Musculoskeletal/Rheum Flashcards
What Salter-Harris Fracture is most common?
SH II
Which Salter Harris Fx involve the cartilage of the growth plate articular surface?
Type IV and V
What is Salter Harris Type I fracture
S=separated or slipped
Physeal separation Without extension into adjacent bone
What is Salter Harris II fx?
A=above the epiphyseal plate
Partial physeal separation with proximal extension into metaphysis
Salter Harris III
L=Lower
Partial physeal separtion with distal extensin into epiphysis
Salter Harris IV
T=Through
Fracture extends through metaphysis, physis, and epiphysis
Salter Harris V
R=ruined
Crush injury of physis
High liklihood of partial growth arrest
Name some child abuse fractures
- Any long bone fracture age <1 y/o
- posterior rib fracture
- “bucket handle” metaphyseal “corner fracture”
- lateral/parietal skull fracture
What nerve controls the extensors of the hands?
Radial nerve
What nerve controls the intrinsic muscle of the hands?
Ulnar nerve
What UE motor functions is the median nerve responsible for?
Pince grasp, Flexor at wrist/elbow, pronators
“Tea drinking”
What nerve is responsible for Thumb OAF (opposition, abduction, and flexion)
Reccurent median nerve (pure motor nerve)
also innervates the thenar immenence
easily injured
Adhesive Capsulitis
AKA Frozen Shoulder
Sxs: slow gradual onset of shoulder pain that can be severe
Formation of adhesions btwn joint capsule and humeral head; may follow injury or occur on own.
RF: diabetes and hypothyroid
Causes reduction in both active and passive ROM
Dx: Arthrography=shows decreased volume in the joint capsule and capsular contraction
Tx: Codman’s exercises: swing arm in pendulum motion with light handheld weights for five minutes 1-2 x daily
NSAIDs, Passive ROM,
Rotator Cuff Tear
- Occurs with overload (throwing athletes)
- Full Passive ROM, but limited active ROM
- pain and weakness during Active ABDUCTION
- dull aching pain in the shoulder-Interferes with sleep
- Impingement of the supraspinatus tendon
- PE: Positive Drop arm; weakness with “empty can” test
- MRIs-dx tears
Tx:small tear=Steroids, Complete tear=surgery; NSAIDs, PT
Of the 4 rotator cuff muscles, which one is most likely to strain causing tendonitis? what are the sxs?
Supraspinatus muscle
decreased ROM due to pain, but no weakness
Impingement syndrome-Sxs, PE, Tx
- Gradual onset of anterior, lateral shoulder pain,
- PE: painful arc from 60 to 100 degrees of elevation
- Pain on passive ROM with abduction
- Hawkins test, Neer test
- Tx: NSAIDs
How do rotator cuff injuries present?
dull aching in the shoulder; Cannot Abduct and externally rotate arm
What is the most common long bone fracture in children and adolsecents?
Fractured Clavicle
Fractured Clavicle
- Cause: FOOSH; birth trauma
- may have brachial plexus injury (sensory/reflex abnormality, pain, weakness)
- Dx: AP x-ray
- Tx: Kids-Figure 8 sling x 4-6 weeks
- 6 weeks in adults
Acromioclavicular Separation
- Tearing of AC or Coracoclavicular ligaments
- Usually caused by fall/impact to tip of shoulder
- Dx: AP view of both shoulders
- may require stress films while the patient holds a weighted object to reveal separation (weight bearing AC views)
- Tx: Sling (mild); surgery (severe)
Difference btwn presentation of anterior AC separtion vs. Posterior AC separation
- Anterior: arm held in external rotation with prominence of the acromion; “squared off” appearance
- Posterior: arm adducted and internally rotated, limited external rotation or abduction
what is the most common cause of Shoulder dislocation?
Fall on outstretched arm in abduction and extension
Anterior shoulder dislocation vs. Posterior
- Anterior more common than posterior
- Ass. with Axillary artery and nerve risk
- Ass. with greater tuberosity fracture and proximal humeral fx
- commin in QB
- Posterior dislocation=radial artery risk
- difficult to identify on x-ray
- usually occurs in seizures
How does Shoulder dislocation present? HOw is it diagnosed?
- Presents supporting the affected extremity
- Loss of shoulder contour is observed-elbow pointed outward with anterior dislocation
- Dx: AP X-ray or Transthoracic “Y” view
- HIll-Sachs lesion: Humeral head deformity found in recurrent dislocations
- MRI: Bankart’s lesion=tear of glenoid labrium
How do you treat shoulder dislocation?
- CLosed reduction (after assessing neurovascular status and obtaining imagery)
- Immobilization in Velpaeu’s sling
- <40 immobilize x 3 weeks
- >40 immobilize x 1 week
- Begin PT after immobilization
Humeral head Fracture
- Common in older adults with osteoporosis
- R/o injuries to brachial plexus and or Axillary artery
- Pain, swelling, tenderness over greater tuberosity
- Ecchymosis after 24 hours
- Dx: AP, lateral, and “Y” views
- Neer classification
- Tx:
- Nondisplaced fx: CLosed reduction (Velpaeu’s sling)
- Displaced fx: ORIF
What would you see with a radial nerve damage?
Wrist drop–>loss of wrist extension
Humeral Shaft fractures
Cause: MVA, FOOSH, penetrating injuries
Look for radial nerve injury!
Dx: AP and lateral views
Tx: Initial: Coaptation splint
then hanging cast, Samiento’s brace, or operative repair
Supracondylar humerus fracture
- AKA Distal humerus fx
- Cause: FOOSH with hyperextension of the elbow
- Sxs: pain worse with flexion or extension
- large effusion or edema and ecchymosis; Pt will not allow you to passively move the elbow
- R/o Brachial artery injury!
- Dx: AP and Lateral views
- Complication: Cubitus Varus (elbow deformity with decreased carrying angle)
- tx: Closed reduction with posterior splint for children; ORIF=adults
What is the most common elbow fracture in Adults?
Radial head fracture
Radial Head fracture
- FOOSH
- Tenderness to palpation of lateral elbow; pain worsens with forearm rotation
- Dx: AP and lateral X-rays
- Look for posterior fat pad sign–>suggesting hemarthrosis
- Tx: Nondisplace with full ROM=sling x 24-48 hours
- Displaced=posterior splint and sling with RAPID ORTHOPEDIC REFERRAL
What is the most common overuse injury of the elbow?
- Lateral Epicondylitis (AKA tennis elbow)
Lateral epicondylitis
- AKA Tennis elbow
- Lateral elbow pain
- Pain with active wrist extension against resistance (while forearm is pronated)
- Pain with lifting objects when arm is pronated
- Stop activity x 6 weeks
- NSAIDs, braces, PT, steroid inj.
medial epicondylitis
- Golfer’s elbow
- tenderness over medial epicondyle
- Pain produced by resisted pronation or flexion of the wrist (in supination)
- Tx: RICE, Nsaids
Elbow dislocation
- Fall with elbow locked in extension
- Posterior most common
- X-rays: check for Coronoid fractures
Nursemaid’s elbow
- Subluxation of the annular ligament
- Most common elbow injury in kids <5 y/o
- Kids come in and will not move arm–refuse to bend elbow; not swollen
- Injury caused by pulling on the forearm while the elbow is in full extension and forearm is pronated
- Tx: Reduction: place thumb ober radial head and fully supinate the arm–child will begin using the arm immediately or within 30 min
Fat pad sign
- Posterior fat pad sign always abnormal!
- =indicates bleeding into the capsule of the elbow
- Seen in Supracondylar humerus fracture, Radial fx, and scaphoid fracture
Galleazi fracture
Radius fx with distal radius ulnar joint (DRUJ)
Requires ORIF
Monteggia fracture
Ulnar fracture with radial head dislocation
Requires ORIF
Essex-Lopresti fracture
Crush to radial head with DRUJ dislocation
DRUJ=distal radius ulnar joint
Requires ORIF
NIghtstick fracture
- DIrect blow to mid-shaft ulna (resultingin mid-shaft ulna fracture)
- Does not disrupt the joint but still must check because do not want to miss a monteggia fracture!
- Tx: ACE wrap
What kind of nerve injuries are common with distal radius fractures?
Median nerve injuries
What kind of nerve injury is common with olecranon fractures?
Ulnar nerve injury
Numbness of little finger (palmer surface)
Colles’ fracture
Distal radius fracture with dorsal angulation
Most common injury of the wrist
“Silver fork deformity”
Results from fall onto the dorsiflexed hand
Tx: Closed reduction with splinting and casting–in most cases
ORIF
Smith’s fracture
Reverse Colles’ fracture
Transverse fracture of the distal radial metaphysis with volar displacement
(versus dorsal displacement in Colles)
How do you treat a scaphoid fracture?
- Displaced: Long arm thumb spica cast
- Non-displaced: short-arm thumb spica
- Displacement of 1 mm or greater–>ORIF
Hook of hamate
Occurs when you land on palm
Order carpal tunnel view
Boxer’s fracture
- fracture of the 5th metacarpal neck from direct impact with clenched/closed fist
- inspect for puncture wound over metacarpal phlangeal joint
- If fracture caused by punch to the mouth
- Eikenella Corrodens
- tx: penicillin or cefoxitin
- Angulation <15: ulnar gutter splint 1-2 weeks
- 15-30-ulnar gutter splint x 3-4 weeks
- Angulation of 30-40 degrees: ORIF, followed by ulnar splint placed
Jersey finger
Rupture of the flexor digitorum profundus tendon
Ring finger gets popped as it grabs someone’s jersey
DIP joint forcefully hyperextended
Sxs: swelling over volar DIP joint and distal phalanx; inability to actively flex DIP joint
Tx: aluminum splint in slight flexion
Mallet finger
- Secondary to forced flexion of the distal phalanx
- Extensor injury; swann neck deformity
- Inability to extend the DIP joint fully-flexed DIP at rest
- may have avulsion fracture
- tx: dorsal splint x 6-10 weeks
Gamekeepers thumb
- Tear or sprain of the ulnar collateral ligament
- Frequently due to forced abduction of thumb against ski pole (skiers thumb)
- swelling at inside of thumb MCP joint
- sxs: inability to oppose thumb; weakness of pinch; pain at base of thumb
- Tx: Partial: thumb spica splint
- complete rupture: surgery
Trigger finger
- INflammatroy process of the flexor tendon sheath-affects thumb, ring, and long finger
- Tendons do not glide under the A1 pulley due to nodules developing on the tendon, causing the tendon to catch under the pulley
- associated with repetitive trauma
- Catching when the finger is flexed
- Tx: NSAIDs, steroid inj., Splint x 2-3 weeks
- Surgery considered if sxs do not resolve
Torus Fracture
- AKA buckle fracture
- distal forearm fx; usually involves the dorsal surface of the distal radius
- FOOSH
- Common in children; will have pain but very little swelling
- tx: Cast x 3-5 weeks
What are the 4 Knaval’s signs and what do they diagnose?
- Flexor tendon sheath INfection
- fusiform soft tissue swelling (along entire flexor surface)
- finger held in flexion
- Severe pain on passive extension
- Pain on palpation of proximal flexor tendon sheath
- *Erythema is usually present, but not one of the 4 signs!!
De Quervain’s tenosynovitis
- Entrapment tendonitis/tenosynovitis of the abductor pollicis longus and extensor pollicis brevis tendons at the styloid process of the radius
- Sxs: + finkelstein test; Pain & swelling over the distal radius and base of thumb;
- Tx: Thumb spica splint, NSAIDs, PT
- Steroid inj (first extensor compartment) if other measures fail
- ortho referral if 3 injections fail
Compartment syndrome: defn, sxs
- Intracompartmental pressure exceeds vascular perfusion pressure (impingement of nerves, blood vessels), leading to ischemia of the muscles, nerves and vessels
- 5 Ps: Pain (1st), paresthesias, pallor, paralysis, pulselss (late)
- Pain out of proportion of exam
- Cast syndrome: swelling in cast can cause this!
Compartment syndrome: Dx/Tx
dx: measure pressure! Greater than 30 mmHg of the diastolic BP–>surgical fasciotomy within 4 hours to prevent necrosis! Leave open 7-10 days
If untreated forearm compartment-> vaulkmann’s contracture (permanent flexure contracture of the hand at the wrist due to ischemia)
Ankylosing Spondylitis
- HLA-B27; seroneagative spondyloarthropathy
- Men, 30-40s
- Low Back pain, stiffness (worse in AM), and hip pain; Pain improved withe bending forward
- Sacroiliitis at start
- Extra-articular manifestations: Uveitis, cardiac abnormalities, interstitial lung dx
- anterior uveitis (40%)
- IMaging: bamboo spine, sacroilitis seen early, squaring of vertebral bodies
- Decreasing ROM (diminished forward flexion) as dz progresses–>fusion of vertebrae
- Tx: PT and NSAIDs
Cauda Equina
- Compression of lower cord in the “horse’s tail” section; sudden reduction in the volume of lumbar spinal canal that causes compression of multiple nerve roots and leads to muscle paralysis
- Most common cause=herniated central disc
- Sxs: Bowel/bladder dysfunction (S2-S4), sexual dysfunction, saddle anesthesia (perianal numbness), severe LBP with BILATERAL sxs (unlike sciatica)
- Dx: Want to dx this before incontinence! Post-void residual (more sensitive)
- Tx: surgical emergency
Herniated Disc Pulposis
- Unilateral pain and radiation in most cases
- most commonly occurs at L4-L5 or L5-S1
- S/S: abrupt onset of severe pain
- radiates from buttocks down
- Posterior/posterolateral leg to ankle or foot
- PE: + straight leg raises, tenderness at sciatic notch; limited ROM
- Imaging: MRI; Plain films are NEG.
- Tx: NSAIDS, rest, steroids, muscle relaxants, Possibly surgery
Sprain vs. Strain
- Sprain=damage to the ligament
- Strain=damage to the muscle
Spinal Stenosis: what part of the spine is most commonly affected; Sxs? Treatment?
- Lumbar spine> cervical
- Sxs: Gradual onset of back and thigh pain exacerbated by walking and alleviated by sitting
- radiates to both legs
- Tx: Initally: NSAIDs/exercise
- Decompressive laminectomy-used when other methods fail
Kyphosis
- Excessive convex (forward) curvature of the thoracic spine
- Juvenile (Scheuermann’s dz)-idiopathic osteochondrosis of the thoracic spine
- Progressive kyphosis: Potts dz (TB of the spine)
- Tx
- Curves 45-60 observe every 3-4 mo.
- Curves >60 degrees: Milwaukee brace
- surgery (Kyphoplasty) if unresponsive to conservative tx.
What vertebraes are most commonly affected in Scoliosis?
- T7, T8 (right thoracic curves)
How do you screen/dx scoliosis? when do you tx?
- screening: Adams forward bends test
- Dx: AP radiograph-confirms
- Cobb’s method: measures degree of curves
- Tx
- 10-15 degrees-f/u in 6-12 months
- 15-20: AP films every 3-4 mo.
- greater than 20: refer to orthopedic
- 25-40: brace
- >45: surgery
Central cord syndrome
- elderly, frail
- UE weakness >LE
Anterior cord syndrome
- Loss of pain and temperature sensation at and below the lesion
- Retained proprioception and vibratory sense
Posterior column syndrome
- Loss of vibratory and position sense below the lesion
- Positive ROmberg; tingling in affected regions
- still have temperature and pain sensory
Brown Sequard cord syndrome
- Penetrating trauma usually with ipsilateral motor and contralateral sensory loss
Slipped Capital Femoral Epiphyses
- Capital femoral epiphysis slips off metaphysis through growth plate
- Occurs during adolescent growth spurts
- Age 12-14 y/o; Boys > Girls; obese
- Can be bilateral
- Presents with hip/knee pain with limp “waddling gait”; limited internal ROM of the hip
- Imaging: xray shows displacement of the epiphysis; frog-leg view
- Tx: surgical pinning, crutches, non-weight bearing before and after surgery
Legg-Calves-Perthes
- Avascular necrosis in pediatrics
- Moth eaten joint
- Acute, slow progresive limp with hip pain; relieved with rest
- Persistent pain and muscle spasms; limp;
- PE: ROM reveals restriction with abduction and internal rotation
- NSAIDs and abduction braces
Developmental dysplasia
- related to the growth and development of the immature hip
- Leg length discrepancy
- barlow test and +Ortolani test
- tx: Pavlik harness–used until infant is 6 months old
- If fails->closed reduction
- Open reduction if closed fails
What is the most common hip fracture?
- Intertrochanteric fracture
What type of hip dislocations are most common? how do they present?
- Posterior (90%)
- Hip held in flexion and internal rotation
- Tx: attempt closed reduction under anesthesia
Injury to what artery of the knee can lead to amputation? what commonly causes injury to this artery?
Popliteal artery; Knee dislocations
ACL: cause, s/s, Diagnostics
- Cause: sudden deceleration, Forced hyperflexion, pivotal motion during running or jumping
- pt hears a pop
- Hemoarthrosis develps quickly
- Dx: lachman’s test
- More commonly injured than PCL
PCL
OUtside direct florce; forced hyperextension
Dx: Posterior drawer test
Meniscus injuries
- Forceful twisting of a planted knee; excessive rotational force
- Medial meniscus more commonly injured
- joint line tenderness; Clicking or locking of knee; where knee gets “stuck”; inability to fully extend the knee
- Dx: Mcmurrays test, Apley’s test
Medially directed blow to the lateral side of the knee can cause what triad?
- Medial meniscus tear
- MCL tear
- ACL tear
What PE test is used to diagnose LCL injury?
Varus stress test
What PE test is used to dx MCL injury?
Valgus stress test
What is the common nerve injury that results with knee injuries?
Deep peroneal nerve: dorsiflexors and sensory to 1st web space (foot drop)
Osgood Schlatter disease
- Apophysitis of the tibial tubercle caused by trauma or overuse
- Anterior knee pain and swelling over the tibial tubercle
- 8-15 y/o males
Achilles Tendon Rupture
- Etiologies: fluoroquinolones, or steroid use; Unfit men participating in sports (basketball)
- Hear a sudden “pop”
- Limited plantar flexion and Positive Thompson test
- Tx: splint in Equinus
Plantar fasciitis
- Leads to flat foot deformity (Pes PLanus)
- Pain at the plantar aspect of the heel with the first steps in the morning and heel pain at night
- Acute tenderness at medial tubercle of the calcaneus and over the course of plantar fascia
- Tx: stretching exercises, NSAIDs, Steroid injection (if not improvement after 6-8 weeks)
- Plantar fascia release (if no improvement in 1 year
What is the most common ankle fracture?
Distal fibula–Result of an inversion injury
What is the weakest ligament within the lateral ankle complex?
Anterior talofibular ligament
What is the appropriate Inial tx for the following: Developmental hip dysplasia, Legg Calves Perthes disesase, Slipped capital Femoral Epiphysis, Tibial Torsion, and Scoliosis?
- Developmental Hip dysplasia: A cloth harness
- Legg Calves Perthes dz: PT, traction, or bracing
- SCFE: Immediate surery
- Tibial torsion: no therapy needed
- Scoliosis: Monitor every 4 months
