Carpo pedal syndrome

Definition:
A spasm of the feet and hand observed in hyperventilation, calcium deprivation, tetany.

-Associated with tetany
-Lowered muscular excitability threshold
-Results in involuntary spasms
-Diffuse muscles involved in severe, spontaneous tetany
-Laryngeal Stridor (noisy breathing, crow like)
-Generalized Tonic Clonic Seizure (seizure involving the entire body. It is also called a grand mal seizure. Such seizures usually involve muscle rigidity, violent muscle contractions, and loss of consciousness)
-Death may occur

Causes
-Hyperventilation
-Hypoparathyroidism
-Hypocalcemia
-Hypomagnesemia

Pathophysiology of hyperventilation
-Triggered by fear, anxiety, stress or pain.
-Involves increasingly rapid breathing.
-Respiratory rate ↑, CO2 level ↓ resulting in alkalosis.
-Causes left shift of oxyhemoglobin disassociation curve in which the hemoglobin hold on tightly to O2 and does not unload them effectively.
-Results in hypoxia and anxiety.
-Carpopedal spasm is a characteristic sign of respiratory alkolosis.
-Involves tingling and contraction of hands and feet due to hypocapnia (↓ level of CO2).

Indications of carpopedal spasm
Trousseau’s sign
-Technique
Occlusion of brachial artery with BP cuff for 3 minutes

-Interpretation: Positive test suggests Carpopedal Spasm Carpal Spasm symptoms elicited

Chvostek’s sign
-A sign of tetany seen in hypocalcemia.
-Tap facial nerve at the angle of jaw (masseter muscle) , facial muscles on the same side will contract momentarily.
-This is due to hypocalcaemia, with hyperexcitability of the nerves

Signs and non surgical treatment for ACL tear

Sign of ACL tear
- Hearing a ‘pop’ sound
- Knee giving out- unstable
- Swelling associated with hemarthrosis and pain
- Unrepaired ACL tears may also lead to early arthritis in the affected knee.

Non surgical treatment
-Decrease pain and swelling in knee by giving simple analgesics eg: acetaminophen or NSAID
-Rest
-Use crutches until you can walk without a limp
-Placing a needle in the swollen joint and aspirating (or draining as much fluid as possible) gives
relief from the swelling
-Physical therapy such as ice, electrical stimulation, and rest periods with your leg
supported in elevation
-Exercises are used to help you regain normal movement of joints and muscles. Exercise helps improve the strength of the hamstring and quadriceps muscles
- ACL brace. usually custom-made

Knee Joint examintaion

1. Pivot shift test

• The patient's foot is wedged between the examiner's body and elbow.
• The examiner places one hand flat under the tibia pushing it forward with the knee in extension.
• The other hand is placed against the patient's thigh pushing it the other way.
• The lower limb is taken into slight abduction by the examiner's elbow with the examiner's body acting as a fulcrum to produce the valgus.
• Th examiner maintains the anterior tibial translation and the valgus and initiates flexion of the patient's knee.
• At about 20-30 degree, the pivot shift will occur as the lateral tibial plateau reduces

2. Posterior drawer test

• It is positive when the proximal head of a patient's tibia can be pushed posteriorly on the femur.
• The patient is placed in a supine position and the knee is flexed to approximately 90 degree with the foot in the neutral position.
• The examiner sits gently on the patient's foot placing both thumbs on the tibial tuberosity and pushing the tibia backward.
• If the tibia plateau moves, the posterior cruciate ligament is torn.
  

Knee examination

http://www.sportsdoc.umn.edu/Clinical_Folder/Knee_Folder/Knee_Exam/lachmans.htm

Rather good website found in the knee joint practical.

Physical examination of the knee - Lachman's test and anterior drawer test.

Lachman's test

Tests for: Anterior cruicate ligament
Look for: End point of the ligament
Points:

• Patient lies down on his/her back
• Slightly flex the knee about 20-30 degrees to relax quadriceps and hamstrings
• Support distal femur
• One hand on the tibial tubeosity/proximal tibia
• Apply a force anteriorly on the tibia.
• If it doesn't come to a stop, ACL tear.

Anterior drawer test

Tests for: ACL
Look for: More than 5 degrees of movement of the tibia anteriorly
Points:

• Patient lies on back
• Knee flexed to 90 degrees
• Ensure hamstrings are relaxed
• Examiner sits on the foot
• Pulls the tibia anteriorly
• According to Gray's, the medial meniscus or meniscotibial ligaments MUST be damaged to elicit this sign.
  

Others

• Look for varus and valgus when checking posture
• Test range of movement/tone, power, bulk.
  
• Patellar tap - bulge sign
• Patellar apprehension test
• Apley's grinding test - meniscal damage
• Distraction test - meniscal damage
• Baker's cyst
  
• McMurray's test - meniscal damage
  

Knee Joint Task Allocation

1. Activity 1 : Bones
(Use articulated skeletons & bone sets, models, plastinated specimens & prosection photos)

Wai Kit
1.1. Review the features in the articulating surfaces of the knee joint:
1.1.1. Distal Femur:
1.1.1.1. Lateral and medial condyles and intercondylar fossa
1.1.2. Proximal tibia
1.1.2.1. Lateral and medial tibial plateau
1.1.2.2. Intercondylar tubercles
1.1.2.3. Intercondylar eminence
1.1.2.4. Lateral & medial condyles of tibia
1.1.2.5. Anterolateral ( Gerdy) tubercle
1.1.2.6. Tibial tuberosity

Niva
1.2. Identify the patella
1.2.1. Identify its apex and margins
1.2.2. Identify the medial and lateral areas and its subdivisions in its posterior articular surface
1.2.2.1. In which movements does these different facets come in contact with the femur?
1.2.2.2. Why is patellar movements examined in full extension?

Matt
1.2.3. What types of bone is it?
1.2.3.1. How does this explain the fact that when it fractures, bony union does not take place easily
1.2.4. In what clinical condition does it simulate a fracture?

Pikky
1.3. Why does patella have a natural tendency to displace laterally?
1.4. What normally prevents a lateral patellar displacement?

2. Activity 2 : Muscles, Fascia & Ligaments
(Use articulated skeletons & bone sets, models, plastinated specimens & prosection photos)

Jeevi
2.1. List & identify the muscles that flex and extend the knee joint.
2.2. Identify the collateral ligaments
2.2.1. How are they different in shape and attachments from each other?
2.2.2. Which structure runs deep to each collateral lig.?
2.2.3. What is found between the lateral ligament & meniscus?
2.3. Explain why a tear of Medial Collateral ligament is associated with medial meniscus tear
2.4. What structures crosses the MCL?
2.4.1. What intervenes between these structures?
2.5. How will you test the stability of the collateral ligaments?

Ian
2.6. Identify the patella tendon.
2.6.1. What are its attachments?
2.6.1.1. What are the clinical applications of this?
2.6.2. When the knee joint is locked which is the only ligament which is not taut?
2.7. Draw a schematic diagram to show the following features and attachments of the upper surface of the tibia: Attachments of the medial and lateral menisci, ACL PCL Shapes of medial and lateral meniscus Transverse ligaments Tibial Spines

PC
2.8. How does the medial meniscus differ from the lateral in shape, attachments and functions?
2.9. Enumerate the functions of the menisci
2.10. What are the different types of Meniscal tears?

Mitch
2.11. Identify the ACL and PCL
2.12. Identify their attachments
2.13. What are the functions?
2.14. What are the components of O‟Donahue‟s Triad/ Terrible Triad?
2.14.1. Demonstrate the mechanism of injury
http://rad.usuhs.edu/medpix/medpix.html?mode=case_viewer&imid=18313&pt_id=6681&quiz=&th=&table=card&showall=#pic

3. Activity 3 : Joints
(Use articulated skeletons & bone sets, models, plastinated specimens & prosection photos)

Ran
3.1. Functionally knee joint is a modified hinge joint – Explain how in relation to shifting of its axes of movement
3.1.1. Briefly discuss the key factors that contribute to the stability of the knee joint.
3.2. Identify the knee joint line
3.2.1. What is the normal “Q” angle of the knee joint ?
3.2.1.1. How does it differ between sexes?
3.3. What obstetric history is present in a person with “ genu recurvatum”?
3.3.1. What is “genu valgum” and “genu varum”?
3.3.1.1. How does these conditions predispose to the degenerative changes in the knee?

Dean
3.4. Demonstrate and explain on an articulated knee, the locking and unlocking of the knee joint.
3.4.1. Which muscle is involved in unlocking?
3.5. Identify the clinically important bursae around the knee joint.
3.5.1. Which of these communicates with the knee joint?
3.5.1.1. How is this clinically important?
3.5.2. What is „Housemaid‟s knee‟?
3.5.3. What is „Clergyman‟s knee‟?

4. Activity 4 : Surface Anatomy
http://www.sportsdoc.umn.edu/Clinical_Folder/Knee_Folder/Knee_Exam/lachmans.htm

Bert
4.1. How will you test for Anterior/Posterior Instability of the Knee joint?
4.2. Demonstrate the Anterior and Posterior drawer signs and the Lachman‟s test.

5. Activity 5 : Procedural Anatomy
5.1. Where will you do an aspiration of the knee?

6. Activity 6 : Radiology
{Refer to radiological images in textbooks & Clinical Imaging software Radiology 2; http://www.radiologyassistant.nl/en/42764e8fe927e }
6.1. Study the following :
6.2. Review of X-ray of the Knee joint (AP & lateral views)
6.3. MRI of the Knee joint : Coronal and Axial images


Task allocation :
1. Wai Kit
2. Niva
3. Matt
4. Pikky
5. Jeevi
6. Ian
7. PC
8. Mitch
9. Ran
10. Dean
11. Bert

PCL 11 (Laxman's knee) tasks

First of all,

1. www.kneeclinic.com.au/index.htm
2. MRI images are available in Gray's Anatomy for Students

Now the tasks,

1. Anatomy/biomechanics of the knee (Pik Yin & Ian)

• Movement
• Stabilty
• Body weight

2. Structures present and damaged by lateral/medial trauma (Ranmali)

3. ACL tear (Bertrand & Mitch)

• Signs and symptoms
• Treatment (surgery and non-surgical)

4. Complete physical examination of the knee (Din & Matthias)

5. Problems in foot affecting knee stability (Phey Chien & Wai Kit)

6. Effects of the knee injury (Niva & Jeevetha)

• Anxiety
• Hyperventilation
• Carpopedal

ROM of joints

http://www.brianmac.co.uk/musrom.htm

Psychosocial Factors and Preventive Methods

Psychosocial Factors that contribute to pain
-preexisting depression and emotional distress
-Job Satisfaction
-Stress and ability to cope with it

Preventive Methods
-exercise regularly
-maintain proper posture
-use good body mechanics
-maintain a healthy body weight, Eat healthy foods
-Plenty of rest

analgesics :

NSAIDs :
Inhibit COX-1 and COX-2 pathways
Inhibit the synthesis of prostaglandin
Precursor : arachidonic acid
Eg. Ibuprofen, naproxen, diclofenac
Side effects :
Ulcer and gastrointestinal bleeding
Renal failure
Skin rash

opioids anagesics :
For severe chronic pain
Natural or synthetic compounds that produce morphine-like effects.
Bind to the specific opioid receptors in the CNS to produce effects that mimic the action of endogenous peptide neurotransmitters
The analgesic properties of the opioids are primarily mediated by the m receptor
Short-acting
Eg. Codeine, Tramadol, Oxycodone
Long-acting
Eg. Morphine, methadone

non-opioids adjuvant anagesics :
Tricyclic antidepressant
Eg. Amitriptyline
Antidepressants :
SSRIs (Selective serotonin reuptake inhibitors)
Eg. Paroxetine, sertraline, fluoxetine
Antiepileptics :
Eg. Gabapentin
Muscle Relaxants
Eg. diazepam