Musculoskeletal injuries 5

Question 1

Kocher criteria

Answer 1

• Use for septic arthritis, pediatric septic hip
  1. Non-weight-bearing on affected side
  2. Erythrocyte sedimentation rate > 40
  3. Fever > 38.5°C
  4. White blood cell count > 12,000

Question 2

Septic arthritis: characteristics

Answer 2

• A collection of pus within the joint capsule
• Must not be missed, as the infection can lead to irreversible damage to the joint, systemic sepsis, or endocarditis
• Can occur in any joint, but knees are more common, and more likely in joints that have had some kind of surgery
• Most often caused by Staphylococcus spp

Question 3

Septic arthritis: lab, Tx, other actions

Answer 3

Send joint fluid to labs for:
1. Cell count and differential
2. Crystals
3. Culture and gram stain
4. Glucose and protein
Tx: Start broad spectrum antibiotics
Other actions: Consult orthopedics, will likely need OR washout

Question 4

Tibial plateau fx: S/Sx, imaging, complications, Tx

Answer 4

S/Sx: knee effusion, and inability to bear weight after trauma, often a blow to the knee.
Imaging: CT > X-ray
Complications: Due to the tibial plateau’s proximity to important vascular (i.e. arteries, veins) and neurological (i.e. nerves such as peroneal and tibial) structures, injuries to these may occur upon fracture.
Tx: knee immobilizer (splinting is not always needed) and strict non-weight bearing, surgery is usually needed to repair the articular surface

Question 5

Ankle sprain: MOI, S/Sx, imaging, Tx

Answer 5

MOI: inversion, eversion, plantarflexion
S/Sx: pain, swelling ecchymosis
Imaging: Xrays indicated for point tenderness, swelling, bruising
Tx: Ace wrap, aircast, crutches, ice, elevation, NSAIDs
*Treatment based on severity, severe sprains (excessive swelling) sometimes need molded, rather than preformed splint

Question 6

Ankle fx: MOI, S/Sx, imaging

Answer 6

MOI: inversion, eversion, plantarflexion
S/Sx: pain, eccymosis, swelling, ligamentous laxity/stability
Imaging: AP, lateral, oblique

Question 7

Ankle fx (undisplaced malleololar fx): Tx

Answer 7

Undisplaced Malleololar fracture
1. Laterally < 3 mm displacement
Walking boot
2. Medially 
Short leg cast
Non-weight bearing
3. If there is any instability, displacement > 3 mm or second associated fracture
-Posterior and Sugar-tong splint
-Non-weight bearing
-Surgical referral

Question 8

Ankle fx (bimalleolar): characteristics & Tx

Answer 8

Bimalleolar: 2 bony structures

• Usually both malleoli, considered unstable, usually there is joint subluxation
• Sometimes is a “Pilon” or “Plafond” fracture, as it disrupts the articular surface of the tibia
• Unstable & require surgical management/ortho referral

Question 9

Ankle fx (triimalleolar): characteristics & Tx

Answer 9

Trimalleolar: 3 bony structures fractured

• Is a misnomer (there are only two malleoli), but involves both malleoli AND the talar dome
• Almost always involves joint subluxation or complete dislocation
• Frequently requires closed reduction
• Can compromise the neuromuscular integrity of the foot
• Unstable, require surgical management/Ortho referral

Question 10

Masionneuve fx: Definition, S/Sx, physical exam, Tx

Answer 10

Definition: Is a proximal fibular fracture accompanying any kind of ankle fracture
S/Sx: Rotational forces are transmitted up to the knee
Physical exam: Always palpate the proximal fibula in any ankle injury and have a low threshold to image the whole fibula
Tx: long-leg posterior splint, referral to orthopedics, strict non-weight bearing

Question 11

Foot fx (calcaneus): MOI, Tx

Answer 11

MOI: Usually a fall or jump from a height landing on the heel
Physical exam: Often lots of swelling. Always look for injuries to the hip and spine
Tx: Non-displaced: soft dressing
Displaced or Avulsion: ortho referral, short-leg splint

Question 12

Foot fx (talus): Tx

Answer 12

Tx: Short leg splint
Non-weight bearing
Ortho referral

Question 13

Foot fx (metatarsal): Type, Tx

Answer 13

Type: (from close to ankle) neck, shaft, base; displaced v. non-displaced
Tx:
1. Non-displaced: crutches, walking shoe
2. Displaced: reduction, short splint, ORIF
- Base 5th: walking shoe
- Shaft 5th: posterior splint, crutches
- Proximal 5th: “Jones fracture,” posterior splint, crutches

Question 14

Foot fx (phalanges): MOI, Tx

Answer 14

MOI: Fracture of the phalanges is common after crush or kicking injuries
Tx: Reduction of displaced fractures can be accomplished after digital block and traction
- Buddy taping 3- 4 weeks
- Ice, NSAIDs, elevation

Question 15

Plantar fasciitis (foot pain): Definition, S/Sx, Tx

Answer 15

S/Sx: Feels “like I stepped on a nail”
Definition: Inflammation of the plantar fascia
Tx: Ice, exercise, orthotics, foot braces at night

Question 16

Calcaneal spurs (foot pain)

Answer 16

S/Sx: Chronic heel pain with weight bearing

Tx: Walking boot, surgery to remove the spur

Question 17

Plantar warts (foot pain): Definition, S/Sx, Tx

Answer 17

Definition: Viral infection
S/Sx: Nuisance, evident of exam
Tx: Duct tape, cryodestruction

Question 18

Morton’s neuroma (foot pain): Definition, S/Sx, Tx

Answer 18

Definition: Is a benign neuroma of an intermetatarsal plantar nerve, most commonly of the second and third intermetatarsal spaces, which results in the entrapment of the affected nerve
S/Sx: Feels like a pebble in a shoe or a fold in a sock. There may be sharp, burning pain or numbness in the ball of the foot or toes.
Tx: Orthotics and corticosteroid injections are widely used conservative treatments