MSK Tests/Signs Flashcards
Dermatomyositis
humeral attack of muscle capilaries and small arterioles - infarctions / proximal muscle weakness
- Gottron’s papules
- Anti-Mi2 & Anti-MDA5
- muscle biopsy
- Rx:
- corticosteroids
- Methotrexate
Polymyositis
T-cell mediated cytotoxic process against muscle antigens
proximal muscle weakness
- Anti-Jo-1
- elevated CK
- muscle biopsy
- Rx
- corticosteroids
- Methotrexate
Fibromyalgia
- no specific tests - test for other causes of symptoms
- Rx
- symtom specific
- pain: analgesics
- acetaminophen
- Tramadol
- muscle relaxants
- Cyclobenzaprine (Flexeril)
- anxiety
- Alprazolam (Xanax)
- insomnia
- Zolpidem (Ambien)
- antidepressants
- Duloxetine (Cymbalta), Venlafaxine (Effexor)
- pain: analgesics
- symtom specific
Chronic Fatigue Syndrome
- no specific test - r/o other causes
Complex Regional Pain Syndrome
follows surgery or trauma
- pain out of proportion
- skin color changes, dryness, shiny, wrinkled
- Rx
- NSAIDs, corticosteroids
- sympathetic nerve block
- PT/OT
- surgery
Marfan Syndrome
autosomal dominant connective tissue disorder
- treat pathology
Ehlers-Danlos Syndrome
heterogeneous disorder of connective tissue affecting collagen - joint hypermobility
- treat manifestations
- B-blocker to protect vessels
Osteogenesis Imperfecta
hereditary defects in bony matrix
- blue sclara
- bony deformities
- Rx
- Risedronate (increases bone density)
Systemic Lupus Erythematous
(SLE)
multisystemic inflammatory autoimmune disease
- non-erosive peripheral joint pain/stiffness out of proportion
- Anti-Smith autoantibody
- Anti-dsDNA
- Rx
- antimalarials
- Hydroxychloroquine
- NSAIDs, corticosteroids
- supplement Ca & Vit D w/ long term steroid
- DMARDs (immunosuppressants)
- Methotrexate (Trexall) - arthritis
- Cyclophosphamide - CNS
- Azathioprine (Imuran) - nephritis
- Mycophenolate (Cellcept) - nephritis
- IV immunoglobulin for flare-ups
- antimalarials
Sjorgren’s Syndrome
autoimmune attack of exocrine glands
- SICCA
- xerophthalmia (keratoconjunctivitis), xerostomia (mouth)
- Anti-SS-A (Ro) -or- Anti-SS-B (La)
- Rx
- fluids, lotion, humidifiers, good oral hygiene, annual eye/dental exams
Polymyalgia Rheumatica
inflammatory condition of shoulders and pelvic girdle
- sudden onset morning stiffness >45 min
- ASSOCIATED w/ GIANT CELL arteritis
- temporal artery biopsy (gold standard)
- Rx
- Prednisone
- Ca/Vit D
Polyarteritis Nodosa
necrotizing inflammation of vessels at branches/bifurcatons
- Livido reticularis
- Rx
- Prednisone
- Methotrexate
- Anti-viral if Hep B
- treat HTN
tumor prefixes
- osteo-
- chondro-
- fibro-
- radiolucent
- osteo - bone forming
- osteoid osteoma
- osteoblastoma
- osteoma
- chondro - cartilage forming
- chondroma
- osteochondroma
- chondroblasoma
- fibro - fibrous bone lesions
- fibrous dysplasia
- nonossifying fibroma
- radiolucent
- giant cell tumor
- unicameral bone cyst
- aneurysmal bone cyst
Osteoid Osteoma
benign ostoid forming tumor
- night pain
- <1cm cherry red lytic nidus
- Rx
- NSAIDs
- curettage/burring
- radiofrequency ablation
Osteoblastoma
large osteoid osteoma
- >2cm and more aggressive
- night pain
- nidus not visible on x-rays
- Rx
- NOT responsive to NSAIDs
- biopsy
- curettage and bone grafting
- tumor excision w/ bone reconstruction -or- internal fixation
Osteoma
benign deposit of new bone
- associated w/ Gardner’s syndrome (colonic polyps)
- firm w/ no pain
- typically on skull, tibia, femur
- Rx
- observation vs. marginal resection
Encondroma
benign cartilage formation in medullary canal
- associated with:
- Ollier’s disease
- Maffucci’s syndrome (+hemangiomas)
- “scalloped”/thinning on x-ray
- Rx
- no tx if asymptomatic
- biopsy
- curettage w/ bone grafting
Periosteal Chondroma
benign hyaline cartilage formation on surface of bone
- painful, sometime palpable mass
- saucerization w/ sclerosis on x-ray
- Rx
- excision
- need to r/o condrosarcoma
Osteochondroma
exostosis - growth on bone surface covered w/ benign cartilaginous cap
- pedunculated vs. sessile stalk
- Rx
- asymptomatic - monitor
- surgical excision
Chondroblasoma
cartilage forming tumor in epiphysis
- radiographic finding - well circumscribed/defined lytic lesion
- histology: “chickenwire calcification”
- Rx
- curettage and bone graft
Nonossifying Fibroma
(NOFs)
proliferation of fibrous tissue / fibrous cortical defect
- children/adolescents
- Jaffe-Campanacci Syndrome: multiple NOFs and cafe au lait spots
- Rx
- observation vs. curettage w/ bone graft
Fibrous Dysplasia
abnormal tissue formation in place of lamellar bone
- pain
- “ground glass” appearance on x-ray
- Rx
- surgery - rigid fixation
- Bisphosphates
Giant Cell Tumor
aggressive benign proliferation of multinucleated giant cells
- pain, swelling, deformity - can met to lungs
- lucent and ecentrically located, bony destruction/cortical breakthrough on x-ray
- Rx
- curettage, ablation, bone grafting, fixation
Unicameral Bone Cyst
fluid filled cyst w/ fibrous lining
- usually incidental finding or mild pain/swelling/stiffness
- Rx
- r/o sarcoma
- interlesion aspiration w/ corticosteroid injection
- curettage and bone graft
Aneurysmal Bone Cyst
aggressive vascular lesion w/ blood filled cavities
- Rx
- curettage and bone grafting
Metatastic Disease
carcinomas of other organs spread to the bones
most common bone tumor
Multiple Myeloma
proliferation of malignant interosseous plasma cells
in bone marrow
- “punched out” roundish lesion in x-ray
- Rx
- surgical fixation of pathologic fxs
- chemo/radiation
Osteosarcoma*
most common malignant bone tumor
- palpable mass, lymphadenopathy
- +/- pain, swelling, night pain
- types:
- telangiectatic
- multifocal
- parosteal
- periosteal - “star burst”/”sun burst”
- Rx
- resection to spare limb
- amputation
Chondrosarcoma
malignant predominantly cartilage tumor
- pain over time w/ or w/out mass
- symptoms depend on tumor location
- “ring and arc” pattern on x-ray, punctate calcifications, scalloping
- Rx
- excistion: wide resection vs. limb sparing
- NO chemo/radiation
Secondary Chondrosarcoma
arises from enchondroma/osteochondroma
- scattered irregular calcification on x-ray
Ewing Sarcoma*
malignant endothelioma -
assoc w/ chromosomal translocation t(11:22)
- young population
- worsening pain, fever, warmth, incr sed rate, WBCs (mimics infection)
- destructive lesion w/ poor borders on x-ray
- Rx
- chemo
- Vincristine, Cyclophosphamide
- radiation
- surgical resectioning
- limb sparing, amputation rare
- chemo
osteocyte receptors/inhibitors regulating osteoclast production
RAKLE and OPG
these determine rate of bone resorption
peak bone mass
18-20: proximal femur
25-30: spine
more loss than formation after this
bone physiology vs. pathology
longitudinal growth, mineralization, remodelling
growth - abnormal size
mineralization - osteomalacia
remodelling - osteoporosis
Osteoporosis
bone remodelling pathology
- no S/s - seen with associated fracture
- Kyphosis - Dowager hump
- FRAX tool
-
Dual-Energy X-ray Abosorbtiometry (DEXA) - gold standard
- T-score: value vs. control at peak BMD
- 1 STD = normal
- (-)1-2.5 STD = osteopenia
- (-)2.5+ = osteoporosis
- Z-score: value vs. age/sex
- >(-)2 = normal
- <(-)2 = below expected range
- T-score: value vs. control at peak BMD
- Rx
- Ca (1000-1200mg/d) + Vit D (600-800 IU/d)
- Bisphosphates - inhibit osteoclasts
- oral
- Alendronate (Fosamax)
- Risedronate (Actonel)
- Ibnadronate (Boniva)
- parental
- Zoledronic acid (Reclast)
- Ibandronate (Boniva)
- oral
- newer/expensive options
- selective estrogen receptor modulators (SERMs)
- Raloxifene (Evista)
- recombinant human parathyroid hormone
- Teriparatide (Forteo)- black box
- human monoclonal antibody
- Denosumab (Prolia)- RANKL Ab inhibits osteoclast
- selective estrogen receptor modulators (SERMs)
Osteomalacia
decreased mineralization
(softening of bone/rickets-children)
- Vit D deficiency, renal/liver disease, minerailzation inhibitors
- +/-Chvostek’s sign: tap on facial nerve elicits twitch
- 25-hyroxyvitamin D (<30 insufficient, <15-20 dificient)
- Rx
- Vit D replacement 400-2000 IU/d
Paget Disease
localized bone remodeling disorder
- deformities, abnormal gait, skull: hearing loss/HA/tinitis/increased hat size
- urinalysis: hyroxyproline, dexypyridinoline, C-telopeptide
- NOT a Vit D disorder
- Rx
- Bisphosphates
- Zoledronate acid (Reclast)
- Alendronate (Fosamax)
- Risedronate (Actonel)
- Bisphosphates
The 4 Spondyloarthropathies
share genetic predisposing factors and clinical features
- ankylosing spondylitis
- reactive arthritis
- psoriatric arthritis
- enteropathic arthritis
- joint ankyloses (new bone formation)
- occular inflammation
- HLA-B27 gene
Ankylosing Spondylitis
axial skeleton inflammation disorder
- HLA-B27
- achilles tendon/heel pain
- Schober test: measure mobility of spine 10cm/5cm
- “bamboo spine” on x-ray, SI joint “missing”
- Rx
- NSAIDs, corticosteroid (injection/systemic)
- Sulfasalazine
- Methotrexate
- DMARDs
- anti-TNF therapy
Reactive Arthritis
aseptic joint inflammation after infection
- salmonella, ersinia, shigella, chlamydia
-
Reiter’s syndrome: “can’t see, can’t pee, can’t climb tree”
- conjunctivitis, urethritis, conjunctivitis
- Mucocutaneous lesions/Papulosquamous eruptions
- HLA-B27
- synovial fluid analysis
- Rx
- no cure - self limiting
- NSAIDs +/- intra-articular injection
Psoriatric Arthritis
- onycholysis, subungual keratosis, pitting, oil staining
- HLA-B27
- Rx
- pain control, anti-TNF
Enteropathic Arthritis
non-erosive asymmetric polyarthritis
- associated w/ Crohn’s and UC
Scleroderma - Systemic Sclerosis
autoimmune thickening of skin/connective tissue
w/ internal organ involvement
- inflammation -> vascular obliteration -> fibrosis
- limited
- trunk spared
-
CREST syndrome
- Calcinous cutis, Raynaud’s, Esophageal thickening, Sclerodactyly, Telangiectasia
- diffuse
- proximal and trunk skin, rapid progression
- mixed
- overlap of SLE and systemic sclerosis (scleroderma)
- localized
- children - morphea (reddish/purple lesion)
- Rx
- no real tx - treat systems involved
- corticosteroids, methotrexate, D-penicillamine, ACE inhibitor
Osteoarthritis
progressive irreversible loss of articular cartilage
- changes to ALL components of joint: bone exposure, bony cysts, sclerosis of bony margins
- Heberden’s nodes (DIP)
- Bouchard’s nodes (PIP)
- Rx
- conservative
- RICE, hyaluronic acid/corticosteroid injections
- NSAIDs
- PT, lifestyle modification
- joint replacement
- conservative
Rheumatoid Arthritis
immune response in synovial tissue
- symmetric “moring stiffness” (gel phenomenon)
- MCP/PIP, C1-C2 subluxation
- deformities:
- ulnar deviation, swan-neck, Boutonniere, nodules, hammer toe
- Felty’s syndrome: RA, splenomegaly, neutropenia
- +RF/anti-CCP
- Rx
- no cure
- NSAIDs or low dose Prednisone
- DMARDs: methotrexate
- Anti-TNF: infliximab, adalimumab, golimumab
RA vs. OA
Gout
monosodium urate crystals (MSU)
- 1st metatarsophalangeal joint (Podegra)
- subcutaneous tophus
- synovial fluid analysis (gold standard)
- needle shaped crystals w/ negative birefringence
-
Rx
- lifestyle
- acute attacks: RICE, NSAIDs, Colchicine
- Xanthine oxidase inhibitor
- Allopurinol (Zyloprim, Aloprim)
- Probenecid (under-excreters)
- Pegloticase (Krystexxa) - rheumatologic, black box
Calcium Phyrophosphate Dihydrate Crystal Deposition Disease
(CPPD Crystal Deposition Disease)
extracellular PPi accumulation around chondrocytes
- synovial fluid analysis - gold standard
- square crystals w/ positive birefringence
-
types
- pseudo gout (single knee)
- chondrocalcinosis (incidental)
- pyrophosphate arthropathy (OA+CPPD)
- Rx
- RICE, NSAIDs, corticosteroids
Hydroxyapatite Arthropathy
(3 manifestations)
species of basic phosphate crystals
in joints, ligaments, tendons, bursa
- calcific tendinitis - sudden onset pain w/out MOI, resolves, back during resorption phase
- Milwaukee shoulder - crystals destroy RC and shoulder joint
- Diffuse idiopathic skeletal hyperostosis (DISH) - bridging in spine
Septic Bursitis
infection of bursa
- if infection of joint - pt will not want to move it!
- aspiration to identify infection
- Rx
- outpatient
- penicillin
- tri/sulfa (Bactrim) if MRSA
- Clindamycin -or- Linezolid if PCN allergy
- inpatient
- Nafcillin, Oxacillin, Cefazolin IV
- MRSA: add Vanco, Daptomycin, Linezolid
- outpatient
Septic Arthritis
infection of joint
- damages articular cartilage and bone - DON’T MISS
- hematogenous w/ UTIs, indwelling catheters
- very painful, red, hot, swollen, +/- fever
- cervical/urethral cultures if +gonococcal
- Rx
- surgery + IV antibiotics
Osteomyelitis
infection of bone
- biopsy or culture (gold standard)
- Rx
- abx spacer; reconstruction; amputation
- IV abx
- methylmethacrylate beads
Cervical Test
spurling
- narrows foramen
- will increase or reproduce radicular symptoms
Lumbar Tests
- straight-leg raise
- herniated disk
- lumbar spine of asymptomatic side
- seated straight-leg raise
- sciatic tenson, pt leans back
- FABER
- figure 4
- hip/SI joint pathology
non-organic pain signs
Waddell signs
- nonorganic tenderness
- axial stimulation/torso rotation
- seated straight-leg raise
- sensory examination
cervical strain
- Rx
- NSAIDs, pain meds, muscle relaxers, corticosteroids
radiculopathy vs. myelopathy
- radiculopathy
- nerve root
- disk herniation, degeneration - spasms, weakness, HA
- relieved w/ hand over head
- myelopathy
- spinal cord
- long tract signs: palmar paresthesia, abnormal unrinary, vibration/position loss
myelopathy tests
- Babinski sign (toe’s open)
- Brudzinski-Kernig test (head lift / leg lift)
- Ankle clonus (dorsiflex foot)
cervical radiculopathy
compressed nerve root
- Spurling test
- pain radiates PAST elbow
- Rx
- resolves in 2-8 weeks
- NSAIDs, traction, NO MANIPULATION
cervical spondylosis
narrowing of neural foramen
- myelopathy symptoms
- Rx
- decompression and fusion
cauda equina syndrome
compression of nerve roots distal to conus medullaris
- bowel/bladder dysfunction
- saddle anesthesia
- weakness in lower extremities
- Rx
- IMMEDIATE decompression surgery
lumbar strain/sprain
- x-ray to r/o other
- patellar tendon reflex (L4)
- Rx
- conservative
- pain control, PT, education, back to work
- conservative
chronic low back pain
- >90 days / 3 months
- LBP radiating to 1 or both buttocks
- relief when lying
- Rx
- psychological testing
- injections
- education
- detoxification
lumbar herniated disk
- L4/L5, L5/S1 most common (L5 and S1 nerves)
- pain past knee to foot
- Rx
- NSAIDs, rest, PT
- microdisection
- laminectomy
spinal stenosis
narrowing of lumbar spinal canal
- neurogenic claudication: weakness proximal to distal
- relief w/ sitting forward/leaning
- Romberg test: lose balance w/ eyes closed
- Rx
- pain control, PT, body mechanics
- decompression vs. spinal fusion
SI joint dysfunction
- trauma, tight iliopsoas, scoliosis, hip OA, pregnancy
- stabbing knife-like pain in butt or posterior leg(s)
- wose w/ sitting/twisting
- FABER test
- pusth on ASIS and rock pt
- Rx
- conservative
coccydynia
tailbone pain
- Rx
- conservative
- PT, change activity, nerve block
- surgical
- coccygectomy
- conservative
spondylolysis / spondylolisthesis
- spondylolysis
- scotty dog fracture - pars interarticularis defect
- spondylolisthesis
- forward translation of one vertebra to another
- Rx
- conservative (including wt. loss)
- surgical
- stabilize defect if skeletally immature
scoliosis
lateral curvature of the spine
- Rx
- immature
- observation
- bracing (25-45 deg): Milwaukee, Boston
- fusion (>45 deg)
- mature
- conservative
- surgical if >50-60 deg
- immature
metastatic spine disease
tumors of the spine
- pain w/ weight bearing/night, radiculopathy, progresses
- +/- constitutional
Jefferson Fracture
burst fracture of C1
Hangman’s Fracture
hyperextension fracture of C2 pedicles
Clay-shoveler’s fracture
spinous process avulsion C7 > C6 > T1
thoracic vertebral fracture
compression fx d/t osteoporosis more common
lumbar vertebral frature
spinal orthosis
- cervical
- soft collar - short term cervical sprains
- Philadelphia - rotational control for suspected fx
- rigid - greater limitation
- halo - immobilization
- thoracic
- corset
- three-point - thoracic sprains or minimal compression fx
- total contact - clamshell for fx, fusions
- lumbar
- elastic belt - support/strains
- corset - sprain/herniation
- rigid
Lower Extremety Measurements
- Q angle: ASIS to mid patella to mid tibia
- F = 17 deg, M = 14 deg
- leg length
- ASIS to medial maleolus
femoral neck angles
coxa vara: <125 deg
coxa valga: >125 deg
hip tests
- Trendelenburg test: hip tilts away from weak gluteus medius
- Thomas test: psoas tightness, flexor contractor
- log roll test: pain w/ internal rotation - acetabular/femoral neck pathology
- FABER (Patrick) test: figure 4- SI joint/hip problem
- Hamstring flexability: knee extension 5-15 deg of straight
hip sprain/strain
- pain and swelling
- Rx
- RICE, NSAIDs, pain relievers, PT
- surgury for avulsion injuries
hip bursitis - trochanteric bursitis
pain w/ abduction
- Rx
- RICE, cortisone injection, NSAIDs, pain relievers, wt. loss
- PT: stretch and strengthen gluteus medias and IT band
piriformis syndrome
piriformis muscle compressing sciatic nerve
- Lasegue sign: pain w/ knee extension when hip 90 deg
- Piriformis sign
- Rx
- NSAIDs, PT, +/- injection
femoral acetabular impingement (FAI)
osseous deformity of acetabular rim leads to
articular cartilage damage
- “C” sign
- Rx
- conservative vs. surgical
hip dislocation
obvious deformity
- Rx
- reduction ASAP
osteonecrosis
bone death
- corticosteroid use
- alocohol abuse
- sickle cell
- RA/SLE
- trauma
- Rx
- w/out collapse: decompression, vacular grafting
- arthroplasy (replacement)
lateral femoral cutaneous nerve entrapment
compression at ASIS
- tight clothes, obesity, scar tissue, trauma
- lateral thigh pain/dysesthesia
- Rx
- remove cause
- cortisone injection
- surgical release of nerve
knee tests
- Patella
- apprehension - move patella laterally
- J sign - shifts up and out w/ extesion
- Meniscus
- McMurry’s test
- lateral meniscus - knee abducted w/ foot in
- medial meniscus - knee adducted w/ foot out
- McMurry’s test
- Ligaments
- Lachman’s/anterior drawer - ACL
- Posterior drawer/sag sign - PCL
- Valgus stress - MCL
- Varus stress - LCL
- positive w/ pain or laxity
patellar bursitis
pre-patellar (trauma/septic) vs.
pes anserine (medial compartment OA)
- apirate
- Rx
- NSAIDs, modify activity, compression
- surgery rare
knee tendinitis
quadriceps tendon (above) vs. patellar (jumper’s knee”)
- anterior knee pain w/ jumping, running, kicking
- Rx
- RICE, NSAIDs, PT
- knee strap/sleeve
knee tendon ruptures
- pain, swelling, discoloration
- Rx
- surgery
patellofemoral syndrome
associated w/ chondromalacia - softening of cartilage
- anterior knee pain worse w/ sitting, climbing, jumping, squatting
- Q-angle, J sign, patellar apprehension
- tight hamstrings and weak quadriceps
- Rx
- NSAIDs, bracing
- PT
patellofemoral instability
lateral subluxation/dislocation
- severe pain, inability to ambulate
- Rx
- RICE, +/- aspiration, braced in extension
- NSAIDs, pain meds
- PT
- surgery if conservative tx fail
meniscus tears
- McMurry test
- EMERGENCY if can’t extend knee
- Rx
- RICE, pain control, PT
- meniscectomy vs. meniscal repair
Baker’s cyst
excessive joint fluid to popliteal bursa
- Rx
- conservative
- surgery rare (fear of transecting popliteal nerve)
ACL tear
- pain, immediate joint effusion
- + Lachman’s exam
- pivot shift test
- Rx
- RICE, ROM
- surgical reconstruction if younger, active
PCL tear
prevents posterior translation
- force to tibia w/ flexed knee
- + posterior drawer test, posterior sag
- Rx
- depends on degree of instability
collateral ligament sprain
- evaluate instability at 0 and 30 degrees: more play 30 > 0
- Rx
- MCL - conservative
- LCL - conservative if grade I-II, surgical grade III
unhappy triad: ACL, MCL, medial meniscus
chondral / osteochondral defect (OCD)
articular cartilage injury
- direct trauma
- Rx
- microfracture vs. OATS vs. implantation
foot ankle tests
- ankle
- anterior drawer - pull heel forward
- Thompson test - sqeeze calf to make foot move (achilles test)
- inversion/eversion stress test
- foot
- interdigital neuroma test - squeeze inbetween toes
ankle sprain
- inversion
- anterior and posterior talofibular ligament (ATFL/PTFL)
- calcaneofibular ligament (CFL)
- eversion
- deltoid ligament
- PALPATE/ASSESS 5th metatarsal - Jones fracture
- anterior drawer, squeeze test, external rotation test
- Rx
- rehab
- surgery rare
achilles tendon rupture
“someone kicked me in the ankle”
- palpable tendon defect
- Rx
- tendon retraction - surgery
- serial casting
tarsal tunnel syndrome
compression of tibial nerve
- vague paresthesis or dysthesias on plantar foot
- worse w/ walking/exercise; relieved w/ rest; night pain
- + Tinel sign
- Rx
- conservative; injection; orthotics
- poor surgical outcomes
plantar faciitis
fascia of medial tuberosity of calcaneous to proximal phalanges
- worse “start up” pain
- Rx
- orthotics, night splint, PT, NSAIDs, injections
pes planus (flat foot)
posterior tendon dysfunction
- hindfoot valgus - “too many toes”
- unable to toe raise
- Rx
- casting, orthotics, PT
- tendon transfer/osteotomy
metatarsalgia
- forefoot pain d/t abnormal metatarsal length/toe deformities
- bony prominences, avascular yellow candle wax callus
- Rx
- conservative
- metatarsal pad/removal of callus, orthotics, PT
- surgical
- realign toes or metatarsal heads
- conservative
interdigital (Morton) neuroma
perineural fibrosis of digital nerve b/t 3rd and 4th toes
- like “walking on a marble”
- + squeeze test
- Rx
- metatarsal pad, shoe change, corticosteroid injection
- surgical excision
hallux valgus (bunion)
lateral deviation of big toe at MTP joint
- Rx
- conservative
- shoe wear, orthotics, PT- biomechanical evaluation
- surgical
- conservative
turf toe
1st MTP joint sprain / hyperextension
- Rx
- orthotics, stiff soled shoes
- surgical only if avulsed or displaced fracture
toe deformities
- hammer toe
- PIP flexion deformity
- claw toe
- MTP extension/PIP flextion (5th/4th toe)
- mallet toe
- DIP flexion
shoulder impingement
- inflammation in subacromial space: arms overhead, throwing, lifting, manual laborers
- Neer test
- Hawkins-Kennedy test
bicipital tendinitis
inflammaton of long head
- Speed’s test
- Yergason’s test
- “Popeye” deformity
- no surgery
rotator cuff tear
- night pain
- tests
- arm drop
- empty can
- Rx
- RICE vs. arthroscopic / open repair
glenohumeral dislocation
- Nerve to test: CN XI (axillary)
- AXILLARY VIEW
- Rx
- reduction
- rest, ice, PT
recurrent instability
- tests
- apprehension test
- Sulcus sign (inferior)
- Load and shift test
- immobilize 2-3 weeks, maybe surgery
anterior dislocation
- Bankart - tear to glonoid labrum
- Hill Sachs lesion - humeral head compression fx
SLAP tear - superior labrum anterior to posterior
- overhead throwing athletes, fall on outstretched arm
- O’Brien test: cross body arm
- Crank test: manipulate humeral head
- check for glenohumeral internal rotation deficit (GIRD)
- Rx
- conservative: rest, ice, PT, throwing protocol
- surgical: arthroscopy for grade 3+
AC joint sprain/dislocation
- always trauma
- Rx
- conservative
- immobilize ~2 days
- rest, ice, NSAIDs, PT
- surgery
- rare - grade 4 and above
- conservative
AC joint OA/osteolysis
- progressively worsening pain
- pain w/ across body adduction
- Rx
- conservative
- surgical
- open vs. arthroscopic excision
adhesive capsulitis
- freezing -> plateau -> thawing
- plain x-ray to r/o other; NO MRI
- Rx
- rest, ice/heat, PT, GH injection, NSAIDs, pain meds
- manipulation under anesthesia
- arthroscopic lysis of adhesions
shoulder joint injections
- subacromial space
- 1cm below acromion, direct medial/anterior/superior
- glenohumeral joint
- 2 fingers medial/inferior acromion, direct anteriormedial
- bicipital tendon sheath
- at point of max tenderness, insert 30-45 deg into sheath - avoid tendon
- AC joint
- superior approach .5cm
- SC joint
- anterior approach .5cm
thoracic outlet syndrome
compression of brachial plexus/subclavian vessels
- paresthesia, color changes, fatigue in arm
- Adson’s maneuver
- elevated arm stress (overhead makes symptoms worse)
-
Rx
- rest, NSAIDs, muscle relaxers, PT
- surgery rare
epicondylitis (lateral & medial)
overuse injuries
- lateral - extensors (tennis elbow)
- medial - flexors (golfer’s elbow)
- Rx
- rest, ice, NSAIDs, +/- cortisone injection, bracing
- surgery no common - drill holes to advance healing
collateral ligament injury (radial - LCL / ulnar - MCL)
- radial (LCL) rare and usually w/ fracture or dislocation
- ulnar (MCL) repetative stress (overhead throwing)
- ulnar paresthesia
- tests
- valgus stress test
- milking maneuer
- +/- Tinel’s
- Rx
- rest, NSAIDs, PT, throwing mechanics
- surgery
- “Tommy John” - ulnar collateral ligament repair
olecranon bursitis
- aspirate
- Rx
- abx for infection
- NSAIDs, elbow pad, corticone injection if no infection
- surgical excision not common
cubital tunnel syndrome
compression of ulnar nerve
- numbness, tingling, atrophy of hand
- claw hand
- Tinel’s sign
- Rx
- conservative
- rest, avoid excessive flexion, night splint
- surgery
- ulnar nerve decompression vs. transposition
- conservative
distal bicep tendon rupture
- pain and defect in antecubital fossa
- “reverse Popeye”
- Rx
- surgery w/in 2 weeks
elbow dislocation
- extreme swelling, pain, inability to move elbow
- Rx
- reduction and splint under conscious sedation
elbow injections
- olecranon bursa
- elbow flexed, 1 cm distal to bursa, 18 ga needle, grasp bursa w/ opposite hand
- elbow joint
- 45 deg bend, center of lateral epicondyle/radial head/tip of olecranon triangle
- lateral epicondylitis
- elbow flexed 90 degrees, 1cm distal to epicondyle, point of max tenderness, 22 ga needle
- medial epicondylitis
- elbow extended 20 deg
carpal tunnel syndrome
- compression of median nerve - numbness in 1st, 2nd, 3rd fingers
- worse at night
- muscle weakness
- tests
- Tinel’s sign
- Phalen’s sign* (reverse prayer)
-
Rx
- NSAIDs, activity modification, bracing, injection
- surgery
- open vs. endoscopic
DeQuervain’s Tenosynovitis
swelling/stenosis in abductor pollicis longus/extensor pollicis brevis tendon sheath
- + Finkelstein test
- Rx
- injection, bracing, PT
- surgical release rare
ganglion cyst
fluid from joint capsule/tendon synovial sheath
- dorsum of wrist, volar radial aspect, base of finger
- can transilluminate
- Rx
- NSAIDs, rest, wrist splint
- aspiration (caution: radial artery)
- surgical w/ recurrent, painful cyst
thumb/finger dislocation
- Rx
- taping
gamekeeper’s (skiier’s) thumb
torn ulnar collateral ligament (UCL)
- Rx
- conservative
- surgical only if UCL ruptured
trigger finger
thickening of flexor tendon sheath
- “feels locked”
- palpable nodule
flexor tendon injury
Jersey finger
- flexion weakness following injury
- surgical repair
with every hand injury evaluate/document flexor tendons
extensor tendon injuries
- Boutonniere deformity
- PIP flexion and DIP extension
- Mallet finger
- rupture to extensor tendon at DIP
- Rx
- splint
swan neck deformity
hyperextension PIP and flexion DIP
felon
finger pulp infection
- severe pain and swelling
- Rx
- digital block with surgical drainage
paronychia
infection of soft tissue around fingernail
- Rx
- Cephalexin (Keflex)
- TMP/SMZ (Bactrim)
- Clindamycin (Cleocin)
septic flexor tenosynovitis
infection in synovial sheath of flexor tendons
“fight bite”
- Kanaval’s 4 Cardinal Signs:
- intense pain (w/ extension)
- flexion posture
- fusiform swelling
- tenderness along flexor tendon sheath
- Rx
- SURGICAL EMERGENCY
herpetic whitlow
herpes simplex 1 or 2 infection
- +/- antivirals
- DO NOT DRAIN
