MSK Flashcards
definition lisfranc injury
spectrum of injury from sprain to complete disruption of tarso-metatarsal joints in midfoot, usually occuring at base of 2nd metatarsal
mechanism of injury associated with lisfranc injury
foot being caught in a hole; falling off horse with foot caught in stirrup; MVC, foot planted in hole, awkward step off curb; bunk bed fracture (leaps onto bunk bed, landing on toes with axial load on plantar flexed ankle
MOA of lisfranc injury
plantar flexion with ER of ankle
Physical Exam findings for lisfranc fracture dislocations
unable to weight bear, hemtama/ecchymosis on plantar aspect of foot
X-Ray orders for LisFranc fracture
3 views - AP, later, standard 45 degrees oblique of foot
XRay findings for Lisfranc injury
widening between bases of 1st and 2nd or 2nd and 3rd metatarsal bases; > 2mm = surgical intervention
Normal alignment of metatarsals and tarsal bones in midfoot
AP view: edge of base 2nd metatarsal lining up with medial edge of medial cuniform; oblique: medial edge of 3rd and 4th metatarsal should line up with medial edges of middle and lateral cuniforms
Pathognomonic for lisfranc injury on XRay
fleck sign: small bony fragment avulsed from second metatarsal base or medial cuniform
Indications for surgery for lisfranc
displaced fracture or subluxation > 2 mm
If highly suspicious for lisfranc despite normal Xrays…
- 30 degrees oblique XRay (eliminate overlap of metatarsals), 2. weight-baring stress views following nerve block, 3. CT of foot
ED MGMT of LisFranc injury
posterior back slab
carpal bones (5) list them
scaphoid, lunate, triquetrum, pisiform, hamate, capitate, trapezoid, trapezium
(3) Physical tests to r/o scaphoid injury
- palpate scaphoid on palmer aspect with wrist radially deviated; 2. thumb axial load tenderness at scaphoid location 3. snuffbox tenderness
what is the watson test?
identifies scapholunate ligament injury or scaphoid fracture; start with palmer aspect on scaphoid wrist deivated ulnar and flexed, then move wrist radially with slight extension; (+) if pain, apprehension or clunk/subluxation
MOI for perilunate injuries
FOOSH
definition of perilunate dissociation
capitate dislocated from lunate
definition of lunate dissociation
lunate dislocated from capitate (more proximal one)
definition of scapholunate dissociation
terry thomas/madonna sign: visible gaps between teeth; gap of > 3 mm between scaphoid and lunate
FOOSH + acute carpal tunnel syndrome =
perilunate dissociation until proven otherwise
Xray finding for lunate dissociation
spilled tea cup - lunate is out of the seat of the capitate
ED MGMT of perilunate dislocation
90 degrees flexed at elbow with finger traps placed 10 - 15 lbs of longitudinal traction for 10 mins, if dorsally displaced, extend wrist and apply traction, then flex with volar/palmer pressure applied to lunate until clunk heard; volar/palmer slab!
DRUJ
distal radial ulnar joint injury
MOI of DRUJ
FOOSH injury +/- distal radial fracture
Physical findings for DRUJ
more prominent ulnar styloid, crepitus or blocking with pronation or supination, piano key sign, ulnar fovea sign
definition of piano key sign
ability to ballot the ulnar styloid (push ulna up and down like piano); + if painful or ulnar laxity
definition of ulnar fovea sign
point tenderness over ulnar capsule palmar to extensor carpi ulnaris tendon
XRay findings of DRUJ
can have normal XRay; widening of ulnar/radial joint of > 2 mm, lateral view: displacement or subluxation of distal ulnar compared to radius
ED MGMT DRUJ
reduction (supination and pressure over ulnar head), above elbow splint similar to smith fracture with forearm supinated and wrist in slight extension
pelvic apophyseal avulsion fracture sites
most common: ischial tuberosity, other sites: iliac crest, ASIS, AIIS, greater trochanter, lesser trochanter
MOI of pelvic apophyseal avulsion fractures
sudden forceful concentric or eccentric muscle contraction during running, jumping, kicking
RFs for pelvic apophyseal avulsion fractures
young athletes, hip pain or buttock/groin pain
MGMT for pelvic apophyseal avulsion fracture
non weight bearing using crutches then weaned; longer healing than sprains
Definition of Trivial Head Injury (pediatric)
GCS 15, no LOC, low mechanism, small frontal hematoma, older than 1 yo
Definition of Minor Head Injury (pediatric)
GCS 14 - 15, LOC/amnesia/confusion, disorientation, vomiting/HA, impact seizure
Definition of Moderate-Severe Head Injury (pediatric)
GCS < 13 or deteriorating GCS, penetrating head injury, focal neurological findings, late seizures (not impact), known child abuse
Glasgow Coma Scale Definition
Eyes (4): closed, responds to pain, responds to voice, spontaneous; Voice (5): no response, sounds, inapproprpiate words, confused, oriented to person/place/time; Motor (6): no response, abnormal extension, abnormal flexion, withdraws from pain, moves to localize pain, obeys commands
RFs for TBI in pediatric patients with head trauma
scalp hematoma > 2 cm that is not frontal, skull fracture in < 2 yo
Tool to use for risk of TBI in patients < 2 yo
PECARN study
Tool to use for CT head imaging in pediatric patients
CATCH Study
Cushing’s Triad
hypertension, bradycardia, abnormal breathing
Agent for sedation in raised ICP patients (pediatric)
etomidate, ketamine
“Red zone” Period for observation in head injury
first 6 hours
“yellow zone” for observation in head injury
next 24 hours
T or F; children have less seizures following HI
false; they have more seizures
T or F; children are more likely to have TBI following head trauma
false; they are less likely to have TBI after head trauma as their skulls are not closed
T or F; children sustain fewer mass lesions and hemorrhagic contusions following a HI
true
T or F; children sustain less diffuse brain swelling following a HI
false; they have more diffuse swelling and can talk and deteriorate with edema alone
T or F; children sustain less diffuse axonal injury in HI
false
T or F; children sustain more hypoxia in HI
true
ACL injury MOI
rotation of knee against immobile foot with sudden deceleration (i.e., basketball), classic pop heard
Physical Exams for ACL injury
pivot shift test, lachman test, anterior drawer (poor sensitivity)
Ottawa Knee rule criteria
not weightbearing more than 4 steps, older than 55 yo, pain at fibular head, isolated patellar tenderness, inability ti flex knee to 90 degrees
Fractures associated with ACL injuries
Segond fracture, tibial spine fracture
definition of Segond fracture
vertical oriented avulsion fracture of the lateral proximal tibia
ED MGMT of ACL injuries
removable splint, crutches, ROM exercises, follow-up in sports clinic
Indications to consult ortho for ACL injuries
displaced fracture or fracture with impaired extensor mechanism associated with ACL injury
DDx for limping child
fracture, septic arthritis, systemic illness; transient synovitis, Legg-Calves-Perthes disease, Slipped capital femoral epiphysis, toddler’s fracture
definition of transient synovitis
self-limited inflammation of synovial lining preceeded by viral infection, resolving 3 - 10 days
definition of toddler’s fracture
spiral fracture seen in ages 9 - 36 months, usually at distal tibia
Signs with toddler’s fracture
pain with ankle dorsiflexion or calf rotation
MGMT of toddler’s fractures
above-knee immobilizing splint with knee in slight flexion, outpt follow-up, can consider not splinting if mild symptoms
definition of Legg-Calves Perthes disease
avascular necrosis of femoral head; ages 4 - 10 , normal or subtle changes in XRay
Slipped Capital Femoral Epiphyses (SCFE)
pain radiating to thigh or knee; Overweight children, pain worst at IR of hip
sign on xray for SCFE
Kline’s line is abnormal (line from external part of femoral neck intersecting part of femoral head)
Kocher’s Criteria for Septic Arthritis in Pediatric Pts
not weight bearing, ESR > 40, fever, WBC > 12000
Red Flags for non-accidental trauma
delay in presentation, vague or inconsistent mechanism, injury inconsistent with developmental stage
Ottawa Ankle Rules age cut off
older than 5 yo
SALTER criteria for ankle fractures
I: slipped, II: above growth plate, III: lower of the growth plate, IV: through growth plate and metaphysis and physis, V: rammed: growth plate is crushed
Tillaux fracture definition
Salter III - intra-articular with avulsion of anteriorlateral tibial epiphysis
Definition of triplanar fracture
combination of salter I, II, III requiring operation, seen in adolescents
Definition of buckle fracture
incomplete fracture of the long bone identified by bulging of cortex
Definition of Greenstick fracture
cortex broken on one side, other side is intact
Acceptabe degrees of angulation for pediatric radial fractures
< 5yo: 30 degrees, 5 - 10 yo: 20 degrees, 10 - 12: 10 degrees
Supracondylar fracture major risk
neurovascualr injury (brachial artery, median/anterior interosseus nerve), compartment syndrome
figure of eight in elbow Xray
confirms lateral position
radiocapitellar line on elbow xray
should bisect capitellum of humerus, if not think fracture
anterior humeral line on elbow xray
line along anterior border of humerus bisecting middle 1/3 of capitellum; if disrupted, think fracture
“CRITOE” approach to elbow xrays
capitellum, radial head, internal epicondyle, trochlea, olecranon, externa epicondyle
ED MGMT of supracondylar fractures
immobilize in above-elbow splint at > 90 degrees flexion; consult ortho immediately if displaced
Test for sensory and motor of radius
webspace (dorsal) 1st thumb and thumbs up with resistance
Test for sensory and motor for median
2nd finger tip, peace sign with resistance
Test for sensory and ulnar
5th finger palmer, OK sign
levels of accepted angulation of metacarpal neck fractures
5th: 40 degrees, 4th: 30 degreed, 3rd: 20 degrees, 2nd: 10 degrees
definition of fight bite
laceration + boxers fracture
ED MGMT of fight bite
Xray to r/o fracture and tooth fragments, high flush irrigation, antibiotics (clavulin), healing by secondary intent, close follow-up; admit if extensor tendon injury or few days after injury
indications for abx for lacerations
hand bites, bites over joints, immunocompromised
boxer fracture definition
4th or 5th MTC neck fracture
MGMT Of boxer fracture
Abx, 2ndary intention if open, if angulated > 45 degrees or rotation > 20 degrees refer to hand surgeon/ortho, reduce with splint
Contraindications to tendon repairs
flexor tendons, contaminated wounds, partial tendons > 50% torn
ED MGMT of tendon repair
can repair if it is partial extensor tendon: thorough washing, loosely close skin, apply splint to avoid tension
(2) flexor tendons in the fingers
flexor digitorum profundas (FDP) - DIP, flexor digitorum superficialis (FDS) - PIP
Method to examining extensor tendon injury
start with palpation for tenderness, then with gradual resistance: gradual resistance test to avoid converting partial tear into complete tear. if normal motor but pain, consider partial laceration
gamekeeper thumb definition
injury to ulnar aspect (medial) of 1st MCP
MOI of gamekeeper thumb injury
commonly skier thumb (lateral or valgus stress to abducted thumb)
Physical exam for gamekeeper thumb
Maximal tenderness on ulnar aspect of 1st MCP, pincer grasp is painful
XRay finding for gamekeeper thumb
avulsion fracture of proximal phalynx
Definition of Stener’s Lesion
displaced proximal end of ulnar collateral ligament of 1st MCP being trapped in adductor aponeurosis, thus not allowing healing
ED MGMT of Gamekeeper thumb
partial injury: 6 week splint; complete tear: surgery, thus requiring thumb spica splint with f/u within 7 days
Complications of gamekeeper thumb
nonunion, reconstruction
Key findings suggesting gamekeeper thumb
weak pincer grasp, tenderness at volar ulnar aspect of MSP, >40 degrees deviation in extension or 20 degrees in flexion
Risk with high-pressure injuries of hand
compartment syndrome: amputation due to ischemia, infections;
Sx of compartment syndrome in hand
pain out of proportion, hand in claw position ( MCP extended PIP flexed), XRay showing subcutaneous air
definition of flexor tenosynovitis
inflammation of synovium due to infection or inflammatory
Kanavel’s 4 Cardinal Signs for Flexor Tenosynvitis
finger held in slight flexion, fusiform swelling, flexor tendon sheath tenderness, pain with passive extension
Complications with flexor tenosynovitis
scarring, necrosis, disability, infection
ED MGMT of flexor tenosynovitis
IV antibiotics, immobilize, elevate; can consider I&D if delayed
paronychia definition
a nail infection where the nail and skin meet at the side or the base of a finger or toenail.
mild paronychia MGMT
soaking finger, PO antibiotics
abscessed paronychia MGMT
blunt dissection with point of surgical blade so lateral nail fold is elevated and sulcus between plate and epithelium is entered, drain pus and irrigate cavity with syringe
abscessed paronchyia MGMT with finger or pulp involvement
can consider additional incision of finger tip pad to drain
Back pain ddx to r/o in th ED
cauda equina (disc herniation), bone mets, spinal abscess, leaking or ruptured AAA, retroperitoneal bleed, spinal bleed
Red flags for back pain
age > 50, history of cancer, fever, IVDU, immunocompromised, trauma, cauda equina/SCC symptoms (erectile dysfunction)
Suspicious back pain signs in the ED
constant back pain that is worse with lying down
Dx to r/o with renal colic
AAA
Dx to r/o with pyelonephritis
spinal infection
Physical examination for cauda equina or SCC
gait, palpation, neurological, abdomen for AAA and bladder distension, DRE
PVR cut off for cauda
< 100 is negative predictive value for 99%
winking owl sign
missing pedicle on PA view of spine, concerning for mets spinal fracture (blastic lesions)
CT vs MRI for spinal fractures/bony mets
CT»_space; MRI for vertebral fracture and mets; MRI»_space; CT for spinal infections, malignancy and cauda equina
Indications for urgent MRI in the ED
sudden or rapid change in back pain WITH new or pgoressive signs of SCC, suspected mets with stable symptoms (within 24 hours), back pain + Xray finding of mets but no neurological deficits (within 3 -7 days)
Bragard sign
specific for sciatica: SLR until point of radiating pain, leg then lowered slightly and ankle is dorsiflexed, if pain returns then it is (+) for sciatica (specific)
Slump test sign
pt sits at edge of bed, slumps forward while flexing neck, knee extended; if +, sciatica
Inv to order in spinal epidural abscess
ESR, CRP
Sx of leaking AAA
groin pain, syncope, paralysis, flank fullness, pulsatile, abdo mass, femoral neuropathy; + Psoas sign: retroperitoneal irritation
Sx of spontaneous retroperitoneal bleed
similar to AAA, low back pain radiating to groin, hip, anterior thigh, RF: anticoagulants
5 initial tests in the ED for LBP
PVR, ESR/CRP, XRay, POCUS, calcium
Talus fracture MOI
axial loading with dorsiflexed ankle and everted, seen in snowboarders
Sx of talus fracture
tender anterior talofibular ligament (like ankle sprains)
DDx for talus fracture
ankle sprain, distal fibular fracture, clcenus fracture, posterior talar fracture, talar dome fracture, achilles tendon rupture
XRay findings in talus fracture
normal often; can consider Broden’s View Xray (mortise ankle view with plater foot flexed), or CT
MGMT of talus fracture
if non displaced or < 2 cm involving lateral talus, immobilization with back slab and non-weight bearing; if > 2 mm displaced ortho!
mimics of ankle sprain
lateral talus fracture (snowboarder fracture), anterior calcaneus fracture, posterior talar fracture, talar dome fracture, achilles tendon rupture
Sx of occult hip fracture
groin pain, tenderness in groin, inability to SLR, painful limitation of rotation of hip, pain on axial loading of limb
Percussion test for hip fracture
stethescope on pubis symphysis and percuss patella on each side; if decreased, consider fracture
XRay of the hip: lines to look for
Shenton’s Line: arc from medial aspect of femoral neck to obturator foramen
occult knee dislocation mechanism
MVC- jammed knee
key thing to r/o with knee dislocation
RULE OUT VASCULAR INJURY = ALWAYS ORDER CT ANGIO
(3) key maneuvers for scaphoid fractures
palpation of snuffbox, axial loading of thumb with pain in the anatomical snuffbox, palpation of palmar aspect of scahpoid with wrist radially deviated
imaging for suspected scpahoid fracture
scaphoid views, clenched fist view, CT
complications with scaphoid fractures
avascular necrosis and fracture nonunion the more proximal
ED MGMT of scaphoid fracture
colles splint, immobilization, consider ortho referral in the ED if > 1 mm displacement
DDx for posterior shoulder dislocation
electrocution, epilepsy, EtOH
Xray view for posterior dislocation
axillary view is key! look for lightbulb sign in AP view
ED MGMT of posterior dislocation
reduction if < 50% displaced and within 6 weeks of injury; consult ortho if > 6 weeks of injury or greater than 50% of humeral surface is involved
MSK injuries associated with fall from height
vertebral fractures, calcaneus fracturs, ankle fractures, lisfranc dislocation
calcaneal fracture mechanism
fall from height
physical findings for calcaneal fractures
plantar ecchymosis
Imaging for suspected calcenal fractures
Xray - look for Bohler’s angle, harris view of the ankle (45 degrees), CT if unsure
Definition of bohler’s angle
posterior tuberosity to the apex of the posterior facet + apex of posterior to apex of anterior process; normal is 20 - 40 degrees; abnormal if < 20 degrees
Hard signs of penetrating vascular injury (5)
arterial bleeding, shock, large pulsatile and expanding mass, new palpable thrill or audible bruit, distal ischemia
soft signs of penetrating injury
minor bleeding, small stable hematoma, injury to nerve, proximity of tract to major vessels
MGMT for penetrating extremity injury
if + hard signs, immediate OR exploration; if soft signs, CT angio
definition of syndesmosis orthopedic injuries
sydnesmosis tear between tibia and fibula
MOI for syndesmosis injuries
rotational force where ER of ankle +/- hyper dorsiflexion, overstretching this area between distal tibia and fibula
physical exams for syndesmosis injuries
toe walking (prevent painful dorsiflexion), squeeze/hopkin test: tibia and fibula squeezed together at mid calf-level, if +, pain is felt at syndesmosis located at distal tibia and fibular junction; ER test: knee flexed at 90 degrees, hold pt’s foot and ER with small amount of dorsiflexion, if pain elicited + test
xray findings for syndesmosis injuries
normal, can have decreased tibio-fibular overlap (< 6 mm in AP or < 1 mm on mortise); increased medial clear space (> 4mm)
ED MGMT of syndesmosis injuries
non weightbearing aircast or backslab, ortho follow-up; r/o associated ankle injuries, 5th metatarsal injuries, proximal fibular fracture (maisonneuve)
MOI distal biceps tendon rupture
construction workers or weightlifters with chronic repetitive microtrauma causing weakning tendon + sudden massive eccentric contraction
Physical findings for bicep rupture
“popeye sign” - bulge in elbow flexion, ecchymosis on anterior aspect of elbow, decreased force of supination +/- pain with supination, Hook sign: use index finger, go lateral to insertion of biceps and hook finger around; if not able to, likely rupture
MOI proximal biceps tendon rupture
seen in elderly patients due to age-related tendon and RC symptoms, no acute injury
ED MGMT of biceps rupture
immobilization, refer to ortho
ED MGMT of proximal biceps injury
physiotherapy
quadriceps rupture sx
triad of acute knee pain, inability to extend knee, suprapatellar gap
associated injuries with quads tendon rupture
patellar fracture, patellar tendon rupture
Physical findings with quadriceps tendon rupture
failed SLR (unable to lift leg up), palpable gap betwen tendon and above the knee (suprapatellar gap)
Xray findings for quadriceps rupture
patella baja (patella rides lower than usual); patellar alta (patella rides higher than usual - seen with patellar tendon rupture
ED MGMT for quadriceps injuries
zimmer splint (knee immobilizer) with orthopaedics follow-up in few days
injuries not requring zimmer splint
meniscal tears, ACl, MCL and PCL injuries
gastrocnemius tears MOI
jumping or running from hill, weekend warrior
difference between gastroc tear vs. DVT
swelling isolated to medial aspect of leg (DVT is entire leg), palpable divot bewteen junction of gastrocnemius and tendon with complete tear, bruising seen
physical findings with gastroc tears
maximal tenderness at medial musculotendinous junction, van see visible defect in medial aspect of gastrocs; + calf raise test
calf raise test
patient stands and plantar flexes one ankle so they can stand up on their tiptoes with one leg; if + but can complete the test, then it is likely gastroc tear; if unable to complete test, consider achilles tear
imaging for gastroc tears
none, ultrasound as outpt
ED MGMT for gastroc tears
conservative, early weight bearing, can consider ankle stirrup for comfort
bloody airway approach in trauma
use direct with bougie; do not use video!
definition of rapid sequence induction
paralytic and sedative at the same time
vasopressors in trauma
no role unless neurogenic shock
high-risk factor of mortality in trauma
hypotension! just one episode can result in poor outcome thus take hypotension seriously even if it normalizes
metabolic acidosis in trauma etiology
secondary to hypo-perfusion (lactate and bicarb); decrease of acidosis can be quantified by base deficit; the greater base deficit, the higher the risk!
“CRUMP” factor for need for operative intervention in trauma
sBP < 105, +FAST, and base deficit > 6
continuous care of trauma patients
serial BW: hematocroit, lactate, EtCO2; hematocrit is surrogate for occult bleeding
occult shock sources
retroperitoneum, chest, abdo, pelvic fractures
“seatbelt sign”
contusion corresponding to seatbelt, increased risk for intestinal and intraabdominal injuries
investigations for occult bleeding
CXR, FAST, pelvic xray
FAST Exam drawbacks
< 200 cc of blood, mesenteric or bowel hematoma, diaphragmatic and pncreatic injuries
FAST Exam sensitivity and specificity
good specificty, poor sensitivity
5 Key Componenets of damage control in trauma resuscitation
hypothermia (bair huggers, level 1 infuser), permissive hypotension (allow for thrombus formation of injured vessels; target sBP 90- 100 except for head injuries (1 episode of hypotnestion associated with mortality), early use of blood products (only 1L if possible), rapid and early correction of coagulopathy, damage control surgery (abdomenpacking, etc.)
indications for MTP
if you need 3+ units of blood, base deficit > 5, INr > 1.5, hemoperitoneum
CRASH-2 Trial results
TXA reduced massive transfusion and reduced mortality (1%); TXA 1 g given over 10 min then 1g infusion IV over q8hrs
CSpine injury guidelines in trauma
DO NOT USE ANY OF THEM! these guidelines are only for non-high risk mechanisms; CT C-spine if concerned, can consider MRI if normal CT but pain
CT chest in trauma indications
only if suspicious of aortic or thoracic injuries as CXR isssensitive for hemothorax and PTX
indication for pan scan in trauma
if intubated and cannot be assessed
thoracic aortic injuries MOI in trauma
high-energy, lateral pevlic fractures, fall from height, anterior-posterior deceleration
blunt cardiac injury in trauma
myocardial contusion, free wall rupture, valvular injury, peicardial injury
rib fractures in eldery patients approach
associatd with high mortality if > 65yo, complications of atelectasis PNA; ED MGMT: observe in ED, repeat CXR, consider admission
pelvic stability exam
gentle inward compression of iliac crest; if mobile, do not let go
sx of pelvic trauma
groin/scrotal pain, suprapubic swelling/hematoma, tenderness at symphysis pubis, blood at urethral meatus, distal peripheral neuropathy, +FAST pelvic fluid
Classification for pelvic fractures
young-bruges classification; A-P compression: open book fracture ( widened pubic symphysis); higher risk of posterior pelvic structures involved (SI joint), lateral compression, vertical shear (MOI of fall from height, worst prognosis)
Physical exam findings for
Anterior shoulder dislocation
Internally rotated, abducted, squaring of
Shoulders
3 views for shoulder dislocation
AP View, scapula Y View, axillary
Complications of anterior shoulder dislocation
Hills Sachs lesion (humeral head fracture), bankcroft (Glenoid ant-inf fracture)
complications of compartment syndrome - name 2
- rhabdomyolysis –> renal failure form myoglobinuria 2. Volkmann’s contracture - ischemic necrosis of muscle resulting in fibrosis and calcification, seen in supracondylar fracture of humerus
XRay findings for osteomyelitis (seen 10-12 days after)
soft tissue swelling, lytic bone destruction, periosteal reaction
XRay findings for septic joint
early: normal, can show soft tissue swelling, joint space widening from localized edema; late: joint space narrowing and destruction of cartilage
order of most common to least for septic joint
knee, hip, elbow, ankle, sternoclavicular joint
findings for septic arthritis in joint aspirate
cloudy yellow fluid, WBC > 50 000, > 90% neutrophils, high protein (4.4+), +glucose is low
RF for septic arthritis
age, prosthetic joint, recent joint surgery, skin infection/ulcer, IVDU, corticosteroid injection, immunocompromised (cancer DM, alcohol, RA)
name 4 joints in shoulder
GH, AC, sternoclagicular, scapulothoracic
passive ROM shoulder normal
forward flexion: 180; extension: 45; abduction 180, adduction: 45; IR - T4, ER: 45
MGMT clavicle fractures
medial/middle third #: displaced > 2 cm, an consider ORIF; distal third: if displaced: ORIF
complication of clavicle fractures
associated rib fractures, brachial plexus injuries, subclavian vessel, shoulder stiffness
frozen shoulder “adhesive capsulitis” definition
progressive pain and stiffness of shoulder, usually self-resolves after 18 months
MOI frozen shoulder
primary: idiopathic, associated with DM, resolves in 9 - 18 months; secondary: due to prolonged immobilization, trauma/MI/stroke
what is CRPS
complex regional pain syndrome: painful conditions characterized by continuing regional pain that is disproportionate in time or degree to lesion/trauma; sx: pain, swelling, limited ROMthen changes in skin and bones
Sx of frozen shoulder
diffuse shoulder pain and BOTH decreased active and passive ROM; pain worse at night preventing sleeping on the side, stiffness as pain subsides
MGMT frozen shoulder
freezing phase: AROM, PROM with PT, NSAIDs, steroids; thawing phase: manipulation under anesthesia and early physiotherapy, arthroscopy for debridement/decompression
RF for adhesive capsulitis
prolonged immobilization, female, age 50+, DM, cervical disc disease, hyperthyroidism, stroke, MI, trauma and surgery, autoimmune
stages of adhesive capsulitis
freezing phase: gradual onset, diffse pain (6-9 months), frozen phase: decreased ROM impacts function (lasts 4-9 months), thawing phase: gradual return of motion
proximal humeral fracture test/investigation
axillary nerve - deltoid contraction and skin over deltoid, XRays, CT scan
classification of proximal humeral fractures
neers: 4 fracture locations/parts, displacement > 1 cm or angulation > 45 degrees,
MGMT proximal humeral fractures
if nondisplaced and minimally displaced, broad arm sling immobilization, begin ROM on day 14 to prevent stiffness
indications for operation for proximal humerus fractures
anatomic neck fractures, displaced, irreducible GH joint dislocation
complications of humerus fractures
AVN, nerve palse (axillary), malunion, post-trauma arthritis, persistent pain and weakness, adhesive capsulitis
MGMT humeral shaft fractures
generally non-operative; hanging cast with collar and cuff sling immobilization until swelling subsides then sarmiento functional brace, followed by RMOM
complication of humeral shaft fractures
radial nerve palsy (usually recovers in 3-4 months), nonunion, decreased ROM, compartment syndrome
