COMMON PROBLEMS & PROCEDURES 

      ACL Reconstruction     Ankle Arthroscopy     Carpal Tunnel Syndrome     Frozen Shoulder  


 Hip Replacement       Knee Arthroscopy      Shoulder Arthoscopy    Tennis Elbow     


Trigger Finger     Wrist Fracture    

       Signs & Symptoms of ACL Injuries

       A twist or strain has occurred which causes the following signs:

• Pop- Many patients, but not all, will hear or feel a “pop” when the ACL tears.  
• Immediate onset of swelling- This is an indication that there is bleeding          from the injured ligament.   
• Pain- Most patients experience quite a bit of pain with an ACL injury.   
• Instability- Patients often describe a buckling or unstable sensation in the knee.  

 Treatment     Non-Operative- Physical Therapy 

• Strength- The muscles surrounding the knee, particularly hamstring muscles, must be strengthened.  These muscles can then take on some of the ACL’s job of stabilizing the knee joint. 
• Proprioception- Proprioceptive nerves in the ligament send important information to the brain about where the body is in space.  The brain then sends information to the muscles to tell them how to move the joint.  The damaged nerves in the ligament must be retrained so that the muscles will move the joint properly. 
• Functional Brace- An ACL brace will usually be prescribed to stabilize the knee and to prevent re-injury.       

Operative

Grafts

Reconstruction of the ACL begins with a small incision in your leg where small tunnels are drilled in the bone (below, left).  To create a replacement ACL the surgeon uses the patellar tendon, which connects the patella to the tibia.  The middle third of the tendon is harvested and used as the new ACL.  This called a patellar tendon autograft, because your own tissue is used                                              

SHOULDER ARTHROSCOPY  

The two main bones of the shoulder are the humerus and the scapula (shoulder blade).  The joint cavity is cushioned by cartilage covering the head of the humerus and face of the glenoid.  The end of the scapula, called the glenoid, meets the head of the humerus to form a glenohumeral cavity that acts as a flexible ball-and-socket joint.  The joint is stabilized by a ring of fibrous cartilage surrounding the glenoid called the labrum.  The biceps tendon attaches the biceps muscle to the shoulder and helps to stabilize the joint.  Four short muscles originate on the scapula and pass around the shoulder where their tendons fuse together to form the rotator cuff. All of these components of your shoulder manage the stress your shoulder receives as you extend, flex, lift, and throw.

FROZEN SHOULDER / MANIPULATION 

If you are having trouble lifting your arm above your head, reaching across your body or behind your back, you may have a problem with the range of motion in your shoulder.  Limited motion is an early symptom of a frozen shoulder, which is a general term denoting all causes of motion loss in the shoulder.

Causes of Frozen Shoulder

The cause of frozen shoulder is unknown, but it probably involves an underlying inflammatory process.  The capsule surrounding the shoulder joint thickens and contracts.  This leaves less space for the upper arm bone (humerus) to move around.  Frozen shoulders can also develop after prolonged immobilization because to trauma or surgery to the joint. 

Stages of Development

• Stage One- Pain increases with movement and is often worse at night.  There is a progressive loss of motion with increasing pain. 
• Stage Two- Pain begins to diminish, and moving the arm is more comfortable.  However, the range of motion is now much more limited, as much as 50 percent less than in the other arm. 
• Stage Three- Surgery may be needed to restore motion to the shoulder. 

Treatment

Non-Operative

Medications (such as aspirin or ibuprofen) to reduce the inflammation and relieve the pain.  Muscle relaxers to help loosen the muscles in the shoulder.

A program of physical therapy, often combined with home exercises and other therapies, to stretch and help restore motion and function.

Heat or ice therapies, Corticosteroid injections, Stretching exercises.

Closed Manipulation

A technique in which the physician stretches and maneuvers the shoulder to break up the scar tissue and adhesions of the joint capsule.  Although no incision is made, the patient is usually given a general or regional anesthetic that produces complete relaxation of the muscles.

Pain management following manipulation is very important.  If pain is not controlled, patients tend to limit shoulder motion, allowing scar tissue to form again.

To minimize discomfort, long-acting analgesics are occasionally administered through a catheter.

A comprehensive stretching program to restore lost motion is then started with a therapist.  After the patient leaves the hospital, this program should continue until almost all motion has been recovered.  

ANKLE ARTHROSCOPY       

Arthroscopy means “scoping of a joint” in Latin, or the surgical treatment of a joint using a small fiber optic telescope-like device.  Arthroscopic techniques allow less invasive surgery, with faster healing, less post operative pain and more rapid return to sports thus most often performed on athletes.

Possible Reasons for Ankle Arthroscopy

• Ankle pain during walking, running or jogging. 
• Ankle sprains due to sports, working, or common day injuries. 
• Swelling of the ankle joint. 
• A “locking or clicking” feeling in the ankle. 
• Weak ankles called ankle instability which causes tripping, falling, or severe ankle sprains. 
• Arthritis type symptoms (capsulitis, synovitis). 
• Chondromalacia (degeneration of cartilage). 
• Small cartilage or bone lesions within the joint as a result of previous ankle trauma. 
• Ligament tears.

Various Ankle Arthroscopy Procedures

• Loose Bodies- Fragments of loose cartilage or bone are removed from the joint (common after multiple sprains). 
• Ostechondritis Dessicans (OCD)- Damaged bone and cartilage on the talus bone of the ankle are treated by drilling deep into the bone to encourage bleeding and in growth of healing cells. 
• Arthritis- Loose debris and inflammatory enzymes are washed free.  Spurs are removed. 
• Fusion- In severe cases of arthritis, the joint can be fused arthroscopically. 
• Impingement- Painful scar tissue that pinches in the front of the ankle is removed. 
• Fractures- In some cases, splinters of bone are removed from the joint after the fractures.

TENNIS ELBOW 

 The elbow is a hinge joint made up of the humerus, ulna and radius.  The unique positioning and interaction of the bones in the joint allows for a small amount of rotation as well as hinge action.  This rotation is easily noticed during activities such as hand-to-mouth eating motions.  The primary stability of the elbow is provided by the ulnar collateral ligament, on the medial (inner) side of the elbow.  One of the most common injuries to the elbow occurs on the lateral, or outer, side of the elbow – nit is called Lasteral Epicondylitis, or Tennis Elbow.

Causes of Tennis Elbow

Tennis elbow or lateral epicondylitis is one of the most common elbow problems seen by an orthopedic surgeon. It is actually a tendonitis of the muscle called the extensor carpi radialis brevis, which attaches to the lateral epicondyle of the humerus.  It may be caused by a sudden injury or by repetitive use of the arm.  Pain is usually worse with strong gripping with the elbow in an extended position =, as in a tennis back hand stroke, but this problem can occur in golf and other sports as well as with repetitive use of tools such as hammering.

Treatment

Non-Operative

• Pain Relief- Cortisone injections, anti-inflammatory medications, braces, splints. 
• Strengthening and Stretching

Operative

A small incision is made and then the doctor will debride the dead, diseased tissue from the affected areas. 

CARPAL TUNNEL SYNDROME 

Carpal Tunnel

A narrow tunnel formed by bones and ligaments.  It contains tendons and a major nerve.   

Carpal Bones

Eight bones at the base of your palm.  They form the bottom and sides of the tunnel.

Transverse Carpal Ligament

A tough, bone-like ligament.  It lies across the carpal bones and forms the cover of the tunnel.

Median Nerve

The nerve that relays sensation from the hand through the arm to the central nervous system.

Motor Branch

A part of the median nerve that controls the use of the thumb.

Flexor Tendons

Nine tendons lined with a lubricant that allows them to slide freely through the tunnel as the wrist and fingers move.

Symptoms of Carpal Tunnel Syndrome (CTS)

A nerve disorder called Carpal Tunnel Syndrome (CTS) can occur after time and repetitive hand movements.  Symptoms such as pain and tingling, in the first three fingers, are common in people with this condition.  Other symptoms include:

• Numbness in part of the hand
• Burning sensations in the fingers
• Morning stiffness and cramping of the hands
• Thumb weakness
• Inability to make a fist
• Shiny, dry skin on the hand 

Causes of Carpal Tunnel

There are many causes of CTS.  Because bones and ligaments do not have much flexibility, pressure is put on the median nerve which cause pain and other related symptoms.  Some of the chief causes of CTS include:

• Wear and Tear- Normal wear and tear from age or repetitive movements can cause the membrane around the tendons to become thick or sticky.  This tends to press the nerve against the tunnel. 
• Fluid Retention- Retention of fluid causes the tissues within the carpal tunnel to swell.  This puts too much pressure on the median nerve.  Sometimes this will occur during pregnancy and corrects itself after delivery. 
• Fractures and Dislocations- Previous fractures or dislocations of your wrist can cause bone to poke into the carpal tunnel.  This narrows the tunnel opening and the affecting nerve. 
• Carpal Tunnel Surgery- The procedure takes about 30-45 minutes.  An incision is made vertically down the middle of the palm.  Care is taken to align the incisions with natural creases of your hand to minimize scarring.  The procedure entails cutting and releasing the transverse carpal ligament to open the carpal tunnel and take the pressure off the median nerve.

WRIST FRACTURES 

Your wrist is made up of eight bones.  They attach to the bones in your forearm and the bones in your hand.  A fracture is a break in a bone.  When you break your wrist, you may have broken the ends of the forearm bones (radius or ulna) or one of the right wrist bones (Navicular, Capitate, Trapezium, Trapezoid, Lunate, Psiform, Triquesturum, Hamate). 

Treatment Options

• Splint- A splint may be used to keep the wrist in a position that is better suited for quick healing.  This allows you to shower easier than with a cast. 
• Cast- A cast keeps the bones in place to assist the healing process.  The cast will be worn for about 4-6 weeks.   
• A Metal Plate with Screws (requires surgery)- This is a strip of metal that covers the fractured region and is held in place with tiny metal screws. 
• Screws Alone (requires surgery) - Hardware that looks like a normal screw.  It pulls the fractured segments together. 
• External Fixator (requires surgery)- Metal pins that cross the one, with a metal splint on the outside of the wrist that holds the pins and the fractured bone in place.

TRIGGER FINGER 

Cause of Trigger Finger

Trigger finger involves the tendons and pulleys in the hand that fend the finger.  The tendons connect the muscles of the forearm with the ones of the fingers.  Each tendon is covered by a slick lining or sheath.  When you bend your fingers, the tendons glide back and forth, guided by a restraining pulley or yoke.

When the tendon sheath becomes inflamed, it swells and may develop a knot or thickening in the tendon.  The knot passes through the pulley as the finger bends, but gets stuck as the finger straightens.  This causes further irritation and results in irritation, swelling, catching until the finger locks in a bent position.

Treatment

• Non-Surgical- Tries to reduce swelling and eliminate catching.  Initial treatment is usually conservative, involving rest, splinting the extended finger, and taking aspirin or ibuprofen to reduce swelling and ease pain. 
• Injection- If symptoms persist, your physician may administer a steroid injection in the tendon sheath.  Although there may be some short-term discomfort from the injection, it can relieve the pain and locking for several months. 
• Surgical- People with diabetes and rheumatoid arthritis will probably require surgery to release the tendon.  It involves a small procedure under local anesthetic.  A slit is made in the mouth of the sheath to prevent the tendon catching at this point. The surgery is done on an outpatient basis and can restore active motion immediately.  However, hand therapy may be needed to regain better use of the finger(s).