Musculoskeletal Flashcards
Anterior glenohumeral shoulder D/L
Abducted and externally rotated. Shoulder will look “squared off”. Hill-Sachs lesion (groove on humeral head). Bankart lesion (glenoid inferior rim fracture). Reduce it. Rule out axillary nerve injury (prick them on the deltoid)
Anterior glenohumeral shoulder D/L
Abducted and externally rotated. Shoulder will look “squared off”. Hill-Sachs lesion (groove on humeral head). Bankart lesion (glenoid inferior rim fracture). Reduce it. Rule out axillary nerve injury (prick them on the deltoid)
Posterior glenohumeral shoulder D/L
Adducted and internally rotated. More commonly caused by seizure or trauma. Reduce that thing
What view is most helpful in determining anterior from posterior shoulder D/L?
Axillary and “Y” view.
How does an AC separation happen?
Direct blow to adducted shoulder
How do you dx it?
Clinical. May have a bump deformity. You should Xray it with WEIGHT
How do you treat an AC separation?
Sling, ice, analgesia, ortho follow up. Grade 3 may need surgery
Radial nerve controls what?
BEEST - brachioradialis, extensor wrist, extensor fingers, supinator, triceps
For humeral shaft fracture, make sure you check for what?
Radial nerve damage (wrist drop). Brachial plexus injury (deltoid sensation).
How would you treat a humeral shaft fracture?
Sugar tong splint or coaptation splint
What is the most commonly fractured bone in children?
Clavicle
Suspect child abuse in child
How would you treat a clavicle fracture?
Sling
Who commonly gets frozen shoulder?
DM and hypothyroidism
What limitations will you see with frozen shoulder?
Decreased ROM (especially external rotation)
Treatment for frozen shoulder?
Rehab
A woman age 20-50 comes in with pain/parasthesias to the ULNAR side of the hand and forearm. What test might you do? How would you formally dx it?
Adson test. Rotate her head to the affected side and see if you lose a pulse. Brachial plexus most commonly affected in women age 20-50. MRI. PT is 1st ling treatment.
A 5-10yo child comes in with swelling and tenderness to the elbow. You note a prominent olecranon with depression proximally. On X-ray you not a posterior fat pad.
Supracondylar fracture
What if you saw the same XR finding in an adult?
Radial head fracture
Who gets supracondylar fractures?
Children most commonly
What would a supracondylar fracture look like if it were displaced vs non displaced?
The anterior humoral line would be abnormal.
Treatment for non displaced supracondylar fracture and radial head fractures?
Splint at 90 degrees. If displaced, you need surgery and probably should admit with ortho consult for open reduction internal fixation.
Pt presents with pain, swelling, and inability to extend elbow after falling directly on it? What is this? What might you see? How will you treat?
Olecranon fracture. You may see the triceps rupture and pull bone proximally. You should look out for ulnar nerve disfunction. Spint at 90 degrees if non displaced. If displaced, will need surgery and ortho consult.
Posterior glenohumeral shoulder D/L
Adducted and internally rotated. More commonly caused by seizure or trauma. Reduce that thing
What view is most helpful in determining anterior from posterior shoulder D/L?
Axillary and “Y” view.
How does an AC separation happen?
Direct blow to adducted shoulder
How do you dx it?
Clinical. May have a bump deformity. You should Xray it with WEIGHT
How do you treat an AC separation?
Sling, ice, analgesia, ortho follow up. Grade 3 may need surgery
Radial nerve controls what?
BEEST - brachioradialis, extensor wrist, extensor fingers, supinator, triceps
For humeral shaft fracture, make sure you check for what?
Radial nerve damage (wrist drop). Brachial plexus injury (deltoid sensation).
How would you treat a humeral shaft fracture?
Sugar tong splint or coaptation splint
What is the most commonly fractured bone in children?
Clavicle
Suspect child abuse in child
How would you treat a clavicle fracture?
Sling
Who commonly gets frozen shoulder?
DM and hypothyroidism
What limitations will you see with frozen shoulder?
Decreased ROM (especially external rotation)
Treatment for frozen shoulder?
Rehab
A woman age 20-50 comes in with pain/parasthesias to the ULNAR side of the hand and forearm. What test might you do? How would you formally dx it?
Adson test. Rotate her head to the affected side and see if you lose a pulse. Brachial plexus most commonly affected in women age 20-50. MRI. PT is 1st ling treatment.
A 5-10yo child comes in with swelling and tenderness to the elbow. You note a prominent olecranon with depression proximally. On X-ray you not a posterior fat pad.
Supracondylar fracture
What if you saw the same XR finding in an adult?
Radial head fracture
Who gets supracondylar fractures?
Children most commonly
What would a supracondylar fracture look like if it were displaced vs non displaced?
The anterior humoral line would be abnormal.
Treatment for non displaced supracondylar fracture and radial head fractures?
Splint at 90 degrees. If displaced, you need surgery and probably should admit with ortho consult for open reduction internal fixation.
Pt presents with pain, swelling, and inability to extend elbow after falling directly on it? What is this? What might you see? How will you treat?
Olecranon fracture. You may see the triceps rupture and pull bone proximally. You should look out for ulnar nerve disfunction. Spint at 90 degrees if non displaced. If displaced, will need surgery and ortho consult.
A pt has an abrupt goose egg on their elbow that is boggy, tender, and red. Limited ROM. Pt has a history of gout and inflammation of joints. Pt also had a recent trauma. What will you do?
Likely olecranon bursitis. If suspected septic you can aspirate. WBC’s will be above 5000. Rest, NSAID’s, local steroid injection, padding, avoiding repetitive motions will be best.
What is the ulnar fracture that dislocates the radial head?
Monteggia. Radial nerve injury (wrist drop???)
What is the radial fracture that dislocates the distal radio-ulnar joint?
Galeazzi (JEEZIE!!!) Unsable…needs ortho.
What does the radial head wedge into with nursemaids elbow (radial head subluxation)
Annular ligament
What might a nursemaids elbow really be if it doesn’t improve with treatment?
Hutchingson’s or Chauffurs fracture
Where is the inflammation with tennis elbow?
Extensor carpi radialis brevis
How will the pain present with tennis elbow?
Pain with gripping, pronation of forearm, wrist extension.
Treat tennis elbow with…
RICE, NSAID’s, injections if bad
A person punches with a clenched fist. What injury? What will you do?
Boxers fracture. (base of 5th metacarpal). Ulnar GUTTER splint (get you mind out of the gutter…two fingers…hahaha) Boxers like to use two fingers…bwahahaha.
What type of olecranon D/L is most common?
Posterior D/L
Nerve and artery injuries are dangerous with olecranon D/L. What ones?
brachial artery, median/ulnar/radial nerves
What do you need to do with an olecranon D/L
Urgent reduction. Then splint at 90 degrees
What is froments sign?
Pt can’t hold piece of paper without flexing IP joint of finger.
Pt has parathesias and pain along the ulnar nerve. What is this? How would you test?
Cubital tunnel syndrome. Tinel sign (tap on funny bone spot and see if medial forearm goes numb or the pinky and half of the ring finger on that same side. Also use froments sign as explained above.
Scaphoid fracture
FOOSH. Pain at radial side of wrist and anatomical snuff box. Treat if symptoms as XR may not show for weeks. Blood flow at risk. Thumb spica.
Which distal radial fracture angles the distal bone anteriorly (palm)
Smiths
Which distal radial fracture angles the distal bone posteriorly (dorsal)
Colles
What is the complication of a Colles fracture?
Extensor pollicis longus tendon rupture.
Treat both with what if stable?
Sugar tong splint
Dinner fork deformity
Colles
Garden spade deformity
Smith
What is the difference between a perilunate and lunate D/L?
Perilunate still articulates with the radius. Lunate doesn’t articulate with the capitate OR the radius. It’s urgent and needs emergency consult.
What signs will you see with perilunate and lunate D/L?
Piece of PIE sign or Spilled teacup sign.
What is the most serious carpal bone fracture?
Lunate. Because it is the one that articulates MOST with the radius.
Treatment for lunate fracture?
Thumb spica
How do you treat complex regional pain syndrome? And what the hell is it?
Pain in upper extremity out of proportion to injury. Vitamin C seems to help. Otherwise, treat as pain problem.
Sudden blow to tip of extended finger forcing flexion. Treatment?
Mallet finger. Splint in extension for 6 weeks. If not healed, will need pinning.
Sharp force against partially extended digit. Treatment?
Boutonniere deformity. PIP flexed DIP extended. Splint PIP in extension for 4-6 weeks. Follow up with hand
PIP hyperextended and DIP flexed?
Swan neck.
A person has suffered multiple forced abductions of his thumb. What is this and how would you treat it? What ligament or tendon is injured?
Gameskeeper or skiers thumb. Can’t pinch and there is a bunch of laxity as you pull the thumb away. Ulnar collateral ligament of thumb.
A person punches with a clenched fist. What injury? What will you do?
Boxers fracture. (base of 5th metacarpal). Ulnar gutter splint (get you mind out of the gutter…two fingers…hahaha)
What do you always want to check for with boxer fracture?
Bite wounds
What is a bennetts or rolandos fracture?
Rolando stuck his thumb up bennetts ass and broke the base of it. Rolandos thumb is worse.
Another name for a torus fracture?
Buckle
SALTR
Same (through growth plate), Above (through metaphysis), Lower (through epiphysis), Through (all three), Rammed (growth plate compression) - worse kind because it can affect growth.
A person who uses their thumb a lot gets pain along the radial aspect of wrist that radiates into their forearm. A lot of pain with extension and thumb gripping. What is this? What test? What treatment?
Dequervian’s tenosynovitis. (abductor pollicus longus and extensor pollicus brevus). Finkelstein test will help. Thumb spica that bitch for 3 weeks. NSAIDS. Injections, PT
What chronic disease leads to an increase in carpal tunnel?
DM
What nerve is entrapped with carpal tunnel?
Radial nerve
What will you see with carpal tunnel? what happens to muscle? When is it bad?
Parasthesias and pain of palmar 1-3 and 1/2 of 4th digits. You may see thenar muscle wasting. Pain will be worse at night
Two signs to test for carpal tunnel?
Tinel’s sign and Phalen’s sign.
Treatment for carpal tunnel?
Volar splint (wrist slightly hyperextended) and NSAID’s.
A pt presents with nodules over the distal palmar crease and proximal phalanx (ring and middle finger). The fingers appear to be fixed in a flexed position. Treat how?
Dupuytren contracture. Steriod injections or collagenase injections. Surgery if contracted >30 degrees. SUCKS to not have treatment.
A woman fell. You suspect hip dislocation based on looking at her. What did you see?
Hip pain, shortened leg, internally rotated hip that is adducted with hip/knee in slight flexion.
Hip dislocations are usually caused by what?
Trauma
What is the worry with hip dislocation?
Avasular necrosis and sciatic nerve injury.
Which hip dislocation (anterior/posterior) is more common?
Posterior
Major complication of hip fracture?
DVT.
What about hip fractures? What do they look like? What is your fear?
Avascular necrosis with femoral neck fractures. High incidence of PE and DVT.
Difference between hip fracture and hip dislocation?
Both times leg will be shortened, but with fracture…the hip will be EXTERNALLY rotated and ABDUCTED (which is the opposite of hip dislocation).
What is Legg Calve Perthes disease?
Avascular necrosis of femoral head in children due to ischemia of the capital femoral epiphysis.
Who gets it?
Children 4-10 mostly boys. Less in african americans.
What is the hallmark feature of L-C-P disease?
Painless limping and loss of abduction and internal rotate. Pain that may radiate into the thigh, knee, or groin.
How is L-C-P disease diagnosed?
XR shows increased density of femoral head and “crescent” sign.
Best treatment for L-C-P disease?
Bed rest. NSAIDS. May need abduction bracing if abduction is lost.
A young 7-16yo obese male has a painful limp with pain in the hip, thigh, and medial knee. The leg appears externally rotated. What is this? What endocrine issue might you suspect? Treatment?
SCFE. Hypothyroidism. Needs surgery. Immediately get off the leg (crutches). Increased risk of AVN
How are buckle fractures caused?
Axial loading. Will see “bump” or “wrinkle” in the bone line.
Varus stress with rotation
LCL injury
Valgus stress with rotation
MCL injury
Treatment for LCL or MCL injuries?
Sprains (I) incomplete tears (II) - conservative (pain, PT, ROM exercises). Tears (III) - surgical repair.
I was playing soccer and I suddenly felt a pop and immediate swelling. Then my knee started to buckle and I couldn’t straighten it. What test?
ACL. Lachman’s (pull tibia anteriorly and it should give more if positive). Anterior drawer test.
What is the most commonly injured knee ligament? What causes it?
ACL. Non contact pivoting injury (deceleration, hyperextension, internal rotation)
What is the most common cause of PCL injury?
Dashboard. (posterior force to anterior tibia with knee flexed.
How do you test for PCL injury? How is it treated?
Posterior drawer and PIVOT SHIFT TESTING. Almost always surgical
A pt says their knee locks, pops, and gives way and feels swollen whenever they are active. Test how?
Meniscal tear. McMurrays sign and Apley test.
Mcmurrays sign = pop or click while tibia is externally and internally rotated with flexion and extension of knee. Apley is applying downward pressure while pt lies prone and rotating externally and internally. Positive is popping, clicking, or pain.
What gets torn most…medial meniscus or lateral?
Medial
Knee fracture? What view?
Sunrise view of knee. Non displaced = Knee immobilizer with 6 week leg cast. Surgery if displaced.
If the patella tendon ruptures…what would happen?
Patella atla (patella ABOVE so defect BELOW the knee)
If the quad tendon ruptures…what would happen?
Patella baha (patella BELOW so defect above the knee
Patellar dislocation. How. What. Treatment?
Valgus stress. Apprehension sign (move knee laterally). Reduce that thing (closed) by pushing anteromedially while extending leg.
What if someone says they dislocated their knee?
BELIEVE THEM. This can be a popliteal artery injury and a perineal and tibial nerve injury. Immediate consult. Should get arteriography.
How would you test for peroneal nerve injury?
1st web space:) - webby nuts
Osteochontritis of patellar tendon
Osgood schlatter. Pain and swelling with activity.
Most common cause of knee pain in adolescents. Treatment?
Osgood schlatter. RICE, NSAID’s, quad stretching.
What is a synovial fluid effusion of the knee that gets displaced?
Bakers cyst. Can mimicking DVT. Conservative treatment.
Pt is a runner and has pain behind the knee. The pain is worse with sitting, jumping, climbing and hyper flexion.
Patellofemoral syndrome. Test with apprehension test. Conservative management.
What muscle should be strengthened in Patellofemoral syndrome
Vastus medialis obliquus.
How would you test for iliotibial band syndrome
Ober test
What ankle dislocation is most common? Treatment?
Posterior. Treat with reduction. Open reduction internal fixation
Most common ankle sprain? Second most common?
ATL (anterior talofibular ligament) then calcaneofibular.
If the ATL stabilizes inversion, what stabilizes eversion?
Deltoid ligament
What are the ottawa ankle rules?
Remember MMM54. Malleolus, Malleolus, Mid foot, 5th metatarsal, 4 steps. Pain along lateral malleolus, pain along medial malleolus, mid foot pain, 5th metatarsal (navicular bone) pain. Unable to walk 4 steps in ER
A sports player gets sudden sharp calf pain with a pop after pushing off to start sprinting. Test how? What are you going to do about it.
Achilles tendon rupture. Thompson test (squeeze achilles with NO flexion of foot). Surgery. Splint with gradual dorsiflexion.
What Weber class is the worse with ankle fracture?
Weber C.
With and ankle fracture, what other imaging should you do? To rule out what?
Proximal fibular XR to rule out maisonneuve fracture (spiral fracture of proximal fibula)
What fracture is caused by impact of the distal tibia with the talus bone. Caused by a forceful axial load.
Pilon (tibial plafond). AKA “Pile On” fracture. Requires surgery.
Where is the most common site of stress fracture?
3rd metatarsal. Then calcaneus, talus, and midshaft leg. Most XR are negative.
Plantar fasciitis. What does it look like?
Heel and mid foot pain. Usually worse in the morning AFTER first few steps after rest then gets better. Pain with dorsiflexion of the toes. Treat with rest, NSAID’s, and plantar stretching exercises.
A pt has pain and numbness of medial malleolus, heel, and sole of foot. It worsens throughout the day. What test will you do? What sign might be positive? What is it?
Nerve conduction tests. Tinel sign. This is tarsal tunnel syndrome. Treat with NSAID’s and steroids if no improvement.
What 3 predisposing factors for a hallux valgus?
Poorly fitting shoes, pes planus (flat feet), RA.
What is hallux valgus? Treatment?
Bunnion over 1st metatarsal. Get them some damn shoes that fit
What the hell is hammer toe.
If you got long dong second toe, then the MTP will be hyperextended with the DIP with the PIP flexed in the middle.
A DM patient has pain, swelling, and alteration of the shape of their foot and some ulcer formation and skin changes. What will imaging show? Treatment?
Chartot’s joint. Obliteration of joint space with scattered chunks of bone in fibrous tissue. Non weight bearing. Rest. Surgical if necessary.
What’s another name for diabetic foot?
Charcot’s joint.
A middle aged woman who wears tight shoes, high heels, and who has flat feet gets lancinating pain with ambulation at the 3rd metatarsal head. You can reproduce this with palpation. What nerve is involved? Treatment?
Mortons neuroma. Plantar digital nerve creating painful mass near tarsal heads. Wide shoes, glucocorticoid injections (USUALLY CURES), surgery may cause permanent numbness!!!
Jones fracture. Treatment? Problems?
Fracture of diaphysis of 5th metatarsal. NWB for 6-8 weaks. Complicated by nonunion and malunion. May require pinning. Shitty break
What is a pseudojones fracture? Caused how?
Avulsion fracture of the base (tuberosity) of the 5th metatarsal due to PLANTAR FLEXION and INVERSION. MUCH MORE COMMON than jones. Treat with a walking cast for 2-3 weeks. Reduction if displaced.
Lisfranc fracture. Where? How? Signs? Treatment?
1st 3 metatarsal heads and respective cuneiforms. Caused by severe axial load or mid foot rotation. Fleck sign is the fracture at the base of the 2nd metatarsal causing misalignment. Widened joint space between 1st and 2nd digit. Open reduction and internal fixation with NO WEIGHT BEARING for 12 weeks. CAST!!! Lisfranc SUCKS!!!
Another name for herniated disc?
Nucleus pulposis (Hernia with nuclear pull ups)
Most common area of herniated discs?
L5-S1.
What is the common presentation for disc herniation?
Sciatica. Pain will be in thigh and buttock with lower leg pain down L5-S1 distribution
What tests for herniated disc?
Straight leg raise and crossover test.
How to remember L4-S1 sensation issues. 4 looks a little like an A = anterior thigh. Everything moves medially on the leg EXCEPT for things that are posterior. S1 is the back and bottom (being the last joint with herniated discs). So…L4 (4 looks like an A) starts with anterior thigh and moves medially to the medial ankle with sensory loss. L5 (L for lateral) starts lateral thigh and moves medially to the dorsum of the foot. S1 starts posterior leg and calf and MOVES straight down to the bottom (S1 is the bottom) of the boot (plantar surface). For weakness…L4 (L Four = Can’t DOR-SIFLEX). S1 (can’t STEP in shit or plantar flex). L5 (you have 5 toes and the the biggest is the Great toe). With reflexes. L4 (knee is higher than ankle) S1 ankle is lower than knee). L5 everything is alive:)
Remember remember remember!!!
Cauda equina syndrome
Pt has new incontinence, saddle parasthesias, DECREASED ANAL WINK!!! This is emergent and requires surgery!!!
Spinal stenosis. Worse with flexion or extension? Treat with what?
Back pain with leg parasthesias. This is worse with extension and relieved with flexion. lumbar epidural steroid injections. May also get a decompression laminectomy. (yikes)
Treatment of back strain
Bed rest, NSAID’s, analgesics, muscle relaxers.
cafe au lait spots, skin tags, axillary freckles and what may mean what?
scoliosis = neurofibromatosis
What is the degree required for diagnosis?
> 10 degrees. Common in girls 8-10
What is lordosis?
Sway back
What is kyphosis?
Humpback
How do you diagnosis scoliosis?
Adams forward bend test. (Adams family scoliosis hunchback Igor)
When do you need surgery with scoliosis?
> 40 degrees curvature. May require bracing if symptomatic
What is spondylolysis? Defect in what?
Pars interarticularis. This is a failure of fusion or stress fracture from hyperextension or trauma. Usually L5-S1.
What does spondylolysis lead to?
Spondylolisthesis or slipping forward of one vertebrae onto another. Can actually cause bowel changes.
What is the most common form of back pain for adolescents?
Spondylolysis.
Who gets osteomyelitis?
50yo
A pt has a bone pain. Pt has high fevers, chills, malaise. You notes an elevated WBC count and ESR. You suspect what?
Osteomyelitis
Who gets osteomyelitis? What is most affected? What organism?
Children most commonly. Hip is most common joint. Staph A most common organism.
If a pt has sickle cell disease with osteomyelitis…what is the likely bacteria?
Salmonella.
What is the gold standard to test for osteomyelitis?
Bone aspiration. However, MRI is the most sensitive in early diagnosis.
What will you see on XR with osteomyelitis?
Soft tissue swelling with periosteal reaction and lucent areas of cortical destruction.
What findings with chronic osteomyelitis?
Sequestrum. (segments of necrotic bone separation from living bone by granulation tissue)
Newborn
Group B strep (gram negative rods). Nafcillin or oxacillin with 3rd gen ceph
> 4 months old with acute osteomyelitis. What bug? What treatment? What if PCN allergy with MSSA?
Staph A. If MSSR - Nafcillin or oxicillin or cefazolin (Ancef). If MRSA - Vancomycin or Linezolide. Clindamycin or Vancomycin with PCN allergy.
Sickle cell disease with acute osteomyelitis. What bug? What treatment?
Salmonella. 3rd gen ceph or FQ (Cipro or levo)
Someone with direct inoculation with a puncture wound with acute osteomyelitis. What bug? What treatment?
Pseudomonas. Cipro or levofloxacin. You could also do Ceftazidime or Cefipime.
A pt has a single, swollen, warm, painful joint with decrease in ROM. It is tender to palpation. What joint is most likely affect?
Knee.
Most common cause of septic arthritis? How is it spread?
Staph. Hematogenous spread, direct inoculation, or contiguous spread (like from osteomyelitis)
How do you diagnose septic joint. What should the WBC count be? Should you gram stain it?
Arthrocentesis. Joint fluid aspiration. WBC > 50,000 made up largely of PMN. Need to gram stain. Then treat.
Septic joint treatment of gram + cocci
Gram + cocci = nafcillin or vanco if MRSA (clinda or vanco if PCN allergy). Gram - cocci, unknown.
Septic joint treatment of gram - cocci or suspected gonorrhea
Ceftriaxone (Cipro if PCN allergy)
Septic joint treatment of gram negative rods
Ceftriaxone (3rd gen ceph) + anti-pseudomonal AG (gentamicin)
What if you don’t know what the organism is that’s causing septic joint?
Nafcillin or vanco + ceftriaxone.
In a nutshell….what the hell is the treatment for septic joint?
Nafcillin or vanco if MRSA. If you don’t know what it is use one of those and add ceftriaxone. If it’s gram negative cocci or rods use ceftriaxone or cipro if PCN allergy. If gay rods (you da moaners in a gay voice) present…add gentamicin.
Pt fractures a long bone. They now have pain inconsistent with injury with deep burning sensation. Their arm is in a contracture of weird shape like they are from the planet volcon. On exam there is what? What is this? Test how? Treat how?
Pain on passive stretching. Limb feels wooden or firm. They have parasthesias, pulselessness, and paresis. This is compartment syndrome. Test with intracompartmental pressure…if >30-45 and CK/myoglobin increased…then you know. Fasciotomy!!!
