed symptom or may not occur at all. Immediate swelling indicates a tear in the peripheral vascular aspect.
o Degenerative tears often manifest with recurrent effusion due to synovitis.
Examination
• Associated findings such as a perimeniscal cyst or ligamentous laxity suggest a higher likelihood of a meniscus injury.
• Joint line tenderness – is an accurate clinical sign, found in 77 – 86% of cases of people with meniscus tears.
• The tenderness must be differentiated from a collateral ligament tear, this pain will extend above and below the joint line towards the ligament attachments.
• Effusion occurs in approx 50% of tears.
• Range of motion
o A mechanical block to motion or frank locking can occur with displaced tears.
o Restricted motion caused by pain or swelling is also common.
• Tests that can be performed are:
o The McMurray test: elicits pain: The medial meniscus is evaluated by extending the fully flexed knee with the foot/tibia internally rotated while a varus stress is applied.
o The Steinmann test: Tibial rotation is performed with the patient seated and the knee flexed 90º. Asymmetric pain is created with external rotation when testing the medial meniscus.
o The Apley test: This maneuver is performed with the patient prone and the knee flexed 90º. An axial load is applied through the heel as the lower leg is internally and externally rotated. This grinding maneuver is suggestive of meniscal pathology if pain is elicited at the medial or lateral joint.
Management
• Physical Therapy/medical management:
A home physical therapy program or simple rest with activity modification, ice, and nonsteroidal anti-inflammatory drugs (NSAIDs) is the non-operative management of possible meniscus tears. The physical therapy program goals are to minimize the effusion, normalize gait, normalize pain-free range of motion, prevent muscular atrophy, maintain proprioception, and maintain cardiovascular fitness. Choosing this course of treatment must include consideration of the patient's age, activity level, duration of symptoms, type of meniscus tear, and associated injuries such as ligamentous pathology. A trial of conservative treatment should be attempted in all but the most severe cases, such as a locked knee secondary to a displaced bucket-handle tear.’
• Surgical Intervention
If symptoms persist, if the patient cannot risk the delay of a potentially unsuccessful period of observation (eg, elite athletes), or in cases of a locked knee, surgical treatment is indicated.
The basic principle of meniscus surgery is to save the meniscus. Tears with a high probability of healing with surgical intervention are repaired. However, most tears are not repairable and resection must be restricted to only the dysfunctional portions, preserving as much normal meniscus as possible.
Surgical options include partial meniscectomy or meniscus repair (and in cases of previous total or subtotal meniscectomy, meniscus transplantation). Arthroscopy, a minimally invasive outpatient procedure with lower morbidity, improved visualization, faster rehabilitation, and better outcomes than open meniscal surgery, is now the standard of care.
Partial meniscectomy is the treatment of choice for tears in the avascular portion of the meniscus or complex tears that are not amenable to repair. Torn tissue is removed, and the remaining healthy meniscal tissue is contoured to a stable, balanced peripheral rim.
Meniscus repair is recommended for tears that occur in the vascular region (red zone or red-white zone), are longer than 1 cm, involve greater than 50% of the meniscal thickness, and are unstable to arthroscopic probing. A stable knee is important for successful meniscus repair and healing. Thus, associated ligamentous injuries must be addressed. The most commonly associated ligamentous disruption is complete tear of the ACL, which must be reconstructed to prevent recurrent meniscal tears. Fortunately, the increased blood and growth factors in the knee during meniscal repair combined with cruciate reconstruction significantly improves the outcome of the meniscal repair. In ACL-intact knees with isolated meniscal tears, healing rates are less than those in ACL-reconstructed knees, but they are higher than those in ACL-deficient knees.
The principles of repair include smoothing and abrading the torn edges and bordering synovium to promote bleeding and healing. Likewise, needle trephination of the meniscal body (poking holes to create vascular channels) can be performed.
Human allograft meniscal transplantation is a relatively new procedure but is being performed increasingly frequently. Specific indications and long-term results have not yet been clearly established. Meniscus transplantation requires further investigation to assess its efficacy in restoring normal meniscus function and preventing arthrosis.
Complications of Surgury:
Can be intraoperative or postoperative
Intraoperative
-anesthetic problems
-articular cartilage damage
-vessel or nerve injury
-instrument failure
Postoperative
-anesthetic concerns
-thrombophlebitis
-hemarthrosis
-infection
-stiffness
-persistent pain
-effusion
-synovitis
Prognosis
Healing of a medial meniscus tear is slow. If surgery is required and the meniscus is removed there is an increase risk of osteoarthritis in later life.
References
• http://www.emedicine.com/SPORTS/topic160.htm
The medial meniscus is a fibrocartilage band that spans the medial knee, and lies on the head of the tibia.
Its anterior end is attached to the anterior intercondyloid fossa of the tibia, in front of the anterior cruciate ligament.
Its posterior end is fixed to the posterior intercondyloid fossa of the tibia, between the attachments of the lateral meniscus and the posterior cruciate ligament.
The medial meniscus separates the tibia and femur and serves as a shock absorber, to increase the contact area between the bones, reducing the peak contact force experienced. It also reduces friction between the two bones to allow smooth movement in the knee
Meniscus tear
There are three types of tear to the meniscus that can occur and these lead to another three types.
Longitudinal tear - Bucket handle tear
Radial tear - Parrot beak tear
Horizontal tear - Flap tear
The medial meniscus has a rich supply to its periphery, a tear there healing fast and usually quite well. However a deeper tear may not heal as well.
The neuroanatomy of the meniscus is not well described. But it is believe to be enervated in a similar manner to the arteries, more on the periphery less deeper, these nerve endings are believed to play a role in sensory feedback and proprioception.
Mechanism of Injury
• The meniscus both medial and lateral are often torn by a twisting injury, common in sporting injuries, which involve twisting and bending of the knee.
• Can also be damaged in the elderly as it becomes weaker, and more likely to tear.
Investigation
• When taking a history these things should be noted:
o Tears sometime related to significant trauma, but not always.
o The injury often results from twisting or bending of a weight bearing knee in various degrees of flexion and extension.
o Pain is often intermittent and results from synovitis or abnormal motion of the unstable meniscus fragment.
o The pain is usually localised at the joint line.
o Patients can complain of: clicking, scratching, catching, locking, pinching or the sensation of giving way.
o Swelling usually occurs as a delayed symptom or may not occur at all. Immediate swelling indicates a tear in the peripheral vascular aspect.
o Degenerative tears often manifest with recurrent effusion due to synovitis.
Examination
• Associated findings such as a perimeniscal cyst or ligamentous laxity suggest a higher likelihood of a meniscus injury.
• Joint line tenderness – is an accurate clinical sign, found in 77 – 86% of cases of people with meniscus tears.
• The tenderness must be differentiated from a collateral ligament tear, this pain will extend above and below the joint line towards the ligament attachments.
• Effusion occurs in approx 50% of tears.
• Range of motion
o A mechanical block to motion or frank locking can occur with displaced tears.
o Restricted motion caused by pain or swelling is also common.
• Tests that can be performed are:
o The McMurray test: elicits pain: The medial meniscus is evaluated by extending the fully flexed knee with the foot/tibia internally rotated while a varus stress is applied.
o The Steinmann test: Tibial rotation is performed with the patient seated and the knee flexed 90º. Asymmetric pain is created with external rotation when testing the medial meniscus.
o The Apley test: This maneuver is performed with the patient prone and the knee flexed 90º. An axial load is applied through the heel as the lower leg is internally and externally rotated. This grinding maneuver is suggestive of meniscal pathology if pain is elicited at the medial or lateral joint.
Management
• Physical Therapy/medical management:
A home physical therapy program or simple rest with activity modification, ice, and nonsteroidal anti-inflammatory drugs (NSAIDs) is the non-operative management of possible meniscus tears. The physical therapy program goals are to minimize the effusion, normalize gait, normalize pain-free range of motion, prevent muscular atrophy, maintain proprioception, and maintain cardiovascular fitness. Choosing this course of treatment must include consideration of the patient's age, activity level, duration of symptoms, type of meniscus tear, and associated injuries such as ligamentous pathology. A trial of conservative treatment should be attempted in all but the most severe cases, such as a locked knee secondary to a displaced bucket-handle tear.’
• Surgical Intervention
If symptoms persist, if the patient cannot risk the delay of a potentially unsuccessful period of observation (eg, elite athletes), or in cases of a locked knee, surgical treatment is indicated.
The basic principle of meniscus surgery is to save the meniscus. Tears with a high probability of healing with surgical intervention are repaired. However, most tears are not repairable and resection must be restricted to only the dysfunctional portions, preserving as much normal meniscus as possible.
Surgical options include partial meniscectomy or meniscus repair (and in cases of previous total or subtotal meniscectomy, meniscus transplantation). Arthroscopy, a minimally invasive outpatient procedure with lower morbidity, improved visualization, faster rehabilitation, and better outcomes than open meniscal surgery, is now the standard of care.
Partial meniscectomy is the treatment of choice for tears in the avascular portion of the meniscus or complex tears that are not amenable to repair. Torn tissue is removed, and the remaining healthy meniscal tissue is contoured to a stable, balanced peripheral rim.
Meniscus repair is recommended for tears that occur in the vascular region (red zone or red-white zone), are longer than 1 cm, involve greater than 50% of the meniscal thickness, and are unstable to arthroscopic probing. A stable knee is important for successful meniscus repair and healing. Thus, associated ligamentous injuries must be addressed. The most commonly associated ligamentous disruption is complete tear of the ACL, which must be reconstructed to prevent recurrent meniscal tears. Fortunately, the increased blood and growth factors in the knee during meniscal repair combined with cruciate reconstruction significantly improves the outcome of the meniscal repair. In ACL-intact knees with isolated meniscal tears, healing rates are less than those in ACL-reconstructed knees, but they are higher than those in ACL-deficient knees.
The principles of repair include smoothing and abrading the torn edges and bordering synovium to promote bleeding and healing. Likewise, needle trephination of the meniscal body (poking holes to create vascular channels) can be performed.
Human allograft meniscal transplantation is a relatively new procedure but is being performed increasingly frequently. Specific indications and long-term results have not yet been clearly established. Meniscus transplantation requires further investigation to assess its efficacy in restoring normal meniscus function and preventing arthrosis.
Complications of Surgury:
Can be intraoperative or postoperative
Intraoperative
-anesthetic problems
-articular cartilage damage
-vessel or nerve injury
-instrument failure
Postoperative
-anesthetic concerns
-thrombophlebitis
-hemarthrosis
-infection
-stiffness
-persistent pain
-effusion
-synovitis
Prognosis
Healing of a medial meniscus tear is slow. If surgery is required and the meniscus is removed there is an increase risk of osteoarthritis in later life.
References
• http://www.emedicine.com/SPORTS/topic160.htm
PCL 11- ACL tear: anatomy, investigation and management
Anterior cruciate ligament
Anatomy
· Origin
o Anterior intercondylar area of tibia
· Attachment
o Posterior to the attachment of medial meniscus
· Function
o Weakest of the cruciate ligaments
o Limits posterior rolling of femoral condyles
o Prevents posterior displacement of femur on tibia
o At 90o flexion, the knee cannot be pulled anterior because ACL prevents this
Investigation
· Physical examination (diagnosis is made with this and presenting complaint)
o Look and feel for swelling, inflammation
o The Anterior drawer sign
§ Flexing the knee at 45o, if the tibia can be pulled anteriorly it shows that ACL is ruptured
o Lachman’s test
§ Passively flex knee to 20-30o, put one hand on calf while the other holds the leg above knee joint, thumb must be on tibial tuberosity
§ Pull tibia towards you, if the tibia move towards you, ACL torn is present
· X-rays
o To rule out possible bone fractures
· MRI
o Unsure about the extent of damage, the doctor might order MRI to check for partial or complete tears
· Arthroscope
o Check for damages
Grading
· grade I sprain: pain with minimal damage to the ligaments
· grade II sprain: more ligament damage and mild looseness of the joint
· grade III sprain: the ligament is completely torn and the joint is very loose or unstable.
Management
· Pain and first aid
o Immobilise, injured knee should be held in a splint
o Elevate joint, use NSAIDS or ice
· Surgery
o ACL Reconstruction surgery (for severe tears)
§ Done with autograft or allograft with and arthroscope
· Using hamstring tendon or patella tendon
§ New tendon is fixed into bone while it heals into the bone
§ Strong enough for sports in 6 months
o Surgeon Martha Murray at Children’s Hospital Boston reported that a collagen gel enriched with platelets can stimulate healing of partial ACL tears
§ 40% strength increase than 14% in ARS
· Rehabilitation
o Rest, ice, elevation, bandage
o Strengthening exercises
§ Bike riding, swimming…
o Is done before (to regain most range of motion, reduce swelling) and after surgery (recover strength)
Reference:
Moore and Dalley 5th edition
http://www.mayoclinic.com/health/acl-injury/DS00898/DSECTION=treatments-and-drugs
http://www.mayoclinic.com/health/acl-injury/DS00898/DSECTION=treatments-and-drugs
http://www.melbourneorthopaedics.com.au/ligament.html#4
http://137.190.56.8/hthsci/casestudies/ACL/examination_of_theanterior_cruci.htm
http://www.med.umich.edu/1libr/sma/sma_ancrulig_sma.htm
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