Ortho Flashcards
Anterior vs posterior shoulder dislocation
Anterior- more common, often d/t direct trauma from fall onto shoulder
Posterior- posterior trauma or force, d/t posteriorly directed force with arm internally rotated
PE of shoulder dislocation
Severe pain with movement Supporting arm with other arm Pos apprehension test Palpable defect and loss of contour Careful NV exam to assess brachial plexus and axillary nerve
Dx of shoulder dislocation
AP X-rays of shoulder including Y view
Post-reduction X-rays
Tx of shoulder dislocation
Reduction and immediate shoulder immobilization
PT to strengthen rotator cuff muscles
Possible surgery
Rotator cuff injury
Composed of supraspinatus, infraspinatus, teres minor, and subscapularis
Tendinitis common in middle aged d/t repeated mechanical injury to tendon and impingement of supraspinatus tendon under subachromial arch
Tear more common in older adults and often d/t acute injury
PE of rotator cuff injury
Overhead activity causes pain often described as “dull and achy”
Pain over greater tuberosity of the humerus
Atrophy may be present
Passive ROM often nl but active ROM decreased
Pos drop arm test- difficulty holding arm at 90 degrees
Dx of rotator cuff injury
X-rays are often completely nl, may see high riding humerus
MRI needed to evaluate
Tx of rotator cuff injury
Rest, sling, PT, NSAIDs
Steroid injections offer short term relief
Surgery indicated for failed rehabilitation and with significant sx
Acromioclavicular joint separation
Fall on tip of shoulder and sports collisions
Classification of AC joint separation
Type 1- AC ligaments partially/completely torn but the joint is capsule intact
Type 2- AC ligaments torn and capsule is damaged
Type 3- clavicle is completely separated from acromion d/t ligaments completely disrupted
PE of AC separation
Pain over AC joint and with abduction and flexion at shoulder
Pt supports arm in adducted position
Dx of AC separation
AP clavicle X-rays displays type 2 and type 3
Weighted X-rays may show increased separation on film
Tx of AC separation
Sling
NSAIDs
Surgery for type 3
Clavicle fractures
MC fx in children and adolescents
Commonly caused by FOOSH, bicycle accidents, skateboarding, and football injuries
Presentation of clavicle fxs
Shoulder slumped downward, forward, and inward
Can be seen with visible deformity or tenting
Arm supported by other arm
PE of clavicle fxs
Make sure pt is neurovascularly intact (brachial plexus injury)
Palpate from sternoclavicular joint across clavicle
Dx of clavicle fxs
AP clavicle X-rays
Tx of clavicle fxs
Typically heals in 6 wks without complications
Sling
NSAIDs or pain control
F/u X-rays
Surgical if severe (comminuted) or neurovascular injury
Humeral head fxs
Commonly d/t FOOSH or direct impact
Common with osteoporosis
Women > men 2:1
Occurs at surgical neck and anatomic neck of humerus
Presentation of humeral head fxs
Pt holds arm against body and resists movement
Pain over greater tuberosity
Dx of humeral head fxs
Plain film X-rays of shoulder
Tx of humeral head fx
Sling or shoulder immobilizer
ORIF for significantly displaced fx
Pain control
Elbow dislocation
Often d/t FOOSH injury
Most commonly posterior dislocation
May have concomitant radial head fx
Presentation of elbow dislocation
Present with severe pain, inability to flex at elbow, and swelling
May have weakness with wrist flexion, finger adduction d/t median nerve injury
May have weakeness with finger abduction with ulnar nerve injury
Dx of elbow dislocation
AP and lateral X-ray films
Anterior and posterior fat pad signs suggest occult radial head fx and/or elbow effusion
Tx of elbow dislocation
Reduction of elbow
Hold elbow flexed at 45 degrees and apply slow, steady downward traction
Splint in posterior long arm splint and cling
Radius fx
Often d/t FOOSH
Should get elbow X-rays along with wrist X-rays to r/o elbow pathology
PE of radius fx
Pain over radial head, shaft of radius, or distal radius
Pain with rotation of forearm
Dx of radius fx
Plain film X-rays may be nl except pos fat pad sign in case of radial head fxs
Epicondylitis
Lateral aka “tennis elbow” pain and swelling at lateral epicondyle at origin of extensor carpi radialis brevis muscle
Medial aka “golfer’s elbow” pain and swelling at the medial epicondyle at origin of pronator and flexor muscles
Presentation of lateral epicondylitis
Gradual onset of pain over the lateral elbow and forearm
Pain with activities of wrist extension (turning a screwdriver or backhand in tennis)
Pain over the lateral epicondyle of elbow
Presentation of medial epicondylitis
Pain with active wrist flexion and forearm pronation (golf swing or throwing motion)
Pain with palpation over the medial epicondyle
Dx of epicondylitis
Often clinical
X-rays to r/o fx
Tx of epicondylitis
NSAIDs
Rest and modification of activity causing sx
PT
Tennis elbow wrap may be helpful
Nursemaid elbow
Common injury in small children
Longitudinal traction often a pull on forearm, lifting child by arm, or swinging
Subluxation of radial head d/t ligament laxity and annular ligament slips between radial head and ulna
PE of nursemaid elbow
Pain noted immediately after the injury
Pt resists using the arm and arm is held at side, slightly bent, and hand pronated
Tenderness over the radial head and pain with elbow flexion/extension or supination
Dx of nursemaid elbow
Most often by hx and clinical findings
X-rays will be nl but must be done if hx does not support MOI
Tx of nursemaid elbow
Often reduced by X-ray
Reduction is performed by placing thumb on radial head, supinate arm, flex, and extend
Sling and parent counseling on risk recurrence
Child will almost immediately begin using the arm
Carpal tunnel syndrome
Median nerve entrapment under transverse carpal ligament
More common in middle aged women
Common in pregnancy d/t fluid retention
Often d/t repetitive use or trauma (typing or assembly line work)
Presentation of carpal tunnel syndrome
Pt complains of aches in wrist, hypothenar, and fingers
Numbness in the 1st, 2nd, 3rd, and medial aspect of 4th digits
Pain worse at night
Severe cases may have thenar atrophy
PE of carpal tunnel syndrome
Phalen test
-Wrist in flexion against each other elicits pain over median nerve
Tinel Sign
-Tingling along median nerve with tapping over median nerve
Dx of carpal tunnel syndrome
Median nerve conduction is abnl on EMG
Tx of carpal tunnel syndrome
Splinting and modification of activities that cause injury
NSAIDs then steroid injection if tx fails
Surgery for muscle atrophy and refractory cases
de Quervain’s tenosynovitis
Inflammation of sheath around abductor pollicis longus and extensor pollicis brevis tendons
PE of de Quervain’s tenosynovitis
Pain and swelling with abduction or opposition of thumb
Pain over radial styloid with movement of thumb
Dx of de Quervain’s tenosynovitis
Finklestein positive- pain with flexion of thumb into palm and ulnar deviation of wrist
Dx made clinically
Tx of de Quervain’s tenosynovitis
Immobilization with thumb spica splint NSAIDs Modification of activities that cause injury Steroid injections Surgery for refractory cases
Buckle fracture
Common fx in children d/t FOOSH
Incomplete fx resulting in “buckle” or bulge of cortex d/t axial load of long bone
Also called torus fx
PE of buckle fracture
Pain over long bone where injury occurred
Most commonly the distal radius
Pain with flexion and extension of wrist
Dx of buckle fracture
Plain film X-rays shows subtle cortex changes, maybe only angulation
Tx of buckle fracture
Immobilization with splint (sugar tong)
Pain control
F/u with X-rays
Colles fx
MOI is d/t FOOSH
Transverse fx of the distal radius with displacement dorsally of the distal fragment
Transverse fx of the distal radius with volar displacement is called Smith Fracture
PE of Colles fx
Dinner fork deformity of the wrist
Dx of Colles fx
Plain film X-rays
Tx of Colles fx
Closed or open reduction and sugar tong splint
Pain control
Boxer’s fx
Axial force load on 5th metacarpal caused by a direct blow of closed fist onto unforgiving object
Fx often distal end of the fifth metacarpal
May involve 4th metacarpal
Presentation of boxer’s fx
Hx of punching hard object
Obvious deformity, swelling, ecchymosis over lateral hand
Finger malrotation
Dx of boxer’s fx
Plain film X-rays
Tx of boxer’s fx
Splinting with ulnar gutter splint and/or surgical percutaneous pinning
Game keeper’s thumb
Ulnar collateral ligament injury at base of the proximal phalanx of thumb
Often d/t FOOSH with hyperextension or extreme abduction of thumb
Named after injury sustained for injury of game keepers but aka skier’s thumb d/t fall holding ski pole
Presentation of game keeper’s thumb
Pain and swelling following injury
Instability of the MCP joint of first phalanx
Weakness with pinching or opposition
Dx of game keeper’s thumb
Plain film X-rays to evaluate for avulsion injury
Tx of game keeper’s thumb
Surgical tx for complete ulnar collateral ligament tears
Thumb spica splints for partial tears
Pain control
Scaphoid fractures
Most commonly fractured carpal bone
May result in AVN and malunion
Missed on initial radiographs 10-15% of the time
Delayed dx greatly increased risk of complication
Blood supply enters at distal end of bone and proximal fractures have greater risk of necrosis
D/t forcibly hyperextending the wrist
Often accompanied by distal radial fx
Often misdiagnosed as wrist sprain
PE of scaphoid fxs
Pain over anatomic snuff box and with movements of thumb, axial load of thumb, or direct palpation
Decreased ROM of thumb and wrist
Dx of scaphoid fxs
Plain 4 view wrist X-rays including scaphoid view (wrist prone with ulnar deviation)
Pay close attention to the middle 3rd or waist of scaphoid (70%)
Tx of scaphoid fxs
Thumb spica splint if any snuff box tenderness
Repeat X-rays in 7-10 days
Pain control with NSAIDs
All scaphoid or suspected scaphoid fx should be referred to ortho
