Basic bone science

Basic knowledge in bone science in a simple and nice way. This is the presentation I prepared for my internship in the Orthopedics and Traumatology department of the Academic Medical Center in Amsterdam.

2 cases with a complete proximal hamstrings rupture

Tomorrow I am going to follow an operation for a patient that had a complete rupture of his proximal hamstrings - left and right side.

Here is some very useful information for anyone that is interested:

1. Hamstring Muscle Injuries - OrthInfo
2. Hamstring Injuries - Orthobullets
3. Case study: Two patients with a complete proximal rupture of the hamstring

Radiology Masterclass - free online tutorial

A very nice and simple online tutorial freely offered by Radiology Masterclass.

These tutorials, and the galleries, will give you a good foundational knowledge in the art of radiological interpretation. Before you start, please read the page on 'using the tutorials'.

The tutorials marked *** are associated with certificated online course assessments, accredited by the Royal College of Radiologists - London - UK.

Drink less for strong bones

How Does Alcohol Harm Your Bones?

When you imbibe too much -- 30 to 60 ml of alcohol every day -- the stomach does not absorb calcium adequately. Alcohol interferes with the pancreas and its absorption of calcium and vitamin D. Alcohol also affects the liver, which is important for activating vitamin D -- which is also important for calcium absorption.

The hormones important to bone health also go awry. Some studies suggest that alcohol decreases estrogen and can lead to irregular periods. As estrogen declines, bone remodeling slows and leads to bone loss. If you're in the menopausal years, this adds to the bone loss that's naturally occurring, says Kaur.

There's an increase in two potentially bone-damaging hormones, cortisol and parathyroid hormone. High levels of cortisol seen in people with alcoholism can decrease bone formation and increase bone breakdown. Chronic alcohol consumption also increases parathyroid hormone, which leaches calcium from the bone, she says.

Also, excess alcohol kills osteoblasts, the bone-making cells. To compound the problem, nutritional deficiencies from heavy drinking can lead to peripheral neuropathy -- nerve damage to hands and feet. And chronic alcohol abuse can affect balance, which can lead to falls.

Postoperative orthopaedic rehabilitation protocols

I just came across a wonderful website with many postoperative orthopaedic rehabilitation protocols. Amazing work and useful especially for Physical Therapists that work in hospitals.

I have also found two books that offer a more detailed presentation of port-op orthopaedic treatment guidelines:

1. Treatment and Rehabilitation of Fractures, authors: Stanley Hoppenfeld, Vasantha L. Murthy, publisher: Lippincott Williams & Wilkins.

Written by leading orthopaedists and rehabilitation specialists, this volume presents sequential treatment and rehabilitation plans for fractures of the upper extremity, lower extremity, and spine. The book shows how to treat each fracture--from both an orthopaedic and a rehabilitation standpoint--at each stage of healing.Introductory chapters review the fundamentals of fracture management--bone healing, treatment modalities, biomechanics, assistive devices and adaptive equipment, gait, splints and braces, therapeutic exercise and range of motion, and determining when a fracture is healed. Subsequent chapters focus on management of individual fractures.Each chapter on an individual fracture is organized by weekly postfracture time zones, from the day of injury through twelve weeks. For each time zone, the text discusses bone healing, physical examination, dangers, x-rays, weight bearing, range of motion, strength, functional activities, and gait/ambulation. Specific treatment strategies and rehabilitation protocols are then presented. More than 500 illustrations complement the text.

2. Rehabilitation for the Postsurgical Orthopedic Patient, 3rd Edition, authors: Lisa Maxey & Jim Magnusson, publisher: ELSEVIER Health Sciences.

With detailed descriptions of orthopedic surgeries, Rehabilitation for the Postsurgical Orthopedic Patient, 3rd Edition provides current, evidence-based guidelines to designing effective rehabilitation strategies. Coverage of each condition includes an overview of the orthopedic patient's entire course of treatment from pre- to post-surgery. For each phase of rehabilitation, this book describes the postoperative timeline, the goals, potential complications and precautions, and appropriate therapeutic procedures. New to this edition are a full-color design and new chapters on disc replacement, cartilage replacement, hallux valgus, and transitioning the running athlete. Edited by Lisa Maxey and Jim Magnusson, and with chapters written by both surgeons and physical therapists, Rehabilitation for the Postsurgical Orthopedic Patient provides valuable insights into the use of physical therapy in the rehabilitation process.

NEMEX-TJR neuromuscular training program

Neuromuscular training seems to gain ground in the therapeutic interventions for almost all the musculoskeletal disorders. It gradually becomes clear to everyone that the neuromuscular adaptations are much more profound and important for our body and its effort to heal itself. Recently, one more study showed the immediate efficacy of neuromuscular exercise in patients with severe osteoarthritis of the hip or knee - See more at Physiospot.

A very nice guideline for the NEMEX-TJR training program presented in this study can be found here.

The myth of core stability?!

A very famous subject in all schools of Physical Therapy. Is it true or not? Is it something that can be applied in practise or not? The myth of core stability is a very interesting work by Professor Eyal Lederman. Whether you agree or not, it worths reading it since it stimulates your brain.

Clinical guidelines for hip fractures in adults

A summary of selected new evidence relevant to NICE clinical guideline 124 ‘The management of hip fracture in adults’ (2011).

An online version also available here.

Wheeless' Textbook of Orthopaedics

Orthopaedics References and Discussions for Physicians

Editor-in-Chief: Clifford R. Wheeless III, MD

Managing Editors: James A. Nunley, II, MD and James R. Urbaniak, MD

Our online textbook, presented by Duke University Medical Center’s Division of Orthopaedic Surgery, in conjunction with Data Trace Internet Publishing, LLC, is a true head to toe, comprehensive discussion of orthopaedic topics.

With thousands of pages in an easy-to-read outline format, accompanied by countless explanatory photos, drawings, radiological images, and videos, Wheeless’ Textbook of Orthopaedics is the premier website for the industrious orthopaedic physician.

This dynamic website is continually updated by experts in their fields. Links to pertinent journal article abstracts and additional, helpful websites provide students, educators, practicing orthopaedists, and patients with valuable medical information.

Simply click on a particular section of the skeleton (to the right) for easy access to our compendium of information, or find specific topics through alphabetical or keyword searches (see search box above).

Using stem cells from hip replacements to help treat ageing adults

From University of New South Wales

The tissue normally discarded during routine hip replacements could be a rich new source of adult stem cells for use in regenerative medicine, UNSW-led research has found.

With tens of thousands of hip replacement surgeries performed each year, this tissue could have “profound implications” in clinical use, the scientists say.

“In hip replacement surgery, the femoral head and part of the neck are resected to accommodate the neck of the implant,” explains study leader Professor Melissa Knothe Tate, the Paul M Trainor Chair in Biomedical Engineering at UNSW.

“Typically this tissue is discarded, yet it may provide an untapped source of autologous stem cells for ageing adults who were born a generation too early to benefit from banking of tissues like umbilical cord blood at birth.”

The study, published in the latest issue of STEM CELLS Translational Medicine, was led by the UNSW Graduate School of Biomedical Engineering and involved orthopaedic surgeon Dr Ulf Knothe of the Cleveland Clinic in Cleveland, scientists from Ludwig Maximilians University in Munich and Case Western Reserve University in Cleveland.

The researchers wanted to determine the feasibility of using the patient’s own tissue removed during routine joint replacement to potentially heal and/or repair failing organs and to treat diseases.

The team collected periosteum derived stem cells (PDCs) from patients with rheumatoid arthritis or osteoarthritis, ranging in age from 30 to 72 years, who had undergone joint replacements. They compared them with commercial bone marrow stem cells derived from prenatal donors in patients up to 72-years-old.

Based on the results, the PDCs exhibited “remarkable similarities” to the bone marrow cells cultured under identical laboratory conditions. They also showed “no significant differences” in their ability to differentiate into other cells due to the donor’s age or disease state,” Professor Knothe Tate and her team said in their paper.

“The use of periosteum tissue that is discarded with the femoral neck in replacing the hip is highly novel, as it represents an unprecedented and to date unstudied source of stem cells from rheumatoid arthritis or osteoarthritis patients,” they said.

Dr Ulf Knothe, the leading clinician on the study, concluded: “Use of stem cells from periosteum may open up unprecedented opportunities for the treatment of disease and tissue/organ failure in a population of osteoarthritic patients born around four decades too early to bank their own cord tissue or blood.”

The full article, “Arthritic periosteal tissue from joint replacement surgery: A novel, autologous source of stem cells,” will be available online after the embargo lifts: http://www.stemcellstm.com.

Media contact for Professor Knothe Tate: Fiona MacDonald, UNSW Media Office, +61 (0) 403 664 438, fionajmacdonald@gmail.com. Images available plus more on Professor Knothe Tate.

Joint Play Techniques In Assessment And Therapy For Upper And Lower Extremities

Beautiful and very detailed website to provide both students of physiotherapy and physiotherapists alike, with an interactive online information source for manual mobilization of the extremities.

Osteoporosis and bone physiology

This is an amazing educational site for physicians and patients. Site maintained by Susan Ott, MD Professor of Medicine University of Washington.

Patient education by Tony Tannoury

A very useful list of high quality guidelines and informational brochures for several spine problems/disorders created by Tony Tannoury, MD and his team.

eorthopod.com

The website eorthopod.com offer you "clear, accurate understandable information about your orthopaedic condition. Start here if you are interested in learning more about the anatomy and cause of your condition, how your doctor will make the diagnosis and what treatment options are available to you."

(suggested to me by my classmate Bita Loftalief)

Differential diagnosis: femoroacetabular impingement

A very useful article on femoroacetabular impingement by orthopedicmanualpt.com. Read it all and keep in mind that

...treatment and diagnosis of femoroacetabular impingement is in its infancy, however by utilizing current evidence and relying on all aspects of your patient’s evaluation and response to treatment, your patient outcomes will continue to improve as our knowledge of this condition continues to grow.

...interventions found to be beneficial included joint mobilization (Long-axis Distraction, Lateral distraction, anterior glide, and posterior glide), core strengthening, gluteal strengthening, proprioception, and hip flexor stretching. Additionally, several studies found that passive range of motion of the hip results in counter-productive exacerbation of symptoms and should be avoided in lieu of the aforementioned beneficial interventions.

Kevin Stone: The bio-future of joint replacement

Arthritis and injury grind down millions of joints, but few get the best remedy -- real biological tissue. Kevin Stone shows a treatment that could sidestep the high costs and donor shortfall of human-to-human transplants with a novel use of animal tissue.

Inspired by www.thestudentphysicaltherapist.com.

The American Academy of Orthopaedic Surgeons

The American Academy of Orthopaedic Surgeons

Founded in 1933, the Academy is the preeminent provider of musculoskeletal education to orthopaedic surgeons and others in the world. Its continuing medical education activities include a world-renowned Annual Meeting, multiple CME courses held around the country and at the Orthopaedic Learning Center, and various medical and scientific publications and electronic media materials.

The American Association of Orthopaedic Surgeons

Founded by the Academy Board of Directors in 1997, the Association engages in health policy and advocacy activities on behalf of musculoskeletal patients and the profession of orthopaedic surgery.

A traditional symbol of orthopaedics is the bent tree that has been braced to make it grow straight.

Why we call it "orthopaedics"

Since orthopaedics' beginnings, its specialists have treated children suffering from spine and limb deformities. The Greek roots of the word "orthopaedics" are ortho (straight) and pais (child). Early orthopaedists often used braces or other forms of treatment to make the child "straigh.

Shoulder disclocation

Anterior (forward)

Anterior dislocations are usually caused by a direct blow to or fall on an outstretched arm. The patient typically appears holding their arm externally rotated and slightly abducted.

Posterior (backward)

Posterior dislocations are occasionally due to electric shock or seizure and may be caused by strength imbalance of the rotator cuff muscles. Patients typically present holding their arm internally rotated and adducted, and exhibiting flattening of the anterior shoulder and a prominent coracoid process.

Inferior (downward)

Inferior dislocation is the least likely form, occurring in less than 1% of all shoulder dislocation cases. This condition is also called luxatio erecta because the arm appears to be permanently held upward or behind the head. It is caused by a hyper abduction of the arm that forces the humeral head against the acromion.

Proximal tibiofibular ligament instability

A nice and simple article by Dr. Robert F. LaPrade on this very rare pathology.

Injury to the proximal tibiofibular joint is rather rare, but it can be debilitating in patients who have symptoms.  The usual mechanism is having a patient fall on a plantar-flexed ankle, with the stress being brought through the fibula, such that the proximal fibula will sublux out of place over the lateral aspect of the knee joint.  In other circumstances, there may be a more obvious injury where one has a significant trauma or motor vehicle accident where the proximal tibiofibular joint is disrupted. 

In most circumstances, it is the posterior proximal tibiofibular joint ligament which is disrupted.  This results in the fibula rotating away from the tibia during deep squatting.  This can result in a feeling of instability, a visible bony deformity, and concurrent irritation of the common peroneal nerve.  This is because the common peroneal neve crosses the lateral aspect of the fibular neck within 2-3 cm of the lateral aspect of the fibular head. 

Read more.

Selected as "one of the Best Doctors in America", Dr. Robert F. LaPrade is a complex orthopaedic (orthopedic) knee surgeon at The Steadman Clinic in Vail, CO specializing in complex knee injuries.  He also serves as Chief Medical Officer, Deputy Director of the Sports Medicine Fellowship Program and Director of the International Research Scholar Program at the Steadman Philippon Research Institute.

The anatomical snuff box

This small cavity that appears at the radial side of the hand when we fully extend and abduct our thumb is call "anatomical snuff box" or "tabatiere anatomique".

The bony borders of this cavity are:

(bottom surface) the trapezium and scaphoideum

(proximally) the styloid process of the radius

(distally) the apex of the muscle tendons triangle

Three tendons define the borders of this cavity, as seen in the picture above:

1. Extensor pollicis longus

Origin: dorsal surface of the ulnar & the membrana interossea

Insertion: phalanx I (dorsally at the base of the distal phalanx)

Action: wrist: RAD DIV, EXT - thump: EXT at the metacarpophalangeal and the interphalangeal joints

While abductor pollicis brevis and adductor pollicis, both attached to the extensor pollicis longus tendon, can extend the thumb's interphalangeal joint to the neutral position, only extensor pollicis longus can achieve full hyperextension at the interphalangeal joint

Innervation: n. Radialis (C7-C8)

2. Extensor pollicis brevis

Origin: dorsal surface of the radius & the membrana interossea

Insertion: phalanx I (dorsally at the base of the proximal phalanx)

Action: wrist: RAD DIV - thump: EXT at the carpometacarpal and the metacarpophalangeal joints

Innervation: n. Radialis (C7-C8)

3. Abductor pollicis longus

Origin: dorsal surface of the ulnar & the radius & the membrana interossea

Insertion: base of the metacarpi I

Action: wrist: RAD DIV - thump: ABD at the carpometacarpal joint

Innervation: n. Radialis (C7-C8)

Besides, the radial artery of the forearm passes through this cavity. It runs distally on the anterior part of the forearm. There, it serves as a landmark for the division between the anterior and posterior compartments of the forearm, with the posterior compartment beginning just lateral to the artery. The artery winds laterally around the wrist, passing through the anatomical snuff box and between the heads of the first dorsal interosseous muscle.

The dorsal (superficial) cutaneous branch of the radial nerve can be palpated by stroking along the extensor pollicis longus with the dorsal aspect of a fingernail.

Pathology

1. Scaphoideum fracture

In the event of a fall onto an outstretched hand, the articulation between the scaphoideum and the radius is the area through which the brunt of the force will focus. In case the force is big enough the scaphoideum may fracture. There are two anatomical peculiarities that make this fracture quite dangerous and difficult to treat:

a. The size of the scaphoideum - the scaphoid is a small, oddly shaped bone whose purpose is to facilitate mobility rather than confer stability to the wrist joint. In the event of inordinate application of force over the wrist, this small scaphoid is clearly likely to be the weak link.

b. The vascularization of the scaphoideum - blood enters the scaphoid distally. Consequently, in the event of a fracture the proximal segment of the scaphoid will be devoid of a vascular supply, and will - if action is not taken - avascularly necrose within a sufferer's snuffbox.

2. DeQuervain’s tenosynovitis

DeQuervain's tenosynovitis is an inflammation of the fluid-filled sheath (called the synovium) that surrounds the tendons of the muscles mentioned above. Mostly, the extensor pollicis brevis and the abductor pollicis longus are the muscles affected in that case. The main reason for this inflammation is overuse syndromes. The main symptoms are pain, tenderness, and swelling over the thumb side of the wrist, and difficulty gripping. The Finkelstein's test may be positive.

3. Cheiralgia paresthetica

Cheiralgia paresthetica or Wartenberg's syndrome is the compression of the radial nerve along its course in the forearm. The area affected is typically on the back or side of the hand at the base of the thumb, near the anatomical snuffbox, but may extend up the back of the thumb and index finger and across the back of the hand. The most common cause is thought to be constriction of the wrist, as with a bracelet or watchband. Symptoms include numbness, tingling, burning or pain. Since the nerve branch is sensory there is no motor impairment.

There might be other injuries that can cause symptoms around the region as well like osteoarthritis, carpal instabilities, or cervical radiculopathy (C7-8). However, these were the 3 main problems that can appear and a Physical Therapist should at least be aware of in order to successfully assess a patient.