trauma and degnerative Flashcards
How are spondylolisthesis graded?
Grade 1: 25% slippage of disc on disc
Grade 2: 50%
grade 3: 75%
Grade 4 and 5: completely seperated
How is a herniated disc treated?
conservative if no motor signs
-NSAIDS, rest, follow up MRI 3 weeks
If motor signs or worsening sensory then surgery to retract nucleous pulposis
How does age affect the spine?
disc degeneration leads to smaller disc space and can impinge roots
Fibrocartilage dehydration happens 10 years earlier in men than women. So Annulus fibrosis can’t hold nucleus pulposus
spinal stenosis due to laxity of ligaments
How does neurogenic claudication present?
numb and paresthesia when walking long distances
How does arterial claudication present?
cramps in muscles when walking and when rest it gets better
What joints does Osteoarthritis affect?
synovial. DIP, PIP, 1st MC of hand, 1st MT of foot, facet joint of vertebrae, Ac joint
How does OA present on x-ray?
abnorm alignment -joint space narrowing, boney ----------subchondral cysts. Boney sclerosis Cartilage---- ----not calcified deformities -----osteophytes no erosions slow progression asymmetrical
How does spondylolisthesis present clinically?
minor: pain with activity
major: pain with flex and extend. Radicular signs (sensory and motor because impingement)
Spinal stenosis is caused by…
hypertrophy of the ligaments-flava ligament compresses spinal cord from anterior
disc bulge and osteophytes also compress
What are 2 types of spinal stenosis?
central and lateral recess.
central is the central canal
lateral recess is area where spinal nerve exits through vertebral foramen
-most common areas are lumbar(can compress caudal equina) and cervical
How does lumbar stenosis present?
- feel better in flexion
2. weakness and paresthesia when extend
What is the treatment for spinal stenosis?
antiinflammatory
surgery-laminectomy then allograft and fusion of segments
What population would present with an anterior femoral neck and posterior femoral epiphysis?
children SCFE boys: 12-15 girls: 10-12 going through growth spurt tend to be overweight and active
What does legg calve perches look like on x-ray?
initially no change but after 2-3 weeks see epiphysis get smaller because lack of blood supply so just thin line on top of growth plate
what population is affected by legg calve perthes?
younger children
what is the most common hip disorder in adolescents?
SCFE
BL in 50%
what are some risk factors for SCFE?
endocrine disorder(hyperthyroid, hypogonadal endocrinopathy, panhypopituitarism, renal osteodystrophy
obese
delayed skeletal maturation
wide epiphysis
tall and thin with recent growth spurt wide
How does a SCFE patient present?
adolescent
external rotated hip-waddle gait or limp
-affected foot turned out
pain with internal rotation
knee pain can be only sign
sometimes hip pain
can have groin painwhat is the treatment for SCFE?
epiphysiodesis-surgical closure of epiphysis (pin)
how is SCFE diagnosed?
frog leg (Lauenstein) view x-ray lateral x-ray classify by degree of slip all are salter fracture type 1
what x-ray view is best for fracture or arthritis of knee?
sunrise view-lateral patella is more elongated so can use to orient
How are the ligaments and joints of the ankle named?
talofibular (fibula always last)
tibiotalar(tibia always first)
talocrural joint is fib and tib on talus subtalar joint is talus on calcaneus inferior tib fib joint is the syndesmosis between the two talonavicular is medial calcaneal cuboid is lateral cuneonavicular is centered
if you want to view the talus, what x-ray view is best?
mortise view (dorsiflex foot and can see more joint space)
what is the fracture called that separates metatarsals from tarsals?
lisfranc
can be subtle or dislocated
what is a fracture of the 5th Metatarsal called?
jones fracture. if avulse the tuberosity then can also call avulsion. poorest vascular supply here because watershed zone.
shoulder dislocation usually occurs in what direction?
anteriorly and inferiorly(physiologic)
see on AP x-ray move out of glenoid fossa
posteriorly is non-physio(seizure or electric shock)
-need Y view to see best on x-ray (see light bulb sign of humerus and humerus is not in middle of the y)
What are the 3 points of a y view x ray?
the spine of the scapula is most lateral, coracoid process is most medial and body of the scapula is the stem
An open fracture (exposed to atmosphere) is treated how?
surgical emergency within 24 hours because of infection
How is an uncomplicated fracture treated?
if no reduction required then immobilize, x-ray and follow up x-rays to make sure hasnt moved and is healing
how is a phalangeal tuft created?
its is a subungal(beneath the nail bed) hematoma
techinically open fracture
USUALLY CRUSH INJURY
pain increased because of Pressure
How is a phalangeal tuft treated?
antiobiotics short course and protect
How is a mallet finger created?
TRAUMA WHEN IN EXTENSION
avulse extensor tendons on dorsal surface-can’t extend DIP joint anymore
can pull off bone or epiphyseal plate
can cause palmar sublux
How does a mallet finger present?
trauma with extension
dorsal swelling
can’t extend DIP
some palmar subluxation
How is mallet finger treated?
extension splint the PIP
How is volar plate injury created?
HYPEREXTENSION OR DISLOCATION OF PIP
can pull off bone
see dorsal subluxation
tear the flexor tendon(volar)
Scaphoid fractures present how?
FOOSH
pain in wrist
snuff box tenderness
x-ray is unreliable
What are some complications of a scaphoid fracture?
lose circulation because retrograde circulation in the area
AVN
SLAC (scaphoid lunate advanced collapse)
Treatment for AVN and SLAC?
surgery
treatment for scaphoid fracture is casting
What is a possible outcome of a distal radius fracture?
4 pieces of bone
after FOOSH
fracture intraarticular or metaphyseal
What is the best view for X-ray of distal radius or colles fracture?
lateral xray
How is a distal radius feature treated?
distal radial plate or external fixation
How is a fracture of the radial head created?
galleozi is a possiblity (radius fracture and ulna dislocated distally)
FOOSH
Where do clavicles usually fracture?
midshaft
see tent of skin(penetration rare)
can use conservative treatment with sling and figure 8
With a proximal humerus fracture what is the treatment?
- make sure vascular supply not compromised(key to healing)
- check neuro
- rule out shoulder dislocation X-ray
- if nondisplaced then sling and immobilize
what are possible etiologies of the fat pad sign?
fat pad sign= increased radiolucent compared to muscle of anterior fat pad or presence of radiolucent posterior fat pad(not ever seen unless pathologic)
1. occult fracture 2. hemarthrosis 3. joint effusion 4. neoplasm 5. infection/inflam
what is the pathophysiology behind the fat pad sign?
posterior capsule fills up with blood but is still enveloped by fibers of the joint capsule
-extrasynovial and intracapusular
what is the carrying angle?
angle created by elbow measure between medial hand and hip normal is 5-15 degrees increased in elbow fracture decreased in gunstock demormity
how is alignment named?
varus- distal part of extremity is medial to proximal
valgus- distal is lateral to proximal
what does an elbow fracture do to the carrying angle?
created cubitus valgus so increased carrying angle
What is the work up for an elbow fracture?
common and troublesome in kids
- check lateral triangle(radial head, lateral epicondyle and olecranon)
- possible to have bursitis or effusion - check medial cubital tunnel with ulnar nerve and medial epicondyle
- often swell and have eccymosis
What is the treatment for an elbow fracture?
closed reduction and pin or open reduction and internal fixation
In a hip fracture, how does the hip present?
shortened and externally rotated
How should the spin be evaluated for fracture?
3 columns: anterior vert body, posterior vert body and facet joint
AP, Lateral, oblique
AP in lumbar will not tell you about disc space because of lordosis
What is a burst fracture?
2 of the 3 columns of the spine are fractured, likely to be unstable
What usually causes a lumbar spine fracture?
compression forces
If a shoulder dislocated posteriorly (nonphysio) then how is the humerus rotated?
internally
The garnder classification of 1 and 2 nondisplaced and 3 and 4 displaced are used to classify which fracture?
femoral neck 1- see fracture line 2-see narrow space 3. wide space, displaced but aligned 4. wide space, displaced and slip
What artery is concerning is femoral neck fracture?
lateral retinacular artery
intracapsular break
high morbidity. increases with age. increases with delay of surgery
what is a common extracapsular fracture of the hip
intertrochanteric fracture
x-ray shows medial cortical bone off line
heals better than femoral neck because good blood supply
How are intertrochanteric fractures classifed?
undisplaced=stable
displaced and reduce- stable medial cortical apposition
displaced and unreduced=unstable no apposition
minuted= unstable, no apposition
How are hip fractures diagnosed?
x-ray view internal rotation, AP and lateral
can do MRI and bone scan
What are some options for tx of hip fracture?
pin(femoral neck but cast in young), sliding screw (intertrochanteric fracture), hemiarthroplasty-replace ball not socket
15 treat as adult and nail
Which population is most at risk for hip fracture?
women, white, osteoporosis, elderly, decreased BMI, smoking and alcohol, previous fracture
other: dementia and psychotropic drugs
what are some complications of fracture?
- acute blood loss
- fat embolism(long bone fracture or crush)
- compartment syndrome
- malunion
- delayed union(takes longer to heal)
- avascular necrosis(talus, scaphoid, femoral neck)
- Reflex sympathetic dystrophy
- complex regional pain syndrome
How does a fat embolism present?
petechia, hypoxia, confusion
can be immediate or 48 hours after injury
in a compartment syndrome what occurs?
Edema that causes a decreased in the arterial venous pressure difference
- pulse might be palpated but not distally
- high Pressure in an enclosed space causes compartment tamponade (loss of blood to muscles)
- muscle hypoxia
- high pressure compresses nerves
- neural injury and volkmann contracture
how can a compartment syndrome be diagnosed?
- pressure is 30-40mmHg or greater then pressure is too high
- pain out of proportion to the injury
- pulses can help but not definite
how is malunion treated?
osteotomy
what causes delayed union?
blood supply and stability of fracture varies (hypertrophic= too much motion)
How should avascular necrosis be treated?
prolonged immobilization
if legg calve perthes then no weight bearing
occassionally it will revascularize
treat immediately otherwise can suffer early OA
How does reflex sympathetic dystrophy present?
- chronic
- severe, burning pain
- vasomotor disturbances-sweating
- pathologic changes in bone and skin
- delayed healing
What is the treatment for reflex sympathetic dystrophy?
sympathetic blockers
analgesics
How does chronic regional pain syndrome present?
after injury(can be fracture)
chronic pain
similar to RSD
What is the etiology of frozen shoulder?
fibroblastic proliferation leading to adhesive capsultitis then joint contracture
What is the presentation of adhesive capsulititis?
- decreased ROM passive and active of 50% or greater
- phases of freezing, frozen, thawing
- 6-24months duration
how is adhesive capusulitis diagnosed?
rule out calcific changes with x-ray
ROM on PE (lose motion 50% in passive and active)
MRI see contracture of capsule
What are some conditions associated with adhesive capsulitis?
diabetes, hypothyroid, CVA, Parkinson’s, cervical disc, duputren’s contracture
what is the treatment for adhesive capsulitis?
palliative
1. NSAID 2. sleep aid 3.PT-gentle stretch 3. hydro-distention injection
Classify an acromioclavicular tear and coracoclavicular sprain.
Type 2 AC seperation
Type 1= sprain AC
Type 2 =tear ac and sprain cc
Type 3= tear ac and tear cc
Type 4-6= irreducible
what are the diagnostic criteria for AC seperation?
AC joint feels lax on internal and external rotation
may feel step off at AC
X-ray
MRI
what is the work up for a humeral shaft fracture?
- check radial nerve integrity-dorsal sensation
- C6 extension wrist - u splint for 2 weeks and fracture brace
- union likely
- malunion well tolerated bc GH mobility - continue nerve checks
based on age how would you diagnose shoulder pain?
<30 yo possible instability(shallow socket)
middle age: impingement, rotator cuff pathology, adhesive capsulitis
elderly: OA, RA of GH and AC, rotator tear, malignancy
describe the location of the rotator cuff muscles.
all are subacromial (beneath bursa too)
anterior to posterior 1. supraspinatus 2.infraspinatus 3. teres major 4. subscapularis
all depress the humerus
How does a shoulder impingement present?
- night pain when sleeping on that side
- touch tender to subacromion
- near’s test (empty can motion with pressure on AC) positive
- lidocaine impinge test
- supraspinatus and infraspinatus atrophy
- rotator cuff weakness
what are 2 areas in the shoulder that can become impinged?
- coracoacromial arch- fibrosis AC, partial or full tear causes edema which occupies space
- hooked acromion - subacromion -physiologically less space <7mm
- tendinopathy or fibrosis
- partial or full tear causes edema and space occupies
- over the head activities so dysfunction of humoral compressors
- age related loss of blood supply
How is impingement treated?
rest from overhead activities 90% works
post-capsular stretch ‘windlass mechanism”
injection with local anesthetic and corticosteriods
(3 x per year)
surgery if after 6- 12m not better
If you suspect an impingement what should you look for on x-ray?
calcification abnomal
- hooked acromion
- measure subacromial space
- AC joint integrity
how many shoulder dislocation/rotator cuff tear reoccur in 11-20 year olds?
60%
What is the presentation for rotator cuff tear?
trauma
instability of motion
positive aprehension test
positive sulcus sign shows ligament laxity
what are possible etiologies of rotator cuff tear?
age
tissue degneration
trauma
Who is full thickness tear of rotator cuff most common in?
25% of people over 60 yo
greater than 40 have greater neuro problems but less likely to reoccur
elderly have no significant symptoms and no significant change from treatment
If rotator cuff tear reoccurs/shoulder dislocation what could happen?
injure articular cartilage (if athlete at risk then consider surgery for first tear or dislocation)
How does a radial head fracture occur?
FOOSH
can also injure the MCL
How are fractures described?
View
Atomosphere: open or closed
Number: comminuted is more than 2 peices
Direction: transverse, oblique, spiral, segemented, impacted, avulsed
Alignment: displacement and angulation(varus/valgus)
-described displacement as where distal is to proximal
Location: cartilage, epiphysis, metaphysis, diaphyiss
What happens when the radial head is displaced?
the head come out of hte annular log(helps with kids who don’t have full boney radial head)
Need to supinate and extend while pushing on radial head or pronate and flex while pushing on radial head
what is the treatment for olecranon bursitis?
compress and decompress, steriods, ABX if aspirate culture is bacterial
Who is most likely to get adhesive capsulitis?
women over 40
what are other diagnoses for olecranon inflammation?
gout, alcohol, RA inflammation infection trauma COPD
Who is most likely to be affected by carpal tunnel syndrome?
women over 50 pregnancy hypothyroid diabetes rheumatism obesity tobacco and alcohol
How does carpal tunnel present?
aching thenar eminence
shaking out hand in morning…sleep with hand out so won’t flex wrist
paresthesias radial 3.5 digits
thenar atrophy
How is carpal tunnel DX?
tinels (can be done on cubital tunnel for ulnar too in DTR position)
phalens 90s
nerve compression test (shoulder shrugged down and elbow at 90 and extended
Rule out double crush_impaired axonplasmic flow so easier to compress other location with less pressure
what is the treatment for carpal tunnel?
nocturnal splint carpal stretching NSAIDS steriod inject ergonomic adjustment surg: carpal tunnel release
What is tenosynovitis of the wrist?
pain from repetitive tasks from elbow to wrist
preciptiates entrapment
flexor and extensor tendons
Who is likely to get tenosynovitis of the wrist?
laborers
Dequervain’s disease affects what?
tenosynovitis of abductor hallucis longus and extensor hallucis brevis(1st dorsal compartment)
How does dequervain’s present?
acute onset with new repetitive tasks
radial sided pain
swell near styloid process
finkelstein’s manuever hurts (thumb in fist and ulnar deviate)
Who is at risk for dequerivain’s?
hypothyroid, diabetes, gout, pregnant
How is dequerivanain’s diagnosed?
X-ray to rule out scaphoid fracture, degenerative joint disease
How is dequerivan’s treated?
rest from repetitive tasks thumb in spica splint NSAID PT inject corticosteriods surgical release of 1st dorsal compartment
What is the most common type of elbow tendinosis?
lateral epicondylitis (over use extendors)
What is the work up for lateral epicondylitis?
rule out radial tunnel syndrome and check median nerve in extension
how does lateral epicondilitis present?
gradual onset of ache and exacerbation in extension(screw driver, jar, hammer)
usually middle age from degeneration of muscles-extensor carpi radials
can follow trauma
what is the treatment for lateral or medial epicondylitis
NSAIDS
counterforce brace
rest
surgery after 1 year of failed treatment to excise degenerated tissue and decortication of cortical bone
in medial epicondylitis what should be ruled out?
cubital tunnel syndrome-ulnar neuropathy
can put in DTR position and tap on nerve or test sensation
What is the most common joint dislocated in kids?
elbow which is #3 in adults
What is the treatment for dislocated elbow?
pronate and extend and distract
reduction urgent to prevent contracture
hinge brace the joint and within 7 days do gentle ROM (avoid Volmann’s contracture)
loss of terminal extension is common but full ROM returns in one year usually
What is volkmann’s contracture?
the ischemia of extensor tendons leading to permanent flexion of wrist and fingers.
What is a complication of a distal humerus fracture (elbow fracture)?
gunstock deformity-decreased carrying angle
adults have intra-articular fractures
chidlren usually have suprcondylar fractures
how is an olcranon fractured?
blow from behind during eccentric contraction
check ulnar nerve when assessing
A painful palmar nodule at the distal palmar crease that causes the ring, middle or thumb to lock in flexion is…
trigger finger. A1 pulley nodule of flexor tendon(can be proximal or distal to the pulley.
Snap heard at PIP
How is trigger finger treated?
MCP extension splint or tendon sheath injection or surgical release of A1.
without tx: patient has flexion contracture at PIP. permanent loss of extension
What is the etiology of trigger finger?
congenital or tenosynovitis
how is lateral epicondylitis diagnosed?
- tender over origin of extensor
- light tap to epicondyle= painful
- pain on extension of wrist
- rule out radial tunnel syndrome by checking median nerve in extension for sensory
What is tendonopathy?
tendinosis and tendonitis(both degnerative and inflammatory)
- initial swell of tendinous sheath
- if chronic then degneration
How does tendinosis present?
- pain on movement
What is the treatment of tendinosis?
- NSAIDS early use when inflam present and late as analgesic
- Doesnt facilitate healing - corticosteriods are controversial
- eccentric training
- ultrasound-little evidence
What are kanavel’s signs?
signs describing flexor tenosynovitis
- intense pain with movement
- tender to percussion along surface of flexor tendon
- swelling of digits
- flexed posture of finger for comfort
What can cause pain with flexion of fingers?
tenosynovitis
midpalmar space abcess(this can present as a horseshoe from pinky to thumb)
Who is dequervain’s tenosynovitis most common in?
women 30-50
manual workers
what 2 tendons are involved in dequervain’s tenosynovitis?
abductor pollicis longis
extensor pollicis brevis
subsequent to inflammation stenosing of compartment can occur
What are some possible causes of osteonecrosis?
corticosteriods
radiation exposure
mechanical stress
how does osteonecrosis present?
- dull, achy, throbbing pain (insidious onset)
2. mild changes on imaging with onset of pain
How should osteonecrosis be diagnosed?
- x -ray
2. MRI gold standard
What is a complication of osteonecrosis?
early OA
what is the etiology of osteonecrosis?
idiopathic
familial collagen II defect
vascular infarct
how is legg calve pethes(cox plans) graded?
Grade 1 s sign)
-metaphyseal rarefication (avasc segment)
grade 3 most of epiphysis is avasc
metaphyseal changes
still viable bone posterior and antioer
grade 4
total collapse of epiphysis and consolidation
diffuse metaphyseal change
-no viable posterior bone
how does a legg calve perthes patient presetn?
more common in boys pre-puberty age 4-12 pain on internal rotation limited ROM AB and Int rotation antalgic limp hip pain or referred to knee insidous onset maybe microtruama
What are some risk factors for legg calve perches?
sickle cell
high dose steroids
trauma
arterial supply reticular and lateral epiphyseal artery at risk
What are the stages of Legg Calve perthes?
- synovitis- 1-3 weeks
inferior aspect of metaphysis is osteopenic
soft tissue swelling - avasular stage (head opacitiy increased)(Ant 1/2 or entire head necrosed)
months-1 year - fragmentation stage after 1year
-areas of rarefied because ingrowth
-femoral head compressed and fragmented - regeneration: replace necrotic with fibrous connective-femoral neck widened though head fragmented (1-3 years)
- residual stage-no rareifed bone, joint incongruent
what should be ruled out when considering diagnosis of Legg Calve perches in synovitis stage?
- Ra
- pigmented villonodular synovitis(young adult)
- knee, hip, ankle - tuberculous arthritis
What shoule be ruled out when considered diagnosis in the avascualr stage of LCP?
juvenile dysplasia
osteoid osteoma
sickle cell
gauchers
what is osteochondritis dissicans?
Aseptic necrosis
chronic repetititve microtrauma of bone or growth center
form of osteochondrosis
who does osteochondritis dissicans present in?
more common in males
What is the most common joint for osteochondritis dissicans to present in?
Talus
