High Yield 3 Flashcards
MOI + RF DIP dislocation
MOI - Hyperextension injury of DIP joint
RF: basketball, football, baseball
Usually dorsal dislocation
Physical for DIP dislocation
Hold PIP joint in extension, check FDP + extensor function
Apply radial + ulnar stress at full extension + 30 degrees flexion to look for laxity
If increased hyperextension of joint = volar plate injury
XRs for DIP dislocation
AP, lateral, oblique if won’t delay reduction
Management of DIP dislocation
Apply steady traction to distal finger
If irreducible - refer to ortho
Splint in slight flexion for 1-2 wks
MOI for PIP dislocation
Hyperextension or hyperflexion, entrapment between objects, fall
Usually dorsal dislocation
Physical for PIP dislocation
Volar tenderness = volar plate injury
Lateral joint line tenderness = collateral ligament injury
Dorsal tenderness = central slip injury
Extend PIP + DIP joints
If unable to extend PIP but able to extend DIP, think central slip rupture
Flex DIP + PIP joints
If unable to flex DIP joint, consider FDP rupture = refer to plastics
Apply radial + ulnar stress at full extension + 30 degrees flexion to look for laxity
If increased hyperextension of joint = volar plate injury
XRs for PIP dislocation
AP + lateral if won’t delay reduction
Management of PIP dislocation
Apply steady traction to distal finger
Splint for 1-2 wks in slight flexion until pain free
If co-existing volar plate injury, splint for 4-5 wks
Buddy tape for additional 3-4 wks
Could buddy tape alone for 3-6 wks if no volar plate injury
What is Dupuytren’s Contracture?
Contracture of palmar fascia causing flexion deformity
Autosomal dominant
Often bilateral
Ring finger more frequent
RF for Dupuytren’s Contracture
Males
Northern European
Fam hx
Smoking
Alcohol use
Increasing age
Diabetes
Sx of Dupuytren’s Contracture
Mild pain
Later, painless lump on palm
Physical of Dupuytren’s Contracture
Firm nodule in palm of hand proximal to MCP
Hueston tabletop test - positive if pt unable to flatten hand on table
Management of Dupuytren’s Contracture
Steroid shot or collagenase clostridium histolyticum shot
Surgery - partial fasciectomy if contracture reaches 30 degrees
What is the TFCC?
Triangular Fibrocartilage Complex
Ligament/ cartilage stabilizer that stabilizes the distal radioulnar joint and absorbs stress on the ulnocarpal joint
MOI of TFCC injury
Acute collision (fall on outstretched hand, traction or hyperrotation)
Repetitive injury (chronic loading of ulnar wrist)
Sx of TFCC injury
Ulnar sided pain + clicking
Weak hand grip
Pain pushing out of chairs
Pain w/ pronation, supination or extension w/ axial load
Physical for TFCC injury
TFCC compression test positive
Fovea sign (point tenderness at recess of TFCC)
Ulnar compression test to r/o instability
Ix for TFCC injury
Lateral + PA XRs
MRI
Arthroscopy can be diagnostic
DDx for TFCC injury
Tendinopathy (ECU, FCU)
DRUJ instability
Carpal instability
Management + RTP of TFCC injury
Conservative up 8-12 wks
NSAIDs
Immobilization (ulnar deviation, slight volar flexion) in short arm cast x4-6 wks if traumatic
Surgery
If sx persist despite immobilization or if any instability
RTP
3mo post op
What is Carpal tunnel syndrome, and what are the causes?
Entrapment of median nerve
Can be acute but usually chronic
Idiopathic
Inflammation, trauma, tumors, OA, RA
Hx of Carpal tunnel syndrome
Pain, weakness, paresthesias on palmar surface of first 3 ½ digits
Nighttime sx
Improved w/ flicking hands
RF for Carpal tunnel syndrome
Females
Increasing age
Repetitive wrist motion
Pregnancy (usually 3rd trimester + often bilateral)
Diabetes
Physical for Carpal tunnel syndrome
Positive Tinel sign
Positive Phalen test
DDx for Carpal tunnel syndrome
De Quervain tenosynovitis
C6-7 radiculopathy
Ulnar neuropathy
Brachial plexus neuropathy
Management of Carpal tunnel syndrome
Conservative
Splinting (24/7 ideally but nighttime still helpful)
NSAIDs
Steroid shot
Oral steroids
Surgery
If failed conservative therapy or severe sx
What is Ulnar Tunnel Syndrome vs cubital tunnel syndrome?
Both types of ulnar nerve entrapment
Ulnar tunnel syndrome = Compression of ulnar nerve in Guyon canal in wrist
Cubital tunnel = compression occurs at elbow
RF for Ulnar Tunnel Syndrome
Repetitive occupational wrist trauma
Baseball catchers
Cyclists
Racquet sports
Wheelchair athletes
Sx of Ulnar Tunnel Syndrome
4th + 5th digit paresthesia
Weakness of grip
Physical for Ulnar Tunnel Syndrome
Positive Tinel sign at pisiform
Sensory loss at tip of little finger
Weakness w/ resistance of adductor pollicis
Decreased grip strength
Ulnar claw hand w/ paralysis of the deep motor branch
DDx for Ulnar Tunnel Syndrome
Proximal ulnar entrapment
Calcific tendonitis of FCU
Management of Ulnar Tunnel Syndrome
NSAIDs
Steroid shot
Splinting
Surgical decompression
RTP 4-8 wks after surgical decompression
Sx of Cubital Tunnel Syndrome/Ulnar nerve entrapment
Medial elbow + forearm pain
Paresthesias in 4th + 5th digits
Worsening grip
Clumsiness
RF for Cubital Tunnel Syndrome/Ulnar nerve entrapment
Males
Overhead throwing athletes
Repetitive upper extremity activities
Diabetes
Obesity
Physical for Cubital Tunnel Syndrome/Ulnar nerve entrapment
Pain w/ palpation of cubital tunnel
Elbow flexion test: flex the elbow past 90°, supinate the forearm, and extend the wrist. Results are positive if discomfort is reproduced or paresthesia occurs within 60 seconds. The addition of shoulder abduction may enhance the diagnostic capacity of this test.
Positive Tinel test in ulnar groove
↓sensation of little finger
Loss of grip and pinch strength and loss of fine dexterity, clawing of baby finger
Management of Cubital Tunnel Syndrome/Ulnar nerve entrapment
Conservative: rest (minimize elbow flexion), splint or foam elbow pad, NSAIDs
Surgery if sx after 3mo
Screen overhead athletes for ulnar collateral ligament instability
What is a Colles #?
Distal rad # w/ Dorsal displacement
Silver fork deformity
What is a Smith #?
Distal rad # w/ Volar displacement + angulation
What is a Barton #?
Fracture dislocation of distal rad w/ displacement of carpus w/ distal fragment
What is a Hutchinson/ Chaffeur #?
Lateral-oriented # through radial styloid process
What is a Galeazzi #?
Fracture of distal ⅓ of radius w/ dislocation of distal ulnar
What is a Monteggia #?
Ulnar fracture Radius dislocation
MOI + RF for distal radius #
FOOSH w/ wrist in extension
OP
Falls
Sx + exam for distal radius #
Pain, swelling, limited ROM
Wrist exam
Tenderness dorsal aspect of wrist
Ix for distal radius #
XRs (consider bilateral) - AP + lateral of wrist, forearm + elbow
CT for surgical planning
Management of distal radius # (displaced, non displaced, general management, recovery timeframe)
Non displaced
Immobilised in radial gutter splint
Repeat XR in 3 days
Short arm cast 4-6 wks
Repeat XRs q2wks
Displaced
Finger trap reduction
Repeat XR in 3 days
Long arm cast 3-4 wks then short arm cast 3-4 wks
Repeat XRs weekly
Vitamin C 500mg PO x50 days reduces incidence of CRPS
Activity modification recommendations + home exercises
Time frame for recovery
6-8 wks in adults
3-4 wks in kids
When to refer to ortho for distal radius #
Open #
Unstable
Neurovascular compromise
Tenting
Significantly displaced
Complications of distal radius #
TFCC injury
Median nerve neuropathy
Ulnar nerve neuropathy
Malunion
Prevention of distal radius #
Wrist guards during high risk activities (beginner snowboarders)
MOI for Scapholunate ligament injury
FOOSH
Axial compression
Sx of Scapholunate ligament injury
Pain and swelling in dorsal wrist
Pain or weakness w/ hyperextension + loading of wrist
Physical for Scapholunate ligament injury
Wrist effusion in acute injuries
Tenderness between lunate and scaphoid
Pain in loaded wrist extension (Ex. push up)
Increase in pain with combined movement of extension and radial deviation of the wrist
Positive Watson test
- The examiner uses their thumb to apply pressure on the scaphoid tubercle (on the radial side of the wrist, just distal to the radial styloid).
The other fingers of the examiner’s hand stabilize the dorsal aspect of the wrist.
The wrist is moved from ulnar deviation and slight extension to radial deviation and flexion while maintaining pressure on the scaphoid.
- positive = pain or clunk
Ix for Scapholunate ligament injury
Wrist x-rays: AP, lateral, scaphoid view, pencil grip PA, clenched fist view
Clenched fist views may show widened gap between the scaphoid and the lunate (> 3mm is concerning)
Comparison views
DDx for Scapholunate ligament injury
Scaphoid #
Radius #
Synovitis
OA
Management of Scapholunate ligament injury
Stabilize w/ thumb spica splint + refer to plastics
Immobilization x6 wks in short arm cast - may be effective in partial tear or patients with lower functional requirements
If complete tear or unstable, refer to surgeon
Immobilize post op x8 wks
RTP when showing progression in strength + ROM
MOI Ulnar styloid #
FOOSH
Often associated w/ distal radius #
MOI for monteggia #
Usually in children
Direct blow to posterior elbow
Hyper-pronated force on an outstretched arm
Contracted biceps resists forearm extension causing dislocation and followed by impact leading to ulna fracture
Types of metacarpal shaft #
Transverse, oblique/ spiral, comminuted
Types of metacarpal base #
Intra-articular:
Bennett fracture: fracture combined with a subluxation or dislocation of the metacarpal joint
Rolando fracture: T- or Y-shaped fracture involving the joint surface
Extra-articular
MOI of metacarpal neck #
axial load on MCP joint while in flexed position (throwing a punch)
AKA Boxer’s # - most common hand #
Sx + physical of metacarpal neck #
Immediate pain + swelling
Extreme angulation can cause pseudoclawing (hyperextension of the MCP joint along with proximal interphalangeal (PIP) joint flexion as the patient attempts to extend the finger)
Evaluate for malrotation by getting pt to bring fingernails into palm - should point towards base of 1st metacarpal
XRs for metacarpal #
AP, oblique, true lateral
Management of metacarpal neck #
NSAIDs
reduction if significant angulation :
- flex the MCP, PIP, and distal PIP joints all to 90 degrees.
- Apply dorsally directed pressure along the proximal phalanx shaft through the flexed PIP joint while simultaneously applying volarly directed pressure over the proximal fracture fragment
Immobilize in radial (for 2nd + 3rd) or ulnar (4th + 5th) gutter splint with the wrist in 30 degrees extension, MCP joint in 70 to 90 degrees of flexion, and PIP/distal interphalangeal (DIP) joints near full extension x3-4 wks
Surgery if significant angulation or any malrotation, open #
RTP when pain free ROM
MOI metacarpal base + shaft #
Direct blow versus indirect blow with rotational torque: Rotational torque often leads to spiral fractures
physical for metacarpal base + shaft #
Tenderness + swelling dorsal hand
Pain w/ motion
Inability to make fist
Evaluate for malrotation
All the fingers of a semiclenched fist should point to the scaphoid tubercle.
In comparison to the asymptomatic hand, no crowding or digital overlap should be present when the digits are fully flexed.
With metacarpophalangeal (MCP) at 90 degrees flexion and digits in extension, the plane of the fingernails should be parallel on the injured and normal hand
Flexor + extensor tendon function
Management of metacarpal base + shaft #
Splinting
Reduction (for transverse fractures, isolated spiral/oblique fractures with <3 mm of shortening, and extra-articular fractures of the thumb)
Closed reduction of metacarpal shaft fractures is performed with longitudinal traction, dorsal pressure at the fracture site, and rotation as needed.
Closed reduction of extra-articular base fractures typically requires only longitudinal traction.
Post reduction XRs + XRs 1 wk after
Ulnar gutter splint for 3 to 4 wk for extra-articular metacarpal base fractures if ring and/or little finger(s) are involved
Volar or radial gutter for 3 to 4 wk for extra-articular metacarpal base fractures of index and long finger
Functional brace (Galveston) if fracture requires significant reduction
Thumb spica cast for extra-articular fractures of the thumb for 4 to 6 wk
Referrals
Referral is needed for unstable or unsatisfactory reductions in children.
Long oblique and spiral fractures typically require closed reduction and percutaneous pinning in children
Metacarpal fractures that are more distal and ulnar are better tolerated and are more amendable to nonoperative treatment
What is a Stener lesion?
An injury that occurs in the thumb, specifically involving the ulnar collateral ligament (UCL) of the metacarpophalangeal (MCP) joint. It is a complication of a complete rupture of the UCL, commonly caused by trauma such as a fall on an outstretched thumb or forced thumb abduction.
In a Stener lesion, the torn UCL becomes displaced proximally and gets caught above the adductor aponeurosis.
This effectively prevents healing without surgical intervention
Common w/ complete tear
What is a skier’s thumb injury?
forceful thumb abduction and hyperextension
UCL Injury +/- avulsion #
RF for skier’s thumb
Ski poles
MOI for skier’s thumb
Stress to the thumb in extended and/or abducted position
Usually in skiing but often occurs in other sports, such as football and mixed martial arts
Sx + physical of skier’s thumb
Pain at origin + insertion of UCL
Swelling over ulnar aspect of 1st MCP joint
Mild-to-complete instability on stress testing of UCL with MCP joint in flexion, depending on whether it is a 1st-, 2nd-, or 3rd-degree sprain:
Tested at 0 and 30 degrees of metacarpal phalangeal joint flexion
There is significant side-to-side variability in UCL testing in noninjured individuals
Most important physical finding is lack of an end point because this indicates complete ligament disruption
Imaging for skier’s thumb
XR: PA, lateral, stress views. Consider local anesthetic infiltration prior to XRs
Sag sign - Volar subluxation of the proximal phalanx in relation to the metacarpal at the MCP joint may indicate UCL injury
May need MRI
DDx for skier’s thumb
Radial collateral ligament sprain
Metacarpal fracture
Proximal phalanx fracture
MCP sprain
Management of skier’s thumb
Acute - ice, elevation, immobilization
Partial tears or complete tears without stener lesion - non surgical
Protection with thumb spica splint or cast
2 to 4 wk of immobilization followed by 2 to 4 wk of protection during activity
Start range of motion after period of immobilization.
Progress to strengthening exercises as symptoms allow.
Avulsion #
Thumb spica cast x4-6 wks
Complete tears w/ Stener lesion or chronic instability
Surgery
Cast or splint x4-6 wks
Complications of skier’s thumb
Instability leading to decreased pinch strength
Qs to ask in hx of wrist laceration
Hand dominance
Pain
Numbness + tingling
Loss of strength
Bleeding
Tetanus
Physical exam for wrist laceration
Inspection - swelling, bleeding, visible tendons/ nerves, hand/ finger resting position
ROM: wrist flexion and extension, ulnar and radial deviation, supination, pronation
Test flexor digitorum superficialis (FDS) by flexing DIP and flexor digitorum profundus (FDP) by flexing PIP and test extensors with flexed MCP
Neuro: test sensation in ulnar and median nerve distributions, radial on dorsum
Vascular: check radial pulse, cap refill
Volar laceration: median and ulnar nerves, FDP, FDS, flexor pollicis longus, flexor carpi radialis and ulnaris, ulnar and radial arteries
Dorsal laceration: extensors and retinaculum
Management of wrist laceration
Control bleeding
Tetanus if not up to date
If nerve or tendon injury refer to plastics for repair, clean and cover wound
Worse prognosis is associated with injuries in zones II and IV, due to the propensity to form adhesions between tendons within a confined space.
MOI + sx of acute scaphoid #
FOOSH
Sx:
Pain and swelling in wrist
Worse w/ gripping + squeezing
Physical for acute scaphoid #
Wrist effusion
Tenderness in anatomical snuffbox (dorsal) and/or scaphoid tubercle (volar)
Pain with resisted pronation
Reduced grip strength
Ix for acute scaphoid #
Wrist x-rays - PA, true lateral, oblique, scaphoid specific (PA of wrist in full pronation + ulnar deviation) + clenched fist views
Look for >3mm scapholunate widening
X-rays may be normal initially, therefore immobilization in thumb spica and repeat x-rays are recommended in 2 weeks if there is clinical suspicion.
If suspicion is still high, can do MRI for radiologically occult fractures.
Management of acute scaphoid #
Stable, non-displaced, waist or distal pole fractures: Immobilization in thumb spica splint or cast. The immobilization time is longer than for other upper extremity fractures. Need to regularly follow and document radiologic healing.
Distal third fractures: 4-6 weeks.
Waist fractures: 6-12 weeks.
Proximal third fractures: Up to 12-16 weeks due to slower healing and higher risk of avascular necrosis (AVN).
Unstable, displaced > 1mm, vertical or oblique, proximal pole fractures, or any concerning features: Immobilization in thumb spica splint or cast and refer to orthopedics for surgery, semi-urgent.
DDx for acute scaphoid #
Scapholunate dissociation
Distal radius fracture
Extensor carpi radialis sprain
1st metacarpal fracture
Flexor carpi radialis sprain
Carpometacarpal or radiocarpal arthritis
Complications of acute scaphoid #
Non union - more common in pole #
AVN leading to OA
Chronic SLAC
What is a Mallet finger?
Mallet finger is defined as a stretching or tearing of the extensor tendon or a complete avulsion of the tendon insertion from the dorsal base of the distal phalanx with or without bony avulsion
A mallet finger occurs when the extensor tendon at the distal interphalangeal (DIP) joint is injured, preventing active extension of the fingertip.
Typically caused by a direct blow to the fingertip (e.g., a ball striking the finger), forcing it into sudden flexion while the extensor tendon is under tension.
MOI Mallet finger
Sudden forced flexion of the fingertip while the DIP joint is actively extended (struck on tip of finger by ball)
Less commonly, it can occur when the DIP joint is forcefully hyperextended with a resulting fracture at the dorsal base of the distal phalanx
Sx + physical of Mallet finger
Pain, swelling, and deformity at the DIP joint of the affected finger
Tenderness especially at the dorsal aspect, with inability to actively extend the DIP joint
Physical
Tenderness on palpation over dorsum of DIP joint
Inability to actively extend the distal interphalangeal (DIP) joint
Ix for Mallet finger
XRs - PA, lateral, oblique (to assess for avulsion #)
Management of Mallet finger
Splint in full extension - no flexion should occur
6-8 wks
Monitor compliance at 2 wk intervals
At the end of continuous immobilization, if a mallet deformity of >20 degrees recurs, continue splinting for an additional 1 to 2 mo.
Consider extension splinting during athletic activities for an additional 2 mo after continuous splinting has been completed.
After splinting, ROM exercises
Complications of Mallet finger
Swan neck deformity if untreated or poor compliance
What is a Jersey finger?
Flexor tendon avulsion injury
MOI Jersey finger
In classic cases this injury happens when a player goes to grab a jersey of an opponent. The DIP is in flexion, holding onto the jersey, and then is suddenly pulled into extension as the opponent pulls away. This causes avulsion of the FDP tendon off the distal phalanx
Sx + physical for Jersey finger
Most common in ring finger
Pain, swelling and weakness in flexion at DIP
Physical
DIP may be in slight extension
Unable or very weak flexion at DIP
Joint swelling and pain to palpate volar aspect of the joint
Sometimes can palpate retracted tendon
Ix for Jersey finger
XR (AP, lateral, oblique) to r/o bony fragment
MRI
DDx for Jersey finger
DIP joint dislocation
Distal phalanx fracture
Flexor digitorum superficialis avulsion
Management of Jersey finger (immediate, general + RTP)
Immediate: dorsal splint to maintain slight flexion at DIP + PIP
Refer urgently to ortho for surgery
Post surgery: dorsal blocking splint w/ wrist in midflexion, MCP joints at 75 degrees flexion + PIP/DIP joints in extension x6 wks
Strengthening at 12 wks
RTP = 4-6mo
What is a trigger finger?
Nodule on flexor tendon catching on first annular (A1) pulley
RF for trigger finger
Females
Age <8yrs or 55-60 y/o
Diabetes
RA
CTD
Repetitive trauma w/ compressive force against MCP (arc welding)
Hx + sx of trigger finger
Painful catching/clicking with finger flexion or extension
Pain over MCP; may refer to palm or proximal interphalangeal (PIP) joint
Digit may be locked, usually in flexion.
Stiffness develops with prolonged symptoms
Physical of trigger finger
Tender, palpable nodule on flexor tendon, just proximal to MCP
Active fist closing reproduces lock/snap.
DDx of trigger finger
Dupuytren contracture
Carpal tunnel syndrome
Gamekeeper’s thumb
RA
Tendon sheath ganglion
Management of trigger finger
Activity modification
Splinting of MCP joint at 10 to 15 degrees of flexion × 6 to 10 wk
Steroid injection into tendon sheath
NSAIDs
Surgical release of A1 pulley if:
locked digit or pediatric trigger thumb, although there is increasing argument toward conservative management for the latter
Indicated if repeat injections ineffective
Complications of trigger finger (if untreated, of injection + of surgical release)
If untreated:
PIP joint flexion contracture
Distal triggering from FDS tendon degeneration
Of injection:
Fat atrophy and necrosis
Local skin depigmentation
Theoretical risk of tendon rupture
Of surgical release:
Bowstringing of flexor tendon
Second annular (A2) pulley injury
Digital nerve injury
Infection
Long-term scar tenderness
Causes of hip labral tear
Trauma
Repetitive movement
RF for hip labral tear inc sports at high risk
Dysplasia
FAI
Ballet, golf and swimming, football and hockey
Hx + sx for hip labral tear
Pain in the hip or groin, often made worse by long periods of standing, sitting or walking or athletic activity
A locking, clicking or catching sensation in the hip joint
Stiffness or limited range of motion in the hip joint
Physical for hip labral tear
FADIR painful
FABER normal
Ix for hip labral tear
XR
MRA
US guided LA for diagnostic purposes
Management of hip labral tear
Rest from aggravating activity
Strengthening of the pelvic and lower extremity muscles helps to stabilize the joint and correct abnormal pelvic tilt, relieving some of the abnormal stress placed on the labrum
If not working, consider arthroscopy
Types of SCFE
Preslip
Acute
Acute on chronic
Chronic
Sx of SCFE
Pain, stiffness, instability in affected hip
Can occur after trauma or a fall
May or may not be able to wt bear
Physical for SCFE
Ht + wt
Knee, hip + back exam
Leg length
Shortened externally rotated leg
Decreased ROM of hip
Only do AROM
Positive Trendelenburg
Palpate adductors
Quadrant test
Tenderness over hip joint capsule
Positive Whitman sign - hip rotates externally and abducts when flexed
Thigh + gluteal muscle atrophy common in SCFE
Unstable SCFE - unable to wt bear, leg in ext rotation
Reduced ROM, muscle guarding, pain at extremes of motion
Ix for SCFE
XR - AP, lateral, frogs leg view (Klein’s line, slip angle)
XR - slipper head of femur
Can have normal XRs initially - MRI then useful
DDx for SCFE
Avascular necrosis/Legg-Calvé-Perthes disease (in younger age range)
Septic arthritis
Transient synovitis
Iliac apophysitis or apophyseal avulsion fracture at avulsion anterior inferior iliac spine (AIIS) and avulsion anterior superior iliac spine (ASIS)
Femoral cutaneous nerve entrapment (more common in muscular girls)
Proximal femur fracture
Avascular necrosis
Juvenile rheumatoid arthritis
Osteomyelitis
RF for SCFE
Pre-teens + teens
Boys > girls
Rapid growth purt
Radiation therapy
Obesity
RF for bilateral slip: DM, hypothyroidism, black, hispanic, obese
Complications of SCFE
AVN
Arthritis
Management of SCFE
Non wt bearing
Emergent ortho for acute, urgent ortho for chronic
Usually in situ screw fixation to prevent further slippage or ORIF
If high risk, may fix other side
Wt bearing after 6 wks
What is osteitis pubis?
Inflammation of pubic symphisis
Sx of osteitis pubis
Gradual onset anterior medial groin pain
Reduced flexibility
Dull ache or sharp stabbing pain when running, kicking or changing direction or standing/ getting out of car
Loss of acceleration
Pain in hip, groin, testicles, adductors
Physical for osteitis pubis
Reduced hip ROM
Lumbar spine/ SI joint dysfunction
Increased rectus abdominus tone
Pain provoked by active adduction if distal symphysis is involved
Squeeze test positive (adductors against resistance)
If pt gets pain more laterally, could be sports hernia
Ix for osteitis pubis
XR (widening of pubic symphysis, although could be normal)
Flamingo test - pt stands on 1 leg while AP view taken - positive if >2mm vertical displacement of pubis
MRI
DDx for osteitis pubis
Athletic pubalgia (sports hernia - pain more lateral + superior)
Adductor strain (usually recovery quicker)
Inguinal hernia
Hip OA, labral tear, SCFE, FAI
Bursitis
Stress #
Osteomyelitis
Referred pain (lumbar, SI)
AS
Appendicitis, diverticulitis
Management of osteitis pubis
Rx - relative rest (x2-3mo), NSAIDs, ice, stretching
Correct biomechanical abnormalities (leg length discrepancy, excessive pronation)
Core shorts
Activity modification recommendations + home exercises
Adductor strengthening (pelvic tilts, dynamic stabilization)
Abdo + hip strengthening
Time frame for recovery = 9 months
Refractory cases
PRP, steroid
Surgery w/ wedge resection in severe cases
RF for osteitis pubis
Sports: running, football, soccer, ice hockey, tennis
Exercising on hard surface
Exercising on uneven ground
Training after long layoff
Increasing exercise intensity + duration too quickly
Ill-fitting shoes
Tight hip/ groin muscles
Leg length discrepancy
Males > females
Complication of suprapubic + pelvic surgery
pregnancy
RF for abdo muscle strain/ tear
Poorly conditioned abdominal musculature or deficits in core strength
Previous abdominal wall muscle strain/tear
Poor weight training or conditioning techniques
Participation in activities that require abrupt and/or repetitive movements of the torso early in the sport season
Sx + physical of abdo muscle strain/ tear
Can be acute or subacute
Abdo wall pain
Worse w/ active contraction
Physical
Tenderness
DDx for abdo muscle strain/ tear
Abdominal wall contusion
Abdominal wall hematoma:
Swelling, periumbilical contusion, and a mass with rigidity and/or guarding are signs of a rectus sheath hematoma.
Abdominal wall hernia (umbilical, spigelian)
Intra-abdominal injury (contusion, laceration, perforation)
Intra-abdominal process (e.g., infection, mass)
Iliac apophysitis
Osteitis pubis
Management + RTP of abdo muscle strain/ tear
Stop aggravating activity
Ice, compression wrap, NSAIDs
Rehab
Passive stretching
Strengthening
RTP = When no tenderness, normal strength
Usually 2-6 wks
What is athletic pubalgia?
Chronic activity related pain d/t weakness or injury of:
posterior inguinal canal
conjoined tendon (internal oblique + transversus abdominus)
common adductor origin
external oblique aponeurosis
rectus abdominus
What structures could be involved in athletic pubalgia?
Rectus abdominus
Conjoint tendon (internal oblique + transversus abdominus)
External oblique
Adductor longus
Gracialis
RF for athletic pubalgia
Males
Soccer, football, hockey, rugby
Sx of athletic pubalgia
Activity-related lower abdominal and proximal adductor-related pain with quick acceleration, deceleration, kicking, twisting, or lateral movement
Often occurs in soccer players from hard or long kicks
Severe pain at time of injury or gradual onset
Reduced pain w/ rest
Increased pain w/ playing, twisting movements
Radiating pain to testes, adductors or lateral thigh
Aggravated by coughing/ sneezing, sex, valsalva
Physical for athletic pubalgia
Resisted sit up = painful
Single or bilateral resisted leg adduction = painful
Diagnosis of sports hernia may be made if at least three of the following five signs exist:
Pinpoint tenderness to the pubic tubercle at conjoint tendon insertion
Tenderness over deep inguinal ring
Pain and/or dilation of the external ring with no palpable hernia
Pain at origin of adductor longus tendon
Dull diffuse groin pain often radiating to perineum and inner thigh or across the midline
Complete exam for other causes of groin pain should be performed:
Hip adductor origin tenderness AND pain with resisted adduction suggest adductor-related groin pain.
Tenderness at pubic symphysis suggests pubic-related groin pain.
Pain with resisted hip flexion AND/OR stretching of hip flexors suggests iliopsoas-related groin pain.
Hip joint–related groin pain may elicit pain with passive range of motion (ROM); flexion, adduction, and internal rotation (FADIR); and flexion, abduction, external rotation (FABER) tests.
DDx for athletic pubalgia
Inguinal or femoral hernia
Hip adductor strain
Rectus abdominis strain
FAI
Osteitis pubis
Bursitis
Snapping hip syndrome
Femoral neck stress fracture
Pubic ramus fracture
Hip apophysitis or avulsion fracture
Nerve entrapment:
Obturator
Ilioinguinal
Genitofemoral
Iliohypogastric
Referred pain from lumbar spine or sacroiliac joint
Intra-articular hip pathology
Testicular/ovarian pathology
Spondyloarthropathy
Lymphadenopathy
Ix, Management + RTP of athletic pubalgia
MRI
Rest x6 wks, compression wrap, NSAIDs,
Then PT rehab x6 wks to increase strength + flexibility in abdo + inner thighs
Initial focus on hip adductor stretching, then advancing to eccentric strengthening of abdominal oblique, rectus abdominis, and adductors, and then progressing to sports-specific functional exercise
RTP usually 8-12wks
If pain w/ RTP, consider surgery
Herniorrhaphy
RTP 6-12 wks post op
What are the adductors?
adductor longus, magnus, and brevis; gracilis; obturator externus; and pectineus
RF for adductor tendon injury/ groin strain
Increasing age
Previous adductor injury
Weak, inactive, or fatigued adductor muscles have less ability to absorb energy and are more likely to undergo acute strain.
Core muscle weakness
Sx of adductor tendon injury/ groin strain
Stretch injury (abrupt cutting motion as in soccer or a straddling injury as in gymnastics, cheerleading, or horseback riding)
May have only minor discomfort with walking, but pain and weakness are noticeable with cutting or running
Physical of adductor tendon injury
Classic triad of tenderness to palpation of the muscle and its bony attachments (proximal third of medial thigh and tendinous origin in pubic region), pain with passive stretching (hip abduction), and pain with resisted contraction (hip adduction)
Swelling, ecchymosis, and significant weakness increase suspicion for tear.
With complete rupture, palpable depression and retraction of torn muscle may be present
DDx of adductor tendon injury
Osteitis pubis
Stress fracture of femoral neck or pubic ramus
Iliopsoas or rectus femoris tendonitis, iliopsoas bursitis
Avascular necrosis of femoral head
Groin disruption (sports hernia, Gilmore groin, athletic pubalgia)
Femoro-acetabular impingement, labral tear, osteochondral lesion, hip osteoarthritis
Myositis ossificans
Avulsion fracture, apophysitis in adolescents
Slipped capital femoral epiphysis (usually seen in early teens)
Inguinal hernia
Nerve entrapment, specifically obturator nerve
Referred pain from spine
Management + RTP for adductor tendon injury
Protection, rest, ice, compression, and elevation (PRICE) is beneficial.
Heat may be added after 2 to 3 days.
Limit activity for 1-2 wks
Refer to ortho if grade 3 tear
PT
Isometric stretching
Progress to dynamic, eccentric strengthening, balance training, and proprioceptive exercises of hip and groin musculature
RTP
When pain free
Grade 1 = 1-3 wks
Grade 3 = 4-8 wks
MOI for posterior hip dislocation
MVA, falls, high energy sports injuries
Sx + physical for posterior hip dislocation
Immediate, severe pain, and disability
Limb shortening with hip flexion, internal rotation, and adduction. In the obtunded patient, the examiner may have to recognize the position of posterior hip dislocation if the patient is not able to verbalize.
Classic position may be absent if there is an associated femoral shaft fracture.
Vital signs and complete trauma evaluation essential because of the high association with life-threatening injuries
Pelvic rocking and pubic compression tests to examine for associated pelvic rim fractures
Distal neurovascular examination to assess for sciatic nerve or vascular injures, which merit more urgent reduction
Imaging for posterior hip dislocation
XR - AP, lateral
CT before reduction in hip dislocation + suspected nondisplaced femoral neck #
Femoral neck # is CI to reduction
Management of posterior hip dislocation
Reduction in under 6hrs reduces rate of AVN
Can be reduced in ED (1 attempt only) or operatively (best)
Complications of posterior hip dislocation
AVN
OA
Sciatic nerve injury
Myositis ossificans
Recurrent instability
Labral tears
Sx, physical findings + causes of iliopsoas injury
Aching pain, gradual onset, in groin or anterior thigh
Tenderness to pressure between midpoint of inguinal ligament
Positive Thomas test
Causes: bursitis, overuse injury
Imaging + Rx for iliopsoas injury
Imaging: US or MRI
Rx: rest, NSAIDs, heat
PT
Stretching of the hip flexors, including iliopsoas and quadriceps
Strengthening of same and of hip rotators (internal and external)
What is snapping hip syndrome, and what are the common causes?
Condition where a snapping sensation occurs when muscle or tendon moves over hip
Lateral = IT band
Anterior = rectus femoris tendon, iliopsoas
Posterior = hamstring tendon
Complications of snapping hip syndrome
Bursitis
What is Legg Calve Perthe’s dz?
Juvenile avascular necrosis of femoral head
Causes of Legg Calve Perthe’s dz
Idiopathic
SCFE
Trauma
Steroids
Sickle cell
Congenital hip dislocation
Sx of Legg Calve Perthe’s dz
Insidious onset
Intermittent limp, especially after exertion
Mild anterior hip/ groin pain, can be referred to thigh
Physical of Legg Calve Perthe’s dz
Reduced ROM (limited abduction and internal rotation)
Leg roll test positive
Ix of Legg Calve Perthe’s dz
AP, frog leg views
Femoral head smaller on affected side
With disease progression, a crescent-shaped radiolucent line may be seen in the central portion of the femoral head, especially on the lateral view.
MRI o r bone scan
DDx of Legg Calve Perthe’s dz
Osteomyelitis
Septic joint
Juvenile idiopathic arthritis
Hemophilia
SCFE
Tumor
Management of Legg Calve Perthe’s dz
Refer to peds ortho
NSAIDs, activity restriction, crutches
Wide stance brace, (abduction bracing), casts
D/C when XR evidence of subchondral reossification (12-18mo)
Can consider surgery (containment of femoral head)
Abduction stretching
Complications of Legg Calve Perthe’s dz
OA, especially if dx >10 y/o
Femoral head deformity
RF for Legg Calve Perthe’s dz
Low birth weight
Short stature
Delayed bone maturation
Involved family member (after index sibling, incidence 1/35)
Familial thrombophilia and hypofibrinolysis (controversial)
Lower socioeconomic status
Typically kids 4-10 y/o
More common in boys
White + chinese pts
What is FAI?
Pathologic malformation of hip
The acetabular rim and the proximal femur have excess contact during the end range of motion (ROM) of the hip.
Leads to pain and restricted hip motion and can lead to chondral or labral injury
RF for FAI
Idiopathic
Trauma—malunion of femoral neck fracture, posttraumatic retroversion of the femoral head
Childhood orthopedic conditions—Legg-Calvé-Perthes disease, slipped capital femoral epiphysis (SCFE), hip dysplasia
Iatrogenic—femoral osteotomy, overcorrection of retroversion in dysplastic hips
High-impact sports/activities during bone development (i.e., soccer, basketball, and ice hockey)
Sx of FAI
Anterior or anterolateral hip pain that refers to the groin, associated with activity
Inability to perform activities such as high hip flexion or internal rotation, including prolonged sitting or squatting
Painful clicking, locking or instability from a labral tear secondary to undiagnosed FAI
Past history of developmental dysplasia, trauma or predisposing factors of avascular necrosis
Insidious onset of symptoms in active young and middle-aged adults
History limited with children, keep FAI in differential with knee or thigh pain, limp after activity
Adults may describe a stiffness in the hip.
Physical exam of FAI
Restricted internal rotation, flexion + adduction
FADDIR positive
Positive posterior inferior impingement test—positive test if pain elicited with the hip in hyperextension + external rotation (by hanging the leg over the side of the bed + externally rotating hip, applying downwards pressure)
DDx of FAI
Hip dysplasia
Leg-Calvé-Perthes disease/avascular necrosis femoral head
SCFE
Hip subluxation—microinstability
Labral tear not associated with impingement
Osteoarthritis
Muscular pathology of iliopsoas/snapping hip syndrome
Spinal deformities—scoliosis or kyphosis
Prior femoral neck fractures or pelvic osteotomy may also cause impingement.
Ix for FAI
XR - AP pelvis + lat femoral neck view, Dunn view - look for CAM or pincer morphologies
Alpha angle calculated to determine amount of cam deformity (>60 degrees = abnormal)
Crossover sign + lateral center edge angle used to determine amount of pincer deformity (>40 degrees = abnormal)
CT (in position of discomfort) or MRA
Management of FAI
Surgery (1st line) to achieve impingement free motion - cam morphology can be reshaped, labrum or articular cartilage resection (hip arthroscopy)
Toe touch wt bearing + ambulate w/ aids for 2-4 wks
Recovery = 6mo
Conservative (NSAIDs, activity modification (avoid excessive hip end ROM)), PT to improve hip stability, movement patterns
Complications of FAI + complications of surgery
Nonsurgical care:
Hip degenerative arthritis
Labral tears
Chondral defects/delamination
Complications of surgery:
Trochanteric nonunion, heterotopic ossification, sciatic nerve palsy, osteonecrosis of the femoral head, femoral neck fracture, injury of the lateral cutaneous femoral nerve, neurapraxia of nerves around the hip joint
What is Shenton’s line?
Formed by medial edge of femoral neck + inferior edge of superior pubic ramus on XR
Loss of Shenton’s line = # neck of femur
Distal femur # MOI
Fractures generally occur from significant axial loading with associated varus, valgus, or rotation force.
May occur from direct trauma as well
In young adults, fractures are usually associated with high-energy trauma such as:
Motor vehicle accidents, falls from heights, direct impact.
Motor sports, downhill skiing.
In older individuals, especially those with osteoporosis, a slip and fall may be enough force to cause injury.
Distal femur # complications
Proximal or shaft fractures of the femur.
Ligament and cartilage injuries of the knee.
Proximal tibia fractures.
Open fractures: 5–10% of all supracondylar fractures.
Quadriceps tendon injury.
Physical of Distal femur #
Tenderness on examination, deformity, thigh shortening, swelling (secondary to hematoma), and crepitus with movement
Limited movement of hips and knees
Commonly presents with associated injuries: chest or abdominal trauma, hip or knee injury, direct blow to the extremity
Vascular compromise (arterial injury): expanding hematoma, absent or diminished pulses, progressive neurologic deficits in a closed fracture (1)
Hypotension and tachycardia secondary to significant blood loss
Imaging Distal femur #
XR - Anteroposterior (AP) view of pelvis, true lateral of hip, AP and lateral views of femur, and complete knee series
CT
Management Distal femur # (acute + ED)
Acute
Long leg splint
In line traction if signs of neurovascular compromise
Wet saline dressing over open #
ED
Reduce w/ in line traction
Tetanus
Ancef + gentamicin if open #
Ortho referral for surgery ASAP
Sx ACL injury
Pain - lateral tibial plateau
Instability, gives way
Audible pop or tear
Quick onset swelling
Locking sensation, loss of full ROM
Physical for ACL injury
Acute: effusion, difficulty weight bearing
Loss of full knee extension can occur
Lachman test
Anterior drawer
Pivot shift (if still positive 3mo after injury, strong predictor for future reconstruction needed)
Posterior sag
Functional tests - squat, hop, single knee squat
Ix for ACL injury
Normal XR (or Segond # anterior lateral capsular avulsion)
MRI
DDx for ACL injury
PFPS, patella subluxation
RF for ACL injury
Females 4-8x greater risk
Anatomical - narrower intercondylar notch, smaller ACL XC area, increased knee joint laxity
Hormonal - increased injuries during follicular phase
Biomechanical - cutting + landing motions w/ reduced flexion and increased valgus
MOI for ACL injury
Sudden changes in direction
Landing from jump in deep flexion, force of quads causes ACL to pop
Contact ACL injury usually in football, causes unhappy triad of ACL, MCL, medial meniscus
Management for ACL injury
Incomplete or partial tears can be managed non operatively
Hinged brace
Complete tears usually require surgery
Patella or hamstring tendon autograft
RTP 6-12mo post surgery
Rehab for ACL injury
Phase 1 pre-op - maintain ROM
Phase 2 (0-2wks) Achieve full extension; maintain quadriceps strength, reduce swelling, and achieve flexion to 90 degrees.
Phase 3 (3 to 5 wk): Maintain full extension and increase flexion up to full ROM; stair climbers and stationary cycle may be used.
Phase 4 (6 wk to 9 mo): Increase strength and agility; progressive return to sports
Prevention of ACL injury
Neuromuscular training - plyometric, strength + balance
Ideally start in early teenage years
Conditions commonly associated w/ ACL injury
Meniscal tears (acutely usually lateral and then medial as ACL tear is more chronic)
MOI LCL tear
Varus stress to partially flexed knee in internal tibial rotation from direct force or distal indirect stress (stepping into a hole) with a fixed foot
Wrestling most common
Sx of LCL tear
Acute lateral knee pain
Pop
Mild-mod swelling
Instability if high grade
Physical for LCL tear
Tender to palpation over ligament
Readily palpated in “figure-of-4 position”: normally, a pencil-like structure but less distinct with partial tears (grade II) or complete tears (grade III)
Varus stress testing
grade I sprain, no increased laxity
grade II sprain, increase in laxity with semifirm endpoint at 25 to 30 degrees of flexion isolates the LCL
grade III sprain, increase in laxity with soft or no endpoint compared with the uninjured knee indicates injury.
Peroneal nerve sensory and motor function should be checked as well
Ix for LCL tear
XR to r/o #
MRI
DDx for LCL tear
Proximal fibula avulsion fracture
Biceps femoris strain
Iliotibial band strain
Popliteus strain/tear/tendinopathy
Associated anterior or posterior cruciate injury
Lateral meniscus tear
Lateral compartment chondral/osteochondral injury
Tibial plateau fracture
Proximal tibiofibular syndesmosis injury
Management + RTP for LCL tear
Ice, compression, NSAIDs
Immobilization:
Grade I injury: crutches PRN for pain; hinged bracing (stabilization while allowing range of motion [ROM]), 4 to 5 wk during weight-bearing activities
Grade II: crutches and knee immobilizer × 1 to 2 wk for pain control and then progress from non–weight-bearing to partial–weight-bearing weeks 2 to 3. A hinged brace may be used once the patient is partial–weight-bearing, usually at 2 to 3 wks.
Grade III: immobilization, non–weight-bearing with crutches, and consultation with an orthopedic surgeon. Immobilization will likely be maintained until surgery is performed, preferably within 2 wk of injury.
When to consider surgery
Grade 3 (if no improvement in 2-4 wks) or combined ligamentous injuries
RTP
Grade 1 = 4 wks
Grade 2 = 10 wks
Rehab for LCL tear
In the acute setting, start isometric quadriceps exercises and straight-leg lifts.
Electrical stimulation/biofeedback to vastus medialis oblique (VMO) quads
Gentle hamstring and calf strengthening in protective ROM
ROM exercises with progression to full ROM over 4 to 8 wk to allow ligament to heal without too much stress
Stair stepper or similar for cardiovascular (CV) conditioning can be added, limiting knee flexion to 45 to 60 degrees when tolerated.
Stationary bike later in rehabilitation when able to flex knee to 115 degrees without pain or residual swelling afterwards
When gait is normal, begin jogging and enhanced resistance exercises.
Progress to half sprints, full sprints, and cutting maneuvers once ligament fully healed
MOI MCL tear
Valgus stress (blow to lateral knee) when foot is planted
In kicking sports, the injury may be seen in players who are struck on the instep while passing the ball.
Skiers can injure the MCL by a noncontact valgus external rotation injury.
Overuse injuries to the MCL have been reported in breaststroke swimmers.
RF sports + sx of MCL tear
Wrestling, hockey, martial arts
Pop or swelling is more concerning for meniscus or ACL injury
Physical for MCL tear
Valgus stress at 0 degree and at 20 degrees. Laxity at 20 degrees alone indicates an isolated MCL injury. Laxity at both 0 degree and 20 degrees indicates an injury to the MCL and POL, knee capsule, and/or ACL
Ix for MCL tear + what is a Pellegrini Stieda lesion?
XR (AP, notch, lateral, sunrise)
Pellegrini Stieda lesion is a calcification of proximal MCL seen in chronic injuries
MRI
DDx for MCL tear
Medial meniscal tear
Medial knee contusion (soft tissue or bony)
Patellar instability (subluxation or dislocation)
Fracture of the distal femoral or proximal tibial physis
Tibial plateau fracture
Management of MCL tear
Grade 1 + 2
PRICE, NSAIDs
Wt bearing as tolerated
Hinged knee brace for comfort
Active ROM immediately
RTP 1-4 wks
Grade 3
Usually non operative
Non wt bearing x1-3 wks
Bracing
Strengthening once painfree + full ROM achieved
RTP 5-7 wks
Operative if complete ligament tear, intra-articular entrapment of the end of the ligament, a large bony avulsion injury, a tibial plateau fracture, a complete tibial side avulsion in athletes, or when AMRI is present
