David Lintonbon DO PG Cert Clin Ed MSc …...Safety first!! Place 128hz tuning fork close to the suspected fracture. Vibration will cause the fracture site to move. Causes “unremitting

David Lintonbon DO PG Cert Clin Ed MSc

www.theartofhvt.com

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Fractures Peripheral Arterial Occlusive Disease

Deep Vein Thrombosis Compartment Syndrome Septic Arthritis Cellulitis

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Note the age differences!! Importance of collecting a full history!!

Red Flag data obtained during the case

history;

History of recent trauma Crush injury RTA Fall from height/ladder Sports injury Osteoporosis All red flags

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# Distal lateral malleolus Fracture or Bad Sprain??

Red flag data obtained during a physical

exam:

Joint effusion and heamarthrosis

Bruising,swelling,throbing pain

Point tenderness over the involved tissue

Unwilling to weight bear

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Safety first!!

Place 128hz tuning fork close to the suspected fracture.

Vibration will cause the fracture site to move.

Causes “unremitting pain” Patient cont's to feel pain after the TF has been removed.

If inconclusive you can use an ultrasound machine on continuous setting or ref

X-Ray/MRI scan.

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Red flag data obtained during the case history;

Age 55+

History of;

Type 2 diabetes

Smoking

Intermittent claudication

Sedentary lifestyle

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Red flag data obtained during a physical exam:

Cool extremity or bilateral if aorta is site of occlusion

Prolonged capillary refill time (>3 secs)

Poor Pulses hair loss on your legs and feet numbness or weakness in the

legs brittle, slow-growing toenails ulcers (open sores) on your

feet and legs, which don't heal changing skin colour on your

legs, such as turning pale or blue

shiny skin

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PAD is largely treated through lifestyle changes and medication.

Walking/Exercising regularly

Stop smoking Eat a healthy diet lose weight, if you're

overweight or obese moderate your

consumption of alcohol

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PAD from an aortic aneurism requires surgery/dacron

Balloon catheter to increase dia artery

Peripheral stenting

All increase arterial flow to extremities

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Red Flag data obtained during the case history;

Recent surgery

Smoking

Contraceptive pill

Immobilisation

Long haul flight

Trauma

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Red flag data obtained during a physical exam:

Swelling of the leg or along a vein in the leg.

Pain or tenderness in the leg, standing or walking.

Increased warmth in the area of the leg that's swollen or painful.

Red or discoloured skin on the leg.

Refer;

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Homan's sign is an indicator of deep venous thrombosis. The sign is present where pain in the calf is produced by passive dorsiflexion of the foot.

Homan's sign, swelling and erythema have sensitivities of 60-88% and specificities of 30-72% in well-designed studies for the diagnosis of deep vein thrombosis (using venography as the reference standard) (2)

studies of Homan's sign suggest it is positive from 8 to 56% of people with proven deep venous thrombosis (DVT), but also positive in more than 50% of symptomatic people without DVT (2)

Homan's sign may be positive in both DVT of the calf and ruptured Baker's cyst (3).

The test has fallen into disfavour because of the lack of sensitivity and specificity for a diagnosis of deep vein thrombosis.

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Devastating condition where an Osseo fascial compartment pressure rises to a level that decreases perfusion

May lead to irreversible muscle and nerve damage

May occur anywhere that skeletal muscle is surrounded by fascia, but most commonly◦ leg

◦ foot

Pathophysiology◦ local trauma and soft tissue

destruction> bleeding and oedema > increased interstitial pressure > vascular occlusion > myoneural ischemia

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Red Flag data obtained during the case history;

History of blunt trauma, crush

injury - or - Recent participation

in a rigorous, unaccustomed

exercise or Excessive training

activity

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Red flag data obtained during a physical exam:

Severe, persistent leg pain Intensified with stretch applied to involved

muscles Swelling, exquisite tenderness

and palpable Tension/hardness of involved

compartment

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1-2 Treatment is possible 3-6 Refer Patient

1. Pain2. Pallor/bruising3. Paralysis4. Paresthesia5. Pulselessness6. Poikilothermia

Refer Patient Medical emergency

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Goal of treatment

Ease pressure

Nsaid/Ice

Stop exercice

Keep muscles/fascia flexible

Massage and stretching

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Inflammation of a joint because of a bacterial infection.

also known as infectious arthritis or bacterial arthritis.often affects the Feet and knees.

Usually affects more than one at the same time.

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Age over 80 years Diabetes mellitus Osteoarthritis Rheumatoid arthritis Immunosuppressive medication Intravenous drug

abuse Recent joint surgery Hip or knee prosthesis skin infection HIV infection

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Rapid onset with intense pain, joint swelling and

fever. Chills Fatigue and

generalised weakness Low-grade fever Inability to move the limb with

the infected joint Severe pain in the affected

joint, especially with movement

Swelling (increased fluid within the joint)

Warmth (the joint is red and warm to touch because of increased blood flow)

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A procedure called arthrocentesis is commonly used to make an accurate diagnosis of septic arthritis.

This procedure involves a surgical puncture of the joint to draw a sample of the joint fluid. 21/05/2018 23

This fluid collected Sent for;

gram stain culture leukocyte count

Also Blood test;

ESR (raised?)WBCRheu factorInflammatory markers

Differential diagnosis;

Crystal induced arthritis gout or pseudo gout

Inflammatory arthritis

Rheumatoid arthritisAnkylosing spondylitisReactive arthritis

Traumatic arthritis due

Hemarthrosis Fracture Foreign body Osteoarthritis

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Antibiotics target the specific

organism Analgesia Washout/aspiration of the joint Draining the pus from

the joint is important and can be done either by needle (arthrocentesis) or opening the joint surgically (arthrotomy)

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When septic arthritis is suspected,

X-rays should be taken.

Used to assess for involvement of surrounding structures such as bone and also for comparison purposes when future x-rays are taken.

Findings include joint space narrowing due to destruction of the joint.

Ultrasound can be done and is effective at detecting joint effusions.

CT and MRI can be used if diagnosis is unclear or hard to examine.

Can help assess for inflammation/infection in or about the joint (ie.osteomyeltis).

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Cellulitis is a skin infection cause;

staphylococcus or

streptococcus bacteria. It is not contagious.

Cellulitis appears as a red, swollen skin rash (usually on the lower legs or arms) that feels tender and hot. It can spread rapidly over the course of 24 hours.

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Bacteria enter the body through cracks/tears in skin Greater risk for cellulitis; Cut, scratch, or bug bite Fungal or viral skin infection (including athlete's

foot or chickenpox) Chronic skin condition (such as eczema) Using medications that suppress your immune system

(such as corticosteroids, chemotherapy) Are obese or overweight Have a weakened immune system from diabetes,

kidney or liver disease, leukaemia, radiation therapy, or HIV/AIDS

Have had oedema, liver or heart disease, or past surgery to remove lymph nodes

Have had cellulitis before

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The symptoms of cellulitis include: Skin rash that begins suddenly and

spreads quickly within 24 hours Areas of inflamed red skin that

grow larger Tenderness in the affected area Pain Skin that appears tight or stretched Fever

If the area is infected, Patient experiences: Chills Fatigue General malaise Muscle aches and pains Sweating

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Cellulitis is treated with a 10- to 14-day course of oral antibiotics.

The following are some examples of antibiotics that have been used to treat cellulitis:

Penicillins Amoxicillin Amoxicillin and clavulanate (Augmentin) Ampicillin and sulbactam (Unasyn) Piperacillin and tazobactam (Zosyn) Cefazolin Cephalexin (Keflex) Ceftriaxone (Rocephin) Cefuroxime (Ceftin, Zinacef) Ceftazidime (Fortaz, Tazicef) Azithromycin (Zithromax, Zmax) Erythromycin (Erythrocin, E.E.S., Ery-

Tab, EryPed) Imipenem and cilastatin (Primaxin) Levofloxacin (Levaquin) Ciprofloxacin (Cipro) Vancomycin

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Although rare in otherwise healthy individuals, necrotizing fasciitis occurs when cellulitis spreads to deeper layers of soft tissue, called the fascial lining.

Symptoms include:

Severe pain Swelling Redness of the infected area Black spots Blisters Ulcers High fever Signs of systemic inflammation

Erroneously referred to as "flesh-eating bacteria," necrotizing

fasciitis can progress rapidly and lead to death.

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intravenous antibiotics (administered in the hospital) and surgery to remove dead tissue.

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