Musculoskeletal Flashcards
What are the physical exam findings associated with neuromuscular injury with fractures.
Pain over fracture site Deformity Crepitus Swelling Bruising Decreased range of motion
Open fracture
“compound” skin is not intact
-most likely will need surgery, debridement and antibiotics
For first 24 hours- cefazolin or vancomycin for PCN allergy
Fracture care
Splinting- Watch for compartment syndrome from splint
Pain control
Tetanus- open fractures
Typical findings with fracture and who they are present in
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Gustilo classification for open fractures type 1
Open fracture with a skin wound < 1 cm in length and clean
Gustilo classification for open fractures type II
Open fracture with laceration > 1 cm in length without extensive soft tissue damage, flaps, or avulsions
Gustilo classification for open fractures type III
Open segmental fracture wound with extensive soft tissue injury
Gustilo classification for open fractures type IIIa
Adequate soft tissue coverage
“Adequate”
Gustilo classification for open fractures type IIIb
Significant soft tissue loss with exposed bone that requires soft tissue transfer to achieve coverage
“Bone”
Gustilo classification for open fractures type IIIc
Associated vascular injury that requires repair for limb preservation
“Circulation”
Closed fracture
“simple” skin is intact
Nondisplaced fracture
The bones remain aligned
displaced fracture
The bones are no longer aligned
Transverse fracture
Across the bone
Often caused by tension
Oblique fracture
At an angle across the bone
Often caused by compression
Butterfly fracture
Transverse which fractures into a wedge
Often caused by bending
Spiral fracture
Fracture around the bone
Often caused by torsion
Longitudinal fracture
Fracture occurs along the axis of the bone
communinuted fracture
Break of bone or splinter into more than two fragments
Segmental
Two fracture lines which together isolate a portion of the bone
Usually affect the diaphysis
Impacted
When one portion is driven into another portion of the bone
Astelette
When the lines of the break radiate from the site of injury
i.e. skull fracture
Avulsion
Injury to the bone where a tendon or ligament attaches to the bone and is torn off with injury
Mal-union
Healing in an unsatisfactory position
Non-union
Failure to heal
Subluxation
Partial dislocation
Pathologic
Weakened areas of bone
Stress
Occur in lower extremity with repetitive trauma
Greenstick
Usually in children- incomplete fracture
Angulated fracture on only one side of bone
Torus
buckling of the cortex
Dislocations
Disruption of the normal relationship of the articular surfaces of the bone that make up a joint
Subluxation
Is an incomplete dislocation
Neuromuscular checks with fractures includes
Checking distal pulses
Checking capillary refill
Checking the motor function of the extremity
Testing the sensation of the extremity include two point discrimination distal to the site
You should splint the fracture “where it lies” unless…
The limb is neurovascularly compromised then you should splint it after you reduce it
Compartment syndrome diagnosis
6 P’s
Pain (out of proportion to injury, with passive stretching)
Pallor
Pulselessness
Parasthesias
Paralysis
Poikilothermia (inability to regulate temperature)
Most are late findings
Compartment syndrome Care
Consult surgery May check compartment syndrome Fasciotomy (definitive treatment) Decrease restriction Limb positioning at the heart Pain control NV checks
Why does compartment syndrome occur?
Compromised blood flow causing increased hydrostatic pressure in closed spaces, ischemia develops because of inability to meet catabolic demands, this leads to compartment pressure increase. Venous return decreased, pressure rises. Blood shunting away from intracompartmental tissue, This causes arterial collapse which leads to increased edema
Other findings in compartment syndrome
Elevated WBC > 14000
Elevated CK, CRP
Myoglobinuria
Elevated LDH (cell damage)
What is the delta pressure?
Diastolic blood pressure- compartment pressure
If this is less than 30 than you have Acute compartment syndrome
You have capillary compromise when
Tissue pressure is within 25-30 of MAP
How to diagnose a shoulder dislocation?
Xray
Brachial Plexus nerves originate from…
C5-T1
Humerus fracture PE findings
Referred shoulder pain
Hold arm adducted
Possible crepitus
Mid shaft arm pain
Axillary nerve damage manifests as
Deltoid weakness
Diminished sensation over deltoid region
Suprascapular nerve damage manifests as…
Supraspinadous (abduction) or infraspinadous (external rotation) muscle weakness
If you see wrist drop you should be thinking…
Midshaft humerus fracture
radial nerve dysfunction
How to test for radial nerve dysfunction
Thumbs up sign
Thumbs up sign against extension resistance
Check the dorsum of the hand between the thumb and finger for sensory loss
How to test for median nerve dysfunction
Try to maintain an OKAY sign against resistance
rare
How to test for ulnar nerve dysfunction
Peace sign, try to push fingers together
How to test for ulnar nerve dysfunction
Peace sign, try to push fingers together
Check for sensation of the palmar aspect of the fifth finger
Humerus fracture treatment
Splint
Ortho follow up in 3-4 days
young patients or multiple fractures may need ORIF
Elbow injury is at risk for…
Medial, Ulnar, Radial nerves
Brachial artery injury
Presentation of elbow injury
Arm will be at flexion
Moderate amount of swelling
Radial head fractures presentation
Pain with supination or pronation
Limited range of motion
Pain over radial head
Elbow dislocation presentation
Holding the elbow at 45 degrees with visible deformity
Elbow dislocation are at risk for
Brachial artery injury
Median nerve injury
Lateral epicondylosis symptoms
Pain with arm and wrist extended
“tennis elbow”
Medial epicondylosis symptoms
Pain during repetitive wrist pronation
“golfers elbow”
Bursitis can occur..
Over any bony prominence (joint) with a bursa
Can be inflamed due to trauma, infection, arthritis
Bursitis presentation
Focal tenderness
swelling
not likely to have ROM difficulty
Can have septic bursitis in afebrile patient
Septic bursitis is ruled out with
Aspiration of fluid
Gram stain and culture
High WBC
Staph aureus most common
Treatment for bursitis is..
Rest
Heat
NSAIDS
local corticosteroid injections
Mechanism of forearm fractures..
direct blow
fall onto outstretched arm
Findings for different locations
Proximal fracture- swelling, inability to flex or extend the elbow
Midshaft fracture- some swelling, tenderness on pronation and supination
Distal fracture- deformed wrist with inability to flex or extend
Treatment nondisplaced
Conservative treatment splints and ortho follow up
Carpel tunnel syndrome mechanism
entrapment of the medial nerve
Carpel tunnel symptoms
pain, burning and tingling in the distribution of the median nerve
Treatment of carpel tunnel symptoms
Trial splinting
Trial NSAIDS
Need release surgery if EMG test is positive
When to refer for carpel
Muscle atrophy or weakness
Pain that persists after conservative treatment
Symptoms > 3 months
Risk factors for osteonecrosis
Steroids alcohol sickle cell Lupus Prior trauma decompression disease
Trendelenberg test for hip
Tests for weakness or instability
Balance on one leg, raise non standing leg to chest
Hop or jump test
Try to hop or jump on the leg
Internal rotation
most sensitive for articular pathology
MCL purpose
Stabilize for stress towards the midline
LCL purpose
Stabilizes for forces away from the midline
ACL and PCL purpose
anterior and posterior displacement of the knee
Meniscus injury
Pain with deep squatting
Lachman test
Patient lays supine
with knee in neutral position hold femur steady and lift tibia anteriorly
Anterior draw test
Lay supine
knee 90 degrees
sit on foot, grab foot and pull forward
Pivot shift test
Lay supine
Knee in full extension
slowly flex while you apply internal rotation
Valgus stress
Supine
outside of patient
MCL
Varus stress
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Posterior drawer test
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McMurray test
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Knee dislocation
Can not be manually reduced, patient will need to go to the OR
Ottawa ankle rules
A series of ankle radiograph films is required if there is any pain in the malleolar zone and any of these findings:
Bone tenderness at the the posterior edge of the lateral or medial malleolus
inability to bear weight
Talar fractures are at higher risk for…
Osteonecrosis
infection
arthritis
problems with healing
L1 radiculopathy
Rare and uncommon
L2,L3,L4
Weakness of hip flexion, knee extension, and hip adduction
L5
Most common
Decreased strength in foot dorsiflexion, toe extension, foot inversion, and foot eversion
S1
Weakness of leg extension and knee flexion
Decreased sensation of the posterior leg
S2,S3,S4
Less common
Minimal weakness but could have urine or fecal incontinence
Bowel and bladder incontinence
Straight leg test
Can determine nerve root compression
and if the symptoms are radicular in nature
L5-S1
Risk factors for OA
Disease of aging
Obesity (knee)
Risk factors for RA
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Risk factors for gout
Men 90% of time
Recurring arthritis from uric acid deposits
Hyperuricemia
Meds- diuretics, aspirin, cyclosporin, niacin
Diseases- sickle cell, CKD, hyperthyroid, sarcoidosis, lead poisoning
Risk factors for osteoporosis
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Characteristics of OA
Joint stiffness
Pain worse with activity
Affects small distal joints most in asymmetrical pattern
Spares the wrist
Characteristics of RA
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Characteristics of Gout
Inflammatory reaction to uric acid crystals
Sudden onset
Happens at night
Synovial fluid finding based on disease
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PE findings of OA
Limited ROA
crepitus
Negative ESR
Imaging findings of OA
Osteophyte formation
Joint space narrowing
Treatment and prevention of OA
Prevention: weight loss, vitamin D
Treatment: Exercise, weight loss, tylenol, NSAIDS, Topical capsaison (best in hand), intra-articular joint injections
surgical options
PE findings of RA
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Treatment of RA
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PE findings of Gout
HOT Tender Red Systemic fever common Pruritis with recovery
Prevention and treatment of gout
NSAIDS Colchicine Corticosteroids Diet- No beer, steaks Med changes Reduction in uric acid Colchicine prophylaxis
OA
Degenerative disorder with minimal inflammation
no systemic symptoms
pain relieved by rest, morning stiffness
Narrow joint space and osteophyte formation
Diagnostics in gout
Labs: Uric acid levels- not always elevated Leukocytosis- Inflammatory response Sodium urate crystals on arthrocentesis Radiograph: No changes early in disease
Pseudogout
Looks like gout but you find calcium pyrophosphate crystals on arthrocentesis
