10% of all fractures. 2nd m/c following femoral neck Fx. Demographics: active young males and older osteoporotic females
Stable Fx: overall prognosis is good
Unstable Fx: require ORIF. 15%-20% chances of 2nd OA.
Role of imaging is to determine the complexity, stability and care planning (i.e., operative vs. conservative)
Weber classification considers tearing of distal tibial-fibular syndesmosis and potential instability
Weber A – below syndesmosis. Stable, typically avulsion of the distal fibular malleolus
Weber B – at the level of syndesmosis: may be outside syndesmosis and stable or tearing syndesmosis and unstable
Weber C – above syndesmosis. Always unstable d/t tearing of syndesmosis
Variations of fractures may involve the position/role of the talus bone during Fx (e.g., abduction, adduction, rotation, etc.) this is known as Lauge-Hanson classification
Reveal infrasyndesmotic Fx of fibular malleolus (Weber A)
Stable Injury
Conservative care in the form of short-leg walking cast/boot can be used. Good recovery. If no evidence of osteochondral injury, relatively low chances of post-traumatic OA
No further imaging required. MRI may help to reveal bone contusion and osteochondral injury
Weber B at Level of Syndesmosis
Can be stable or unstable. On occasions, the decision is made during operative exploration.
CT scanning may help with further evaluation
Management: depends on stability. Additional stabilization required if syndesmosis is ruptured
Weber C
AP, medial oblique and lateral views reveal Weber C – suprasyndesmotic injury with abnormal joint widening d/t disruption of the tib-fib syndesmosis. Very unstable injury.
Occasionally, when Weber C Fx positioned 6-cm from the tip of the lateral malleolus, it may be termed as Pott’s ankle Fx (name after Percival Pott’s who has proposed the original classification of ankle fractures based on their stability and degree of rotation). The term is somewhat outdated.
Management: operative with additional stabilization of the syndesmosis
Maisonneuve Fracture
Often spiral fracture of the proximal fibula combined with an unstable ankle injury
No immediate ankle fracture is noted radiographically, thus can be missed on ankle views and require tibia and fibula views
Rad features: widening of the ankle d/t syndesmosis tear and sometimes deltoid ligament disruption. Interosseous membrane is torn with proximal fibular Fx caused by pronation with external-rotation force
Management: operative
Bimalleolar & Trimalleolar Fx
Above top images Bimalleolar Fx v. unstable, the result of pronation and abduction/external rotation. Rx: ORIF.
Trimalleolar Fx: 3-parts ankle Fx. Medial and lateral malleolus and avulsion of the posterior aspect of tibial plafond. More unstable. Rx: operative
Tillaux Fx
Pediatric Fx affecting older child when the medial side of the physis is closed or about to close with lateral side till open. Avulsion by the anterior tibi-fibular ligament. Complications: 2nd dry/premature OA. Rx: can be conservative if stable by boot cast immobilization.
Pediatric Growth Plate Injuries
Salter-Harris classification helps to diagnose and prognosticate physeal injuries.
Helpful mnemonic: SALTR
S: type 1-slip through the growth plate
A: type 2-above, Fx extends into the metaphysis
L: type 3-lower, intra-articular Fx extends through the epiphysis
T: type4, “through” Fx extends through all: physis, metaphysis, and epiphysis.
R: type 5, “ruined.” Crush injury to physis leading to complete death of the growth plate
Type 1 and 5: present with no fracture
Type 2: has the best prognosis and considered the most common.
Management: referral to a pediatric orthopedic surgeon
Complications: early physis closure, limb shortening, premature OA and others.
Calcaneal Fracture
Most frequent tarsal Fx. 17% open Fx
Mechanisms: axial loading (intra-articular Fx into sub-talar and calcaneal-cuboid joints in 75% cases). Avulsion by Achilles tendon (m/c in osteoporotic bone). Stress (fatigue) Fx.
Intra-articular Fx carries a poor prognosis. Typically comminuted. Rx: operative.
B/I calcaneal intra-articular fx with associated vertebra compression Fx with associated vertebral compression Fx (T10-L2) often termed Casanova aka Don Juan (Lover’s) fx.
Imaging: x-radiography with added “heel view” 1st step. CT scanning is best for Dx and pre-op planning.
M/C fractured tarsal bone is the Talus. M/C region: talar neck (30-50%). Mechanism: Axial loading in dorsiflexion. Complications: Ischemic osteonecrosis (AVN) of the talus. Premature (2nd OA). Imaging: 1st step: radiographs, CT can be helpful with further delineation
Hawkins classification helps with Dx, prognosis & treatment. “Hawkins sign’ on plain film/CT scan may help with AVN Dx. (above blue arrows indicate good prognosis d/t radiolucent line indicating no AVN because the bone is vascularized and hence resorbed)
Rx: Type 1: conservative with short leg cast or boot (risk of AVN-0-15%), Type 2-4-ORIF (risk of AVN 50%-100%)
When the weather warms, melting the snow and ice as it ushers in the newness of spring, people are drawn outdoors, and increased activity soon follows. Runners top the list, training for upcoming marathons and races, or to get faster and increase endurance.
While some runners won�t let anything stop them, be it rain, sleet, or snow, most will not venture outside or engage in more rigorous training until the environment is more pleasant. This increased activity, though, can increase a person�s risk of injury, especially if they have been mostly inactive during the winter months. The most prevalent injury is runner�s knee, an umbrella term used to describe a variety of knee injuries including patellofemoral tracking syndrome.
What is Patellar Tracking Disorder?
When the patella, or kneecap, does not remain in place as the leg straightens or bends, it is called patellofemoral tracking syndrome. Many people believe that the kneecap only moves up and down, but that is not accurate. The kneecap is very mobile, rotating and tilting so that there are a variety of contact points between the femur and patella. The most common way that this disorder presents is the kneecap extends too far to the outside of the leg. Less frequent is when the kneecap shifts to the inside. The result is pain (sometimes severe) and limited mobility.
Understanding the syndrome means understanding the mechanics of the knee joint. The thighbone (femur) and lower leg (tibia and fibula) are joined by the knee, a large, complex hinge. A groove runs along the front of the joint, where the thighbone ends. The patella sits in the groove and is held in place by a network on the sides by ligaments and at the top and bottom by tendons. The underside of the kneecap is a layer of cartilage that allows it to move easily, or glide, along with the groove. When there is a problem with any of the parts that make up the knee it can lead to patellofemoral tracking syndrome.
Causes of Patellofemoral Tracking Syndrome
While overuse of the knee is the blanket term that describes the cause of patellofemoral tracking syndrome, it is the result of a combination of several problems. These can include:
Leg ligaments, tendons, or muscles that are too loose or too tight
Structural problems with the knee bones
Weak thigh muscles
The continuous stress put on the knee, such as activities that use a twisting motion to the knee
Repetitive, high-stress activities like running
Repeated movements like squatting, knee bending, or jumping
Improper alignment of the knee bones
Trauma to the knee that forces the kneecap off track, usually to the outside area of the leg
People who are most likely to develop the syndrome are those who experience any of these problems in addition to playing sports or running. Obesity or being overweight, when combined with the above problems can also put a person at risk for the syndrome.
Chiropractic for Patellofemoral Tracking Syndrome
Many people have experienced relief from the pain of patellofemoral tracking syndrome by using chiropractic care. Chiropractic for patellofemoral tracking syndrome is a medication free, non-invasive treatment that quickly and effectively treats the pain and helps to restore mobility. This is usually done by bringing the body back into alignment and performing specific manipulations depending on the unique needs of the patient. Treatment may involve the foot, ankle, spine, and hip in addition to the knee.
The patient may also be advised to make specific dietary adjustments, take special, targeted supplements, and do specific exercises in addition to the chiropractic treatments. Stretching is often recommended, and Kinesio taping is also a standard therapy to aid healing. Chiropractic will not only return the body to its natural balance and alignment, but it will get it to a state where it can begin healing itself.
Louie Martinez has been a Wrestling coach for 15 years, coaching young athletes ranging from 8 to 15 years old. Louie Martinez shares how he met Dr. Alex Jimenez 10 years ago after he suffered an initial injury. Coach Martinez has experienced a variety of injuries throughout his coaching career, from shoulder injuries to back injuries, and every time, Dr. Alex Jimenez has helped Coach Martinez regain his health. Before meeting Dr. Jimenez, Louie Martinez didn’t understand the importance of seeing a chiropractor. Louie Martinez recommends Dr. Alex Jimenez as the non-surgical choice for sports injuries.
Sports Injury Rehabilitation
When visiting a chiropractor for sports injuries, a physical exam will help pinpoint the health issue to make an individualized treatment plan to treat it. Chiropractic care was observed in several studies to reduce the healing time of sports injuries, as well as help prevent future sports injuries. It’s important to understand your chiropractor. The healthcare professional might have useful suggestions that can keep you healthy as you work to attain your athletic objectives.
We are blessed to present to you�El Paso�s Premier Wellness & Injury Care Clinic.
As El Paso�s Chiropractic Rehabilitation Clinic & Integrated Medicine Center,�we passionately are focused on treating patients after frustrating injuries and chronic pain syndromes. We focus on improving your ability through flexibility, mobility and agility programs tailored for all age groups and disabilities.
If you have enjoyed this video and we have helped you in any way, please feel free to subscribe and recommend�us.
The way a person walks, their gait, can be very telling. It can reveal problems in the feet, ankles, knees, and hips � even in spinal alignment. A problem with gait can indicate pain in a patient as well as serious conditions like diabetes and arthritis. It, is a diagnostic tool for many conditions, injuries, and syndromes including autism. When it comes to chiropractic care, a patient�s gait can offer critical clues regarding the root of their complaints, allowing for a more well-rounded, whole body approach to treatment. If you think that the way you walk or moves doesn�t matter, think again. It most certainly does matter.
What is Gait Analysis?
Gait analysis is a set of tests that are designed to provide a comprehensive evaluation of a person�s gait. It is a systematic study of human motion that involves observation as well as the use of instruments that measure body movements, muscle activity, and body mechanics.
It is intended to be used as an assessment tool and provide insight into devising a treatment plan for people who have conditions or injuries that affect their ability to walk. It is often used in sports biomechanics to aid athletes in more efficient movement and to identify problems with movement or posture, particularly those with injuries.
During the analysis, the patient may walk in a prescribed pattern or on a treadmill, that is often connected to a computer, while the chiropractor observes them from various angles. Often cameras are used, places at multiple points to capture different views including the anterior, posterior, and sides.
The patient may have markers applied to specific points on the body such as the knee, ankle, pelvis, and other areas. As they move, the computer captures specific data of the movement, providing a three-dimensional calculation of each marker. It then applies a model to assess the movement of the skeletal structure, resulting in a detailed analysis of each joint�s movement.
Factors that Affect Gait Analysis
Certain factors affect a person�s gait, and that information must be included for the gait analysis to be accurate. The gender, age, height, and weight of the person is vital because men and women move differently and as a person ages their structure changes.
Excess weight or they physique can affect a person�s posture and their gait. The individual�s shoes (or lack of shoes) is essential, as is their clothing, the terrain they are walking on, and anything they may usually carry, such as a purse. Other factors include:
Physiological factors such as body proportion
Psychological factors such as their state of mind, emotions, stress level, and personality type
Pathological factors such as neurological diseases, psychiatric disorders, trauma, and musculoskeletal anomalies
It will also measure and factor into the analysis data that includes the patients:
Getting a gait analysis can be very advantageous because it can provide invaluable insight into how your body is aligned and how it moves. It is an excellent diagnostic tool for identifying health issues related to the gait, spine, and feet and can also help provide early detection of health issues before the onset of symptoms.
If your chiropractor recommends that you get a gait analysis, it could be that he or she suspects that something is going on, or it could simply mean that they want to examine you to provide optimal care more thoroughly. If you have any concerns, you should sit down with your chiropractor and ask them any questions that you have before undergoing the analysis. Stress and anxiety can put tension on the muscles and body, affecting the results.
Truide Torres started having back pain throughout the progression of her pregnancy. After she began to experiencing many limitations with her daily physical activities, Truide Torres visited Dr. Alex Jimenez, chiropractor, to receive chiropractic care for her back pain. Because of her pregnancy, Truide Torres had some doubts, and she felt unsure about receiving chiropractic care. However, Dr. Alex Jimenez and his staff reassured her and gave her the confidence to follow through with her treatment. Truide Torres recommends Dr. Alex Jimenez to anyone.
Chiropractic Help in Pregnancy
Chiropractic care provides maintenance to the spinal column, discs, bones, and nerves without drugs/medications or surgery. It helps correct any spinal misalignments, or subluxations, which reduces spinal nerve strain and promotes health and wellness throughout the body. There are no known contraindications to chiropractic care during pregnancy. All chiropractors are trained to work with women who are pregnant. Providing chiropractic care for pregnant women is routine care for the majority of chiropractors.
We are blessed to present to you�El Paso�s Premier Wellness & Injury Care Clinic.
As El Paso�s Chiropractic Rehabilitation Clinic & Integrated Medicine Center,�we passionately are focused on treating patients after frustrating injuries and chronic pain syndromes. We focus on improving your ability through flexibility, mobility and agility programs tailored for all age groups and disabilities.
If you have enjoyed this video and we have helped you in any way, please feel free to subscribe and recommend�us.
Sagittal Fluid Sensitive MR slice showing large synovial popliteal (Baker’s) cyst (above top image) and sizeable synovial effusion (above bottom image)
Note multiple patchy dark signal areas on both images, representing fibrinoid inflammatory deposits aka “rice bodies” a characteristic MRI feature of RA
Management Rheumatological Referral & DRM
Conservative management followed by operative care in complicated cases of tendon ruptures and joints dislocations
Supplemental reading:
Diagnosis and Management of Rheumatoid Arthritis – AAFP
Septic arthritis – d/t bacterial or fungal contamination of the joint. SA may cause rapid joint destruction and requires prompt Dx and antibiotic administration
Joints affected: large joints with rich blood supply (knee 50%>hips>shoulders).
Routs of Infection:
1) Hematogenous is m/c
2) Spread from an adjacent site
3) Direct implantation (e.g., trauma, iatrogenically)
Patients at risk: children, diabetics, immunocompromised, pre-existing joint damage/inflammation, e.g., RA, etc.
I.V. drug users are particularly at risk and also may contaminate atypical joints “the S joints” SIJ, SCJ, Symphysis pubis, ACJ, etc.
Clinically: may vary and depends on host immune response and bacterial virulence. May present with rapid onset or exacerbation of pre-existing joint pain, swelling, limitation of ROM. General signs of malaise, fever, fatigue and elevated ESR, CRP, Leucocytosis may be present.
N.B. Diabetics and immunocompromised may present with fewer manifestations and lack of fever d/t declining immune response
Dx: clinical, radiological and laboratory. Arthrocentesis may be necessary for culture, cell count and purulent synovial examination
Management: I.V. antibiotics
Imaging Dx: begins with radiography but in the early stage most likely will be unremarkable. MRI can be sensitive and help with early identification of joint effusion, bone edema, etc. US may be helpful in the superficial joints and children. US helps with needle guidance. Bone scintigraphy may be used occaisonally if MRI is contraindicated
Routes of Joint Contamination
1. Hematogenous (M/C)
2. Spread from the adjacent site
3. Direct inoculation
M/C organism-Staph aureus
N.B Gonococcal infection may be a top differential in some cases
IV drug users: Pseudomonas, candida
Sickle cell: Salmonella
Animal (cats/dogs) bites: Pasteurella
Occasionally fungal contamination may occur
Radiography
Initially non-specific ST/joint effusion, obscuration/distortion of fat planes. Because it takes 30% of compact and 50-75% trabecular bone to be destroyed before seen on x-rays, radiography is insensitive to some of the early changes. MR imaging is the preferred modality
If MRI is not available or contraindicated. Bone scintigraphy with Tc-99 MDT can help
In children, US preferred to avoid ionizing radiation. In children, US can be more sensitive than in adults due to lack of bone maturation
Radiographic Dx
Early findings are unrewarding. Early features may include joint widening d/t effusion. Soft tissue swelling and obscuration/displacement of fat planes
1-2 weeks: periarticular and adjacent osseous changes are manifesting as patchy demineralization, moth-eaten, permeating bone destruction, loss, and indistinctness of the epiphyseal “white cortical line” with an increase in soft tissue swelling. MRI may be helpful with early Dx.
Late features: complete joint destruction and ankyloses
N.B. Septic arthritis may progress rapidly within days and requires early I.V. antibiotic to prevent major joint destruction
T1 & T2 Knee MRI
T1 (above left) and T2 fat-sat sagittal knee MRI slices reveal loss of normal marrow signal on T1 and increase on T2 due to septic edema. Bone sequestrum d/t osteomyelitis progressing into septic arthritis is noted. Marked joint effusion with adjacent soft tissue edema is seen. Dx: OSM and septic arthritis
Imaging may help the Dx of the septic joint. However, the final Dx is based on Hx, physical examination, blood tests and most importantly synovial aspiration (arthrocentesis)
Synovial fluid should be sent for Gram staining, culture, glucose testing, leukocyte count, and differential determination
ESR/CRP may be elevated
Synovial fluid: WBC can be 50,000-60,000/ul, with 80% neutrophils with depleted glucose levels Gram stain: in 75% gram-positive cocci. Gram staining is less sensitive in gonococcal infection with only 25% of cultures +
In 9% of cases, blood cultures are the only source of pathogen identification and should be obtained before antibiotic treatment
Gout: MSU deposition in and around joints and soft tissues. Elevated levels of serum uric acid (UA) (>7mg/dL) caused by overproduction or under-excretion of uric acid
Once UA reached/exceeded 7mg/dL, it will deposit in the peripheral tissues. Primary gout: disturbed metabolism of nucleic acids and purines break down. Secondary gout: increased cell turnover: Psoriasis, leukemia, multiple myeloma, hemolysis, chemotherapy, etc.
Gout presents with 5-characteristic stages:
1)asymptomatic hyperuricemia (years/decades)
acute attacks of gouty arthritis (waxes and wanes and lasts for several years)
Interval phase between attacks
Chronic tophaceous gout
Gouty nephropathy
Clinical Presentation
Depends� on stages
Acute attacks: acute joint pain “first and the worst” even painful to light touch
DDx: septic joint (both may co-exist) bursitis etc.
Gouty arthritis typically presents as monoarthropathy
Chronic tophaceous stage: deposits in joints, ear pinna, ocular structures, and other regions. Nephrolithiasis etc. Men>women. Obesity, diet, and age >50-60.
Radiography: early attacks are unremarkable and may present as non-specific joint effusion
Chronic tophaceous gout radiography: punched out peri-articular, para-articular and intraosseous erosions with overhanging edges. A characteristic rim of sclerosis and internal calcification, soft tissue tophi. Target sites: lower extremity m/c
Rx: allopurinol, colchicine (esp. preventing acute episodes and maintenance)
Synovial Aspiration
Synovial aspiration with polarized microscopy reveal negatively birefringent needle-shaped MSU crystals with large inflammatory PMN presence. DDx: positively birefringent rhomboid-shaped CPPD crystals (above bottom right) seen in Pseudogout and CPPD
Large S.T.
Density and joint effusion punched out osseous erosion with overhanging margins, overall preservation of bone density, internal calcifications Dx: chronic tophaceous gout
MRI Gout Features
Erosions with overhanging margins, a low signal on T1 and high on T2 and fat-suppressed images. Peripheral contrast enhancement of tophaceous deposits d/t granulation tissue
Dx: final Dx; synovial aspiration and polarized microscopy
Edgar M. Reyes works for the city of El Paso, TX. Recommended by one of his wife’s friends, Mr. Reyes visited Dr. Alex Jimenez, chiropractor, to receive treatment for his sciatica symptoms. Edgar Reyes struggled to walk due to his sciatic nerve pain before seeing Dr. Jimenez, but thanks to the chiropractic care he’s received, Mr. Reyes can walk again. Edgar M. Reyes highly recommends Dr. Alex Jimenez as the non-surgical choice for sciatica treatment.
Sciatica Chiropractic Treatment
The primary objective of sciatica treatment is to alleviate pain in the legs and lower back. This can be accomplished via a variety of methods, including medications and physical therapy. Chiropractic care can also help. Doctors of Chiropractic (DC) or chiropractors, regularly treat sciatica. Sciatica is characterized by pain that originates in the lower back or buttock which travels into one or both legs. Sciatic nerve pain varies in intensity and frequency; minimum, moderate, severe and intermittent, frequent or constant.
We are blessed to present to you�El Paso�s Premier Wellness & Injury Care Clinic.
As El Paso�s Chiropractic Rehabilitation Clinic & Integrated Medicine Center,�we passionately are focused on treating patients after frustrating injuries and chronic pain syndromes. We focus on improving your ability through flexibility, mobility and agility programs tailored for all age groups and disabilities.
If you have enjoyed this video and we have helped you in any way, please feel free to subscribe and recommend�us.
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