MSK Intro/terms Flashcards
Initial imaging study of choice following skeletal trauma
X-ray
When ordering an X-ray how many view should you Order? What are the names of these views?
AT LEAST 2 views
AP/Lateral usually suffice
Pt presents with extremity pain but shows and initial negative x-ray for fx.
How do we treat?
If patient symptomatic and high clinical suspicion for fracture:
- Treat as fracture and splint
- Have patient follow up with ortho in 7-10 days
- Repeat x-rays may show cortical changes suggesting a fracture
ALWAYS treat as a fx !!!
CT scans are used in trauma to identify and characterize injury _____/_____.
pattern/severity
What scenarios are CT better than x-ray?
There are 3**
- Identifying subtle fractures
- Visualizing articular extension of fracture
- Assessing for the presence of articular step-off/gap
What are the uses of MRI?
- Primarily for soft tissue evaluating - Mass/lesion
- Diagnosing occult fractures (i.e. femoral neck fx)
- Concern for associated ligament or articular cartilage injury
MRI is the modality of choice for diagnosing what type of condition?
disc herniation
Assess “internal derangement” of joints; ex. ACL tear
Ultrasound is used in trauma to assess ____?
soft tissue injury
Pt presents with what you believe is an achilles tendon rupture.
What imaging do you order to confirm your dx?
Ultrasound
also used for quad tendon rupture
What do bone scans most commonly detect?
- Metastases
- Stress fractures
- Insufficiency fractures
What presents as an optical illusion, usually appearing at sites of cortex overlap between two bones, or skin fold overlap of the cortex?
Mach Bands
Most fracture lines appear as?
Lucent fracture lines - radiolucent line
Name the abnormality.
What pt population is this seen in?
Corticol Buckling
children - children buckle adults break
What are 2 contributing conditions to tendon rupture?
- Injection of steroids into tendon
- Use of fluoroquinolone ABX
Identify.
Intra-articular Extension
Name the type of fx that involves articular cartilage only?
Both the bone and articular cartilage?
chondral fracture
osteochondral fracture
both types of Intra-articular Extension
Name the fracture line caused by compression fractures and may appear as a bright white line.
Sclerotic fx line
Name the most common locations to find a Sclerotic fracture line?
there are 2**
vertebral bodies
distal radium
Identify the type of fx line?
Mach Bands
Identify the type of fx line?
Sclerotic Fx Line
Identify the type of fx line?
Lucent Fracture Lines
Name the most common locations to find Mach Bands?
Ankle radiographs (tibia overlaps fibula)
Name 3 aspects of Displacement?
Translation
Angulation (in degrees)
Rotation
Describe how you would look at Translation on an x-ray and how it is measured.
line drawn down center of bone not continuous at the fracture site
Graded in terms of shaft width in quartiles (25%, 50%)
Described in terms of position of distal fragment compared to proximal
How would you describe the angulation of a fracture?
How is it measured?
Line drawn down center of bone angled at the fracture
Direction of angulation of distal fracture component as compared to proximal
DEGREES (estimate)
Where anatomically should you look on an x-ray to identify if the fx is rotated? (2 places)
looking at orientation of joints above and below fracture
•Can be seen on orthogonal views
Define rotation when talking about displacement of a fx?
Turning of the distal fracture fragment in relation to proximal portion
What are we measuring?
Translation
What are we measuring?
angulation
Common with transverse fractures that result from a tension force that pulls or stretches two objects apart.
Distraction
Injury seen on x-ray that is NOT a fx and is often missed by inexperienced readers?
Joint alignment
Name type of injury?
Distraction
_____ joint alignment is an important check area when assessing hand and wrist x-rays.
CMC (carpometacarpal joints)
In normal anatomical alignment what bone of the wrist should the 5th metacapral attach to?
Hamate
T/F
There’s too much swelling to identify a fracture
FALSE
→It’s possible to not be able to identify a fracture initially; splint/protect and repeat x-rays in 3-5 days
→Soft tissue swelling at some sites of injury can help identify an underlying fracture
T/F
Soft tissue swelling at some sites of injury can help identify an underlying fracture
TRUE
When bone breaks there is bleeding which causes swelling. This finding can be helpful in a patient who is noncommunicative (young child, elderly patient with dementia)
Identify the type of injury and the makeup of the fluid we would find here?
Soft tissue injury
•Blood (hemarthrosis) -> Result of an intra-articular injury, Soft tissues or adjacent bone
Define impaction fx?
Is it stable?
Fx edges wedged into one another
Yes- stable
What is the name of the Fx that is caused by abnormal tensile stress on ligaments or tendons?
Avulsion
name the 3 most common locations we would see an avulsion fx?
hands
feet
pelvis
where would an avulsion fx occur in the hands?
dorsal distal phalanx with extensor tendon avulsion
where would an avulsion fx occur in the Feet?
base of fifth metatarsal with peroneus brevis avulsion
where would an avulsion fx occur in the pelvis?
ischial tuberosity with hamstring tendon avulsion
Name that fx?
avulsion
Name that fx?
What type of force usually causes this?
Transverse fx
direct (also can be tension)
you are clinically suspicous of a quad tendon tendon rupture.
what diagnostic imaging should you order? (pick BEST option)
ultrasound
What type of fx is commonly caused by Indirect Force, usually both compression and angulation forces?
Oblique fx
Name type of Fx?
Stable or unstable?
oblique
unstable - repaired in OR w/ plates and screws
Name the fx that results from rotation/shear forces that cause twisting movement through the long bone axis?
Spiral fx
Name that fx?
stable or unstable?
Spiral
Unstable
define comminuted fx:
•Contains >2 fracture fragments
Inherently unstable fracture
How do we repair a comminuted fx what is the goal?
Goal is function!!!
Hemiarthroplasty/ arthroplasty
Identify the fx:
butterfly fragment
Name incomplete fx that usually occurs in forearm of young child that results from a bending force applied perpendicular to the shaft?
Greenstick Fx
Name the fx that typically occurs in children at the metaphyseal diaphsyeal junction after FOOSH.
Buckle or Torus Fx
Name that fx?
Greenstick
Name that fx?
Greenstick
Name that fx?
Most common injury that results in this fx?
Buckle (Torus fx)
FOOSH
Name that Fx?
Stable or unstable?
Buckle Fragment -Torus Fx
stable
When describing angulation what are the 4 ways of describing the position of the fx?
dorsal
volar
varus
valgus
Varus/Valgus??
excessive inward angulation (medial angulation, that is, towards the body’s midline) of the distal segment of a bone or joint.
Varus (knock-kneed)
Varus/Valgus?
excessive outward angulation (lateral angulation, that is, away from the body’s midline) of the distal segment of a bone or joint.
Valgus (bow-legs)
Varus/Valgus?
Varus - distal portion TWOARD midline
Valgus/Varus?
valgus
3 most common musculoskeletal conditions reported each year:
Trauma
Back pain
Arthritis
What does the axial skeleton consist of?
Name the 6 parts.
•Bones of head and trunk
Six parts
- skull bones
- ossicles of middle ear
- hyoid bone
- rib cage
- sternum and vertebral column
Name the regions of appendicular skeleton:
- Pectoral girdles
- Clavicles and scapulae
bones of the:
shoulder girdle
the upper limbs
the pelvic girdle
the lower limbs.
Name the 2 types of bone:
Cortical (hard outer surface)
Cancellous (spongy/trabecular bone)
Type of bone that provides skeletal support and is site of attachment for tendons and ligaments?
Cortical
where is cancellous bone found?
found at ends of long bones, pelvis, ribs, skull, and vertebrae
Name 2 types of Bone marrow and their functions.
Red - precursor for RBCs
Yellow- Contains fat and undergoes continuous change due to biochemical and mechanical forces
Define osteoclast vs osteoblast.
- Osteoblast: build bone
- Osteoclast: break down bone
Define bone resportion.
is this done by osetoclasts or blasts?
Begins when osteoclasts remove a portion of the bone that will be replaced later with the action of osteoblasts
Define Bone formation:
osteoblasts lay down collagen and mineral deposits over the area previously remodeled by osteoclasts
Are osteoclasts or blasts vital for maintaining bone mineral density and strength?
blasts
Explain approximate locations of PROXIMAL:
Epiphysis
Metaphysis
Diaphysis
Define tendons and ligaments.
Tendons: Fibrous cords of tissue that attach muscles to bone
Ligaments: Fibrous cords of tissue that attach bone to another bone
What is the timeframe when differentiating b/w an acute vs chronic injury?
- Acute: < 6 weeks –> Typically injury related
- Chronic: > 6 weeks
Name the causes of acute MSK injury:
Fractures
Dislocations
Ligament sprains
Septic joints
Name causes of chronic MSK injury:
Overuse syndromes
Tendonitis
Osteoarthritis
Stress Fractures
Define a provocative tests
•recreate mechanism of injury to reproduce patient’s pain
What is the name of the test:
apply load to test ligament stability.
Stress
What test is useful to assess injury severity and ADLs
Functional Test
Name the 3 tests to assess joints
Provocative
Stress
Functional
Contrast closed vs open fx
closed: Skin envelope is in tact - watch for soft tissue injury
open: Break in skin envelope and underlying soft tissue, Surgical treatment within 6 hours recommended
Name fx classification system used when looking at Epiphyseal plate(growth plate)fractures.
Salter-Harris System
Explain Salter-Harris System Type I-V fx:
Name 4 classification systems for fx:
- Salter-Harris System (Peds)
- AO System
- Garden System (hip fx)
- Gustilo system (open fx)
Fx care method used to stabilize/immobilize fractures until the patient can be evaluated by ortho?
Splinting
When applying a splint that wraps an extremity, wrap from _____ to _____.
distal to proximal
Evaluate distal ______, ____ _____, and _______ before and after splinting
circulation, motorfunction and sensation
Purposes of splinting
- Stabilize fractures
- Decrease pain
- Prevent further soft tissue, vascular, or neurologic injury
- May provide definitive treatment for some injuries
- Used to stabilize/immobilize fractures until the patient can be evaluated by ortho (usually within 2-3 days)
Name 2 types of splints
orthoglass
plaster
Name the purpose of casting
- Maintain position to provide for bone healing
- Prevent displacement of fracture
- Protect from further injury
- Usu. on for 4-6 weeks
•Some fractures (i.e. ______ ______) not amenable to casting
proximal humerus
treatment of choice for most nonoperative fractures
casting
Name 3 types of casts we use on Upper extremities
short arm
long arm
Thumb spica
Name type of cast we use on a wrist fx
short arm
Name the type of cast we use on an unstable wrist fx:
Long arm
Name the type of cast we use on a scaphoid fx:
Thumb Spica
Name type of cast we use on a radial styloid fx:
Thumb Spica
Why do we use Long Arm casts on forearm fx?
Prevents ____/_____
supination/pronation
What pt population would we almost always cast a lower extremity?
Used more with children to protect from themselves
Name 2 types of Lower extremity casts
Short leg
Long leg
What are the indications for a short leg cast?
Foot
Ankle
Achilles tear
what are the indications for a long leg cast?
Tib/fib fx
Quad tendon repair
•Successful casting requires three things:
- proper materials
- proper positioning
- selection and application of the appropriate type of cast
What type of reduction was done here:
“Recreate the fracture” to align
•Closed Reduction Percutaneous Pinning (CRPP)
What reduction is approproate when a pt presents with an unstable closed fx where casting alone would be ‘not enough’?
•Closed Reduction Percutaneous Pinning (CRPP)
•Closed Reduction Percutaneous Pinning (CRPP) how long until the pins are out?
3 wks
Pt presents w/ an unstable fx, what method was used to repair?
ORIF plates and screws
WHat is the name of the open reduction performed here:
ORIF Intramedullary Nail/Rod
When performing an ORIF w/ plates and screws we need how many cortices above and below the fx?
Needs 6 cortices above and 6 below the fracture
What type of injury would require an Ex-Fix?
- Trauma indication
- When major non-lifesaving procedures must be avoided
What open reduction is referred to as an “Internal splint’
ORIF
What reduction is used as bridge to definitive internal fixation
External Fixator
What are the 3 stages of fx healing
- Inflammatory phase (hematoma and granulation tissue)
- Reparative phase (callus formation)
- Bone remodeling
What phase of bone healing includes the formation of a hematoma and granulation tissue.
how long does this phase last?
Inflammatory phase
2 wks
What phase of fx healing consists of:
Compact bone replaces spongy bone around fracture periphery
- Bone remodeleing
What phase of fx healing includes Fibrocartilaginous Callus Formation?
how long does this phase last?
Reparative phase
3-4 mo.
Explain the inflammatory phase of fx healing:
- Hematoma and granulation tissue form
- Blood vessels across fracture are disrupted and leak blood
- Blood clot forms at fx. site within 8 hours
- Phagocytes (neutrophils and macrophages) and osteoclasts remove necrotic tissue at fx. Site
last 2 wks
Explain the reparative phase of fx healing:
- Fibrocartilaginous Callus Formation
- Fibrovascular tissue invades hematoma
- Fibroblasts develop into chondroblasts and produce fibrocartilage
- Results in fibrocartilaginous “callus”
- callus lasts 3-4 months
Explain the final phase of fx healing
Compact bone replaces spongy bone around fracture periphery
Remaining dead fracture portions reabsorbed osteoclasts
Define a strain and the most common mechanism of injury:
- Injury to muscle or muscle and tendon from overuse
- Muscle fibers tear
- Often caused by overextension or over stretching
Most common area that is sprained and the mechanism of injury:
- Ankle most common
- Inversion with plantar flexion most common type
Most common area of muscle strain
calf
Medial head of the gastrocenmius muscle
•Strain Typical symptoms:
- Pain –> Worse with use
- Muscle spasm/weakness
- Swelling
- Cramping
Tx for sprains and strains
RICE
Splint/Brace
Protect, comfort
NSAIDs
Early ROM
Physical Therapy referral
Define RICE
Rest
Avoidance of pain
? crutches
Ice
20-30 min, protect skin
Multiple times/day x as needed
Compression (wrap)
Reduces swelling
Give muscles proprioceptive support
Elevation
Above heart level
Manage swelling
Pt presents to clinic after an injury to his shoulder.
You note asymmetry with deformity and swelling, along with the inability to move his shouder.
His x-rays are below:
what type of injury is this?
Dislocation
Tx for dislocations:
reductions
- Evaluate neuro-vasc status before AND after reduction
- Analgesia
- Reduction maneuver
- Splint/sling for pain relief
- Appropriate referral for further eval
Define a sprain and the mechanism of injury:
Stretching/tearing of ligaments
MOI: twist
Pt presents w/ pain and tenderness directly on the tendon of elbow.
Dx?
what are the common sites where we encounter this? (4)
Tendinitis
shoulders
elbows
wrists
knees
Can we inject a steroid into a tendon?
NO!!
Pt presents to clinic with pain in his achilles. He is a runner who had a big race he could not miss so one week prior he saw the doc who injected a steroid into the area to help with the pain and get him through the race.
Dx?
what could also contribute to this condition?
tendon rupture
Contributing Conditions:
- Injection of steroids into tendon
- Use of fluoroquinolone ABX
4 most common tendons ruptured
- Achilles
- Biceps (proximal>distal)
- Rotator Cuff
- Quad
Common sports injury that results from a valgus stress or direct fall onto joint
Ligament Rupture
- Example: ACL, MCL
- Athletic young women 3x > athletic young men
Tendon/Ligament Rupture Tx
- Splint/protect
- Ice
- NSAIDs
- ? Repair/reconstruction
- Early ROM
- Physical Therapy
- Goal is to return to previous level
Step-wise approach to pain management
- Splint/cast, brace
- Ice/Cryocuff
- NSAIDs
- Acetaminophen
- ? Narcotics
- Steroids
- Topicals
Name 2 topical analgesics used to tx pain
Topical diclofenac (Voltaren Gel)
Aspercreme- Trolamine salicylate
What pharmacological pain management must we use caution when reccommending to pts w/ liver disease or ETOH abuse?
What is the proper dosing regimen?
Max daily doses?
acetaminophen (Tylenol)
Max dose 4g/day
max dose 2g/day if chronic ETOH or liver disease
(325 to 650 mg q 4-6 hrs. on a scheduled basis)
When prescribing NSAIDs to pts what should we always explain to them regarding the length of time it takes to see anti-inflammatory benefits?
•Analgesic effects begin within 1 to 2 hours, whereas anti-inflammatory benefits may require 2 weeks of continuous therapy
Dosing of NSAIDs - naproxen (alieve)
- Naproxen 220 mg PO bid (OTC Aleve)
- Naproxen 220 mg, Take 2 tabs PO bid
