MSK 5 with pictures Flashcards
What part of the femur is associated with abduction?
Greater trochanter
What part of the femur is associated with adduction?
Lesser trochanter
What are the 2 greatest risk factors of hip fx?
Osteoporosis and female gender
What is very important to determine w/hip fx?
Baseline ambulatory status (after fx move one step down i.e. if cane, now need walker)
Approximately how many pts don’t survive past 1 year post-hip fx?
25%
What is the weakest part of the femur?
femoral neck
What are the 3 types of fractures of the neck of the femur?
-Subcapital: femoral head/neck junction -Transcervical: midportion of the femoral neck -Basicervical: base of femoral neck
What are the 2 hip x-ray views?
AP pelvis frog lateral
What are 6 findings on x-rays of femoral neck fxs?
1) Loss of contour b/w normally continuous line from medial edge of femoral neck and inferior edge of the superior pubic ramus 2) Lesser trochanter is more prominent d/t external rotation of femur 3) Asymmetry of lateral femoral neck/head 4) Sclerosis in fx plane 5) Smudgy sclerosis from impaction 6) Bone trabeculae angulated
What are the steps for tx a femoral neck fx?
Hemiarthroplasty→ protected weight bearing for 6 weeks and DVT prophylaxis w/Lovenox for 2 weeks, then low dose ASA after
In what 3 instances do you use cannulated screws instead of a hemiarthroplasty for femoral neck fxs?
(1) in younger pts w/an impacted fx (2) in pts too sick where it is too big of a surgery for them (3) if a pt is very immobile
What are the 3 tx principles of intertrochanteric hip fxs?
(1) traverse the fx as a rigid support (2) nail prevents fx translation ant/posterior (3) locking screws prevent rotation of the fx
What is the main tx used for intertrochanteric fxs?
Intramedullary (IM) nailing (w/protected weight bearing for 4-6 wks and DVT prophylaxis)
What is a key finding indicating a pubic rami fx and how is it treated?
Pain with weight bearing tx: walker/crutches, non-weight bearing, pain management, anticoagulation
What are 4 findings on clinical presentation of hip arthritis?
(1) insidious onset achy pain in hip +/or groin (2) ℅ stiffness in morning or after prolonged sitting w/”loosening up” after ~30 mins of activity (3) pain inc after prolonged activity relieved w/rest (4) pain/stiffness affecting ADLs and causing dec ROM
What are 6 things to assess/check in pts w/suspected hip arthritis?
1) Assess gait: antalgic gait, trendelenburg gait 2) Tenderness to palpation over anterior hip and groin 3) Active ROM limited by pain +/or structural deformity 4) Passive ROM limited by structural deformity 5) Assess neurovascular status in bilat LEs (not all hip pain comes from hip) 6) Check for pelvic obliquity which suggests leg-length discrepancy
What type of walk is commonly found in hip arthritis?
Trendelenburg gait
What are the 2 x-rays ordered for hip arthritis?
AP pelvis lateral of affected hip
What 2 things should you assess on x-ray of suspected hip arthritis?
Joint space and congruity of femoral head/acetabular surface
What is a traumatic cause and 5 atraumatic causes of AVN?
Traumatic: femoral neck fx Atraumatic: chronic corticosteroid therapy, alcoholism, smoking, chronic renal failure, diabetes
What is the most common finding on clinical presentation of AVN?
Pain out of proportion in region of affected hip
What x-ray view do you need to order to find a crescent sign and what is a crescent sign?
Need to order frog leg view crescent sign: linear area of subchondral lucency→ indicates imminent articular collapse
What is the first line tx of hip arthritis? What are the 5 other tx options?
1st line: Tylenol (w/NSAIDs adjunct) 1) Activity modification 2) PT for strengthening/ROM 3) Ambulatory assistive devices (cane, brace) 4) Intra-articular cortisone injections (under fluoroscopy) 5) Total hip arthroplasty
Where is the pain usually located with greater trochanteric bursitis?
lateral hip
What are 5 possible clinical presentations of greater trochanteric bursitis?
1) Aching, lateral-sided hip pain; worsened w/direct pressure like sitting, lying on affected side 2) Pain radiates down lateral thigh 3) Pain over lateral hip w/pain to palpation over greater trochanter 4) Pain w/passive hip rotation, abduction 5) Inc pain w/resisted hip abduction
What is the main tx of greater trochanteric bursitis?
Corticosteroid injection: 1 ml of 80 mg of depo-medrol 2 ml of 1% lidocaine w/o epi 2 ml of .25% marcaine
What is slipped capital femoral epiphysis (SCFE)?
A disorder of proximal femoral physis, leading to slippage of epiphysis from femoral neck
What is the pathophysiology of SCFE?
d/t mechanical forces acting on susceptible physis; slippage occurs through hypertrophic zone of physis
What is the most important x-ray view to order for SCFE?
frog-leg lateral
What is the tx of SCFE?
Percutaneous in situ fixation; stabilize epiphysis from further slippage and promote closure of the proximal femoral physis
What 2 x-ray views should be ordered for femur fxs?
AP and lateral of the femur
What are the 5 components of femur fx tx?
1) Treat life-threatening injuries first 2) Ex-fix as temporizing measure 3) IM nailing preferred for definitive tx 4) Analgesics and anticoags after 5) PT
What 2 things do you order when suspecting a tibial plateau fx?
(1) Standard trauma series of knee (2) CT scan to determine if unstable fx requiring ORIF
What is the tx for stable tibial plateau fxs?
-Hinged-knee brace, crutches -NWB, but can do active ROM exercises from seated/lying position +/- long-leg cast for initial immobilization
What is the tx for unstable tibial plateau fxs?
-ORIF w/side plate and screws -NWB but can do active ROM exercises from seated/lying position
What is ex-fix and when should it be used?
A bridge to definitive internal fixation; used when life-saving procedures should/must be avoided or in concert w/life-saving procedures
What is the tx of a patella fx?
-ORIF w/tension band wiring -NWB in hinged knee brace locked in extension -Mild active ROM in brace under PT direction after 4 weeks
What causes quad tendon ruptures and where are they usually seen?
“Forced flexion during extension” usually at the musculotendinous junction
What mechanism is absent with quad tendon ruptures?
Absent extensor mechanism (pts ℅ not being able to extend their leg)
Which 2 knee x-ray views should be ordered if suspecting quad tendon rupture?
AP and lateral
What is the tx of quad tendon ruptures?
Surgery→ pt held out to -20 degree extension and NWB in locked hinged knee brace until healing allows for gentle active ROM; may transition to partial WB after 6 wks as tissue heals
How long may it take for a pt to return to normal after a quad tendon rupture?
Up to one year before return to normal
What is a patella tendon rupture?
Disruption of tendon attaching patella to tibial tubercle
What is the mechanism of a patella tendon rupture?
Sudden quad contraction w/knee in a flexed position (how most occur)
What are 6 findings on the clinical presentation of a patella tendon rupture?
1) Popping sensation 2) Infrapatellar pain w/reduced ROM 3) Difficulty weight-bearing 4) Usually large hemarthrosis and ecchymosis 5) Palpable gap below the inferior pole of patella 6) Unable to perform active straight leg raise (absent extensor mechanism)
What are 2 things you assess on PE of knee arthritis?
Joint space (congruity of condylar and tibial surfaces), and alignment
What x-ray do you order when suspecting knee arthritis?
Arthritis series w/a 30 deg PA flexed view
What is the first line tx of knee arthritis?
Tylenol
What is an ACL tear commonly caused by?
Valgus-type force directed to the lateral knee
What are 5 findings on ACL tear clinical presentation?
(1) mild/mod pain (2) large effusion to knee (3) dec ROM (4) protected weight bearing (5) instability w/side-to-side movement
What test is positive in an ACL tear? What other 2 dx tests do you order?
(+) Lachman test; x-ray to r/o segond fx and MRI to assess joint integrity
What is a concern of the affected knee post-ACL tear?
Higher risk of post-traumatic DJD arthritis
What is a MCL tear caused by?
Valgus-type force directed to the lateral knee (any trauma to lateral knee)
What are 7 findings on clinical presentation of MCL?
1) Acute onset medial knee pain 2) May ℅ instability in changing direction/stairs 3) +/- effusion, unusual w/isolated MCL injury (common if ACL involved) 4) Antalgic gait 5) Tender to palp over tract of MCL medially (femoral condyle to proximal tibia) 6) ROM usually preserved if no effusion 7) Will have pain w/valgus stress at 0 and 30 deg
What is a finding on ACL tear clinical presentation that isn’t a finding with an MCL tear (usually)?
ACL has a large effusion, MCL doesn’t (it’s unusual unless ACL also involved)
What causes patellofemoral syndrome?
Lateral mal-tracking of patella during flex/extension activity; relative weakness of the vastus medialis obliques (VMO) and tightness of IT band contribute
What are 5 findings on clinical presentation of patellofemoral syndrome?
1) Usually have normal weight bearing and minimal effect on ADLs 2) Diffuse pain around knee, often localized to medial joint line 3) Pain w/activities like deep flexion of knee, stairs (particularly descending) 4) Pt will report stiff feeling when getting up from prolonged sitting 5) Usually pain free during activities but achy discomfort afterwards
What are 5 findings on PE of patellofemoral syndrome?
1) No effusion, but synovial inflammation may be felt 2) VMO likely atrophied compared to rest of quad 3) IT band tenderness/tightness 4) Patella apprehension test often (+) 5) ROM not usually affected
What 2 x-ray views are ordered and which one is most important when suspecting patellofemoral syndrome?
Standard views, sunrise (merchant) is most important
What is the key finding in a meniscus tear?
Locking of knee
What test is positive with a meniscus tear?
McMurray test
What 2 dx tests are ordered in meniscus tears?
X-rays to r/o fx, MRI to assess surgical need
What type of activity results in a tibia fx?
High-energy deceleration
What 2 x-ray views are ordered for a suspected tibia fx?
AP, lateral
How is a midshaft tibia fx txed?
IM nail fixation
What is compartment syndrome usually associated with?
closed injuries to extremities
What is a major finding of compartment syndrome?
Pain level higher than expected
What are the 5 P’s of late compartment syndrome?
pain, pallor, pulselessness, paresthesia, paralysis
What is the surgical intervention of compartment syndrome?
Fasciotomy (remove fascia to relieve pressure)
Regarding ankle fractures, what type of fxs do external rotation lead to?
Spiral fx of fibula + greater force→ medial malleolus fx
Regarding ankle fractures, what type of fxs do abduction forces lead to?
Transverse fx of fibula + avulsion fx of medial malleolus
What is important to assess in ankle fxs?
proximal fibula
What is the tx for stable ankle fx? Unstable ankle fx?
stable: cast or walking boot unstable: ORIF
What is the most commonly sprained ligament?
anterior tibiofibular ligament
What is the most common mechanism of an ankle sprain injury?
Inversion and plantarflexion sprain→ injures the ATF ligament
What causes injury to the deltoid ligament in an ankle sprain?
eversion
What 3 ligaments is there tenderness to palpation over in a lateral ankle sprain?
(1) ATF ligament (2) calcaneofibular ligament (3) PTF ligament
What 2 ligaments/tendons is there tenderness to palpation over in a medial ankle sprain?
(1) deltoid ligament (2) posterior tibial tendon
What are calcaneus fxs usually a result of?
High energy deceleration injuries (MVC, fall from height)
What are 5 aspects of tx a calcaneus fx?
1) A well padded posterior splint to LE 2) Protected WB w/crutches→ wheelchair if cannot manage crutches 3) Analgesics (very painful fxs) 4) ORIF usually delayed 7-10 days to allow swelling to resolve 5) Pts often have chronic heel pain, even if ORIF
What should you absolutely do when fixing a calcaneus fx?
Pad the splint (pad, pad, pad!)
What are 3 risk factors of plantar fasciitis?
(1) obesity (2) pes planovalgus orientation-flat feet (3) reduced dorsiflexion-tight heel cords
What are 6 findings on clinical presentation/PE of plantar fasciitis?
1) Sharp volar sided foot/heel pain of mod-severe intensity 2) Pain worst “first thing in the morning when I get out of bed” 3) Pain reduces as pt ambulates for a bit 4) TTP at origin of plantar fascia on the calcaneus; may be found distally as well 5) Pes planovalgus orientation common finding 6) Tight achilles’ w/active/passive dorsiflexion of ankle
What is a great tx recommendation for pts with plantar fasciitis?
Freeze water bottle and periodically roll it back and forth over area
What are 2 usual mechanisms of injury for Achilles’ tendon rupture?
Sudden forced plantar flexion or dorsiflexion on a plantar flexed foot (usually occurs 4-6 cm above the calcaneal insertion in hypovascular region)
What test is performed to assess for Achilles’ tendon rupture?
Thompson test
What is the maneuver of Thompson test?
w/pt lying prone on table, flex knee to 90 degrees→ squeeze calf muscle at position slightly distal to area of widest girth→ examine movement at foot
What is a positive finding on a Thompson test indicative of Achilles’ tendon rupture?
Calf is squeezed and no resultant plantar flexion of foot
What type of fx?
Transcervical neck fx
What type of fx?
Intertrochanteric fx
What type of fx?
Subcapital neck fx
What type of fx?
Subtrochanteric fx
What type of fx?
Fx of the greater trochanter
What type of fx?
Fx of the lesser trochanter
What type of fixation? Which bone fx?
IM nail ORIF of an intertrochanteric hip fx
What’s wrong with this hip?
Hip arthritis
What type of weight MRI is this, and what is shown in the circled area?
T1 image; no vascularity found in circled area
What is the arrow pointing to?
Crescent sign found in AVN
What wrong with femur epiphysis?
Slipped capital femoral epiphysis (SCFE)
What bone is fx?
Femur fx
What type of fx?
Tibial plateau fx
What sort of soft tissue injury?
Quad tendon rupture
What position?
Varus
What position?
valgus
Name what’s occurring in this knee?
Knee DJD
What type of fx is this and what is this tx called?
Tibia fx w/IM nail fixation
What type of fx and which bone?
Spiral fx of the fibula
