Tendinitis and Bursitis

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Bursitis ???

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• ?????????????????????????????,?????????????,?????,
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• 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.

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• 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.

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  ??,?????????????????????????

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• 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.

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• 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.

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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
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• 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.

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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.

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• 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.

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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.

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• 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.

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• 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.

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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

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• 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.

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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.

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• 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.

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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.

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• 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.

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• 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.

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• Adhesive Capsulitis
• (frozen shoulder.)
• ????????

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• 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.

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• 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.

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• 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

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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.
  

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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.

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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.

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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.

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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.

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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.

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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.

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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

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Treatment

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

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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??? .

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• 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.

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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.

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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.
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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 ).

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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.

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• 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

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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.

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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.

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• 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.

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Treatment

• Core decompression
• Bone Grafting
• Vascularized Fibular Grafting
• Osteotomies of Proximal Femur

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• 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.

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Epiphysitis of tibial tuberosity???????

• (Osgood-Schlatter disease) (Osteochondrol
  disease of the tibial tubercle)

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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.

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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.

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• 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.

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• 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.

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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.

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• 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.

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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.

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• excision of ununited tibial tuberosity. A, Tibial
  tuberosity has been exposed. B, Bony prominence
  has been excised.

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Legg-Calve-Perthes DISEASEPerthes?

• The cause
• The clinical sign
• Plain roentgenographic changes
• Bone scintigraphy
• MRI
• Treatment

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• 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.

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• 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.

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• 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.

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• 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.

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• 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.

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• 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.

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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

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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.

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• 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.

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• 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.

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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

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Four basic patterns of meniscal tears I,
longitudinal II, horizontal III, oblique and
IV, radial
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Horizontal tears BOblique tears C Radial tears D
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• 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

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• 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.

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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.

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• 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.

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• 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.

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• 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

• ????!
• Thank you very much for your attention!