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Samenvatting Orthopedie
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Dit document bevat alle hoofdstukken van de cursus 'orthopedie'. Dit vak werd gegeven door prof. Degreef.
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INHOUDInleiding................................................................................................................................................................. 10
Definitie ............................................................................................................................................................. 10
Belangrijke etiologische factoren die pathologische veranderingen in beenderen en gewrichten veroorzaken
.......................................................................................................................................................................... 10
Congenitale afwijkingen, vaak genetische aandoeningen ............................................................................ 10
Trauma .......................................................................................................................................................... 11
Mechanische oorzaken ................................................................................................................................. 11
Infecties ......................................................................................................................................................... 11
Reumatoïde aandoeningen ........................................................................................................................... 11
Degeneratieve aandoeningen ....................................................................................................................... 11
Metabole stoornissen ................................................................................................................................... 11
Endocriene stoornissen ................................................................................................................................. 12
Tumoren ........................................................................................................................................................ 12
Circulatoire stoornissen ................................................................................................................................ 12
Neurologische aandoeningen ....................................................................................................................... 12
Orthopedische behandelprincipes .................................................................................................................... 12
Fysiotherapie/farmacotherapie .................................................................................................................... 12
Infiltraties ...................................................................................................................................................... 12
Gips ............................................................................................................................................................... 13
Bracing – orthesiologie.................................................................................................................................. 13
Chirurgie ........................................................................................................................................................ 13
Hoofdstuk 1: het klinisch onderzoek van de patiënt met orthopedische problemen .......................................... 14
Anamnese ......................................................................................................................................................... 14
Klinisch onderzoek ............................................................................................................................................ 14
Instrumentarium ............................................................................................................................................... 14
Musculoskeletaal onderzoek ............................................................................................................................ 14
Inspectie ........................................................................................................................................................ 14
Palpatie ......................................................................................................................................................... 14
Gewrichtsmobiliteit....................................................................................................................................... 15
Neurologisch onderzoek ............................................................................................................................... 15
Vasculair onderzoek ...................................................................................................................................... 15
Specifieke tests ............................................................................................................................................. 15
Onderzoek van aanpalende gebieden........................................................................................................... 16
Normale en abnormale gang ............................................................................................................................ 16
Normale gangcyclus ...................................................................................................................................... 16
1
, Bijkomende componenten ............................................................................................................................ 17
Abnormale gang (manken)............................................................................................................................ 17
Bovenste lidmaat: kinematica ........................................................................................................................... 18
Overzicht van de fysiologische assen/bewegingen in de gewrichten – terminologie ...................................... 18
Onbeweeglijke gewrichten ........................................................................................................................... 18
Halfbeweeglijke gewrichten .......................................................................................................................... 19
Beweeglijke gewrichten ................................................................................................................................ 19
Kogel- en bolgewricht ............................................................................................................................... 19
Eivormig/ellipsoïde/condylair gewricht .................................................................................................... 19
Zadelgewricht ............................................................................................................................................ 19
Scharniergewricht (hinge) ......................................................................................................................... 19
Rol- en draaigewricht (pivot)..................................................................................................................... 19
Vlak gewricht ............................................................................................................................................. 19
Asafwijkingen ................................................................................................................................................ 19
Orthopedische terminologie van de gewrichtsmobiliteit ............................................................................. 20
Wervelkolom ............................................................................................................................................. 20
Schouder ................................................................................................................................................... 20
Elleboog..................................................................................................................................................... 20
Pols ............................................................................................................................................................ 20
Vingers ...................................................................................................................................................... 20
Duim .......................................................................................................................................................... 20
Heup .......................................................................................................................................................... 20
Knie ........................................................................................................................................................... 20
Enkel en voet ............................................................................................................................................. 21
Gemiddelde beweging gewrichten (range of motion – ROM) .......................................................................... 21
Hoofdstuk 2: algemene aandoeningen in orthopedie .......................................................................................... 23
Inleiding............................................................................................................................................................. 23
Calcium en fosfor metabolisme .................................................................................................................... 23
Algemene aandoeningen met orthopedisch impact ......................................................................................... 23
Chronische inflammatoire gewrichtsaandoeningen ..................................................................................... 23
Osteoporose .................................................................................................................................................. 24
Etiologie .................................................................................................................................................... 24
Klinisch beeld ............................................................................................................................................ 24
Bone mineral density (BMD) ..................................................................................................................... 25
Risicofactoren............................................................................................................................................ 25
Preventie ................................................................................................................................................... 25
Behandeling .............................................................................................................................................. 25
2
, Osteomalacie ................................................................................................................................................ 26
Etiologie .................................................................................................................................................... 26
Behandeling .............................................................................................................................................. 26
Osteitis deformans (ziekte van Paget) .......................................................................................................... 27
Pathologie ................................................................................................................................................. 27
Röntgenonderzoek .................................................................................................................................... 27
Klinisch beeld ............................................................................................................................................ 27
Behandeling .............................................................................................................................................. 27
Neurofibromatosis (ziekte van Von Recklinghausen) ................................................................................... 27
Maligne aandoeningen ................................................................................................................................. 28
Histopathologie ......................................................................................................................................... 28
Röntgenonderzoek .................................................................................................................................... 28
Klinisch beeld ............................................................................................................................................ 29
Behandeling en prognose ......................................................................................................................... 29
Aandoeningen van gewrichten ......................................................................................................................... 29
Intrinsieke factoren ....................................................................................................................................... 29
Osteonecrose ............................................................................................................................................ 29
Kraakbeenletsels ....................................................................................................................................... 30
Geïsoleerde kraakbeenletsels – osteochondritis dissecans (OCD) ...................................................... 30
Veralgemeende kraakbeenletsels – artrose ........................................................................................ 31
Extrinsieke factoren ...................................................................................................................................... 31
Artrofibrosis .............................................................................................................................................. 31
Ossificaties (PAO) ...................................................................................................................................... 32
Complex regionaal pijnsyndroom (CRPS) .................................................................................................. 32
Doorbloedingsproblemen in orthopedie .......................................................................................................... 34
Orthopedische aanpak van neurologische letsels ............................................................................................. 34
Primaire diagnose en herstel ........................................................................................................................ 34
Secundair herstel .......................................................................................................................................... 34
Laattijdige orthopedische behandeling coping ............................................................................................. 35
Hoofdstuk 3: infecties van botweefsel en gewrichten .......................................................................................... 36
Inleiding............................................................................................................................................................. 36
Infecties van botweefsel ................................................................................................................................... 36
Pyogene osteomyelitis .................................................................................................................................. 36
Hematogene osteomyelitis ....................................................................................................................... 36
Exogene osteomyelitis .............................................................................................................................. 39
Abces van Brodie ....................................................................................................................................... 40
Niet-pyogene osteomyelitis .......................................................................................................................... 40
3
, Cierny-mader classificatie ............................................................................................................................. 40
Infecties van gewrichten ................................................................................................................................... 41
Pyogene artritis ............................................................................................................................................. 41
Tuberculose van locomotorisch stelsel ......................................................................................................... 43
Geïnfecteerde artroplastiek .............................................................................................................................. 44
Spondylodiscitis................................................................................................................................................. 44
Ankylosis ........................................................................................................................................................... 45
Oorzaak ......................................................................................................................................................... 45
Behandeling .................................................................................................................................................. 46
Preventief .................................................................................................................................................. 46
Fibreuze ankylose ...................................................................................................................................... 46
Benige ankylose......................................................................................................................................... 46
Inflammatoire aandoeningen ........................................................................................................................... 46
Hoofdstuk 4: aandoening van de rug .................................................................................................................... 47
Inleiding............................................................................................................................................................. 47
Functionele anatomie ....................................................................................................................................... 47
Triage ................................................................................................................................................................ 47
Rode vlaggen ................................................................................................................................................. 48
Algemeen .................................................................................................................................................. 48
Ruggerelateerd.......................................................................................................................................... 48
Gele vlaggen .................................................................................................................................................. 49
Presentatie ........................................................................................................................................................ 49
Acute lage rugpijn ......................................................................................................................................... 49
Chronische lage rugpijn ................................................................................................................................. 50
Radiculopathie – ischias .................................................................................................................................... 51
Symptomatologie .......................................................................................................................................... 51
Cauda-equina syndroom ............................................................................................................................... 52
Spinaalstenose – neurogene claudicatio....................................................................................................... 52
Behandeling radiculopathie .......................................................................................................................... 53
Algemeen klinisch onderzoek van rugpatiënt ................................................................................................... 53
Inspectie ........................................................................................................................................................ 53
Palpatie ......................................................................................................................................................... 54
Technische onderzoeken .................................................................................................................................. 55
Elektromyografie (EMG)................................................................................................................................ 55
Röntgenonderzoek ........................................................................................................................................ 55
Differentiaaldiagnose van enkele rode vlaggen ................................................................................................ 56
Infectie .......................................................................................................................................................... 56
4
, Tumoren ........................................................................................................................................................ 56
Spondylitis ankylopoetica (ziekte van Bechterew)........................................................................................ 57
Reumatoïde artritis (RA) ............................................................................................................................... 57
Osteoporose en osteomalacie ...................................................................................................................... 58
Spondylolysis en spondylolisthesis ............................................................................................................... 58
Kinderleeftijd ............................................................................................................................................. 58
Jeugdige sporters ...................................................................................................................................... 58
Degeneratieve spondylolisthesis............................................................................................................... 58
Gynaecologische rugpijn ........................................................................................................................... 59
Viscerale rugpijn ............................................................................................................................................ 59
Coxartrose ..................................................................................................................................................... 59
Heelkunde bij rugproblemen ............................................................................................................................ 59
Coccygodynie .................................................................................................................................................... 60
Hoofdstuk 5: aandoening van hals en schouder ................................................................................................... 61
Aandoeningen van de hals ................................................................................................................................ 61
Thoracic-outlet syndroom (TOS) ................................................................................................................... 61
Cervicale artrose ........................................................................................................................................... 62
A vertebralis-syndroom................................................................................................................................. 64
Aandoeningen van schoudergewricht .............................................................................................................. 64
Functionele anatomie ................................................................................................................................... 64
Schouderinstabiliteit ..................................................................................................................................... 65
Recidiverende anterieure schouderluxatie ............................................................................................... 65
Multidirectionele instabiliteit.................................................................................................................... 65
Rotatorcuff aandoeningen ............................................................................................................................ 65
Calcificerende rotatorcuff tendinopathie – bursitis calcarea.................................................................... 65
Rotatorcuff impingement.......................................................................................................................... 66
Rotatorcuff scheur .................................................................................................................................... 66
Rotatorcuff artropathie – omartrosis........................................................................................................ 67
Andere rotatorcuff aandoeningen ............................................................................................................ 67
Frozen shoulder ............................................................................................................................................ 68
Hoofdstuk 6: aandoeningen van elleboog, pols, hand en vingers ........................................................................ 69
Elleboog............................................................................................................................................................. 69
Cubitis valgus en cubitus varus ..................................................................................................................... 69
Tendinosis rond elleboog .............................................................................................................................. 69
Epicondylitis lateralis (tenniselleboog) ..................................................................................................... 69
Epicondylitis medialis (golferselleboog) .................................................................................................... 70
Andere tendinosen.................................................................................................................................... 70
5
, Bursitis olecrani ............................................................................................................................................. 71
Cubitale tunnelsyndroom.............................................................................................................................. 71
Ellebooginstabiliteit ...................................................................................................................................... 72
Stabiliteit ................................................................................................................................................... 72
Mediale instabiliteit .................................................................................................................................. 73
Laterale instabiliteit .................................................................................................................................. 73
Traumatische artrofibrosis en myositis ossificans ........................................................................................ 74
Osteochondritis dissecans............................................................................................................................. 74
Elleboogatrosis of cubartrosis ....................................................................................................................... 75
Pols en hand ...................................................................................................................................................... 75
Aandoeningen van pezen, peesscheden, palmaire fascia ............................................................................. 75
Overkruisingparatenonitis......................................................................................................................... 75
Ziekte van Quervain .................................................................................................................................. 76
Spring- of trigger-finger/-duim .................................................................................................................. 76
Peesrupturen............................................................................................................................................. 76
Extensoren ........................................................................................................................................... 76
Flexoren ............................................................................................................................................... 77
Ziekte van Dupuytren ................................................................................................................................ 77
Aandoeningen van spieren en zenuwen in de hand ..................................................................................... 78
Verlammingen van de hand ...................................................................................................................... 78
Compressie van n medianus aan de pols: carpale tunnelsyndroom......................................................... 79
Aandoeningen van beenderen en gewrichten van de hand ......................................................................... 80
Polscyste.................................................................................................................................................... 80
Aseptische necrose (AN) van os lunatum (ziekte van Kienböck) .............................................................. 80
Pseudartrose en aseptische necrose van os scaphoïdeum ....................................................................... 80
Ligamentaire letsels in de pols .................................................................................................................. 80
Duimbasis artrosis (rizartrose) .................................................................................................................. 81
Infecties van de vingers en de hand .............................................................................................................. 82
Paronchium ............................................................................................................................................... 82
Panaritium (witvinger – felon) .................................................................................................................. 82
Etterige tenosynovitis van flexoren, infecties van peesscheden .............................................................. 83
Subfasciale flegmonen van de hand.......................................................................................................... 83
Hoofdstuk 7: aandoeningen van de heup ............................................................................................................. 84
Inleiding............................................................................................................................................................. 84
Peri-articulaire heuppathologie ........................................................................................................................ 85
Bursitis rondom heup .................................................................................................................................... 85
Snapping hip .................................................................................................................................................. 85
6
, Meralgia paresthetica ................................................................................................................................... 85
Articulaire heuppathologie ............................................................................................................................... 85
Avasculaire necrosis (AVN) van de heup bij volwassenen ............................................................................ 85
Voorkomen................................................................................................................................................ 85
Pathologische anatomie ............................................................................................................................ 86
Kliniek ........................................................................................................................................................ 86
Röntgenonderzoek .................................................................................................................................... 86
Behandeling .............................................................................................................................................. 86
Heupartrose of coxartrose ............................................................................................................................ 86
Inleiding ..................................................................................................................................................... 86
Voorkomen................................................................................................................................................ 87
Röntgenonderzoek .................................................................................................................................... 87
Klinisch beeld en onderzoek ..................................................................................................................... 87
Behandeling .............................................................................................................................................. 87
Heupartroscopie ....................................................................................................................................... 88
Heupprothese ........................................................................................................................................... 88
Hoofdstuk 8: aandoeningen van de knie .............................................................................................................. 89
Inleiding............................................................................................................................................................. 89
Meniscusletsels ................................................................................................................................................. 90
Functie........................................................................................................................................................... 90
Letsels van mediale meniscus ....................................................................................................................... 90
Letsels van laterale meniscus ........................................................................................................................ 91
Ligamentletsels ................................................................................................................................................. 92
Letsels van mediale ligament ........................................................................................................................ 92
Scheuren van mediale collaterale ligament (MCL).................................................................................... 92
Aandoening van Pellegrini-STieda ............................................................................................................. 93
Letsels van laterale ligament......................................................................................................................... 93
Voorste kruisbandscheuren (VKB) ................................................................................................................ 93
Klinisch onderzoek .................................................................................................................................... 94
Behandeling .............................................................................................................................................. 94
Achterste kruisbandscheuren (AKB) ............................................................................................................. 95
Aandoeningen van patellafemorale gewricht ................................................................................................... 95
Kraakbeenaantasting .................................................................................................................................... 96
Instabiliteit van patella .................................................................................................................................. 96
Overbelastingsletsels ........................................................................................................................................ 97
Paratenonitis – tendinose – peesruptuur (jumper’s knee) ........................................................................... 97
Iliotibiale-bandfrictiesyndroom..................................................................................................................... 98
7
, Synoviale aandoeningen ................................................................................................................................... 99
Plica synovialis............................................................................................................................................... 99
Chondromatose............................................................................................................................................. 99
Gepigmenteerde villonodulaire synovitis (PVNS) ......................................................................................... 99
Prepatellaire bursitis (kapucijnenknie) ....................................................................................................... 100
Baker-cyste .................................................................................................................................................. 100
Kraakbeendestructie ....................................................................................................................................... 100
Asafwijkingen .............................................................................................................................................. 100
Artritis en artrose ........................................................................................................................................ 101
Hoofdstuk 9: aandoeningen van enkel en voet .................................................................................................. 102
Inleiding........................................................................................................................................................... 102
Bewegingen van de voet ............................................................................................................................. 102
Vorm van de voet ........................................................................................................................................ 102
Aandoeningen van de enkel ............................................................................................................................ 102
Enkelinstabiliteit.......................................................................................................................................... 102
Tendinopathie ............................................................................................................................................. 103
Tibiotalair impingement .............................................................................................................................. 103
Artrose ........................................................................................................................................................ 103
Aandoeningen van de hiel............................................................................................................................... 104
Ontstekingen rond aanhechting van de achillespees ................................................................................. 104
Paratenonitis – tendinosis....................................................................................................................... 104
Bursitis..................................................................................................................................................... 104
Scheur van achillespees .......................................................................................................................... 105
Exostose van Haglund ................................................................................................................................. 105
Hielspoor en bursitis onder calcaneum....................................................................................................... 105
Vormafwijkingen van de voet ......................................................................................................................... 105
Pes planus (platvoet) ................................................................................................................................... 105
Soepele platvoet ..................................................................................................................................... 105
Rigide platvoet ........................................................................................................................................ 106
Tibialis posterior dysfunctie .................................................................................................................... 106
Pes cavus (holvoet) ..................................................................................................................................... 107
Pijn in de voorvoet .......................................................................................................................................... 107
Metatarsalgie .............................................................................................................................................. 107
Morton-neurinoma ..................................................................................................................................... 108
March-fractuur ............................................................................................................................................ 108
Sesamoïditis ................................................................................................................................................ 108
Aandoeningen van de voetzool....................................................................................................................... 108
8
, Callusvorming .............................................................................................................................................. 108
Verruca plantaris ......................................................................................................................................... 109
Malum perforans pedis ............................................................................................................................... 109
Aandoeningen van de tenen ........................................................................................................................... 109
Afwijkingen van de hallux ........................................................................................................................... 109
Hallux valgus ........................................................................................................................................... 109
Hallux rigidus ........................................................................................................................................... 110
Afwijkingen van andere tenen .................................................................................................................... 110
Hamer, mallet, klauwteen ....................................................................................................................... 110
Curling toe, over- en onderlappende tenen............................................................................................ 110
Nagelafwijkingen ......................................................................................................................................... 110
Unguis incarnatus (ingegroeide teennagel) ............................................................................................ 110
Onychogryphosis ..................................................................................................................................... 111
Subunguale exostose .............................................................................................................................. 111
Inflammatoire aandoeningen ..................................................................................................................... 111
Reumatische artritis (RA) ........................................................................................................................ 111
Jicht ......................................................................................................................................................... 111
9
, MENSELIJK BEWEGINGSSTELSEL:
ORTHOPEDIE
INLEIDING
DEFINITIE
Orthopedie = gebied van de geneeskunde dat zich bezighoudt met het behoud en herstek van de functie van
het locomotorisch stelsel: het skelet, de gewrichten en de hierop betrekking hebbende structuren
- Ορθος: recht + παιδιον: kind
- Mechanische, heelkundige en geneeskundige middelen aanwenden om afwijkingen van steun- en
bewegingsapparaat
Kinesiologie = studie der bewegingen: baseren op onderzoek naar de biomechanica, anatomie en fysiologie om
de motoriek van het menselijke lichaam te evalueren
Biomechanica = toepassing van mechanische en technische principes op het menselijk lichaam
Orthopedische stoornissen worden veroorzaakt door disfunctie, vormverandering of beschadiging van de
anatomische structuren (botten, kraakbeen, gewrichten, kapsel, ligamenten, spieren, pezen, neurovasculaire
structuren, bindweefsel):
- Aangeboren aandoeningen vs verworven aandoeningen
- Groeistoornissen
- Doorbloedingsstoornissen
- Trauma (acuut, chronisch)
- Systeemziekten
- Tumoren
- Sportletsels
- Arbeidsgerelateerde aandoeningen
- Degeneratieve afwijkingen (artrose, bv vargus)
- Infecties
- Reumatoïde aandoeningen (jicht)
- Metabole stoornissen
BELANGRIJKE ETIOLOGISCHE FACTOREN DIE PATHOLOGISCHE VERANDERINGEN IN BEENDEREN
EN GEWRICHTEN VEROORZAKEN
CONGENITALE AFWIJKINGEN, VAAK GENETISCHE AANDOENINGEN
- Misvormingen van skelet- of spierstelsel
- Neurologische afwijkingen
- Chromosomale afwijkingen
Primaire congenitale misvormingen: tgv defecten in eicel
Secundaire congenitale misvormingen: tgv invloeden gedurende intra-uteriene leven (= connatale afwijkingen)
10
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