Musculoskeletal Orthopedic trauma SIG

When we talk about back pain, we are actually talking about painful conditions of the spine. This spine is made up of 24 movable, articulated vertebrae, which determine 3 regions:

• the cervical region: 7 vertebrae
• the dorsal region: 12 vertebrae
• the lumbar region: 5 vertebrae
• 5 fused vertebrae which form the sacrum
• 3 to 5 vertebrae which constitute the coccyx (Steissbein, “Krippchen”).

The spine performs two essential functions:

• a support function: it supports the trunk and the head, the limbs (arms and legs) are attached to it via the shoulder and hip joints
• a protective function: it protects the spinal cord (Knochenmark) from where the spinal nerves leave between each pair of vertebrae

The individual vertebrae are connected to each other by strong muscle ligaments and especially in front by the intervertebral discs (Bandscheiben).

The intervertebral disc is made up of two parts:

• a peripheral part: the annulus fibrosus
• a central part: the nucleus pulposus

The role of the intervertebral disc is multiple. It gives the spine its flexibility, allowing for flexion, extension, and rotation movements, and at the same time acts as a shock absorber. Excessive loads or stresses can cause disc damage. It can crack and allow the nucleus or part of it to pierce the annulus fibrosus and enter the spinal canal (herniated disc), or it can dehydrate and gradually lose its effectiveness in absorbing shocks and vibrations, thus promoting the onset of osteoarthritis.

At a conference in Zurich, Professor Alf Nachemson, a pioneer in the study of the spine, told a galvanized audience that the true cause of back pain often remains unknown. This means that one must be very careful before undertaking any treatment and, above all, that one must thoroughly examine and question one's patient.

In fact, the causes are multiple and often far from the painful source of the spine.

We distinguish local causes:

• traumatic (fractures, dislocations)
• degenerative (osteoarthritis)
• inflammatory
• metabolic
• tumors

and remote causes:

• foot or knee problems
• organ disorders (heart, digestive system, reproductive organs)
• psychosocial problems

Without wanting to give it too much importance, it is important to bear in mind that the psychological state and socio-economic and professional constraints can influence back pathologies.

• Biometeorological phenomena

In some sensitive individuals, bio-meteorological factors may act as catalysts or amplifiers of latent symptoms.

Therefore, great care must be taken in interpreting radiological examinations, because any image only reflects an instantaneous state. Some images very suggestive of axial deviations (scoliosis) or degeneration (osteoarthritis) encourage us to relate them to the patient's pain. However, we must remain cautious, very attentive to the patient's story and continue to investigate.

The spine has a very high capacity for compensation and often acts as a "fuse" for a whole range of ailments in the body.

Neck pain or cervical pain is located in the back of the neck, at the base of the skull and can radiate to the shoulders and even the arms.

The main causes are:

• static disorders (poor posture)
• of traumatic origin (whiplash, fracture)
• degenerative type (osteoarthritis)

Infectious, tumoral, and inflammatory causes are much rarer.

Common neck pain

The main cause is a postural imbalance of the cervical spine due to prolonged flexion of the head, poor lying position, long car journeys, working with raised arms and extended head.

The physiotherapy treatment is as follows:

• thermotherapy: fango aimed at relaxing the muscles
• analgesic electrotherapy
• relaxing massage
• Bindegewebsmassage
• deep transverse massage, Cyriax type
• sanding of painful reflex points: Trigger
• manual therapy
• spinal mobilization
• manual cervical traction
• functional rehabilitation
• active exercises
• resistance exercises
• muscle toning
• healthy lifestyle advice
• relaxation exercises
• learning resting positions

Arnold's neuralgia

These are pains in the posterior and lateral aspect of the head, along the path of Arnold's occipital nerve, which can radiate to the forehead. This is an irritation at the various passages of the nerve through the ligaments and muscles that are contracted.

Physiotherapy treatment is that of common neck pain, emphasizing massage techniques to release muscle contractures and manual stretching techniques.

Torticollis or twisted neck

Benign or acute torticollis in adults is characterized by contractures due to the retraction of the neck muscles, mainly the sternocleidomastoid muscle and the trapezius muscle. As a result of this contracture, the head is tilted toward the contracted muscle and turned toward the opposite side. Torticollis can be accompanied by severe pain and an inability to move the head. Even the slightest movement is painful.

The causes of toticollis are:

• a false move, a sudden uncontrolled movement
• prolonged poor posture (during sleep for example)
• prolonged exposure to a draft (air conditioning)

The treatment aims to calm the pain and relieve muscle contraction.

Medical treatment includes:

• painkillers (aspirin, paracetamol)
• muscle relaxants
• anti-inflammatories
• resting
• possibly wearing a neck brace

In the acute phase, physiotherapy includes:

• thermotherapy, fango
• analgesic electrotherapy
• gentle massage of the neck and shoulder region

and in regression phase:

• see acute phase
• mobilization
• manual traction
• self-aggrandizement exercises
• muscle strengthening exercises for the cervicoscapular region
• static correction exercises

Congenital torticollis

Congenital torticollis is a fairly common condition in newborns. The baby presents with its head tilted to one side and turned to the opposite side.

On examination, we find:

• muscle tension of the sternocleidomastoid muscle
• a palpable mass located in the belly of the muscle
• a decrease in the range of head movement

The exact cause of congenital torticollis is still unknown, but it is suggested that its origin is due to:

• a stretching of the sternocleidomastoid muscle during childbirth
• a subluxation of the first cervical vertebrae resulting from intrauterine malposition or during childbirth

Physiotherapy plays an important role in treatment. It combines:

• massage of contracted muscles
• gentle mobilization of the head
• the postures
• advice to parents

Congenital torticollis usually progresses to complete recovery.

Whiplash

Whiplash injury (Schleudertrauma, whiplash syndrome) is a trauma to the cervical spine caused by a sudden flexion-hyperextension movement of the head. This condition most often occurs following traffic accidents.

The lesions are generally located in the soft tissues:

• ligament elongation
• muscle strain
• sprain

more rarely

• fracture of a vertebra
• fracture of the odontoid process of the axis
• wing ligament tear
• herniated disc
• nerve damage

Symptoms:

• headaches
• muscle contractures
• limitation of head movements
• balance disorders
• nausea
• eye disorders
• swallowing disorders
• sleep disorders
• ringing in the ears
• depression

Treatment should take into account the patient's complaints, even if the pain and complaints described by the patient cannot be linked to the observed lesions.

Medical treatment is similar to that for torticollis.

Physiotherapy

• rest, wearing a neck brace
• thermotherapy, fango
• analgesic electrotherapy
• massage of the cervico-scapular region
• light manual traction
• mobilization
• isometric exercises
• static rebalancing exercises

Back pain can have many different causes.

The causes of back pain that are of interest to physiotherapy are:

• static disorders, fatigue or positioning pain
• interapophyseal or costotransverse joint disturbances
• musculoskeletal insufficiencies
• spondylarthrosis
• ankylosing spondylitis
• Scheuermenn's disease
• osteoporosis

The pain is located in the trapezius muscles, between the shoulder blades and between the spinous processes.

Physiotherapy

• relaxing massage
• thermotherapy, fango
• analgesic electrotherapy
• relaxation exercises
• flexibility exercises
• self-aggrandizement exercises
• postural gymnastics, RPG
• bodybuilding
• spinal mobilization

Scheuermann's disease

It is an osteochondroepiphyseal dystrophy which affects the growth zone of the vertebral plates and which causes modifications
structural deformities of the vertebrae. This disease is highly frequent (0.5-10%) and occurs during the pubertal growth phase of the spine, between 13 and 17 years of age, mainly in boys.

It is often asymptomatic and diagnosed on standard x-rays taken for other reasons. Usually
The predominant symptoms are fatigue and dull pain in the back. This pain can be exacerbated by physical exertion,
intensive sport being an aggravating factor.

The diagnosis is made by X-ray with profile and frontal views of the entire spine, and profile views of the dorsal spine from D7 to
D10.

We distinguish:

• large radius kyphosis
• the wedge-shaped appearance of the vertebrae located at the top of the kyphosis
• irregular and flaky vertebral endplates
• sometimes intra-spongy or retro-marginal hernias
• sometimes a disc compression

Treatment consists of stopping intense efforts, therefore giving up sport, with the exception of swimming. Awareness of
certain postures and above all adapted and active physiotherapy is essential.

Physiotherapy

• respiratory rehabilitation
• relaxing massage
• analgesic electrotherapy
• relaxation
• awareness of body schema
• postural exercises, RPG
• flexibility exercises
• exercises to tone the erector spinae and abdominal muscles
• healthy lifestyle advice

Low back pain is lower back pain. It can be chronic or acute. The latter is called lumbago.

The origin of low back pain can be very diverse. There are tumoral, infectious, vascular or visceral causes. Hence
the importance of an accurate diagnosis by the doctor. In this context, we will only discuss lower back pain of degenerative or mechanical origin.

Acute low back pain or lumbago

Acute low back pain that begins suddenly may be due to:

• an effort to lift a load
• a sudden uncontrolled movement (false movement)

Lumbago, especially of mechanical origin (sprain of the vertebral functional unit), is a real blockage of the lumbar spine manifested by the following symptoms:

• severe lumbosacral pain, often in a bar shape
• significant and characteristic analgesic attitude
• possible irradiation of pain to the buttocks, thighs, knees (sciatic type)

Medical treatment

• relative rest
• painkillers
• muscle relaxants
• anti-inflammatories

Physiotherapy

• analgesic electrotherapy, TENS
• sanding of painful trigger reflex points
• thermotherapy
• analytical mobilization, Sohier
• spinal mobilization
• manual therapy

To avoid recurrence:

• postural exercises, RPG
• flexibility exercises
• toning exercises
• healthy lifestyle advice
• back school
• adaptation of the workstation

Chronic low back pain

Chronic low back pain is slow and insidious in onset. It is due to the degeneration of one or more mobile segments
intervertebral (disc or interapophyseal osteoarthritis).

Symptoms

• diffuse lower back pain
• possible irradiation to the buttocks
• increased pain from exertion and fatigue
• reduction of pain through rest
• Medical treatment is similar to that for acute lower back pain, but physiotherapy plays an important role in pain relief
  and allow normal activity.

Physiotherapy

• relaxing massage
• sanding of painful reflex points, Trigger
• analgesic electrotherapy
• Sohier-type analytical mobilization
• manual therapy
• postural rehabilitation, RPG
• stretching and flexibility exercises
• toning exercises
• adapted sports practice, cycling, swimming, fitness
• relaxation exercises, yoga
• back school

Herniated disc

We speak of a herniated disc when the nucleus pulposus of the intervertebral disc crosses the fibrous ring, sometimes with perforation
complete of the latter and penetration into the spinal canal, compressing the emerging nerve root. A herniated disc can occur at all vertebral levels but 80% of herniations are lumbar.

The causes of a herniated disc are:

• degeneration of the intervertebral disc
• a sudden, uncontrolled movement of the trunk bent forward

The symptoms are those of acute low back pain

• lower back pain
• sciatica-type pain
• paresthesias (sensitivity disorders)
• paresis
• amyotrophy (muscle weakness)
• anesthesia
• paralysis (extreme case)

Neurological disorders depend on the level of the herniated disc and the severity of nerve root compression. Diagnosis is confirmed by CT or MRI.

Conservative treatment is effective. It is that of acute low back pain with possibly in addition:

• spinal traction
• wearing a lumbostat (lumbar belt)

Physiotherapy treatment is the same as for acute lower back pain.

If properly conducted conservative treatment is not successful after 6 to 8 weeks, or if there is a neurological deficit,
surgery is necessary.

Modern surgical treatment consists of endoscopic removal of the hernia. This is a minimally disabling procedure.
which only requires short-term hospitalization (2-3 days).

Postoperative physiotherapy treatment is essential to prevent recurrence.

• relaxing massage
• thermotherapy
• analgesic electrotherapy
• flexibility exercises
• toning exercises
• postural exercises
• back school
• tips for daily domestic and professional driving
• adaptation of the workstation

Sciatica or sciatica

The name sciatica is often used to refer to any kind of lower back pain. In fact, sciatica is an irritation of
the root of the sciatic nerve, either between L4 and L5 or L5 and S1.

Symptoms:

• intermittent pain on one side
• irradiation to the buttock, the posterior surface of the thigh and sometimes as far as the toes
• increase by coughing or defecating efforts
• decrease by resting in a lying or standing position
• sometimes tingling or loss of feeling in part of the leg
• The pain is reproduced by the so-called "Lassègue" maneuver, which consists of flexing the hip with the knee extended. When the pain appears during the first 40 to 45 degrees, the presence of a herniated disc should be feared.

The cause of sciatica

• mechanical, blocking
• spinal stenosis
• tumor process
• infectious process
• herniated disc in 90% of cases

Diagnosis is made by imaging, CT scan or MRI. These tests may be supplemented by electromyography in certain cases.

Physiotherapy treatment is for lower back pain or herniated disc, depending on the case.

Sport is responsible for a range of muscle injuries of varying severity. Muscle injuries are the most common pathology affecting athletes, regardless of their level of practice. Their severity varies greatly. It is important that any muscle injury be diagnosed early and accurately so that the player can resume their sporting activity without unnecessary delay.

Muscle injuries fall into two distinct groups

• Benign muscle lesions, i.e. without visible anatomical damage, which are simple to develop and short-lived
• More serious muscle injuries, i.e. with clearly visible anatomical damage, especially with ultrasound and MRI

1) Benign muscle lesions

By definition, they can be diagnosed by simple clinical examination, and ultrasound or MRI is useless here, and in any case would not objectify any abnormality. Classifying them in order of increasing severity, we distinguish: cramps, then aches, then contractures and bruises.

a) Cramps

They are due to an intense and involuntary contraction of the muscle. It occurs suddenly and is accompanied by significant pain, which lasts only a few minutes, but nevertheless leaves a contracture in the days following its onset. The cramp most often appears during exercise but can also occur at rest. Treatment is based on stretching, followed by massage and application of ice. Prevention involves hydration, the intake of mineral salts and stretching before and after sports.

b) Aches and pains

Delayed onset muscle soreness or muscle pain is also called DOMS (Delayed Onset Muscle Soreness). This is muscle pain that occurs 12 to 48 hours after exercise. It generally disappears within 5 to 7 days. The pain is less severe and, moreover, it affects muscle groups. Although muscle soreness is included in the usual classification of an injury without anatomical lesions, it presents microlesions of the muscle fibers due to excessive eccentric contractions and/or failure to adapt to a training level (muscle unsuited to the intensity of the training). The most severe muscle soreness is observed when running downhill, when working against gravity or when practicing maximum strength training. There is impairment of muscle function and is accompanied by an increase in the inability to produce maximal force and an increase in muscle stiffness, often seen during the first 4 days with muscle pain.

While some treatments appear to alleviate DOMS, none of them have yet demonstrated their real effectiveness, particularly in accelerating muscle regeneration. The treatment is based on alternating hot/cold baths and a return to moderate activity. The severity of symptoms related to muscle soreness could be limited by: maintaining good muscle flexibility, especially those muscle groups involved in the targeted physical activity, pre-conditioning the main muscle groups with some high-intensity eccentric contractions one or two weeks before scheduling difficult sessions, using specific warm-up exercises for the main muscle groups

c) Contractures

As its name suggests, contracture results from the exaggerated contraction of a part of the muscle. The pain is first felt at the end of the exercise, during the rest phases. If the effort is continued, the muscle “stiffens” more and more; the pain becomes noticeable during the exercise and then very uncomfortable at the end of it. The athlete clearly perceives a troublesome area. On examination, we generally find only a single muscle, or even a simple muscle bundle, indurated and painful. Ultrasound will not reveal any abnormality. The contracture lasts over time from 5 to 10 days. The contracture can come from a reflex contraction aimed at protecting the muscle and the joint(s) involved following significant stretching. The origin can also be significant fatigue of the muscle leading to disorders of certain molecules at the cellular level (calcium, potassium, magnesium). This pathology can finally be favored by a recent muscular injury (elongation, tear, contusion, etc.) which means that the muscle fiber is not fully functional.

Treatment is based on the use of ice packs, muscle relaxant medications, massage, physiotherapy and functional rehabilitation.

d) Bruises

Unlike the previous pathologies, contusion is a trauma due to a direct impact on the muscle. (Fall on a barrier, blow to the muscle, crutch, etc.). Following the trauma, the muscle may be more or less injured, the muscle fibers more or less damaged (crushing, tearing). A slight internal bleeding (intramuscular hematoma) or subcutaneous swelling may occur. The consequences can be relatively minimal if the impact was light. Most often they do not prevent physical activity. On the other hand, in the case of a severe blow, the muscle fibers may have suffered a significant tear equivalent to a tear, or even a muscle rupture. The pain is sudden and exquisite, leading to a cessation of activity. The important thing is to treat the hematoma in order to prevent it from preventing the muscle from healing and/or calcifying, which in both cases weakens the muscle fiber.

2) Severe muscle injuries

Here, the clinical examination remains important, but muscle ultrasound becomes essential to specify the type of injury, and therefore, its treatment. However, it should not be performed too early. The ideal time is between the 48th and 72nd hour: in fact, the hematoma, resulting from damage to the muscle bundles, often only appears after a certain period of time, and performing the ultrasound too early risks overlooking more serious injuries than expected.

In order of increasing severity we distinguish:

• elongation
• then the tear
• then the breakup
• and finally muscle disinsertion.

a) Muscle elongation

These are micro tears in the muscle bundle, sometimes associated with simple fraying of myofibrils. They are due to excessive stress on the muscle working at the limit of stretching. They are recognized because of a sudden but moderate pain, poorly localized, causing relatively little discomfort. The athlete has little pain when asked to perform movements alone, however, stretching is painful, as is isometric contraction (during a thwarted movement). Finally, note the absence of visible bruising. Palpation finds an indurated cord. Ultrasound shows an elongated hypoechoic area.

Treatment must be immediate and allows recovery after 10 to 15 days thanks to elastoplast-type support (tape), ice packs, rest, local anti-inflammatories as well as other specific physiotherapy methods.

b) Muscle tears - “The STRAIN”

This time, it involves tears in fibers, or even entire muscle bundles.

They are due to two causes:

• Either a contraction that is too violent and too rapid (start type)
• Either a shock on a contracted muscle

They are recognized by a sudden, well-localized pain associated with a complete inability to move. The tear occurs during exercise and leads to immediate cessation of exercise.

Obviously, in this case, we won't even attempt any stretching or other maneuvers because the injury is too serious. The strain is mainly seen in the hamstrings and the medial gastrocnemius.

Moreover, a hematoma does not take long to appear. If the lesion is superficial or interstitial, a bruise appears within a few days. It constitutes a good prognostic element. If the lesion is deep, intramuscular, the hematoma does not spread, the bruise is missing and the ultrasound shows it very clearly and can guide us towards a possible puncture. The treatment lasts from 21 to 30 days. It is also urgent to immediately apply a compressive support supplemented by a splint, and to apply icing which can last for 21 days relayed by more specific methods of physiotherapy.

d) Muscle rupture and detachment

These are, unfortunately, the same problems, in the first case, the muscle is completely torn in its fleshy part, in the other case the tear occurs in its osteo-ligamentous insertion. Often there is an added popping noise. They are due to the same mechanisms as before: too violent and too brief effort or direct shock. The pain can go as far as loss of consciousness, the injured person is totally helpless and a hematoma or swelling appears in a few hours which can mask the palpable notch of the fibers. Ultrasound confirms the true “fracture” of the muscle. The treatment lasts from 45 to 60 days during which strict immobilization must be respected (21 days) then a surgical opinion is systematically requested.

These lesions are subluxations and dislocations.

Dislocation is the complete loss of contact between the articular surfaces of a joint. When this loss of contact is only partial, it is called subluxation. Any joint can be the site of dislocation, but some are preferentially so due to the configuration of their very loosely fitted articular surfaces. We will discuss some fairly common dislocations.

Shoulder dislocation

Shoulder dislocation or scapulohumeral dislocation most often results from trauma occurring to the arm in abdduction and external rotation (fall on the outstretched arm). The humeral head can dislocate in any direction, but the most common form is antero-internal.

The symptoms are very suggestive:

• generally intense pain
• inability to move the arm
• protrusion of the humeral head below the clavicle
• the head can be felt in the deltopectoral groove

Confirmation of the diagnosis is done by X-ray, frontal and profile views. It also allows for the exclusion of possible complications:

• bone: fracture of the humeral glenoid
• nervous: lesion of the circumflex nerve
• tendinous: rotator cuff rupture

In the absence of complications, it is advisable to reduce the dislocation as quickly as possible. Reduction is generally performed without anesthesia by a doctor experienced in this area, or under very light general anesthesia if the pain is too severe.

The arm is immobilized in a sling. The duration of immobilization is inversely proportional to the patient's age.

Rehabilitation plays a vital role in treatment, particularly to avoid relapses, which are very common in young people.

During the period of immobilization:

• mobilization of the fingers, wrist and elbow
• relaxing massage of the cervico-scapular region
• analgesic electrotherapy
• very gentle and painless mobilization of the shoulder in small amplitudes

after the period of immobilization:

• see above
• progressive mobilization of the shoulder
• toning of the shoulder muscles, especially the internal rotators; subscaplar muscle, pectoralis major muscle, latissimus dorsi muscle
• proprioceptive reeducation of the shoulder

Recurrent dislocations are common in young people. If conservative orthopedic treatment fails to produce the desired results, surgery is used. The most commonly used surgical technique involves reinsertion of the anterior labrum and inferior glenohumeral ligament according to Bankart. This technique can be performed arthroscopically. Postoperative immobilization is 2 to 3 weeks in a removable splint.

Rehabilitation is gentle and progressive, aiming for recovery of joint range of motion and muscle toning, and finally proprioceptive reprogramming.

Acryomoclavicular dislocation

This is a benign lesion that affects young people. It results from a sudden fall on the shoulder (fall from a bicycle, motorbike) and consists of a total rupture of the acromioclavicular and coracoclavicular ligaments.

Symptoms

• elective pain on the acromioclavicular joint
• projection of the outer end of the clavicle
• “piano key” sign, lowering the end of the clavicle by simple pressure
• anteroposterior drawer

The treatment is surgical with repositioning and blood fixation.

The physiotherapy treatment is identical to that described for scapulohumeral dislocation.

These are sprains, i.e. traumatic injuries to the ligaments of a joint. Ligaments are stays that
join the bones of a joint and, together with the joint capsule, ensure passive stability of the joint. Depending on the severity of the injury, different stages of sprain are distinguished:

• mild sprain, simple ligament stretching
• medium-severity sprain, rupture of several ligament bundles
• severe sprain, complete rupture of the ligament(s) with possible bone lesions

The most common sprains are in the ankle, knee and wrist.

Ankle sprain

see sports pathologies

Knee sprain

This is the damage to one or more ligaments of the knee. The cause is a forced rotational movement of the femur on the tibia, the knee being
bent.

The mild sprain

It is characterized by the elongation of the lateral ligaments, most often the internal lateral ligament.

Symptoms:

• pain especially during insertion and when applying tension (flexion)
• effusion
• limitation of movements

The immediate treatment is cryotherapy and then, after confirmation of the diagnosis, the application of a soft support for a few days.

After immobilization:

• thigh massage
• deep transverse massage Cyriax
• US
• Electrotherapy
• passive and active mobilization of the knee to recover full range of motion
• isometric quadriceps toning
• proprioceptive rehabilitation on mobile platforms
• retraining for effort
• isokinetic rehabilitation

The serious sprain

This is the damage to the cruciate ligaments.

Bone injuries are primarily fractures. A fracture occurs when there is a discontinuity in the bone. There are several types of fractures:

• closed fracture: the bone fragments do not pierce the skin
• open fracture: bone fragments pierce the skin
• communicative fracture: fracture that includes several intermediate fragments that escape description
• stress fracture: due to repeated microtraumas in young people and athletes
• pathological fracture: due to weakening of the bone caused by cancer, osteoporosis, osteomalacia

Wrist fracture

The most common fracture is the Colles-Pouteau fracture, or frog fracture. This is a fracture of the distal end of the radius with the fragment displaced backward and outward. It is most often caused by a fall onto the open hand.

Treatment

It consists of reducing the fracture, i.e. putting the fragments back in place and keeping them in place until they have consolidated (4-6 weeks). Immobilization can be done using a plaster cast.

Today, treatment is most often surgical using pins or screwed plates to fix the fragments.

The advantage of surgical treatment is that immobilization is generally not necessary and rehabilitation can begin early, which helps avoid complications (neuro-algodystrophic syndrome).

Physiotherapy

• careful and painless passive mobilization of the fingers, wrist and elbow
• mobilization against progressive resistance of the fingers, wrist and elbow
• functional rehabilitation and occupational therapy

Elbow fracture

Elbow fractures are articular fractures that involve the distal end of the humerus, the proximal end of the radius (radial head), and the proximal end of the ulna (olecranon).

These are serious fractures because they affect the function of the elbow. For reasons that are unclear, the elbow joint tends to stiffen (stiffness in flexion-extension) after trauma, hence the importance of proper treatment.

Except for small fractures without displacement, treatment will always be surgical with fixation by pins, screw plates, external fixator, prosthesis with the aim of restoring the articular surfaces as perfectly as possible.

Physiotherapy treatment will only begin after the edematous and inflammatory phenomena have regressed.

It will consist of:

• massage of the scapular region
• mobilization of the fingers in passive, active
• careful mobilization in pronation-supination
• careful mobilization in flexion-extension
• static contractions of the biceps, triceps
• “contract-release” exercises to gradually recover maximum extension and flexion
• only after recovery of full amplitude: retraining for effort
• functional exercises

IMPORTANT: If the recovery of the amplitude no longer progresses, it may be useful to interrupt the rehabilitation for a certain time (2 weeks) and then resume it.

Shoulder fracture

This is a fracture that is more common in older people and occurs after a minor shoulder injury. In younger people, it is secondary to a violent trauma (traffic accident, sports accident, etc.). The mechanism is either direct by a fall on the shoulder stump or indirect by a fall on the hand or elbow. The anatomical type of fracture depends on the age of the person, the severity of the trauma, and the position of the upper limb at the time of the accident.

Symptoms:

• extremely severe shoulder pain at rest
• functional impotence
• possible deformation of the shoulder
• appearance of a hematoma

Treatment

When the fracture is not or moderately displaced, the treatment is conservative through immobilization that is not too restrictive (risk of neuro-algo-dystrophy) with the elbow against the body for 3 weeks.

When the fracture has many fragments or is very displaced and the subject is young enough, surgical treatment should be considered, the aim of which is to restore the original shoulder anatomy, the only guarantee of recovery of function. The fragments will be placed and then fixed with screws and/or a plate.

When the fragments are multiple and the displacement is very significant in the elderly subject, it is sometimes necessary to place a shoulder prosthesis immediately.

The complications that can be encountered are:

• neurological complications involving the circumflex nerve or brachial plexus
• vascular complications involving the axillary vessels with loss of pulse and large axillary hematoma
• neuro-algo-dystrophic syndrome
• appearance of a viscious callus

Physiotherapy treatment is very cautious and progressive:

• massage of the cervico-scapular region
• active mobilization against resistance of the fingers, wrist and elbow
• passive mobilization in shoulder flexion
• active-assisted (using the healthy hand) anteflexion exercises
• pendulum exercises

after consolidation:

• see above
• abduction mobilization
• rotating mobilization
• recovery of joint range of motion
• muscle strengthening

Hip fracture

These are fractures that affect the acetabulum or the head of the femur.

Acetabulum fracture

It is a relatively common injury, mainly due to traffic accidents, and more rarely to falls. In the elderly, a simple fall can cause a fracture.

Pain and total functional instability are the rule.

The X-ray that confirms the diagnosis.

The treatment

It depends on the patient's age, the type of fracture, and associated injuries. Surgery is generally preferred in young people. In older people, a complex fracture requires orthopedic treatment.

Arthritis is an inflammation of a joint. The term arthritis covers more than 100 diseases.
Different rheumatic diseases. These diseases can affect the joints, muscles, tendons and ligaments as well as the skin and certain internal organs.

Ankylosing spondylitis

Ankylosing spondylitis is a form of arthritis that affects the spine. It is characterized by pain, stiffness
in the back, as well as a curvature of the spine. In severe cases, the inflammation can lead to fusion of the vertebrae and a
significant loss of mobility.

Physiotherapy is used to maintain spinal mobility through specific rehabilitation.

Rheumatoid arthritis

Rheumatoid arthritis, often referred to as rheumatoid arthritis, is an autoimmune disease of unknown cause that manifests itself through inflammatory signs such as redness, pain, swelling
and a feeling of warmth in the joint. The inflammation can also affect other organs such as the eyes, lungs and
the heart.

This disease affects healthy joints, most often the joints of the hands and feet. It is distinguished from other forms
arthritis because it affects several joints symmetrically, i.e. on both sides of the body.

Physiotherapy treatment is complementary to drug treatment. It consists of exercises aimed at increasing
range of motion, to build muscle strength and endurance.

Walking, swimming and cycling are among the recommended activities.

Fibromyalgia

Fibromyalgia is characterized by widespread pain in the muscles, ligaments, and tendons, as well as stiffness, especially
morning in the joints.

Treatment aims to relieve pain and maintain mobility. Physiotherapy is part of this treatment, including rehabilitation and physiotherapy for pain relief and anti-edema.

Scapulohumeral periarthritis (SHP)

PSH is a rheumatic condition located outside the shoulder joint and affecting all the muscle and tendon tissue surrounding the joint.

The term PSH is often misused to designate very specific pathologies such as rupture of the cuff of the
rotators, acetabular labrum injury, calcification of the infraspinatus muscle tendon.

It is important to make a differential diagnosis. Additional tests such as X-ray, MRI, arthrography or
Ultrasound can provide useful information and make an accurate diagnosis.

Tendinitis

Tendonitis is an inflammation of the tendon.

The main signs of tendonitis are pain when moving and palpating the affected area, as well as pain when
mobilization thwarted.

The causes are generally overwork of the tendon by intense and/or repeated efforts or more rarely due to malposition
articular.

Treatment consists of rest and/or immobilization, taking anti-inflammatories, injections and physiotherapy.
The most used techniques are deep transverse massage (Cyriax), physical agents and manual therapy

The most affected regions are:

• shoulder supraspinatus tendinitis
• the knee
  goose foot tendonitis, usually in cyclists)
  patellar tendonitis
• the elbow
  epicondylitis (tennis elbow)
  epitrochleitis (golfers elbow)
• the foot
  Achilles tendonitis
• the hip
  gluteus medius tendonitis
  pyramidal muscle tendonitis

Bursitis (or hygroma) is an inflammation of the bursa in a joint region.

The origin of bursitis may be infectious, metabolic (gout), traumatic or micro-traumatic.

Bursitis is most often located at the level of:

• sub-Achilles (ankle)
• retroolecranon (elbow)
• prepatellar (knee)
• ischiatic (hip)
• subdeltoid (shoulder)

Treatment will be carried out by liquid puncture, corticosteroid infiltration and compression bandages.

Physiotherapy mainly involves cryotherapy (application of cold).

Tenosynovitis is an inflammation of the tendon sheath. The origin can be infectious, rheumatic, or micro-traumatic.

Symptoms are well-localized pain during tendon movements, sometimes with crepitation.

The medical treatment is immobilization, anti-inflammatories and infiltrations.

Sometimes surgery may be necessary to release the tendon (tenosynovectomy)

Physiotherapy is used before and during immobilization by physical agents and after surgery through gentle and progressive functional rehabilitation to avoid tendon adhesions and accompanied by ultrasound.

Tenosynovitis most often occurs in the fingers.

Trigger finger (or spring finger)

This is a particular clinical form characterized by a more or less painful catching in the flexion-extension movements of the finger, the movement being slowed down halfway through and ending abruptly as if moved by a spring.

Dupuytren's disease

Dupuytren's contracture is a retractile fibrosis of the palmar fascia of the hand (the membrane located between the flexor tendons and the skin). It causes progressive and irreducible retraction and flexion of the fingers. The fibrosis leads to the transformation of the palmar fascia and results in the formation of fibrous bands.

The origin of this disease is unknown, the only thing established is the existence of a genetic factor.

Symptoms are the appearance in the palm of the hand of one or more nodules located at the base of the 4th and/or 5th finger. Over time, the nodules lengthen and form longitudinal cords, and gradually an irreducible flexion of the fingers of the first two phalanges appears. In severe forms, the hand may close completely.

Treatment is surgical by percutaneous aponeurectomy or fasciatomy.

Physiotherapy is used after surgery through scar massage, functional rehabilitation and ultrasound.

Periostitis is an acute or chronic inflammation of the periosteum, most often located on the tibia, and the tendon fibers that insert into it. This condition is frequently encountered in athletes. It is due to vibrations caused by running on hard ground, the use of unsuitable shoes, and repeated trauma to the periosteum.

The treatment consists of resting the leg.

Physiotherapy includes cryotherapy , ultrasound and massage according to Vodder.

Osteoarthritis is a degenerative condition of joint cartilage without infection or inflammation. This degeneration can occur in any joint, but is most common in weight-bearing joints such as the knees, hips, or spine. Other joints (shoulder, elbow) are less commonly affected.

Osteoarthritis is a chronic, slowly progressive disease. It affects women more often than men.

The cause of osteoarthritis is unclear, but overload or poor load distribution across the joint surface plays a major role. Other causes of osteoarthritis may be traumatic (fracture, sports or domestic accident), congenital (joint malposition or malformation), genetic (cartilage quality), endocrine, or other. The age and lifestyle of the person affected also play a role in the onset of osteoarthritis. Thus, it is important to emphasize that weight is a major risk factor.

The main symptoms of osteoarthritis are of two types:

• mechanical pain that is triggered and aggravated by movement and disappears or lessens more or less completely when the joint is at rest. It is less severe in the morning and gradually increases during the day. It reappears each time the affected joint is subjected to exertion.
• functional discomfort which corresponds to a limitation of the mobility of the joint.

The treatment is initially medicinal with analgesics, anti-inflammatories, infiltrations and others.

Physiotherapy is essential because it helps to delay joint stiffness. It also helps strengthen the muscles surrounding the joint to relieve pain.

The most used techniques are physical agents, massage, joint mobilization and peri-articular muscle strengthening.

Preventive surgery helps restore the correct mechanical conditions in the event of joint abnormalities (congenital hip dislocation, varum knee).

In advanced and disabling cases, surgery offers arthrotomy, arthrodesis (blocking of the joint) and, most frequently, total prosthesis.

A prosthesis is a surgical procedure in which parts of a joint are removed and replaced with a device made of synthetic material, ceramic, or metal, called a prosthesis. The prosthesis is designed to allow the joint to move like a normal, healthy joint.

Total joint replacements have been performed since the 1960s. Today, it is recognized that this procedure allows for significant reconstruction of function and pain relief for 90% to 95% of patients. While the expected lifespan of prostheses is difficult to estimate, it is not unlimited. Artificial joints can become unstable over the years and require revision surgery.

Recent improvements in surgical techniques and instrumentation contribute to the success of treatment. The use of advanced materials such as titanium or ceramic and the use of new synthetic joint coatings offer the surgeon options that can help increase the longevity of the prosthesis.

Total joint replacements are mainly used in the hip, knee, and shoulder. However, other joints (thumb, elbow) can also benefit from total joint replacements.

Total hip replacement

A total hip replacement replaces the damaged part of the hip joint. It consists of two interlocking pieces. One piece replaces the articular portion of the pelvis (acetabulum). The other replaces the neck and head of the femur; it is made of stainless steel. It includes a stem that is implanted in the femur, a neck, and a head that articulates with the acetabulum.

There are many different types of prosthetics, varying in shape and materials. This variety of prosthetics will result in few changes to the rehabilitation process.

The current general trend is toward early, non-intensive rehabilitation that places little strain on the new joint. A significant emphasis is placed on adaptation to the new situation and proprioceptive exercises.

Post-operative physiotherapy

During the hospitalization period, the patient must be taught the permitted movements and clearly understand those to be avoided. The hip is mobilized in active assisted, in flexion-extension and in slight abduction. Added to this is the isometric contraction of the quadriceps and glutes, standing with two canes and progressive support on the ground. Learning to go up (healthy leg first) and down (operated leg first) stairs is essential. Follow the advice for daily life from your physiotherapist.

At first, hip flexion will be limited and painful, so you'll need to be imaginative and find some tricks.

Some tips:

• sit on a hard, high chair rather than in an armchair
• get a toilet seat riser
• take a shower, possibly sitting down, rather than a bath
• put on shoes that are easy to put on, use a shoehorn
• avoid excessive hip flexion
• avoid standing on one leg on the operated side
• do not carry heavy on the side

The length of hospitalization is becoming increasingly shorter. Often, if the patient's general condition and postoperative assessment allow it, they can leave the hospital after a few days. Several options are available for the rest of their rehabilitation.

• home rehabilitation
• rehabilitation at the physiotherapist's office
• rehabilitation in a rehabilitation center

It is up to you to freely choose the type of rehabilitation you prefer.

All three options have their advantages and disadvantages. Generally speaking, for a relatively young person (70 years old), alone, with a generally impaired general condition, rehabilitation in a rehabilitation center, followed, if necessary, by treatment in a physiotherapist's office, is the best solution to ensure a quick and complete recovery.

Total knee replacement

Osteoarthritis is a consequence of wear and tear on the various components of the knee. It begins by affecting the menisci and cartilage, then spreads deeper and can destroy the underlying bone. The symptoms are mainly

• Pain, especially when walking and going up and down stairs
• Swelling (related to synovial effusion)
• Progressive deformation into varum knee (O-shaped legs) or valgus knee (X-shaped legs)

The causes are

• the after-effects of fractures of the tibia, femur or patella
• axial deviations of the femoro-tibial axis, either in the frontal plane or in the sagittal plane
• overweight
• meniscal and/or ligament injuries
• inflammatory rheumatic sequelae (polyarthritis, juvenile chronic arthritis)

The treatment is medicinal with painkillers, anti-inflammatories, infiltrations and chondroprotectors and physiotherapy intervenes through analgesic and anti-inflammatory electrotherapy and functional rehabilitation to maintain joint mobility and muscle strength.

Surgery may be required depending on the stage of osteoarthritis, the cause and the patient's age.

Arthroscopy is performed under anesthesia on an outpatient basis. It removes wear debris and synovial effusion, which causes swelling. Results are inconsistent.

Osteotomy is used for localized osteoarthritis in younger people (under 55). It modifies the axis of the tibia by directing the weight bearing towards the healthy area. It often provides complete relief of pain for a period of 10 to 15 years.

Total knee replacement has revolutionized the treatment of knee osteoarthritis. A distinction is made between unicompartmental replacement and total or tricompartmental replacement.

A unicompartmental prosthesis is a partial prosthesis. It replaces worn cartilage on one side of the knee between the femur and the tibia, without affecting the other femoro-tibial compartment or the patella.

The criteria for a unicompartmental prosthesis are:

• joint wear limited to a single femoro-tibail compartment
• the absence of significant overweight or osteoporosis
• lower limbs moderately arched in genu varum <5°

The unicompartmental prosthesis consists of two parts: a tibial element made of a metal plate covered with a polyethylene sole and a metal femoral element which is applied without resection to the corresponding condyle.

Physiotherapy treatment begins the day after the procedure with:

• passive manual knee flexion
• passive knee flexion on Kinetec (machine that flexes the knee)
• standing up
• learning to walk with canes
• learning to go up and down stairs

After hospitalization, rehabilitation continues in a rehabilitation center or at the patient's home and then at the physiotherapist's office by:

• active flexion-extension
• quadriceps and hamstring strength training
• progressive support
• going up and down stairs
• proprioception exercises

The total prosthesis replaces all of the worn cartilage and reproduces the movements of the knee in the three planes of space.

The total prosthesis consists of three parts: a metal femoral element which fits onto the end of the femur, a tibial element which sits on the tibia as a plate, consisting of a base on which a polyethylene sole is inserted and a polyethylene patellar medallion if necessary.

Rehabilitation begins the day after the operation with:

• passive flexion
• flexion on Kinétec
• walking with two canes and going up and down stairs as soon as possible (4-5 days)
• the wheelchair placement
• cryotherapy
• isometric contractions

After 8-10 days you should try to achieve a 90° flexion.

Rehabilitation continues either in a rehabilitation center, or at the patient's home and then at the physiotherapist's office by:

• active flexion-extension
• quadriceps and hamstring strength training
• proprioceptive rehabilitation
• progressive total recovery and rehabilitation to daily life

Total shoulder prosthesis

Shoulder prosthesis may be considered in several cases:

• Wear of the joint surfaces in relation to osteoarthritis, inflammatory diseases and certain shoulder traumas
• Complex fractures of the upper end of the humerus with numerous displaced fragments
• Massive rupture of the rotator cuff tendons with elevation of the humeral head below the acromion

These three cases, all very different in terms of pathology, can find a solution thanks to shoulder prosthesis.

This procedure involves replacing worn joint surfaces with prosthetic parts:

• a metal sphere mounted on a rod for the upper end of the humerus
• a polyethylene capsule for the glenoid cavity of the scapula

The goal of prosthetic shoulder joint replacement is to relieve pain and restore a significant amount of mobility and strength.

Physiotherapy treatment begins immediately, on the second day after surgery. Hospitalization lasts approximately 8 days. Rehabilitation can be carried out either at the rehabilitation center, at home and then at the physiotherapist's office by:

• mobilization of the fingers, wrist, elbow
• passive shoulder mobilization
• active-assisted shoulder exercises
• self-mobilization of the shoulder
• pendulum exercises

and in a second step by:

• active shoulder mobilization
• muscle strengthening
• rehabilitation to daily life

Adhesive capsulitis is called adhesive capsulitis because the joint capsule contracts, preventing the shoulder from functioning normally. This condition is also known as "frozen shoulder." Some people consider adhesive capsulitis to be a form of regional pain syndrome (RPS) in the shoulder, but while the two conditions are related, they differ in their clinical signs and progression.

Adhesive capsulitis can occur for no reason, but in some cases there may be contributing factors such as trauma, painful shoulder conditions, thoracic surgery, or hemiplegia.

The development of adhesive capsulitis occurs in three stages:

• The installation stage characterized by the appearance of permanent pain (a few weeks to a few months). At this stage, the clinical examination is still normal
• The stage of stiffness is characterized by the appearance of progressive stiffness. As stiffness sets in, pain disappears, but shoulder movements become increasingly limited.
• The recovery stage is characterized by the gradual disappearance of stiffness. Joint mobility will return to normal.

Sometimes a limitation of a few degrees, especially in external rotation, can remain without hindering daily movements.

Physiotherapy

Even without treatment, adhesive capsulitis will progress to healing within 6 to 18 months. However, physical therapy can greatly accelerate this process and has its place during the stiffness phase and especially during the recovery phase.

In the stiffness phase, she fights pain with relaxing massages, treatment with physical agents and the Trigger Points method.

It maintains the mobility of the shoulder girdle by mobilizing the scapula and the cervical spine. This mobilization of the shoulder is done within the possible ranges, but above all without causing pain . It also maintains muscle function by actively working the shoulder muscles.

In the recovery phase, it provides massage of the shoulder girdle and cervical spine, passive, active assisted and active mobilization to recover full shoulder range of motion, and retraining for effort.

Throughout this process different manual therapy techniques can be used.

Algoneurodystrophy is a regional vasomotor and trophic pain syndrome resulting from a poorly understood neurovegetative disturbance and various causes. There are several synonyms for this disease: "Sudeck's disease", "reflex sympathetic dystrophy", "shoulder-hand syndrome".

The symptoms of algoneurodystrophy are pain that leads to functional impotence, trophic disorders with vasomotor disorders (edema, changes in temperature and skin appearance), as well as epiphyseal demineralization.

Algoneurodistrophy is rarely idiopathic, but usually secondary and localized to the extremities of the limbs.

The causes can be:

• traumatic (50% of cases): surgery, fracture, sprain, dislocation, prolonged immobilization)
• neurological: hemiplegia, head trauma
• visceral: myocardial infarction, tumors
• medicinal
• metabolic: diabetes, hypothyroidism

Finally, there is an anxiety-depressive and emotional background favorable to the appearance of algodystrophy, but its psychosomatic role should not be overestimated.

The course of the disease is generally favorable with complete recovery within a few months (6 to 24 months).

This evolution takes place in two phases:

• a hot or pseudo-inflammatory phase, characterized by sharp pain and vasomotor disorders (heat, edema, shiny skin)
• an inconstant cold phase, marked by the appearance of trophic disorders (cold limb, pale, smooth and atrophic skin). There are sometimes capsulo-ligamentous retractions responsible for progressive joint stiffening

Treatment

There is no specific treatment for complex regional pain syndrome (CRPS). It combines rest, appropriate physical therapy, and medication. Its goal is to reduce pain and maintain joint mobility.

Rest is recommended during the warm phase. For the lower limb, removing weight is a crucial measure while pain persists. Immobilization should be avoided.

Physiotherapy

It must be careful and well conducted. It must be progressive and above all painless, because pain, in the hot phase, can aggravate the disease.

In the hot phase, it uses cryotherapy, Trigger Points, analgesic electrotherapy, cautious and painless mobilizations of the affected joint.

In the cold phase, capsulo-ligamentous stretching and active mobilization are added.