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  7. Menselijk Bewegingsstelsel: Orthopedie En Traumatologie

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Volledige samenvatting met illustraties en notities uit de les van orthopedie

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  • Menselijk Bewegingsstelsel: Orthopedie En Traumatologie
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  • Katholieke Universiteit Leuven (KU Leuven)

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  • January 5, 2022
  • 61
  • 2021/2022
  • Summary

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  • orthopedie
  • ilse
  • degreef
  • menselijk
  • bewegingsstelsel
  • geneeskunde
  • samenvatting

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  • Katholieke Universiteit Leuven (KU Leuven)
  • Geneeskunde
  • Menselijk Bewegingsstelsel: Orthopedie En Traumatologie
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ORTHOPEDIE

INHOUDSOPGAVE

Inleiding ......................................................................................................................................................... 6
Belangrijke etiologische factoren die pathologische veranderingen in beenderen en gewrichten veroorzaken 6
Orthopedische behandelprincipes ...................................................................................................................... 6

H1: Klinisch onderzoek van de patiënt met orthopedische problemen ........................................................... 7
Anamnese ........................................................................................................................................................... 7
Klinisch onderzoek .............................................................................................................................................. 7
Instrumentarium................................................................................................................................................. 7
Musculoskeletaal onderzoek .............................................................................................................................. 7
Inspectie ......................................................................................................................................................... 7
Palpatie .......................................................................................................................................................... 7
Gewrichtsmobiliteit........................................................................................................................................ 7
Neurologisch onderzoek ................................................................................................................................ 7
Vasculair onderzoek ....................................................................................................................................... 7
Normale en abnormale gang.............................................................................................................................. 8
Normale gangcyclus ....................................................................................................................................... 8
Abnormale gang ............................................................................................................................................. 8
Kinematica bovenste lidmaat ............................................................................................................................. 9
Overzicht van de fysiologische assen/bewegingen in de gewrichten – terminologie ......................................... 9
Conceptmappen ............................................................................................................................................... 10

H2: Algemene aandoeningen in de orthopedie ............................................................................................. 11
Inleiding ............................................................................................................................................................ 11
Algemene aandoeningen met orthopedische impact ....................................................................................... 11
Chronische inflammatoire gewrichtsaandoeningen .................................................................................... 11
Osteoporose ................................................................................................................................................. 11
Osteomalacie ............................................................................................................................................... 12
Osteitis deformans of ziekte van Paget........................................................................................................ 12
Neurofibromatosis of ziekte van Von Recklinghausen................................................................................. 12
Maligne aandoeningen ................................................................................................................................ 13
Aandoeningen van de gewrichten .................................................................................................................... 13
Intrinsieke factoren ...................................................................................................................................... 13
Osteonecrose ........................................................................................................................................... 13
Kraakbeenletsels ...................................................................................................................................... 13
Extrinsieke factoren ..................................................................................................................................... 14
Artrofibrosis ............................................................................................................................................. 14
Ossificaties ............................................................................................................................................... 14
Complex regionaal pijnsyndroom ............................................................................................................ 14
Doorbloedingsproblemen in de orthopedie ...................................................................................................... 15
Orthopedische aanak van neurologische letsels............................................................................................... 15

1

, Primaire diagnose en herstel ....................................................................................................................... 15
Secundair herstel ......................................................................................................................................... 16
Laattijdige orthopedische behandeling, coping ........................................................................................... 16
Conceptmappen ............................................................................................................................................... 16

H3: Infecties van het botweefsel en de gewrichten....................................................................................... 17
Inleiding ............................................................................................................................................................ 17
Infecties van het botweefsel ............................................................................................................................. 17
Pyogene osteomyelitis ................................................................................................................................. 17
Hematogene osteomyelitis ...................................................................................................................... 17
Exogene osteomyelitis ............................................................................................................................. 18
Abces van Brodie ..................................................................................................................................... 18
Niet-pyogene osteomyelitis ......................................................................................................................... 18
Cierny-Mader classificatie ............................................................................................................................ 19
Infecties van gewrichten ................................................................................................................................... 19
Pyogene artritis ............................................................................................................................................ 19
Tuberculose van het locomotorisch stelsel .................................................................................................. 20
Geïnfecteerde artroplastiek .............................................................................................................................. 20
Spondylodiscitis ................................................................................................................................................ 21
Ankylosis ........................................................................................................................................................... 21
Conceptmappen ............................................................................................................................................... 21

H4: Aandoeningen van de rug ...................................................................................................................... 22
Functionele anatomie ....................................................................................................................................... 22
Triage................................................................................................................................................................ 22
Rode vlaggen ................................................................................................................................................ 22
Gele vlaggen ................................................................................................................................................. 23
Presentatie ....................................................................................................................................................... 23
Acute rugpijn ................................................................................................................................................ 23
Chronische lagerugpijn................................................................................................................................. 23
Radiculopathie-ischias ...................................................................................................................................... 24
Symptomatologie ......................................................................................................................................... 24
Cauda-equina syndroom .............................................................................................................................. 25
Spinaalstenose – neurogene claudicatio...................................................................................................... 25
Beleid radiculopathie ................................................................................................................................... 25
Algemeen klinisch onderzoek van de rugpatiënt .............................................................................................. 25
Inspectie ....................................................................................................................................................... 25
Palpatie ........................................................................................................................................................ 25
Technische onderzoeken ................................................................................................................................... 26
Differentiaaldiagnose van rode vlaggen .......................................................................................................... 26
Heelkunde bij rugproblemen ............................................................................................................................ 27
Coccygodynie .................................................................................................................................................... 27
Conceptmappen ............................................................................................................................................... 27

H5: Aandoeningen hals en schouder............................................................................................................. 29
Aandoeningen van de hals ............................................................................................................................... 29
Thoracic-outlet syndroom ............................................................................................................................ 29
Cervicale artrose .......................................................................................................................................... 29
2

, Aandoeningen van het schoudergewricht ........................................................................................................ 30
functionele anatomie ................................................................................................................................... 30
Schouderinstabiliteit .................................................................................................................................... 30
Rotatorcuffaandoeningen ............................................................................................................................ 30
Calcifierende rotatorcufftendinopathie – bursitis calcarea ..................................................................... 30
Rotatorcuffimpingement ......................................................................................................................... 31
Rotatorcuffscheur .................................................................................................................................... 31
Rotatorcuffartropathie – omartrosis ....................................................................................................... 31
Andere rotatorcuffaandoeningen ............................................................................................................ 31
Omartrosis ................................................................................................................................................... 32
Frozen shoulder ........................................................................................................................................... 32
Conceptmap ..................................................................................................................................................... 33

H6: Aandoeningen van de elleboog, pols, hand en vingers ........................................................................... 34
Elleboog ............................................................................................................................................................ 34
Cubitus valgus en cubitus varus ................................................................................................................... 34
Tendinosis rond de elleboog ........................................................................................................................ 34
Epicondylitis lateralis of tenniselleboog .................................................................................................. 34
Andere tendinosen .................................................................................................................................. 34
Bursitis olecrani ............................................................................................................................................ 35
Cubitaletunnelsyndroom ............................................................................................................................. 35
Ellebooginstabiliteit ..................................................................................................................................... 35
Mediale instabiliteit ................................................................................................................................. 36
Laterale instabiliteit ................................................................................................................................. 36
Traumatische artrofibrosis en myositis ossificans ....................................................................................... 36
Osteochondritis dissecans............................................................................................................................ 37
Elleboogartrosis of cubartrosis .................................................................................................................... 37
Pols en hand ..................................................................................................................................................... 37
Aandoeningen van de pezen, peesscheden en palmaire fascia ................................................................... 37
Overkruisings-para-teno-nitis .................................................................................................................. 37
Ziekte van de Quervain ............................................................................................................................ 38
Spring- of triggerfinger/-duim ................................................................................................................. 38
Peesrupturen ........................................................................................................................................... 38
Ziekte van Dupuytren .............................................................................................................................. 38
Aandoeningen van spieren en zenuwen in de hand .................................................................................... 39
Verlammingen van de hand ..................................................................................................................... 39
Compressie van de nervus medianus aan de pols: carpaletunnelsyndroom........................................... 40
Aandoeningen van de beenderen en gewrichten van de hand ................................................................... 40
Infecties van de vingers en de hand ............................................................................................................. 41
Conceptmap ..................................................................................................................................................... 42

H7: aandoeningen van de heup .................................................................................................................... 43
Inleiding ............................................................................................................................................................ 43
Periarticulaire heuppathologie ......................................................................................................................... 43
Bursitis rondom de heup .............................................................................................................................. 43
Snapping hip................................................................................................................................................. 43
Meralgia paresthetica .................................................................................................................................. 44
Articulaire heuppathologie ............................................................................................................................... 44
Avasculaire necrose van de heup bij volwassenen ...................................................................................... 44
Voorkomen .............................................................................................................................................. 44
Kliniek ...................................................................................................................................................... 44
RX ............................................................................................................................................................. 44
Behandeling ............................................................................................................................................. 44

3

, Heupartrose of coxartrose ........................................................................................................................... 45
Inleiding ................................................................................................................................................... 45
RX ............................................................................................................................................................. 45
Klinisch beeld en onderzoek .................................................................................................................... 45
Behandeling ............................................................................................................................................. 45
Heupartroscopie ...................................................................................................................................... 45
Heupprothese .......................................................................................................................................... 46
Conceptmap ..................................................................................................................................................... 46

H8: Aandoeningen van de knie ..................................................................................................................... 47
Inleiding ............................................................................................................................................................ 47
Meniscusletsels ................................................................................................................................................. 48
Functie ......................................................................................................................................................... 48
Scheuren van de mediale meniscus ............................................................................................................. 48
Letsels van de laterale meniscus .................................................................................................................. 48
Ligamentletsels ................................................................................................................................................. 49
Letsels van het mediale ligament ................................................................................................................. 49
Scheuren van mediale collaterale ligament............................................................................................. 49
Letsels van het laterale ligament ................................................................................................................. 50
Voorste-kruisbandscheuren ......................................................................................................................... 50
Achterste-kruisbandscheuren ...................................................................................................................... 51
Aandoeningen van het patellofemoraal gewricht ............................................................................................ 51
Kraakbeenaantasting ................................................................................................................................... 51
Instabiliteit van de patella ............................................................................................................................ 52
Overbelastingsletsels ........................................................................................................................................ 52
Paratenonitis – tendinose – peesruptuur (jumper’s knee) .......................................................................... 52
Iliotibialebandfrictiesyndroom ..................................................................................................................... 53
Synoviale aandoeningen ................................................................................................................................... 53
Plica synovialis.............................................................................................................................................. 53
Chrondromatose .......................................................................................................................................... 53
Gepigmenteerde villonodulaire synovitis (PVNS) ........................................................................................ 53
Prepatellaire bursitis (kapucijnenknie) ........................................................................................................ 53
Baker-cyste................................................................................................................................................... 53
Kraakbeendestructie......................................................................................................................................... 54
Asafwijkingen ............................................................................................................................................... 54
Artritis en artrose ......................................................................................................................................... 54
Conceptmap ..................................................................................................................................................... 54

H9: aandoeningen van enkel en voet ............................................................................................................ 55
Inleiding ............................................................................................................................................................ 55
Bewegingen van de voet .............................................................................................................................. 55
Vorm van de voet ......................................................................................................................................... 55
Aandoeningen van de enkel ............................................................................................................................. 55
Enkelinstabiliteit........................................................................................................................................... 55
Tendinopathie .............................................................................................................................................. 56
Tibiotalair impingment ................................................................................................................................. 56
Artrose ......................................................................................................................................................... 56
Aandoeningen van de hiel ................................................................................................................................ 56
Ontstekingen rond de aanhechting van de achillespees.............................................................................. 56
Exostose van Haglund .................................................................................................................................. 57
Hielspoor en bursitis onder het calcaneum ................................................................................................. 57

4

, Vormafwijkingen van de voet ........................................................................................................................... 57
Pes planus of platvoet .................................................................................................................................. 57
Pes cavus of holvoet..................................................................................................................................... 57
Pijn in de voorvoet ............................................................................................................................................ 58
Metatarsalgie ............................................................................................................................................... 58
Morton-neurinoma ...................................................................................................................................... 58
March-fractuur ............................................................................................................................................. 58
Sesamoïditis ................................................................................................................................................. 58
Aandoeningen voetzool .................................................................................................................................... 58
Callusvorming............................................................................................................................................... 58
Verruca plantaris .......................................................................................................................................... 58
Malum perforans pedis ................................................................................................................................ 59
Aandoeningen van de tenen ............................................................................................................................. 59
Afwijkingen van de hallux ............................................................................................................................ 59
Afwijkingen van de andere tenen ................................................................................................................ 59
Nagelafwijkingen .......................................................................................................................................... 59
Inflammatoire aandoeningen ...................................................................................................................... 59
Conceptmappen ............................................................................................................................................... 60

H10: Kinderorthopedie ................................................................................................................................. 61




5

, INLEIDING

BELANGRIJKE ETIOLOGISCHE FACTOREN DIE PATHOLOGISCHE VERANDERINGEN IN
BEENDEREN EN GEWRICHTEN VEROORZAKEN
• Congenitale afwijkingen, vaak genetisch
o Primair: defecten eicel (meest frequent)
o Secundair: tgv intra-uteriene invloeden
• Trauma (meestal)
• Mechanische oorzaken: overbelasting
• Infecties: pathogene micro-organismen naar bot of gewricht via bloed, wonde of
verspreiding vanuit naburige infectiehaard
o Osteomyelitis = infectie bot, beenmerg en periost
o Artritis = infectie gewricht
• Reumatoïde aandoeningen
o Reuma = verzamelnaam van > 200 acute en chronische aandoeningen die ons
bewegingsstelsel en bijhorende bindweefsels aantasten
o Bekendste vorm = reumatoïde artritis = auto-immuunaandoening die synovitis
veroorzaakt in gewrichten, peesscheden en slijmbeurzen -> secundair belangrijke
afwijkingen vd gewrichten -> misvorming
• Degeneratieve aandoeningen
• Metabole stoornissen
o Vb diabetesvoet (gangreen, diabetes ulcus)
• Endocriene stoornissen
o Vb hyperparathyroïdie -> hypercalcimie en botpijn, myalgie en osteoporose
• Tumoren
o Goedaardig en kwaadaardig
o Bot- en wekedelentumoren
o Primair (vb osteosarcoma) vs secundair (botmetastasen)
• Circulatoire stoornissen
o -> ‘aseptische’ of ‘avasculaire’ necrose
o Kind: stoornis bloedvoorziening epifyse -> ernstige letsels
o Volwassene: necrose tgv stoornis bloedvoorziening
• Neurologische stoornis: 1/3 van alle orthopedische aandoeningen


ORTHOPEDISCHE BEHANDELPRINCIPES
• Fysiotheraptie/farmacotherapie – multidisciplinaire aanpak
• Infiltratie: inbrengen corticoïden om inflammatie te bestrijden
• Gips: minder en minder gebruikt
• Bracing – orthesiologie: beter dan gips, zsm revalidatie starten om verstijving te voorkomen
• Chirurgie
o Osteosynthese: botbreuken herstellen
o Sutuur: hechten van pees-, zenuw- en bloedvatletsels
o Osteotomie: doorzagen van bot om het terug juist te zetten vb na mal-union
o Externe fixator vb Ilizarov frame
o Prothese = kunstgewricht
o Artrodese = gewricht vastzetten als te pijnlijk en prothese niet mogelijk (vb door
infectie)


6

, H1: KLINISCH ONDERZOEK VAN DE PATIËNT MET ORTHOPEDISCHE
PROBLEMEN

ANAMNESE
• Pijnklacht, functiebeperking en/of zichtbare afwijking?
• Zwelling, roodheid, koorts
• Geschiedenis van de klacht
• Persoonlijke ziektegeschiedenis


KLINISCH ONDERZOEK
• Grondig regionaal onderzoek + locomot stelsel in zijn geheel

1. Test aan pt uitleggen en wat je juist gaat doen
2. Communicatie, observeren vd reacties vd pt
3. Vergelijk de 2 zijden
4. Onderzoek hele lidmaat, let op gerefereerde pijnklachten
5. Zoveel mogelijk in dezelfde houding


INSTRUMENTARIUM
• Plankjes -> beenlengteverschil
• Lintmeter -> atrofie/zwelling en lengteverschil meten
• Goniometer -> gewrichtsmobiliteit
• Reflexhamer, stemvork, veiligheidsspeld -> neurologisch, sensorisch onderzoek
• Stethoscoop: vasculaire occlusies of letsels


MUSCULOSKELETAAL ONDERZOEK
Inspectie
• Bij het binnenkomen
• Voldoende uitkleden
• Misvorming, atrofie, huidverkleuring, zwelling, littekens, huidletsels, gang, houding en
beweging
• Documenteer in dossier
Palpatie
• Oppervlakte anatomie, drukpijn, misvorming, temperatuur, zwelling en crepitatie
Gewrichtsmobiliteit
• Actief en passief
• Goniometer
Neurologisch onderzoek
• Gevoel, motorisch en reflexen
• Atrofie meten met lintmeter
Vasculair onderzoek
• Arteries palperen en ausculteren


7

, NORMALE EN ABNORMALE GANG
Staanfase (60%)
• Heel strike
• Foot flat
Mid-stance
• Heel off
• Toe off
Zwaaifase (40%)
• Teen vrij
• Voet vrij
Mid-swing
• Hielaanslag

NORMALE GANGCYCLUS
• Bekken aan dezelfde zijde zakt tijdens zwaaifase
• Bekken roteert in de zwaaifase vooruit en in de staanfase achteruit
• Bekken en wervelzuil verplaatsen 2,5 cm lateraal in de richting van steunend been in
staanfase
• Basis = afstand tussen de voeten wanneer ze allebei op de grond staan, 5-10 cm
• Schrijdlengte = afstand tussen de hielaanslag van een voet en de hielaanslag van dezelfde
voet
• Staplengte = afstand van de hielaanslag van de ene voet en de hielaanslag van de andere
voet

ABNORMALE GANG
Moet je herkennen
• = manken -> verschillende soorten
• Door pijn, spierzwakte of gewrichtsafwijkingen
• Antalgisch manken
o Pijn
o Verkorte staanfase van aangetaste been
• Abnormale hielaanslag
o Hielpijn
o Pt loopt op tenen
o Gefixeerde equinus door enkelproblemen, verkorting gastro-soleus
• Quadricepsparese: knie kan niet strekken bij hielcontact -> knie in extensie of recurvatum
• Steppage of dropvoet
o Verlamming dorsiflexoren van de voet -> komt moeilijk vrij van de grond
o Zwaaiende been abnormaal hoog opheffen
o Neerslaan vd voet op de grond aan het einde van de zwaaifase (klapvoet)
• Recurvatum: gefixeerde equinus en quadricepsverzwakking
• Gluteus medius manken: pt zwaait bekken en romp over het steunbeen naar lateraal
• Trendelenburg: bekken aan contralaterale zijde zakt
• Gluteus-maximusgang: bij verzwakking helt pt met romp naar achteren
• Calcaneusgang
o Pijn in voorvoet of verzwakking plantaire flexoren
o Pt stapt op de hiel

8

, • Hip-hike-gate
o Ankylose knie of dropvoet
o Pt heft heup en bekken naar aangedane zijde om voet vrij te krijgen
o Pt zwaait been naar lateraal in circumductie beweging
• Bekkenrotatie kan toenemen bij verzwakking heupflexoren
• Gang met brede basis bij evenwichtsstoornissen


KINEMATICA BOVENSTE LIDMAAT
• Weinig geautomatiseerde cyclische bewegingen zoals bij onderste lidmaat
• Functie: manipulatief
o Hand = werkinstrument -> grip (krachtige grijpfunctie) en pinch (knijp/pincetfunctie)
o Pols: juiste prepositie
• Schouder
o Kogelgewricht
o Verplaatsing werkinstrument in de ruimte
• Elleboog: scharniergewricht dat afstanden overbrugt


OVERZICHT VAN DE FYSIOLOGISCHE ASSEN/BEWEGINGEN IN DE GEWRICHTEN –
TERMINOLOGIE
• Onbeweeglijke gewrichten: vb schedelnaden
• Halfbeweeglijke gewrichten
o Door kraakbeen verbonden
o Vb os pubis
• Beweeglijke gewrichten
o Kogelgewricht: heup- en schoudergewricht
o Eivormig: pols
o Zadelgewricht: duimwortel
o Scharniergewricht: elleboog
o Rol-/draaibeweging: radiuskop in elleboog
o Vlak gewricht: wortelbeentjes handen en voeten
• Asafwijkingen
o Varus: O-benen
Valgus: X benen (elleboog)
o Overstrekken vb recurvatum
Strektekort
o Toeing in
Toeing uit




9

, CONCEPTMAPPEN




10

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