MSK Flashcards
AC Separation
Sx: pain over AC joint
- shoulder weakness
- Kiss Test: pain w/cross-body adduction
Dx:
- Xray (AP, chest, clavicle)
Tx:
- Type 1, 2: nonsurgical = immobilize, Codmans
- Type 3: usually non-operative; sx for manual laborer/athlete
- Type 4-6: surgery
AC Dislocation
D/t: direct fall on shoulder
Sx: deformity, swelling
Tx:
- Grade 1, 2: sling w/ortho f/u
- Grade 3: surgery
Clavicle Fracture
MC: middle 1/3
Dx: AP chest, clavicle views
Tx: most non-operative + Codmans
Surgery:
- open fracture
- fracture w/scapula-thoracic dislocation
- relative indications: multiple trauma, skin tenting, competitive athlete
GH Joint (Shoulder) Dislocation
MC dislocation in the ED
Anterior (85%): direct blow; abduction, extension, external rotation
- severe pain worse w/mvmt
- squared off shoulder appearance
- complications: recurrence; nerve injury; rotator cuff; Hill-Sachs or Bankart fracture
Posterior: seizure, electric shock; adduction, internal rotation
- flat appearance of anterior shoulder
Inferior: humerus fully abducted, elbow flexed, humeral head palpable on lateral chest wall
- a/w prox humerus fracture and rotator cuff injury
Dx: Xray pre/post reduction
Tx: ice, muscle relaxation, pain control
- usually requires conscious sedation
- shoulder immobilizer/sling in IR after reduction
- re-assess neurovascular status
- OP ortho f/u
Shoulder instability
Load shift test: posterior instability
Sulcus sign: inferior laxity
Apprehension test: anterior instability
Proximal humerus fracture
RF: osteoporosis, age; d/t FOOSH injury
Complications: adhesive capsulitis (MC)
- neurovascular injury
- avascular necrosis of femoral head
Sxs:
- pain, tenderness, deformity, dec mobility
Neer Classification of XR (based on displacement of fragments >1cm or angulation <45deg):
- anatomical neck
- surgical neck
- lesser tubercle
- greater tubercle
Mgmt
Nondisplaced (80%)
- sling or shoulder immobilizer
- opioids; ortho referral
Neer 2, 3, 4
- immobilize, emergent ortho consult
- may require surgical repair
Humeral shaft fracture
Direct blows to upper arm
- MVC
- FOOSH
Dx
- check radial nerve function
Mgmt
majority = nonoperative
- brace/coaptation splint + Codmans
- hanging arm cast for shortened fracture
Surgery:
- open fracture
- pathologic fracture
- poorly controlled by closed ttechnique
- concomitant ipsilateral forearm fracture; multiple fractures
Rotator Cuff injury
H/o falls or lifting in middle-aged men
MC: supraspinatous (abduction)
- subscab (IR)
- infraspinatous (Add)
- teres minor (Abd, ER)
Sxs: pain, dec ROM
- Positive drop arm test
Dx: Xray r/o fracture; will require MRI
Tx:
- sling
- PO analgesics: NSAIDs, opioids
- Ortho f/u for MRI
Bankart Tear
Detachment of anterior-inferior labrum & capsule from anterior glenoid rim
Disruption of the anterior band of the IGHL
Sxs:
- anterior shoulder instability
- Apprehension test with ER +
Mgmt: Bankart repair to prevent dislocation
SLAP Tear
Superior labrum anterior to posterior tear
Sxs: pain and mechanical symptoms w/overhead and throwing activities
Labrum: seal around glenoid, provides stability, deepens glenoid
SGHL: primary restraint to anterior translation, 0-45deg abduction, can be absent
Radial nerve injury
A/w humeral shaft fracture
Sxs: inability to extend wrist/fingers and absent sensation on the back of hand
Dx: f/u for EMG if no improvement
Tx: observed, unless it occurs after reduction
- most regain function in 6mo w/wrist splint and finger exercises
- surgical exploration if no improvement after 6mo
Shoulder impingement
Mechanical:
- bone spur prevents greater tuberosity from clearing the coracoacromial arch = painful arc of motion
AC Joint Arthrosis:
- common in overhead workers (electricians) and athletes
Sxs:
- Neers: forward flexion while resisting scapular rotation
- Hawkins: IR w/arm abducted and External rotation 90deg while resisting scapular rotation
Dx: outlet view Xray for subacromial bone spurs
Long head of biceps rupture
MC in older pt w/long standing h/o impingement OR wt lifter, throwing sport
Sxs:
- present w/lump in arm
- Ludington’s Test (lump w/flexion of biceps)
- sudden pain in upper arm w/audible snap
- pain w/palpation of bicipital groove
Dx: Xray, eventual MRI
Tx: usually non-operative; outpatient ortho f/u
Adhesive capsulitis
“Frozen shoulder” d/t DM (MC)
- other cause: prolonged hospitalization, surgery, immobilization
Sxs: loss of active and passive ROM
Tx:
- conservative PT, intra-articular corticosteroid injections
- may take 1yr to “unfreeze”
- analgesics
- surgery
Nursemaid’s elbow
MC 1-3yo; MC elbow injury in children
Radial head subluxation
- longitudinal traction on extended/pronated arm w/sudden traction on distal radius
- annular ligament slips over head of radius and slides into radiohumeral joint where it becomes trapped
Sxs:
- “pull” injury but can be more traumatic (fall/twist)
- child will not move arm
- mild tenderness over anterolateral aspect of radial head
- pain w/even mild supination
Dx: post-reduction neurovascular evaluation
- typically don’t need Xray
Tx:
- reduction
- supination with flexion** = moderate pressure on radial head; distal forearm pull w/gentle traction and supinate and flex
- hyperpronation may work also
Supracondylar Elbow Fracture
MC elbow fracture in kids d/t FOOSH
- usually posterior displacement
Complications:
- Volkmann’s ischemic contracture: compartment syndrome d/t brachial artery disruption
- other UE nerve injury
Dx: Xray
Mgmt:
- splint if posterior fat pad + significant tenderness
- ophtho consult
nondisplaced w/intact neurovascular:
- long arm splint
- sling
- close ortho f/u
displaced:
- admit for ortho surgical reduction, fixation
Elbow dislocation
Perform neurovascular checks pre/post reduction
Mgmt:
- reduced in ED w/sedation
- initial immobilization in posterior mold splint
- transition to hinged elbow brace for early motion
- surgery for failed outpatient reduction or in certain fracture dislocation patterns
Olecranon bursitis
A/w olecranon bone spur
- suppurtive vs. non-suppurtive
If not inflamed, warm, no signs of infection can do compression wrap, will reabsorb on its own
Dx: synovial analysis
Mgmt:
- compressive wraps, padded elbow sleeve, aspiration; avoid resting on elbow
- may require IV abx (suppurtive)
- surgery for bursectomy
Lateral epicondylitis
Tennis elbow
Sxs:
- pain, fullness of lateral elbow
- pain with resisted wrist extension
- chronic tendinosis of extensor origin
Tx:
- avoid using extensors
- therapy: stretching, eccentric loading, NSAIDs, ice, counterforce brace, wrist splint, cortisone injection
- failed conservative tx: surgery
Medial epicondylitis
Golfers elbow
Sxs:
- pain, fullness of medial elbow
- pain with resisted wrist flexion
Tx:
- therapy for stretching, eccentric loading, NSAIDs, ice, wrist splint, cortisone injection
- surgery for failed conservative management
Radial head fractures
FOOSH injury
Sxs:
- medial bruising of elbow
R/o medial collateral injury of elbow
Dx:
- Sail sign* : displaces fat pat d/t effusion in joint (presumed fracture)
Mgmt:
- minimally displaced: conservative w/sling, edema control, early ROM
- a/w medial injury to MCL w/pain and ecchymosis requiring limits in valgus to protect MCL
- displacement or comminution = surgery
Distal biceps rupture
D/t forceful lifting
Sxs:
- feel a pop, bruising in AC fossa
- weakness w/resisted supination
Mgmt:
- limited time to fix, otherwise biceps tendon can retract away
- surgery
- control extension, INC by 10deg/wk
Cubital tunnel syndrome
Compression of ulnar nerve at medial elbow
R/o diabetic polyneuropathy, drugs (amiodarone), neck compressive neuropathy
Sxs:
- pain, numbness, tingling in ulnar nerve distribution
- Positive Tinnel’s and elbow flexion testing
- extreme cases: “clawing” d/t prolonged ulnar neuropathy
Motor
- Froments: pinch paper between thumb, first finger
- Wartenberg’s: ulnar drift of pinky
Dx: confirm w/EMG/NCS
Tx:
- nerve glides, splinting at night
- surgery for failed conservative treatment (anterior transposition for gliding a better pathway)
Carpal tunnel syndrome
D/t flexion/extension
- use of vibratory tools (jackhammer)
- acutely = trauma (distal radius fracture)
Sxs:
- numbness, tingling, pain in median distribution
- reduced grip strength
Positive Tinel, Phalens, carpal compression testing
Motor involvement can include weak extensor pollicis brevis
Mgmt:
- night splints, nerve glides, cortisone injection, modification of activity
- failed = surgery
Osteoarthritis of 1st CMC Joint
d/t overuse
Sxs:
- pain, fullness, limited function
Complication: thumb in palm deformity, hyperextension at MCP joint
Dx: Xray
Tx:
- splinting, APAP, NSAIDs, cortisone
Surgery:
- remove trapezium +/_ ligament reconstruction, tendon interposition (anchovy procedure),cast for months, splint, therapy
DeQuervain’s stenosing tenosynovitis
Inflammation of 1st doral compartment (APL, EPB)
Sx: pain, swelling of radial aspect of wrist
Dx: + Finkelstein test
Tx:
- rest
- tendon glides
- splinting
- NSAIDs, cortisone injection
- surgery: release 1st dorsal compartment
Ganglion cyst
MC soft tissue tumor of wrist and hand
- joint = mucus cyst
- tendon sheath = retinacular cyst
- may be dorsal or volar
D/t insult to joint, often don’t remember initiating injury
Tx:
- avoid aspiration of volar ganglion to avoid injury to radial artery
- recurrence up to 30% with or without surgery
- can scar after surgery
Distal radius fracture
Need plain lidocaine w/out epinephrine
R/o EPL rupture w/the injury +/- surgery (can’t lift thumb off table)
Dx: Xray
Tx:
- nondisplaced: short arm cast
- displaced: reduce using hematoma block (w/lidocaine) and traction w/finger traps w/application of Sugar Tong Splint** (prevents forearm rotation)
surgery: failed conservative mgmt, open fracture, younger age, significant displacement
Scaphoid fracture
MC fracture wrist bone d/t FOOSH
- commonly results in nonunion if displaced, d/t poor blood supply to proximal aspect
Sxs: anatomical snuffbox pain
Dx: may not be evident on initial film
Tx:
- thumb spica cast* - hand in position like you’re going to shake their hand
- surgery
Osteoarthritis (hand joints)
DJD; irreversible loss of articular cartilage
RF: Fhx, obesity, age, trauma
Sxs:
- stiffness, pain
- Herberden’s = DIP nodes
- Bouchard = PIP nodes
- Osteophytes (bone spurs) = can wear on the extensors
- Mucous cysts = DIP, ganglion cyst
Dx: Xray to r/o other pathology
Mgmt:
- exercise in pain free range to maintain motion/strength
- wt loss
- pain mgmt: APAP, NSAIDs, topicals, intraarticular injections
- surgery
Rheumatoid arthritis
Systemic, disabling polyarthritis resulting in chronic synovitis w/erosive articular changes
Sxs:
- ulnar deviation at MCP, caput ulnar
Dx: RF, CBC
Mgmt:
- Salicylates, NSAIDs, corticosteroids
- DMARDs: methotrexate, hydroxychloroquine
- splinting, assistive devices
- surgery
Trigger finger
D/t
- congenital d/t widened FPL
- acquired: age>40, diabetes, RA
Sxs:
- inflammation of flexor tendon sheath
- form nodule along flexor, does not glide
- pain, locking, catching
- tenderness at A1 pulley, can lock in flexion or can hear clicking*
Mgmt:
- A1 pulley release: NSAIDs, cortisone injections, surgery
- splint to keep pt from going all the way into flexion (+ cortisone injection)
Mallet finger
A/w avulsion of base of distal phalanx
- injury of distal extensor mechanism
Sxs: cannot extend DIP
Mgmt:
- reduce into extension; if not, pin
- splint or serial casting in slight hyperextension for 6wk followed by prn splinting until week 8 vs. surgical pinning
Jersey Finger
common athletic injury (football, wrestling)
Rupture of distal flexor digitorum profundus (FDP)
Mgmt: surgical repair to reattach FDP to distal phalanx
Gamekeepers Injury
A/w ski pole injury (forceful radial deviation)
Rupture of ulnar collateral ligament (UCL) of thumb +/- avulsion injury
[main stabilizer of MCP joint]
Dx: confirm w/clinical exam and stress views under fluoroscopy of the thumb - valgus stress and see if it opens up
Complication: long term instability may lead to arthritis
Mgmt:
- nonsurgical: cast, splint
- surgical: required for large avulsion fracture
Dupuytren’s disease
Scandinavian >50 a/w DM, alcohol, epilepsy, pulmonary disease
Sxs:
- thickening and contraction of palmar fascia
- painless palmar nodule and progress to flexion deformity
- 4th or 5th digit
Dx:
- >30deg = intervention
Mgmt:
- invasive fasciectomy
- CCH or PNF
- high risk of recurrence
Finger dislocation
D/t sporting injury
Document neurovascular pre/post
Dx: Xray to r/o fracture
Mgmt:
- reduce by applying longitudinal traction distally, and gentle pressure over dorsal deformity to guide reduction
- if unable to reduce with or without digital block, may require open reduction
- immobilize w/splinting or casting
Finger fractures
Mgmt:
- ice, elevation, pain mgmt, mobilization of unaffected joints
- immobilization w/splinting or casting
- closed reduction +/- percutaneous pinning
- open reduction internal fixation w/pin, screw, plate
Boxer’s fracture
Punching w/fist
Sxs:
- fracture of metacarpal neck
Complication: may end up with a little palmar deformity
Mgmt:
- non surgical treatment unless severe
Finger tip injuries
E.g. industrial, snow blower, nail bed crush
common in children
Sxs:
- bleed a lot
Consider open fracture if nail bed involved and must cover w/abx
Tuft fracture: injury to distal pharynx, swollen, tender, nail involvement, splint
Mgmt:
- remove nail and inspect nail bed
- use nail or foil to split eponychial fold = best chance for nail regrowth
- might require revision amputation
Lateral Femoral Cutaneous Nerve Syndrome (Meralgia Paresthetica)
Compression/entrapment of LFCN
- compression where it exits pelvis medial to ASIS under inguinal ligament
Et: thin female w/heavy workmans belt
- other RF: obesity, tight clothing, scar tissue from previou surgery/trauma
Sxs: SENSORY only
- pain, burning, hypoesthesia; anterolateral or lateral thigh
- joggers: “electrical jab” w/hip extension
- strength/DTR unaffected
Dx: clinical
- abd/pelvic exam to r/o intraabdominal pathology
- AP pelvis, AP/lateral hip; r/o bony pathology
- CT/MRI if intrapelvic mass suspected
Mgmt:
- remove compression
- wt loss
- cortison injection
- surgical release rarely required
Red flags:
- intolerable sxs failing conservative treatment warrant referral for further eval
Osteonecrosis of the Hip (AVN)
Bone death in femoral head d/t disruption of vascular supply to femoral head from trauma
- progresses to bone structure fragment, collapse resulting in articular surface collapse and progressive arthritis
- MC 3-5th decades; often bilaterally
- RF: trauma, corticosteroids, ETOH, SCD, RA, SLE, HIV
Sxs: gradual dull ache or throbbing in groin* or lateral hip*
- severe pain w/bone death
- limited ROM, antalgic limp
PE:
- pain w/active SLR
- pain w/active/passive ROM of hip
Dx: AP pelvis, AP/frog-lateral
- *crescent sign: well-defined sclerotic area just beneath articular surface representing a subchondral fracture
- MRI if indicated
Mgmt:
- limit weight bearing
- intraarticular corticosteroid injection
- surgical: refer to ortho [core decompression, vascularized fibular grafting, osteochondral allografting, total hip arthroplasty]
IT Band Syndrome (Snapping Hip)
Snapping/popping sensation occurring as tendons move over bony prominences
- MC: IT band snapping over greater trochanter
Sxs:
- pain if trochanteric bursitis (often coexist)
- iliopsoas tendon involved: felt in groin as hip extends from flexed position (rising from chair)
Limitation in IR, a limp, or shortening of limb suggests problems w/in joint and not IT band
Dx: clinical
- AP pelvis, lateral hip Xray
- MRI r/o acetabular labrum tear
Mgmt: PT, NSAIDs, corticosteroid injection
- surgery (rare)
Refer:
- unclear diagnosis
- intraarticular pathology
- failure of conservative measures
Trochanteric bursitis
Inflammation/hypertrophy of greater trochanteric bursa
- may be secondary to lumbar spine disease, intraarticular hip pathology, leg length discrepancy, inflammatory arthritis, prior hip surgery
Sxs:
- pain/tenderness over greater trochanter; pain w/hip abduction; worse rising from seated position
- night pain
- may radiate distally to knee or proximally into butt
- Trendelenburg sign*
Dx: clinical
- AP pelvis, lateral hip Xray
Refer: failure of tx, uncertain dx, suspected fracture
Mgmt:
- PT
- corticosteroid/local injection into greater trochanteric bursitis
- NSAIDs, ice/heat
- activity modification - use of cane
- surgery rare
Osteoarthritis of Hip (DJD)
Loss of articular cartilage of hip joint
- idiopathic; secondary to hip problems
Sxs: gradual onset groin/anterior thigh pain
- butt or lateral thigh pain; may be referred to knee
- initially pain w/activity but progress to pain at rest/night
- antalgic gait
- loss of ROM
- abductor lurch (sway trunk over affected hip) to compensate for pain and abductor weakness
- pain w/active SLR
Dx: AP pelvis/hip, lateral
- joint space narrowing
- osteophyte formation
- subchondral cyst formation
- subchondral sclerosis
Mgmt: NSAIDs/APAP, activity mod, PT, corticosteroid injection (fluoroscopic or US guided)
- surgery: THA (replace femoral neck, head, acetabulum)
Referral/Red Flag:
- persistent pain despite conservative treatments
- all young patients
Pelvic Fractures
Pelvic Ring: different fracture patterns that occur based off applied forces to the pelvis
Pubic symphysis = surgery
Rami fracture can be managed with protected wt bearing and not surgery
Dx:
- pelvic ring: AP (standard) & inlet/outlet views
- acetabular: AP (standard) & Judet (45deg oblique)
- CT scan
Mgmt:
- protected weight bearing (6-12wk)
- certain patterns are stable and patients can wt bear as tolerated
Surgical stabilization:
- widened pubic symphysis
- SI joint widening or dislocation
- extended sacral fractures
Refer ALL to ortho
Acetabulum fractures
Fracture pattern depends on position of femoral head at time of injury, magnitude of force, and age
MC: trauma when femoral head takes out superior part of acetabulum
Dx: Xray
- check pulse/sensation after traction
- if you lose pulse, get vascular surgeon involved
Tx:
- distal femoral traction: preserve soft tissue, maintain length, maintain femoral head reduction if dislocated
- non-op tx: minimally displaced, joint maintained, no intraarticular fragments, poor surgical candidate
- surgical tx: min posttraumatic arthritis, repair acetabulum, toe-touch weight bearing up to 3mo postop
Complications:
- posttraumatic arthritis
- neurovascular injury
- heterotopic ossification
- avascular necrosis
Femoral head fracture
Almost all a/w hip dislocation
Look for intraarticular fragments a/w fracture
Dx: Xray
Mgmt:
<1mm step off = closed treatment
>1mm step off = surgery (ORIF)
Femoral neck fracture
MC older women r/t osteopenia/osteoporosis
- other: falls in elderly, high energy trauma in younger pt
Sxs: affected leg is shorted and ER**
Garden Classification system
- impacted - femoral neck shortened
- non-displaced
- partially displaced
- completely displaced w/vertical fx line
Dx: xray
- intraoperative imaging
Mgmt:
- nondisplaced: pinning; usually younger pt
- displaced: hemi or total hip arthroplasty
Percutaneous pinning: restricted weight bearing
Hemi arthroplasty: WBAT
Intertrochanteric fractures
Area between greater/lesser trochanter
- F 60-70yo, r/t osteopenia/osteoporosis
- h/o fall, direct trauma to greater trochanter
Sxs: leg shortened, ER**
Mgmt:
- most need surgical stabilization (sliding/dynamic hip screw; intramedullary nail)
- non-op: high-risk pt or demented nonambulator
Trochanteric fracture
Greater: obtain MRI
- operative mgmt
Lesser: elderly, look for evidence of pathologic process (tumor, osteoporosis)
- tx sxs
Subtrochanteric Fractures
Point between lesser trochanter and point 5cm distal
- high energy (GSW in young pt)
- falls in elderly
Dx: xray
Mgmt:
- placed initially into bucks traction if going to OR w/in 24hr
- non-op mgmt for very poor surgical candidate only
- surgical stabilization**
- restricted WB 6-10wk, PT, short-term nursing home
Femoral Shaft Fracture
Good healing rate d/t large blood supply
Mgmt:
- typically placed in some type of traction prior to proceeding to the OR
- intramedullary nailing
Distal Femur Fractures
- any fracture involving the distal 9cm of the femur
- usually d/t high energy trauma; elderly may be d/t osteoporosis and low-energy injury
A: supracondylar
B: condylar
C: combination
Mgmt:
- non-op: nondisplaced or incomplete fracture
- operative [intramedullary nailing or ORI w/surgical plating]: intraarticular, displacement, ipsilateral LE fracture
MC Complication*
- loss of knee motion, results if you don’t maintain articular surface of the knee
ACL Tears
MC knee tear
- d/t twisting of hyperextension injury
- MCL/meniscus may be involved
Sxs:
- sudden onset pain; unable to return to activity following injury
- audible pop
- development of hemarthrosis in the following 24hr
- chronic instability if not treated
PE:
+ Lachman
+ Anterior Drawer
Dx:
- AP, lateral, tunnel views of the knee: usually only positive for effusion, possibly avulsion fracture of lateral capsular margin of tibia
- fall injury = Xray to r/o other fracture
- Knee MRI: if ACL suspected but not confirmed w/PE
Mgmt: Refer all to ortho*
- RICE, crutches, WB if tolerated in knee immobilizer
- PT
Surgical options
- young, active pt: ACL reconstruction
- older, less active pt: PT +/- ACL functional bracing
PCL Tears
Isolated injury is less common than combination injury w/ACL
Cause: dashboard injury*, fall onto flexed knee, pure hyperflexion injury (usually ACL/PCL)
Sxs:
- pain, joint effusion w/in 24hr; limited ROM
- instability w/weight bearing
- may not have tenderness to palpation
PE:
+ posterior drawer
+ sulcus sign (hold tibia up)
Dx: MRI**
- AP, lateral Xray to identify bony pathology
Mgmt: RICE, knee immobilizer
- PT, early ROM; functional bracing
- surgery: less common to repair
MCL Tears
D/t valgus force w/out rotation
Sxs:
- usually able to ambulate after injury
- localized swelling (less than ACL/PCL)
- limited motion
- mechanical symptoms or instability infrequent
- ecchymosis/effusion 24-48hr
PE:
- tenderness along MCL
- Valgus stress test
Dx: MRI*
- AP, lateral Xray may show avulsion fracture
Mgmt:
- RICE, crutches, NSAIDs, PT
- Grade II: refer, protective bracing, WBAT [5-10mm laxity]
- Grade III: refer, 3-4mo protective bracing w/gradual return to WBAT over 4-6wk [>10mm laxity]
LCL Tears
D/t varus force w/out rotation
- less common than MCL
Sxs:
- usually able to ambulate following injury
- localized swelling
- mechanical sxs or instability infrequent
- ecchymosis/effusion after 24-48hr
- limited motion
PE
- tenderness along LCL
- varus stress test
Dx: MRI**
- AP, lateral Xray may show avulsion fracture
Mgmt:
- RICE, crutches, NSAIDs, PT
- Grade II: refer, protective bracing, WBAT [5-10mm laxity]
- Grade III: refer, 3-4mo protective bracing w/gradual return to WBAT over 4-6wk [>10mm laxity]
Meniscal tear general
Acute injury - traumatic twisting of knee
Older pt - degenerative
May be a/w injury of another knee ligament
Sxs:
- sudden onset pain, swelling, stiffness over 2-3d
- joint effusion w/acute injury
- mechanical sxs** : locking, catching, popping
- large fragment, knee may become “locked”
- medial or lateral pain, with twisting or squatting
- pain waxes and wanes
PE:
- tenderness over medial/lateral joint line
- limited ROM
- McMurray test
- Apley’s test
Red Flags:
- traumatic effusion
- mechanical symptoms
- ligamentous instability
- no response to conservative treatment
- persistent joint line tenderness or effusion
Meniscal tears Dx/Tx
Dx:
- AP, lateral, sunrise Xray if trauma or effusion
- chronic: AP, lateral should be weight-bearing
- MRI if not responding to conservative treatment or if ligament injury suspected
- Aspiration if crystal disease or joint infection suspected
Mgmt:
Conservative: no mechanical sxs; degenerative
- RICE, PT, NSAIDs, APAP
Surgery: acute injury, locking or catching*, younger pt
- meniscectomy vs. repair
- red: vascular
- white: non-vascular
Bursitis of the Knee
Sxs:
- pain w/activity or direct pressure
- often worse if sedentary for long period, limp
- localized swelling and tenderness
- numbness below patella if saphenous nerve and infrapatellar branch compressed by pes and anserine bursa
Dx:
- aspiration of prepatellar bursa for fluid analysis to r/o infection
- purulent or seropurulent material
- gram stain, culture, crystal analysis, synovial fluid analysis
- AP, lateral Xray of knee
Mgmt:
- NSAIDs, ice, activity modification, PT
- aspiration, corticosteroid injection
- IV/PO abx if infection
- surgery to resect bursa (rare)
Red Flags:
- symptoms not responding to conservative tx
- signs of ligament or tendon problems
- infected bursa not responding to conservative treatment
Prepatellar bursitis
- bursa lies between skin and patella to anterior aspect of knee
- MC caused by direct trauma* or chronic kneeling*
- may be infected w/Staph aureus or streptococcus
Pes anserine bursitis
- bursa lies under sartorius, gracilis, semitendinosus on medial aspect of tibia just below tibia plateau
- MC cause by OA of medial compartment
Osteochondritis dissecans
Osteonecrosis of subchondral bone
- MC medial femoral condyle
- d/t repetitive small stresses to subchondral bone that disrupt blood supply
- osteonecrotic bone becomes separated from surrounding bone, weakens, and gradual fracture of articular cartilage surface occurs becoming loose bodies in joint
Sxs:
- gradual onset of knee pain, knee effusions, catching or locking
- walking w/foot externally rotated may relieve pain
- tenderness to palpation
PE: + Wilson Test
- supine, flex hip and knee to 90deg, internally rotate tibia and slowly extend knee
+ = pain at 20-30deg and pain relieved w/ER of tibia
Dx: AP, lateral, tunnel Xray - necrotic area of bone or FB in joint
- MRI assess overlying articular cartilage and stage lesion
Mgmt: goal is heal lesion
Nonsurgical:
- child prior to skeletal maturation (overlying cartilage still intact)
- activity modification, crutch use
Surgical:
- adults, articular cartilage that has been separated from bone
- intact lesion - drill to promote vascular growth
- unstable lesion - temporary internal fixation
- remove loose fragment, debride articular surface defect
Patellar/Quadriceps Tendonitis [“Jumpers Knee”]
D/t overuse or overload syndrome; common in younger pt (<40y) but may occur in older pt after lifting strain
Sxs: anterior knee
- pain following exercise or w/prolonged sitting, squatting, kneeling
- increased pain w/stairs, running, jumping, squatting
- tenderness over tendon or attachments
- warmth, swelling, soft-tissue crepitus
- normal ROM but pain w/resisted knee extension or hyperflexion
Dx: AP, lateral Xray (-) but may see osteophyte or heterotopic ossification
- MRI for surgical cases or when partial rupture suspected
Mgmt: rest (days-wks) + NSAIDs, analgesics, ice after/heat before activity
- avoid corticosteroid injection into tendon (may increase r/o tendon rupture)
- PT, knee sleeve
Red Flags:
- possible or confirmed rupture of the extensor mechanism
- failure of conservative treatment
Patellofemoral Pain Syndrome
Diffuse anterior knee pain increased w/activity
- usually r/t overuse or overloading of patellofemoral joint
- chondromalacia not always present
Sxs:
- sense of instability or catching; no swelling or prior trauma
- worse after prolonged sitting, stairs, jumping, squatting
- knee angulation; increased Q angle
- J sign: active knee flexion then extension - patella moves laterally >1cm
- pain w/patellar compression
- crepitus w/knee flexion –> extension
- patellar apprehension sign* (instability)
Dx: AP, lateral, sunrise view
Mgmt: activity modification, PT, NSAIDs, APAP, wt loss
- surgery
Red flag:
- persistent symptoms, recurrent effusions
- findings of patellar instability
OA (Knee)
MC >55yo; gradual onset pain especially w/weight-bearing activity
Sxs:
- may have mechanical symptoms of buckling or giving away
- stiffness, intermittent swelling
- progresses to pain at rest or w/sleeping
- tenderness to joint lines
- valgus or varus deformity
- mild effusion
- crepitus to patellofemoral joint
- decreased ROM w/progressive disease
Dx:
- weight-bearing* AP Xray, lateral, sunrise
- joint space narrowing, osteophyte formation, sclerosis, periarticular cysts
Mgmt: Conservative - NSAIDs/APAP; PT; intraarticular corticosteroid injection - Ice, heat, topical analgesics - ambulatory device
Surgical: indicated when pt cannot stand the pain anymore
- TKA
Red flags:
- failure of conservative tx
- pain at rest, decreased ROM, significant functional limitations
Baker’s cyst [Popliteal cyst]
MC synovial cyst/bursa in the knee
- communicates w/knee joint and becomes more prominent when trauma creates excess joint fluid
- a/w degenerative meniscal tears or systemic inflammatory conditions (RA)**
Sxs
- swelling or fullness to popliteal fossa w/pain and tenderness; mechanical symptoms
- severe pain and swelling in calf if rupture occurs
- mass seen and/or palpated at popliteal fossa
- effusion and mechanical symptoms usually indicate intraarticular irritation
Dx:
(-) Xray, but may show DJD or calcification of cyst
- U/S to differentiate cyst/vascular*
- do NOT aspirate pulsatile mass
Mgmt:
- RICE
- aspiration only transient and fluid often reaccumulates
- treat cause of increased fluid and cyst usually resolves spontaneously [meniscectomy, TKA]
- cyst excision
Shin Splints
Gradual onset pain to posteromedial aspect of distal third of leg
- develops w/exercise; a/w prolonged walking or running
- may be inflammation of tibial periosteum secondary to repetitive muscle contraction
Sxs: gradual onset; pain to distal third of medial tibia, site of origin of posterior tibialis
- tenderness to distal third of medial tibia
- pes planus, overpronation
Dx: AP, lateral views of tibia to r/o stress fracture
Mgmt:
- activity modification, NSAIDs, ice massage, analgesic, shoe inserts
Red flags:
- r/o stress fracture and exertional compartment syndrome w/neurovascular checks, pain out of proportion to injury
Patella Fracture
Mechanism: direct or indirect
- quad tendon attaches superiorly, patellar tendon attaches distally
Dx:
- important to assess active knee extension: ability to perform active extension must be assessed w/SLR*
- Xray
Complications:
- loss of knee motion
- loss of extensor strength
- posttraumatic arthritis
Mgmt:
Nonoperative:
- <3mm displacement, minimal articular disruption, intact extensor mechanism
- WBAT in knee immobilizer
- Knee ROM 4-6wk once callus begins to form
Operative:
- 3mm of displacement, >2mm articular disruption, disrupted extensor mechanism
- WBAT in knee immobolizer postop
- repair tendon
- patellectomy vs. ORIF
Tibial plateau fracture
Mechanism: forceful varus/valgus stress
- elderly: fall
- involves articular surface; more serious when involving joint
- MC = lateral plateau
- may be a/w ligament injury
Dx: CT
Mgmt:
Initial: long leg cast
Nonop: nondisplaced, comorbid conditions, preexisting arthritis
Op: perform when soft tissue swelling improved (10-14d s/p injury)
- ORIF + NWB x 3mo
Achilles tendon tear
Usually occurs 5-7cm proximal to calcaneus
Med: ciprofloxacin
Sxs: sudden, severe calf pain, rapidily achy
- partial: calf strain or pull w/maintainence of function
- complete: weakness, loss of function
PE: + thompson test
- check palpable deficit, tenderness, achilles swelling
Dx: MRI
Mgmt:
Nonsurgical: partial tear or poor surgical candidate
- splint in plantarflexion, then subsequent casting is less and less flexion
Surgical: complete tear
- treatment must not be delayed as deficit widens as muscle belly retracts end of tendon*
- refer all suspected partial or complete tears
Achilles tendonitis
Posterior heel “start up” pain
Tenderness w/palpation of Achilles
Dx: imaging not requires; may show calcification if chronic
Mgmt: PT, NSAIDs
- refer if conservative failure after 1wk
- NO steroid injections
Ankle sprain
MC: ATFL
MC inversion injury
High ankle sprain: tibiofibular syndesmosis injury
Sxs:
- pain over anterolateral ankle; swelling and loss of function common
- inability to walk
- ecchymosis and swelling
- tenderness over affected ligament
PE:
- anterior drawer: laxity suggesting higher grade ligament tear
- squeeze test: high ankle sprain
Dx: AP, lateral Xray IF [Ottawa rules]
- tenderness at tip of malleolus
- inability to weight bear immediately after injury or take four steps in the ER
- pain at the base of 5th metatarsal (may pull off part of the bone)
MRI rarely indicated; if you think it is required = refer
Mgmt:
Goal - prevent chronic instability and pain
- RICE, NSAIDs, PT
- severe: 2-3wk NWB boot
Refer:
- high ankle sprain, fracture
- significant instability
- failure of conservative measures
Foot and ankle arthritis
Cause: idiopathic, inflammatory, posttraumatic
90% of ankle DJD = prior injury*
Sxs: pain w/activity, swelling, stiffness, rest pain
- decreased ROM
- pain w/palpation, creptius
- swelling, fullness, warmth
Dx: Xray
Mgmt:
- NSAIDs, immobilization, bracing, shoe modification; temporary steroid injections
Refer:
- pain and ambulation problems
- worsening sxs
- failure of conservative treatment
Surgical:
- fusion = remove arthritis
- fix w/plate, screw
Tarsal tunnel syndrome
Entrapment of tibial nerve in tarsal tunnel
Sxs: pain, swelling in posterior medial ankle w/associated radiating neuritis sxs in the tibial nerve distribution
PE: + tinel
Dx: EMG
- MRI preop, r/o tarsal tunnel mass
Mgmt:
- immobilization for acute inflammation
- PT for nerve glide exercises
- Gabapentin (Neurontin) or Pregabalin (Lyrica) for neuropathic pain
Surgical: fail conservative; tarsal tunnel mass
Plantar fasciitis
H/o increased physical activity or obesity
Sxs: start-up pain
- pain over plantar fascia origin or throughout fascia
+/- Baxter’s nerve
Dx: radiograph may show heel spur
Mgmt:
- 1yr of conservative treatment: NSAIDs, heel cord stretches, night splint, PT
- cortisone injection from medial aspect (NOT plantar)
Surgical: plantar fasciotomy + stretching
Haglund Deformity
Females
Symptomatic in shoes
“Pump bump” - posterior lateral prominence
- soft tissue changes first, then bony
Dx: Xray
Mgmt: gel sleeve, heel lift, surgery
Central fat pad atrophy
+/- h/o trauma
Worse in barefoot or hard floor; only w/weight bearing activity
Comparable to plantar fasciitis - but NO startup pain
Sxs: pain over central heel on exam
+/- palpable bone indicating fat pad atrophy
- adequate fat pad but + pain w/palpation = maybe bruised fat pad
Dx: Xray r/o stress fracture
Mgmt:
- orthotic pads help cushion
- no injections, no replacement therapy
Calcaneal stress fracture
Military recruit, marathon runner
PE: provocative test = + pain w/squeezing of calcaneal body
Dx: Xray; but MRI confirms*
Mgmt:
- NWB boot x 4-6wk, then PT to stretch area that tightened up in boot
- gradual return to activity
Lisfranc injury
D/t forced plantar flexion; easily missed as ankle or foot sprain
Sxs: pain over dorsal midfoot, usually mild to significant swelling
- swelling, pain over tarsal-metatarsal joint
- stabilization of ankle and hindfoot w/sagittal stress of the midfoot will create pain and occasionally instability is felt
Dx:
- Fleck sign: metatarsals and bones of foot don’t line up
- Xray
Mgmt:
- immobilization
- urgent surgery* to stabilize medial column
- posterior splint at 90deg from base of foot to base of knee
Metatarsal fracture
D/t trauma or fatigue (stress)
Sxs: swelling, pain w/weight bearing
- new or INC training regimen is common for stress fracture
Dx: Xray
Mgmt:
- NWB x 4-6wk then WBAT
- refer to Ortho
Surgery:
- significant shortening, displacement, angulation, subluxation
- painful non-union at 8wk
Jones Fracture
5th metatarsal fracture
- classic: zone 2 [NWB cast 6-8wk, surgery In athlete or sxs non union at 3mo]
- pseudo jones: zone 1 [NWB cast x 4-6wk]
- zone 3: stress induced [usually need surgery as delayed union is common]
Dx: Xray
Metatarsal stress fracture
Sxs: pain, swelling, erythema
Dx: Xray often negative
Mgmt: NWB in post op shoe
- followed by gradual increase in WB, activity
Hallux valgus (bunion)
Lateral deviation of hallux d/t hereditary, acquired, traumatic
- more common in females d/t shoe wear
Sxs: prominent medial eminence, pain w/activity, problems in shoe wear
Mgmt: shoe modification
- surgery: deformities w/sxs on regular basis
Lesser toe deformity
Cause: shoe, trauma, high arches, pressure from bunion
Hammer toe: flexion at PIP, extension DIP
Claw toe: flexion at both PIP, DIP
Mallet toe: neutral PIP, flexion DIP
pain over deformity prominence can cause corns or distal tip of toe rubbing
Dx: Xray
Mgmt: reduce w/pencil, buddy tape
- reassure that it may be tender for a while
- surgery: percutaneous fixation for significant angulation fracture or cannot be reduced
Toe fractures
Direct trauma - stubbed toe, kicked something
Permanent deformity is uncommon unless significantly displaced
Sxs: swelling, pain, ecchymosis
Dx: Xray
Mgmt: reduce w/pencil, buddy tape
- reassure that it may be tender for a while
- surgery: percutaneous fixation for significant angulation fracture or cannot be reduced
Metatarsalgia
Common in walkers or d/t overuse, poor shoes
Sxs:
- pain in ball of foot: worse in barefoot or hard floors (“walking on stones”)
- pain with palpation of metatarsal heads: callous, fat pad atrophy, hammer toe, bunion
Dx: normal Xray
Mgmt: orthotics w/metatarsal pad
- refer if no improvement in a few weeks
Morton’s neuroma
Hard to differentiate w/metatarsalgia
Pain worse in tight shoes* and better barefoot
Neuritic symptoms radiate into affected toes
Pain w/compression in web space (2nd, 3rd, webspace)
Dx:
- negative radiograph
- U/S
- diagnostic lidocaine* : dec pain in Morton’s but not metatarsalgia
Mgmt:
- orthotics w/MT pad
- Neurontin
- sclerosing agent?
- Surgical excision if conservative measures fail
Sesamoiditis
Anatomy
- 2 sesamoid bones surround by FHB and plantar plate fibers
- tibial (medial) and fibular (lateral)
Causes: inflammation from overuse/direct trauma; fracture; AVN
Sxs: pain under 1st MT head
+/- h/o forced DF injury (Turf Toe)
- may fracture sesamoids
Dx: best visualized on AP Xrary
- presence of sesamoids alone not indicative
Mgmt:
- if overuse, orthotics w/sesamoid protection
- refer to ortho if fail orthotic treatment or if fracture or AVN are present
Charcot Marie Tooth (CMT)
Hereditary neuromuscular disorder w/multiple variants
Sxs: weakness of tibialis anterior and peroneal
- neuropathy symptoms
- Cavovarus deformity: ankle instability; 5th MT stress fractures
Mgmt:
- bracing for weak tibialis anterior (foot drop)
- reconstructive surgery (refer to ortho)
Charcot Neuropathy
DM pt d/t breakdown of bone from trauma or DM neuropathy
Sxs: acute erythema, warmth, edema
- improves w/elevation and off-loading*
- chronic: bone destruction leaves a rocker bottom deformity - at risk of ulcer, infection, or loss of limb
Dx: initial Xray may be negative
- classic sign: fragmentation of bone and subsequent collapse
Tx: manage DM
Pilon Fracture
D/t high energy trauma (fall)
- fracture of distal tibia w/extension into ankle joint
Sxs: pain, severe swelling quickly*
Dx: CT Weber class (based on fibular involvement)
Weber A: below tibial plafond = stable; NWB cast 4-6wk
Weber B: at tibial plafond
- w/out displacement, tx nonop
- deltoid tenderness of medial clear space widening: ORIF
- stress test if unclear
- may have syndesmotic injury
Weber C: above tibial plafold
- indicates syndesmotic injury
- requires ORIF
Mgmt: call ortho immediately
- external fixation until definitive fixation can be performed
Medial malleolus fracture
Isolated
Check proximal fibula
Xray if malleolus tender
Mgmt:
- nondisplaced: cast
- displaced: ORIF
Bimalleolar fracture
Lateral + medial
Xray
Mgmt:
- unstable: ORIF surgery
- no displacement and multiple comorbidities: consider casting
Trimalleolar fracture
high rate of associated dislocation
Lateral + medial + posterior
Xray
Mgmt:
- very unstable and requires ORIF
- usually 7-10d after injury to allow soft tissue to settle down
- initially splint in stirrup + posterior rigid splint - call ortho*
Maisonneuve fracture
External rotation injury
- medial deltoid ligament tear + syndesmotic tear + proximal fibular fracture
Xray
Unstable = ORIF
Hindfoot fracture
Talus, calcaneus d/t very high energy trauma
- MVA, fall from height
Dx: check spine for concomitant injury**
- Hawkins classification
- Xray
Talar neck fracture
Nondisplaced: cast immobilization 6-8wk
Displaced: ORIF
Talar fracture
Mgmt:
- immediate reduction & fixation
- complications: AVN
Talar AVN
MC complication from fracture
Hawkins sign: subchondral lucency of talar body; occurs 6-8wk postop
- confirm w/MRI
Mgmt:
- NWB in boot w/bone stimulator
- more diffuse alteration in blood supply compared to OLT
Calcaneus fracture
D/t high impact trauma
Sxs: pain/swelling around heel
Dx: Xray, CT if needed
Complications:
- high rate of posttraumatic subtalar DJD
- chronic heel pain d/t fat pad injury - treat w/orthotics
Mgmt:
- refer all to ortho*
- short leg splint ASAP
- 10d NWB for both surgical and nonop pt
Woudn dehiscence MC postsurgical complication
Ankylosing spondylitis
Inflammatory back pain (lumbar, SI, hip)
Manifestations:
- acute anterior uveitis (MC)
- bowel disease
- enthesitis
- peripheral arthritis
- psoriasis
Dx:
- Schober test <4cm
- Occiput to wall - cervical mobility
- Labs: HLA-B27*, inc ESR/CRP
Imaging - lags behind presentation 7-10y
- Bamboo spine** - bone building disease, dec ROM
- Sacroilitis = radiograph hallmark**
Mgmt: tx current manifestations of dz
- NSAIDs for pain, stiffness
- pt ed, exercise, PT
- NO DMARDs
- corticosteroid injections may be helpful
- may consider surgery
Back strain/sprain general
Strain: paravertebral muscles
Sprain: facet joints, disc, spinal ligament
Most injuries thought to be a combo of both*
PE: neck, back, PV
Red flags:
- h/o CA
- unexplained weight loss
- urinary retention, incontinence
- progressive motor or sensory loss
- loss of anal sphincter tone
- saddle anesthesia*
- trauma, fever, UTI, infection
Back strain/sprain dx/tx
- imaging does NOT improve outcomes in pt w/o sxs of serious underlying condition, therefore not indicated for most
significant trauma: plain film*, may need CT or MRI
- concern for serious neurologic cause = MRI (r/o cauda equina syndrome)
- even w/minor red flags, 4-6wk of conservative treatment reasonable prior to imaging
Mgmt:
- pt ed; avoid bedrest; NSAIDs/APAP; muscle relaxants; warm compress; PT
- oral steroids; lumbar supports; massage; spinal manipulation
Kyphosis
Anterior compression (>5deg) in at least three adjacent vertebral bodies, as measured on lateral spine radiograph
- MC in tall boys; a/w w/back pain in adulthood
- affects thoracic or thoracolumbar spine
Sxs: subacute pain w/out precipitant
- pain worse after activity and at end of day
- pain improved w/rest and age
PE: curvature does not flatten w/forward bending, extension, or lying supine*
Dx:
- standing lateral spine radiograph**
criteria: - anterior wedging >5deg in three adjacent vertebral bodies
Mgmt:
- conservative: strengthening, stretching, analgesics, avoidance of precipitants
- bracing or surgery may be warranted w/persistent pain or kyphosis >60deg
Scoliosis
Lateral curvature of spine
Sxs: generally painless* MC R thoracic curvature
- asymmetry of shoulder heights, scapular prominence or position
- waistline or pelvic height discrepancy
- rib hump when pt bends over and comes back up slowly
Dx:
- females screened twice at ages 10/12 and boys once at 13 or 14
- standing AP spine radiograph*
- location of curve defined by apical vertebrae; direction of curvature defined by direction of convexity
- Cobbs Angle* = degree of curvature; > 15 is abnormal
Mgmt:
- ortho referral
- curve 20-25: monitor
- curve 25-45: no bracing in skeletally mature; Milwaukee brace in growing children
- curve >45: may require surgery regardless of skeletal maturity; refer regardless of age
Osteoarthritis general
Non-inflammatory DJD, MC arthritis in adults
- leading cause of hip/knee replacement
- progressive erosion of articular cartilage* leading to sclerosis and osteophyte formation
- synovitis (cool effusions) and synovial hypertrophy
- ligamentous laxity and disruption of joint capsule w/out injury
Causes:
- aging
- congenital, obesity*, injury
RF: age, female, AA, genetic, obesity, joint stress
Sxs:
- joint pain INC w/activity, relieved w/rest; worse in evening
- stiffness <30min, restricted ROM
- asymmetric sxs
- weakness, atrophy
- no systemic sxs
- Herberden’s, Bouchard’s nodes
OA dx/tx
Dx:
- normal ESR/CRP
- neg rheum tests
- noninflammatory synovial fluid (WBC <2k)
xray: joint space narrowing, osteophytes, sclerosis, subchondral cysts, nodes
Mgmt:
- limited to sx control; wt loss!!
- joint protection
- APAP
- NSAIDs + PPI
- can’t tolerate NSAIDs: capsaicin cream, methylsalicylate cream, diclonfenac sodium gel
- intraarticular steroid injection (or hyaluronic acid)
Surgical indications:
- pain affecting work, sleep, walking, leisure
Osteoporosis general
Skeletal fragility w/compromised bone strength predisposing to an INC r/o fracture
- primary: reduced bone mass/fractures in postmenopausal women or older men d/t age related factors
- secondary: bone loss from clinical disorder
bone mass peaks by 18-25yo
RF: female, white, petite, Fhx, early menopause, immobilization, ETOH, cigarette, Ca/Vit D def, meds, gastrectomy, intestinal surgery
- meds: steroids, heparin, AEDs
Sxs:
- fractures, complications
- MC: vertebral, proximal femur, distal forearm
- no pain prior to fracture
- fracture can result in chronic pain and disability
Osteopenia Pt
- T-score -1 to -2.5
- FRAX: calculate 10y risk of hip and major osteoporotic fracture (based on femoral neck BMD + RFs) - only applies before treatment
Osteoporosis dx/tx
Dx: BMD, hp/vertebral fx w/o trauma
- all postmenopausal women, men >50yo eval for need of BMD
BMD testing
- women >65
- men >70
- adult w/fracture over age 50
- adult w/condition (RA) or taking medication (glucocorticoid) associated w/low bone mass or bone loss
Osteoporosis: T-score at or below -2.5
Mgmt:
- Calcium [men 1000mg/d female 1200mg/d]: Ca carbonate take w/food; citrate for pt on PPIs or if they have constipation
- Vit D 600-800 IU/day
- PT/OT, smoking cessation, dec ETOH
Prevention:
- estrogen
- raloxifene
- alendronate, risedronate, ibandronate
Treatment:
- raloxifene (SERM)
- bisphosphonates**
- calcitonin, teriparatide, IV zoledronic acid, denosunab
Treat 4-5y w/bisphosphonates then drug holiday 1-2y
R/o osteonecrosis of jaw, atypical fremur fracture
