Clinical Medicine Exam 1 MSK Flashcards
Grades of sprains I,II,III
I = Partial tear but no instability of joint
II = Partial tear with some instability and laxity of joint
III = Complete Tear with laxity and instability of joint
Open fracture anitbiotics
IV antibiotics (Usually 1st-2nd generation cephalosporins and aminoglycosides should be administered 48 hours after fracture and for 48 hours after surgery.
Long bone ends are also known as
Proximal and distal
Epiphysis
Osteosarcoma
common malignant bone tumor
children & adolescents
Distal femur most common site, followed by proximal tibia and then proximal humerus.
pain before tumor is noticed
xray then MRI
Chemo, surgery (amputation is rare)
osteoarthritis
stiffness lasting less than an hour
crepitus
Females, age
asymmetry
Bouchards / Heberdens node
nsaids, rice, steroids, bracing, exercise
Rickets
Due to a lack of vitamin D or calcium and from inadequate sunlight exposure, which destroys normal bone growth.
This primarily occurs in children
Laminectomy –
most common, removal of lamina, bone spurs
Spinal stenosis
Juvenile RA
females 2 to 1
unknown cause
autoimmune
criteria = under 16 arthriris for 6 weeks exclusion of other arthritis 5 joints or more
nsaids
methotrexate
PT/OT
torticollis
Neck tilt in infants (injury if adult)
can be from illness or injury
May be caused by sternocleidomastoid muscle contracture
Head will tilt toward side of contracture
May follow URI or mild trauma in children
Spinal cord tumor, RA other etiologies
stretching
Jones Fracture
junction of the metaphysis and diaphysis of the proximal end of the 5th metatarsal
Untreated risks Avascular necrosis
restand to preventmovementin the foot.
surgerymay be needed
Subluxation
Partial or incomplete misalignment of bones and joints
5 P’s of compartment syndrome
5 P’s
Pain
(late findings) Pallor Pulselessness Parasthesia Paralysis
Long bone shaft is also known as
Diaphysis
Pediatric bones (Fx)
Young skeletal bone is much more flexible than mature adult bone
The bones will bend, buckle before they break
Adhesive capitus
Frozen shoulder
Build up of scar tissue resistricts the movement inside the joint
(GH joint) (between humeral head and socket)
this results in pain and severe ROM decrease
Endosteum
inner layer of medullary cavity
also has layer of cells that breakdown and dissolve bone cells for reabsorption
Pediatric Fx
Greenstick (Surgeon for greater thatn 15 degrees)
Salter Harris types 1-5
Heberdens node
Bony lumps in the distal joint of phlange (DIP joint)
can cause pain and inflammation
Nutirent foramina
minute holes in bone surface that allows blood vessels to penetrate
Rhabdomyosarcoma
more than half of the soft tissue sarcomas in children
most typical in head and neck
Very uncommon in adults
Orbital RMS may present with pain in eye, orbital swelling, bulging of eye.
can mask as URI in nose and mouth
Surgery
Fibromyalgia
women 20-55
No specific tests.
all the problems!
Rule out Differential diagnosis (Hypothyroidism, Hep C, Vitamin D deficiency)
psych meds, ssri, gaba, meditation
Nerve conduction velocity test
Test to diagnose carpal tunnel syndrome
Osteoporosis
Primary vs secondary
Primary =
more common, age related
Type 1 = due to decrease in estrogen
type 2 = lack of Vitamin D3
Secondary = Result of other diseases that cause bone loss medications hyperparathyroidism alcohol smoking
Calcium, vitamin D phosphorus, fosamax
Nursemaids elbow
Radial head subluxation
“Pulled elbow”
Usually due to a pull and twist
Sudden acute pain
Child refuses to move arm
On exam, child will be holding arm in slight flexion and pronation
No swelling or tenderness to palpation
HOWEVER – significant tenderness elicited with pronation/supination of the forearm
Sprain
Stetched or torn ligament
Radial Neck Fracture
FOOSH
Typically unstable
This is a fracture that is best NOT immobilized
due to possible loss of ROM
Septic arthritis
Inflammation of a synovial membrane with purulent effusion into the joint capsule, due to infection
Knee mostly
IV drugs, bacterimia, diabetes, RA joint surgery, HIV
Infection symptoms
Antibiotics (vanc, cef)
olecranon bursitis
Students elbow
Enlarged bursa in elbow (point of elbow)
Swelling, pain
ROM not really affected
RICE
Outer layer of long bone is made up of
Compact bone (osteons)
Grade III Strain
III = Tear all muscle fibers, fascia still intact
Pain with weakness and loss of function
Low back pain
Usually prolapsed intervertebral disk and low back strain or Sciatica
Imaging not usual initially
nsaids, rest, PT/OT, fitness
surgery last resort
Fx complications
Hemorrhage DIC Neurologic injury Vascular injury Compartment syndrome
RA Treatment
PT/OT nsaids methotrexate steroids sulfa antimalarials
Gout
Podagra (big toe gout) small joints (toes, ankles, wrist, fingers) earlier in men, Rare in childhood Meat seafood beer worsen red, swollen, tophi
negatively birefridgerantly needle shaped crystals
RICE, nsaids, colchicine, steroids, indomethacine
no thiazides or ASA
Grade III Sprain
III = Complete Tear with laxity and instability of joint
Protected motion, possible, likely repair needed
Articular cartilage
layer of hyaline cartilage that covers joint surface
allows the joint to move moe freely
(at the ends of long bones) (covers the “head”)
Ortho Emergencies
Knee dislocation with vascular compromise (not patella)
Amputation
Spinal fracture
Open fractures
Foraminotomy -
decompression allowing room for nerve root exit
Spinal stenosis
Grade I Strain
I = Tear a few muscle fibers with fascia intact
Pain, very little weakness or loss of function
Bouchards node
Bony lumps in the second distal joint of phlange (middle joint or PIP)
can cause pain and inflammation
Common Type of ankle x ray
AP
Lateral
Mortise
Oblique
Kyphosis
Humpback, curve of spine
Congenital, traumatic or acquired
Fracture Blisters
Occur on overlying skin due to swelling
Appear as early as 6 hours post injury
Usually clear fluid – if hemorrhagic, worse prognoses
Femur Neck “surgical neck” (Hip Fx)
Thinnest, most fragile part of the femur Very common (blood supply can be interuppeted) avascular necrosis can occur usually surgical
Cartilage injury treatments
Steroid injection
Glucosamine
Hyaluronic acid
Rheumatoid arthritis
is a chronic autoimmune disease characterized by an inflammatory polyarthritis that preferentially affects the small joints.
Anti-cyclic citrullinated peptide (anti-CCP or ACPA) is more specific and 95% of patients. Low in early disease.
Erythrocyte Sedimentation rate (ESR) and C-reactive protein are elevated.
RF is positive in 80 of patients but nonspecific
Multiple myeloma
Most common primary tumor of bone
45% of all bone tumors
over 40
Bone pain, increased protein, anemia, hypercalcemia, acute renal failure
“punched out” lesions on imaging
Hip Fx
2 types
Intertrochanteric Fracture
Area between the greater and lesser trochanters
(blood supply ususally intact)
Femur Neck “surgical neck”
Thinnest, most fragile part of the femur
Very common
(blood supply can be interuppeted)
Comminuted Fx
Comminutedfractures have > 2 bone fragments.
Comminuted fractures include segmental fractures (2 separate breaks in a bone).
i.e. shattered
Medial Epicondylitis
Medial = golfers elbow
Pain on inside of elbow
repetitive stress
MRI useful
surgery rare
osgood schlatter disease
inflammation and pain below patella
relieved by rest
patellar tendon pulls on growth plate of tibia repeatedly
imaging not necessary
self limiting once growth plate ossifies
Nsiads, RICE
pediatric disease
overuse injury
What accelerates the loss of bone mass in osteoporosis
gonadla steroid deficiency
estrogen deficiency in postmenopausal women
(lower bone mass than men)
Men can experience this too
Lewy bodies
Lewy bodies are a characteristic feature present in the brains of patients with Parkinson’s disease and Lewy body dementia.
Mechanisms of injury in musculoskeletal
Repetitive stress/injury
Stress fractures
ie shin spints
Anterior should dislocation
Most common joint dislocation,
95% of dislocations
loss of rounded appearance of shoulder
Segmented Fx
Segmental fractures are broken completely into seperate pieces
i.e. an island
Common Type of Hip x ray
AP hips
Frog Leg
Where is yellow bone marrow located
Medullary cavity on diaphysis or shaft of long bone
Spinal fusion –
reserved for patients with radicular pain, or unstable spine and other options have not been effective. Long recovery.
Spinal stenosis
Open Reduction Internal Fixation (ORIF)
Open Reduction Internal Fixation (ORIF) – surgical procedure with use of plates, rods, screws, pins, staples.
talipes equinovarus
club foot
internal rotation of foot
contracted achilles tendon (plantar flexion)
Osteoarthritis details
Osteoarthritis
Articular cartilage softens and degenrates
Bone spurs can develop
Cracking and crepitus
progressive loss of cartilage
Schleroderma clinical presentation
CREST
Calcinosis (Calcium deposits in skin)
Raynauds
Esophageal dysfunction
Sclerodactyly (thickend collagen on fingers)
Telangiectasias (dilation of capillaries on skin) (redness)
Oblique Fx
Obliquefractures occur at an angle.
Spondylolysis
fracture of the pars interarticularis
Schistocytes
Schistocytes are fragmented pieces of red blood cells. These are commonly found in patients with hemolytic anemia or microangiopathic diseases, such as disseminated intravascular coagulation.
Bone repair process
Osteoblasts seek out microcracks
They then secret RANKL
RANKL binds with monocytes
This causes them to form osteoclasts
Osteoclasts secrete enzymes (dissolves and creates holes in bone
This causes the hydroxyapatite to break down in calcium and phosphate releasing it into the blood
Osteoblasts then begin to secrete osteoprogenrin that deactivates RANKL
This slows the osteoclast activity
Calcium and phosphate deposit on the seams, some osteoblasts get trapped in the lacunae and turn into osteocytes
Avascular necrosis
Osteonecrosis
blood supply is cut off
Bone & tissue die
MRI without a contrast agent continues to be the “gold standard
4 Fracture repair steps
hematoma
fibrocartilaginous callus forms
Bony callus forms
Bone remodeling
Osteopenia
bone density has decreased but is not considered dangerous yet
precursor to osteoporosis
Laminoplasty –
lamina removed, plates and screws replace
Spinal stenosis
Spongy bone
At the ends of long bone
epiphysis
and metaphysis
lattice of bone
slivers of bone called spicules
thin plates of bone call trebeculae
spaces filled with red marrow
very few osteons (no central canals)
provides strength with minimal weight
How to counteract aging process
Exercise and stretching
much is the result of being sedintary and under use
Grade I Sprain
I = Partial tear but no instability of joint
Symptomatic treatment only
Polyarteritis nodosa (PAN)
Virus caused
Skin lesions-palpable purpura, and livedo reticularis
Fever, anorexia, weight loss, abd pain, peripheral neuropathy, arthralgias, HTN, edema, uremia, oliguria
HEp b antigen, ESR & CRP elevated, proteinuria
steroids, cytotoxic drugs
10-20% die (GI / CV issues)
Colles Fracture
distal end of radius with dorsal angulation
FOOSH Most common type
Pseudogout
large joints
not uric acid (calcium pyrophosphate crystals)
Painful, red, swollen but no tophi
Rhomboid shaped crytals positively birefridgerant
RICE, nsaids, colchicine, steroids, indomethacine
Impacted Fx
impactedfractures, bone fragments are driven into each other, shortening the bone;
these fractures may be visible as a focal abnormal density in trabeculae or irregularities in bone cortex.
Sarcopenia
Age related Muscle loss
Reduced satellite cells loss of muscel mass increased adipose tissue fiber types transition from fast toslow twitch fibers reduced number of mitochondria calcium deficits/release
Boxers Fx
distal 3rd of the 5th metacarpal
Osteoporosis bone density measurements**
Standard deviations from the mean for young adults
DEXA Scan
Normal = 1 or less
Osteopenia = between 1 & 2.5
Osteoporosis = more than 2.5
Severe osteoporosis = more than 2.5 w/ Fx
Synovial joint accessory structures
Bursa
-fibrous sac filled with synovial fluid
Tendon sheath
-elongated cylindrical bura wrapped around a tendon
Meniscus
-moon shaped cartilage in the knee
Viewing imaging
Systematic Approach to Radiograph
ID patient and right/left
Bone and Joint Alignment
Joint spaces
Cortical outline
Bone texture
Soft tissues
Immobilization complications
DVT Infection PE Muscle atrophy Psychiatric disorders
Geriatrics are increased risk
4 stages of gout
1 High uric acid levels
2 Acute gout
3 intercritical gout (remission periods)
4 Chronic gout
Giant cell tumors of bone
Many types
females, 3rd decade
knee, distal radius, sacrum
large effusion, painful
surgery
Type A and B Cells in joints (osteoarthritis)
Type A = clears debris
Type B = produce components of synovial fluid
Fracture Healing Steps (4)
Hematoma formation
Soft callus forms
Hard callus forms
Bone Remodeling
Metabolic syndrome
Elevated
BP, Blood sugar, Chloesterol
increased body fat around waist
Ankylosing Spondylitis
Chronic inflammatory disease of the axial skeleton
human leukocyte antigen (HLA)- B27 surface antigen found in 88 to 96% of patients.
It is thought that the combo of this antigen and an exogenic component (Klebsiella or Chlamydia) trigger disease process
Imaging = bamboo spine
30 degree forward lean (posture)
nsaids, bracing, swiming PT for posture
may need surgery
What does the inorganic matter in bones do
it causes the bones to harden
in children this is called ricketts
in adults it can be osteomalcia
without it you end up with soft bones
reactive arthritis
Reiters syndrome (rare)
Can’t see, cant pee, cant climb a tree
vision (conjunctivitis), urinary issues, arthritis
STI of Chlamydia urethritis or gastroenteritis
HLA-b27 antigen 80% positive
PT, nsaids, antibiotics
7 types of fractures
Stable Open, compund Transverse Oblique Comminuted Compression Stress
Structural Joint types
Fibrous
3 fibrous are suture, gomphosis, syndemosis
Cartilaginous
synchondroses (connected by hyaline cartilage) ribs and sternum
and
symphyses (connected by fibrocartilage) ie intervertebral discs
Synovial
Schirmers test
filter paper is placed inside lower eyelid
eyes closed for 5 mins
paper is then measured for moisture
Carpal Tunnel Syndrome
Median neuropathy
Compression of median nerve as it crosses under the flexor retinaculum at wrist
Tinel test, phalen sign
nsaids, splinting, may need surgery
Bruxism
Teeth grinding
Descriptions of fractures
Location Direction Alignment Open vs closed Displaced
Russell bodies
Russell bodies are the accumulation of immunoglobulin in plasma cells: a characteristic finding in patients with multiple myeloma
Spontaneous reduction of dislocation
Dislocations that reduce spontaneously require immobilization for 2-4 weeks then ROM activity then return to normal activity
Rib Fractures
Excellent blood supply
Heal without immobilization
Think about a pneumothorax with high impact injury
(Sports, osteoporosis, cancer)
Spiral Fx
Spiralfractures result from a rotatory mechanism;
on x-rays, they are differentiated from oblique fractures by a component parallel to the long axis of bone in at least 1 view
Systemic lupus erythematosus
Autoimmune disorder characterized by inflammation, positive ANA level and involvement of multiple organs.
ANA 99%, also Anti-dsDNA, anti-Smith antibody
women, AA
unkown cause, maybe genetic, environmental, dietary
Malar rash, fatigue, fever, UV sensitivity, hair loss, joint issues
Sun protection, hydroxychloroquine
Lateral Epicondylitis
Lateral = Tennis elbow
Pain on outside of elbow
Most common elbow injury
4th decade
surgery rare
Name for the outer layer of long bone
Periosteum
Osteoporosis
bone density decreases
age, postmenopausal women
Compartment syndrome
Most common site – anterior compartment of lower leg
pain increases or seems out of proportion to known injury
5 P's Pain Pallor Pulselessness Parasthesia Paralysis
TMJ
Stress, teeth grinding
Restricted ROM, pain, click/pop
normal xray
Compact Bone tissue make up
One third is organic matter
Osteoblasts synthesize
collagen, carbohydrate protein complexes,
two thirds is inorganic matter
85% hydroxyapatite (crystalized calcium salts)
10% calcium carbonate
other misc minerals
Wolffs law
the ability to adapt to stress
(plasticity of bone)
Increase the stress to a bone, it will increase bone density
Decreasing the stress will reduce the density
Spinal stenosis
Laminectomy – most common, removal of lamina, bone spurs
Laminoplasty – lamina removed, plates and screws replace
Foraminotomy - decompression allowing room for nerve root exit
Interspinous Process Spacers – spacers placed between spinous processes to create room, also involves a partial laminectomy
Spinal fusion – reserved for patients with radicular pain, or unstable spine and other options have not been effective. Long recovery.
4 types of spinal fx
Compression 1pt
Burst 2pts
Translation / rotation 3pts
Distraction 4pts
Hip fractures
90% are from falls
Women 2-3 times more likely
Types=
Subcapital neck fx (top of neck)
Transcervial neck fx (mid neck)
intertrochanteric fx (below neck)(through trochanter)
Subtrochanteric fx (top of shaft below trochanter)
Greater trochanter fx
lesser trochanter fx
Benign bone tumors
Usually asymptomatic
x ray
Distal Tibia Fractures
Notorious for having a poor blood supply, particularly at the junction of the middle and distal thirds
Very prone to nonunion
Calcium needed daily
1200 for women
1000 for men
ages 51-70
1200 for all over 70
Fat Pad (sail sign)
Signs of inflammation
Swelling around fracture site
Functional joint types
Synarthroses (no movement) ie sutures in skull
Amphiarthroses (small amount of movement) ie pubic symphysis
Diarthroses (freely movable) ie regular joints
Strains
Trauma to muscle or musclotendinous unit
Tendons
Muscles to bone
Hormones that cause bone to be broken down
Calcitirol
PTH (parathyroid hormone)
Ligaments
Bone to bone
Inner portions of long bone are mde up of
Spongy bone
filled with red bone marrow
Rotator cuff syndrome
MRI is gold standard
Nsaids, rest, steroid injection, PT, strength exercises
Can need surgical repair
Grades of Strains
I = Tear a few muscle fibers with fascia intact
II = Tear moderate amount of muscle fibers fascia is intact
III = Tear all muscle fibers, fascia still intact
IV = Tear all muscle fibers, Fascia is disrupted
Strain
Musculotendinuos unit injury
pulled muscle
Epiphyseal line
In an adult when the growth plate is closed (line of compact bone between the epiphysis and the metaphysis)
Achilles tendon
Tendonitis (inflammed) Tendinosis (tiny tears, still intact) Tendon rupture (tears)
NO STEROIDS INJECTIONS
Usual surgery for rupture
MRI
Grade II Strain
II = Tear moderate amount of muscle fibers fascia is intact
Pain with weakness, no loss of function
Compartment syndrome times
3-4 hours changes are reversible
6 hours muscle damage
8 hours irreversible muscle damage
Fracture Mneumonic
OLD ACID
O Open or closed
L Location
D degree (Complete vs incomplete) (broken in 2 parts)
A Articular extenision (joint involvement)
C Comminuted (shattered?)
I Intrinstic bone quality (pathology)
D Displacement?
Waddell Signs
Disc herniation
Assist in identifying patients most likely to benefit from surgery
The presence of 3 or more Waddell signs is associated with poor outcomes due to underlying psychosocial issues.
Signs are: superficial and non—atomic tenderness, axial loading and acetabular rotation simulation, distraction, regional sensory disturbance and weakness, overreaction
Inner lining of medullary cavity
endosteum
Polymyalgia rheumatica (PMR)
50% temporal arteritis
over 50
associated with Giant cell arteritis
ESR levels are markedly elevated. Temporal artery biopsy if suspected GCA
steroids long term (2 years)
Sprains
Injuries to ligaments
A “starry sky” pattern
A “starry sky” pattern is seen in patients with Burkitt’s lymphoma as a result of macrophages engulfing cellular debris.
Minimum Xray views for fracture
AP
Lateral
Lower limbs might also add weight bearing and non
weight bearing
What do perforating (sharpeys) do
They give the tendon (muscle) something to adhere to on the bone
What runs through the central canal of the osteon
Nerve and vascular bundle
perforating canals branch off periodically to spread supply around to bone
Hip fractures misnomer
Hip is a joint not a bone
Hip = Ball of the femur and acetabular socket of the pelvis
Irony –
neither a fracture of the ball of the femur (femoral head) or the acetabular socket is considered a “hip fracture”
polymyositis
WBC attack muscles (auto immune)
unknown cause
Trunk and torso
higher in females
gradual skeletal muscle weakness (usually painless), Dysphagia Malar skin rash Polyarthralgias Muscle atrophy
CPK and aldolase levels are elevated
steroids, methotrexate
5% die (usually due to cardiopulmonary complications)
Spondylosis
a type of arthritis spurred by wear and tear to the spine.
It happens when discs and joints degenerate, when bone spurs grow on the vertebrae, or both.
Can also cause referred pain in the shoulder
Spinal compression fx
Most spinal compression fractures are due to osteoporosis
no history of trauma dowagers hump (loss of height and rounded back
vertebral body collapse
anlagesic, brace, possible surgery
red flag is neuro compromise, bladder dysfunction
Osteoporosis
A state of Low bone mass
Mechanisms of injury in musculoskeletal
Pathology/injury
Diseased and Weakened bone
ie osteoporosis
hip/tochanter fractures
microfractures in bones
What is within the periosteum of long bones
Perforating (sharpeys) fibers (collagen fibers)
External sheath
Neuro assessment of injury (Fx)
Assess neuro function of injured limb
Before and after every intervention
i.e. immobilization, patient movement, pre and post op, on daily rounds, while waiting for radiology etc.
Swelling or effusion on Xray
Can be seen as a haze or shading around bone
Ankylosing Spondylitis signs/symptoms
Insidious onset of pain in lower back, buttocks and heels
Symptoms improve with activity during the day, and return in the evening
Earliest changes – sacroiliac joints, proceeds up spine
Loss of motion
Lordosis of cervical and lumbar spine
Synovitis, progressive fibrosis and ankylosis of joints
Spinal kyphosis
Greenstick Fx
greenstickfractures (cracks in only 1 side of the cortex) are childhood fractures.
Things to do when first seeing patient with possible fracture
Confirm Name and date Search for old films for comparision Identify bones and joints Is skeleton mature? Soft tissue injury or swelling Fractures, dislocations, joint
Best spinal cord injury imaging
MRI
Scotty (or Scottie) Dog sign with collar
pars fracture or defect (seen on oblique view)
Meniscus injury
Excess rotation of femur
Medial most comon
usually with other ligament injury
MRI gold standard
Mcmurray test
Hand / Wrist pain
Mostly due to OA & RA
Neck Pain
Spondylosis is the most common condition affecting the cervical spine.
Growth plate fractures
Salter Harris Fx
Mechanisms of injury in musculoskeletal
Fractures/injury
Direct
bone breaks at site of impact or force
indirect
force occurs at a distance from wear fracture occurs
ie twisting, spiral, bending, tension
Disc Herniation
a disc herniation will have a clinical presentation based upon where the herniation occurs
L4/5 , L5/S1 most common
Age, genetic inheritance, occupational and recreational injury, smoking, obesity
Pain and symptoms worse in forward flexion, better in extension
MRI
Surgery not always required
90% spontaneous resolution in 12 weeks
nsaids PT rest, oral steroids
Spinal stenosis
Etiology: hypertrophic degenerative processes and spondylolisthesis compressing the cord, cauda equina, individual nerve roots, arterioles and capillaries
No need for plain radiographs – lead to no change in treatment
CT and MRI are helpful to guide intervention via injection or surgery
nsaids, gaba, lyrica, PT, epidural, possible surgery
Sjogren syndrome
Dry eyes, mouth
Autoimmune disorder that destroys the salivary and lacrimal glands
RF is present in over 70%
ANA in 60%
Anti-Ro (SS-A) antibodies in 60%
Anti-La (SS-B) antibodies in 40%
Artificial tears, hydration, cyclosporin
Pseudo tumor
Cystic bone lesions
Simple Bone Cyst
usually from child hood fracture
aspiration with steroid injection
Avascular necrosis sites from Fx
Femoral head
5th metatarsal (jones Fx)
Scaphoid Fx
Long bone : Cavity in the diaphysis or shaft
Medullay cavity
filled with yellow bone marrow
Morton neuroma
interdigital neuroma
pain in third web space between thrid and fourth metatarsals, radiating to third and fourth toes
Ice, massage, inserts, nsaids
Aging Muscle loss
Sarcopenia
Loss of muscle mass over time and age
fibers decrease water in tendons decreases grip strength decreases heart muscle declines metabolism slows lipids increase
Muscle replaced by adipose tissue
Epiphyseal plate
In children this is where the bone is elongating
thin layer of hyaline cartilage between epiphysis and metaphysis
Interspinous Process Spacers –
spacers placed between spinous processes to create room, also involves a partial laminectomy
Spinal stenosis
Epiphysis
Enlarged ends of long bone
strengthen joint and anchor ligaments and tendons
Epicondylitis (2 types)
Lateral = Tennis elbow
Pain on outside of elbow
Medial = golfers elbow
Pain on inside of elbow
Schleroderma
excess thickened collagen
raynauds is symptom
females 4 to 1, 30-50
Chronic and rare autoimmune systemic vascular and connective tissue disease
localized or systemic
ANA is present in 90% with diffuse scleroderma
PPIs for GI, CCB for raynauds, immunosuppressive
Malunion
Malunion – healing occurs but not in correct anatomical position
Factors contributing to malunion –
poor skill of clinician, inadequate blood flow, loss of reduction
Pectus excavatum
Sunken chest
Fatigue
Shortness of breath/decreased exercise tolerance
Chest pain
Fast heart rate (tachycardia)
Torus Fx
Torusfractures (buckling of the bone cortex)
Bulging
Fat embolism
Long bone fractures
occur in 3 days from injury
Tachypnea
PE
Confusion
Petechial rash
Most common form of arthritis
Osteoarthritis
Caudal equina syndrome Classic findings
S P I N E
Saddle anaesthesia Pain incontinence Numbness Emergency
Emergent condition
Grade IV Strain
IV = Tear all muscle fibers, Fascia is disrupted
Pain with weakness and loss of function
Complete rupture
Cruciate ligmanet injury
Anterior and posterior
acl more common than pcl
women more affected
Lachman, anterior drawer test
MRI
Transverse Fx
Transversefractures are perpendicular to the long axis of a bone.
Four rotator cuff muscles
SITS Supraspinatis Infraspinatie Teres Minor Subscapularis
SCFE
Slipped capital femoral epiphysis
Males, AA, athletes, 12-14 years
pain, altered gait
obese teen, dull nonradiating aching pain in hip, groin, thigh or knee, no trauma
trendelenburg gait (pimp stroll)
Urgent ortho eval
Acute = under 2 weeks
Chronic over 2 weeks
will eventually progress to other side 30-60%
Fracture terminology Classifications
displaced = bone is not in normal alignment
non displaced = bone is still in anatomical position
Angulated = i.e. broken “v” angle
Bayonetted = bone overlaps longitudinally
Distracted = Bones are seperated by a Gap between
Bones (segmented)
Aging bone issues
Mineral content decreases
crush fractures of spine can occur
less water in cartilage
connective tissues lose elasticity
Salter harris Fx’s undetectable on xray
Types I and II
Psoriatic arthritis
Arthritis found in people with psoriasis
Spinal stenosis
Narrowing of any part of
the lumbar spine – spinal canal, nerve root canal and intervertebral foramina
usually in 60’s, degenerative,
CT or MRI
Low back pain, pain in legs while walking
similar to claudication
RICE, nsaids, PT, steroid inection, possible surgery
Osteoporosis
Bone density decrease
Caudal equina syndrome
not a true spinal cord syndrome
instead it effects lumbar, sacral and coccygeal nerve roots
Numerous etiologies – trauma, degenerative changes, vascular, Iatrogenic, neoplastic
Diagnostic – high post-void residual, MRI
Emergent condition
Fracture terminology Closed vs open
Closed = doesnt break skin
open =breaks skin
Type I collagen and Type II Collagen in joints (osteoarthritis)
Type I collagen is found in bones and skin
Type II collagen is the main collagen in cartilage
5 types of laceration
Split Stretch Avulsion Tear Cut
Diaphysis
Shaft of long bone (provides leverage)
Distal Radial Head fracture
FOOSH
Most common type is Colles
Fracture managment
immobilize, reduce sweling RICE Nsaids possible sedation, anesthesia, blocks possible surgery
C spine trauma
Stabalize neck
CT or MRI whichever is fast
perform neuro exam, get Neuro consult
Fractures in elderly
Hip Fx's Ankle Proximal humerus Distal radius Vertebral compresion Fx
all more common in women
Osteoarthritis of the knee
Spurring femur bone
Degenerated articular cartilage
Spurring tibia bone
Females, age
Non-union
Non-union – failure of the fractured ends to bond, heal back together
Factors influencing non-union –
smoking, venous stasis disease, atherosclerosis, malnutrition
Common Type of shoulder x ray
AP shoulder view
True AP = shows GH joint
Ankle strain and sprain
Strain is tendon
Sprain is ligament
Most common ankle injury
inversion on injury of the
Anterior Talofibular ligamnet (sprain) (ATL)
Anterior drawer test
RICE, PT, xray to r/o Fx
Ordering imaging
General Basic Guidelines
Typically begin with plain radiograph
CT to see bone well
MRI to see tissue well
Lot’s of exceptions!
Knee Fx
Probably the injury that is the worst of all of the possible knee injuries
4 bones meet at knee
Imaging pearls
Fracture not involving a joint – plain X-ray
Fracture involving joint – plain X-ray if NO ligamentous injury on clinical exam, MRI if joint function impaired or suspected injury
Complex fractures requiring reconstruction – CT, spiral
CT – think tri-malleolar ankle fracture, pelvic crush injury.
Spine – typically MRI, especially if neurological deficit exists
Back pain – typically does not require X-ray in younger adult with no history of injury
Dislocation
Complete misalignment of the bones and joint
RA vs OA
RA = women 3 to 1 20-40 weeks to months symmetry improves with usage fatigue malaise
OA= older years asymmetry Worse with use no additional symptoms
Reduction
Reduction – the action of re-aligning fractured pieces of bone or placing a dislocated joint back into correct anatomical position
Osteomyelitis
Bone infection
Staph most common
salmonella, pseudomonas, strep, e.coli etc
Infection symptoms, fever, fatigue etc.
xray, ct, mri, ultrasound (MRI is best)
Woundcare, antibiotics (VANC)
Ewing sarcoma
Second most common bone tumor
Aggressive malignancy with high rate of metastasis
5-25 y/o, males
femur, pelvis, tibia, humerus, scapula
“Hair on end” appearance, “onionskin”,
Chemo, surgery
Pelvic Rami Fracture
Superior and inferior rami – non-weight-bearing areas
Typically occur in geriatric patients, trauma or demineralizing conditions
Do not require surgery, can not be immobilized
Curtail weight-bearing only for pain management
Get patient up and mobilizing as soon as pain is tolerable
Refer to Physical Therapy
Fracture reduction
Can..
alleviate pain
relieve tension on nerves and vessels
eliminating risk of conversion to open restores circulation to pulseless ext.
PARS Defect and Fracture
PARS defects are small stress fractures resulting from over-use, typically in a young athlete, results from repetitive hyperextension.
rest, strength, streching splint
Scotty dog sign with collar
Hormones that cause bone genesis
Calcitonin
6 features of synovial joints
Articular cartilage (hyaline cartilage)
Joint cavity
Articular capsule
Synovial fluid
3 possible reinforcing ligaments (capsular, intracapsular, extracapsular)
Rich nerve and blood supply
Intertrochanteric Fracture (Hip Fx)
Area between the greater and lesser trochanters
(blood supply ususally intact)
surgical fixation is common
Two joint classifications
Functional Joints
Structural Joints
Scaphoid Fx
Common
Difficult ot see on film (might need MRI/Bone scan)
avascular necrosis possible if untreated
pain, swelling, bruising over snuff box
THumb psica csat
Drug induced lupus drugs
I hate multiple meds causing queer problems
IHMMCQP
INH Hydralazine Minocycline Methyldopa Chlorpromazine Quinidine Procainamide
Where is red bone marrow located
Spongy bone (long bone) epiphysis
DDH
Developmental dysplasia of hip
ball of hip comes out of socket
can be due to shallow socket (acetabulum)
can be comletely dislocated or subluxed (partial,loose)
Tends to run in family
usually left hip
girls, first born, breech baby, low amniotic fluid (oligohydramnios)
Legs differnet lenghts, skin folds uneven,, limb,
Barlows test, ortalanis test
May need pavlik harness or spica cast
possible surgery
Grade II Sprain
II = Partial tear with some instability and laxity of joint
Protected motion, full healing expected
Avulsion Fx
Avulsionfractures are caused by a tendon or ligament dislodging a bone fragment.
Disc herniation surgery
Persistent treatment in spite of a reasonable course of nonoperative treatment
Profound or progressive motor deficit
Cauda Equina Syndrome
Intractable pain
Patient preference
Sprains in children
Sprains are uncommon in children with open growth plates.
This is because the physis is weaker than the ligaments and the physis may fail before the ligament does
Salter-Harris fractures & Avulsion fractures are more likely
Fibromyalgia cardinal symptoms
Pain
stiffness
fatigue
non restorative sleep
Mechanisms of injury in musculoskeletal
Injury
Repetitive stress
pathology
Clavicle Fractures
Strong blood supply
Most managed conservatively with “figure 8” brace or sling of arm on fx side
Out of activity ~ 8 weeks – 4 in a sling, 4-6 out
Weight restriction to a few pounds
May return to full weight training/physical work at 3 months
Need radiographic confirmation of healing prior to returning to full activity
Marfan Syndrome
A connective tissue disorder, which causes skeletal defects.
Is typically recognized by long limbs and ‘spider-like’ fingers, chest abnormalities and spine curvature
Metaphysis
Below the ephyiseal line and above the diaphysis
Salter Harris Fx (info)
5 types All involve growth plate adult cannot have a SH Fx Type II is most common Worst prognosis is TYpe V
Teardrop-shaped erythrocytes (dacrocytes)
Teardrop-shaped erythrocytes (dacrocytes) are commonly present in patients with myelofibrosis, myeloid metaplasia, and beta-thalassemia major.
Plantar Fasciitis
Inflammation of the plantar fascia
heel pain, walking, weightbearing
middle age, women, lots of walking, runner, poor flexion
RICE, nsaids, stretches, inserts
Dequervain syndrome
Inflammation of two tendons and the sheath that controls thumb movement
Women, 30-50, pregnancy
lifestyles with frequent wrist movement
Finklestein sign (thumb in fist, pain over thumb)
nsaids, spica, PT/OT, Steroid inj, surg decompression
osteon
Tree trunk looking like bone cells (compact bone)
concentric rings of osseus tissue
Contain dark spots which are osteocytes
Parts include osteocytes, lacuna (lake around dark spots or osteocytes), canalculi, central canal, Lamella
Spondylolisthesis
a vertebra shifts due to instability
can be degenerative or traumatic
External fixation
External fixation – the use of an external brace to maintain alignment during healing
Scoliosis
lateral curve of spine
idiopathic, cogenital, neuromuscular
admas test, forward bend test
25% is significant
Bracing, surgery
Ankylosing Spondylitis Pearls
Associated with HLA-27 surface antigen
Progressive
First radiologic sign – increased SI joint space
Classic radiographic sign – “Bamboo Spine”
Multi – system disease
Hereditary component
Loss of Kyphotic curve, plantar fasciitis, inflamed costosternal joints – typical triad, though not all will be present in all patients
Salter Harris Fx Types
Mneumonic
SALTR (in relation to growth plate)
Type =
I = Straight (parallel and inside growth plate)
II = Above
III = Lower
IV = Through (vertically through growth plate)
V = Rammed together (crushed)
Ankylosing Spondylitis classic presentation
Young adult male
Late teens to late twenties
Better with activity, worse with rest
Pain fluctuates
Low back pain, SI pain, buttock pain
Morning stiffness
Kyphoplasty vs vertebroplasty
both are used for compression fractures of spin
Kypho a ballon is used, then cement
Vertbro, imaging is used then cement (no ballon)
Acromioclavicular Seperation
AC seperation, seperated shoulder
6 types
Type 1 Ligament stretched
Type 2 Partial rupture
Type 3 Complete rupture
Type 4 Clavicle is displaced over acromion process
Type 5 Clavicle is displaced up, just under skin
Type 6 Clavicle is displced uner acromion process(very rare)
Sciatica
Caused by disc herniation
Compression of the L4 nerve
Pain from lower back down to knee
Compression of S1 nerve
pain can go all the way to ankle
Or can be caused by piriformis syndrome
swollen piriformis muscle compresses nerve
Scotty (or Scottie) Dog sign
a NORMAL appearance of the lumbar spine when seen on oblique view
Rotator cuff syndrome causes
Occurs with eccentric overload (Throwing objects),
underlying glenohumeral instability,
poor muscle strength and training errors.
impingement of the supraspinatus tendon as it passed beneath the subacromial arch.
