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Orthopedic anaphy, casting & traction, Lecture notes of Medicine

University of Pangasinan (UP)Medicine

Lecture notes for orthopedics

Typology: Lecture notes

2021/2022

Uploaded on 09/23/2022

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ORTHOPEDIC
FUNCTIONS OF BONE:
➔to support and to give shape to the body
➔to protect the different structures of the body
➔to provide attachment for muscles, tendons, and ligaments
➔aids in the formation of blood cells
➔regulates calcium and phosphate concentrations
AXIAL SKELETON
➔Cranium
➔Vertebrae
➔Ribs
APPENDICULAR SKELETON
➔Limbs (upper/ lower extremities)
➔Shoulder (pectoral) girdle
➔Hip (pelvic) girdle
Development of the Skeleton
➔MESODERM or MESENCHYME
◆gives rise to bone, cartilage, fascia, & muscles
➔5th Embryonic Week - cartilage
➔7th Embryonic Week - bone
a. Membranous Bones - undergo: periosteal ossification
b. Cartilaginous Bones - undergo: Endochondral Ossification (responsible for growth in length)
Periosteal Ossification (responsible for growth in thickness)
MORPHOGENESIS OF THE AXIAL SKELETON
➔intersegmental arteries separate the sclerotomes
➔each sclerotome then differentiates into a caudal compact portion and a cranial less-dense half
➔the denser caudal half then unites with the looser cranial half of the succeeding sclerotome to form the
substance of the vertebra
➔the two parts of sclerotomes, in joining, enclose the intersegmental artery which now passes through the center
of the vertebral body
➔the mesenchymal tissue in the intervertebral fissure gives rise to the intervertebral disk
➔the nucleus pulposus in the disk constitutes the remnant of the notochord
➔both the condensed and the looser portions grow about the notochord to form the body of the vertebra
➔the denser (now cranial) half form dorsal extensions which pass around the neural tube to form the vertebral arch
and paired costal processes or forerunners of ribs
MORPHOGENESIS OF THE APPENDICULAR SKELETON
➔derived directly from the unsegmented somatic mesenchyme (definite masses are formed at the sites of the
future pectoral and pelvic girdles and limb buds)
➔CLAVICLE - first bone of the skeleton to ossify
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ORTHOPEDIC

FUNCTIONS OF BONE:

➔ to support and to give shape to the body ➔ to protect the different structures of the body ➔ to provide attachment for muscles, tendons, and ligaments ➔ aids in the formation of blood cells ➔ regulates calcium and phosphate concentrations AXIAL SKELETON ➔ Cranium ➔ Vertebrae ➔ Ribs APPENDICULAR SKELETON ➔ Limbs (upper/ lower extremities) ➔ Shoulder (pectoral) girdle ➔ Hip (pelvic) girdle Development of the Skeleton ➔ MESODERM or MESENCHYME ◆ gives rise to bone, cartilage, fascia, & muscles ➔ 5th Embryonic Week - cartilage ➔ 7th Embryonic Week - bone a. Membranous Bones - undergo: periosteal ossification b. Cartilaginous Bones - undergo: Endochondral Ossification (responsible for growth in length) Periosteal Ossification (responsible for growth in thickness) MORPHOGENESIS OF THE AXIAL SKELETON ➔ intersegmental arteries separate the sclerotomes ➔ each sclerotome then differentiates into a caudal compact portion and a cranial less-dense half ➔ the denser caudal half then unites with the looser cranial half of the succeeding sclerotome to form the substance of the vertebra ➔ the two parts of sclerotomes, in joining, enclose the intersegmental artery which now passes through the center of the vertebral body ➔ the mesenchymal tissue in the intervertebral fissure gives rise to the intervertebral disk ➔ the nucleus pulposus in the disk constitutes the remnant of the notochord ➔ both the condensed and the looser portions grow about the notochord to form the body of the vertebra ➔ the denser (now cranial) half form dorsal extensions which pass around the neural tube to form the vertebral arch and paired costal processes or forerunners of ribs MORPHOGENESIS OF THE APPENDICULAR SKELETON ➔ derived directly from the unsegmented somatic mesenchyme (definite masses are formed at the sites of the future pectoral and pelvic girdles and limb buds) ➔ CLAVICLE - first bone of the skeleton to ossify

TYPES OF BONES

ACCORDING TO STRUCTURE:

  1. Cancellous or Trabecular or Spongy
  2. Cortical or Compact or Dense ACCORDING TO SHAPE:
  3. Long bone
  4. Flat bone
  5. Small bone a. Short b. Irregularly-shaped PERIOSTEUM ➔ membrane covering the outer surface of the bone ➔ 2 layers: A. FIBROUS - serves for attachment of tendons and ligaments B. OSTEOGENIC
  6. OSTEOBLASTS - bone formation
  7. CHONDROBLASTS- cartilage formation
  8. OSTEOCLASTS- bone resorption and remodeling ENDOSTEUM ➔ lines the walls of bone cavities CORTICAL or COMPACT or DENSE BONE ➔ the outside part of the bone; it covers the spongy bone forms a cylinder around a central marrow cavity CANCELLOUS or TRABECULAR or SPONGY BONE ➔ located within the bone; in the medullary cavity BASIC UNIT STRUCTURE OF BONE: OSTEON OR HAVERSIAN SYSTEM HAVERSIAN CANALS - passageways for blood vessels (for diffusion of nutrient fluids toward the osteocytes and waste products back to the nutrient artery) ● VOLKMANN’S CANALS - connect the Haversian canals LACUNAE ➔ contain the osteocytes CANALICULI ➔ connect the lacunae (and therefore the osteocytes) LAMELLAE ➔ circles of mineralized bone matrix; patterns of collagen and bone formation CEMENT LINE ➔ outer perimeter of an osteon (where bone resorption stopped and new bone formation began)

JOINT or ARTICULATION CHARACTERISTICS OF JOINTS: ➔ consist of bone ends which are covered with cartilage & enclosed in a capsule; cavity is filled with synovial fluid (serves as lubricant)

  • traversed by ligaments which hold the bones and the joint in correct alignment
  • traversed by muscles which provide the force to move the bones; muscles assist in maintaining posture FUNCTIONS OF JOINTS: ➔ hold the skeleton together ➔ give the skeleton mobility 3 TYPES OF JOINTS: A. SYNARTHROSIS ➔ immovable joint ➔ ex. skull sutures B. AMPHIARTHROSIS ➔ slightly movable ➔ ex. connection between ribs and sternum / spine C. DIARTHROSIS ➔ freely movable 6 TYPES:
  1. BALL and SOCKET - with the widest ROM ex. shoulder and hip joints
  2. CONDYLOID - allows for angular motion but not rotation ex. metacarpals and phalanges of the fingers, metatarsals and phalanges of the toes
  3. SADDLE - when the touching surfaces of two bones have both concave and convex regions with the shapes of the two bones complementing one another and allowing a wide range of movement *the only saddle joint in the body is in the thumb
  4. PIVOT - these joints occur where: a. a bony ring rotates round the pivot (axis) of another bone such as the ring-like atlas rotating around the odontoid process of the axis, allowing the head to turn from side to side b. the end of one one bone rotates round the axis of another bone such as the end of the radius rotating around the ulna as the palm of the hand is turned inwards or outwards
  1. HINGE - a convex projection on one bone fits into a concave depression in another permitting only flexion and extension as in the elbow and knee joints
  2. GLIDING JOINTS - allows for gliding movements between flat surfaces as the surfaces slide over one another only a limited amount of movement is allowed such as the joints between the carpal bones, the joints between the tarsal bones COMMON DIAGNOSTIC TESTS UTILIZED IN ORTHOPEDICS AND THEIR CORRESPONDING NURSING INTERVENTION RADIOGRAPHY ➔ the machine produces a tiny burst of radiation, at a safe level, that passes through the body and records an image on film or on a specialized plate ➔ as X-rays pass through the body, different tissues absorb different amounts of the X-rays; for example, bones are dense and absorb X-rays well but soft tissues, such as skin, fat, muscles and organs, allow more X-rays to pass through them - the result is that bones appear white on the X-ray NURSING INTERVENTION: ➔ handle injured area carefully ➔ administer analgesics as prescribed before the procedure ➔ remove any radiopaque material e.g. metal, jewelry ➔ shield the client’s testes, ovaries, or pregnant abdomen, if x-ray must be performed ➔ instruct the client to be still during a radiograph ➔ inform the client that exposure to radiation is minimal and not dangerous ➔ if staying with the client during a radiograph, the health care provider must wear a lead apron ARTHROCENTESIS ➔ process of inserting a needle into a joint cavity and aspirating fluid e.g. synovial fluid, blood, pus ➔ medication may be also be instilled into the joint after aspiration NURSING INTERVENTION: ➔ obtain an informed consent ➔ apply a compress bandage postprocedure as prescribed ➔ instruct the patient to rest the joint for 8 to 24 hrs. after the procedure ➔ instruct the client to notify the physician if fever or joint swelling occurs postprocedure ARTHROGRAM ➔ an x-ray of the joint wherein a contrast media is used to visualize the joint more clearly ➔ a preliminary film of the joint will be taken and the joint will be cleaned with a special solution; infiltration ➔ with local anesthetic is done before placing a needle into the joint area after which, a contrast media will then be injected ➔ X-rays pictures will then be taken of the joint NURSING INTERVENTION: ➔ some require total fasting from food and fluids for 8hrs; some require fasting for 8hrs.but allow drinking and eating of clear liquids 2 to 3 hrs. before the procedure ➔ assess the client for allergies to iodine or seafood before the procedure ➔ obtain an informed consent ➔ inform the client to remain still during the procedure unless he/she is asked to reposition ➔ minimize the use of the joint for 12hrs.

➔ tracers emit gamma waves of radiation, which are detected by a special camera

  • a bone scan is the opposite of a standard X-ray examination
  • an X-ray passes radiation into or through your body to create an image on film placed on the other side of your body
  • in a bone scan, the source of radiation is inside your body and travels to the surface, where a camera detects it NURSING INTERVENTION: ➔ hold fluids 4 hrs. before the procedure ➔ obtain an informed consent ➔ remove all jewelry and metal objects ➔ following injection of the radioisotope, the client must drink 32oz. Of water (if not contraindicated) to promote renal filtering of excess isotope ➔ 1 to 3 hrs. following the injection, ask the client to void and then perform the scanning procedure ➔ inform the client of the need to lie supine and to remain motionless when told to do so and that the procedure is not painful ➔ no special precautions are required after the procedure because there is only a minimal amount of radioactivity ➔ monitor the injection site for redness and swelling ➔ encourage oral fluid intake following the procedure BONE/ MUSCLE BIOPSY ➔ may be done through aspiration, punch, or needle biopsy NURSING INTERVENTION: ➔ obtain an informed consent ➔ monitor for bleeding, swelling, hematoma, or severe pain ➔ elevate the site for 24 hrs. following the procedure to reduce edema ➔ apply ice packs as prescribed following the procedure to prevent the development of a hematoma ➔ monitor for signs of infection following the procedure ➔ inform the client that mild to moderate discomfort is normal following the procedure EMG-NCV (ELECTROMYOGRAPHY - NERVE CONDUCTION VELOCITY) ➔ ELECTROMYOGRAPHY ◆ technique for evaluating and recording physiologic properties of muscles at rest and while contracting ◆ to perform EMG, a needle electrode is inserted through the skin into the muscle tissue and the electrical activity is observed while inserting the electrode ◆ the electrical activity is studied during insertion of the electrode and then when the muscle is both at rest and while contracting ➔ NERVE CONDUCTION VELOCITY ◆ measures how quickly electrical impulses move along a nerve; it is often done at the same time as an electromyogram, in order to exclude or detect muscle disorders ◆ a healthy nerve conducts signals with greater speed and strength than a damaged nerve ◆ the speed of nerve conduction is influenced by the myelin sheath - the insulatingcoating that surrounds the nerve ◆ the nerve conduction velocity test is used to distinguish between:
  1. true nerve disorders (e.g. damage to the nerve's axon)
  2. and conditions where muscles are affected by nerve injury (e.g. damage to the myelin sheath surrounding the nerve)
  • during the test, flat electrodes are placed on the skin at intervals over the nerve that is being examined (a low intensity electric current is introduced to stimulate the nerves)
  • if a response is much slower than normal, damage to the myelin sheath is implied
  • if the nerve's response to stimulation by the current is decreased but with a relatively normal speed of conduction, damage to the nerve axon is implied MYELOGRAM ➔ a procedure in which contrast material (dye or air) that can be seen on an x-ray, is injected into the fluid-filled space around the spinal cord ➔ this is used to detect abnormalities in the spinal column, spinal cord, and the sorrounding structures NURSING INTERVENTION: PREPROCEDURE: ➔ obtain an informed consent ➔ provide hydration for at least 12hrs. before the test ➔ assess clients for allergies to iodine or seafood (shellfish) POSTPROCEDURE: ➔ obtain vital signs and perform neurological assessment regularly ➔ encourage fluids and monitor intake and output ➔ position based on contrast material used: a. WATER-BASED DYE - elevate the head 15 to 30 degrees for 8 hrs. As prescribed b. OIL-BASED DYE - keep the client flat on bed for 6 to 8 hrs. As prescribed c. AIR - keep the head lower than the trunk for up to 48 hrs. As prescribed RADIOGRAPHY ARTHROCENTESIS

ARTHROGRAM ARTHROSCOPY

DEXA (DUAL ENERGY

X-RAY

ABSORPTIONMETRY)

BONE SCAN BONE/ MUSCLE BIOPSY ELECTROMYOGRAPHY NERVE CONDUCTION

VELOCITY

MYELOGRAM

TRAUMATIC MUSCULOSKELETAL DISORDERS

SOFT TISSUE INJURIES

SPRAIN

rupture (excessive stretching) of ligaments

STRAIN

rupture (excessive stretching) of muscles or tendons CONTUSION or BRUISE Capillaries beneath the skin ruptured by a blunt blow

  1. Comminuted- A bone splintered or crushed into more than three fragments
  2. Oblique- A fracture straight across the bone obliquely
  3. Spiral- also known as torsion fracture. A fracture that is shaft around the bone
  4. Transverse- A fracture, in which the break is across the bone, at a right angle to the long axis of the bone. FRACTURE TREATMENT: METHODS & PRINCIPLES
  5. CASTING ➔ application of plaster-of-Paris or a synthetic (fiberglass) material to a body part for the purpose of immobilization ➔ the cast serves to hold the broken bone in place to allow for healing even when the client is up and about ➔ to be effective, the cast should include both joints above and below the fracture line ➔ * 3 methods of CAST application: (historically) A. SKIN-TIGHT CAST (BÖHLER) ➔ POP applied directly to the skin without any intervening padding ➔ Advantage: provides the most efficient form of immobilization ➔ Disadvantage.: greatest danger of pressure sore & circulatory embarassment, difficult to remove B. BOLOGNA CAST (emanated from RizzoliInstitute / advocated by Charnley) ➔ With generous amounts of cotton wadding applied to the limb followed by compressive effect of POP (applied with “just the right amount of tension”) C. THIRD WAY ➔ Stockinette, then sheet wadding, then POP STOCKINETTE (^) SHEET WADDING ELASTIC BONDAGE PLASTER OF PARIS (POP)
  6. TRACTION ➔ Utilized when reduction through the use of a cast is impossible A. SKIN TRACTION ➔ named after Gurdon Buck hence the term “Buck’s traction (although he never invented it nor did he ever claim to have done so) ➔ traction weight must only be 5 to 7 lbs. ➔ aside from immobilization and fracture reduction, it can also relieve muscle spasm B. SKELETAL TRACTION ➔ as we know it today, the bone is transfixed with a pin (Fritz Steinmann hence Steinmann pin) ➔ K-wire (Kirschner), a smaller diameter pin, was used for some time because it offered less trauma to the soft and bony tissues but when applied for prolonged periods, it had a propensity to cut through bone. so… back to Steinmann pin ➔ can apply traction weights of up to 10% of the person’s body weight

SKIN TRACTION SKELETAL TRACTION^ KIRSCHNER PIN & STEINMANN PIN

3. FRACTURE REDUCTION

A. CLOSED

➔ attempts to achieve adequate or acceptable alignment of the fracture fragments; it is neither necessary, nor, in some cases, desirable to achieve an anatomical reduction ➔ Reasons for reducing a fracture (Lloyd Griffiths):

  • to ensure recovery of function of the limb where that is threatened by displacement of the fracture
  • to prevent or delay degenerative changes in joints (particularly weight-bearing joints) which will result from persisting deformity
  • to minimize the deforming effect of injury B. OPEN - (by surgery) indications: ➔ when closed methods have failed ➔ when it is known from experience that closed methods will be ineffective ➔ when articular surfaces are fractured and are displaced ➔ when the fracture is secondary to tumor metastasis ➔ when there is an associated neurovascular injury ➔ when multiple injuries are present ➔ where continued confinement to bed is undesirable ➔ when the cost of treatment may be substantially reduced
  1. FIXATION A. INTERNAL ➔ through the use of screws, wires, plates, intramedullary rods and nails, pins, spinal fixation devices INTERNAL FIXATION INSTRUMENTS

SPINE INJURIES

NURSING INTERVENTION:

➔ turn patient side to side every 2 hrs. ➔ turn the patient as one unit ➔ e.g. logrolling HIP FRACTURE IN THE ELDERLY 2 TYPES:

  1. INTRACAPSULAR - femoral neck fracture ➔ patient needs to have surgery ➔ e.g. pinning; DCS; partial hip replacement
  2. EXTRACAPSULAR ➔ intertrochanteric fracture ➔ subtrochanteric fracture ➔ patient may be treated conservatively ➔ e.g. skin or skeletal traction / skillful neglect ➔ surgically (dynamic compression screw fixation/ partial hip replacement) POST-OPERATIVE CARE: ➔ limb positioning: depends on the surgical approach *if anterior approach - maintain limb in internal rotation *if posterior approach - maintain limb in external rotation ➔ turning patients - turn client fom back to unaffected side (do not position the client on the affected side) ➔ ensure that hip flexion does not exceed 60 to 80 degrees; head of bed may be elevated to 30 to 45 degrees (only for meals) ➔ maintain leg abduction to prevent internal/external rotation; use trochanter roll to prevent external rotation ➔ avoid low chairs when out of bed; instruct the clients not to cross legs; avoid bending over COMPLICATIONS OF FRACTURES
  3. COMPARTMENT SYNDROME ➔ a condition in which the circulation and function of tissues within a closed space are compromised by an increased pressure within that space ➔ S/Sx: 4 Ps - Pain / Pallor / Paralysis / Pulselessness
  • although none is pathognomonic, pain is the most important
  • best indicator: tissue pressure measurement ➔ a surgical emergency (fasciotomy)
  • results in permanent neurovascular damage if not relieved in 4 to 6 hrs.
  • the normal tissue pressure within closed compartments is approximately 0 mmHg ➔ pressures of within 10 to 30mmHg of a patient’s diastolic blood pressure - there will be inadequate tissue perfusion and relative ischemia ➔ if the pressure within a compartment equals or exceeds the patient’s diastolic blood pressure - there will be no effective tissue perfusion Whitesides Technique
  • for measuring intracompartmental pressure
  1. Cast Syndrome ➔ results from obstruction of the third portion of the duodenum by the superior mesenteric artery leading to high intestinal obstruction ➔ associated with the use of hyperextension body jackets which were used to treat spinal fractures in the past ➔ presently, the typical presentation is abdominal pain, distension and vomiting following application of a spica cast ➔ Treatment: ◆ Nasogastric tube suction and IV fluid for 3 to 4 days ◆ Occassionally these symptoms may become intractable and may require surgery consisting of a side to side duodenojejunostomy
  2. Fat Embolism ➔ Usually seen in long bone fractures / after reaming ➔ Restlessness, altered mental staus, dyspnea, tachypnea, tachycardia, petechial rash over the chest, axilla, neck ➔ NURSING INTERVENTION: ◆ Notify MD immediately ◆ High-Fowler’s position
  3. Plaster Sores (Cast Pressure Ulcers) ➔ Pressure sores result from skin necrosis caused by localized pressure from the inner aspect of the cast ➔ They occur over prominent bony areas, from ridges formed in the plaster during improper application and from foreign bodies placed under the cast ➔ Note for foul odor and/or moist areas on the cast - this may point to a unseen weeping lesion ➔ * these pressure ulcers may occur with little or no pain
  4. A. Malunion - fracture healing in a non-acceptable angulation B. Non-union - refers to an arrest of the healing process and the formation of a typical pseudoarthrosis or a fibrous union in which the bone ends are either osteoporotic and atrophied, or sclerotic C. Delayed Union - one that takes longer than the average for a given bone injury to heal
  5. Heterotopic Ossification or Myositis Ossificans ➔ generally occurs in a muscle (or adjacent to a muscle) near bone ➔ if it occurs, it will become apparent radiographically within 3 to 4 weeks after the initial injury
  6. Osteomyelitis ➔ infection of the bone ➔ suppurative process in bone caused by a pyogenic organism ➔ Types of Osteomyelitis (Waldvogel) - based on the pathogenesis a. Hematogenous osteomyelitis b. Osteomyelitis secondary to a contiguous focus of infection c. Osteomyelitis from direct inoculation of bacteria at the time of injury or surgery - this is the type most frequently associated with fractures
  • why? - because this results in the lowest incidence of avascular necrosis von Rosen splint Pavlik harness (^) Frejka splint Septic Arthritis (Suppurative Arthritis / Pyogenic Arthritis) ➔ mode is often hematogenous from an infective focus; less commonly it is spread from an adjacent focus (e.g. osteomyelitis) or by direct inoculation through a wound ➔ most common sites - hip (in infants), knee, shoulder joints ➔ in infants and children, this may follow an apparently innocent bout of colds ➔ in adults, there is usually a history of antecedent trauma Septic Arthritis (Suppurative Arthritis / Pyogenic Arthritis) Osteoporosis ➔ a diffuse reduction in bone density that results when the rate of bone resorption exceeds the rate of bone formation ➔ most commonly associated with the aging process in which bone formation generally proceeds at a normal rate but bone removal occurs at an increased rate ➔ in and by itself, it does not cause pain; pain occurs when because of bone thinning microfractures occur or when the relative immobilization of a person results in soft tissue contractures so that physiologic allowance for stretch is reduced and exceeded by physical activity ➔ in osteoporosis, bone minerals are lost

Arthritides

  1. Osteoarthritis ➔ also known as osteoarthrosis, chondromalacic arthrosis, degenerative arthritis, hypertrophic arthritis, arthritis deformans ➔ 2 types: A. primary - degenerative process affecting the articular cartilage of a previously healthy joint B. secondary - degenerative process precipitated by specific factors (e.g. incongruity of joint surfaces resulting from unreduced or inadequately reduced osteochondral fractures)
    • present day solution for crippling osteoarthritic changes: joint replacement a. hip joint replacement The Assembly Relationship to host bone^ Implant in place^ Actual implantation NURSING INTERVENTIONS: (POST-THA: TOTAL HIP ARTHROPLASTY) ➔ maintain leg and hip in proper alignment ➔ monitor the wound dressing for hemorrhage; maintain the Hemovac (drain) if in place and record the drainage output at regular intervals (drainage should decrease in amount with the passing of days) ➔ monitor neurovascular status of operated side ➔ maintain the use of anti-embolism stockings and encourage the patient to perform isometric exercises while on bed to minimize atrophy of disuse ➔ prevent internal and external rotation of the affected lower extremity
  • to prevent internal rotation ➔ position the affected extremity in abduction (to ensure this, place a pillow between both lower extremities
  • to prevent external rotation ➔ place a trochanter roll along the lateral aspect of the affected lower extremity

➔ a chronic autoimmune disorder characterized by destructive and proliferative changes in the synovial membrane, periarticular structures, skeletal muscle, and perineural sheaths ➔ criteria for diagnosis: (American College of Rheumatology) ➔ * Any 4 criteria must be present for at least 6 weeks to classify patients as having rheumatoid arthritis:

  1. Morning stiffness for ≥ 1 h†
  2. Arthritis of ≥ 3 joints†
  3. Arthritis of hand joints (wrist, metacarpophalangeal, or proximal interphalangeal joints)†
  4. Symmetric arthritis†
  5. Rheumatoid nodules
  6. Serum rheumatoid factor (positive in < 5% of normal control subjects)
  7. Radiographic changes (hand x‑ray changes typical of rheumatoid arthritis must include erosions or unequivocal bony decalcification)
    • †Must be present for ≥ 6 wk. Nursing Interventions: ➔ instruct the client on the use of crutches to avoid weight bearing on ambulation ➔ maintain traction in order to separate joint spaces ➔ administer precribed medications
  8. Gouty Arthritis ➔ the typical gouty patient has an asymptomatic hyperuricemia for a number of years ➔ the initial acute attack which often comes during nighttime and without warning is preceded by a provocative factor e.g. trauma (long walks), dietary indiscretions (high fat diet), drugs (liver extract), surgical operations, exposure to cold, etc. ➔ usual site: metatarsophalangeal joint of the first toe (becomes very swollen, red, and tender) ➔ the inflammation may involve a non-articular urate deposit ➔ e.g. subcutaneous tophus or in a bursa Back Pain Scoliosis (^) Kyphosis (Scheuermann’s disease) Herniated Nucleus Pulposus (or Slipped Disc/Disk)
  9. Scoliosis ➔ lateral deviation of the spine (on AP view) ➔ the greater majority of cases are idiopathic (70% of all cases)
  10. Kyphosis (Scheuermann’s disease) ➔ excessive antero-posterior angulation of the spine (on lateral view) ➔ rounding of the back
  11. Herniated Nucleus Pulposus (or Slipped Disc/Disk)

➔ in between 2 successive vertebral bodies is an intervertebral space which contains soft tissue consisting of: A. the nucleus pulposus (intervertebral disc/disk) ➔ firm and incompressible but classified as a soft tissue because it is not a bone B. the annulus fibrosus (the fibrous material covering the intervertebral disk) ➔ the soft tissues within the intervertebral space collectively function as: a. a joint - allows for spine motion b. a shock absorber - dampens the jarring effect of each step to the brain and spinal cord c. a spacer - adds height ➔ everytime a person moves, there is a tendency to push the disc away from the center along the path of least resistance e.g. with forward bending, the disc is forced to the posterior aspect of the intervertebral space ➔ with time, these intervertebral soft tissues degenerate and get worn down so that the effective barrier to keep it anchored at the center is somehow lost ➔ with movement then the intervertebral disc is literally forced to move away from its original anatomical site which is at the center ➔ when then disc migrates from its original position, it is said to have “slipped” from its original position hence the term slipped disc ➔ when that happens, the direction of movement may be: a. to the left posterolateral aspect b. to the posterior aspect^ c. to the right posterolateral aspect ➔ there would not have been any problem with the disc movement but these are the structures that will get in the way of that “slippage” ➔ when the disc moves far enough posteriorly or posterolaterally to compress either the cord or the cauda equina (depending on the level affected) or the nerve roots (at all levels), neurologic symptoms start to manifest Bone Tumors ➔ most common bone tumor - metastatic (spread from other non-osseous sites) ➔ second most common malignant bone tumor - osteosarcoma ➔ most common benign tumor - osteochondroma ➔ most common primary malignant bone tumor - malignant myeloma ➔ most common benign tumor - osteochondroma ORTHOPEDIC APPLIANCES A. AMBULATION AIDS a. Canes ➔ useful but less efficient than crutches for maintaining balance and relieving weight b. Walkers ➔ designed for the elderly and for those who lack the strength nor the agility to use crutches or canes