MSK Precision and Pearls #1 Flashcards
What is a Boxer’s Fracture what what is the mechanism of action for this fracture?
Fracture at the neck of the 5th metacarpal
-Punching with a clenched fist
Treatment for a Boxer’s Fracture (remember to check for something)
-Ulnar gutter splint with joints at 60 degrees
-Check for bite wounds. If present, treat with Augmentin.
A shoulder dislocation is a dislocation of what joint? What type is MC? What is the MOA of this type of dislocation?
Glenohumeral joint
Anterior
FOOSH
Specifically, what causes an anterior shoulder dislocation?
Blow to an abducted, externally rotated arm that’s extended.
What radiographs should be obtained with a shoulder dislocation?
What should also be ruled out and how do you test for it?
Axillary and scapular Y views
Axillary nerve injury (deltoid pinprick sensation test)
What are two unique findings on radiographs that can be seen with an anterior shoulder dislocation?
Hill Sach Lesion: groove fracture of humerus
Bankart Lesion: glenoid rim fracture
A posterior shoulder dislocation is MC associated with what things?
Seizures and electric shock
Treatment for shoulder dislocations
Reduction and immobilization
Lateral epicondylitis (also known as ________) is inflammation of which tendon? What motions cause this condition? What motions exacerbate the pain?
Tennis elbow
Extensor carpi radialis brevis
Repetitive pronation of forearm and wrist extension
Lateral elbow pain with wrist extension and gripping
Name the carpal bones in order from the thumb to pinky (what is the acronym used?)
Some Lovers Try Positions That They Can’t Handle
-Bottom row: Scaphoid, Lunate, Triquetrum, Pisiform
-Top Row: Trapezium, Trapezoid, Capitate, Hamate
A rotator cuff tear is an injury to one of the SITS muscles. Name these muscles. Which is the MC injured? What are some risk factors for this condition?
-Supraspinatus, Infraspinatus, Teres Minor, Subscapularis
Supraspinatus
Age >40, Overhead use, chronic/repetitive use, trauma
What are some symptoms of a rotator cuff tear? A supraspinatus tear has pain against what motion?
-Anterolateral (deltoid) shoulder pain
-Decreased ROM, especially overhead, ER and abduction
-Inability to sleep on that side
-Night pain
-Crepitus
-Pain with resisted abduction
What are four tests that can be done for a rotator cuff tear? Explain them.
-Empty can: 90% specificity for supraspinatus tear. (arm out, thumb down (IR), push down)
-Hawkins: arm in front, IR (move down)
-Neer: IR and raise arm (gymnast arm in air)
-Drop Arm Test: pain with lifting arm above shoulder level or slowly lowering it
Explain the proper protocol for an amputated digit
Wrap in gauze and soak in sterilized isotonic saline to prevent it from drying.
Then placed in a plastic bag that is immersed in ice water for cooling.
NEVER place directly in ice water because the fluid may jeopardize the microcirculation.
name the four muscles of the rotator cuff and the actions they perform
-Supraspinatus: abduction
-Infraspinatus: ER
-Teres Minor: ER and adduction
-Subscapularis: IR and adduction
Treatment for a sprain of the shoulder
Conservative: arthroscopic subacromial decompression if resistant
A proximal humerus fracture, commonly from a _______, is the common site of what? What is the treatment? What should you check for?
FOOSH
Metastatic breast cancer
Sling/Swathe + ortho follow up in 24-48 hours
Check deltoid sensation to rule out axillary nerve injuries or brachial plexus injuries
With a humeral shaft fracture, though, you must rule out what, which can lead to ______
Radial nerve injury
Wrist drop
What is the treatment for a humeral shaft fracture that is open or has nerve injuries?
Operative: ORIF
Treatment for an open wound on the hand
Thoroughly irrigate
Check for bite wounds
ABX: Augmentin
Tetanus Shot
Adhesive capsulitis is also known as ________. Explain what this is caused by and two conditions that are commonly associated with it.
Frozen Shoulder Syndrome
Shoulder stiffness due to inflammation, scarring, fibrosis
DM, Hypothyroidism, hyperthyroidism, prolonged immobility
Symptoms of adhesive capsulitis
-Restriction of both active and passive ROM that occurs in absence of known shoulder disorder
-Pain, dull ache
-Pain worse at night
-Insidious onset over months
-Gradual return of ROM
-Inability to sleep on affected side
-Late in disease, patients unable to reach overhead, scratch their back, or put on a coat
Treatment for adhesive capsulitis
-Rehab ROM (Mainstay)
-Do not immobilize
-Codman Exercises: let arm dangle and do circumduction
-Manipulation under anesthesia if all else fails
What is a Colles Fracture and what is the mechanism in which it occurs?
Distal radius fracture with dorsal angulation (dinner fork deformity)
FOOSH with wrist extension
What type of radiograph do you get for a Colles Fracture?
Lateral view - shows dorsal angulation of distal radius fracture
Treatment for a stable vs unstable Colles Fracture.
Stable: Closed reduction and sugar tong splint
Unstable: (>20’ angulation) = ORIF
What is the MC complication of a Colles Fracture?
Extensor pollicis longus tendon rupture
In short, what is a Bennett’s Fracture?
What is a Rolando Fracture?
-Intraarticular fracture through the base of the 1st metacarpal MCP bone
-Comminuted Bennett’s Fracture
Explain what a monteggia fracture is. What is the acronym to remember these two fractures by.
Fracture of proximal 1/2 of ulnar shaft + radial head dislocation
GRUMUR
Treatment for both Monteggia and Galeazzi Fracture
ORIF
Explain what a galeazzi fracture is and the acronym to remember these fractures by.
Mid distal radial shaft fracture with dislocation of DRUJ
GRUMUR
What is a complication of a monteggia fracture? What is a complication of a galeazzi fracture (what does this mean)
Radial nerve injury (wrist drop)
Anterior interosseous nerve injury: unable to pinch thumb and index finger together
what is a smith fracture? What is the mechanism that causes it most times?
Distal radius fracture with ventral angulation (garden spade deformity)
FOOSH with wrist flexed
Management of a stable vs unstable Smith fracture
Stable: closed reduction and sugar tong splint
Unstable: ORIF
What is thoracic outlet syndrome (in the name)?
-Compression of the subclavian artery, subclavian vein, or brachial plexus (MC) as they exit shoulder girdle to the first rib
What are the symptoms of thoracic outlet syndrome?
-Vascular compression: swelling of arm, decreased pulses
-Nerve compression: ulnar neuropathy, pain and paresthesia to forearm and arm (medial side of forearm and 4th and 5th fingers)
Two unique exam findings of a patient with thoracic outlet syndrome. They are tests that can be done.
Positive Adson Sign: loss of radial pulse with head tilted toward affected side.
Roos Test: hands up like being held at gunpoint, open/close fists for 1 minute exacerbate the symptoms
What diagnostic is done to confirm the diagnosis of thoracic outlet syndrome? What is the treatment?
MRI
Joint protection, PT, ortho consult
What is a Dupuytren Contracture?
Progressive fibrosis of palmar fascia leading to contractures
Risk factors of a Dupuytren Contracture
Genetics
ETOH abuse
DM
Men > 40
Northern European
Symptoms of a Dupuytren Contracture
-Palpable nodules over distal palmar crease along course of flexor tendon
-Thickened skin or bands in palmar fascia
-Fixed flexion deformity at MCP joint
Management of a Dupuytren Contracture
Intralesional corticosteroids injections
-Fasciotomy or fasciectomy if refractory, recurrent, or impaired function
Medial epicondylitis, also known as _______, is inflammation of which two muscles due to repetitive overuse and stressor? What motions make this pain worse and where is the pain located?
Pronator teres and flexor carpi radialis
Worse with pulling motions, wrist flexion against resistance with elbow extended
pain over medial epicondyle
When should you perform an X-ray of a finger with a subungal hematoma?
When the hematoma is >50% of the nail to evaluate for phalanx fracture
A radial head subluxation, also known as a Nursemaid’s Elbow, occurs when _______. The MOA for this injury is _________. it is MC in _________
The radial head slips out of the annular ligament
Lifting, swinging, or pulling a chill while forearm pronated and extended
MC In kids 2-5 years old
What treatment should be done for a Nursemaid’s Elbow?
Closed reduction: pressure on radial head with supination of the elbow followed by flexion of the elbow.
-Observe for 15 minutes and then ok to discharge if symptoms resolve.
Explain the radial, ulnar, and median nerve on the hand as well as a motion you can do to test these nerves.
-Median: thumb opposition (flexors)
-Radial: thumb extension (extensors)
-Ulnar: criss cross fingers (intrinsics)
Explain what impingement syndrome is, what motions exacerbate it, and three tests that can be done to determine this diagnosis.
Entrapment of supraspinatus tendon
Overhead motions
Hawkins, Neer, Empty Can
What is the MC fractured bones in newborns (from birth) and kids, as well as adolescents?
Clavicle fracture
If no history of trauma with a clavicle fracture, what should you think in children < 2 years old?
Malignancy, rickets, child abuse if < 2 years old
What are the three types of clavicle fractures, which type is MC, and what are some exam findings of a clavicle fracture?
Type 1: (mid shaft): middle 1/3 (MC)
Type 2: (lateral 1/3 or distal)
Type 3: proximal 1/3 or medial
Pain over area, tenting of clavicle, crepitus
For a mid 1/3 clavicle fracture, what is the treatment?
How about for a proximal 1/3 fracture?
-Sling immobilize, Figure 8 splint
Ortho consult
What is cubital tunnel syndrome and what are the symptoms associated with it?
Ulnar nerve compression in the cubital tunnel along the medial elbow
Pain and paresthesia along the nerve length, worse with elbow flexion. In small and ring fingers (4th and 5th fingers)
Two tests you can do to check for cubital tunnel syndrome
Tinel’s Sign at elbow: tap on sulcus near medial epicondyle
Froment Sign: pinch paper between adducted thumb and index finger. Positive if can’t hold it or if they flex the IP joint of the thumb to help.
Treatment for cubital tunnel syndrome
Wrist immobilization, long arm splint in elbow extension
Steroid Injections
NSAIDs
What are the three causes of olecranon bursitis?
Direct trauma or overuse
Gout, inflammation
Infectious/Septic: penetrating trauma (staph A)
Although a clinical diagnosis, what should you do if you suspect an infectious cause or gout as cause of olecranon bursitis?
Aspiration: WBC > 2,000 is positive
If septic olecranon bursitis, what should be given?
ABX: Dicloxacillin or Clindamycin
What is a torus (buckle) fracture and what is the treatment for it?
Incomplete forearm fracture with “wrinkling or bump” of metaphyseal-diaphyseal junction due to axial loading
Closed reduction with long arm cast
Salter-Harris Classification System of Fractures applies to epiphyseal plate fractures. Explain the pneumonic to use and what each means. What is the MC type?
SALTR
Same (isolated growth plate fx)
Above (growth plate fx + fx of metaphysis)
Lower (growth plate fx + fx of epiphysis)
Through (fx extending across metaphysis, growth plate, and epiphysis) - needs reduction
Rammed (growth plate compression injury)
MC type is Type II (Above)
What is a nightstick fracture and what is the treatment?
Middle portion of ulnar shaft fx
Cast if nondisplaced
ORIF if displaced
What is suppurative flexor tenosynovitis and what is the MCC?
Infection of flexor tendon sheath of finger
Staph A from a penetrating injury
What are the symptoms of suppurative flexor tenosynovitis? Think FLEX
Knavel’s Signs
Finger held in flexion
Length of tendon sheath tender
Enlarged finger
Extension of finger causes pain
What diagnostic should you do and what is the treatment for suppurative flexor tenosynovitis?
Aspirate and biopsy
I&D, IV ABX
Carpal Tunnel Syndrome is what? What are risk factors of this condition?
Entrapment of the median nerve and compression –> neuropathy
RF: DM, RA, Pregnancy, Hypothyroidism, Occupational
Symptoms of carpal tunnel syndrome
-Paresthesias and pain in palmar aspect of first three (and radial half of fourth digits) especially at night
-Clumsiness
-Thenar muscle wasting
If thenar muscle wasting is present in carpal tunnel syndrome, what should you do?
Referral to ortho!
Tests that can be done to diagnose carpal tunnel syndrome?
Tinel Sign: Tap over median nerve
Phalen: flexion of both wrists for 1 minute
Management for carpal tunnel syndrome
Volar splint
NSAIDs
Injections
Surgery if refractory or no improvement
A ganglion cyst is a _____ filled synovial cyst. Describe this cyst.
Mucin filled
Firm, well circumscribed painless mass fixed to deep tissue. Translucent with illumination.
DeQuervain’s Tenosynovitis is entrapment of which two tendons/muscles?
APL and EPB
Abductor pollicis longs and extensor policis brevis
What are some causes of Dequervain’s, what are the symptoms, and what test can be done to prove this diagnosis?
Overuse, DM, Postpartum (lifting baby)
Sharp pain along radial aspect of wrist and base of thumb radiating to forearm especially with gripping.
Finkelstein Test: pain with ulnar deviation while thumb is flexed in the palm.
Treatment for DeQuervain’s?
Thumb spica splint, NSAIDs, PT
Steroid injections if unsuccessful
MC fractured wrist bone and symptoms associated with it
Scaphoid fracture
Snuffbox tenderness, radial wrist pain
What radiograph views are obtained if you suspect a scaphoid fracture of the wrist?
AP, lateral, and scaphoid view
Because a scaphoid fracture may not show up for 2 weeks, you should treat it as such even if negative radiographs and snuffbox tenderness for two reasons. Name them.
High risk of nonunion and AVN
Treatment for scaphoid fracture
-Nondisplaced: thumb spica splint
-Displaced: ORIF
What is scapholunate dissociation and what is diagnostic for this?
Widened space between scaphoid and lunate bones
> 3mm (Terry Thomas Sign)
Treatment for scapholunate dissociation
Radial gutter splint initially
Surgical repair if needed
What is the most serious carpal fracture?
What is Kienbock’s Disease?
Lunate fracture
AVN of the lunate bone
How does a mallet (baseball) finger occur?
Avulsion of extensor tendon after blow to tip of finger causing forced flexion of an extended finger
What is seen on exam for a mallet finger?
Treatment for this condition
Unable to actively extend DIP joint of the finger affected
Uninterrupted extension splint of DIP joint for 6-8 weeks
A gamekeeper’s (skiers) thumb is a sprain or tear of which ligament of the thumb? What is the treatment?
Ulnar collateral ligament
Thumb spica splint & referral to hand surgeon
Pronator Teres Syndrome, much like carpal tunnel syndrome, is compression of which nerve. However, it occurs ______. The symptoms of this condition are more aimed at including ______ but not _________
Median nerve compression
where nerve transverses pronator teres muscle
Proximal forearm pain
No pain at night
