Musculoskelatal 10% Flashcards
Types of fractures
Displaced or nondisplaced; open or closed; complete or incomplete or according to the direction of the fracture line.
Salter-Harris classification to classify epiphyseal fractures based on their relationship to the growth plate.
SALTER is a mnemonic which stands for S - Straight Across, A - Above, L - Lower or beLow, T - Two or Through, ER - ERasure of growth place or cRush.
Dislocation that is the most common; cause
Anterior; abducted and externally rotated
Shoulder dislocation signs
Squaring of the shoulder: loss of rounded appearance (humeral head) and sharp prominence of the acromion (squaring).
Shoulder dislocation presenting with numbness or tingling over the lateral shoulder indicates _____
Axillary nerve injury
Shoulder dislocation treatment
Reduce, post-reduction films, sling, and swath, physical therapy.
Clavicular fracture presentation
Swelling, erythema, and tenderness on the anterior aspect of the right shoulder; middle third fracture is most common.
Clavicular fractures treatment
Conservative - sling and swathe; PT after 4 weeks with light strengthening after 6 weeks.
AC Joint Separation presentation
Elevation of the clavicle (step off deformity) and point tenderness and pain with cross chest testing.
AC Joint Separation treatment
Sling and analgesia. More severe injuries usually will require operative repair.
Biceps tendonitis presentation
Pain with resisted supination of the elbow.
Biceps tendonitis testing
MRI:can show thickening and tenosynovitis of proximal biceps tendon - increased T2 signal around biceps tendon. A “Popeye” deformity - indicates a rupture.
Biceps tendonitis treatment
NSAIDS, PT strengthening, and steroid injections. Surgical release reserved for refractory cases.
Shoulder pain exacerbated by sleeping on the affected shoulder, and reaching overhead.
Rotator cuff tendinopathy/tear
Rotator cuff tendinopathy/tear
Severe focal tenderness at the insertion of supraspinatus (anterolateral shoulder) and decreased active elevation with a normal passive range of motion.
Rotator cuff tendinopathy/tear diagnosis; treatment
Magnetic Resonance Imaging (MRI); physical therapy (for all patients), NSAIDs, steroid injections and surgical repair for patients with complete tears.
Insidious onset of shoulder stiffness; pain at rest and with movement. Decreased active and passive range of motion.
Adhesive capsulitis (frozen shoulder)
Adhesive Capsulitis (frozen shoulder)
MR arthrogram - loss of axillary recess indicates contracture of joint capsule.
Apley scratch test: the patient tries to bring hands together on the back while one hand comes from above and the other from below. Positive test - restriction with movement.
Adhesive Capsulitis (frozen shoulder) treatment
NSAIDs, physical therapy, and intra-articular steroid injections.
Shoulder pain with reaching or lifting, and pain with overhead motions. Crepitus with range of motion.
Subacromial Impingement
Subacromial Impingement testing
(+) Neer test: arm fully pronated (thumbs down) with pain during forward flexions while shoulder is held down to prevent shrugging.
(+) Hawkins: Elbow/shoulder flexed at 90 degrees with sharp anterior shoulder pain with internal rotation.
(+) Drop arm test: pain with inability to lift arm above shoulder level or hold it or severe pain slowly lowering arm after shoulder abducted to 90 degrees.
Subacromial Impingement treatment
Rest, ice, activity modification, NSAIDS, and corticosteroid injections.
Shoulder pain often not associated with trauma. Pain on motion and at rest, can cause fluid to accumulate.
Subacromial bursitis
Subacromial bursitis treatment
Prevention of the precipitating factors, rest, NSAIDs, and Cortisone injections.
Shoulder pain at night and pain with activities involving shoulder motion.
Glenohumeral joint osteoarthritis
Glenohumeral Joint Osteoarthritis testing
Radiographs demonstrate subchondral sclerosis and osteophytes at the inferior aspect of humeral head.
Glenohumeral Joint Osteoarthritis treatment
NSAIDS, physical therapy, corticosteroid injections. Total shoulder arthroplasty if unresponsive to nonoperative treatment.
Accounts for approximately 3% of all fractures - increasing incidence in the elderly.
Humerus fractures
Humerus fractures are the most common site of _____ nerve injury.
Radial
Humerus fracture locations
Proximal, midshaft; distal (less common) - posterior fat pad or sail sign.
Supracondylar in children (above the growth plate) – worry about compartment syndrome and the brachial artery.
Humerus fracture treatment
Sugar tong splint (distal) coaptation splint (shaft); ortho follow up in 24-48 hours.
The most common cause of a radial head fracture.
Falling with an outstretched arm. Elbow in extension + forearm in pronation - most force transmitted from wrist to radial head.
Radial head fracture treatment
Sling, long arm splint at 90 degrees, open reduction, and internal fixation.
Most common pediatric elbow fracture - accounts for 41% of all serious pediatric elbow injuries.
Usually occurs from fall to an outstretched hand.
Supra-condylar fracture
Supra-condylar fracture X-ray
X-ray demonstrates anterior fat pad sign = dark area either side of the bone.
Supra-condylar fracture neurologic or vascular involvement
May cause median nerve and brachial artery injury, as well as radial nerve injury.
Supra-condylar fracture treatment
Long arm posterior splint followed by long arm casting - open reduction with internal fixation for all displaced fractures.
Common upper extremity injury in infants and young children. Generally occurs with a pulling upward type of motion while the child has an outstretched arm. Child refuses to move the arm on presentation.
Radial head subluxation (Nursemaid’s elbow)
Radial head subluxation (Nursemaid’s elbow) reduction technique
The supination-flexion technique is the classic method of reducing a subluxed radial head. It has a success rate of 80-92%. Always ensure the child spontaneously uses the arm after reduction before discharging to confirm success.
Isolated fractures of the ulna, typically transverse and located in the mid-diaphysis and usually resulting from a direct blow.
Nightstick Fracture (Isolated fracture of the ulna)
Nightstick Fracture (Isolated fracture of the ulna) treatment
Functional brace with good interosseous mold for isolated non-displaced or distal 2/3 ulna shaft fx (nightstick fx). ORIF if displaced.
Proximal ulnar shaft fracture with radial head dislocation.
Traumatic injury - Fall On an OutStretched Hand (FOOSH) or a direct blow to the ulna.
Monteggia fracture
Monteggia fracture ______ nerve injury causes _____
Radial; wrist drop in 17% of patients.
Monteggia fracture treatment
Open Reduction and Internal Fixation (ORIF)
Distal radial shaft fracture with dislocation of the ulnar-radial joint, or, mid-distal radial shaft fracture with dislocation of the radio-ulnar joint.
Galeazzi Fracture
Galeazzi fracture history
Following a direct blow to the dorsolateral forearm, Fall On an Out-Stretched Hand (FOOSH), falling on a pronated forearm.
Galeazzi fracture treatment
Unstable fracture, needs ORIF, long arm splint.
Distal radial fracture (posterior angulation)
Colles fracture
Most common forearm fracture - considered 1 of 3 common “fragility fractures” associated with osteoporosis.
Colles fracture
Colles fracture history
Fall On an OutStretched Hand (FOOSH) causes distal radial fracture and dorsal (posterior) angulation “dinner fork” deformity (Mom “Colles” you for dinner).
Colles fracture diagnosis
Lateral X-Ray to make the correct diagnosis
Colles fracture may cause _______ rupture.
Extensor pollicis longus tendon
Colles fracture treatment
Treat with a sugar tong splint/cast.
Distal Radial Fracture (Anterior Angulation).
Reverse Colles fracture, is an extra-articular metaphysical fracture of the radius with volar angulation and displacement - garden spade deformity.
3D’s (dorsal displacement of the distal fragment).
Smith fracture
Smith Fracture history
Results from a fall with palm closed, hands flexed, or blow to the back of the wrist.
Smith fracture: ______ nerve injury is common (over time can develop _______).
median; carpal tunnel
Smith fracture treatment
Reduction/surgery or casting; PT for ROM and strengthening.
Scaphoid fracture presentation
Fall on an outstretched hand.
Pain along the radial surface of the wrist at anatomical snuffbox.
The fracture may not be evident for up to 2 weeks.
Scaphoid fracture complication
Avascular necrosis
Scaphoid fracture treatment
10-12 weeks of casting with a thumb spica splint.
Fracture at the neck of the 5th ± 4th metacarpal.
Usually caused by punch with a clenched fist.
Look for associated carpal fractures.
Boxer’s Fracture
Boxer’s fracture treatment
Ulnar gutter splint with joints at least 60 degrees flexion.
Intracellular fracture through the base of the 1st metacarpal (thumb) with large distal fragment dislocated radially and dorsally by abductor pollicis longus muscle.
Bennett fracture (intra-articular)
Bennett fracture (intra-articular) treatment
Unstable fracture which requires open reduction and internal fixation.
Comminuted intra-articular fracture of base of 1st metacarpal characterized by intra-articular comminution.
Rolando fracture (intra-articular)
Rolando fracture (intra-articular) treatment
This is an unstable fracture and requires open reduction and internal fixation.
Overuse syndrome that results in pain in the myotendinous junction between the wrist flexors and medial epicondyle.
Medial epicondylitis (Golfer’s/Pitcher’s elbow)
Medial epicondylitis (Golfer’s/Pitcher’s elbow) symptoms
Pain with resisted wrist flexion and pronation at the medial elbow epicondyle that may radiate to the wrist.
Medial epicondylitis treatment
Activity modification, physical therapy, corticosteroid injections - orthopedic surgery in patients who failed physical therapy for 4-6 months.
Overuse syndrome that results in pain in the myotendinous junction between the wrist extensors and lateral epicondyle.
Lateral epicondylitis (Tennis elbow)
Lateral epicondylitis (Tennis elbow) symptoms
Pain with wrist extension or forearm supination.
Lateral epicondylitis (Tennis elbow) treatment
Activity modification, counterforce bracing, physical therapy, and corticosteroid injections - orthopedic surgery in patients who failed physical therapy for 4-6 months.
Elbow swelling; pain or fever may suggest an infectious etiology
Olecranon bursitis (Scholar’s Elbow)
Nonseptic olecranon bursitis (Scholar’s Elbow)
Acute trauma or repetitive trauma causes inflammation of the olecranon bursa.
Septic olecranon bursitis (Scholar’s Elbow)
Infection from microorganisms transferred via trauma to the skin overlying the bursa.
Olecranon bursitis (Scholar’s Elbow) diagnosis; treatment
R/O septic or gout – aspirate.
PT, rest and ice, systemic antibiotics based on culture if septic, NSAIDS, injected corticosteroids and joint, operative bursectomy.
Cubital tunnel syndrome
Ulnar nerve compression at the elbow.
Ulnar tunnel syndrome
Ulnar nerve compression at the wrist in Guyon’s canal.
Cubital/ulnar tunnel syndrome symptoms; signs
Same for both cubital and ulnar tunnel syndrome.
Paresthesias over the small finger and ulnar half of 4th finger and ulnar dorsum of the hand.
Exacerbating activities include cell phone use (excessive flexion).
Night symptoms caused by sleeping with the arm in flexion.
Cubital/Ulnar tunnel syndrome diagnosis treatment
Tinnel sign positive over cubital tunnel.
Cubital/Ulnar tunnel syndrome treatment
NSAIDS, activity modification, and nighttime bracing. Operative - ulnar nerve decompression.
Carpal tunnel syndrome
Pain or paresthesia in the median nerve distribution - the first 3 digits and radial half of 4th digit. Symptoms are typically worse at night.
Carpal tunnel syndrome diagnosis
+ Phalen (pushing backs of hands together), + Tinel test (tapping over nerve). Diagnosis can be clinically made; however, it is confirmed by nerve conduction studies.
Carpal tunnel syndrome treatment
Splint (particularly at night), corticosteroid (oral or injection), surgical decompression for severe median nerve injury
De Quervain’s tenosynovitis
Pain and swelling at the base of the thumb often radiates into the radial aspect of the forearm.
De Quervain’s tenosynovitis test
+ Finkelstein (make fist with thumb inside, then ulnar deviate)
De Quervain’s tenosynovitis treatment
Thumb spica splint x 3 weeks, NSAIDs x 10-14 days, steroid injections and PT
Thumb Collateral Ligament Injury - Gamekeeper’s Thumb; Skier’s Thumb
Ulnar collateral ligament injury. Result from a fall on an abducted (hitchhiker) thumb.
Laxity and pain with valgus stress.
Gamekeeper’s thumb for chronic injury.
Skier’s thumb for acute injury.
Thumb Collateral Ligament Injury - Gamekeeper’s Thumb & Skier’s Thumb diagnosis
Radiographs to evaluate for avulsion injury. MRI can aid in diagnosis if exam equivocal.
Thumb Collateral Ligament Injury - Gamekeeper’s Thumb & Skier’s Thumb treatment
Immobilization (thumb spica splint) for 4 to 6 weeks for partial tears or ligament repair.
Dupuytren Contracture (Claw hand)
A benign fibroproliferative disorder characterized by contracture of the palms and palmar nodules.
Associated with alcoholic cirrhosis.
Dupuytren Contracture (Claw hand) presentation
Painless nodules on palms, contractures may limit function - patients often have difficulty wearing gloves or doing household chores like washing dishes or cleaning.
Dupuytren Contracture (Claw hand) diagnosis
Tabletop test is positive if the patient is unable to lay their palm completely flat against the table.
Most cases are diagnosed clinically.
Dupuytren Contracture (Claw hand) treatment
First-line therapies include injected collagenase and/or steroids. Fasciotomy or fasciectomy if patients are refractory to first-line therapies.
Mallet (Baseball) finger
Tear at DIP joint.
Avulsion of extensor tendon - with sudden blow to tip of extended finger with forced flexion.
Patient is unable to straighten distal finger (flexed at DIP joint) commonly associated with an avulsion fracture of the distal phalanx.
Mallet (Baseball) finger testing; treatment
Radiographs - usually see bony avulsion of distal phalanx.
Splint DIP uninterrupted extension x 6 weeks or surgical pinning.
Boutonniere Deformity
Tear at PIP joint (jammed finger).
Sharp force against tip of partially extended digit (jammed finger) - hyperflexion of middle joint (flexion at PIP and extended at DIP) causing disruption of extensor tendon at base of middle phalanx.
The deformity is characterized by PIP flexion and DIP extension.
Boutonniere Deformity diagnosis
Elson test: bend PIP 90° over edge of a table and extend middle phalanx against resistance. In presence of central slip injury there will be weak PIP extension and the DIP will go rigid.
Radiographs are not required in evaluation and treatment of Boutonniere deformity.
Boutonniere Deformity treatment
Splint PIP in extension x 4-6 weeks with hand surgeon evaluation.
Cellulitis organisms
Usually strep or staph.
Infection next to fingernail anywhere around the eponychium; acute = ______; chronic = ______.
Bacterial; fungal
Felon
Abscess in tip of finger.
Herpetic whitlow
Herpes virus infection around the fingernail (thumb sucking).
Ankylosing spondylitis
Seronegative spondyloarthropathy that primarily affects the sacroiliac joint and spine
Ankylosing spondylitis presentation
Chronic low back pain and morning stiffness with pain that decreases with exercise and activity.
Associated with psoriasis, inflammatory bowel disease, anterior uveitis, and aortic regurgitation.
Ankylosing spondylitis diagnosis
HLA-B27 positive.
Radiography: bamboo spine - squaring of vertebral bodies.
Ankylosing spondylitis treatment
NSAIDs, PT and tumor necrosis factor (TNF) inhibitors.
Cervical strain (Whiplash)
Injury occurs as a result of a rear impact, with rapid extension followed by flexion of the cervical spine (usually after MVA or fall).
Cervical strain (Whiplash) symptoms; signs
Stiffness and pain in the neck.
Will present with paraspinal muscle tenderness and spasm and a positive Spurling test.
Cervical strain (Whiplash) treatment
Includes a soft cervical collar (2 to 3 days), application of ice or heat, analgesics, and gentle active ROM very soon after injury.
Back strain
Most common cause of back pain - associated with activity.
Characterized by stiffness and difficulty bending.
The patient will present with axial back pain and no radicular symptoms.
Back strain treatment
The patient should resume activity as tolerated.
Patients who have not improved in 4-weeks should be re-evaluated.
In the absence of ‘red-flag’ symptoms, treat conservatively with NSAIDs, heat or ice, PT, and home-based exercises (avoid bed-rest). May include a muscle relaxant such as cyclobenzaprine or short-term use of a benzodiazepine.
Cauda equina syndrome
Rare condition usually involving a large midline disk herniation that compresses several nerve roots, usually at L4-L5 level.
Cauda equina syndrome symptoms
Leg pain, numbness, saddle anesthesia, bowel/bladder dysfunction and/or paralysis. This is a surgical emergency requiring immediate referral.
Herniated nucleus pulposus
Prolapse of an intervertebral disk through a tear in the surrounding annulus fibrosus. The tear causes pain; when the disk impinges on an adjacent nerve root, a segmental radiculopathy with paresthesias and weakness in the distribution of the affected root results.
Lumbar radiculopathy most commonly involves either the ___or___ root.
L5; S1
L1
Rare - symptoms involve pain, paresthesia, and sensory loss in the inguinal region.
L2, L3, and L4
In older patients with spinal stenosis. They are generally considered as a group because of marked overlap of innervation of the anterior thigh muscles. Acute back pain is the most common presenting complaint, often radiating around the anterior aspect of the thigh down into the knee.
L5
The most common radiculopathy affecting the lumbosacral spine. It often presents with back pain that radiates down the lateral aspect of the leg into the foot. On examination, strength can be reduced in foot dorsiflexion, toe extension, foot inversion, and foot eversion. Reflexes are generally normal.
S1
Pain radiates down the posterior aspect of the leg into the foot from the back. On examination, strength may be reduced in leg extension (gluteus maximus) and plantar flexion. Sensation is generally reduced on the posterior aspect of the leg and the lateral foot. Ankle reflex loss is typical.
S2, S3, and/or S4
Patients can present with sacral or buttock pain that radiates down the posterior aspect of the leg or into the perineum. Weakness may be minimal, with urinary and fecal incontinence as well as sexual dysfunction.
C5-C6, C6-C7
Cervical radiculopathy most commonly posterolateral
C4
May affect the levator scapular and trapezius muscles, resulting in weakness in shoulder elevation. There is no reliable associated reflex.
C5
Weakness of the rhomboid, deltoid, bicep, and infraspinatus muscles. Patients may have weakness of shoulder abduction and external rotation. The bicep reflex may be diminished.
C5-C6
Affects the C6 nerve root and produces pain at the shoulder tip and trapezius with radiation to the anterior upper arm, radial forearm, and thumb, and sensory impairment in these areas. C6 radiculopathy can easily be confused for C5 or C7 radiculopathy. Weakness can overlap with the C5 or C7 muscles. Muscles affected include infraspinatus, bicep, brachioradialis, pronator teres, and triceps. Weakness involves flexion at the elbow, or shoulder external rotation. The bicep or brachioradialis reflex may be diminished.
C6-C7
Affects the C7 nerve root and produces pain at the shoulder blade, pectoral area, and medial axilla with radiation to posterolateral upper arm, dorsal elbow and forearm, index and medial digits or all of the fingers, and sensory impairment in these areas. C7 radiculopathy can result in weakness of the triceps, pronator teres, flexor carpi radialis. Weakness involves the elbow extensors and forearm pronators. There may be a diminished triceps reflex.
C7-T1
Causes C8 radiculopathy. Weakness can be present in the opponens pollicis, flexor digitorum profundus, flexor pollicis longus, and hand intrinsic muscles. Clinically, patients present with symptoms similar to an ulnar or median motor neuropathy and can have weakness of finger abductors and grip strength; they may also have findings suggesting median motor neuropathy. No reliable reflex test is available.
Kyphosis
Increased convex curvature of the thoracic spine.
Kyphosis treatment
Curves of 45 - 60 degrees should be observed every 3-4 months and exercise prescribed for lumbar lordosis.
Curves > 60 degrees or with significant pain should be treated with bracing (Milwaukee brace). Surgery is sometimes indicated.
Scheuermann’s Kyphosis
A rigid thoracic hyperkyphosis of childhood defined by > 45 degrees curvature.
Scheuermann’s Kyphosis treatment
Curves < 60°: most patients fall in this group and can be treated with observation alone.
Curves 60°-80°: bracing with an extension-type orthosis.
Curves > 75 degrees : Operative treatment.
Scoliosis
Defined as a lateral spinal curvature with a Cobb angle of 10° or more.
Scoliosis testing
On Adams forward bending, asymmetry in scapular height is noted.
Radiographs: standing PA and lateral.
Scoliosis treatment
> 20° refer to orthopedics may need bracing; observation in most cases.
Bracing or surgery if > 40°.
Spinal Stenosis
Pain in elderly that increases with extension (walking downhill and standing upright) and is relieved with flexion at the hips and by leaning forward (sitting, leaning over shopping cart).
Spinal Stenosis - neurogenic claudication
Pain, numbness, and weakness in the calves, buttocks, and/or thighs during walking or weight bearing - a symptom of nerve root compression.
Spinal Stenosis testing
Kemp sign - Unilateral radicular pain from foraminal stenosis made worse by extension of the back.
Straight leg raise (nerve root tension sign) is usually negative.
MRI show spinal stenosis.
Spinal Stenosis treatment
NSAIDS, physical therapy, weight loss and bracing - epidural injection of steroids or decompression laminectomy.
Avascular necrosis hip
Insidious onset of a dull ache or throbbing localized to the groin, lateral hip, or buttocks - think trauma, steroid use, or sickle cell.
Legg-Calve’ Perthes disease
Avascular necrosis in children and will present with persistent pain and a limp.
Avascular necrosis hip dignosis; treatment
MRI is the study of choice for early detection.
Treatment may be conservative or may eventually need a joint replacement.
Developmental Dysplasia of the Hip
Will present with asymmetric skin folds and limited hip abduction on the affected side.
Hip exam at every well-child visit until 2 years old.
Developmental Dysplasia of the Hip - Barlow test
Hip adduction causes dislocation.
Developmental Dysplasia of the Hip - Ortolani test
Hip flexion and abduction with anterior pressure causes reduction of hip dislocation (CLICK auscultated).
Developmental Dysplasia of the Hip testing
Ultrasound is used to assess. Radiographs are unreliable until the patient is at least four months old because of radiolucency of femoral head.
Developmental Dysplasia of the Hip treatment
< 6 months old: Pavlik harness (abduction bracing).
6-15 months old: hip spica cast.
15-24 months old: open reduction followed by hip spica cast.
Hip Fractures presentation
Femoral head and neck fracture will present with severe hip, groin, or thigh pain often with a history of recent trauma or fall. Occurs after a fall in elderly patients with osteoporosis.
Hip fractures signs
Involved leg is abducted and externally rotated and may appear shortened.
Hip fractures management
Open reduction and internal fixation (ORIF) - 48 hours for best results.
High incidence of avascular necrosis with femoral neck fractures.
DVT prophylaxis until ambulatory.
Hip dislocation presentation
Hip pain with leg shortened and internally rotated and adducted after a trauma is the most common cause (fall from a height, motor vehicle accident).
Posterior hip dislocation signs
90% of cases hip will be adducted, flexed, and internally rotated.
Anterior hip dislocation signs
Hip will be abducted, flexed, and externally rotated.
Hip dislocation diagnosis
Radiographs: anteroposterior (AP) pelvis.
Hip dislocation treatment
Closed reduction under conscious sedation. Open reduction if failure of closed reduction or radiographic evidence of incarcerated intra-articular fragments.
Repeat X-Ray and neurovascular exam after reduction.
Slipped capital femoral epiphysis
Hip disorder common in adolescents in which the head of the femur slips off the neck of the femur inferiorly and posteriorly, often due to mechanical overload.
Slipped capital femoral epiphysis presentation
Patient will present as → a 7-16 y/o obese male during a growth spurt with a limp and knee pain with external rotation of affected the leg.
Slipped capital femoral epiphysis diagnosis
Radiography - AP and frog-leg lateral of both hips.
Slipped capital femoral epiphysis treatment
Surgical fixation with screw for all patients.
Knee Dislocation presentation
Often after a high impact trauma and patient cannot extend knee
Knee Dislocation testing
Worry about popliteal artery injury diagnosed with arteriogram.
Pre-and post reduction x-rays.
MRI required to evaluate soft tissue injury (ligaments, meniscus) and for surgical planning.
Knee Dislocation treatment
Orthopedic emergency: early reduction is essential. Check distal pulses and peroneal nerve function.
Tibial Plateau Fractures presentation
Commonly in children in MVA.
Tibial Plateau Fractures diagnosis
AP, lateral and oblique radiographs are performed.
If displaced check peroneal nerve (foot drop) hard to see on X-ray; may need to confirm with CT/MRI.
Tibial Plateau Fractures treatment
Nondisplaced cast 6-8 weeks.
Displaced ORIF.
Patella Fracture presentation
High impact trauma to a flexed knee. Hemarthrosis and inability to extend the knee.
Patella Fracture diagnosis
Radiographs: patella alta - the pull of quad muscles cause fracture displacement. Best evaluated on lateral x-ray. The degree of fracture displacement correlates with degree of retinacular disruption
Patella Fracture treatment
6-8 weeks or immobilization- partial weight bearing.
Displaced fractures will need open reduction and internal fixation (ORIF).
Knee Osteoarthritis
Degenerative disease of synovial joints that causes progressive loss of articular cartilage.
Knee Osteoarthritis symptoms; signs
Pain worse with activities, swelling, stiffness, sticking and grinding; palpable crepitus on exam.
Knee Osteoarthritis diagnosis
Radiographs - weight-bearing views of affected joint - joint space narrowing, osteophytes, subchondral sclerosis.
Knee Osteoarthritis treatment
Acetaminophen is considered first-line treatment. If acetaminophen fails, NSAIDs can be prescribed.
Total joint replacement may be indicated in advanced cases.
Osgood-Schlatter disease presentation
Tenderness over the tibial tubercle in a 9-14 year old male who has undergone a rapid growth spurt and is doing sports that involve running. Repetitive traction of the apophysis of the tibial tuberosity results in microtrauma and micro-avulsion; the proximal patellar tendon insertion separates from the tibial tubercle.
Osgood-Schlatter disease symptoms; signs
Pain and swelling over the tibial tubercle at the point of insertion of the patellar tendon.
Pain on resisted knee extension with a lump below the knee and prominent tibial tuberosity.
Osgood-Schlatter disease testing
Lateral radiograph of the knee demonstrates irregularity and fragmentation of the tibial tubercle.
Osgood-Schlatter disease treatment
Benign and self-limiting; conservative analgesics, ice, and physical therapy is first-line treatment.
Prepatellar Bursitis (Housemaid’s Knee) presentation
Pain with direct pressure on the knee (kneeling).
Swelling over the patella. Common in wrestlers: concern for septic bursitis.
Prepatellar Bursitis (Housemaid’s Knee) testing
Septic bursitis in wrestlers - aspiration with gram stain and culture.
Prepatellar Bursitis (Housemaid’s Knee) treatment
Compressive wrap, NSAIDs, +/- aspiration and immobilization for 1 week. Corticosteroid use is controversial.
Patellar Tendinitis presentation
Activity-related anterior knee pain associated with focal patellar tendon tenderness. Also known as “jumper’s knee” (up to 20% of jumping athletes).
Patellar Tendinitis symptoms; signs
Swelling over tendon and tenderness at the inferior border of the patella.
Basset’s sign: tenderness to palpation at distal pole of the patella in full extension and no tenderness to palpation at distal pole of the patella in full flexion.
Patellar Tendinitis diagnosis
Radiographs - AP, lateral, skyline views of the knee - usually normal - may show inferior traction spur (enthesophyte) in chronic cases.
Ultrasound - thickening of tendon and hypoechoic areas.
MRI in chronic cases - demonstrates tendon thickening.
Patellar Tendinitis treatment
Ice, rest, activity modification, followed by physical therapy. Surgical excision and suture repair as needed.
Cortisone injections are contraindicated due to risk of patellar tendon rupture.
Anterior Cruciate Ligament (ACL) Tear presentation
Pop and swelling along with instability or “giving out” the knee after a quick plant and twist injury.
Quickly stopping movement and changing direction while running, landing from a jump, or turning leads to rotation or valgus stress of the knee and can result in injury to the ACL. Common in skiers, football, and basketball players.
Contact injury that causes hyperextension or valgus deformation of the knee.
Anterior Cruciate Ligament (ACL) Tear diagnosis
Anterior Drawer Test: the proximal tibia is anteriorly pulled while the patient is supine and the knee is flexed at 90 degrees - if there is anterior translation then the test is positive.
Lachman’s Test (most sensitive): the proximal tibia is anteriorly pulled with one hand, while the other hand stabilizes the distal femur while the knee is flexed at 30 degrees.
Magnetic resonance imaging (MRI) can confirm the diagnosis.
Anterior Cruciate Ligament (ACL) Tear treatment
Physical therapy and lifestyle modifications for low demand patients with decreased laxity.
Surgical reconstruction performed in young and active patients with high demand sports or jobs and/or significant knee instability.
Medial Collateral Ligament (MCL) Tear presentation
Results when the knee is forced into valgus and external rotation force to the lateral knee.
A “pop” reported at the time of injury along with medial joint line pain and difficulty ambulating due to pain or instability.
Medial Collateral Ligament (MCL) Tear diagnosis
Valgus stress test - Patient will have pain with valgus stress applied to the knee. MRI definitive study
Medial Collateral Ligament (MCL) Tear treatment
Conservative treatment with bracing and therapy typically effective. Surgery for chronic instability.
Lateral Collateral Ligament (LCL) Tear presentation
The main cause of LCL injuries is direct-force trauma to the inside of the knee causing excessive varus stress, external tibial rotation, and/or hyperextension.
Isolated injury extremely rare: 7-16% of all knee ligament injuries, when combined with lateral ligamentous complex injuries, particularly posterolateral corner (PLC) injury.
Lateral Collateral Ligament (LCL) Tear diagnosis
Varus stress test
Radiographs - AP, lateral, and varus stress radiographs
MRI definitive study - provides information about severity (complete vs. partial rupture) and location (avulsion vs. midsubstance tear).
Lateral Collateral Ligament (LCL) Tear treatment
Conservative treatment with bracing and therapy typically effective. Surgery for grade III LCL injury.
Posterior Collateral Ligament (PCL) Tear presentation
Blow to the knee while it is flexed, or bent, such as landing hard during sports or a fall, or from a car accident (also known as dashboard knee). May result from non contact hyperflexion with a plantar-flexed foot or a hyperextension injury.
Posterior Collateral Ligament (PCL) Tear diagnosis
Posterior drawer sign, sag sign (tibia sagging posteriorly), active quad test.
MRI is the confirmatory study.
Posterior Collateral Ligament (PCL) Tear treatment
Protected weight bearing and rehab indicated for isolated Grade I (partial) and II (complete isolated) injuries.
Surgical repair for PCL + ACL or PLC injuries and PCL + Grade III MCL or LCL injuries.
Meniscal Tear presentation
After a “twist” injury with locking, a feeling of the knee giving away, walking up and down stairs or squatting is difficult and painful.
Meniscal Tear symptoms; signs
Triad of joint line pain, effusion, locking
Effusion typically 6-24 hours after injury
Roughly 1/3 experience locking
Meniscal Tear diagnosis
McMurray test: patient is supine, knee flexed and externally (medial meniscus) or internally (lateral meniscus) then extended - pain indicates a tear.
Apley test: Pt prone, knee to 90 degrees, axial load with rotation causes pain with meniscal pathology.
Ottawa ankle rules
Order an X-ray if any of the following apply:
Pain along lateral malleolus, medial malleolus.
Midfoot pain, 5th metatarsal or navicular pain.
Unable to walk more than four steps.
Jones fracturebearing.
Proximal 5th metatarsal diaphysis fracture; this area has a poor blood supply.
Jones fracture symptoms
Pain over lateral border of the forefoot, especially with weight bearing.
Jones fracture treatment
Walking boot/cast, RICE, surgery for displaced fractures. Requires 6 weeks of non-weight bearing.
Stress Fracture presentation
Common in athletes, military - due to overuse.
Most common in 3rd metatarsal, calcaneus, talus, midshaft of tibia, femur, and humerus.
Stress Fracture diagnosis; treatment
Bone scan/MRI.
Treatment: rest (avoid high impact activities), splint or post-op shoe.
Talus Fracture presentation
High force impact -falling from a significant height, high energy trauma - incidence common in snowboarders.
Talus Fracture diagnosis; treatment
X-ray demonstrates talus fracture.
Non-weight bearing cast typically used in non-displaced fractures. Surgery typically in displaced fractures.
Tibial Plafond Fractures presentation
Forceful axial load, high-impact trauma (motor vehicle accidents, falls from height).
Tibial Plafond Fractures diagnosis; treatment
X-ray demonstrates fracture.
ORIF definitive fixation for the majority of pilon fractures.
Ankle Dislocation presentation
Usually as a result of a fall, motor-vehicle crash, or sporting injury. In addition to the bony injury, there can be damage to blood vessels, nerves, and skin.
Ankle Dislocation diagnosis; treatment
X-ray reveals dislocation.
Treat with reduction +/- ORIF.
Weber Ankle Fracture Classification
Level of fibular fracture relative to the syndesmosis:
A: below syndesmosis.
B: level of syndesmosis.
C: above level of syndesmosis.
Ankle Sprains
Anterior talofibular ligament (ATFL) with inversion 85%. The deltoid ligament is affected by eversion injuries.
Range from stretching with microscopic damage (grade I) to partial disruption (grade II) to complete disruption (grade III).
Ankle Sprains
Anterior drawer test: assesses for anterior displacement of the talus on the tibia - suggests injury to the anterior talofibular lateral ligament.
Talar tilt test: assesses the integrity of the calcaneofibular ligament.
Achilles Tendon Rupture presentation
Pop with weakness and difficulty walking along with pain in the heel.
Achilles Tendon Rupture diagnosis
(+) Thompson test - weak/absent plantar flexion (when gastrocnemius is squeezed).
MRI will show acute rupture with retracted tendon edges.
Achilles Tendon Rupture treatment
Surgical repair allows for early ROM. Splint with gradual dorsiflexion.
Plantar Fasciitis presentation
Pain on plantar surface, usually at the calcaneal insertion of plantar fascia upon weight bearing, especially in morning or on initiation of walking after prolonged rest.
Dancers, runners, court sport athletes.
Calcification may lead to the development of heel spur.
Plantar Fasciitis treatment
Stretching, ice, calf strengthening and NSAIDS.
Tarsal Tunnel Syndrome
Posterior tibial nerve compression from overuse, restrictive footwear, edematous states.
Tarsal Tunnel Syndrome symptoms
Pain and numbness at the medial malleolus, heel, and sole. Pain worsens at night with activity. Pain with prolonged standing or walking, often vague and misleading medial foot pain, sharp, burning pains in the foot.
Tarsal Tunnel Syndrome diagnosis
(+) Tinel’s sign - symptoms exacerbated with dorsiflexion. Nerve conduction tests, electromyography.
Tarsal Tunnel Syndrome treatment
Involves avoiding exacerbating activities. NSAIDs, corticosteroids injection if no improvement, surgery.
Bunion (Hallux Valgus)
Hallux valgus deformity of bursa over 1st metatarsal. History of poorly-fitted shoes, pes planus (flat feet), or rheumatoid arthritis.
Difficulty with shoe wear due to medial eminence, pain over prominence at MTP joint compression of the digital nerve may cause symptoms.
Bunion (Hallux Valgus) diagnosis; treatment
Radiographs - lateral displacement of sesamoids.
Treatment: comfortable, wide-toed shoes; surgical - when symptoms present despite shoe modification.
Morton’s Neuroma presentation
Degeneration/proliferation of plantar digital nerve producing painful mass near tarsal heads. Most common in women 25-50 y/o especially with tight-fitting shoes, high heels, and flat feet.
Morton’s Neuroma symptoms; signs
Sharp pain with ambulation at the 3rd metatarsal head. May be associated with numbness/paresthesias. Reproducible pain on palpation.
Morton’s Neuroma diagnosis; treatment
MRI may be needed for diagnosis.
Treatment: Wide shoes, glucocorticoid injections, surgical resection if conservative management fails.
Acute and chronic osteomyelitis etiology
Staphylococcus aureus - most common cause overall. Pasteurella multocida - seen in cases caused by cat and dog bites.
Salmonella spp. in patients with sickle cell.
Acute and chronic osteomyelitis diagnosis
Classic X-ray triad of demineralization, periosteal reaction, and bone destruction.
Acute and chronic osteomyelitis treatment
Treat with surgical debridement.
IV antibiotics - Empiric therapy (vancomycin + ciprofloxacin or ceftazidime or cefepime) pending cultures and sensitivities.
Septic arthritis presentation
Single, swollen, warm, painful joint that is tender to palpation along with constitutional symptoms: fever, sweats, myalgia, malaise, and pain.
Most common in the knee (50%).
Septic arthritis etiology
Staphylococcus aureus is responsible for 40-50% of cases.
Neisseria gonorrhea in sexually active young adults.
Septic arthritis diagnosis
Joint fluid analysis: Purulent fluid, >50,000 leukocytes, >75% neutrophils, organism present.
Septic arthritis treatment
Healthy patients: Vancomycin. IV drug users and sick patients: Vancomycin + ciprofloxacin or an antipseudomonal beta-lactam (ie. Ceftriaxone).
Osteosarcoma
Kids 10-14 years. Progressively worsening night pain, bone pain/joint swelling – may look similar to growing pains and can be easily missed.
Osteosarcoma diagnosis
X-ray: sun ray/burst or hair on end appearance followed by bone scan look for metastasis. Lung is the most common site of metastasis, followed by bone.
Osteosarcoma treatment
Treat with limb-sparing resection or radical amputation - 76% long-term survival with modern treatment.
Ewing’s Sarcoma
Kids 5-25 years. Pain often accompanied by fever, often mimics an infection. May have palpable mass, swelling, and local tenderness.
Ewing’s Sarcoma diagnosis
X-Ray: appears as a lytic lesion with an onion-skin appearance of the periosteum.
Ewing’s Sarcoma treatment
Chemotherapy, surgery and radiation therapy.
Chondrosarcoma
Adults 50 + years. Cancer of cartilage seen commonly in adults ages 50+ years.
Chondrosarcoma diagnosis
X-Ray: intra-lesional popcorn mineralization may be seen described rings, arcs, and stipples of mineralization.
Chondrosarcoma treatment
Complete surgical ablation is the most effective treatment, but sometimes this is difficult leading to amputation.
Osteochondroma
10-20 years. Benign chondrogenic lesion derived from aberrant cartilage - the most common benign bone tumor mostly in males ages 10-20 years old.
Osteochondroma diagnosis
X-Ray: sessile (broad base) or pedunculated (narrow stalk) lesions found on the surface of bones_
Osteochondroma treatment
Observation, resection if it becomes painful.
Ganglion
Noncancerous mucin-filled synovial cyst caused by either trauma, mucoid degeneration or synovial herniation.
Ganglion presentation
Usually on the hands, especially on the dorsal aspect of the wrists.
Median or ulnar nerve compression and hand ischemia due to vascular occlusion may be caused by volar ganglion.
Ganglion findings
Firm and well circumscribed often fixed to deep tissue but not to overlying skin, transilluminates. Allen’s test to ensure radial and ulnar artery flow.
Ganglion treatment
Usually, observation, aspiration second line, and excision.
Osteoarthritis presentation
Defined by morning stiffness lasting < 30 minutes, evening joint stiffness, worsens with use and improves with rest.
Worsened by use and relieved by rest. Crepitus or grating sensations may develop.
Commonly involves the hands, hips, and knees.
Osteoarthritis nodes
Heberden nodes: swelling of the distal interphalangeal joints.
Bouchard nodes: Swelling of the proximal interphalangeal joints.
Osteoarthritis treatment
Stretching, acetaminophen, NSAIDs (oral and topical), joint replacement surgery.
Osteoporosis diagnosis
DEXA (Dual-energy X-ray absorptiometry (DXA, previously DEXA) is a means of measuring bone mineral density (BMD)). in all women ≥ 65 and all men ≥ 70 years of age
Osteoporosis T-score ≤ -2.5.
Osteopenia T-score -1 to - 2.4.
Z score: same age/gender
Osteoporosis treatment
Oral bisphosphonates are taken on an empty stomach with a full glass of water and remain upright for 30 min. Associated with osteonecrosis of the jaw.
Compartment Syndrome presentation
Presents with 6 P’s: pain out of proportion, paresthesias, pallor, paralysis, pulselessness, and poikilothermia (limb unable to regulate temp).
Acute muscle pain with a background of fracture, trauma, burns, and tight casts or pressure dressings.
Compartment Syndrome diagnosis
Measurement of compartment pressure > 30-45 mmHg; Increased CK and myoglobin.
Compartment Syndrome treatment
Fasciotomy and decompression of pressure.
Fibromyalgia findings
Pain on palpation, with a 4-kg force, in 11 of the following 18 sites (9 bilateral sites, for a total of 18 sites).
Occiput: at the insertions of one or more of the following muscles: trapezius, sternocleidomastoid, splenius capitis, semispinalis capitis.
Low cervical: at the anterior aspect of the interspaces between the transverse processes of C5 to C7.
Trapezius: at the midpoint of the upper border.
Supraspinatus: above the scapular spine near the medial border.
Second rib: just lateral to the second costochondral junctions.
Lateral epicondyle: 2 cm distal to the lateral epicondyle.
Gluteal: at the upper outer quadrant of the buttocks at the anterior edge of the gluteus maximus muscle.
Greater trochanter: posterior to the greater trochanteric prominence.
Knee: at the medial fat pad proximal to the joint line.
Fibromyalgia treatment
Tricyclics (TCAs) - Cymbalta, SSRIs, Neurontin, and exercise.
Pregabalin (Lyrica) is the only drug FDA approved to treat fibromyalgia.
Gout
Accumulation of uric acid in the soft tissue of joints and bone.
Gout presentation
Inflammatory joint pain. The great toe is often first affected. Associated with purine-rich foods (alcohol, liver, oily fish, yeasts) and diuretic use.
Gout diagnosis
Joint fluid analysis: rod-shaped, negatively birefringent urate crystals.
Gout treatment
Acute- indomethacin.
Chronic- allopurinol.
Pseudogout
Accumulation of crystals of calcium pyrophosphate dihydrate (CPPD) in the connective tissues.
Pseudogout presentation
Inflammatory joint pain (knee most common), often associated with hyperparathyroidism.
Pseudogout diagnosis
Joint fluid analysis: Rhomboid-shaped calcium pyrophosphate crystals, positive birefringent crystals.
Pseudogout treatment
Corticosteroids are 1st line, NSAIDs, Colchicine (prophylaxis).
Juvenile rheumatoid arthritis presentation
A group of rheumatic diseases that begin at or before age 16. Evening fever spikes, salmon pink maculopapular rash, and Koebner’s phenomenon.
Juvenile rheumatoid arthritis types
Oligoarticular JIA (60%) is the most common form and usually affects young girls. Involvement of ≤ 4 joints during the first 6 mo of disease. Polyarticular JIA is the second most common form. It affects ≥ 5 joints at onset and is divided into two types: RF negative and RF positive. Systemic JRA is Still’s disease: it is the least common form and involves fever and systemic manifestations.
Juvenile rheumatoid arthritis treatment
NSAIDs, intra-articular corticosteroids, and disease-modifying antirheumatic drugs - methotrexate.
Polyarteritis nodosa
Systemic vasculitis of medium and small arteries affecting men in their 40-50’s. Associated with Hepatitis B/C (20%).
Polyarteritis nodosa symptoms/signs
Various combinations of symptoms, such as unexplained fever, arthralgia, subcutaneous nodules, skin ulcers, pain in the abdomen or extremities, new footdrop or wrist drop, or rapidly developing hypertension. Livedo reticularis and palpable purpura.
Polyarteritis nodosa diagnosis; treatment
Diagnostic studies: ↑ ESR, ↑ CRP, ANCA negative, and definitive diagnosis with vessel biopsy.
Treatment includes steroids +/- cyclophosphamide if refractory.
Polymyositis
Autoimmune myopathy characterized by symmetric proximal muscle weakness and no rash.
Polymyositis presentation
Proximal muscle weakness in the shoulders and hips: difficulty combing hair, difficulty raising arms, difficulty rising from a chair.
Associated with malignancy.
Polymyositis diagnosis
Muscle biopsy showing perimysial inflammation, Anti-Jo antibodies, ↑ creatinine phosphokinase (CPK or CK),↑ creatine kinase-MB (CK-MB).
Polymyositis treatment
Steroids, followed by long-term immunosuppression.
Dermatomyositis
Autoimmune myopathy characterized by symmetric proximal muscle weakness and characteristic cutaneous findings.
Dermatomyositis signs
Gottron’s papules: raised violaceous, slightly scaly plaques, on bony prominences of the hands and elbows.
Shawl or V-sign: a photosensitive pink rash of the neck and trunk. Often appears as sunburn with V-neck t-shirt.
Heliotrope rash: purple/lilac or red rash around eyes and on eyelids.
Dermatomyositis diagnosis; treatment
Muscle biopsy showing endomysial inflammation.
Treat with steroids, followed by long-term immunosuppression.
Polymyalgia rheumatica presentation
Chronic and inflammatory rheumatic disease characterized by pelvic girdle and shoulder pain and stiffness. Severe after rest. Stiffness is more prominent in the morning.
Difficulty rising out of the chair or lifting arms above head.
Normal muscle strength, reduced active and passive range of motion, joint swelling may be appreciated.
Associated with temporal arteritis - headache may indicate giant cell arteritis.
Polymyalgia rheumatica diagnosis; treatment
ESR: >50 mm/hr.
Treatment: Steroid taper for 2 years.
Reactive arthritis (Reiter syndrome)
Autoimmune response to infection in another part of the body.
Reactive arthritis (Reiter syndrome) presentation
The classic triad of urethritis, conjunctivitis, and oligoarthritis (can’t see, can’t pee, can’t climb a tree). After recent infection with Gonorrhea, Chlamydia, Shigella, Salmonella, Yersinia, or Campylobacter.
Reactive arthritis (Reiter syndrome) diagnosis
HLA-B27 positive (80%), synovial fluid is aseptic with negative bacterial cultures.
Reactive arthritis (Reiter syndrome) treatment
NSAIDs are the mainstay of therapy, antibiotics to treat the underlying genitourinary infection if still present.
Rheumatoid arthritis
Chronic autoimmune inflammatory disease with persistent symmetric polyarthritis with bone erosion, cartilage destruction, and joint structure loss.
Rheumatoid arthritis symptoms
Small joint (MCP, PIP, wrist, knee, MTP, shoulder, ankle) morning stiffness >30 mins that is worse with rest and improves through the day.
Rheumatoid arthritis signs
Joint inflammation visible. 3+ symmetrical joints - DIP joint usually spared.
Boutonniere deformity: flexion at PIP, hyperextension of DIP.
Swan neck deformity: flexion at DIP with joint hyperextension at PIP.
Rheumatoid arthritis diagnosis
Rheumatoid factor (RF) (sensitive but not specific), anti-CCP (most specific for RA). Joint Fluid analysis: Yellow to white fluid, 2,000-50,000 leukocytes, 50% neutrophils, no organisms.
Rheumatoid arthritis treatment
DMARD (Disease-Modifying Anti-Rheumatic Drugs). Methotrexate is usually first. (Contraindicated in pregnancy).
Systemic lupus erythematosus
Systemic autoimmune disease characterized by acute flares, commonly presenting with the triad of joint pain, fever, and malar (butterfly) rash.
Multiple organ systems are involved - Serositis, Oral ulcers, Arthritis, Photosensitivity, Blood disorders, Renal involvement.
Often drug-induced: procainamide, hydralazine, INH, quinidine.
Systemic lupus erythematosus diagnosis
Antibodies: anti dsDNA (best test), ANA (not specific), anti-Smith.
Systemic lupus erythematosus treatment
Sun protection, hydroxychloroquine (for skin lesions), NSAIDs or acetaminophen for arthritis. Pulse dose steroids; cytotoxic drugs (methotrexate, cyclophosphamide).
Systemic sclerosis - Scleroderma
Systemic connective tissue disorder causing thickened skin (sclerodactyly), lung, heart, kidney and GI tract.
Systemic sclerosis - Scleroderma - CREST Syndrome
Calcinosis, Raynaud’s phenomenon, Esophageal dysfunction (GERD), Sclerodactyly, and Telangiectasis.
Systemic sclerosis - Scleroderma diagnosis
Antibodies: Anti-centromere (limited) and anti-topoisomerase (systemic)
Systemic sclerosis - Scleroderma treatment
Acute management with DMARDs and steroids. Treat Raynaud’s with vasodilators (CCBs and prostacyclin).
Sjögren syndrome
Multisystem autoimmune disease characterized by dryness due to exocrine gland destruction.
Sjögren syndrome presentation
Patients complain of xerostomia (dry mouth), xerophthalmia (dry eyes), and have joint involvement in the form of arthritis.
Sjögren syndrome diagnosis
Schirmer’s tear test is positive if < 5 mm lacrimation in 5 minutes.
Diagnosis can be made via testing for anti-SS-B (La) and anti SS-A (Ro) antibodies.
Sjögren syndrome treatment
Artificial tears, pilocarpine (cholinergic) for xerostomia.
