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Musculoskeletal injuries 4 Flashcards

1
Q

Wrist gross anatomy

A 
Radius (thicker bone along w/ thumb side)
Ulna
Eight carpal bones
Tendons/Nerves
Vessels
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2
Q

Six common wrist problems

A

Dorsal pain: sprain, carpal tunnel syndrome, fractures
Nodules: ganglion cysts
Parasthesias/Hypesthesias: carpal tunnel syndrome
Weakness/Pain: deQuervains tendinopathy
Pain/Stiffness: osteoarthritis
Trauma: sprains, fx

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3
Q

Wrist assessment (what to assess)

A
  1. ROM: Flexion, extension
  2. Nerve exam
  3. Assess for proper sensation across radial, median and ulnar nerve distributions
  4. Vascular exam
    Allen’s test
    Grip strength
    Hoffman-Tinel Test
    Finkelstein Test
    Phalen/Reverse Phalen
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4
Q

Hoffman-Tinel Test

A

With wrist and fingers extended, percuss the carpal tunnel to accentuate nerve entrapment

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5
Q

Finkelstein Test

A

Assess extension of the thumb against resistance, weakness or pain suggests deQuervain’s tendinopathy or Gamekeeper’s thumb

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6
Q

Phalen/Reverse Phalen test

A

Hands pressed against each other or pressed together, compresses carpal tunnel and accentuates nerve entrapment

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7
Q

deQuervain’s tendinopathy: Characteristic, Assessment, Tx

A
  • Over-use injury, a.k.a. “iPhone thumb”
  • Tenosynovitis of the sheath or tunnel that surrounds two tendons that control movement of the thumb
  • Detected by Finkelstein test
  • Treatment: immobilization with thumb spica splint followed by steroid injection
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8
Q

Carpal tunnel: Characteristic, MOI, Tx

A

Entrapment of the median nerve
Often over-use injury, although many other risk factors are implicated
Treatment: splinting at night, physical therapy, but if these fail then carpal tunnel release surgery

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9
Q

Scaphoid fx: Characteristic, MOI, Assessment, Imaging, Tx

A
  • Most common carpal fracture, although it is actually hard to see on plain films
  • Must not be missed as the scaphoid is poorly vascularized and will often not heal properly if not treated correctly
  • MOI: FOOSH, with pain in the wrist and hand
    Snuff box tenderness (suspect fracture in anyone with classic MOI and then tenderness even if X-rays negative)
  • CT, MRI, Bone Scan
  • Immobilize with thumb spica
    *Refer to hand
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10
Q

Colle’s fx: Characteristic

A

Fracture of the distal radius, sometimes with fracture of the distal ulna or ulnar styloid
If displaced, there will be dorsal angulation of the bone fragment
Most are stable, without much angulation, others involve the articular surface, and become unstable

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11
Q

Distal Phalanx fx: Characteristics, MOI, imaging, Tx

A

Nail injuries common
Open fractures common
MOI: Crush injuries, direct blow, sharp trauma, partial amputations
Imaging: 3 views usually needed
Referral: tendon injury, sensory compromise, intraarticular fractures
Tx: Splint, ice, nailed repair as needed, antibiotics for any suspected or obvious open fracture

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12
Q

Colle’s fx: MOI, imaging, Tx

A

MOI: FOOSH
Quite apparent on X-rays, rarely require more detailed imaging
Tx varies based on stability and deformity
If stable and non-angulated, a simply volar splint is enough
If unstable or angulated, closed reduction is needed to better align the bones
If performing closed reduction, perform a hematoma block, then use traction/countertraction
Most require surgery, even after closed reduction
After closed reduction, use either volar or sugartong splint

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13
Q

Tenosynovitis: Characteristic, Tx

A

Can be inflammatory or infectious (more serious)
Infectious tenosynovitis cases should be managed with tendon sheath irrigation and drainage, with or without debridement of surrounding necrotic tissue, with antibiotics
Rarely, amputation is needed to prevent further spread

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14
Q

Middle phalanx fx: MOI, imaging, Tx

A

MOI: Direct blow
Three view plain films (AP, lateral, oblique)
Tx:
- Treatment varies on angulation, involvement of articular surfaces
- Closed reduction can be attempted after digital block
- Volar splint
- Ice
- Referral for all

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15
Q

Proximal phalanx fx: Characteristics, MOI, Tx, imaging

A

Often unstable as they involve the delicate muscles of the hand and the flexor and extensor tendons
MOI: Direct blow, hyperextension
Imaging: Three view plans films plus carefully exam
Tx:
- Closed reduction can be very challenging
- Ulnar/Radial gutter splint
- Referral for all

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16
Q

Subungual hematoma: Characteristics, MOI, imaging, Tx

A

Collection of blood under considerable pressure causing pain
MOI: direct blow to the nail
Xray to assess for fracture
Relieve pressure by trephination

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17
Q

Metacarpal fx: MOI, assessment, imaging, Tx

A

Often called a “boxer’s fracture”
MOI: Blow/Punch with closed fist
Exam: Assess for wounds over the fracture, many contaminated with oral flora
Imaging: Three view plain films
Tx
- Depends on skin integrity, degree of angulation, proximity to either end of the bone
- Closed reduction sometimes needed
- Splinting should be either radial or ulnar gutter (most common)
- Often need ORIF

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18
Q

Hip fx: MOI, exam, characteristics

A

MOI: Usually a fall, landing squarely on the hip
Physical exam: groin pain, inability to ambulate, shortening/rotation
Characters: Can be atraumatic. Can occasionally ambulate, with pain. Area of pain can be vague

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19
Q

Pt who needs blood transfusion from a hip fx

A

Anemic Pts

* You lose good amount of blood from hip fx

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20
Q

Hip fx: locations

A
  1. Femoral neck (intrascapsular)
  2. Intertrochanteric (extracapsular)
  3. Trochanteric
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21
Q

Femoral neck (intracapsular) hip fx: repair method & risk

A 
Repair: usually ORIF or arthroplasty
At risk for:
1. avascular necrosis
2. non-union
3. chronic pain
22
Q

Intertrochanteric (extracapsular) hip fx: repair method

A

Always needs surgical repair unless the patient is not expected to survive to mobility

23
Q

Trochanteric hip fx: repair method

A

Depending on the fracture, surgery is usually indicated, but occasionally can be avoided

24
Q

Hip fx: complications and prevention methods

A 
DVT
Thromboprophylaxis: 
1. Fondaparinux 2.5 mg post op
2. Enoxaparin 40 mg SQ
3. UFH
4. Pneumatic compression
5. Graduated stockings
25
Pelvic fx: MOI, exam, red flag
MOI: Motor vehicle crashes, falls, and pedestrians struck by motor vehicles Exam: CT imaging preferred --> CT imaging can assist extent of bleeding and organ injury Red flag: Vertical shear fx or "open book" pelvic fx are very high-energy fx and life threatening
26
Open book pelvic fx (vertical shear fx): MOI
Common high energy seatbelt injury
27
Femur fx: MOI, fx type, treatment
MOI: high energy (rare since it requires high energy. Seen in young men and elderly women) Type: unstable Tx: almost always ORIF
28
Femur fx: Things to do prior to surgery
Traction splint Liberal analgesia Prep for complications Admit, consult ortho immediately, consider transfer to trauma center
29
Femur fx: complications
1. compartment syndrome 2. neurovascular compromise 3. fat embolism 4. concomitant injuries
30
Meniscus injury: MOI, characteristics, S/Sx, prognosis
MOI: overuse, wear and tear; twisting on wt bearing leg Characteristics: most common knee injury, heals slowly *Meniscus is non-vascular, nourished by joint fluid alone S/Sx: medial pain more frequent than lateral pain Prognosis: injury heal slowly and poorly
31
Meniscus: anatomy
- C-shaped fibrocartilagenous structures | - in contact w/ the femur and tibia articular surfaces
32
Meniscus injury: physical exam
1. Determine where pain is worst, take Hx - Tenderness medially, laterally - “Locking” of the joint - Knee “buckling,” subjective weakness - Stair climb/squatting - McMurray’s test
33
McMurray's test
Lie the patient supine, flex the knee and hip to 90 degrees, grasp the heel and rotate the lower leg medially and laterally and assess for pain
34
Meniscus injury: Tx
Ice, NSAIDs, Crutches, Quad exercises
35
Knee osteoarthritis: characteristics
- Extremely common, overuse injury, causes gradual degradation of the meniscus - Age > 50 yrs
36
Knee osteoarthritis: S/Sx, assessment, Tx
S/Sx: Morning stiffness, joint crepitus, bony tenderness * Normal joint: no effusion/ erythema Assessment: Plain films to assess for joint space narrowing Treatment: Tylenol, Voltaren Gel, exercise, braces, joint replacement
37
Prepatellar bursitis: MOI, S/Sx
Also known as “housemaid’s knee” MOI: kneeling, bending Signs and symptoms: Swelling over the patella, impaired flexion, easy extension, ballotable cyst, erythema, warmth
38
Prepatellar bursitis: assessment, DDx, Tx
Assessment: when in doubt, aspiration can be performed to assess for infection Differential diagnosis: gout, infection Tx: rest, compression, NSAIDs, & Abx (if indicated) Admit if infection is suspected
39
Baker's Cyst: S/Sx, exam, imaging, Tx
S/Sx: Pain in the posterior knee, often associated with some swelling distally (the cyst compresses the vasculature at times, mimicking a DVT) The cyst similar to a ganglion cyst in the wrist, a harmless fluid collection Exam: fullness to the popliteal fossa, tenderness to the popliteal fossa, occasionally deep palpation will reveal the cyst itself, decreased ROM due to swelling Imaging: US (also r/o DVT) Treatment: ACE, ice, NSAIDS
40
Knee pain causes
1. Patellar tendonitis 2. Ileotibial band syndrome 3. Patellofemoral pain syndrome 4. Osgood-Schlatter dz
41
Patellar tendonitis: definition
A tendinopathy of the patellar tendon resulting from frequent running and jumping (track and field athletes), or climbing many stairs
42
Ileotibial band syndrome: definition
An inflammation of the tendon insertion of the IT band at the medial femoral condyle, often seen in runners
43
Patellofemoral pain syndrome: definition
a non-specific pain at or behind the patella, most often seen in athletes
44
Osgood-Schlatter dz: definition
An osteochondritis of the tibial tuberosity by repeated strain of the IT band on an open growth plate, more common in boys than girls, limitation of activity and braces are needed to prevent further damage to the tibia
45
Anterior cruciate ligament (ACL) injury: MOI, S/Sx
MOI: twisting with hyperextension, Classic “pop” with immediate hemarthrosis Symptoms: Weakness, swelling, pain
46
Anterior cruciate ligament (ACL) injury: Exam, imaging, Tx
Exam: Immediately, the swelling is often too great to get a good exam, but some excessive laxity can be noted, Lachmans, Anterior Drawer can be attempted after swelling is reduced Imaging: Plain (detects effusion, can sometimes spot avulsion fracture), MRI needed to detect extent of injury Treatment: RICE, crutches, surgery if desired by the patient, knee immobilizer not helpful or needed
47
Lachman test
- Assess integrity of the anterior cruciate ligament (ACL) - Place the patient's knee in about 20-30 degrees flexion. Place one hand behind the tibia and the other on the patient's thigh. On pulling the tibia anteriorly, an intact ACL should prevent forward translational movement of the tibia on the femur.
48
Anterior drawer test
- Assessment of ACL injury - Pt lies supine on a plinth with their hips flexed to 45 degrees, the knees flexed to 90 degrees and feet flat on the plinth. - The examiner sits on the toes of the tested extremity to help stabilize it. The examiner grasps the proximal lower leg, just below the tibial plateau or tibiofemoral joint line, and attempts to translate the lower leg anteriorly.
49
Acute patellar dislocation: MOI, physical exam, Tx
MOI: Valgus strain, medial blow Physical exam: Lateral displacement of the patella, knee flexed, pain/swelling Treatment: Reduction, ice/analgesia, knee immobilizer *Chronic subluxation can occur if injury is repeated
50
Knee effusion: MOI, assessment, Tx
- Non-specific collection of fluid within the joint capsule MOI: Can be inflammatory (as in gout, pseudogout, or reactive arthritis), traumatic (either hemarthrosis or serous), or infectious Assessment: Arthrocentesis can help determine one from the other Tx: In general, non-infectious cases respond well to simple compression and elevation

AGACNP (21 decks)

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