Symptoms and Causes of Chronic Fatigue Syndrome: 

Chronic Fatigue Syndrome (CFS) is a controversial condition, the existence of which is hotly debated within the medical profession. The term itself was first used in 1988 but the syndrome has existed for much longer. It has previously been known as neurasthenia and myalgic encephalomyelitis (ME). The term CFS has been adopted to define a sufficiently homogeneous group of patients to allow research into etiology, pathogenesis, natural history and management. As the word syndrome suggests, CFS is not recognized as a distinct disease process.

Definition

A number of definitions of CFS have been proposed. All include the concept of fatigue that interferes with activities of daily living and is of at least six months duration. The Center for Disease Control (CDC) in Atlanta has defined CFS as the presence of:

1. Clinically evaluated, unexplained, persistent or relapsing fatigue that is of new or definite onset; is not the result of ongoing exertion; is not alleviated by rest; and results in a substantial reduction of previous levels of occupational, educational, social or personal activities.
2. Four or more of the following symptoms that persist or recur during six or more consecutive months of illness and that do not predate the fatigue:

• Self-reported impairment in short-term memory or concentration
• Sore throat
• Tender cervical or axillary nodes
• Muscle pain
• Multi -joint pain without redness or swelling
• Headaches of a new pattern or severity
• Un-refreshing sleep
• Post-Exertional malaise of at least 24 hours

Symptoms

The most prominent symptom of CFS is usually overwhelming fatigue, especially after exercise.

• Other common symptoms include headaches, sore throat, enlarged lymph nodes, muscles pain especially after exercise, un-refreshing sleep, chest and abdominal pains.
• The diagnosis of CFS is difficult to confirm in the absence of any definitive sign or test.
• It is often a diagnosis of exclusion.
• The other problem with the diagnosis of CFS is that there are a number of conditions whose symptoms overlap with those of CFS.
• The two most significant are fibromyalgia and depression.
• The major presenting symptom in fibromyalgia is usually widespread muscle and joint pain but fatigue is nearly always present.
• Fibromyalgia is characterized by the presence of multiple tender points in the muscles.
• Trigger points are also frequently seen in patients with CFS and form an important part of the treatment.
• Fatigue is often the primary presenting symptom in patients with depression and many of the symptoms described in CFS are found in depressive patients.

Management

Management of the patient with CFS (or fibromyalgia and depression) is a considerable challenge for the practitioner. The natural history of CFS is of a very gradual improvement over a period of months and sometimes years.

• Treatment should be oriented towards psychological support and symptom relief.
• It is essential that the treating practitioner acknowledges that the patient has a real problem and is prepared to give the patient a diagnosis.
• It is important to give the patient plenty of time and both the patient and those close to her (or him) will have many questions.
• We recommend seeing the patient at least weekly in the initial treatment phase and later on a less frequent but still regular basis.
• Exercise is the cornerstone of treatment of chronic fatigue.
• This may seem strange when one considers that post-exercise fatigue and muscle pain are two of the most significant features of the disease but a slow, graduated increase in activity is an essential part of management.
• The exercise program may have to commence at a ‘ridiculously’ low level considering the history of some athletes.
• But it should commence at a level that the patient can achieve comfortably with minimal or no adverse effects in the 24-48 hours post-exercise.
• The increase in activity should be very gradual and if adverse symptoms develop, the patient should return to the previous level of activity and build up even more slowly.
• In a six-month randomized blinded prospective trial in individuals with CFS, it was found that a graded exercise program significantly improved both health perceptions and the sense of fatigue whereas the use of an antidepressant (fluoxetine) improved depression only.
• Another study of 66 patients with CFS also demonstrated a positive effect with graded aerobic exercise.
• Many drug treatments have been advocated but with little evidence of their efficacy.
• Simple analgesics may be helpful and we recommend the use of a tri- cyclic antidepressant (e.g. amitryptiline 10-25 mg) in a single nocte dose.
• This drug seems to improve sleep quality and patients will usually wake up more refreshed as a result.
• Many nutritional supplements have also been advocated but again there is no evidence of their efficacy we have found the treatment of muscle trigger points with dry needling to be helpful in reducing muscle pains and headaches in a number of patients with CFS.

Other Causes of Tiredness

A number of psychological problems are associated with a feeling of excessive tiredness. The two most common states are anxiety and depression. These problems may be related to the athletes sporting endeavors or, alternatively, may be quite unrelated.

• The presence of eating disorders such as anorexia, nervosa and bulimia should also be considered.
• Hypothyroidism is more common than most realize, occurring in 1% of adults, with subclinical disease in Solo. The condition can affect any organ system.
• Hypothyroidism is characterized by a general slowing of body processes and can present as chronic fatigue, cold intolerance, weight gain and, in women, menorrhagia.
• It is often associated with high cholesterol levels.
• An elevated serum thyroid stimulating hormone level is a sensitive indicator and patients with this condition generally respond well to treatment with levothyroxine.
• Diabetes, neuromuscular disorders and cardiac problems are all associated with excessive tiredness.
• Exercise induced as the major symptom rather than the more typical cough, chest tightness or shortness of breath post exercise.
• A number of medications may cause excessive tiredness.
• These include beta-blockers, antihistamines, diuretics, anticonvulsants, sedatives and muscle relaxants.

Physical Health Benefits of Exercise:

Physical activity benefits all body organs as well as the psyche. The most dramatic benefits have been found in the cardiovascular system. Exercise interventions in older patients with coronary heart disease decreased morbidity, mortality and symptoms, and reduced cardiac re-hospitalizations.

Benefits of Exercise

Numerous mechanisms may contribute to these benefits. Increased demand on the myocardium improves oxygen utilization. Capillaries dilate and multiply to improve the delivery of oxygen and other nutrients to muscles. The myoglobin content of muscle is increased, thus improving the transfer of oxygen from the red blood cells to muscle cells. Inside the cell, the number of mitochondria increases, enhancing aerobic metabolism. There is also an increase in the glycogen storage sites of muscle. Here following are the exercise benefits:

• Exercise tends to lower the resting heart rate and the resultant increased diastolic time allows improved coronary blood flow. Stroke volume increases.
• Exercise also has an effect on blood lipid levels, raising levels of high-density lipoprotein cholesterol, the cardio protective lipid, and lowering levels of low-density lipoprotein cholesterol.
• Exercise lowers blood pressure and reduces obesity. A combination of these two factors, in addition to the reduction in cholesterol, decreases the risk of ischemic heart disease.
• Exercise may also improve exercise tolerance in older people with chronic obstructive pulmonary disease. They will also benefit from the associated benefits of aerobic fitness.
• Exercise may improve blood sugar control in people with diabetes by decreasing insulin resistance, and may reduce the need for medication.
• Resistance training and high-impact activities help maintain bone mass in the elderly.
• An exercise program may also be beneficial for older people with osteoarthritis by improving joint mobility and increasing muscle strength.
• Exercise in the form of strength and balance training has been shown to reduce an older person’s risk of falling.
• Along with the physical benefits of exercise, the older athlete benefits from improved sleep, cognitive function and mood.
• The muscle control and weight loss associated with exercise may lead to improvements in body image and reverse the elderly person’s fear of activity.
• Exercise reduces anxiety in elderly patients, especially in those recovering from illness.
• Exercise can lessen depressive symptoms and perhaps even reduce the risk of developing depression.

Risks of Exercise in the Elderly

The risks associated with a sedentary lifestyle are well known although difficult to quantify objectively and compare with the risks associated with exercise in later years. Underlying co-morbidity is often cited as a reason to preclude exercise despite the overwhelming evidence to support the benefits of exercise in many common and chronic diseases.

From a safety standpoint, clinicians prescribing exercise for older people are concerned that exercise may induce myocardial ischemia and, in turn, precipitate myocardial infarction or sudden death. Gill and colleagues have provided recommendations regarding precautions that can be taken to minimize the risk of serious adverse cardiac events among previously sedentary older persons who do not have symptomatic cardiovascular disease and are interested in starting an exercise program.

Reducing the Risks of Exercise

Before starting an exercise program, all older persons should have a complete history and physical examination performed by a physician. Contraindications to exercise outside of a monitored environment include: myocardial infarction within six months, angina or physical signs and symptoms of congestive heart failure, and a resting systolic blood pressure of 200 mmHg or higher. A functional test of cardiac capacity is to ask the patient to walk 15 m (50 ft) or climb a flight of stairs. A resting ECG/EKG should be reviewed for new Q waves, ST segment depressions or T-wave inversion.

Persons who have features of cardiovascular disease should be referred for appropriate management. If the patient has no overt cardiovascular disease, and no other medical or orthopedic contraindications to exercise, he or she can begin a low-intensity exercise program.

Treatment of Headache:

Cervical or cervicogenic headache is a term used to describe headache caused by abnormalities of the joints, muscles, fascia and neural structures of the cervical region. There are a number of classifications for cervical or cervicogenic headache with differing criteria for physical dysfunction.

Mechanism

The mechanism of production of headache from abnormalities in the cervical region is variable. It may be primarily referred pain caused by irritation of the upper cervical nerve roots. This may be due to damage to the atlantoaxial joint or compression of the nerves as they pass through the muscles. Headache emanating from the lower cervical segments probably originates from irritation of the posterior primary rami, which transmit sensation to the spinal portion of the trigeminocervical nucleus.

Commonly, pain may also be referred to the head from active trigger points. Frontal headaches are associated with trigger points in the suboccipital muscles, while temporal headaches are associated with trigger points in the upper trapezius, splenius capiitis and cervicis, and sternocleidomastoid muscles.

Clinical Features

History

A cervical headache is typically described as a constant, steady, dull ache, often unilateral but sometimes bilateral. The patient describes a pulling or gripping feeling or, alternatively, may describe a tight band around the head. The headache is usually in the suboccipital region and is commonly referred to the frontal, retro-orbital or temporal regions.

Cervical headache is usually of gradual onset. The patient often wakes with a headache that may improve during the day. Cervical headaches may be present for days, weeks or even months. There may be a history of acute trauma, such as a whiplash injury sustained in a motor accident, or repetitive trauma associated with work or a sporting activity.

Cervical headache is often associated with neck pain or stiffness and may be aggravated by neck or head movements, such as repetitive jolting when traveling in a car or bus. It is often associated with a feeling of light-headedness, dizziness and tinnitus. Nausea may be present but vomiting is rare. The patient often complains of impaired concentration, an inability to function normally and depression. Poor posture is often associated with a cervical headache. This may be either a contributory factor or an effect of a headache. The abnormal posture typically seen with cervical headache is rounded shoulders, extended neck and protruded chin. This results in tightness of the upper cervical extensor muscles and weakness of the cervical flexor muscles.

Stress is often associated with cervical headache. It may be an important contributory factor to the development of the soft tissue abnormalities causing the headache or may aggravate abnormalities already present. Thus, it is important to elicit sources of stress in the clinical history.

Exercise-Related Causes of Headache

Benign Exertional Headache

Benign exertional headache (BEH) has been reported in association with weightlifting, running and other sporting activities. The IHS criteria include that the headache:

• Is specifically brought on by physical exercise
• Is bilateral, throbbing in nature at onset and may develop migrainous features in those patients susceptible to migraine
• Lasts from 5 minutes to 24 hours
• Is prevented by avoiding excessive exertion
• Is not associated with any systemic or intracranial disorder.

The onset of the headache is with straining and Valsalva maneuvers such as those seen in weightlifting and competitive swimming. The major differential diagnosis is subarachnoid hemorrhage, which needs to be excluded by the appropriate investigations. It has been postulated that exertional headache is due to dilatation of the pain-sensitive venous sinuses at the base of the brain as a result of increased cerebral arterial pressure due to exertion. Studies of weight- lifters have shown that systolic blood pressure may reach levels above 400 mmHg and diastolic pressures above 300 mmHg with maximal lifts.

A similar type of headache is described in relation to sexual activity and has been termed benign sex headache or orgasmic cephalalgia (IHS 4.6). The management of this condition involves either avoiding the precipitating activity or drug treatment, for example, indomethacin (25 mg three times a day). In practise, the headaches tend to recur over weeks to months and then slowly resolve in some cases they may be lifelong.

Treatment

• Treatment of the patient with cervical headache requires correction of the abnormalities of joints, muscles and neural structures found on examination as well as correction of any possible precipitating factors such as postural abnormalities or emotional stress.
• Treatment of cervical intervertebral joint abnormalities involves mobilization or manipulation of the Cl-2 and C2-3 joints.
• Stretching of the cervical extensor muscles and strengthening of the cervical flexor muscles are important.
• Soft tissue therapy to the muscles and the fascia of the cervical region is aimed at releasing generally tight muscles and fascia (commonly the cervical extensors).
• Active trigger points should be treated with spray and stretch techniques or dry needling.
• Cervical muscle retraining has been shown to be beneficial by itself and in combination with manipulative therapy in reducing the incidence of cervicogenic headache.
• This includes retraining of the deep cervical flexors ,extensors and scapular stabilizers.
• Postural retraining is an essential part of treatment. The patient must learn to reduce the amount of cervical extension by retracting the chin.
• Identification and reduction of sources of stress to the patient should be incorporated in the treatment program.

Symptoms And Treatment of Knee Pain :

Anterior knee pain is the most common presenting symptoms in many physiotherapy and sports physician practises.1 It contributes substantially to the 20-40% of family practise consultations that relate to the musculoskeletal system. Two common causes of anterior knee pain in sports people are patellofemoral pain and patellar tendinopathy.

We first outline a practical approach to assessing the  patient  with  anterior knee pain particularly with a view to distinguishing the common conditions; we  then detail their management. These concludes with an outline of other cause of anterior knee pain such as fat pad impingement, which may mimic features of both patellofemoral pain and patellar tendinopathy.

Clinical approach

Distinguishing between patellofemoral pain and patellar tendinopathy as a cause of anterior knee pain can be difficult as their clinical features can be similar. Furthermore, on occasions, the two conditions may both be present.

History

There are a number of important factors to elicit from the history of a sportsperson with the general presentation of anterior knee pain. These include the specific location of the pain, the nature of aggravating activities, the history of the onset and behaviour of the pain and any associated clicking, giving way of swelling.

Although it may be difficult for the patient with anterior knee pain to be specific, the area of pain often gives an important clue as to which structure is contributing to the pain .For example, retropatellar or peripatellar pain suggests that the patellofemoral joint (PFJ) is a likely culprit, lateral pain localized to the lateral femoral epicondyle indicates iliotibial band friction syndrome and inferior patellar pain implicates the patellar tendon or infrapatellar fat pad. The patient presents with bilateral knee pain is more likely to have patellofermoral pain or tendinopathy than an interal derangement of both knees.

The onset of typical patellofemoral pain is often insidious but it may present secondary to an acute traumatic episode (e.g. falling on the knee) or post other knee injury (e.g. meniscal, ligament) or knee surgery. The patient presents with a diffuse ache, which is usually exacerbated by loaded activities, such as stair ambulation or running. Sometimes patellofemoral pain is aggravated by prolonged sitting (movie-goers knee), but sitting tends to aggravate pain of patellar tendinopathy so is not diagnostic of patellofemoral pain. Pain during running that gradually worsens is more likely to be of patellofemoral origin, whereas pain that occurs at the start of activity, settles after warm-up and returns after activity is more likely to be patellar tendinopathy. To clinical differentiation of patellofemoral pain, patellar tendinopathy and fat pad impingement. As these conditions can coexist, accurate diagnosis can be challenging.

A history of recurrent crepitus may suggest patellofemoral pain. A feeling that the patella moves laterally at certain times suggests recurrent patellofemoral instability. An imminent feeling of giving way may be associated with patellar subluxation, patellofemoral pain or meniscal abnormality, although frank, dramatic giving way is usually associated with anterior cruciate ligament instability. Nevertheless, giving way due to muscle inhibition, or due to pain, is not uncommon in anterior knee pain presentations.

Examination

Initially, the primary aim of the clinical assessment to determine the most likely cause of the patient’s since location of tenderness and aggravating factors are integral to the differential diagnosis, it is critical to reproduce the patient’s anterior knee pain. This is usually done with either a double- or single-leg squat. A squat done on a decline may make the test more specific to the anterior knee. The clinician should palpate the anterior knee carefully to determine the site of maximal tenderness.

Examination includes:

1. Observation

• standing
• walking
• supine

2. Functional tests

• squats
• step-up/step-down
• jump
• lunge
• double-then single – leg decline squat

3. Paplation

• patella and inferior pole
• medial lateral retinaculum
• patellar tendon
• infrapatellar fat pad
• tibial tubercle
• effusion

4. PFI assessment

static assessment of patella position

• superior
• inferior
• medial
• lateral glide
• dynamic assessment of patella position
• assessment of vasti function

5. Flexibility

• lateral soft tissue structures
• quadriceps
• hamstring
• iliotibial band
• gastrocnemius

Investigations

Imaging may be used to confirm a clinical impression obtained from the history and examination. Structural imaging includes conventional radiography, ultrasound, CT and MRI. Occasionally, radionuclide bone scan is indicated to evaluate the metabolic status of the knee (e.g. after trauma, in suspected stress fracture).

The majority of patients with patellofemoral pain syndrome will require either no imaging, or plain radiography consisting of a standard AP view, a true lateral view with the knee in 300 of flexion, and an axial view through the knee in 300 of flexion. Plain radiography can detect bipartite patella and osteoarthritis, provide evidence of an increased likelihood of Sinding-Larsen-Johansson lesions as well as rule out potentially serious complications such as tumor or infection .Although CT and three dimensional CT have been used to assess the PFI ,MRI is gaining increasing popularity as an investigations of patellofermoral pain, and the unstable patella because of its capacity to image the patellar articular cartilage.

Treatment

Treatment of patellar tendinopathy requires patience and a multifaceted approach, which is outlined. It is essential that the practitioner and patience recognize that tendinopathy that has been present for months may require a considerable period of treatment associated with rehabilitation before symptoms disappear. Conservative management of patellar tendinopathy requires appropriate strengthening exercises, load reduction, correcting biomechanical errors, and soft tissue therapy. An innovation has been the use of sclerotherapy of neovessels with polidocanol.

Surgery is indicated after a considered and lengthy conservative program has failed. This section outlines the physical therapy approach of correction of biomechanics that might be contributing to excessive load on the tendon, targeted exercise therapy and soft tissue treatment before outhning medical treatments including medication, sclerotherapy and surgery.

How you get relief from Stress Fracture of the Tibia?

Symptoms:

Stress fractures are more commonly a cause of shin pain in athletes in impact, running and jumping sports. Overall limb and foot alignment as well as limb length discrepancy may also play a role. The incidence of stress fractures is increased by playing on more rigid, unforgiving surfaces.

Approximately 90% of tibial stress fractures will affect the postero-medial aspect of the tibia, with the middle third and junction between the middle and distal thirds being most common. Proximal metaphyseal stress fractures may be related to more time loss from sports as they do not respond as well to functional bracing, which allows earlier return to play.

Stress fractures on the anterior edge of the tibia, the tension side of the bone, are more resistant to treatment and have a propensity to develop a non-union when compared to the risk of posteromedial stress fractures. A simple memory tool for the problematic anterior tibial stress fracture is anterior is awful.

A classic case presentation for a routine postero-medial stress fracture is as follows:

• Gradual onset of leg pain aggravated by exercise.
• Pain may occur with walking, at rest or even at night.
• Examination-localized tenderness over the tibia.
• Biomechanical examination may show a rigid, cavus foot incapable of absorbing load, an excessively pronating foot causing excessive muscle fatigue or a leg length discrepancy.
• Tenderness to palpation along the medial border with obvious tenderness. A stress fracture of the posterior cortex produces symptoms of calf pain.
• Bone scan and MRI appearances of a stress fracture of the tibia. MRI scan is of particular value as the extent of edema and cortical involvement has been directly correlated with the expected return to sport.
• A CT scan may also demonstrate a stress fracture.

Treatment:

Prior to initiating treatment or during the treatment plan, it is important to identify which factors precipitated the stress fracture. The most common cause is an acute change in training habits, such as a significant increase in distance over a short period of time, beginning double practice days after lying off training for a season, or a change to a more rigid playing surface. Shoe wear, biomechanics and repetitive impact sports such as running and gymnastics have also been implicated. The athletes coach can play a key role in modifying training patterns to reduce the risk of these injuries. In women, reduced bone density due to hypoestrogenemia secondary to athletic amenorrhea (the female athlete triad) may be a contributing factor. All female athletes with a first-time stress fracture should be screened for the female athlete triad.

The classic treatment plan is as follows:

• Initial period of rest (sometimes requiring a period of non-weight-bearing on crutches for pain relief) until the pain settles.
• The use of a pneumatic brace has been described. Studies have shown a markedly reduced return to activity time with such use compared with average times in two of three studies and compared with a traditional treatment group in the third. In this latter study the brace group returned to full, unrestricted activity in an average of 21 days compared with 77 days in the traditional group. The brace should extend to the knee as the mid-leg version may actually increase the stresses across a mid shaft stress fracture. Once a stress fracture is clinically healed the athlete is advised to use the brace during practise and competition. Clinical healing implies minimal to no palpable pain at the fracture site and minimal to no pain with activities in the brace. Using this plan, there have been no reported cases of progression to complete catastrophic fracture of the tibia.
• If pain persists, continue to rest from sporting activity until the bony tenderness disappears (four to eight weeks).
• Once the patient is pain-free when walking and has no bony tenderness, gradually progress the quality and quantity of the exercise over following month. The athlete should be asked to continue to use a pneumatic brace to complete the current season until an appropriate period (four to eight weeks) of rest can occur.
• Cross training with low impact exercises, including swimming, cycling and deep water running, maintains conditioning and reduces risk of recurrence.
• Pain associated with soft tissue thickening distal to the fracture site can be treated by soft tissue techniques.
• General principles of return to activity following overuse injury should be followed.

WRYNECK :  Causes, Symptoms and Treatment

Congenital disorders are defined as those abnormalities of development that are present at the time of birth. It is quite a common problem exceeded in frequency only by those of CNS and CVS systems.

Congenital disorders can be placed in three groups.

• Those easily noticed by the mother, e.g. clubfoot.
• Those not readily noticed, e.g. congenital dislocation of hip (CDH).
• Those clinically undetected but diagnosed radiologically, e.g. spondylolisthesis.

Congenital disorders are more prevalent in diabetic mothers, multiple pregnancies, older mothers, etc. Male and female have equal predilection.

Causes

The exact cause is not known. Most congenital disorders begin early in the life of the embryo when cell division is most active. Although a few congenital disorders may be due to uterine malposition, most are believed to be due to genetic defects, environmental influences or a combination of both.

Genetic Factors

Defects in the chromosomes of sperm and ovum result in specific disorders ,which follows Mendel’s law.

Embryonic Trauma

Congenital disorders can also result from injury to the developing embryo at the time of differentiation of embryonic tissue into specific tissues by extraneous factors.

CONGENITAL TORTICOLLIS (WRYNECK)

Congenital torticollis is a condition where the sternocleidomastoid muscle of the neck undergoes contractures pulling it to the same side and turning the face to the opposite side. The exact cause of this condition is unknown; but hypothetically, it may be due to fibromatosis within the sternomastoid muscle.

Etiology

• Middle part of the sternomastoid is supplied by an end artery, which is a branch of the superior thyroid artery that is blocked due to trauma, etc.
• Birth trauma-Breech delivery, improper application of forceps, etc. may cause injury to the sternomastoid muscle.

The above two reasons can result in sternocleidomastoid muscle ischemia, necrosis and fibrosis later on.

Clinical Features

Deformity is the only complaint initially. Later, facial changes and macular problems in the retina may develop.

Radiograph

Plain X-ray of the neck AP and lateral views are essential to detect any congenital abnormality of the cervical vertebra that could lead to this condition.

Treatment

Principles

• During infancy, conservative treatment consists of stretching of the sternomastoid by manipulation and physiotherapy. Excision is unjustified in infancy.
• Surgery is delayed until fibroma is well-formed. The muscle may be released al one or both ends and the muscle may be excised as a whole.
• If the muscle is still contracted at the age of 1 year, it should be released.
• If wryneck is persistent for I year, it will not resolve spontaneously and needs to be interfered operatively.
• Exercise program is successful:

1. When restriction of motion is less than 30 degree.
2. When there is no facial asymmetry.

• Non-operative treatment after 1 year is rarely successful.
• Any permanent torticollis becomes worse during growth. Head is inclined towards the affected side, face is turned towards the opposite side, ipsilateral shoulder is elevated and the fronto-occipital diameter is increased.

Surgical Method

The most commonly employed surgical method is subcutaneous tenotomy of the clavicular attachment of the sternomastoid muscle. This procedure is inaccurate and dangerous as there could be an injury to the external jugular vein and phrenic nerve. Hence, release from its attachment on the mastoid process is also tried. Open tenotomy if done before the child is 1 year old, tethering of the scar takes place. If the surgery is done between 1 and 4 years of age, tilt of the head and facial asymmetry are corrected less satisfactorily. If done after 5 years of age, the secondary deformities are less corrected.

For older children or after failed operation, bipolar release of the muscle from both sides, Ferkel’s modified bipolar release or Z-plast of the muscle is tried.

Symptoms And Treatment of Hands Infection:

Hand is a very important organ of the body. Disorders affecting the hand could lead to loss of hand function in various forms and degrees. Thumb itself accounts for over 40 percent function of the hand. It is imperative that the problems affecting the hand should be diagnosed and managed correctly. The following are the various disorders affecting the hand.

CONGENITAL ANOMALIES OF THE HAND:

Some of the important congenital anomalies of the hand are:

Polydactyly: It is a duplication of one or more digits and may require amputation for cosmetic purposes.

Syndactyly: This is fusion of digits and usually occurs between the middle and ring fingers and is 3 times more common in males.The fusion may be only in the skin or all the structures. In the latter case, surgery is done early at 18 months age and in the less severe former case, surgery is done after 5 years.

Macrodactyly: This is a rare congenital anomaly and is characterized by enlargement of all structures especially of the nerves of a single or more digits. It is often associated with neurofibromatosis, lymph-angioma, arteriovenous malformation, etc.

Congenital trigger digits: Thumb is more commonly involved. It is frequently bilateral and is due to flexion contracture of the distal joint of the thumb. More than 30 percent of these cases resolve after first year and the remaining may require surgical release after 2 years of age.

Streeter’s dysplasia: This is a syndrome of congenital constrictions, which may affect any part of the body. In the hand, it may range from simple constriction to congenital amputation. To prevent distal circulatory compromise, it frequently requires surgical release by Z-plasty.

Camptodactyly: This is a flexion contracture of the proximal interphalangeal joint especially of the little finger. It may rarely be seen in other fingers too. Severe deformity in older patients requires tendon lengthening procedures. Clinicodactyly is angulation of the finger in radioulnar direction. Mild clinicodactyly is seen in normal children, while the severe ones are associated with mental retardation.

Cleft hand (also called Lobster claw hand): This is frequently bilateral and is associated with cleft foot, cleft lip, cleft palate, etc. There are two varieties: in the first type, a deep palmar cleft separates the two central metacarpals; and in the second type, the central rays are absent .Both the varieties require surgical excision and Z- plasty.

Mirror Hand (reduplication of ulna): Here the ulna and carpus are reduplicated and there may be seven or eight fingers with no thumb. Pollicisation of a finger solves the problem of the absent thumb.

Congenital absence of radius or ulna:  Congenital absence of radius is more common than that of ulna. The radius may be completely absent or in parts. The forearm is short, wrist is highly unstable and the hand is deviated radially. It requires complex and difficult surgical corrections. This deformity of radius absence is also called radial club hand and the absence of ulna is called the ulnar club hand.

Kirner’s deformity: This is a spontaneous injuring of the terminal phalanx of the fifth digit. It is a rare disorder and is more often seen in females.

Infections of the Hand

The effects of hand infection can be as devastating as major trauma. Trivial injuries like a scratch, a prick, small punctured wounds, etc. cause hand infections. Staphylococcus aureus (80%) ,Streptococcus pyogenes and gram-negative bacilli are the famous trio who inflict the infective unmitigated disaster in the hand. The sequelae of these infections are edema, abscess, necrosis, fibrosis and lastly contractions leading to a grotesque, debilitating hand. The presence of an abscess seems to send a message to the surgeons, “Drain me I’ll drain Myself! ” Hence, an abscess caused should be drained; the surgeon only has to decide the proper time and incisions. Early use of potent antibiotics has considerably downed the threat of serious hand infections.

Treatment

As elsewhere before we delve into the discussions on individual hand infections, it helps considerably to know the principles of treatment:

• Hands should be kept elevated to facilitate gravity to drain and thereby prevent edema and swelling of the hand.
• Following the treatment, the hand needs to be placed in functional position for optimum results.
• Early and appropriate use of IV antibiotics prevents pus formation (within 24-48 hours).
• If pus is formed, let it out through proper incisions at the appropriate time.
• Local anesthetic may help the spread of infection and adds more fluid to the already existing swelling. Hence, general anesthesia or regional block is preferred.
• Tourniquet is indicated, but exsanguinations are not preferred as it helps spread the infection (alternatively, elevation of hand for three minutes is ideal).
• Do not forget the all important hand aftercare, which has a direct bearing on the outcome of the hand function.

With the principles of treatment as a backdrop, let us now consider the important hand infections in order of importance.

Treatment of Hand and Wrist Fracture:

Colles’ Fracture

This is also called as Poutteau’s fracture in many parts of the world. Abraham Colles first described in the year 1814.

Definition

It is not just fracture lower end of radius but a fracture dislocation of the inferior radioulnar joint. The fracture occurs about 11/2″ (about 2.5 cm) above the carpal extremity of the radius.

Following this fracture, some deformity will remain throughout the life but pain decreases and movements increase gradually.

Mechanism of Injury

The common mode of injury is fall on an outstretched hand with dorsiflexion ranging from 40-900 .The force required to cause this fracture is 192 kg in women and 282 kg in men.

Fracture pattern:  It is usually sharp on the palmar aspect and comminution on the dorsal surface of the lower end of radius.

Clinical Features 

Usually, the patient is an elderly female in her 60s and the history given is a trivial fall on an outstretched hand. The patient complains of pain, swelling, deformity and other usual features of fracture at the lower end of radius. Though dinner fork deformity is a classical deformity in a Colles’ fracture, however, it is not found in all cases but seen only if there is a dorsal tilt or rotation of Colles’ Fracture.

Styloid Process Test

Normally, the radial styloid process is lower by 1.3cm when compared to the ulnar styloid process. In Cones’ both radial and ulnar styloid processes are at the same level and are found in all displacements of Colles’ fracture. Hence, this is a more reliable sign than dinner fork deformity.

Radiology

Radiographs of the wrist both AP and lateral views of the affected wrist and lower end of the radius are taken. The Points noted in the AP view are metaphyseal comminution, fracture line extending into the radiocarpal or inferior radioulnar joint and fracture of the ulnar styloid process (seen in about 60% of the cases). In the lateral view, the points noted are dorsal displacement and dorsal tilt of the distal fragment, sharp palmar surface and dorsal comminution of the lower end of radius, distal radioulnar joint subluxation, etc.

Classification

Contrary to popular belief, Colles’ fracture is both intra-articular and extra-articular and not only extra-articular. Frykmann’s classification takes into consideration both and the fracture of ulna.

Treatment Methods

Aim: The aim of treatment is to restore fully functional hand with no residual deformity. The treatment methods include Conservative methods, Operative methods and External fixators.

Conservative Methods

Here fracture reduction is carried out by closed methods under general anesthesia (GA) or local anesthesia (LA). The examiner holds the hand of the patient as if to shake hand. With an assistant giving counteraction by holding the forearm or arm of the patient, the examiner gives traction in the line of the forearm. This disimpacts the fracture and the examiner corrects the other displacements of the fracture. At the end of the procedure, styloid process test is carried out to check the accuracy of reduction. If the level of the styloid processes is restored back to normal, it indicates that the reduction has been achieved satisfactorily. Then the limb is immobilized by any one of the methods in the table above (mainly Cones’ cast) and a check radiograph is taken. The plaster cast is removed after 6-’8 weeks and physiotherapy is begun.

The common causes for failure of reduction are incomplete reduction of the palmar fracture line and dorsal comminution of the lower end of radius.

Operative methods

Operative treatment is rarely required for Colles’ fracture and may be required in the following situations:

Indications: Extensive comminution, impaction, median nerve entrapment and associated injuries in adults.

Modalities of operative treatment: Depending upon the degree of comminution and the intra-articular extensions, one of the following surgical methods is chosen:

Closed reduction and percutaneous pinning with K-wires: Here, after closed reduction by the usual methods the fracture fragments are held together by percutaneous pinning by one or two K-wires.

Arm control: This method is known to prevent collapse and gives good results in a few select cases.

Open reduction: in certain fractures involving of the distal articular surfaces (Bartons variety open reduction and plate fixation (Ellis’ plate) is advocated.

Indications: Same as for external fixation and for marginal volar or dorsal Barton’s fractures.

Advantages

• Provides buttress
• Resists compression
• Load sharing
• Early mobilization

External fixators

These are found to be extremely useful in highly comminuted fractures, unstable fractures , compound fractures and bilateral Colles’ fracture. Through a lightweight UMEX frames, two pins are placed in the forearm bones and two pins in the metacarpal bones of the hand. These pins are then fixed to an external frame and the fracture fragments are held in position by ligamentotaxis. The frame should be applied after obtaining closed reduction by the usual method.

Complications

The important complications of Colles’ fracture are listed in. Few significant complications are discussed here.

• Malunion: This is the most common complication of Colles’ fracture. Six important causes are responsible for it.
• Improper reduction: If the fracture is not reduced properly, in the initial stages it may result in mal-union later.
• Improper and inadequate immobilization: This fracture needs to be immobilized at least for a period of six weeks failing which malunion results.
• Comminuted dorsal surface: Due to extensive comminution, the fracture collapses and recurs after reduction and casting.
• Osteoporosis may lead to collapse and recurrence.
• Recurrence:  This is due to extensive comminution and osteoporosis.
• Rupture of the distal radioulnar ligament: This usually goes undetected in the initial stages of treatment and is responsible for the later recurrence.

Treatment

There are six options of treatment in a malunited Colles’ fracture:

• No treatment is required if the patient has no functional abnormality.
• Remanipulation is attempted if fracture is less than 2 weeks old.
• Darrach’s operation is more often indicated if the patient complains of functional disability.
• Corrective osteotomy and grafting if the patient wants cosmetic correction and if the patient is young (Fernandez and Campbell). Fernandez is a dorsal wedge osteotomy and Campbell is a lateral wedge osteotomy.
• Arthrodesis (for intra-articular fracture): The patient complains of pain in the wrist joint due to traumatic osteoarthritis following an intra-articular fracture. In these patients, arthrodesis of the wrist in functional position is the surgery of choice.
• Combination of these like Darrach’s operation with osteotomy, etc. is also tried in some situations.

Rupture of extensor pollicis tendon: This occurs due to the attrition of the tendon as it glides over the sharp fracture surfaces. This usually occurs after 4-6 weeks and may be repaired or left alone with no residual disability.

Sudeck’s osteodystrophy: This is due to abnormal sympathetic response, which causes vasodilatation and osteoporosis at the fracture site. The patient complains of pain, swelling, painful wrist movements and red-stretched shiny skin. Treatment consists of immobilization of the affected part with plaster splints, injection of local anesthetics near the sympathetic ganglion in the axilla or cervical sympathectomy in extreme cases.

Frozen hand shoulder syndrome: This is a troublesome complication, which develops due to unnecessary voluntary shoulder immobilization by the patient on the affected side for fear of fracture displacements. It is said that the patient has performed a mental amputation and kept the limb still.

Carpal tunnel syndrome: Malunion of Colles’ fracture crowds the carpal tunnel and compresses the median nerve.

Nonunion: This is extremely rare in Colles’ fracture because of the cancellous nature of the bone, which enables the fracture to unite well. However, soft tissue interposition may cause this problem. The treatment consists of open reduction, rigid internal fixation and bone grafting.

Do you want to get relief of your Lower Back Pain ?

SPINAL CANAL STENOSIS

Spinal canal stenosis is narrowing of the spinal canal and the consequent compression of the cord and the nerve roots. It may affect the cervical thoracic or lumbar spine.

Canal stenosis is common in lumbar vertebrae. One or more roots of the cauda equina may be affected due to the constriction in spinal canal before it exits through the foramen. This condition was first described by Portal in 1803.

LUMBAR CANAL STENOSIS

Lumbar canal stenosis is a cauda equina compression in which the lateral or anteroposterior diameter of the spinal canal is narrow with or without a change in the cross-sectional area. The nerve root canals and the IV foramen may also be narrowed.

Patient may present with low backache, neurological symptoms in the lower limbs and bladder, bowel dysfunctions in extreme cases

CLASSIFICATION

1. Generalized/localized
2. Segmental (local area of each vertebral spinal segment is affected).

• Central
• Lateral Recesses
• Foraminal
• Far Out

3. Anatomical area:

• Cervical (seen)
• Thoracic(rare)
• Lumbar (most common)

CAUSES

1. Pathological:

• Congenital , For Example. Achondroplasia
• Acquired- degenerstive , iatrogenic, and spondylitic.

2. Other Causes:

• Paget’s Disease
• Flurosis
• Kyphosis
• Scoliosis
• Fracture Spine
• DISH (Diffuse idiopathic skeletal hyperostosis) syndrome.

3. Latrogenic causes ,For Example, hypertrophy of posterior bone graft, incomplete treatment of stenotic condition, etc.

Degenerative lumbar disk disease leading to thickening and narrowing of the spinal canal is the most common cause.

CLINICAL FEATURES

Lumbar canal stenosis is common in males above 50 years. Usually, the symptoms are fewer in number, but the patient may complain of low backache.

Cauda equina claudication is the common symptom. Here, the patient complains of pain in the buttocks and legs after walking, which decreases sitting, rest and forward bending. Patient may complain of hypoesthesia and paresthesia. Usually, the patient finds no problem walking uphill or riding a bicycle. Nerve root entrapment in the lateral recess causes claudication and sciatica.

INVESTIGATIONS

Radiographs of the lumbar spine consisting of AP, lateral and oblique views are recommended. However radiology may not show stenosis. The following points are looked for:

• Reduced interpedicle distance.
• AP or midsagittal diameter of the affected vertebra (Normal-15 mm), absolute midsagittal diameter of the canal is decreased.
• Measurement of the lateral sagittal diameter.
• Hypertrophy and sclerosis of the facet joints.
• Reduced interlaminar space and short, stout spinous process.
• Associated features like presence of listhesis, prolapsed disk, osteophytes, etc.

TREATMENT

Conservative Methods

This aims at symptomatic relief of pain.

• Drug therapy like the NSAIDs, etc.
• Epidural steroids may help in some cases.
• Physiotherapy with heating modalities helps.
• Pelvic traction may help relieve compression.
• Exercises:  General  conditioning  exercises like walking, swimming   and   flexion-oriented exercises are  useful.
• Deweighted Treadmill Ambulation: This consists of applying vertical traction with a harness  while doing the treadmill  exercises. This offers twin benefits of both exercises and traction.
• Belts and corsets (soft): These  may  offer  some relief.

Surgical Methods

Most of the surgical methods described for lumbar canal stenosis aim at decompressing the constricted lumbar canal. Laminectomy is useful in central canal stenosis. Diskectomy and osteotomy of inferior articular process to remove the hypertrophic elements help.

For lateral canal stenosis laminotomy, disk excision, partial medial facetectomy and foraminotomy help. Spinal fusion to stabilize the lumbar spine is usually not required as instability is less commonly seen in lumbar canal stenosis.

It should be noted that neurogenic claudication responds poorly to the conservative treatment but responds well to surgical decompression.

How Physical Therapy Treatment Works With Bone Injury

Stress fractures, a common injury among sportspeople, were first reported in military recruits in the 19th century. A stress fracture is a microfracture in bone that results from repetitive physical loading below the single cycle failure threshold. Overload stress can be applied to bone through two mechanisms:

1. The redistribution of impact forces resulting in increased stress at local points in bone.
2. The action of muscle pull across bone.

Histological changes resulting from bone stress occur along a continuum beginning with vascular congestion and thrombosis. This is followed by osteoclastic and osteoblastic activity leading to rarefactio , weakened trabeculae and microfracture and ending in complete fracture. This sequence of events can be interrupted at any point in the continuum if the process is recognized.

Similarly ,the process of bony remodeling and stress fracture in athletes is recognized as occurring along a clinical continuum with pain or radiographic changes presenting identificable markers along the continuum. Since radioisotopic imaging and MRI can detect changes in bone at the phase of accelerated remodeling, these investigations can show stress-induced bony changes in the continuum.

Stress fractures may occur in virtually any bone in the body. The most commonly affected bones are the tibia, metatarsals, fibula, tarsal navicular, femur and pelvis. A list of sites of stress fractures and the likely associated sports or activities . The diagnostic features of a stress fracture.

It is important to note that a, bone scan although a routine investigation for stress fractures, is non-specific, and other bony abnormalities such as tumors and osteomyelitis may cause similar pictures. It may also be difficult to localize the site of the area of increased uptake precisely, especially in an area such as the foot where numerous small bones are in close proximity.

Diagnostic Features

1. Localized pain and tenderness over the fracture site.
2. A history of a recent change in training or taking up a new activity.
3. X-ray appearance is often normal or there may be a periosteal reaction.
4. Abnormal appearance on radioistopic bone scan (scintigraphy), CT scan or MRI.

MRI is being increasingly advocated as the investigation of choice for stress fractures. Even though MRI does not image fractures as clearly as do computed tomography (CT) scans, it is of comparable sensitivity to radioisotopic bone scans in assessing bony damage. The typical MRI appearance of a stress fracture show speriosteal and marrow edema plus or minus the actual fracture line.

The treatment of stress fractures generally requires avoidance of the precipitating activity. The majority of stress fractures heal within six weeks of beginning relative rest. Healing is assessed clinically by the absence of local tenderness and functionally by the ability to perform the precipitating activity without pain. It is not useful to attempt to monitor healing with X-ray or radioistopic bone scan. CT scan appearances of healing stress fractures can be deceptive as in some cases the fracture is still visible well after clinical healing has occurred.

The return to spot after clinical healing of a stress fracture should be a gradual process to enable the bone to adapt to an increased load. An essential component of the management of an over use injury is identification and modification of risk factors. There are, however, a number of sites of stress fractures in which delayed union or non-union of the fracture commonly occurs. These fractures need to be treated more aggressively. The sites of these fractures and the recommended treatment.