TRIPLER

ORTHOPEDICS
Lecture by: M.K. Sastry
Program Director,
Post Graduate Studies and PhD Program
 Back / Spine
 Cervical Pain
 Hand
 Shoulder
 Knee
 Ankle
 Foot
 Back Pain
 Diagnosis / Definition
 A condition of pain in the lower (lumbar
sacral) back region, with or without radiation
of symptoms to the buttocks or lower
extremities, in the non-pregnant patient.
 Initial Diagnosis and management
 Elicitation of history and performance of physical
examination. Special attention to presence or
absence of "red flags" to include: age <18 or >55;
history of malignancy, steroid use, or HIV positivity;
weight loss or constitutional symptoms; structural
deformity; anal or urethral sphincter disturbance;
saddle anesthesia; gait disturbance; or widespread
neurologic deficit.
 Initial Diagnosis and management
 If red flags are present, diagnostic testing may
include plain radiographs; CBC; ESR; bone scan; CT
scan and/or MRI scan and electro diagnosis as
indicated.
 Initial Diagnosis and management

 If red flags are absent a diagnostic workup

is generally not necessary.
 Initial Diagnosis and management
 Initial treatment for the first 2 weeks consists of:
reassurance that most episodes resolve
uneventfully within 6 weeks; encouragement to
maintain as close to normal activity as is
tolerable; avoidance of bed rest greater than 24
hours; NSAIDS (unless contraindicated); muscle
relaxants for up to one week; acetaminophen as
needed; weak opiates (codeine; propoxyphene)
unless contraindicated; passive modalities (e.g.
ice, heat) for symptomatic relief, profiling for
active duty personnel or duty limitations.
 Ongoing management and objectives
 If pain has not improved in 2 weeks: re-evaluate for
"red flags", change NSAID, and consider referral to
Physical Therapy for evaluation and treatment while
continuing to follow patient.
 Indication a profile is needed
 Any limitations that affect strength, range of
motion, and general efficiency of feet, legs, lower
back and pelvic girdle.
 Slightly limited mobility of joints, muscular
weakness, or other musculo-skeletal defects that
may prevent hand-to-hand fighting and
disqualifies for prolonged effort.
 Indication a profile is needed
 Defects or impairments that require significant
restriction of use .
 Specifications for the profile
 Weeks 1-2
 Run at own pace and distance
 No marching greater than 2 miles
 No sit ups
 No ruck sacks
 No lifting greater than 15lbs
 No repetitive bending
 Specifications for the profile
 Weeks 2-4
 Gradually return to normal activity
Patient / Soldier Education or Self care Information

 Demonstrate deficits that exist

 Describe/show soldier his/her limitations
 Explain injury and treatment methods
 Use diagram attached to describe injury,
location and treatment.
Patient / Soldier Education or Self care Information

 Instruct and demonstrate rehab techniques

 Demonstrate rehab exercises as shown in
attached guide
 Warm up before any sports activity
 Participate in a conditioning program to build
muscle strength
 Do stretching exercises daily
Patient/Soldier Education or Self care Information
“Continued”
 Ask the patient to demonstrate newly learned
techniques and repeat any other instructions.
 Fine tune patient technique .
 Correct any incorrect ROM/stretching
demonstrations or instructions by repeating and
demonstrating information or exercise correctly.
Patient/Soldier Education or Self care Information
“Continued”
 Encourage questions.
 Ask soldier if he or she has any questions .
 Give supplements such as handouts.
 Schedule follow up visit with primary care .
 If pain persists or worsens .
 The pain does not improve as expected.
Patient/Soldier Education or Self care Information
“Continued”
 Schedule follow up visit with primary care.
 Patient is having difficulty after three days of
injury.
 Increased pain or swelling after the first three
days.
 Patient has any questions regarding care .
 Acute Low Back Pain
 Diagnosis/Definition
 A condition of pain in the lower (lumbar-sacral)
back region, with or without radiation of
symptoms to the buttocks or lower extremities, of
less than 6 weeks duration, in the non-pregnant
patient.
 Initial Diagnosis and Management

 The initial diagnosis is clinical with the acute or

subacute development of low back pain usually
with sciatic pain following minimal low back
trauma.
 In patients under the age of 50, no x-ray or lab
studies are necessary.
 Initial Diagnosis and Management

 Over the age of 50, disc abnormalities are

possible, but initial lumbar sacral spine series
should be considered which might exclude bony
structural abnormalities such as severe
degenerative changes, osteoporosis with
compression or metastatic involvement.
 Initial Diagnosis and Management
“continued”
 MRI and/or CT scan are not necessary to confirm
the initial diagnosis of lumbar disc syndrome
except when there is failure to respond to
conservative therapy or there is development of
neurologic deficit (see Indications for Specialty
Care Referral below).
 Initial Diagnosis and Management
“continued”
 The initial objective of management is to reduce
lumbar nerve root tension. Depending upon the
severity, bed-rest or reduction of activity level for
one to two weeks is indicated. Analgesics and
muscle relaxants are usually helpful.
Ongoing Management and Objectives

 During the acute period, the major

consideration is that the sciatic pain is
decreasing and overall mobility is
increasing. Conservative therapy as
described above is indicated.
 Indications for Specialty Care
A. Failure to respond to two to four weeks of
conservative therapy.
B. Worsening of sciatic pain during adequate
conservative therapy.
 Indications for Specialty Care
C. Development of neurologic deficit that includes
lower extremity motor or sensory deficit and/or
loss of bowel or bladder control.
 Indications for Specialty Care
 Condition A indicates a routine referral, however, a
diagnostic study (MRI) should be obtained at this
time by the primary care provider or at MAMC before
the neurosurgery consult. Often a telephone
consultation (576-8900) might be helpful here in
establishing the need for further primary care or
arranging more urgent consideration depending upon
the case.
 Indications for Specialty Care
 Conditions B and C often indicates urgency. The
patient may need to be seen immediately or possibly
within 24 hours. A telephone consultation (576-
8900) should be obtained to arrange immediate
disposition. Imaging study (usually MRI) is indicated
urgently.
Criteria for Return to Primary Care
 Surgery is not presently indicated and a
reasonable course of conservative therapy
is defined which can be followed at primary
care level.
 Spinal Stenosis (Cervical)
 Diagnosis/Definition
 Cervical pain that is muscular, discogenic,
or arthritic in nature. Patient may be
experiencing limited ROM of C-spine or
have pain referred to the trapezius or
upper extremity.
Initial Diagnosis and Management
 History and physical examination.
 Radiograph of the spine if cervical pain
started with trauma.
 MRI/CT not indicated initially.
Initial Diagnosis and Management
 Initial Management:
 NSAIDs.
 Do not prescribe muscle relaxants as
they are not effective.
Initial Diagnosis and Management
 Initial Management:
 Soft collar not recommended except for
1-5 days s/p high speed whiplash trauma
(i.e., MVA).
 Appropriate activity limitations on lifting,
overhead work, heavy headgear, etc.
Initial Diagnosis and Management
 Initial Management:
 Ice packs every 20 minute q2h x 72 hours
- then change to heat PRN.
 Encourage gentle, pain-free ROM.
 Ongoing Management and
Objectives
 Should observe a reduction in pain level
within 5-7 days.
 Chronic upper trapezius tension may persist
for up to 2 months.
 Ongoing Management and
Objectives
 Expect increased AROM of C-spine and
decreased muscle spasm within 2 weeks,
complete resolution will take longer.
 Indications for Specialty Care

 Specialty Care Referral (Physical Therapy):

 No improvement after 7-10 days of initial
primary care management.
 If the patient has radicular symptoms.
 Indications for Specialty Care

 Specialty Care (Neurosurgery or

Orthopedic):
 If the patient has neurological findings
(motor, sensory, or reflex deficits) and/or
has positive MRI findings
Criteria for Return to Primary Care
 Chronic conditions with a stable neurologic
exam in patients that have been evaluated
by Orthopedics or Neurosurgery and are
not surgical candidates.
 Cervical Disk Syndrome
 Diagnosis/Definition
 Cervical pain that is muscular, discogenic,
or arthritic in nature. Patient may be
experiencing limited ROM of C-spine or
have pain referred to the trapezius or
upper extremity.
Initial Diagnosis and Management
 History and physical examination.
 Radiograph of the spine if cervical pain
started with trauma.
 MRI/CT not indicated initially.
Initial Diagnosis and Management
 Initial Management:
 NSAIDs.
 Do not prescribe muscle relaxants as
they are not effective.
Initial Diagnosis and Management
 Initial Management:
 Soft collar not recommended except for
1-5 days s/p high speed whiplash trauma
(i.e., MVA).
Initial Diagnosis and Management
 Initial Management:
 Appropriate activity limitations on lifting,
overhead work, heavy headgear, etc.
 Ice packs every 20 minute q2h x 72 hours
- then change to heat PRN.
 Encourage gentle, pain-free ROM.
 Ongoing Management and Objectives

 Should observe a reduction in pain level within

5-7 days.
 Chronic upper trapezius tension may persist for
up to 2 months.
 Ongoing Management and Objectives

 Expect increased AROM of C-spine and

decreased muscle spasm within 2 weeks,
complete resolution will take longer.
 Indications for Specialty Care
 Specialty Care (Physical Therapy):
 No improvement after 7-10 days of initial
primary care management.
 If the patient has radicular symptoms.
 Indications for Specialty Care
 Specialty Care (Neurosurgery or Orthopedic):
 If the patient has neurological findings (motor,
sensory, or reflex deficits) and/or has positive
MRI findings.
Criteria for Return to Primary Care

 Chronic conditions with a stable neurologic

exam in patients that have been evaluated
by Orthopedics or Neurosurgery and are
not surgical candidates.
 Lumbar Disk Syndrome
 Diagnosis/Definition
 A condition of radicular leg pain,
sometimes accompanied by low back
pain which may be accompanied by a
motor or sensory deficit.
 Initial Diagnosis and Management
 Elicitation of history and performance of physical
examination. Special attention to presence or absence of
"red flags" to include: age <18 or >55; history of
malignancy, steroid use, or HIV positivity; weight loss or
constitutional symptoms; structural deformity; anal or
urethral sphincter disturbance; saddle anesthesia; gait
disturbance; or widespread neurologic deficit.
 Initial Diagnosis and Management
 If red flags are present, diagnostic testing may include
plain radiographs; CBC; ESR; bone scan; CT scan and/or
MRI scan and electro diagnosis as indicated.
 Initial Diagnosis and Management
“Continued”
 If red flags are absent a diagnostic workup is
generally not necessary.
 Initial Diagnosis and Management
“Continued”
 Initial treatment for the first 2 weeks consists of: reassurance
that most episodes resolve uneventfully within 6 weeks;
encouragement to maintain as close to normal activity as is
tolerable; avoidance of bed rest greater than 24 hours; NSAIDS
(unless contraindicated); muscle relaxants for up to one week;
acetaminophen as needed; weak opiates (codeine;
propoxyphene) unless contraindicated; passive modalities (e.g.
ice, heat) for symptomatic relief.
 Ongoing Management and Objectives
 If pain has not improved in 2 weeks: re-evaluate
for "red flags", change NSAID, and refer to
Physical Therapy for evaluation and treatment
while continuing to follow patient.
 Indications for Specialty Care
 Focal neurologic signs with abnormal
imaging studies (urgent consult if
worsening) - Neurosurgery or Orthopedics
referral. MRI prior to referral (without
contrast unless tumor suspected).
 Indications for Specialty Care
 Focal neurologic signs with normal imaging
studies (urgent if worsening) - Neurology.
 Indications for Specialty Care
 Incapacitating radiculopathy unresponsive
to therapy - Neurosurgery or Orthopedic
referral. MRI of lumbar spine prior to
referral (without contrast usually).
 Indications for Specialty Care
“Continued”
 Abnormal plain radiographs associated with
red flags - Neurosurgery or Orthopedics
referral. MRI of lumbar spine prior to
(without contrast usually).
 Indications for Specialty Care
“Continued”
 Loss of bladder or bowel control - (urgent)
Neurosurgery or Orthopedic referral.
 If pain has not improved within 6 weeks,
refer to Physical Medicine and Rehabilitation
for evaluation and management.
 Criteria for Return to Primary Care
 Resolution of symptoms or implementation of
continuing treatment program that can be
managed in primary care portal with periodic
subspecialty follow-up.
 Cervical Pain / Stiffness
 Diagnosis/Definition
 Cervical pain that is muscular, disco genic, or
arthritic in nature. Patient may be
experiencing limited ROM of C-spine or have
pain referred to the trapezius or upper
extremity.
 Initial Diagnosis and Management

 History and physical examination.

 Radiograph of the spine if cervical pain
started with trauma.
 MRI/CT not indicated initially.
 Initial Diagnosis and Management

 Initial Management:
 NSAIDs.
 Do not prescribe muscle relaxants as
they are not effective.
 Initial Diagnosis and Management

 Initial Management:
 Soft collar not recommended except for
1-5 days s/p high speed whiplash trauma
(i.e., MVA).
 Appropriate activity limitations on lifting,
overhead work, heavy headgear, etc.
 Initial Diagnosis and Management

 Initial Management:
 Ice packs every 20 minute q2h x 72 hours
- then change to heat PRN.
 Encourage gentle, pain-free ROM.
 Ongoing Management and Objectives

 Should observe a reduction in pain level within

5-7 days.
 Chronic upper trapezius tension may persist for
up to 2 months.
 Ongoing Management and Objectives

 Expect increased AROM of C-spine and

decreased muscle spasm within 2 weeks,
complete resolution will take longer.
 Indications for Specialty Care for Specialty

 Specialty Care (Physical Therapy):

 No improvement after 7-10 days of initial
primary care management.
 If the patient has radicular symptoms.
 Indications for Specialty Care for Specialty

 Specialty Care (Neurosurgery or Orthopedic):

 If the patient has neurological findings (motor,
sensory, or reflex deficits) and/or has positive
MRI findings.
 Criteria for Return to Primary Care
 Chronic conditions with a stable neurologic exam
in patients that have been evaluated by
Orthopedics or Neurosurgery and are not surgical
candidates.
 Ganglion Cysts
 Diagnosis/Definition
 Ganglion cysts arise from joint capsules or
tendon sheaths.
 They are the most common benign soft tissue
tumor of the hand and wrist.
 They are filled with inspissated fluid.
 Initial Diagnosis and Management
 The anatomical location of ganglion cysts in
descending order of frequency is:
 Dorsal wrist
 Radio-palmar wrist, and
 Arising from the annular pulley at the
palmo-digital crease.
 Initial Diagnosis and Management
 The history is of an enlarging mass that may
vary over time and with activity.
Complaints including aching or pain with
wrist or digital motion.
 Initial Diagnosis and Management
 Examination reveals a palpable mass which
is usually soft but occasionally firm. The
masses are variably tender to direct
pressure.
 Initial Diagnosis and Management
“Continued”
 Additional diagnostic tests include trans-
illumination (digital ganglions usually do
not trans-illuminate), aspiration or
ultrasound.
 Initial Diagnosis and Management
“Continued”
 Initial management may be observation
only, splinting to relieve acute discomfort or
aspiration.
 Aspiration of radiovolar wrist ganglions may
entail significant hazards and is not
recommended.
 Ongoing Management and Objectives

 The objective of initial management is

resolution of symptoms, not necessarily
disappearance of the cyst.
 Aspiration frequently results in recurrence.
 Ongoing Management and Objectives

 More definitive treatment need not be

undertaken if the cyst is asymptomatic.
 Indications for Specialty Care
 Failure to achieve a cosmetically and/or
clinically acceptable result with non-surgical
management.
 Surgical removal of a ganglion cyst is a low
risk low morbidity procedure done
electively at the patient's request.
 Criteria for Return to Primary Care

 Successful surgical treatment or refusal of

surgical treatment.
 Recurrence rate after surgical excision of a
ganglion cyst is 5 to 10 percent.
 De Quervain's Syndrome
 Diagnosis/Definition
 Tendonitis/Tenosynovitis of the extensor
pollicis brevis and abductor pollicis
longus within the extensor sheath of the
first digit.
 Initial Diagnosis and Management
 History and physical exam.
 Plain films, MRI, CT not required.
 Splinting: Wrist or thumb spica splint for
one month (at minimum for aggravating
activities).
 Initial Diagnosis and Management
 Activity Modification.
 Work simplification techniques.
 Modalities (i.e., heat, ice, ultrasound) as
clinically indicated.
 Prescribe NSAID.
 Ongoing Management and Objectives

 Modification / continuation of initial

management.
 Indications for Specialty Care

 Consider for injection in chronic cases.

 X-ray for chronic/traumatic cases.
 Criteria for Return to Primary Care
 Chronic condition that can be managed at
primary care level with intermittent
specialty care evaluation as needed.
Thank You