MSK Lower Extremity Injuries and Infections Flashcards
Approx. 25% of pts with hip fx do not survive past ____ year.
1 :(
What classifcation system is used when identifying femoral neck fx?
Garden classification I-IV
How would we tx Stage I and II: stable hip fractures?
•Treated with internal fixation (head-preservation)
How would we tx stage III and VI: unstable fractures
- Treated with arthroplasty
- Hemi vs. total arthroplasty
Explain the difference b/w Garden Stage I vs Stage II femoral neck fx?
Garden stage I: non-displaced incomplete, including valgus impacted fracture
• Medial femoral neck trabeculae may reveal greenstick fracture
Garden stage II: non-displaced complete
•No disturbance of medial trabeculae
Explain the difference b/w Garden Stage III vs Stage IV femoral neck fx?
- Garden stage III: complete fracture, incompletely displaced
- Femoral head tilts into varus position
- Garden stage IV: complete fracture, completely displaced
Define the location of an Intertrochanteric Fracture.
Are they intra or extra caspsular?
•Fracture between greater and less trochanters
extracapsular
How would we tx an intertrochanteric fx?
- IM Nailing
- DHS Compression Screw
Intertrochanteric Fx occurs thru ______ bone with excellent blood supply-thus heals well.
cancellous
When assessing a hip fx that you believe is an intertrochanteric it is not always possible to distinguish b/w IT and _________ fx?
•basilar femoral neck fx
How would we tx a subtrochanteric fx?
IM Nailing
Pt presents to clinic complaining of “achy” pain in her hip. She tells you she feels very stiff in the morning or after prolonged sitting with “loosening up” after approx. 30 min of activity.
Dx?
Tx (pharmacologic?)
hip arthritis
NSAIDS/Tylenol
•Intra-articular cortisone injection (done under fluoroscopy)
Pt arrives to clinic c/o aching, intense lateral-sided hip pain. She says she can no longer sleep on her dise or apply pressure to the area.
After taking a hx she tells you that a few weeks ago she walked into the side of her counter-top and had a bruise over her lateral hip.
Dx?
is surgery necessary?
Greater Trochanteric Bursitis
No- NSAIDS/ tylenol ice.
Pt complains of pain in groin; that sometimes radiate to lateral hip. she Describes it as dull ache which waxes/wanes with activity/rest.
DX?
FAI
Explain 2 types of bone spurs seen in Femoral Acetabular Impingement.
- Cam bone spur
- Abnormal Femoral Head/Neck junction; increased radius at waist
- Impingement occurs primarily during flexion, adduction, IR
- Pincer bone spur
- Excessive Acetabular Coverage
- Linear Contact between the labrum and femoral head/neck junction
What is the area affected in FAI?
•Femoroacetabular joint
What type of spur is pictured?
pincer
- Excessive Acetabular Coverage
- Linear Contact between the labrum and femoral head/neck junction
Pt complains of sharp stabbing pain may occur with turning, twisting, and squatting.
Upon x-ray you notice:
Dx?
what type of spur?
FAI
CAM
- Abnormal Femoral Head/Neck junction; increased radius at waist
- Impingement occurs primarily during flexion, adduction, IR
When assessing a hip fx on physical exam you note sensitivity on active and passive ______ rotation
Internal rotation.
Pt arrives to clinic complaining of leg pain after a fall (high-energy deceleration injury).
you X-ray the knee:
Dx?
Tx for stable fx?
Tibial Plateau Fracture
•hinged-knee brace, crutches. Pt NWB but can do active ROM exercises from seated/lying position
What is the name for an avulsion fracture involving lateral aspect of tibial plateau.
What ligament is most likely to be disrupted?
Segond Fracture
ACL (75%)
Pt arrives to clinic after a skiing injury.
She presents with knee pain and swelling. She appears to be holding her knee in approx. 20 degree flexed position for comfort.
When examining she resist full extension and is not be able to flex past 90 degrees due to secondary to hemarthrosis.
Dx?
Segond Fracture
When taking an x-ray of a suspected Segond fx, what may appear on the film?
•May show curvilinear fracture- elliptic bone fragment parallel to lateral aspect of tibial plateau
Pt arrives to clinic after falling due to a sports injur (basketball). They complain of knee pain.
You notice hemarthrosis and swelling of the affected knee.
You initally take an x-ray to see whats going on and note a curvilinear fracture- elliptic bone fragment parallel to lateral aspect of tibial plateau.
Is this a tibeal plateau fx or should you continue to investiagte and order an MRI?
YES - MRI essential to identify internal derangement (MCL/ACL) usually ACL
this is a segond fx due to hemarthrosis, sports injury fall and the curcilinear fx!!!!
2 MOI that cause patellar fx?
- Direct trauma to anterior patella, i.e. dashboard injury
- Sudden forceful contraction of quad muscles in context of sport injury
how do we tx a patellar fx?
- ORIF with tension band wiring
- NWB in hinged knee brace locked in extension
Pt arrives to clinic after a severe fall.
she c/o not being able to extend their leg (absent extensor mechanism) and you also note swelling in the affected knee and a defect in the distal quad tendon.
Dx? (this is a fracture)
patellar fx
Do quad tendon rupture or patella tendon rupture occur in pts <40 y/o??
- Patellar tendon ruptures usually occur in pts < 40 y/o
- Quad tendon ruptures in pts > 40 y/o
A heavy set 45 y/o male presents to clinic complaining of leg pain. He just returned from a boating trip w/ friends where he tells you the EXACT moment he heard a “pop” when jumping onto his friends boat from the dock.
On assessment you notice swelling, and he has an inability to extend his knee.
Dx?
Tx
Quad Tendon Rupture - usually heavy set male, forced flexion against resistance/extension and can tell you exact moment they heard “popping” sound.
surgically repaired
Pt arrives to clinic complaining of knee pain. On examinination you notice a Patella alta.
He is partially able to extend his knee?
Dx? (full/partial)
Partial Patellar tendon tear - complete tear pt would be unable to extend at all.
•can be treated w/ immobilization in hinged knee brace for 4-6 weeks
what type of tear is this?
quad tendon rupture
what type of tear is this?
patellar tendon
Complete Patellar tendon ruptures are rare in young athlete unless assoc w/ _____?
steroids
Identify the Fx?
NOTE: also a spiral fracture of proximal fibula not shown
Maisonneuve Fracture
what is a Maisonneuve Fracture
- Combination of spiral fracture of proximal fibula with ankle injury of one or more:
- Widening of ankle joint due to rupture of distal tibiofibular syndesmosis
- Deltoid ligament disruption
- +/- fracture of medial malleolus
______ is one of strongest predictors of knee OA progression
malalignment
_______ progression of knee OA 4X more likely in individuals with _______ alignment
_______progression 5X more likely in individuals with ___________ alignment
Medial / varus
Lateral / Valgus
When looking for knee arthritis how should you order your x-ray?
WEIGHT baring arthritis series (with 30 deg PA flexed view)
What injection other then cortisone is helpful is managing knee arthritis
Viscosupplement - used after failing other therapy options.
what is a characterisitic finding of OA on xray?
narrowing of joint space
Pt presents to clinic after a sports injury that occured 3 hrs ago. Upon immediate examination you notice massive effusion. The patient also complains of a “looseness” in the knee. You were not able to witness the fall but the PT wrote in the chart that:
“the fall resulted in valgus stress to knee with ipsilateral foot planted”
Dx?
Why would we also order an x-ray?
ACL tear
X-Rays to R/O Segond fx
What test would you perform during a physical exam to help support an ACL tear dx?
- Lachman (superior) – move tibia anteriorly
- A positive test reveals increased laxity – often without a definite end-point.
- Anterior Drawer
- Hip 45 deg – move tibia anteriorly
- (+) tibia translates anteriorly more then 6mm
When watching sunday night football, you notice this injury occur. The fall was caused by valgus-type force directed to lateral knee. The doc on the field forgot to turn his mic off and you hear him ask the pt if he is experiencing any “locking” the pt replies no. He also asks if there was a “pop” sound when the injury occured. Pt says no.
Just upon witnessing the fall what is your suspected dx?
MCL tear
differentiate from meniscus as “locking” sensation is key finding for meniscus tears!
Also “pop” is usually heard w meniscus tear
what is the “Unhappy Triad”
an injury to the anterior cruciate ligament, medial collateral ligament, and meniscus.
what runs with the MCL
medial meniscus
What is the cause of the lateral mal-tracking in patella femoral syndrome?
•The relative weakness of the vastus medialis obliques (VMO) and tightness of IT Band and other quad muscles
What x-ray view is most important when evaluating patella femoral syndrome?
•Sunrise (Merchant) view is most important
Pt comes to clinic complaining of diffuse pain around the knee and a “stiff” feeling when getting up. They report no pain with activities but usually become “achy” afterward.
Upon exam you note there is no effusion and the vastus medialis obliques (VMO) are atrophied compared to the rest of the quad. The IT band is also tender.
Dx?
Patella Femoral Syndrome
Are medial or lateral meniscus tears more common?
medial
what type of tear is a McMurray test useful in dx?
what is a + McMurry test?
Meniscus Tears
- rotates the leg internally while extending the knee to 90 degrees of flexion.
- (+) If a “thud” or “click” is felt along with pain
When would we choose a Meniscal repair vs Meniscectomy?
- Meniscal repair in younger pts
- Requires protected WB, gentle ROM x 6weeks as tissue heals
- Meniscectomy in older less active pts
- WBAT post-op and quicker return to sports/employment
Key finding in meniscus tears
•“locking” is key finding.
what is the most common sports injuries seen in outpatient clinics?
ankle sprain
How do we tx a midshaft tibia fx?
(remember these are mostly unstable)
IM nail fixation
•If multi-trauma pt., may need to temporize with Ex-Fix (Damage Control Ortho)
When looking at ankle fx _____ rotation causes spiral fx of fibula and greater force will also lead to _____ _______ fx.
external rotation
medial malleolus fx
Pt presents with ankle pain: more specifically
pain/ tenderness over ATF ligament, also calcaneofibular and PTF ligaments.
dx?
lateral ankle sprain
pt presents with ankle pain more specifically
pain /tenderness over deltoid ligament also posterior tibial tendon.
Dx?
Medial Ankle Sprain
most common MOI in an ankle sprain
an inversion and plantarflexion sprain, which injures ATF ligament (lateral ankle sprain)
younger pt comes to clinic complaining of moderate foot psin. Upon taking a detailed history they tell you they were playing with friends and jumped off their parents van onto the pavement.
on examination you see severe swelling.
Dx?
where else in their body should you ask them if they are noticing pain?
Calcaneus Fracture
Lower back!!! - secondary to associated lumbar compression fx
how do we tx a calcaneous fx? (what type of splint?)
- Well padded posterior splint to LE
- Jones Wrap
(NWB!!)
When examining xrays of feet you notice a transverse fracture at base of 5th metatarsal, 1.5 to 3 cm distal to the proximal tuberosity at the metadiaphyseal junction.
what is the dx?
what are these fx prone to?
Jones Fx
non-union - bone doesnt heal
Identify where we would see these fx:
Jones fx?
Avulsion fx?
green - Jones
avulsion - pink
stress fx- blue
5th metatarsal fx are usually due to forcible inversion of foot in plantar flexion, as may occur while stepping on a curb or climbing steps. The force pulls at insertion of _______ ______ .
peroneus brevis
when looking at 5th metatarsal fx where do 90% of them occur?
•base of the 5th metatarsal
The fracture is believed to occur as a result of significant adduction force to the forefoot with the ankle in plantar flexion.
jones fx
The base of the 5th metatarsal is the is insertion point of _____ ____ and is affected in a jones fx.
peroneus tertius
T/F
Jones fx in general, can be treated conservatively and heal well.
FALSE
jones fx prone to non-union
•Immobilization is important as part of the initial therapy, with a non-weight bearing cast for 6-8 weeks
this is TRUE for –> 5th metatarsal avulsion fx
Pt comes to clinic reporting sharp volar sided heel pain of moderate to severe intensity. He reports that pain is worst “first thing in the morning when I get out of bed” and the “first few steps” are brutal but the pain resides with ambulation.
Upon examination you note Pes planovalgus orientation.
Dx?
Tx?
Plantar Fasciitis
- Night Splint
- Ice, NSAIDs
- Physical therapy
- +/- Corticosteroid injection
- (inform of potential fascial rupture)
- Surgery rarely indicated/necessary
Risk factors for plantar fascitis:
- Obesity
- Pes planovalgus orientation (flat feet)
- Reduced dorsiflexion (tight heel cords)
risk factors for achilles tendon rupture
- “weekend warrior”
- Fluoroquinolones-> Reported in literature
- Steroid injections
Pt arrives to clinic complaining of weakness and difficulty walking along w/ heel pain.
When you ask about the onset of the pain they tell you there was no severely traumatic injury but while running on the bleachers at their local football field they heard a “pop” and a sudden sharp pain that “felt like someone kicked me”.
Upon examination you notice weak plantarflexion.
Dx?
what PE test could you use to support dx?
Achilles tendon Rupture
Thompson test
Explain a positive thompson test?
A positive test occurs when the calf is squeezed and no plantar movement occurs at the foot.
This indicates an Achilles’ rupture
How would we surgucall tx an achilles tendon rupture
“end to end”
boot post op
Most common organisms that result in ortho infections
staph
strep
MRSA
what labs should you order if you suspect an ortho infection?
CBC
cultures
Renal function, liver function
inflammatory markers (ESR, CRP)
Periosteal thickening coupled with bone erosion in setting of clinical infection may indicate _______?
osteomyelitis
When you are suspicious of an orthopedic infection, when is it appriopriate to use ultrasound?
If deep abscess is suspected
Osteomyelitis approach to imaging:
- *X-rays
- *US if appropriate
- **MRI
- *3-Phase Bone Scan
what is the common pathogen responsible for osetomyelitis
S. aureus in bone tissue.
How is osteomyelitis dx? (3 things)
blood tests
bone biospy
imaging
Kanavel’s 4 cardinal signs indicate infective flexor tenosynovitis:
- Fusiform swelling of an entire finger
- Partially flexed posture of the finger
- Tenderness limited to course of flexor tendon sheath
- Disproportionate pain on passive extension of the finger
Usual bacteria responsible for hand infections? (4)
staph
- Strep
- Pasteurella
- Oral anaerobes
pt arrives to clinic w/ an erythematous, swollen, warm area. They are a known IVDU.
You suspect a hand infection as a result of a puncture wound.
what must you ALWAYS do in this pts case?
•Always x-ray Heroin users
what are hand infections often from
- Cat bite
- Human bite
- Puncture wounds
- Always x-ray Heroin users
Pt arrives to clinic complaining of paresthesia and pain in their hand. You note they have on a cast.
When you ask about their injury they tell you they had a minor fracture to their radius that has been healing for 3 weeks.
When you ask about their pain level out of 10 they report a 12.
what are you HIGHLY suspicious of?
compartment syndrome - presents w a cast and pain out of proportion to injury.
tx for compartment syndrome
Fasciotomy
what type of fractures most commonly cause compartment syndrome?
leg and forearm (fx of radius and ulna)
what are the early signs of compartment syndrome?
- Pain out of proportion to injury
- Paresthesia – pins & needles sensation
During Compartment syndrome muscle fascia prevents expansion of tissue. Venous outflow _______, as arterial flow is ____.
•Venous outflow decreases, as arterial flow is greater
what are the late signs of compartment syndrome?
5 P’s •
•Pain • Pallor • Pulselessness • Paresthesia • Paralysis
what are the 5 presenting sx of OA
Joint-line tenderness
Decreased range of motion (ROM)
Swelling
Joint deformity
Instability
Non-modifiable systemic risk factors for OA
Age / gender (women)
Genetics (60% hip and hand, 40% knee)
what is the modifiable systemic risk factor for OA
Obesity
Dose–response relationship exists between obesity and risk of knee OA
For every 5-unit increase in body mass index (BMI), there is an associated 35% increased risk of knee OA
What are the 4 modifiable local risk factors of OA
muscle strength
physical activity / occupation
joint injuries
alignment
when looking at modifiable risk factors for a pt with knee OA what muscle should you look to strengthen?
quad femoris
•Improvement in strength, through exercise, associated with reduced pain and improved function in people with knee OA
what is the most important joint / knee injury in the context of OA
ACL
Large percentage will show changes within 10 yrs. after initial injury
first line tx for pain management of OA / DJD
acetaminophin
•325 to 650 mg q 6 hours on a scheduled basis (maximum dose 4 g/day;
maximum 2 g/day if chronic alcohol intake or underlying liver disease
what is prescribed to pts with OA if acetaminophen proves ineffective
NSAIDS
Topicals
what topical analgesic is used to manage pain in OA
•Diclofenac Gel (Voltaren)
When a pt is dx with OA it is important to educate them on weight management as, for each kg weight loss, knee experiences _______ reduction in load during daily activities.
fourfold
what is the tx algoirthm (1st and 2nd line) for pain management of OA?
- Mild-moderate pain
- Acetaminophen used first line
- Add topical analgesics prn
- If measures fail
- NSAIDs, Viscosupplementation
what is the hallmark of Complex Regional Pain Syndrome
•Hallmark: Pain presentation is disproportionate in degree to what is typically expected from injury
what are the 2 types of Complex Regional Pain Syndrome?
type I: reflex sympathetic dystrophy (90% of cases, no peripheral nerve injury)
Type II: causalga (+ peripheral nerve injury)
pt arrives to clinic experiencing spontaneous pain, swelling and different skin temperatures with NO precipitating event. Upon examination you notice bone atrophy.
what type of complex regional pain syndrome is this?
Type I: not always a precipitating event (Type II there ALWAYS is a precipitating event)
Type I (+) for bone atrophy (Type II will be -)
what are the 3 cardinal signs of type 2 complex regional pain synd?
burning pain
allodynia
hyperalgesia
what are the 3 cardinal signs of type 1 complex regional pain synd?
spontaneous pain
swelling
different skin temps
3 most common MSK lesions
- Undifferentiated pleomorphic sarcoma
- Liposarcoma
- Leiomyosarcoma
Upon physical exam of a MSK lesion what size is concerning?
>5cm
when working up an MSK lesion what should you always start with ?
X-ray!
when working up an MSK lesion what are bone scans used to detect??
- Metastatic lesions
- Stress fractures
- Insufficiency fractures
what imaging technique is best indicated for smaller MSK lesions involving cortical structures of bone or spine?
CT scan
when working up a soft tissue MSK lesion what is the imaging technique of choice?
MRI
- Modality of choice for evaluating:
- Bone marrow involvement
- Non-calcific soft-tissue lesions
what is ALWAYS needed to dx MSK lesion?
tissue biopsy
When preforming a biopsy on an MSK lesion where is hightest quality diagnostic tissue found?
Highest-quality diagnostic tissue usu. found at periphery of lesion, at interfaces of normal surrounding tissue
when preforming a biopsy of an MSK lesion what are the 3 types for musculoskeletal neoplasia:
Excisional- discouraged unless
Lesion 2–3 cm
In location where a section of healthy tissue can be resected as a margin without significantly increased morbidity
Incisional
Needle
what are the goals of MSK cancer staging
- treatment guidance
- prognostic stratification
- investigation continuity
How are Benign Orthopedic Lesions classified
- matrix which the tumor cells produce:
- Bone
- Cartilage
- Fibrous tissue
- Fat
- Blood vessel
why would a Benign Orthopedic Lesion be classified as “aggresive”
they may recur locally after removal (resection)
name a Benign Orthopedic Lesion that rarely metastasize
giant cell tumor
In the context of malignant ortho lesions what is the most common site of mets
lungs
Term “malignant” indicates
moderate to high probability that the tumor will metastasize
most common type that originates in bone
Osteosarcoma
cancer of cartilage cells
Chondrosarcoma
2nd most common form of malignant bone tumor
MSK malignant cancer that often arises in diaphysis of long bones of legs & arms
•Ewing’s Sarcoma
where are we most likely to find osteosarcome?
arms
legs
pelvis
cancer that is uncommon in < 20 y/o and those > 75
Chondrosarcoma
in what type of cancer would you find a periosteal reaction?
what does this look like?
and what does it indicate?
Ewing’s Sarcoma
sun burst appearance - indicates an aggressive process
where are you most likely to see Chondrosarcoma
Arms
Legs
Pelvis
Ribs (sometimes)
what is this lesion called?
dx?
codmans triangle
ewings sarcoma
what age group does osteosarcoma most frequently present in
between 10-30 y/o
Chondrosarcoma may also form within prior benign tumors of cartilage and bone called _____ and normall develops from (normal / abnormal) cartilage.
Osteochondromas
normal
identify the lesion
Chondrosarcoma
identify the lesion
Osteosarcoma
identify the lesion
ewing sarcoma
