Jonathan Blood Smyth
This user hasn't shared any profile information
Posts by Jonathan Blood Smyth
The Thoracic Outlet Syndrome – Part Two
Physiotherapy examination starts with the therapist assessing the posture of the patient, often before they have taken any of their clothes off. A rounded or slumped shoulder posture and a poking forward neck and head stretch the neck and shoulder blade muscles and may make this syndrome more likely to occur. Active range of movements of the neck will be examined and any restrictions noted. The neck may be placed in combined positions involving two or more pure movements plus downward pressure in an attempt to bring on symptoms. Range of motion of the shoulders is also assessed.
The examination will include the ability of the nervous and vascular system to supply the requirements of the arm, with most of the deficiencies involving the lower nerves of the brachial plexus. Compression of the veins in the armpit area results in an arm which is bluish in colour and swollen, whilst if the part of the vascular system which is compressed is an artery this makes the arm cooler, lacking in a pulse and often having a lower blood pressure of 20 mmHg or more compared to the normal arm.
In the case of thoracic outlet syndrome due to neurological compression the finding are often of weakness and wasting of the small muscles of the hand. There may also be reduced sensation in the areas supplied by the ulnar nerve, which again reflects the fact that the lower nerves of the brachial plexus are most often involved. The last type of this syndrome, that of non-specific thoracic outlet syndrome, has widespread but less precisely located pain, with less precise and clear examination findings, making the diagnosis unreliable at best.
Thoracic outlet syndrome can be brought on by a large number of neck and shoulder anatomical structures and this is reflected in the numbers of diagnostic tests which have been developed to investigate this problem. A significant problem with these tests is the occurrence of false positive and false negative tests. False negatives mean that the test shows the problem not to be present when it really is and false positives mean the test indicates the tested problem to be present when in reality it is not.
A typical test is Roos stress test, where the patient keeps their arms up in a "hands up" position, opening and closing the fist. If the symptoms come on or the arms feel heavy or tired then the test may be taken to have a positive result. The reasons for thoracic outlet syndrome can either be due to bony structures or soft tissue structures. Bony structures which might cause compression or obstruction include cervical ribs and bony outgrowths on the ribs or collar bone. Soft tissue structures involved include abnormal fibrous bands or abnormally large muscles in weight training athletes.
Trauma to the neck and mechanical stressors may combine with any abnormalities in neck anatomy such as cervical ribs to increase the likelihood of developing thoracic outlet syndrome. Obstruction of the blood supply is an emergency and should be speedily assessed and surgically decompressed with repair to the arteries or veins. Most people with this syndrome are however treated conservatively with anti-inflammatory drugs, transcutaneous electrical nerve stimulation (TENS) and assessment and mobilisation or exercise prescription by a physiotherapist.
Many patients are helped by conservative management and those whose pain continues to be troublesome may eventually be considered for surgery. Physiotherapists look at the postural attitude taken by patients and muscle imbalances which may be present around the neck and shoulders. Patients who maintain static postures for long periods or continually return to one particular posture may develop dysfunctions.
Abnormalities of posture can elevate local tension or compressive forces and cause chronic compression of the nerves in the area. Maintenance of muscles in a shortened position can cause them to shorten permanently and then react with pain when they are put on a stretch. The idea of muscle imbalance implies that some muscles are stretched by the person's function and become weaker whilst others become shorter in consequence and so stronger, perpetuating abnormal function. Management of these conditions starts with patient education as understanding is vital if they are to make long term postural changes.
Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapists, physiotherapy, Physiotherapists in Coventry, back pain, orthopaedic conditions, neck pain and injury management. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.
Fixing Fractures – Part Two
If used for permanent fixation pins and wires are usually chosen if very little load is going through the fracture site or they are adding to the stability of a plate or an external fixator. Typical uses for wires or pins are to fix finger fractures, hand fractures, shoulder fractures and wrists. K-wires are often used to assist with the fixation in fractures of the patella, elbow and ankle. A device known as an image intensifier is often used to insert the device under x-ray guidance, allowing insertion of the pin or wire through the skin without operation.
Steinmann pins, being larger and which can be threaded are mostly used for applying skeletal traction to a fracture of the long bones. They are passed through a bone and a stirrup device attached to a weight provides the traction to keep the bone in alignment until a sufficient amount of healing occurs. This technique has largely been superseded by the use of more advanced techniques of internal fixation which means that long term traction, with its many negative side effects due to the patient being kept in bed for weeks or months, is rarely required.
Bone Screws
Using bone screws is a basic technique of modern orthopaedic and trauma management, used either on their own or as part of another implant technique. Screws can be self tapping or need tapping beforehand. The force needed to pull a screw out of the bone is affected by various factors and the main determining factor is the density of the bone into which it is inserted. The total area of contact between the bone and the threads is also important and self tapping screws are typically used. Screws are inserted clockwise either straight in or along a path already drilled and once the screw head hits the cortical bone it generates tension with screws typically inserted at a force equivalent to 80 percent of the force which would strip them.
Bone is an active and dynamic body organ and can adapt to the stresses formed by the application of the screws, allowing a gradual reduction in fixation force with time. However, the fracture is usually healed before the fixation is likely to loosen. The two main kinds of screws available are cancellous and cortical bone screws, the denser bone of the cortex being fixed with cortical screws and the more honeycomb bone of the bone ends fixed with cancellous screws. The surface areas of contact between thread and bone are greater in cancellous screws, allowing cancellous screws to achieve purchase in less dense bone.
Pre-drilling or tapping is not generally needed in cancellous bone due to its porosity and ease of insertion. Lack of tapping is often better as the insertion of the screw compresses the bone and may increase the local density of the bone, making the screw purchase more secure. Positional screws are used to attach an implant device such as a plate to the bone by compressing between the bone and the plate. Typical insertion involves drilling a pilot hole with a matching bit for the screw size and an appropriate thread tap is used unless self tapping screws are to be inserted.
A degree of compression can be produced by inserting lag screws across the line of a fracture to increase alignment and stability of a long bone fracture and to produce and maintain reduction of a fracture across a joint. To provide the greatest degree of stability requires the screw to be placed at right angles to the line of the break. It is unlikely that lag screws will give sufficient stability alone so they are often supplemented with added stability from an external fixator or a plate.
In a percutaneous technique often used for hip fracture fixation, cannulated screws can be inserted along the previously inserted guide wire which has been located under the control of x-ray guidance, completing the fixation started by wiring. As surgeons always try to minimise the size of operations and the resulting damage to soft tissues and bone membranes, cannulated screws are typically used in limited open surgery. Screws are now typically self drilling and self tapping although they are much more expensive than normal screws.
Total Hip Replacement – Exercising
Total hip replacement rehabilitation is not a complex process but it is useful for a skilled eye to be kept on the progress of the patient if the outcome is going to be optimal. The muscles around a painful joint weaken due to lack of use and this reduces the support of the joint given by them. Tightness may develop in the joints due to the restrictions in the movements which are limited by the pain and so the patient may develop an abnormality of gait to cope with the pain and tightness.
Pre-operative education and rehabilitation is important so the person knows what they are trying to achieve with their exercises and gait practice. Range of motion and strengthening exercises can be given along with gait correction. If the gait cannot be easily corrected by instruction, consideration should be given to using a walking aid. Either a stick or a crutch can be used depending on the degree of support needed, held in the opposite hand to the arthritic joint. If the patient walks with a good pattern this is sufficient, but if they still walk poorly they may need two sticks or crutches to achieve a reasonable gait pattern.
After the operation patients are routinely reviewed by a physiotherapist the day following the procedure. Initial instruction will be in regular contraction of the buttock and quadriceps muscles to reactivate their use and restore some joint movement. Range of motion exercises of the hip might include gentle hip flexion, sliding the heel towards the body as the knee rises. This is a functional movement patients need to be able to perform to move themselves around the bed. Ankle movements are also encouraged to aid circulation, although this effect may be small.
The ability to move the operated leg about is produced by instruction to perform muscle contractions and joint range of movements hourly in the bed. The physiotherapist and an assistant will get the patient out of bed and walking with a frame or crutches. Early sitting in a moderately high seat for the patient is routine, to prevent hip flexion attaining too great a level. The lateral incision up the side of thigh can inhibit patients from stretching that area when they bend their knees in sitting so they need to be encouraged to slide their feet towards themselves regularly while they are sitting.
Giving the patient confidence to independently perform a safe and relatively normal gait pattern is the initial goal of mobilisation. This progresses into teaching a walking technique which approximates as closely as possible to normal walking. Once this has been well learned the patient should walk with a pattern very close to a natural gait, with an observer only understanding they have a restriction by the presence of crutches. The natural sequence of muscle activation is promoted by an involuntary and repetitive function such as walking and this reduces the energy cost of walking and facilitates return of muscle power.
If a patient does not gain in muscle strength which is required then specific exercises can be performed. Initially the patient can be in standing and holding on to a high table or back of chair for balance. The operated leg is bent up gently with the knee coming up forwards for five repetitions, increasing as it gets easier with time. The second movement is to move the straight leg out to the side which strengthens the stabilising muscles of the buttock. The third movement is to move the straight leg backwards and behind without bending the body forwards to activate the large hip muscles.
In some cases these exercises will need to be supplemented by harder ones or by prescribing hydrotherapy. Pool therapy is very useful for patients after their joint replacement as they feel supported and in control of the leg but the water gives significant resistance to muscular activity. Resistance can be increased by using floats attached to the foot and the water resists the practice of the gait pattern, resisting the whole process. Care must be taken not to exercise hip replacements unduly or this can loosen the cement-bone interface and reduce the life expectancy of the replacement.
