MSK Flashcards
What are the functions of the skeletal system?
Support
Protect
Movement
Mineral homeostasis
Blood cell production
Triglyceride storage
Where does red blood cell production occur
Red bone marrow
Where is triglyceride storage
Yellow bone marrow
What are the parts of a long bone
Diaphysis- shaft
Epiphyses - ends
Metaphyses - growth plate between shaft and end of long bone
What cells are a part of the microscopic structure of the bone
Osteoblasts - bone BUILDING
Osteocytes - Maintain by exchanging nutrients and wastes
Osteoclasts - DIGEST bone matrix for normal bone turnover
What are the three types of joints
Fibrous - dense irregular connective tissue
Cartilaginous - bones held together by cartilage
Synovial - have a synovial cavity and many other components such as ligaments
What is an example of fibrous joints
Sutures in the skull
They add strength to the joint
What is an example of interosseous membrane
Between long bones
Radius-ulna
Tibia-fibula
What are sacs that contain synovial fluid
Bursae
What is the function of ligaments
Connects bone to bone
What is the function of tendons
Connects muscle to bone
What is the function of cartilage
Covers ends of bones to absorb shock and reduce friction
(It’s in the join but IS NOT a cartilaginous joint)
What is the function of bursa
Decrease friction in areas where friction can occur with movement
What conducts most movement of bones/body parts and stabilizes body positions
Skeletal muscle
What are the four major function of muscular tissue in the body
Produce body movement
Stabilize body position
Store and move substances
Produce heat
What is a decrease in the angle between articulating bones
Flexion
What is an increase in angle between bones
Extension
What is bending beyond 180 degrees such as moving the humerus backwards behind the anatomical plane
Hyperextension
What is movement away from the midline
Abduction
What is movement toward the midline
Adduction
What is movement of distal end in a circle
Circumduction
What is a bone revolving around its own longitudinal axis
Rotation
What is movement of the soles of the foot medially
Inversion
What is movement of the soles of the foot laterally
Eversion
What is bending the foot toward the dorsum (standing on heels)
Dorsiflexion
What is bending the foot toward the plantar surface (standing on toes)
Plantarflexion
What is the scale used to evaluate muscle strength
0- no evidence of muscle function
Trace - muscle contraction but no or very limited joint motion
Poor - complete range of motion with gravity eliminated
Fair - complete range of motion against gravity
Good - complete range of motion against with some resistance
Normal - complete range of motion with full or normal resistance
3 or less = disability is present
What are the regions of the vertebral column
Cervical - 7
Thoracic - 12
Lumbar - 5
Coccyx - 4
What is cervical and lumbar vertebrae curves called
Lordotic
What is thoracic and sacral curves called
Kyphotic
What portion of the vertebrae is largest and strongest
Lumbar
L1-L5
What is the foundation for the pelvic girdle
Sacrum
What are the bones of the thorax
Ribs
Sternum
-Manubrium
-Body
-Xyphoid process
Which ribs are true ribs
R1-R7
- costal cartilage articulates DIRECTLY to the sternum
What are false ribs
R8-R10
Articulate with the sternum by cartilage of rib 7
What are floating ribs
R11-r12
Do not articulate with the sternum at all
What are the bones of the pectoral girdle
Clavicle
Scapula
Acromion
Coracoid
What articulates with the sternum medially and acromion laterally
Clavicle
What is part of the scapula that forms the “tip of the shoulder”
Acromion
What provides an attachment site for muscles and ligaments
Coracoid
What are the ligaments of the pectoral girdle
Acromioclavicular ligament
Coracoclavicular ligament
Coracoacromial ligament
What articulates with the head of the humerus to form the shoulder joint
Glenoid cavity
What deepens the glenoid and provides more stability to the joint
Glenoid labrum
What are the muscles of the rotator cuff
Supraspinatus - assists deltoid in abduction of the numerous at the shoulder
Infraspinatus - external rotation of the humerus at the shoulder joint
Teres minor
Subscapularis - internal rotation f the arm at the shoulder
What muscle abducts, flexes and rotates arm at the shoulder joint
Deltoid
What has multiple fibers in it and moves the scapula multi-directionally
Trapezius
What elevates the scapula and rotates downward
Levator scapula
What elevates and abducts the scapula and rotates downward as well as stabilizes the scapula
Rhomboid major
What muscle adducts and rotates arm medially at the shoulder as well as flexes the arm at the shoulder joint
Pectoralis major
What muscle extends, adducts and rotates the arm medially at the shoulder joint and draws arm downward and backward
Latissimus dorsi
What muscle extends the arm at the shoulder joint and assists with adduction and rotation of arm medially
Teres major
What muscle flexes and adducts the arm at the shoulder
Coracobrachialis
What are the bones of the elbow
Humerus
Radius
Ulna - olecranon is the proximal aspect of the ulna and is the medical term for elbow
What is the only hinge joint that supination and pronation occurs at
The elbow
What muscles move the radius and the ulna
Biceps brachii
Brachialis
Brachioradialis
Tricep brachii
Supinator
Pronator teres
What muscle flexes arm at the shoulder as well as flexes and supinates the forearm at the elbow
Biceps brachii
What muscle extends the forearm at the elbow joint and extends the arm at the shoulder
Triceps brachii
What muscle flexes the forearm at the elbow joint
Brachialis and brachioradialis
What muscle supinates the forearm
Supinator
What muscle pronates the forearm
Pronator teres
What are the bones of the hand
Carpals
Metacarpals - base body and head
Phalanges - numbered 1-5
What muscle flexes ad abducts the hand at the wrist
Flexor carpi radialis
What muscle flexes and adducts hand at the wrist
Flexor carpi ulnaris
What muscle weakly flexes hand at the wrist joints
Palmaris
What muscle flexes the hand at wrist and flexes phalanges of each finger at the PIP joint
Flexor digitorum superficialis
What muscle flexes phalanges of each finger at the DIP
Flexor digitorum profunus
What muscle extends and abducts the hand at the wrist JOINT
Extensor carpi radialis longus
What muscle extends and adducts hand at the wrist JOINT
Extensor carpi ulnaris
What muscle extends the hand at the wrist joint
Extensor digitorum
What nerve is sensation to little finger and 1/2 of ring finger
Ulnar - most of the intrinsic hand muscle motor supply
What nerve is to the palmar and dorsal aspect of first 3 and 1/2 fingers
Median nerve
What nerve is on the dorsum of the hand and lateral first three fingers and one half of fourth finger
Radial nerve
What special test is used to diagnose shoulder impingement or rotator cuff tears
Neers impingment sign
What special test reinforces a positive Neers and pain in the subacromial space is indicative of rotator cuff tears or tendinitis
Hawkins
What special test detects tears in the rotator cuff (supraspnatus)
Drop arm test
What special test evaluAtes the teres minor
Hornblower
Weakness is a positive sign
What special test is useful in diagnosing biceps tendonitits
Speeds test
What special test is for subscapularis strength and possible tendon rupture
Gerber lift off
What is a postive sulcus sign
A visible dimple and suggests that the patient has inferior shoulder instability
What is a positive O’Briens test
Pain is worse with thumbs down and relieved with forearm supination. Suggests labral pathology
What does the valgus stress test assess
Stability of the medial ligamentous structures
What does the varus stress test assess
The stability of the lateral collateral ligament
What is a positive elbow flexion test
Tingling, numbness, and parathesia of the ulnar nerve = positive for cubical tunnel (ulcer nerver) syndrome
What is a positive tinel sign
Reproduction of parenthesis into the ulnar nerve distribution - suggests ulnar nerve entrapment
What does a positive froments sign suggest
Suggests ulnar nerve paralysis
What is a type I clavicular separation
AC ligaments partially disrupted and coracoclavicular ligaments are intact.No superior separation of clavicle from acromion
What is a type II clavicular separation
AC ligaments are torn and CC are intact resulting in partial separation of the clavicle from Acromion
What is a type III clavicular separation
AC and CC ligaments are completely disrupted resulting in complete separation of the clavicle from acromion
What is type IV separation
AC and CC ligaments are completely disrupted with superior and prominently posterior displacement
What is a type V separation
AC and CC ligaments are completely disrupted with CC interspace more tan twice as large as opposite shoulder
What is type VI separation
Uncommon.
Clavicular periosteum and/or deltoid and trapezius muscle are torn resulting in wide displacement
What is the treatment for type I and II clavicle separation
Sling for 24-48 hours
Ice
Analgesics
Home exercise
Return to full duty as pain permits
What is the treatment for a type III separation
Ortho consult
Sling for 24-48 hours
Ice
Analgesic
Light duty until evaluated by Ortho
What is the treatment for IV-VI separations
Ortho - will require surgery
Sling until ortho
Ice
Analgesic
MEDEVAC
What is the most common bony injury
Fracture of the clavicle
What special tests will be performed with a suspected clavicle fracture
Cross body - positive with possible grinding
But is not required if obvious deformity is noted
What is the treatment for a clavicle fracture
Ice
Analgesic
Ortho
Midshaft fracture with minimal displacement and no Neuro vascular injury = figure 8 strap for 6-8wks
All fractures require referral - MEDEVAC
What is a gradual onset of anterior and lateral shoulder pain that is made worse with overhead activity and has associated night pain when sleeping on affected side
Impingement syndrome of the shoulder
What is the treatment for impingement syndrome of the shoulder
NSAIDs
Ice
Light duty
Home exercise
Physical therapy consult if failed local management
When would you refer to ortho on someone with impingement syndrome
Failed conservative management after 2-3 months or other pathology is suspected
What is another name for a rotator cuff tear
Musculotendinous cuff rupture
Rotator cuff rupture
Rotator cuff tendinitis
What is the likely cause of pain with someone who presents with chronic shoulder pain, specific injury triggered that triggered pain, night pain and difficulty sleeping on affected side or complaints of weakness, catching or grating especially with overhead activities
Rotator cuff tear
What special tests are performed on someone with a suspected rotator cuff tear
Drop arm - positive
Empty can - positive
Who does bicep tendon injuries most commonly occur in
People who pull, lift, reach or throw for work or recreation
- weight lifters
- rock climbers
- degenerative tendinopathy of the tendon in older patients
How does a bicep tendon injury commonly present
Anterior shoulder pain that radiates dismally down the arm over the bicep muscle
What differentiates a bicep tendon injury and a rupture
Tendon rupture would be suspected if there was a single injury (a “pop”) with ecchymosis and swelling
- deformity only presents in severe cases
What is the mainstay of treatment for a bicep tendon injury
NSAIDs
Ice
Duty modification
Physical therapy/ HEP
What are the synonyms for shoulder instability
Dislocation
Multidirectional instability
Recurrent dislocation
Subluxation
What are the two instability patterns for the shoulder
TUBS - traumatic unilateral dislocation with a bankart lesion that can be successfully treated with surgery
AMBRI - a traumatic multidirectional instability that is commonly bilateral and is often successfully treated with rehab and occasion an inferior capsular shift surgery
What are the clinical symptoms of shoulder instability
“Shoulder feels like its slipping out of joint” when arm is abducted and externally rotated
Initial anterior dislocation is associated with trauma from a fall or forceful throwing
Recurrent dislocations may occur with positioning arm over head
Posterior dislocation will describe posterior directed force
Multidirectional instability may have vague symptoms but usually related to activity
What special tests will be postive with a shoulder dislocation
Sulcus
Apprehension test with anterior instability
Anterior/posterior drawer test - will have laxity
Jerk test - positive instability
What is the treatment for a shoulder dislocation
Reduce acute dislocations
Immobilize arm in a sling in a neutral direction
Light duty 2-3 weeks
Begin rotator cuff strengthening 2-3 weeks post reduction
Physical therapy consult
When would you refer for a shoulder dislocation
First time dislocation - medevac
Neuro vascular compromise requires orthopedic consult with possible surgery - medevac
What are some mechanisms of injury on someone who may have a SLAP lesion (labrum tear)
Falling back on an outstretched arm
Tries to prevent fall by grabbing an object
Suddenly tries to lift a heavy object
Forceful throwing or overhead activity
Chronic overuse vs acute injury
What are the symptoms of a SLAP tear
Anterior shoulder pain
Clicking or clunking of the shoulder in certain positions
Swelling, parathesias , severe night pain is uncommon
What special tests are recommended for evaluating a SLAP tear
O’Brien and speeds
Who is adhesive Capsulitis (frozen shoulder) more commonly seen in
Older populations 50-60s
Often associated with other disease and conditions
What are the three phases of adhesive capsulitis (frozen shoulder)
Diffuse, severe and disabling shoulder pain with increasing stiffness, last 2-9 months
Stiffness and severe loss of shoulder motion with pain less pronounced, lasts 4-12 months
Recovery phase - with stiffness and gradual return of shoulder motion that takes about 5-24 months to complete
What are the signs of someone who may have frozen shoulder
History of shoulder pain with complaints of
- severe pain that is worse at night, “nagging pain”
- decreased ROM in shoulder
- issues with various daily living tasks
What is the treatment for frozen shoulder
Early mobilization for those with shoulder injuries
- avoid slings when possible
Shoulder motion exercises
- PT consult
NSAIDS
Tylenol
Consider referral for steroid injections
What is lateral tendinitis
Tennis elbow
What is medial tendinosis
Golfers elbow or bowlers elbow
What are the symptoms of lateral epicondylitis
Gradual onset of pain in lateral elbow and forearm during activities involving gripping and wrist extension
- lifting
- turning screwdriver
- hitting backhand in tennis
- excessive typing
- less common, results from a direct blow to lateral aspect of the elbow
What is the clinical symptoms of someone with medial epicondylitis
Gradual onset of pain at the medial aspect of elbow, exacerbated by activities that involve wrist flexion and forearm pronation
- golf swing
- baseball pitch
- pull through stroke of swimming
- weight lifting
- bowling
What is the treatment for epicondylitis
Light duty
Limit repeative activities to allow for healing
Nsaids
Tennis elbow strap for comfort
Pain free stretching and forearm strengthening
PT consult if failed conservative treatment
Ortho consult
Steroid injections
What is likely the diagnosis of someone who has sudden (infection or trauma) or gradual swelling in the effected area, pain ranging in severity, limited ROM from pain or pressure, and as the mass diminishes in size the patient may feel firm lumps or nodules that result from scar tissue
Olecranon bursitis
What diagnostic testing is used for someone with suspected olecranon bursitis
Aspiration may be diagnostic and therapeutic
- lab testing of aspirate for WBC count, crystals, gram stain and culture
Radiographs to rule out a fracture
What is the treatment for olecranon bursitis
Light duty to avoid hyper flexion against hard surfaces
Mild cases:
- NSAIDs
- pressure wrap
- ice
Moderate to severe:
- fluid aspiration, refer to ortho for evaluation
Septic
- requires organism specific antibiotics- refer for treatment
Where is the most common site for cubical tunnel syndrome
Where the ulnar nerve passes in groove on the posterior aspect f medical epicondyle (cubital tunnel)
What are the causes of nerve compression syndrome of the upper extremities
Direct blow to cubital tunnel
Nerve stretched from flexed elbow for prolonged periods of time
Cubits valgus (carrying angle greater than 10 degrees)
Osteophytes or scar tissue
If someone has numbness and tingling in the 4th and 5th digits, elbow pain/ache that may radiate proximally to shoulder and neck, inability to do activities of daily living such as opening jars or turning a key in door (late signs)
Ulnar nerve compression
- intrinsic muscle atrophy implies nerve compression of several months
What is the treatment for ulnar nerve compression
Modify activities to limit elbow flexion and direct pressure on the ulnar nerve
Splint elbow or wrap towel around elbow
NSAIDs
Surgical decompression and transposition of ulnar nerve if 3-4 months of conservative management
What is the common injury that results in ulnar collateral ligament tear
Overhead throwing motions (baseball pitcher)
If someone presents with acute onset of a “pop” while throwing and experiences a gradual onset of symptoms with progressive medial elbow pain with valgus stresses, may also experience symptoms consistent with ulnar neuritis
Ulnar collateral ligament tear
What is the treatment for ulnar collateral ligament tear
Light duty
Ice for acute injury
NSAIDs
Pain free elbow and wrist strengthening
Who does elbow dislocations most commonly occur in
Children
Third most common dislocation in adults
What does an elbow dislocation result from
Resulting from a fall on an outstretched hand (FOOSH)
What is the treatment for an elbow dislocation
Ice
Pain management
Splint
Consider emergency reduction if delayed medevac time or neurovascular compromise
Repeat neuro checks after reduction
How do you perform an elbow reduction
Extend elbow to 45 degrees
Slow, steady downward traction of forearm in line with long axis of humerus
Gentle pressure over olecranon tip
Repeat neuro checks
What is the most common neuropathy of the upper extremity
Carpal tunnel
Who is most commonly affected by carpal tunnel
Middle aged or pregnant women
If someone has numbness and tingling into radial three digits of the hand, pain and paratheisis or numbness of the median distribution (then, index finger, long finger and radial half of ring finger), pain is worse at night and reports needing to rub hands to “get circulation back”. They also frequently drops objects or cannot open jars with twist lids and the pain is worse repetitive motion of the hand or stationary tasks
Carpal tunnel
What is the treatment for carpal tunnel
Splint wrist in neutral position
NSAIDs
Light duty
Ergonomic modification
Ortho consult if failed conservative management
What is precipitated by repetitive use of the thumb, pain/swelling and triggering phenomenon resulting in locking or sticking of the tendon as patient moves thumb and commonly effects middle aged women
De quervain tenosynovitis
What is the treatment for de quervain tenosynovitis
NSAIDs
Thumb spica splint
Light duty
- refer to ortho if failed conservative management
What is the most commonly fractured carpal bone
Scaphoid fracture
A patient presents with a pain on the radial side of the wrist in the anatomical snuff box as well as pain with wrist motion and gripping. they also describe a dorsiflexed wrist injury before the pain began. what is the likely diagnosis
Suspected scaphoid fracture
What is the treatment for a suspected scaphoid fracture
Thumb spica splint
Light duty
Treatment strategy should focus on definitive diagnosis with radiographs or mri as soon as possible
Consult to ortho
Analgesics
What is the most common soft tissue tumor of the hand that effects ages 15-40 years old, arising from capsules of a joint or a tendon synovial sheath
Ganglion of the wrist
A patient present with a firm modular swelling in wrist that may vary in size and increases in size, and pain with wrist motion
Ganglion of the wrist
- bump at MCV or on the dorsum of the finger distal to DIP would suggest hand or finger ganglion
What is the treatment for a ganglion
Splint wrist or finger
NSAIDs
Consult to ortho for aspiration or surgical excision
What is a rupture of the flexor digitorum profundus tendon from its distal attachment site and is common in contact sports. Commonly overlooked as a jammed finger
Jersey finger
- ring finger is involved in 75% of cases
What is rupture or avulsion of the insertion of the extensor tendon and base of distal phalanx, usually from a direct blow to the finger causing sudden forced flexion of the DIP/distal phalanx and has pain at the DIP joint
Mallet finger
- commonly a flexed DIP at rest
What is the treatment for mallet finger
Maximize function, minimize discomfort
- splint finger in full extension
- if fractured do not reduce
- 6-8 weeks of splinting, sleep with it on as well
What is an extensor tendon rupture at insertion of middle phalanx, flexion of PIP/extension of DIP, and a painful PIP joint
Boutonnière deformity
What is the treatment for boutonnière deformity
Splint PIP in extension for 3-6 weeks
Allow DIP to move freely
PT for ROM
Ortho consult for ongoing deformity
What are the hip bones composed of
Ilium - largest most superior
Ischium - “sit bone”
Pubis - lower anterior portion
What forms the socket for the head of the femur
Acetabulum
What is the largest foramen in the body
Obturator foramen
What muscle flexes and rotates thigh laterally
Psoas major
Iliacus
What muscle helps lock the knee in extension
Gluteus Maximus
Tensor fascia latae
What muscle abducts and rotates the thigh medially
Gluteus medius
What muscle flexes and abducts the thigh at the hip joint
Tensor fascia latae
What muscle adducts, rotates and flexes thigh at hip joint
Adductor longus
What muscle adducts, flexes, rotates and EXTENDS thigh at the hip joint
Adductor magnus
What muscle is the external rotation of thigh laterally and abducts
Piriformis
What flexes and adducts the thigh
Pectineus
What is the strongest bone in the body
Femur
What are the bones of the knee
Femur
Patella
Tibia
Fibula
Patellar ligament
What is the attachment site for the patella ligament
Tibial tuberosity
What provides leverage for the quadriceps muscle and protects the knee
Patella
What attaches to the tibia via the interosseous membrane
Fibula
What strengthens the anterior surface of the knee
Patellar ligament
What ligament strengthens the medial aspect of the knee
Medial collateral ligament (MCL)
What ligament strengthens the lateral aspect of the knee
Lateral collateral ligament (LCL)
What ligament extends posteriorly and laterally from the tibia to the femur and limits hyperextension of the knee/prevents anterior sliding of the tibia on the femur
Anterior cruciate ligament (ACL)
What ligament extents anteriorly and medially from the tibia to the femur and prevents posterior sliding of the tibia on the femur
Posterior cruciate ligament (PCL)
What are the fibrocartilage discs that fit between tibial and femoral condyles and allow the bones to “fit” together more appropriately as they are irregular in shape
Menisci
Where is bursae located in the knee
Prepatellar
Pen anserine
Infrapatellar
Suprapatellar
What muscle adducts and medially rotates the thigh as well as flexes the leg at the knee
Gracilis
What muscles adducts the femur
Adductor magnus
Adductor longus
Pectineus
What muscle extends the knee, flexes the hip and is located anterior to other quadricep muscles
Rectus femoris
What muscles extend the knee
Vastus lateralis
Medialis
Intermedius
What muscle flexes at the knee, weakly flexes the hip and abducts/laterally rotates the thigh
Sartorius
What muscle extends thigh at the hip and flexes the leg at the knee joint
Bicep femoris (hamstrings)
What extends the thigh at the hip and flexes leg at the knee
Semitendinosis.
What muscle extends the thigh at the hip and flexes leg at the knee
Semimembranosis
What are the seven bones (tarsals) of the ankle
Large talus (ankle bone)
Calcaneus (heel bone)
Cuboid (lateral)
Navicular (medial)
Cuneiforms (numbered 1-3 medial to lateral)
Metatarsals (1-5/ base, body and head)
Phalanges (1-5/base, body and head)
What are the ligaments of the lateral ankle
Anterior talofibular ligament (ATFL)
Calcaneofibular ligament (CFL)
Posterior talofibular ligament (PTFL)
What is the ligaments of the medial ankle
Deltoid ligaments
- four fused into one
- connects the tibia to the talus, calcaneus and navicular bones
What muscle dorsiflexes and inverts the foot
Tibalis anterior
What muscle dorsiflexes and everts the foot as well as extends the toes
Extensor digitorum longus
What muscle plantar flexes and Everts the foot
Fibularis longus
What muscle plantar flexes the foot and flexes the leg at the knee
Gastrocnemius
What muscle plantar flexes the foot
Soleus
What muscle plantarflexes and inverts the foot
Tibalis posterior
What muscle plantar flexes the foot and flexes the toes
Flexor digitorum longus
What special test of the lower extremity detects gluteus medius muscle weakness
Trendelenburg test
What special test detects hip and sacroiliac pathology
Faber test
What special test is used to detect acetabular or femoral neck pathology such as osteoarthritis or osteonecrosis
Log roll test
What special test is used to test for a tight piriformis impinging the sciatic nerve
Piriformis
What special test assess for labral pathology, loose body or other internal derangement of the hip
Scour
What special test detects flexion contractors or tightness of the hip
Thomas test
What special test, tests for patellar instability
Patellar apprehension test
What special test assesses for cartilage degeneration in the knee
Patellar grind test (clarke)
What special test evaluates the health of the menisci in the knee
mcmurray test
What does the varus stress test evaluate
Integrity of the LCL
Valgus evaluate integrity of the MCL
What special test detects instability of the anterior cruciate ligament
Lachmans
What special test assesses for posterior cruciate ligament stability
Posterior drawer test
What special test is used to see if the PCL is Lax
Sag
Positive - tibia will sag down when knee is at rest
What special test detects iliotibial band (ITB) contractures or tightness
Ober test
What special test assesses integrity of the Achilles’ tendon
Thompson test
What special test, tests for possible tibio/fibula syndemosis injury
Tib/Fib squeeze
(High ankle sprain)
What does a posterior hip dislocation show in a physical exam
Affected limb short, hip is flexed in adducted and internally rotated position
What does an anterior hip dislocation show in a physical exam
Hip held in abduction and externally rotated
What is the treatment for a hip dislocation
MEDEVAC
Reduction - going to need narcotics
SIQ until eval by ortho
What may also present with a fracture of a femoral shaft
Mostly caused by high energy trauma
- pulmonary injury
- vascular complications
- intra-abdominal
- head injuries
What is the treatment for a femoral fracture
Immediate splinting and traction
MEDEVAC
Surgical management required
If open wound, apply dressing
What is a common injury that occurs because of repetitive impact and is seen in military recruits, athletes and runners
Stress fracture of the femoral neck
What is the likely cause of someone who has vague pain in anterior groin or thigh that is exacerbated by activity and weight bearing but relieved with rest. They may also report a story of increasing activity prior to the pain onset
Stress fracture of femoral head
What is the treatment for a stress fracture of the femoral head
Analgesics
Ortho evaluation
Activity modification
- crutches
- non weight bearing
What might be the cause of someone who has pain in the groin area with attempted weight bearing and a sensation of “coming apart” at the hip when bearing weight. This person may also be in shock and have other distracting injuries to the head, chest or abdomen
Pelvic fracture
What is the treatment for a pelvic fracture
MEDEVAC
Hemodynamic resuscitation
No weight bearing
Narcotic pain management
PELVIC BINDER
What might be the cause of someone with sudden onset of posterior or thigh pain that occurred while running, water skiing or other rapid movement and may of heard a “pop” at the onset of pain.
Thigh strain
- quadriceps strains are associated wit direct blows during contact sports that result in a contusion
What is the treatment for a thigh strain
Initial treatment - prevention of further swelling or hemorrhage by having patient rest and elevate limb while applying ice and compressive wraps as needed
After some time - begin rehab with pain free stretching and strengthening of the injured muscle
NSAIDs
What may be the cause of someone who has pain and tenderness over the greater trochanter (lateral hip pain) that may radiate distally to the knee or ankle and pain worsening when going from sit to stand but may decrease after warming up or return after 30 min to 1 hour of walking.
Trochanteric bursitis
What is the treatment for trochanter bursitis
NSAIDs
Light duty
Hip strengthening
Refer to ortho if conservative management fails
What does ACL tears result from
Rotational (twisting) or hyperextension force of the knee
What might be the cause of someone who reports sudden pain and giving way of the knee from a twisting injury as well as heard a “pop”
ACL tear
What is the treatment for an ACL tear
RICE
Light duty
Ortho consult
PT consult
Knee immobilizer
What is the strongest ligament of the knee
PCL
What does a PCL tear result from
Stretch or complete rupture of the ligament
- less common than the other ligament injuries
What are the four injury patterns that suggest a PCL tear
Dashboard injury - direct force to the anterior knee with knee in flexion
Pure hyper flexion of the knee
Hyperextension - ACL goes first then the PCL
Fall onto a flexed knee with the foot in plantar flexion
How does MCL and LCL tears result
MCL - Valgus force
LCL - Varus force
What is the treatment for an MCL tear and LCL tear
Usually non-operative and heal within 4-6 weeks (MCL)
Grade III LCL tear requires surgery
Contact MO
PT
NSAIDS
rice
Hinged brace
Crutches and weight bear as tolerated
Ortho consult if conservative fails
How does bursitis of the knee present
Prepatellar bursitis - dome shaped swelling over the anterior aspect of the knee
Pes anserine - mild swelling to the medial aspect of the knee
What is the treatment for bursitis of the knee
Rice
NSAIDs
Light duty
Pain free LE stretching
Antibiotic treatment for septic bursitis
What might be the cause of someone who has focal pain at the anterior lateral aspect of the knee that worsens with activity and is worse when running downhill, mostly during heel strike but only has minor discomfort when as rest
ITB syndrome
What is the treatment for ITB syndrome
NSAIDs
Foam rolling
Light duty
Modified training regiment
What might be the cause of someone who has locking, catching or popping with squatting or twisting
Meniscal tear
What type of meniscus tear requires a more urgent orthopedic evaluation
Bucket handle tear - leading to a “locked knee”
What is the treatment for a meniscal tear
Locked knee - urgent referral
RICE
NSAIDs
ROM and pain free strengthening exercises
Consult to ortho
What may be the cause of anterior knee pain that is exacerbated by exercise, prolonged sitting, squatting, kneeling and climbing, descending stairs, running and jumping increases the pain
Patellar tendonitits - jumpers knee
What is the treatment for patellar tendonitits
NSAIDs
Rice
Light duty
Pain free stretching and strengthening
Patellar tendon strap for comfort
What might be the cause of diffuse aching anterior knee pain that is exacerbated by prolonged sitting, climbing stairs, jumping or squatting. No preexisting trauma and some patients may report a sense of instability or retropatellar catching or grinding sensation
Patellofemoral pain
What is the treatment for Patellofemoral pain
NSAIDs
Ice
Light duty -active rest
Quad and hamstring flexibility and stregthening
Weight loss if obese
McConnel taping
Patellar tracking brace
Motion control shoe/inserts
What might be the cause of someone who has swelling/fullness in the popliteal fossa, posterior knee pain, and knee stiffness
Popliteal cyst
What must be considered in your differential in someone suspected to have a popliteal cyst
DVT
What is the treatment for a popliteal cyst
NSAIDs and/or analgesic
Ice
Light duty
How does osgood schlatter disease present
Ages 14-18 possibly later in males
Pain and swelling at the tibial tubercle
Anterior knee pain that increases gradually
Typically asymmetrical
VISUAL - normal to slight swelling/bony prominence of tibial tubercle
What is the treatment for osgood schlatters disease
Usually benign and self limiting - resolves when the growth plate reaches skeletal maturity
NSAIDs
Protective pad
Avoid complete rest
Home exercise
What may be the cause of pain that is localized to the distal third of the medial tibia and the patient has increased training intensity, pace or distance.
PALPATION: Tenderness along posterior medial crest of tibia in the middle to distal third of leg
Shin splints
What is the treatment for shin splints
NSAIDs
Ice
Light duty
Gradual pain free return to running
Weight loss if needed
Proper running shoes
What presents similar to shin splints but pain increases over weeks to months and also begins to occur or worsen at rest
Tibial stress fracture
All patients with a suspected tibial stress fracture require what
Imaging
- plain radiographs, but negative X-rays can’t rule out a stress fracture
- MRI/Bone Scan/CT are better at detecting stress fractures
What is the treatment for a tibial stress fracture
Rest/duty modification
Weight bearing mod
NSAIDs and Tylenol for pain
Duty modification for 12 weeks
What might be the cause of severe leg pain out of proportion to apparent injury, persistent deep ache or burning pain, parasthesia and symptoms progress over a few hours
Compartment syndrome
What are you looking for in your physical exam on someone who may be experiencing compartment syndrome
Seven P’s
- pain
- pallor
- parasthesias
- paresis
- poikilothermia
- pulselessness
What is the treatment for compartment syndrome
Acute is a medical emergency requiring fasciotomy by a surgeon
Place limb in neutral position
Analgesics and oxygen
Rest
NSAIDs
Ice is contraindicated
What is the largest tendon in the body
Achilles’ tendon
Who is at risk for an Achilles’ tendon rupture
Athletes
30-40 year olds
Male
Obesity
Running mechanism issues
FLUOROQUINOLONE ANTIBIOTIC USE
Rheumatologic diseases
What are the areas required to be checked for the Ottawa ankle rules when ruling out an ankle sprain
Posterior edge/tip of lateral malleolus
Posterior edge/tip of medial malleolus
Base of 5th metatarsal - navicular
If someone reports pain localized to the dorsum of the mid foot with minimal swelling what might you suspect
Lisfranc fracture
What is the treatment for a lisfranc fracture
Ortho
Non displaced = 6-8 weeks non weight bearing
Displaced = surgery
Analgesics
Medevac
What might be the cause of pain and swelling aggravated by shoe wear, and the great toe pronates with resulting callus on medial aspect
Bunion
What is the treatment for a bunion
Initial - patient education and shoe wear modification
Light duty
Ice
What might be the cause of plantar pain in the forefoot, dysesthesia into the affected two toes or burning plantar pain
Morton neuroma
What is the treatment for Morton neuroma
Wear low-heeled, softsoled shoe with wide toe box
Metatarsal pads
What might be the cause of someone with pain that is most severe on awakening or when rising from a resting position, prolonged sitting or standing increases the pain, and the pain is focal over the medial calcaneal tuberosity and 1-2 cm distally along the plantar fascia
Plantar fasciitis
What is the treatment for plantar fasciitis
NSAIDs
Light duty
OTC heel pads
Night splints may be helpful
What might posterior heel pain arise from
Insertion of the Achilles’ tendon at the calcaneus - Achilles tendinosis
Retrocalcanel bursa
Prominent process of calcaneus impinging on retrocalcanel
Inflammation of the bursa between the skin and the Achilles’ tendon
What might be the cause of pump bump that is irritated by shoe wear, pain after activity and antalgic gait
PALPATION: tenderness noted over heel or directly on Achilles’ tendon
Posterior heel pain
What is the treatment for posterior heel pain
Light duty
Heel lift or open back shoes
Ice massage
Achilles stretch
Casting for 6 weeks in extreme cases
What is an hyperextension injury of the first metatarsal and patients usually report swelling, tenderness and limited ROM of the first metatarsal
Turf toe
What is the treatment for turf toe
Rice
NSAIDs
Stiff shoe inserts
Severe injury requires non weight bearing and immobilization for 1-2 weeks
What is an intra-articular fracture
Crosses the joint line
What is cervical radiculopathy
Clinical condition that involves the neck, shoulder or arm pain
Radiculopathy - affecting nerve root
What might be the cause of neck, shoulder or arm pain, muscle weakness, sensory changes, diminished DTR, and headaches
Cervical radiculopathy
What is the treatment for cervical radiculopathy
Spontaneous resolution in weeks to a couple months
NSAIDs, Tylenol, muscle relaxers
Pt or chiropractor
What might be the cause of non-focal neck pain from the base of the skull to the cervicothoracic junction, trapezius and SCM that is worse with ROM, has paraspinal spasms, occipital headaches, irritability, fatigue or sleep disturbances
Cervical strain
What is the treatment for a cervical strain
Soft c collar
NSAIDs and muscle relaxers
Massage
Return to activity as soon as possible
What are red flags for imaging of the spine
Saddle anesthesia
Loss of bowel/bladder function
Lower extremity weakness
What might be the cause of abrupt or gradual unilateral radicular leg pain that has various aggravating factors.
Herniated disk
Possible neurological involvement
- L4/L4, L5-S1 distribution
- L1-L4 refers pain to the anterior thigh
What is the treatment for a herniated disk
Control pain
Lifestyle modification
Rehab
Consult chiro/pt
Lumbar scoliosis greater than what degree is disqualifying
20 degrees
30 degrees for thoracic scoliosis
What is the goal of treatment with scoliosis
Improve function
Quality of life
Stamina improvement
- correction of spinal deformity is not a realistic goal for all cases
What might be the cause of reproducible chest pain that is exacerbated pain with palpation on physical exam and patient may also have viral illness or other cause of inflammation in the chest
Costochondritis
What is the treatment for costocondritis
Most improve over a course of a few weeks
NSAIDs
Home stretching activity modification
What might be the cause of knee pain that was initially sharp and then with time foes to an aching deep pain that is alleviated with rest and exacerbated with use.
VISUAL: bony swelling possible
PALPATION: Joint line tenderness
ROM: Limited
Osteoarthritis
What is the treatment for osteoarthritis
Pain control
- NSAIDs
- Tylenol
Stop insult to cartilage
- weight reduction
- activity/lifestyle modification
Rehab
- Aerobic and strengthening exercises
4 out of the 7 ACR criteria must be met to diagnosis Rheumatoid arthritis. What are the 7?
Morning stiffness for one hour duration of 6 weeks
Arthritis in 3 or more joints for 6 weeks
Swelling of the hand joints
Symmetrical joint swelling
Rheumatoid nodules
Positive RF factor
Erosions or osteopenia in hand X-RAY
May have myelopathy with c1-c2 involvement
What is the treatment for rheumatoid arthritis
Medavice with GMO or refer to internal medicine
Typical pain medications
Physical therapy/surgery
What is reactive arthritis
Spondyarthropathy that is preceded and precipitated by infection in the body:
- urinary tract infection
- diarrheal illness
- sexually transmitted infection
How does reactive arthritis present
Acute onset joint pain 1-4 weeks after infection
- enthesistis = inflammation of insertion sites for ligaments, tendons, fascia
- dactlyitis = sausage fingers
- lower back pain
- nail changes
- conjunctivitis
- oral lesion
What is the treatment for reactive arthritis
Treat infection if active
Symptoms are self limited and may last up to 6 months
NSAIDs for pain
What is psoriatic arthritis
Associated with psoriasis
How does psoriatic arthritis present
Pain and stiffness in affected joints
Stiffness sometimes alleviated by physical activity
Asymmetry distribution of joint pain
Skin lesions prior to pain
Nail lesions
Ocular lesions
What is the treatment for psoriatic arthritis
Do not attempt to manage, refer to derm or rheumatology
What is ankylosis spondylitis
Inflammatory arthritis of the spine
- potential cause of lower back pain
How does ankylosing spondylitis present
Back pain
Bamboo spine in late stage cases - sever restricted back mobility
What is the treatment for ankylosis spondylitis
Recognize and refer
Initial pain relief with NSAIDs
Expect use of demands after rheumatology referral
Minimize damage to spine
What is gout
Monsodium urinate crystal deposition in joint and tissues
- i.e. uric acid deposition
What are the common sites of involvement for gout
1st toe, ankle, knee, wrist, fingers and elbows
How does gout present
Intense pain, redness and swelling that occurs within hours to days
LABS: Uric acid
NEEDLE SHAPED, NEGATIVE BIREFRINGENT (joint space fluid aspiration)
What is the treatment for gout
Acute:
- NSAIDs = INDOMETHACIN
- colchicine
- steroids
Prophylaxis:
- allopurinol
- probenecid
DIET MODIFICATION:
- AVOID:
- meat
- seafood
- alcohol
- high fructose corn syrup
What is pseudo gout
Similar to clinical presentation of gout but Uric acid levels are normal
What is the treatment for pseudo gout
NSAID - indomethacin
Lifestyle changes
What is the most common cause of septic arthritis
Staphylococcus aureus
If someone presents to medical following a recent surgery that has severe pain, swelling and decreased mobility as well as fever and tachycardia what might be the cause
Septic arthritis
What is the treatment for septic arthritis
Supportive if in shock (iv, monitors, vs, bolus of IVF)
IV antibiotics (ceftriaxone or vancomycin) - joint fluid aspirate helps determine the antibiotic needed
MEDEVAC
What is virchow triad
Hypercoagulabilty
Venous stasis
Endothelial damage
What might put someone at risk for a DVT
MSK surgery
Polytrauma
Spinal cord injury
Immobilization
Cancer history
Smoking
Diabetes
Estrogen use
Obesity
Age
What are the symptoms of a fracture
Severe pain, swelling and decreased mobility
Limited weight bearing
Numbness, tingling pallor, ecchymosis, and deformity
What are the classifications of a fracture
Skin integrity - broken skin = open fracture, bone doesn’t have to be the cause of skin break
Displacement/angulation/rotation
Orientation
What is the treatment for a fracture
Four r’s
Recognition
Reduction
Retention of reduction while achieving union
Rehabilitate
What further treatment may be required with fractures
Pain control
Rule out other life threatening injuries
Copious irrigation for open fractures
Tetanus prophylaxis
When should you check pulses when splinting
Before and after
What splints are required for the different types of fractures
Traction = femoral
Spine board/c-collar= spine
Sling = clavicle
Pelvic binder = pelvis
All should be in position of comfort/natural positioning and loose to allow for swelling/well padded
What are the carpal bones
Scaphoid
Lunate
Triquetrium
Pisiform
Trapezium
Capitate
Hamate
- scared lovers try positions that they can’t handle
What are the muscle groups of the hip
Iliopsoas
Sartorius
Rectus femoris
