MSK Re-Up #5 (Arm & Elbow) Flashcards
A supracondylar humerus fracture occurs due to __________. It is MC in what population?
What is seen on radiographs to diagnose a displaced supracondylar humerus fracture?
-FOOSH
-MC in 5-10 year olds
-Displaced anterior fat pad sign or posterior fat pad sign (hemarthrosis) is suggestive of fracture
What is one other thing to remember about radiographs and what is seen with supracondylar humerus fractures?
Look at the radiocapitellar line. The radial head should dissect the capitellum. If not, it is likely displaced.
What are some complications of a supracondylar humerus fracture that you should be aware of?
-There is a specifically named one
-And another one
-Median nerve and brachial artery injury may lead to Volkmann ischemic contracture (claw like deformity from ischemia with flexion of the wrist)
-Radial nerve injury
Treatment for a supracondylar humerus fracture if:
-Nondisplaced
-Displaced
-Nondisplaced: long arm posterior splint followed by long arm casting
-Displaced: closed reduction and pinning
A radial head fracture, usually also from a FOOSH, usually the patient presents with …
What is present on radiographs for a radial head fracture?
-Inability to fully extend the elbow
-Displaced anterior fat pad sign (hemarthrosis)
Cubital Tunnel Syndrome is compression of which nerve at the cubital tunnel along the medial elbow?
The patient has paresthesia and pain along the nerve distribution that is worse with…
-Ulnar Nerve Compression
-Elbow Flexion
What are some physical tests you can do to diagnose cubital tunnel syndrome?
-Tinel’s at the elbow
-Froment Sign (holds paper and compensates with flexion of IP joint –pinching effect – to evaluate adductor pollicis)
-Decreased sensation to fifth and ulnar side of fourth finger
Treatment for cubital tunnel syndrome
-Wrist immobilization with sleep
-NSAIDs
-Steroid injections if chronic
What are some etiologies of olecranon bursitis?
How does this present?
-Repetitive trauma or pressure
-Gout, inflammation
-Infectious (Staph A) after injury to skin
-Goose egg boggy swelling to posterior olecranon process area
-Usually painless
-Full ROM
-Infectious: erythema, warmth, tenderness with painful, limited ROM
Usually olecranon bursitis is a clinical diagnosis; however, if inflammatory cause is suspected, aspirate bursa to evaluate for septic bursitis or gout.
If septic bursitis, Staph A is the cause. What are some ABX treatment options?
-Dicloxacillin or Clindamycin
Lateral Epicondylitis (Tennis Elbow) is inflammation of the __________ muscle due to repetitive pronation of the forearm and wrist extension.
What is the symptom you should remember with this?
-Extensor carpi radialis brevis
-Lateral elbow pain with wrist extension and gripping
Treatment for Tennis Elbow
-RICE, activity modifications, NSAIDs, physiotherapy, steroid injections, volar splint (palm side)
On the other hand, medial epicondylitis (golfer’s elbow), is inflammation of what TWO muscles from overuse and stress?
The pain is worse over the medial epicondyle and worse with what motions?
What is the treatment
Pronator teres-flexor carpi radialis muscles
-Wrist flexion against resistance with elbow extended
Activity modification, RICE, NSAIDs, steroid injections
Radial Head Subluxation (Nursemaid’s Elbow) occurs when the radial head is wedged into the stretched __________. It is MC in what population?
How does this occur?
Stretched annular ligament
MC in kids 2-5 years old
Lifting, swinging, or pulling a child while the forearm is pronated and extended
What is one thing the child will be doing to the arm if the radial head is subluxed?
-Arm slightly flexed and child refuses to use the arm
-Tenderness of radial head (lateral elbow)
Management for Nursemaid’s Elbow (Radial Head Subluxation)
-Closed reduction: pressure on radial head with supination of elbow followed by flexion of elbow.
-Hyperpronation technique
-No immobilization. Observe for 15 minutes.
What is the difference in a pediatric forearm fractures… Greenstick Fracture vs a Torus (Buckle) Fracture?
What do they occur from?
What should you do?
What should you be aware of if the MOI doesn’t match the injury?
-Greenstick: incomplete fracture with periosteal tearing on convex side of fracture (bowing)
-Torus: Incomplete fracture with wrinkling or bump of metaphyseal-diaphyseal junction due to axial loading
-FOOSH
-Closed reduction, long arm cast
-Child abuse!
Salter-Harris Classification of Fractures is for growth (epiphyseal plate) fractures. What is the pneumonic to use and what do they mean?
-SALTR
–Same, Above, Lower, Through, Rammed
-Type I: Isolated growth plate fracture
-Type II (MC type): Type I + fracture of metaphysis
-Type III: + fracture of epiphysis
-Type IV: fx extending across metaphysis, growth plate, and epiphysis (needs reduction)
-Type V: growth plate compression injury
What is a Nightstick Fracture?
Treatment?
Fracture of middle portion of ulnar shaft
Short arm cast vs long arm cast.
-If displaced, ORIF
A Monteggia Frature is ….
What is a complication of this?
-Fracture to proximal 1/3 of ulnar shaft + radial head dislocation
Radial nerve injury (may develop a wrist drop)
On the other hand, a Galeazzi Fracture is
What is the management for this?
What is a complication of this type of fracture?
-Mid-distal radial shaft fracture with dislocation of distal radioulnar joint
ORIF (unstable fracture)
Anterior interosseous nerve injury: loss of pinch between thumb and index finger
What is the acronym to use for Monteggia and Galeazzi Fractures?
-GRUesome MURder
–Galeazzi: Radial shaft fracture with dislocation of RadioUlnar joint
-Monteggia: Proximal 1/3 of ulnar shaft fracture + radial head dislocation
MC type of elbow dislocation?
What is seen on physical exam with an elbow dislocation?
-Posterior
Flexed elbow, marked olecranon prominenence, inability to extend elbow
Treatment for elbow dislocation?
-Emergent reduction with posterior splint at 90’ and ortho follow up
What is the pathophysiology of osteogenesis imperfecta?
What are some symptoms and clinical manifestations of this condition?
Autosomal dominant disorder leading to defects in gene that codes for Type I collagen
-Severe premature osteoporosis: multiple recurrent spontaneous fractures
-Presenile deafness
-Blue-tinted sclerae *****
-Brown teeth
Complex Regional Pain Syndrome (CRPS) is autonomic dysfunction following bone or soft tissue injuries (30% have no history of injury, though). What are symptoms of this condition?
4 main symptoms after initiating event:
-Sensory: Pain, hyperalgesia out of proportion
-Motor/Trophic Changes: decreased ROM, increased hair and nail growth initially
-Edema: Or sweating changes
-Vasomotor: temperature and skin color asymmetry
What is the management for CRPS?
-NSAIDs initially, PT or OT
-Oral corticosteroids, TCA’s
-Electric nerve stimulation
What should be given to patients with fractures to reduce the incidence of CRPS?
Vitamin C prophylaxis
What is the cause of osteoporosis (pathophysiology)?
-Loss of bone density over time to imbalance of increased bone resorption > formation of new bone
Primary osteoporosis has causes such as…
Secondary osteoporosis, due to disease or medications, has causes such as…
-Primary: Postmenopausal and senile
-Secondary: Glucocorticoid use, Cushing’s Syndrome, Heparin, Phenytoin, Lithium, Levothyroxine, DM, Low estrogen
What are other risk factors for osteoporosis?
What are some symptoms that would make you think osteoporosis?
-RF: Caucasians, Low BMI (thin body habits), corticosteroid use, smoking, CKD, alcohol, physical inactivity, low calcium and Vitamin D intake
-Symptoms: usually asymptomatic, pathologic fractures (vertebrae MC), spine compression (loss of vertebral height, shortening of stature, kyphosis AKA hunchback, back pain)
What is the best diagnostic test for osteoporosis?
Explain the T scores and what each means.
-DEXA scan (bone densitometry)
-Normal: 1.0 or greater
-Osteopenia: -1.0 to -2.5
-Osteoporosis: -2.5 or less
Who should you screen for osteoporosis?
-DEXA scan in patients 65 years or older
Management for osteoporosis?
-Lifestyle modification: Vitamin D, Calcium supplements, weight bearing exercise, smoking cessation
-Bisphosphonates: inhibit osteoclast turnover
-Denosumab: RANKL inhibitor that is used if unresponsive to other therapies
Osteosarcoma is the MC primary bone malignancy in Children and young adults. It MC occurs in what bone?
Where are the METS MC to (this is the MCC of death).
Distal femur (long bones)
MC mets to the Lungs
Symptoms of an osteosarcoma
-Localized bone pain, worse at night
-Joint swelling without systemic symptoms
-Palpable soft tissue mass (may be tender to palpation)
Radiographs are usually done first for osteosarcoma, what is shown on them?
What is the definitive diagnostic for this?
-hair on end or sunburst appearance due to tumor spicules of calcified bone radiating in right angles.
-Biopsy is definitive
Treatment for osteosarcoma?
-Chemotherapy + surgical removal with possible amputation of limb
On the other hand, a chrondrosarcoma is …..
What is seen on radiographs?
What is the treatment?
-Cancer of the cartilage. MC in adults 40-75.
Punctate or ring and arc appearance calcification
Surgical resection +/- chemotherapy
A Ewing Sarcoma, the second MC primary bone malignancy in children and young adults, occurs due to a translocation between what two chromosomes?
Whats the MC site for mets?
MC location for this condition?
Chromosomes 11 and 22
Lungs
Femur or Pelvis MC
Symptoms of a Ewing Sarcoma
What is shown on Radiographs for this condition?
Localized bone pain and swelling with systemic symptoms (fever, malaise, weight loss)
Periosteal reaction (onion skin appearance), lytic lesions with moth-even appearance
What is seen on histology for a Ewing Sarcoma?
-sheets of monotonous small round blue cells
Treatment for Ewing Sarcoma?
-Chemotherapy with limb-sparing resection when possible
In benign bone tumors, osteochrondroma is the MC type. It occurs in 10-20 year old males MC and what symptoms does it have?
What is shown on radiographs?
Treatment?
-Painless, palpable mass.
-Pedunculated (narrow stalk) that grows away from the growth plate and involves the medullary tissue.
-Biopsy is definitive.
Observation if asymptomatic. Marginal resection if painful or location in pelvis.
An osteoid osteoma, a benign bone tumor characterized by small radiolucent nidus, MC presents in the second decade of life. what does the nidus produce?
What are symptoms of this condition?
-Nidus produces high levels of prostaglandins.
-Progressively increasing pain that is worse at night and unrelated to activity. Pain is relieved within 20-25 minutes of NSAID administration (prostaglandin inhibition)
-May develop a limp, decreased ROM
Treatment for Osteoid osteoma
-NSAIDs with serial X-rays every 6 months
