Clinical Mentoring: Joint Problem Management

CLINICAL MENTORING
JOINT PROBLEM MANAGEMENT
dr. Muh. Ardi Munir, M.Kes., Sp.OT., FICS., M.H

ORTHOPAEDICS PROBLEMS
HOW TO DIAGNOSIS JOINT PROBLEM
HISTORY
• PAIN
• DEFORMITY
• STIFFNESS
• SWELLING
• INSTABILITY
• WEAKNESS
• LOSS OF FUNCTION
PHYSICAL EXAMINATION
• LOOK  COLOUR CHANGES, CHARACTERISTIC POSTURE
• FEEL  CHANGE OF TEMPERATURE, EXCESSIVE JOINT
EFFUSION
• MOVE  STIFFNES (ABSENT, LIMITED, OR PARTIAL),
UNSTABLE MOVEMENT, JOINT LAXITY, JOINT DEFORMITY
(CONTRACTURE, MUSCLE IMBALANCE, DISLOCATION,
JOINT DESTRUCTION)
DIAGNOSTIC IMAGING
• PLAIN X-RAYS
• ARTHROGRAPHY
• COMPUTED TOMOGRAPHY
• MAGNETIC RESONANCE IMAGING
• DIAGNOSTIC ULTRASOUND
• RADIONUCLIDE IMAGING
BLOOD TEST AND SYNOVIAL FLUID ANALISYS
OSTEOARTHRITIS
X-RAY KNEE NORMAL VS OA
KELLGREN-LAWRENCE GRADING SCALE
MEDICATION - FIRST LINE
• NSAIDs, including COX-2 inhibitors, are mainstays in the non
operative treatment of arthritis.
• Meta-analysis shows these medications to be slightly more
effective than a placebo in the short term.
• NSAIDs have a high rate of side effects, including
gastrointestinal bleeding.
• Acetaminophen is widely used for pain relief.
MEDICATION - SECOND LINE
• The use of nutraceuticals, such as glucosamine and chondroitin
sulfate, is controversial, with a recent study showing no benefit
• Intra-articular injection:
- With corticosteroids, decreases pain for short periods
- With hyaluronic acid, may have a small effect on knee pain
• Opioid pain medicine may be used for severe pain in patients
who are not operative candidates.
INTRA-ARTICULAR INJECTIONS
SURGERY
Realignment osteotomy:
• The joint surfaces are repositioned by cutting the bone and
changing the axis of weight bearing.
• Purpose: Allows the healthiest articular cartilage to bear the
most weight
• May be combined with ligament or meniscal repair
REALIGNMENT OSTEOTOMY:
SURGERY
Joint Replacement - Arthroplasty:
• The arthritic joint surfaces are removed, and a new joint surface
is implanted.
• The bearing surface is typically metal on high-density
polyethylene.
• Examples are total hip arthroplasty, total knee arthroplasty, and
total shoulder arthroplasty.
OA SHOULDER JOINT  TSR
OA HIP JOINT  THR
OA KNEE JOINT  TKR
SPECIAL THERAPY - PHYSICAL THERAPY
• Patients should begin a program to preserve muscle strength
and ROM and to avoid contractures.
• Heavy-impact activity (such as running, contact sports, and
heavy work) exacerbates symptoms.
• A cane used in the opposite hand substantially reduces the
forces across the hip joint and will relieve discomfort and
improve gait.
SPECIAL THERAPY - COMPLEMENTARY AND
ALTERNATIVE THERAPIES
• Acupuncture may provide pain relief for knee arthritis in the
short term.
• Many herbal medicines are used for the treatment of
osteoarthritis.
• Evidence to support their use is limited.
PROGNOSIS
• Osteoarthritis progressively worsens with time.
• No cure exists.
• Modern methods of joint replacement provide excellent function
and pain relief.
COMPLICATIONS
• Progressive arthritis leads to worsening deformity and stiffness.
• In the lower extremity, patients may stop walking and rely on
wheelchairs
• In the upper extremity, prevents activities and leads to lack of function
• Treatment also may lead to complications.
• The side effects of NSAIDs include gastritis and gastrointestinal
bleeding.
• Surgical intervention may lead to infection, DVT, or failure of the
replacement mechanical joint.
ANKLE SPRAIN
HISTORY
Mechanism of injury causing sprain:
• Inversion in plantarflexion:
ATFL injury
• Inversion in dorsiflexion:
CFL injury
TREATMENT
• RICE protocol
• Partial weightbearing with crutches in the acute phase (first 3-7
days), which is advanced as tolerated to full weightbearing
• Stirrup ankle brace to facilitate early ambulation
• Gentle active ROM as tolerated is advised.
• Activity modification (rest, sports restriction) until strength
returns
RICE PROTOCOL
RICE
MEDICATION (DRUGS)
First Line
• NSAIDs and analgesics can be used for severe sprains, but they
usually are not necessary.
SURGERY
• Surgical repair of acute ankle ligament tear is rarely indicated
• Primary repair of ATFL and CFL
• Surgery may be indicated for patients with recurrent instability.
• In such patients, repair of the lateral ankle ligaments or
reconstruction with part of the peroneus brevis tendon usually is
successful.
PHYSICAL THERAPY
• ROM
• Strengthening exercises
• Proprioceptive retraining
ANY QUESTION

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CLINICAL MENTORING

JOINT PROBLEM MANAGEMENT

dr. Muh. Ardi Munir, M.Kes., Sp.OT., FICS., M.H

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