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MSK CCC 1: DDX of Cervical Pain
Cervical Radiculopathy – direct irritation of cervical nerve root from:
Osteophyte, space occupying lesion, increased stress or tension in foraminal area
S/S: Arm pain
Clumsiness
Pain in Trapezius, Paraspinal, Interscpular muscles
Dermatomal paresthesias or hypesthesia
Cervical Spondylosis – various degenerative diseases of spine, ankylosis of adjacent vertebral bodies,
degeneration of intervertebral disc from:
Age related degeneration, trauma or genetics
S/S: Decreased ROM
Pain in paracervical, trapezius, interscapular muscles
Pain with upward gaze or rotation of neck, extension of neck
Progression leads to:
Dehydration of the disc, thinning of disc space, protrusion of disc
Buckling/dysfunction of intralaminar ligaments
Abnormal loading and fxn of joint surface
Compensatory Changes (ex. Osteophytes)
PE: Spasm of cervical m. knotty or firous texture of muscles
Loss of normal cervical lordosis
Somatic dysfunction
Cervical Degenerative Joint Disease – degenerative/hypertrophic changes in bone/cartilage of 1+ joints
with progressive wearing down of opposing joint surfaces => distortion of joint position
DDX of non-traumatic cervical pain
Somatic Dysfunction Cervical Spondylosis/DJD
Cervical Radiculopathy Visceral Referred Pain
Mechanical Referred pain Pathologic Fracture
Infection
Diagnosis:
X-rays: AP/lat/oblique views Myelogram
EMG MRI CT
Treatment approach for cervical pain
OMT, PT, Cervical traction, Medications, Surgical referral
Cervical Dermatomes/Muscle Groups
C5 – elbow flexors
C6 = wrist extensors
C7 – elbow extensors
C8 - finger flexors
T1 – small finger abductors
Hints for PE:
If during gross motion testing, the head automatically sidebends and rotates in opposite
directions, think OA &/or Sternocleidomastoid (SCM).
If during gross motion testing, the head automatically sidebends and rotates in same direction,
think single SDs (perhaps a few of them).
If restriction in flexion, think trapezius; restriction in extension SCM & strap muscles (muscles
that connect to the hyoid).
If dysphagia (sensation of swallowing difficulties), think strap muscles and hyoid.
If radiation of pain to upper extremities, think entrapment (spondylosis, scalenes, first rib
dysfunction, herniated disc).
If radiation of pain to occiput - many muscles, occipital nerves.
If headache with pressure and tight headband sensation, think suboccipital and occipitalis
muscles and greater & lesser cranial nerves.
Any kind of symptom, think somatic dysfunction.
If dizziness or syncope, especially on head turning, think compromise of carotids &/or vertebral
arteries. Be Careful
In cases of respiratory disease, think scalenes & sternocleidomastoid (secondary muscles of
respiration) and C3,C4, & C5 (attachment of scalenes and origin of phrenic nerves)
If radiation of pain to the ear or jaw, think SCM and stylohyoid
MSK CCC 2: Imaging of spine
Why imagine the spine?
trauma, pain, disturbance in sensation/movement, neoplastic disease workup
Techniques:
Plain radiographs
Cervical: AP, lat, obliques, open mouth (c1-c2), swimmer’s (c7)
Assess lines on lateral (anterior, posterior, spinolaminar, posterior spinous)
Thoracic: AP, lat
Lumbar: AP, lat, obliques, lateral sacrum
Sacrum/coccyx: AP, lat, obliques for SI joints
CT + CT thin section - Better for bony structures
Needed for many thoracic cases because of superimposed structures seen on xray
Lumbar – disc or bone abnormality
MRI - Better soft tissue structures: cord, ligaments, discks, marrow
Cervical – axial + sagittal + coronal without contrast
Thoracic – not good due to pulsating structures
Lumar – cord, disc abnormalities, bone contusion, ligamentous injury
Bone scan – look for multiple areas of involvement or unsuspected lesions
Traumatic lesions – most from blunt trauma
Indications for imaging: pain, neurologic deficit, distracting injuries, altered consciousness, high
risk MOI, vascular injury
Initial screen = plain films, then follow up with a spiral CT
Compression fracture – in thoracic/lumbar spine
Jefferson Fracture – in bony ring of C1
Dens fractures (Type I, II, and III)
Flexion teardrop fracture
Burst fracture – of C3-C7 from axial compression injury, common to injure cord due to posterior
displacement of fragments
Signs of instability:
Interspinous, interlaminar widening
>50% compression of vertebral body
>20° of kyphosis Interpediculate widening
>2 mm of translation Dislocation
Degenerative spine disease – major cause of neck and back pain
Cervical between C5-6, C6-7
Dessication disk bulge protrusion herniation extruded disk
Osteophytes
Spondylolysis – defect of parsinterarticularis
Shows collar on the scotty dog
Sondylolisthesis – anterior displacement of the upper vertebral body
MC at L4-5 or L5-S1
Extradural processes:
Disc protrusion/spondylosis
Metastasis, B9, malignant neoplasms
Infection, Trauma
Intradural extramedullary:
Meningiomas
Schwannomas
Embryonal tumors
Infection, Trauma
Intramedullar:
Demyelinating disease
Tumors: gliomas, ependymomas, hemagioblastomas
Hydrosyringomyelia
Infection, Trauma
MSK CCC 3: Benign Bone Tumors
Questions to ask in a possible tumor:
Age – certain tumors for certain age groups
Duration of complaint
Rate of growth
Pain associated with the mass – B9 are not painful
History of trauma
Personal/family hx of cancer
Systemic signs or symptoms
Tumors are named by tissue origin and location within the bone:
Know: Tumors that recur and tumors that can become BAD
Osteochondroma from bone and cartilage “harmatomas”
MC B9 bone tumor that arise near the ends of long bones
10-20 years of age
Secondary malignant chondrosarcoma arises in 10%
X-ray shows bony outgrowth from cortex (most of tumor is in cartilage cap so opacity on xray is
smaller than the mass feels clinically)
Tx: Necessary if tumor is near a nerve, causes pain (fxs), disturbs growth or becomes malig
Hereditary multiple osteochondromatosis
AD inheritance, lots and lots of tumors
Risk for chondrosarcoma development is higher
Fibrous Dysplasia – defect in osteoblastic differentiation and maturation
Any bone can be affected with medullary bone replaced by fibrous tissue
Appears “ground-glass” on xray
CT scan can show expansion of the bone due to intramedullary expanding lesion
*Monostotic is 7-10x times more common than polyostotic
Associated with systemic conditions (precocious puberty/McCune-Albright/myxomas)
Tx: conservative primarily to prevent deformity
Surgical indications: severe/progressive, nonunion, painful, fx
Chondroma – uncommon B9 tumor within bone marrow that forms mature cartilage
Men in 2-4th decade, asymptomatic – found incidentally as lytic lesions with stippled calcification
when x-rays are taken for something else
~small bones of hand/feet usually
~can be mistaken for chondrosarcoma
Tx: asymptomatic requires no tx, but need to rule out progressive
Non-ossifying fibroma – nonneoplastic, asymptomatic
Usually found in children with 75% occurring in the 2nd decade
Femur > Tibia at juxtaepiphyseal region
Larger lesions presents as a pathologic fracture
Xrays show lesion migrating away from epiphyseal plate with time
Normally regress spontaneously – treat only if it has a pathologic fx
Chondroblastoma “Codman’s tumor”
Rare B9 tumor originating from cartilage
See pain wherever the tumor is, especially at ends of long bones
People age 10-20 years
X-ray: cyst containing spots of calcification that must be excised
Tx: sx, bone graft, PT – tumor may recur
Chondromyxofibroma
Rare, occurs before age 30
Located near end of long bones
Xray: lytic lesion with well defined margins in the metaphysic of leg
Radiolucent area is a giveaway
Tx: excision or curettage
Osteoid osteoma – MC benign osteoid-forming tumor
Primarily seen in long bones (proximal femur), classically causes pain at night in young adults
Xrays: new bone formation with sometimes a lucent spot
Tx: NSAIDs for pain
Benign giant cell tumor – in epiphyses and erode bone into soft tissues, known to recur
S/S: pain at adjacent joint, visible mass, swelling, bone fracture, limited ROM, fluid
accumulation
Osteoblastoma – selflimited producing osteoid and bone
Occurs in vertebrae, metaphysic/diaphysis of long bones, sometimes pelvis
S/s: pain of long duration, swelling/tenderness, tumors of the spine
Bonescan: increased isotope uptake on bone scan
Endochondroma – B9 cartilage tumors
Commonly found in tubular bones of hand/foot that may cause unsightly swelling/fx
Be able to recognize the radiographs of this for test.
S/S: no symptoms but could have hand pain if large tumor/fx
MSK CCC 4: Osteoporosis, Osteoarthritis
Osteoporosis
Indications that acute back pain may involve underlying conditions
Patient demographics
Age > 70 yr
History of cancer
Glucocorticoid or immunosuppressive drug therapy
Alcohol or I.V. drug abuse
Historical features
Weight loss
Fever
Pain increased by rest
Bowel or bladder dysfunction
Neurologic symptoms
Saddle block anesthesia
Progressive motor weakness
Osteoporosis Vertebral Fractures
Acute or chronic?
Vary in degree from mild wedges to complete compression
Degree of compression does not correlate to amount of pain
Some fractures could have occurred gradually, and will not cause acute pain
Stable or unstable?
Most are stable -- rest
Diagnosed by spinal radiograph do a DEXA scan to confirm osteoporosis
kyphosis or height
Treatment: NSAIDS, calcitonin, OMT, PT, Educaiton, support groups
Surgery to rebuild their spines:
Vertebroplasty
Kyphoplasty
Osteopenia – weak bone that doesn’t necessarily fit the osteoporosis requirements
T score < -1 but > -2.5
Osteoporosis – T-score < -2.5
Risk factors: low calcium, smoking, alcoholism, meds
Age Women Men
Puberty to mid-20s & 30s Bone mass increases rapidly, reaching peak bone mass
Mid-30s to 40s A few years of stability, then slow bone loss No risk factors
bone loss 1% / yr
Mid-40s to 50s Menopause w/o estrogen replacement, then rapid
bone loss 7% / yr for With risk factors (smokers, i
7 yrs bone loss 6% / yr
Mid-50s to late life Continuing bone loss of 1% to 2% / yr
Epidemiology of Osteoporosis Fractures:
High prevalence
1.25 million female & 500,000 male hip fractures worldwide (1990)
250,000 hip & 500,000 vertebral fractures in U.S. annually
Causes of Osteoporosis:
*Estrogen deficiency
Calcium deficiency & secondary hyperparathyroidism
Androgen deficiency
Changes in bone formation (getting older)
Secondary causes/meds (steroids, diuretics, heparin, etc.)
Evaluation:
BMD, assess for secondary causes of bone loss, biochemical markers
BMD measure – best predictor of fracture if in lowest quartile
DEXA – method of measurement
Treatment: PREVENT! Modify risk factors!
Wt-bearing exercise – walking!
Ca+2: 1200mg/day
Vitamin D: 400-800 IUday regardless of sunlight exposure
Estrogen replacement: worried about side effects (PMS-like syndrome), risk of
endometrial/breast cancer
Big difference between natural and equine estrogen.
Bisphosphonates: stops the resorption of bone
Bad dentition! Do not give! Can cause osteonecrosis of the jaw!
Selective Estrogen receptor modulators
Prevent osteoporosis
Antagonists in breast/uterine tissue = less risk of cancer development
Calcitonin: hormonal inhibitor of bone resorption
Osteoarthritis/Degenerative Joint disease = MC type of arthritis
Layer of cartilage breaks down and wears away
Degree of abnormality on x-ray and clinical findings/symptoms do not always correlate
Spinal – intervertebral disks, vertebral bodies, posterior apophyseal joints
Nerve root compression = radicular pain
Degenerative changes:
Apophyseal joint
Spondylosis – degenerative DISK disease
Spondylolysis – classic OA change!
Spondylolisthesis – one slips forward
Spondylitis
Risk factors:
Age – older you get, higher the risk
Female – hand/knee
Joint trauma – more than likely develop DJD in that joint
Repetitive stress
Obesity – highest correlation with knee OA
Pathology:
Most striking changes are seen in load-bearing areas of the articular cartilage
Early stages: cartilage is thicker
Progression: joint surface thins, cartilage softens, integrity of surface is breached
Deep cartilage ulcers extending to bone
Treatment:
Reduce joint loading, exercise, PT, intraarticular therapy, sx, drugs
Spinal stenosis
Lumbar spine MC in middle-aged/eldery
Classic Syndrome: neurogenic intermittent claudication
Rule out: PVD by checking pulses in their feet
S/S: Dull to severe pain in buttocks
Numbness, weakness, paresthesias in lower extremities
Relieved by bending forward, sitting, lying down.
Gets worse when going up hills/stairs
Treatment:
OMT, PT, wt change, posture change, pain medications with limited usefulness
Inversion table
Laminectomy
MSK CCC 7: Nontraumatic disorders of hand/wrist
H&P
Inspection
Carrying angle – normally 10-15° with F > M carrying angle
Palpation
Motion Testing
Anatomy – bones: Some Lovers Try Positions That They Can’t Handle
Ganglion cyst
Soft tissue mass of hand/wrist usually attached to a tendon sheath or joint
MC scapholunate joint
Lining herniates out of the ligamentous defect causing a “cyst”
Full of jelly-like fluid due to inflammation
S/S: Vague wrist pain, mildly tender mass that may be reducible
Fusiform mass freely mobile, + transillumination, may be mistaken for bony prominence
Common hx of repetitive wrist loading
Tx: Alleviate symptoms/cause of problem
Aspiration (seldom curative)
Injection with steroid
Surgery
Mallet Finger – DIP joint injury
Flexion deformity caused by loss of continuity of extensor mechanism to distal phalanx
Common in 4th/5th digits
MOA: sudden forceful flexion of DIP joint (blunt object)
S/S: Pain, swelling, lack of extension at DIP joint
X-rays: Bony avulsion off dorsal proximal distal phalanx + volar joint subluxation
Tx: Splinting DIP in full extension, encourage proximal joint motion for 6-8 weeks
Surgery if fracture fragment involves >30% of articular surface or volar subluxation
Trigger Finger
Stenosing tenosynovitis due to repetitive finger flexion in any finger (MC thumb, middle, long
fingers)
S/S:
X-rays: Not needed
Tx: Avoid aggravating factors, US, local friction massage, NSAIDs
Corticosteroid injection every 6-8 wks, splint at night
Gets worse – consider surgical release of sheath
Thumb MCP – Ulnar collateral ligament Tear
Tear of UCL of thumb = “gamekeeper’s thumb, skier’s thumb”
Hyperabduction of thumb MCP joint (after a FOOSH)
Cannot perform an effective pinch
S/S: Pain over UCL area, weak/painful pinch
Tenderness, swelling over ulnar aspect of thumb MCP
X-rays: Fx associated?
Stress x-ray shows >20 of instability compared with contralateral side, complete tear likely
Stener lesion – occurs in complete UCL tears
Cannot heal normally residual instability
Tx: Immobilization or functional bracing with MCP in slight flexion for 4-6 wks
Sx if completely torn
DeQuervain’s Tenosynovitis
Inflammation of the tendons and synovial sheaths, esp 1st dorsal compartment of wrist
Common in repetitive motion activities
S/S: Pain in 1st dorsal compartment with gripping/rotational motions
+ Finkelstein test
Tx: Splinting in thumb spica, avoid repetitive activity, OMT, NSAIDs, steroid injections*, Sx.
Intersection Syndrome (do not confuse with DeQuervain’s!)
“Squeaker’s wrist” – tendon movement is sometimes audible
Overuse injury due to repetitive twisting motions irritation of overlapping tendons
Wt lifters, skiers, canoeists, raking, shoveling
S/S: Pain along dorsoradial wrist worsening with gripping/twisint motions
Local crepitus with wrist extension
Tx: Avoid repetitive activity, thumb spica split, NSAIDs, OMT, PT/OT, injections
Rarely need surgery
Dupuytren’s Disease – NOT a consequence of activity!!!!
Insidious onset of thickening and contracture of the palmar fascia with isolated nodular
thickening skin on distal side drawn up into a fold fingers become progressively flexed at
MCP/PIP joints
S/S: +Table top test of Hueston
Tx: Hyperextension exercises of the fingers
With 30° contracture – consider Surgery
Nerve entrapment injuries
Carpal tunnel syndrome– median nerve entrapment
S/S: Tingling in fingertips, nb/pain at night waking the patients referred to elbow/shoulder/neck
+Tinel’s +Phalen’s +EMG +NCV
Late findings: wkness of abductor pollicus brevis, atrophy of thenar eminence, l/o sensory in
median nerve distribution
Tx: Correction of MOA, splitting wrist neutrally (at night), NSAIDs, OMT, Injections, Sx
Cubital Tunnel syndrome – ulnar nerve entrapment in posterior-medial aspect of elbow
MOA: repetitive elbow flexion activities
S/S: Tenderness in cubital tunnel
+ Tinel’s test +EMG/NCV Wk/sensory loss in intrinsic (ulnar nerve distribution)
Tx: Avoid repetitive flexion, PT/OMM/ Splinting/NSAIDs/ Sx
Guyson’s Canal Entrapment – ulnar nerve entrapment medial to carpal tunnel
Between pisiform and hook of hamate
MOA: Repetitive trauma (mass lesion, direct trauma to hook of hamate, cyclists’ palsy, jackhammer
use)
S/S: point tenderness, sensory loss of ulnar 1 ½ digits
DDx: hook of hamate fracture
Tx: rest, OMT, avoidance, NSAID, splint, sx
Triangular Fibrocartilage Complex
MOA: Fall on pronated hyperextended wrist
Twisting w/ palmar rotation
Repetitive forced ulnar deviance
Distal radius fracture
S/S: Ulnar sided pain, clicking sensation
X-rays: Ulnar variance (Positive) – less space so ulnar deviance leads to more trauma
Tx: Injection* splint/cast, rest, NSAIDs, sx, reduce stressors
Kienbock’s Disease (Idiopathic Avascular Necrosis)
MOA: repetitive compressive forces affecting the blood supply
Dominant wrist in younger men and older women
S/S: Vague aching wrist pain with stiffness, tenderness/swelling at lunate, painful ROM
X-rays: initially normal eventually collapse of lunate
MRI: study of choice for early diagnosis
Tx: Conservative = symptom control, immobilization
Failed conservative = surgical intervention (lunate excision, fusion, revascularization)
MSK CCC 8: Nontraumatic disorders of Forearm, Elbow, and Wrist pain
H&P
Inspection
Normal carrying angle = 10-15°
Elbow Anatomy
Median nerve passes through two heads of the pronator teres
Ulnar nerves through cubital tunnel
Radial nerve – divides into superficial and deep branch
Deep branch passes through Arcade of Frohse (most susceptible to injury)
PE: ROM, DTRs, muscle testing, special tests
Elbow
Anterior Pain
Biceps Tendonitis
MOA: repetitive overloading of biceps, result of excessive elbow flexion and supination
S/S: Increased pain on resisted forearm supination
Anterior elbow pain with flexion/supination
Wkness secondary to pain, tender biceps tendon to palpation
DDX:
Tx: Activity modification, stretching/strengthening/OMM
Rest/ice, NSAIDs, bracing
Posterior pain
Triceps Tendonitis
MOA: Overuse due to overloading triceps by repetitive extension (throwing/hammering)
S/S: Pain at posterior elbow, tenderness at/above insertion of triceps
Increased pain with resisted extension of elbow
X-ray: Could see: degenerative calcification, hypertrophy of ulnar, triceps traction spur
DDx:
Tx: activity modification, stretching/strengthening/OMM
Rest/ice, NSAIDs, bracing
Olecranon Bursitis “miner’s elbow,” “student’s elbow”
MOA: repetitive compression causes irritation to the bursa
S/S: Painless swelling of the elbow, no erythema
DDX: Septic bursitis (infxn)
Tx: Protection
Aspiration (risk for sepsis), culture if suspected sepsis
Lateral pain
Epicondylitis “tennis elbow”
MOA: repetitive overuse of wrist extensors, 10X more frequent than Golfer’s elbow
Risks:
S/S: Aching over lateral epicondyle
Difficulty with wrist extension
X-ray: Ca deposits in extensors due to bleeding from microtears/chronicity
Tx: Activity modification, stretching/strengthening/OMM
Rest/ice, nsaids, bracing, steroid injections, sx (last resort)
Medial pain
Epicondylitis “Golfer’s elbow”
MOA: repetitive tension overloading of wrist flexors
S/s: Painful inflammation over medial epicondyle, wkness secondary to pain
Tenderness at flexor origin - Tinel’s
Increased pain with resisted wrist flexion and forearm pronation
X-ray: Rarely done, but if done negative except for some calcifications due to microtears
DDx:
Tx: Activity modification, stretching/strengthening/OMM
MCL (Ulnar collateral ligament) SPRAIN
Most important stabilizer of valgus stress
MOA: repetitive valgus stress microtears/ruptures
Pitching/throwing, racquet sports
S/S: Gradual onset of medial elbow pain that is relieved by rest
Tenderness over humeroulnar joint (at sublime tubercle)
PE: valgus stress, moving valgus stress, “milking” maneuver
Tx: Strengthening/stretching, OMM
Rest, NSAIDs, PT
Fail rehab reconstruct anterior band of MCL
Ulnar nerve entrapment (Cubital tunnel syndrome)
MOA: repetitive elbow flexion
S/S: +Tinel’s, Elbow pain radiating to wrist, 4th/5th fingers, +EMG, +NCV
Parethesias on ulnar side of hand, wkness/sensory loss in intrinsic later
Tx: Avoid repetitive flexion
Rest, NSAIDs, OMT, PT, Splinting in flexion at night, decompression
Pronator syndrome – pure sensory
MOA: trapping of median nerve between heads of pronator teres
Racquet sports, throwing
S/S: Pain, paresthesias, reduced sensation in median n. distribution
Resisted pronation of forearm reproduces symptoms, - Phalens, + Tinels
Tx: Modification of activities, splinting, OMT, sx
Anterior interosseous syndrome – mostly motor
MOA: strenuous or repetitive elbow motion compressing the anterior interosseous (branch of median
nerve) by the deep head of the pronator teres
S/S: Wkness or loss of flexion of DIP joint of thumb index finger
Tx: Depends on cause, lifestyle modification, splinting, PT, OMT, NSAIDs, surgical decompression
If advanced osteophytes can form on the olecranon and in the olecranon fossa
MSK CCC 10: Lupus vs. Rheumatoid Arthritis
Systemic Lupus Erythematosus – chronic, recurrent, fatal multisystem inflammatory disorder
Clinical Findings:
Migratory arthritis and arthralgia that is symmetrical and polyarticular
*monoarticular – think infxn*
Predilection for knees, carpal joints (PIP joints)
Morning stiffness for minutes vs hours in RA
Degree of pain > physical findings
Tenosynovitis: epicondylitis, rotator cuff tendinitis, Achilles tendinitis, posterior tibial tendinitis,
plantar fasciitis
Diagnosis:
No single diagnostic marker
Lupus presents with one or several of the following:
Unexplained nonspecific symptoms such as fever, fatigue, wt loss, or anemia
Photosensitive rash
Arthralgia, arthritis
Raynaud phenomenon
Serositis
Nephritis or nephritic syndrome
Neurologic symptoms (seizures or psychosis)
Alopecia
Phelbitis
Frequent miscarriages
Laboratory testing:
CBC, creatinine, albumin, ESR, CRP, UA, 24 hour urine
ANA (negative makes it unlikely – good for ruling out, not for positive diagnostic)
Antiphospholipid antibodies for hypercoagulability
*Anti dSDNA
*Anti Smith Abs
*+ abs confirm a diagnosis of SLE
Treatment:
1st line for pain + inflammation – NSAIDs or acetaminophen
Contraindicated in lupus nephritis (also COX-2)
Inflammation as prominent feature = NSAIDs (ibuprofen, naproxen, nabumetone)
Use with PPI if at risk for NSAID-induced GI toxicity
Pain without inflammation = Acetaminophen
Contraindicated in liver disease/alcoholism
Hydroxychloroquine (antimalarial) – for joint symptom relief, prevention of clinical relapse
For articular manifestations, rashes, and fatigue
Corticosteroids – used infrequently, only for inflammation – not pain
Risk of developing osteoporosis
Goal – use for acute flare-ups but get dose reduced as quickly as possible
Anakinra – IL1 receptor antagonist – for severe arthritis patients unresponsive to other rxs
Methotrexate – resistant inflammatory arthritis
Methotrexate + prednisone = more effective than pred alone
Amitriptyline – TCADs – when pain is unresponsive to other measures
Rheumatoid Arthritis – chronic systemic inflammatory disorder of unknown origin
*Causes inflammation of synovium causing chemicals to be released to thicken the
synovium/damage the cartilage/bone or affected joint inflammation pain + swelling
Clinical findings: Polyarticular, symmetrical, joints/tendons involved with destruction + synovitis
May be relapsing/remitting
Symmetric Joints involved: shoulders, ankles, wrists, hands, elbows, MCPs
Extraarticular findings:
Anemia Scleritis
Fatigue Splenomegaly
Sub-Q nodules Sjogren’s syndrome
Pleuritis Vasculitis
Pericarditis Renal Disease
Neuropathy
Patho:
Joint destruction starting with cartilage erode bone/ligaments/tendons = deformation
Fibroblasts/monocytes secrete proteinases that break down collagen/proteoglycans
Diagnosis:
At least 4 of the following criteria:
Morning stiffness >1 hr, for > 6 wks
Swelling of 3+ joints for at least 6 wks
Swelling of wrist, MCP, PIP joints for at least 6 wks
Symmetric joint swelling
Hand x-ray typical of RA including erosions/ bony decalcification
Rheumatoid nodules (subQ)
Rheumatoid factor*
Present in majority of pts (w/o RF may be seronegative, but can still have RA)
Labs:
Rheumatoid Factor
70-80% of pts, also found in CT disorders/endocarditis
Anti-Citruline containing peptides (CCP)
Also seen in active TB
Complications:
Joint destruction
Deformities
Boutonniere’s
Swan neck’s
Ulnar deviation Rheumatoid nodules
Tendon ruptures Baker’s (popliteal) cyst
Tenosynovitis of C1 transverse ligament producing C1-C1 instability/subluxation
Treatment:
Early diagnosis + early aggressive treatment!! -- key to minimizing disability
Immunosuppressing – be more aggressive in treating infxns in these folks!
DMARDS (methotrexate, leflunomide, hydroxychloroquine)
NSAIDs/Steroids
TNF-alpha agents
Physical/Occupational Therapy
Comparing Lupus to RA
Feature Lupus Rheumatoid arthritis
Arthralgia Common Common
Arthritis Common Deforming
Symmetry No Yes
Joints involved PIP>MCP>wrist>knee MCP>wrist>knee
Synovial hypertrophy Rare Common
Synovial membrane abnormality Minimal Proliferative
Synovial fluid Transudate Exudate
Subcutaneous nodules Rare 35 percent
Erosions Very rare Common
Morning stiffness Minutes Hours
Myalgia Common Common
Myositis Rare Rare
Osteoporosis Variable Common
Avascular necrosis 5 to 50 percent, often at hip Uncommon
Deforming arthritis Uncommon Common
Swan neck 10 percent, reducible Common, not reducible
Ulnar deviation 5 percent, reducible Common, not reducible
*RA causes EROSIVE arthritis vs. SLE causing a NON-EROSIVE arthritis*
DDX of inflammatory Arthritis:
• Infections • Seronegative spondyloarthridities
Bacterial (Lyme, bacterial endocarditis) Ankylosing spondylitis
Viral Psoriatic arthritis
• Reative Inflammatory bowel disease
Rheumatic fever • Rheumatoid Arthritis
Reiter’s • Inflammatory Osteoarthritis
Enteric infections
Still’s disease
Behcet’s syndrome
• Crystal-induced arthritis Relapsing polychondritis
• Systemic rhemmatic illnesses • Other systemic illnesses
SLE Sarcoidosis
Systemic sclerosis Familial Mediteranean fever
Systemic vasculitis Malignancy
Polymyositis Hyperlipoproteinemias
Dermatomyositis
MSK CCC 11: Trauma to shoulder/elbow
Proximal Humeral Fractures
Young high energy & old low energy
45% of all humerus fx, 77% occur in female
Consequences/associated injuries:
LOM, LOreduction, AVN, heterotopic bone
Associated with (rotator cuff, nerve, vascular, scapula and clavicular injuries
Anatomy:
Proximal humerus – broken down in 4 parts
Head, greater, lesser tuberosity, shaft
Blood supply to humerus:
Anterior humeral circumflex/*arcuate artery (ascending branch)
Posterior humeral circumflex
Nerve damage: Test Question
Axillary, suprascapular, musculocutaneous (all from brachial plexus)
Muscle damage:
Rotator cuff: supraspinatus, infraspinatus, subscapularus, teres minor
Deltoid, pectoralis, long head biceps
X-ray Workup:
Trauma Series: AP, Axillary, Scapular Y (oblique views)
CT:
Articular fractures (impression, head split) & Glenoid fractures
Tx:
Closed treatments
Considerations – age, displacement, fxnal demand, arm dominance, ability to salvage with
arthroplasty later if needed
Methods:
Sling Sling + Swath
Hanging cast Abduction pillow
ORIF (test question – indications)
Indications: Displaced GT fx > 5mm, fx that involves articular surface, surgical neck fx, displaced
anatomical neck in young pt, displaced 3-/4- part fractures
Hemiarthroplasty - best for elderly, head splits, AVN
Indications – young/middle age with severe head split or extruded anatomic neck OR elderly
Technique – beach chair position with deltopectoral approach, retain tuberosity fragments,
bone graft from head if necessary
Ends up with unpredictable results from a functional standpoint
Complications of proximal humerus fracture
Avascular necrosis – due to disrupted arcuate artery
Adhesive Capsulitis – almost always develops, minimized by early motion and controlled PT
May be fixed with arthroscopic release
Acromioclavicular Joint Injuries
Anatomy
Clavicle – S shaped bone
SC joint, AC joint, CC ligaments with muscles attached : SCM, trap, pec major
AC joint – between acromion and lateral clavicle stabilized on all sides by ligaments (superior AC
most important)
CC ligs – at distal clavicle (suspend Upper extremity)
Trapezoid + conoid = stronger than AC, provide vertical stability to AC joint
MOI for AC joints
Moderate/high-energy traumatic impacts to the shoulder
PE:
Neurovascular exam (cervical roots)
UE motor/sensation + Shoulder ROM
Radiographic Evaluation:
AP, Zanca (orthogonal view)
Axillary, Stress views
Types of AC separations (for test)
Type I – AC ligament sprained with all ligaments/joint/muscles intact
Type II – vertical displacement, with joint disrupted
Type III - AC joint dislocated and the shoulder complex displaced inferiorly
Type IV - AC joint dislocated and clavicle displaced posteriorly into or through the trapezius
muscle, seen on axillary view
Type V - AC joint dislocated and gross disparity between the clavicle and the scapula (100-300%)
Type VI - AC joint dislocated and clavicle displaced inferior to the acromion or the coracoid
process
Treatment
Type I/II – conservative with rare surgery for type II
Type III – may or may not need acute surgery, conservative tx unless an overhead arm user
Type IV, V, VI - Surgery
Indications for Late surgical Treatment of AC injuries (if a Type I-III was treated and failed)
Pain, weakness, deformity
Clavicle Fractures
<5 mm – acceptable results at 5 years
>20 mm shortening associated with increased risk of nonunion, poor functional outcome
Treatment
Nonoperative – difficult to reduce clavicle fxs by closed means
They will heal, but are they healing correct? May not have union of fxed ends
Simple sling until signs of healing ROM exercises
Plate Fixation – ORIF (open reduction internal fixation)
For acute displaced fractures and nonunions
Plate applied superiorly or inferiorly
new gold standard
Neurological Complications
Brachial plexus symptoms treated by reduction/fixation of fx, resection of callus
Radial Head Fractures
Elbow Anatomy
3 joints: Humeral-ulnar, humeral-radial, proximal radial-ulnar
Valgus Elbow Stability – from MCL and radial head
MOI – usually a fall with axial load to elbow + valgus force
Could be combined with high energy injuries: elbow dislocation, coronoid fx, collateral lig injury
PE:
Neurovascular
Valgus stress, PLRI (valgus, supination, axial load)
Distal radio/ulnar joint stability
Forearm rotation
Radiographic Evaluation:
X-rays: AP, Lat, Oblique
MRI: ligamentous injury
Classification: 3 Types increasing in severity – not responsible for these for test
Treatment: radial Head Fixation
ORIF difficulties:
Communition is worse than anticipated
Fixation into the head is difficult
Essex - Lopresti Lesions
Defined as longitudinal disruption of forearm interosseous ligament, usually combined with
radial head fx and/or dislocation plus distal radioulnar joint injury
Difficult to diagnose
Treatment requires restoring stability of both elbow and Distal Radial Ulnar Joint components of
injury.
Radial head excision in this injury will result in disabling proximal migration of the radius.
Complications of Tx:
Improperly placed headward
Loss of fixation
Posterior interosseous nerve injury
Elbow Stiffness
MSK CCC 12: Thoracolumbar Spine Fractures
90% occur between T11 and L4, with 60% between T12-L2
Majority due to MVA
Biomechanics
Burst Fractures – from compression
Wedge Fractures – from Flexion
Fracture Dislocations – from Rotation
Seatbelt Type Fracutres – from shear
Thoracic spine – stabilized by ribs, MC flexion/compression injuries
Thoracolumbar junction– predisposed to rotation/axial compression injuries
B/w rigid thoracic and mobile lumbar spine
TL experiences compression when T goes into kyphosis and L goes to lordosis
Lacks ribs, transition point between Anterior facets and inward facets
Classification
Denis Three Column Model – to explain injuries/guide treatments
Columns: Anterior, middle*, and posterior
Instability = failure of 2+ columns
Middle distinguishes 4 types of spinal fractures
1st degree = mechanical
2nd degree = neurological
3rd degree = mechanical + neurological
Imaging:
Plain film series – most important with lateral being most informative
Pedicle or TP splaying
Fracture on lateral
Vertebral body widening
Listhesis
CT – bony anatomy
MRI – for spinal cord/ligament anatomy
Evaluation
Hx – blunt trauma must have spine cleared
Exam – sans clothes, full neuro exam (rectal tone, perianal sensation), log roll for bruising, deformity,
tenderness/crepitus, etc.
Imaging
X-rays – AP/Lat for all spinal injuries (excludes the most dangerous pathology)
CT – abdomen/pelvis for trauma management, abdominal can pick up TL fxs
MRI – upon request, useful for soft tissue and cord injuries
Classification of TL fractures:
Flexion-Compression
MC type, failure of anterior column, generally stable
Tx: Hyperextension orthosis, kyphoplasty, vertebroplasty, sx stabilization
Burst
Retropulse into canal + fx of posterior elements
Failure of anterior and middle columns = unstable
Widening of intrapedicular distance = decreasd body height
MC T10-T12
Tx: Decompress/stabilize with neurological deficits
Without neuro deficit – based on stability of fracture
Seat Belt/Chance
Hyperflexion-Distraction of posterior elements
Middle/posterior columns fail
S/S: Posterior tenderness, hematoma, interspinous widening + abdominal injuries
Tx: Osseous – bracing
Ligamentous - fusion
Fracture-Dislocation
All 3 columns under compression, distraction, rotation, or shear forces
Types:
A – flexion-rotation (3/4 with neuro deficit)
B – shear (all with neuro deficit)
C – flexion-distraction (3/4 with neuro deficit)
Tx: Rapid mobilization and rehab!
Treatments
One column = stable
Two columns = mixed, if neuro injury surgery
Three columns = surgery
Decompress neurological elements (remove structures causing compression)
Stabilize spine
Spine fusion
Corpectomy with retroperitoneal flank approach to decompress
Kyphosplasty for stable compression fractures – relieves pain
MSK CCC 13: Peds UE Disorders
Pediatrics vs. Adults
Overuse injuries are common
Bones bend before they break
Greenstick fractures,
Plastic deformity
Torus fracture/Buckle fracture
Peds bones have more collagen/cartilage – improves resilience/reduced tensile strength
More metabolically active = rapid callus formation, rapid union of fx, high potential to remodel
History – Age is very important for DDX
Lots of Falls
Inspection
Physical Exam
ROM – supinate, pronate
Ossification Centers of Elbow – growth plates
Could look like fracture patterns on x-ray, but may be growth plates that hurt
Heal in a clockwise pattern
C - capitellum
R – radial head
I – internal/medial epicondyle
T - trochlea
O - olecrenon
E – external/lateral epicondyle
Fat Pad Signs
Anterior – anatomic
Posterior – pathologic (75% chance of occult fx) – may not see any boney signs, but good chance
they have a fracture
MC occult fxs: Supracondylar > proximal ulnar > lateral condyle
Salter-Harris Classification – do not memorize for test, but useful for clinical years
I and V often missed on x-rays
Little League Elbow Syndrome
Overuse – due to excessive valgus stress, pain at medial epicondyle
MC in baseball, gymnastics
MOI: Overuse/fatigue altered biomechanics medial traction (valgus stress) lateral
compression -> microtrauma overuse
Tx: prevention! Rest, ice, NSAIDs, OMM, PT
Radial Head Subluxation/Dislocation “nursemaid’s elbow”
MC < 6 years/old, refuses to use arm held in a flexed position against body
MOI: Sudden traction on extended + pronated arm, radial head slips under annular ligament
Tx: Never requires surgery, reduction, arm sling use as tolerated, prevent recurrence
Congenital Radial Head Dislocation
MC congenital deformity in elbow, found incidentally or following an injury
60% have other abnormalities
Typically lose ability to supination/pronation
Does not necessarily need treatment
Radial Head/Neck Fractures
MC 9-15 yrs old, more likely to fracture neck
70% have MCL injury at elbow
MOI: FOOSH injury
Inspection: Ecchymosis, swelling
ROM: pain w/ supination/promotion, ↓ROM, crepitus
X-rays: AP, lat, oblique, CT
Mason Classification – do not need for test
Supracondylar Fracture
MC children’s elbow fracture (10% of childhood fx overall)
MOI: FOOSH injury (extension injury)
10-20% also have neurologic injury (anterior interosseous nerve is MC injured)
Can they make the “OK” sign with their fingers?”
S/S: Swelling, localized tenderness, proximal depression of triceps
X-rays: AP, Lateral (look for anterior humeral line, proximal radial line)
Gartland Classification – NOT for test
Complications
Neurovascular – nerve damage (median, anterior interosseous, radial, brachial artery)
Compartment Syndrome
Malunion “gunstock deformity” – due to mal-reduction at time of surgery, cosmetic > functional
Lateral condyle Fractures
MC 5-7 years/old
MOI – FOOSH with varus force
S/S: Pain, decreased ROM, localized tenderness
Medial Condyle Fractures
MC 7-15 yrs
MOI – acute valgus stress
S/S: Ulnar n. injury common
Forearm Fractures – to shaft of radius/ulna (night stick injury)
MOI: FOOSH
Monteggia – proximal 3rd of ulna with radial head dislocation
Median/radial nerve injury, presents with obvious dislocation, very complex – needs sx
Distal fractures – 35-45% of all fractures in children
MOI: FOOSH
Transverse fractures of radius:
Colles’ – dinnerfork deformity, dorsal displacement of distal fragment, median n. damage
Smith – reverse colles, volar displacement of distal fragment, fall on flexed wrist
Greenstick – clinical diagnosis, cast with possible of recurrence
Galeazzi – fx distal radius with disruption of radioulnar joint
Congenital Radio-Ulnar Synostosis – do not remember for test
MSK CCC 14: Disorders of Thoracic Spine, Clavicles and Rib cage
Chest Wall
Costochondritis – chest pain, dull pain worsened by movement/respiration
Tenderness along costochondral joints, no swelling
Tx: rest, nonsteroidal meds
Tietze syndrome – rare form often at 2nd rib
*Pectus carinatum
Pectus excavatum – posterior asymmetric depression of the sterum
Normal 1st, 2nd manubrium
May cause anterior indentation of the heart, usually comes with congenital cardiac deformities
Poland Syndrome – congenital anomaly, not very common
Absence of hypoplasia of unilateral pectoralis muscle with syndactyl (fingers grown together)
Possible absence of associated ribs
Barrel Chest – AP diameter > transverse diameter, seen in patients with emphysema
Ribs become horizontal, sternum forward, senile kyphosis
*Expiratory phase inhibited (increased)
Rib Fractures – trauma, osteoporosis, could be palpable
Self-limited, lots of pain 4-6 weeks and then pain disappears
Flail Chest – multiple rib fractures
*Develop paradoxical movement of chest wall!
Medical emergency, may be associated with pneumothorax, severe trauma
Atrophy of Myopathy of Chest Wall
Cicatrix of the Chest
Burns may serious limit chest excursion = decreased respiratory volumes
Rickets
Vitamin D deficiency multiple bony deformities
*Rachitis rosary along chest wall – failure of bones to harden
Harrison groove or sulcus above pot belly
Rib notching – due to collateral circulation intercostals artery dilation from cardiac problems
Dilation of arteries wears away the ribs
Coarctation of the aorta & Neurofibromatosis*
Dock’s sign – due to collateral circulation 4-8 which anastomose with the internal mammary
artery supplying the descending aorta = erosion of costal groove by dilated intercostals arteries
Sternal malformations
Suprasternal
Foramen with cleft
Cervical Ribs – anomalous accessorib rib (eve’s rib)
From C7 transverse process
Small or full rib that can cause impingement syndromes, Thoracic outlet syndromes (+Adson’s)
90% are asymptomatic
Bifid ribs – usually not a problem Supranumery ribs (Gorilla rib – 13th)
Thoracic Spine
Exam: observe, palpate, ROM testing
Thoracic Kyphosis – MC from osteoporosis*
No lateral curvative
someone younger – metabolic/congenital, hyperparathyroidism, ankylosing spondylitis
Osteoporosis and Fractures
Frequently in thoracic spine, MC cause of thoracic fx is osteoporosis
*Anterior Wedging of vertebral body contributes to kyphosis, not always trauma
Scoliosis – could cause restricted lung diseases if severe
Weird AP diameter
Arthritis
MC is OA
RA – leads to chronic respiratory failure due to spinal problems
Psoriatic
Anklylosing Spondylitis
If seen in thoracic – a late finding
HLA-B27, if seronegative worsens with age
Inflammatory changes + new bone formation
Begins with sacroiliac are and progresses superiorly
“poker spine” and *bamboo spine” – causing back pain b/c spine is encased in calcium
Other symptoms: anterior uveitis, vascular problems as it’s a connective tissue disease
Clavicle
*80% of fractures occur in the middle third which lacks ligamentous support
Pay attention to LNs: supraclavicular (gastric ca), infraclavicular
AC Joint Dislocation – tear of coracoclavicular ligament
Complete dislocation = sx
Clavicle Dysostosis – incomplete ossification of the clavicles = abnormalities of shoulders/ rib cage
Cleidocranial Dysostosis – lack of clavicle development
MSK CCC 16: DDX Acute lumbar Pain
Low back pain = pain affecting the lumbar segment of the spine
Acute < 3 months, Chronic >3+ months
14.3% of new patient visits are for LBP, 13 million for chronic LBP
60-90% of lifetime incidence, most expensive cause of work-related disability
Only a small % of pts will ever experience lumbar radiculopathy or sciatica as a result of LBP
*Strongest predictor for future back pain is a history of prior back pain.
Red flags for a patient with back pain:
Major trauma mechanism Age >50 or < 20
Hx of cancer Cauda equine syndrome
Atherosclerotic disease Use of corticosteroids
Hx of osteoporosis Constitutional symptoms
PE
No one test, look above/below, palpate, test ROM, do some provocative tests
CLUES: pain with backward bending
Radiation or reproduction of pain with certain maneuvers
Differentiate between lumbar, sacrum, pelvis, and hip problems
Localize the problem:
Standing flexion test seated flexion test
Double leg raise (SI vs. LS)
Goldthwaite’s test – SLR + palpation (SI vs LS)
Lumbosacral mechanics
Sacrum and lumbar spine move in opposite directions
Lumbar flexion sacral extension, etc.
Lumbar rotates R sacrum rotates L
Lumbar sidebends R sacrum takes on an ipsilateral oblique axis
Ligaments and Fascia
Stabilize, set motion limits (subject to fatigue failure)
SI ligaments have mechanoreceptors to gauge strain
Thoracolumbar fascia transfers load from trunk to legs
Pain Generators:
Discogenic Stenosis
Facet Spondylolysis-listhesis
Soft tissue (muscle, ligament, tendon, capsule)
Lumbar tests
Nerve tension tests:
SLR
Bowstring/cram
Lasegue
Braggard’s/Sicard’s
Slump
Nachlas
Bonnet’s
Buttock
Malingering tests
Flip test
Hoover
Axial compression
Simulated rotation
Acute Lumbar Sprain “Mechanical back pain”
Acute injury to soft tissues with no neurologic component
85% of patients, never will ID the pain generator
Iliolumbar Ligament Sprain
Refers pain to anterior thigh or groin, easy to miss
Palpate or inject for diagnosis
Tx: Acute – OMT, active rest, SI belt
Chronic – prolotherapy, ablation, SI belt, OMT
Facet Syndrome – mimics pars fx
Focused pain, worse w/ extension
Dx: Standing/seated Kemp’s test
Hyperflexion test
Tx: therapeutic exercise, PT, OMT, prolotherapy
Lumbar somatic dysfunction
Lumbar disc herniation
Usually preceded by bouts of varying degrees and duration of back pain
Pain eventually radiates to the leg (shooting/stabbing)
Dependent on level of nerve root irritation:
Higher (L3/L4) groin or anterior thigh
Lower (S1) calf or bottom of foot
L5 – MC, lateral/anterior thigh and leg pain
Eval: MRI, CT + myelograph
Surgical indications: cauda equine syndrome, progressive neurologic deficit, persistent
bothersome sciatic pain despite convservative management for 6-12 weeks.
Contraindications: unrelenting back pain, incomplete workup, inadequate conser tm
Lumbar Discitis
Infxn of the disc post surgery or from hematogenous spread
Increasing pain/stiffness + fever
Eval: MRI, Labs (CBC, ESR, CRP)
Tm: Aggressive workup, surgical referral, long term antibiotics
Spondylolisthesis – defect in pars interarticularis that leads to top vertebrae moving more anterior to
the one below it, MC at L5-S1, then L4-L5
Type I: Congenital
Type II: Isthmic – during 1st/2nd decades
MC occurs at time of adolescent growth spurt
Focal back pain and radicular pain with larger slips, some pts are asymptomatic
Tight hammies, lumbar muscle spasm
Larger slips: dermatomal weakness/radiculopathy
Extension = provoked pain
Type III: Degenerative F:M = 5:1, >40 years of age, MC at L4-L5
Insidious onset pain with radiation to posterior upper thighs, chronic progressive
Extension = provoked pain, sometimes involves reflex changes
Type IV: Traumatic
More likely to have neurologic compromise due to severe slipping
Type V: Pathologic
Grading: 1 – 5 with 5>100% slip and 1 with 0-25% slip
Risk factors:
Athletic activityes Congenital defects Age
MC in boys, but females that get it get it worse and probably will need surgery
Younger patients are at higher risk for progression
Do serial radiographs every 6 months
High grade slips require surgery due to pain + neuro compromise
Imaging: Xrays – looking for scotty dog, bone scan, CT, MRI
Tx: PT, Bracing, OMT (NOT in acute spondy), injections, surgery
Lumbar Spondylolysis – defect in pars interarticularis
Pars Interarticularis Fracture – pars fracture
“collar on the scotty dog” on plain films
Focused pain that is worse with extension
Tx: active rest, brace/PT, OMT
Lumbar Spinal Stenosis – neurogenic intermittent claudication
MC middle-aged, elderly population
Bony encroachment or nonosseous encroachment by ligaments, discs, etc.
S/S: begin/worsen with ambulation or standing, relieved with sitting/lying down
Back pain 1st leg fatigue, pain, numbness, wkness
Eval: Pheasant’s/Homer Pheasants Test
Bicycle Test (neural vs. circulatory claudication)
Tx: normally surgical decompression
MSK CCC 17: DDX Hip, Pelvic Pain
To develop a DDX:
List of possible diagnosis
Know anatomy and physiology
Appropriate hx
PE to match the working diagnosis
Choose further work up based on the conditions you think are most likely
Anterior hip pain
OA Nerve entrapment
Inflammatory Arthritis Sports hernia
Osteitis pubis Muscle strains
Femoral neck stress fracture Tendinosis
Acetabular labral tear Referred pain
Osteoarthritis and inflammatory arthritis –
Both have gradual onset, morning symptoms, worsening with activity, stiffness (gel
phenomenon)
Osteoarthritis tends to have decreased motion on internal rotation and extension
Inflammatory conditions are associated with abnormal blood tests ( ESR), white blood
cells in the joint fluid and other joint involvement, perhaps skin or bowel symptoms
(rheumatoid usually doesn’t hit the hips)
ancer
Some start with bone: osteoid osteoma, sarcoma
Some mets TO bone: breast, prostate, lung, kidney, thyroid
Associated with constitutional symptoms, night pain, original site symptoms
Other causes of Groin Pain
Intraabdominal disorders
GU abnormalities
Referred lumbosacral pain from lumbar disc disease
Hip Joint disorders
Avulsion Fractures – such a forceful contraction that some bone is pulled off
Common Hip Problems
Groin Strain
Hernias
Iliopsoas Bursitis
Snapping Hip
Muscle Strains and Tendinosis
Delayed Onset Muscle Soreness
• Diagnosis is by history 24-48 hours after exertion. Muscles are sore. No distinct areas of pain as
in acute strains. Usually bilateral (unless a unilateral overuse – like arm-wrestling…)
• Rhabdomyolysis – Can present like delayed onset muscle soreness. Usually associated with
Being immobilized for a prolonged period
Acute dehydration with overuse
Diagnosis is with a blood test – looking for elevations of creatine phosphokinase (CPK)
Trauma due to Anterior Hip Pain
Greater Trochanteric Bursitis
Labral tear
Avulsion Fxs
Lateral Hip & Thigh Pain
Common Hip Problems
Hip Pointer
Meralgia Parethestica
Iliotibial Band and Tensor Fascia Latae Syndrome
Buttock and Posterior Thigh Pain
Sciatica
SI joint and Ligaments
Gluteal strain
Gluteus medius weakness – due to overuse, associated with SI dysfunction
Hamstring strain – due to acute overstretching, running, sprinting
Local pain, deformity, poor ROM & strength
Piriformis Syndrome
Dislocation – direct blow with hip abducted
Posterior: short leg, hip adducted, severe pain, inability to move, foot points to other leg
Anterior: abducted, short, points away from other leg
Complications: Avascular necrosis
MSK CCC 18: Adult hip pain – refer to lecture slides for cases and answers
MSK CCC 19: Congenital/Ped Disorders of Lumbar/Thoracic Spine
Myelomeningocele – localized failure of the embryonic neural tube to close properly
Chiari II Malformation
Tethered Cord
Congenital Deformities of the Spine
Congenital Scoliosis
Idiopathic Scoliosis
Leg Length Discrepancy
Infant and Juvenile scoliosis
Congenital Kyphosis
Congenital Lordosis
Spondylolysis/Spondylolisthesis
MSK CCC 20: Peds LE disorders
Rotational Deformities
Intoeing
Metatarsus Adductus
Clubfoot
Tibial Torsion
Medial Femoral Torsion
Outtoeing
Angular Deformities
Blount disease
Foot Deformities
Clubfoot
Cavus Foot
Calcaneovalgus Foot
Pes Planus
Hip disorders
Developmental Dysplasia of the Hip
Slipped Capital Femoral epiphysis
Legg-Calve-Perthes Disease
Coxa Vara and Valga
Toewalking
MSK CCC 21: DDX Limping child without fever
Developmental Dysplasia of the Hip –involve proximal femur/acetabulum
F/P: occurs in 1.5% of neonates
Risks: female, +Fa Hx, breech birth, multiple gestation, 1st prego, fat baby, oligohydramnios,
clubfoot, caucasian
L hip > R hip
Pathophys: early disruption of relationship b/w femoral head and acetabulum, inadequate contact =
neither forms normally
Could be due to high levels of estrogen/relaxin in females
Clinical Findings:
Ortolani maneuver – to reduce a dislocated hip
Barlow maneuver – to determine if hip is dislocatable
+ Galeazzi/Allis sign – shortened thigh, decreased adduction
Typical dislocation – majority, in infants w/ no other problems, a developmental disorder
Teratologic dislocations – due to underlying NM disorder, occur in utero
Eval:
PE! If abnormal Ultrasound in coronal or transverse planes or hip x-rays
Lines drawn: Hilgenreiner, Perkins, Sheton (disruption here suggest DDH)
Tm: Restore normal relationship b/w femoral head/acetabulum
Paclik harness to keep hips in flexion/abduction until clinical/radiographs are normal (<6mos)
>6 months – may require a closed reduction
Slipped Capital Femoral Epiphysis – Salter-Harris type 1 fx through proximal femoral physis due to
stress around the hip
F/p: MC hip abnormality in adolescence
M > F, AA affected more
Just after puberty, associated with fat kids
Risks: Skeletal immaturity malnutrition
Overweight Prior dx of DDH
Chemotherapy use Endocrine dx
Irradiation Renal failure
Pathophys: Fx is due to stress at growth plate, role in hormones is strong b/c this occurs exclusively
during pubertal growth spurt
Clinical Findings:
50% present with hip pain, 25% present with knee pain
Could complain for weeks, watch for ddx (acute muscle strain, Osgood-Schlatter, flat feet)
Outcome is related to severity of the slip
Eval:
H & P, baseline radiographs (AP of pelvis + lateral frog-leg)
Obligate ER of hip, soft tissue changes near iliac crests
TM: Stabilization of the hip to avoid further damage to the blood supply
F/U: DJD in middle age,
Legg-Calve-Perthes Disease – avascular necrosis of the proximal femoral head due to compromised
blood supply
F/P: mean age 7, M>F, unilaterally most of the time
Risks: Trauma SCFE steroid use sickle-cell crisis
Toxic synovitis DDH delayed bone age* short stature*
Pathophys:
Interruption of blood supply to secondary ossification centers due to rapid growth joint
prone to avascular necrosis replacement with new bone that may appear normal on xray
Clinical Findings:
MC: painless limp, may present after exertion
Intermittent pain w/ walking or altered gait in children between 4-10,
Referred pain to lateral thigh, contralateral knee, gluteal pain
Pain with passive ROM (IR and abduction)
Eval:
CBC, ESR for infection
AP, frog-legs
Bone scan to eval the blood supply
Tm:
Protect hip joint! ↓wt bearing, keep femur in Adduct/IR position
keep head inside acetabulum by bracing or sx
F/U:
Short term prognosis is related to severity of disease process or age at onset (older – worse)
Long term - OA
Transient Synovitis – arthralgia from inflammation in the synovium of the hip
F/P: one of MC causes of joint pain in peds, M>F, between 3-10 y/o
Pathophys:
Non-specific inflammation of synovial membrane synovial bulging/pain
May have hx of trauma or hx of viral infection preceding the joint pain
Clinical Findings:
Pain with walking, fever, Hx of recent URT infection
↓ROM for AB and IR, hip is tender to palpation
NO skin erythema
Eval:
Leg Roll Test – most sensitive + with muscle guarding
Examine knee
AP/frog leg films show increased joint space
↑WBC, ↑ESR – monitor for bacterial joint infection
Needle aspiration with ultrasound guidance if: temp > 99.5, ESR > 20, severe hip pain/spasm
Check for WBC, Gram stain, culture, ↓glucose in aspirate
Tm:
Bed rest with no wt bearing, restrict activities
NSAIDs (ibuprofen, naproxen)
Any manipulation of the hip is contraindicated until the diagnosis is confirmed!
F/U: Reeval in 12-24 hours
Resolves spontaneously in 2 wks, so if symptoms are still present – check for something else!
Recurrence 4-17%, sm risk for OA
MSK CCC 22: Genetic Musculoskeletal Disorders
Osteogenesis imperfecta – defects in Type 1 collagen very fragile, brittle bones that break easily
Freq/Pred: MC is Type 1, IV, V and VI are really rare
No known racial/ethnic predilection, no gender preference
Pathophys: mutations on loci encoding for alpha1/2 chains of type I collagen
Clinical Findings:
Type I - onset in infancy
A – dentinogenesis imperfecta absent
B – dentinogenesis imperfect present
Both – blue sclera, in utero fractures, kyphoscoliosis, hearing loss, easily bruised, mild,
short stature
Grow up normally functioning despite lots of fractures
Type II - onset in utero, do not survive 1st year, most are stillborn
Dentinogensis imperfecta, blue sclera, NO hearing loss, perinatal lethality
Small nose, CT fragility, 100% have in utero fractures, short trunk
“beaded ribs” on x-ray
Type III - 50/50 infancy and utero with fairly normal life span if they survive early life
Dentinogenesis imperfect, no hearing loss, variable sclera
50% with in utero fractures
Limb shortening with progressive deformity
Pulmonary HTN
Triangular face, frontal bossing
Type IV - onset in infancy
A – w/o dentinogenesis imperfecta, B – w/o dentinogenesis imperfect
Both – normal sclera/hearing, angulation of long bones, no bleeding diathesis
Type V and VI – variable onset
Eval: Collagen synthesis analysis to differentiate OI from child abuse/genetic counseling
BMD (not proven to be sensitive)
Chromosomal gene markers
Prenatal testing via chorionic villus sampling
Imaging of skull, chest, long bones, and pelvis as soon as diagnosis is thought of
TM and Management:
No medical therapy exists but some experimental use of bisphosphonates has been tried
Pamidronate, Clodronate – both experimental
Surgical for severe problems
Intramedullary rodding
OMT, Genetic counseling
F/u: Educate. Achieve maximal mobility and prevent fractures!
Endochondroma/Enchondromatosis – B9 bone neoplasms that can cause pathologic fxs and pain
Fre/Pred: Risk for malignancy with multiple enchondromas – seen in long/flat bones
Pathophys: Ectopic hyaline cartilage resting in intramedullar bone, replace normal bone with
cartilage – look lytic or circular on x-ray
Pathologic fxs can occur due to “replacement” phenomenon
MC malignant tumor associated: Chondrosarcoma
Clinical Findings:
Asymptomatic and usually enchondromas cause no problems
With malignancy – pain, pathologic fxs
May get calcified over time
Eval:
Xrays are modality of choice
MRI and CT reserved for further delineation
Rare to use biopsy or bone scan
Tx:
No medical treatment necessary unless they become malignant or cause fractures
PREVENTION!
Subtypes:
Ollier – nonhereditary presenting with multiple enchondromas with unilateral distribution
Good prognosis
Maffucci – nonhereditary with multiple hemangiomas and multiple enchondromas
Metachondromatosis – multiple enchondromas and osteochondromas
Mucopolysaccharidosis – result of defective lysosomal enzymes, cells accumulate
proteins/glycosaminoglycans
Freq/Pred: Sanfilippo is 80% of cases, all AR except Hunter which is X-linked
Pathophys: By-products of incomplete lysosomal processes build up in tissue and alter cell function
Diagnosis is made by seeing these by-products in the urine
Eval:
Prenatal diagnosis
UA shows excessive excretion of GAGs
Xrays – basis of diagnosis show skeletal abnormalities
Head CT to r/o hydrocephalus and an echo to check the heart
Tx and management:
No cures – enzyme laronidase for MPSI
Management of symptoms, BM transplant for some
F/U: Prognosis is based on type, but most have a shortened life span
Subtypes:
Hurler – deficiency in alphaLiduronidase
Normal at birth, dx @ 6-24 months
Corneal clouding, skeletal dysplasia, coarse facial features, lg tongue, short stature
Developmental delay, hearing loss, hydrocephalus
Death by age 1
Hunter – deficiency in iduronate sulfatase
Pebbly skin lesions on the back, arms, thighs
Mild: slower progression with normal intelligence and hearing loss
Severe: at age 2-4 y/o, progressive neurological involvement
Retinal degeneration, MR, joint stiffness/deformities
Death by 10-15 years
Sanfilippo – deficiency in heparin N-sulftase or glucosaminidase
MC MPS disorder, with 4 subtypes
Severe CNS involvement with severe behavioral disorders
Mental deterioration, lg head, H/S megaly, coarse hair, joint stiffness
Death by 2nd/3rd decade
Morquio – deficiency in acetyl galactosamine sulfatase or beta galactosidase
Orthopedic problems: spondyloepiphyseal dysplasia
Genu valgum, short status, scoliosis, odontoid hypoplasia, AA instability
Mild: normal life span
Severe: death by age 30
MSK CCC 24: Juvenile Rheumatoid Arthritis
Freq/Pred
10-20 cases/100,000 kids
Native Americans have higher incidence
AAs are older when diagnosed, more likely to have +RF
Pauci/polyart more common in girls
Pauci – early childhood, system – any age
Pathophys:
True etiology is unknown
Synovium has an infiltration of B-cells, plasma cells, monocytes = extra synovial fluid = increased
pressure = distention of the joint capsule = more inflammation
Cytokines/proteases destroy the joint cartilage breakdown of bone/joint infrastructure
Clinical subtypes:
Systemic onset (Still’s Disease)– high spiking fevers several times daily for 2-3 wk period,
may/maynot affect joints
S/S: Very high spiking fever at about the same time everyday
Not responsive to antipyretics
Pink rash on trunk/extremities
Joint swelling does not occur, but arthralgia is common
+/- Lymphadenopathy, +/- hepatosplenomegaly
Definitive diagnosis cannot be made until arthritis appears
Pauciarticular – 4 or less joints involved, usually the larger joints
S/S: MC involves larger, wt-bearing joints
Flexion contractures of the joints
Morning limping w/ knee involvement
+/- Iridocyclitis/iritis
*Include LCP disease, transient synovitis, SCFE and osteomyelitis in differential
*chronic involvement atrophy of thigh/hamstring muscles/ligaments
Polyarticular – 5+ joints affected
Subtypes: RH factor + and RH factor –
+ group – arthritis is similar to adult RA with +/- extensor nodule presence
S/S: Lg joints w/ symmetric involvement of small joints in hands/feet
Pain + ↓ROM of cervical spine
Low grade fevers
Eval
Labs ESR CBC LFTs
UA ANA RF
HLA-B27 antigen
For systemic JRA: total protein/albumin fibrinogen
Imaging:
X-rays of affected joints, bone scan, MRI, CT, echocardiogram
Other procedures:
Aspiration, synovial biopsy, pericardiocentesis
Slit lamp exam of eye in all children with JRA symptoms of any type
DEXA scan to rule out osteopenia
Treatment
Nothing standard, exact is determined by diagnosis and symptoms
Require team approach b/c this involves lots of systems/lifelong problem
Goals: Reduce joint pain, preserve joint function, maintain growth, minimize meds and side
effects and minimize osteoporosis. Screen for iridocyclitis to reduce vision problems and maintain
function and self-esteem
Meds: NSAIDs, etanercept (TNF inhibitor)
F/U: No prevention, OMT, may need sx with aggressive arthritis, joint replacement
MSK CCC 25: Non-traumatic Foot, Ankle pain – Bolin assignments
Medial Foot Pain DDX
Bone
Ligaments/fascia
Nerve
Tendon
Somatic dysfunction
Pes cavus – high arch Pes planus – low arch
Arch Assessment:
Inspection Functional (forward squat test)
Functional Arches of the Foot
Lateral
Medial
Metatarsal
Transverse
Posterior tibial tendinitis
38-58 year old woman who starts new exercise program and complains of progressive, achy pain
in medial arch
Exam: Pain with posterior tibialis MMT
Unilateral pronation, PF and inversion
Work up: Xray
Tx: cast/boot with orthotics
Surgical consult Risk of DJD with rupture
DDx for posterior heel pain:
Haglund’s deformity (retrocalcaneal bursitis)
Os trigonum/impingement
Insertional tendinitis
Retrocalcaneal fat pad
Sever’s Disease
True Achilles tendinitis
Somatic Dysfunction
Achilles Tendinitis
Pain in posterior heel that is insidious in onset (stiffness with runnin and in AM)
Swelling, nodule or both that migrates proximally with PF
Affects 18% of runners
Risks: age, cavus feet, tibia vara, varus deformities, overuse/jumping
Tx: stretching of gastroc/soleus
Eccentric exercise
Achilles Tendon Rupture
Complication of Achilles tendinitis
Hx of activity with a sudden pop “like someone shot me in the back of the leg”
Hx of fluoroquinolone use
Dx: Thompson test, palpation, MRI
Tx: surgery
DDX for Heel Pain:
Fat pad syndrome
Plantar fasciitis – morning symptoms related to fascial tension
Pain at medial insertion
Windlass manuever
Foreign body
Medial plantar nerve entrapment
Bone bruise/stress fx/fracture
Ddx for pain in metatarsals/phalanges
Stress/true fx
Tendinitis
Infxn Tumor Synovitis
Metatarsal:
Metatarsalgia Interdigital neuroma
Turf toe Sesamoid pathology
Friedberg’s infarction
Morton’s Neuroma
Fibrosis of perineural area of common digital nerve leading to entrapment between 3rd and 4th
metatarsal causing sharp, stabbing, lacinating pain
Worse when wearing shoes (small toe box size)
Dx: clinically, palpation of distal intermetatarsal spaces
Mulder’s sign
Laseague’s sign
Workup: Xrays to look for osteophytes/masses
Tx: Conservative injections surgery
March Fracture
90% of all metatarsal stress fxs occurring at neck of 2,3,rth MT
Very common in runners, or 1st MT in dancers
Dx: XRAY
Tx: stiff shoe for 4-6 weeks
5th Metatarsal Stress Fxs
Distal proximal = stress Jones Avulsion
Dx: Clinical suspicion, xrays are usually negative, bone scan shows bone turnover
Tx: modified rest gradual reintroduction of sport
Sesamoids Injured during running, jumping, typically medially
Dx: Pain on plantar 1st MTP joint, pain with maximal DF with 1st ray
Inability to push off
Bunion – Hallux Valgus
Valgus deformity at 1st MTP joint associated with shoes with tight shoe box
Tx: orthotics, wide toe box, sx when conservative measures fail
Hallux Rigidus
Limits 1st MTP joint dorsiflexion
MSK CCC 26: Traumatic foot, ankle
X-rays involved in a work up:
Foot: AP/Lat/Oblique
Ankle: AP/Lat/Mortise view/Broden views
Fracture Types:
Transverse – across bone
Oblique & spiral
Comminuted - fragmented
Compound – bone through skin
Fracture Healing:
Hematoma soft callus + new vessels osteoblasts lay down new bone (bony callus)
Talar Fractures – relatively rare
Talus compressed within mortise (dorsal to plantar shear)
Neck fx is most common, complication is Avascular necrosis
Shepherd’s Fracture – due to forceful plantar flexion (confused with os trigonum)
Frequently missed (on xray) complications are pain/tendinitis
Tx: crutches for 6 weeks
Talar dome fracture – injury to articular cartilage/subchondral bone
Osteochondritis dissecans (loose body separates and floats in the joint)
Prolonged ankle pain after a sprain
Tx: surgery, untreated leads to DJD
Heel fracture – calcaneal most common
MOI: fall from height
Dx: xrays, ct scan
Tx: compression, elevation, foot pumps, early ROM, sx if displaced
Lisfranc Fx/Dislocation
MOI: “foot folded beneath me”
S/S: pain, edema, ecchymosis, inability to bear weight or push off
Dx: subtle dorsal disloation of first MTT joint, wt-bearing xray
Tx: short leg cast or boot 4-6 weeks
>2 mm separation requires surgery
Toe Fractures
MOI: secondary to “stub” or direct impact
Tx: conservative with “buddy taping”
Tendon injuries
Flexor tendons
Extensor tendons
Complication of missed diagnosis: retraction
MSK CCC 27: Non-traumatic knee pain
90% of these problems can be diagnosed with good hx, physical and plain x-rays. MRI is seldom needed.
Hx alone can give diagnosis up to 70% of pain.
PE:
Peri-patellar palpation, patellar gliding/ballotment, patellar grind
Joint line palpation
Varus/valgus stress tests
McMurray’s test
Lachman’s
Anterior/posterior drawer
Pivot shift test
Osteopathic eval – “kinetic chain”
Pronation/supination
Understand “real world” muscle fxn – econcentric function
Influence of compensation and accommodation
Imaging: Only needed if H & P do not provide enough info
Plain films
Functional standing xray – shows true alignment and joint space narrowing
Do at least 4 views: standing AP, lateral, 30° sunrise for patellar tracking, tunnel view)
Asses for arthritis, fracture, growth plate injury, loose body, joint effusion, alignment
Risk factors for Overuse Injury:
Biomechanical
Age:
Peds - rapid growth, usually injury to the apophysis (where tendon attaches to bone)
Middle aged – inadequate conditioning and flexibility
Senior – look for meds or underlying disease process
Extrinsic Factors:
Mechanical, coaching, environment, drug use, training
Classification:
Grade I – post activity pain only
Grade II – pain with activity, does not restrict
Grade III – pain with activity + restriction in performance
Grade IV – pain with activity & rest
Tendonitis (chronic or acute)
Causative factors: changes in mechanical loading or changes in muscle tendon extensibility
Intrinsic factors: structural failure due to overload, wkness, or a combo
Extrinsic Factors: impingement by bone or other structures
“choking the tendon”
Pediatric and Growth Issues
Apophyseal injury – traction induced microtrauma at tendon-bone junction
Physeal injuries – repetitive loading causing metaphyseal ischemica and poor growth in the
proliferative zone widening or narrowing of growth plate
Osgood Schlatter’s Disease – common cause of knee pain in active adolescents (M>F 10-14 years)
Diagnosis – localized pain at tibial tuberosity, no need for radiographs but they can confirm your
suspicion and exlude other causes of knee pain
Patho – microtrauma at deep fibers of patellar tendon at its insertion on the tibial tuberosity
“apophysitis”
Usually self-limited with resolution at skeletal maturity
Tx – relative rest and enhance strength/flexibility
Popliteal (Baker’s Cyst) – distended bursa in the popliteal space
MC bursa involved is beneath the medial head of the gastroc or semi-membranous tendon
Present with complaint of aching pain in the posterior knee/proximal calf
Diagnosis: AP, lateral, tangential X-rays of the knee
Adults – usually associated with intra-articular pathology
Tx: children – may resolve with time, occasionally have to excise
Adults – treat intra-articular pathology first, if discomfrt still remains excise (rare)
Lg, tense cysts can be aspirated with common recurrence
Sinding – Larsen – Johansson Syndrome – inflammation of patella at its inferior pole at the origin of the
patellar tendon, “traction injury”
S/S: swollen, warm, tender bump below the kneecap
Pain w/ activity especially when straightening the leg against force or post vigorous
activity, if more severe – pain with any activity
Tx: Ice, stretching, strengthening, exercises, modification of activities
Patellar band (brace b/w kneecap/tibial tubercle on top of patellar tendon)
Patellofemoral Pain Syndrome
Multifactorial: overuse/overload, biomechanical problems, muscular dysfunction
Pes planus (pronation)
Pes cavus (high-arched foot, supination)
Q Angle – alignment (increased = knocked knees)
Muscular causes
Patellar Tracking – tilt, subluxation with inverted J sign, apprehension test, functional evaluation
Tx: relative rest with temporary change to non-impact activity
Quad strengthening, flexibility (address kinetic chain)
Orthotics, icing, knee sleeve
Osteochondritis Dissecans – unknown etiology
S/S: generalized pain with swelling/aching post activity
Intermittent pain/mild swelling that just doesn’t get better (knee sprain forever)
MC found on medialfemoral condyle weightbearing surface
Diagnosis: Tunnel view x-ray with radiolucent defect on femoral condyle, confirm on MRI
Tx: Rest, period of non-weight bearing or sx if necessary
MSK CCC 28: Traumatic Knee Pain
Bone Trauma
Patella Fracture
Tx: ORIF > 2mm articular displacement
Tibial Plateau fracture (wt bearing surface of proximal tibia)
Tx: >3-5mm, surgery required
Knee joint unstable, fx is open, compartment syndrome surgery
Also fix meniscus injury that may have occurred
Lateral fx can be arthroscopically reduced and treated with leg screws
Medial fx require a buttress plate and screws
Distal Femoral Condyle Fxs and Supracondylar Femur Fractures
Avulsion of Tibial Spine or “bicycle” fracture in children
Soft Tissue Trauma – rare to occur in children
Knee Ligament Tears
Internal: ACL/PCL will not heal on their own (ACL more commonly repaired – must do a graft)
Recovery takes 6 months
External: MCL/LCL – heal on their own
Meniscus Tears – require major trauma at young ages, but minimal twisting/squatting if >35 years
S/s: Pain along joint line, stiffness, mild swelling or knee with or without locking/catching
Audible popping with flexion/extension
Repair is one of the top 3 orthopedic surgical procedures done in US
Repaired with sewing/stapling if the tear is in the right location
Transplant cadaver menisci but unproven efficacy
Articular Cartilage Damage
Poor healing potential, nearly always leads to arthritis
Repair techniques:
Trimming/contouring of torn surface
Abrasion/micro fracture in an attempt to grow fibrocartilage repair cartilage
Filling a contained defect with cartilage and bone grafts from elsewhere
Growing autologous cartilage cells in tissue culture and implanting them
Combos of the above + Knee Dislocation
Patellar Tendon Rupture
Suturing tendon back to patella with large and strong sutures – very successful if done acutely
MSK CCC 30: Bone, joint infections – Palmieri
Review cases
MSK CCC 31: Traumatic injuries to wrist/forearm
Dislocation – bony components of joint are no longer in contact with one another/complete disruption
Incomplete fx – Greestick or Torus
Subluxation – bony compartments are partially in contact with one another/partial disruption
Description:
Direction of fx line
Transverse
Diagonal/oblique
Spiral
Relationship of fragments
Displacement/Translation – sideways motion of a fx
Angulation – amt of bend at a fx line
Shortening – amt a fx has collapsed/bayonet opposition
Rotation
# of fragments
2 – simple
2+ - comminuted
Communication with atmosphere (best evaluated clinically)
Closed
Open
Gustilo classification used for prognosis
Treatment:
Immediate
Debridement of skin, muscle, bone, tendon
Colle’s Fracture
Of the distal radius with dorsal angulation
Jones’ Fracture
Fx of base of 5th metacarpal
Boxer’s Fracture
Fx head of 5th metacarpal with volar angulation
MOI: punching a person/wall
Fractures in Children
Salter-Harris classification (kids fx that involve the growth plate)
I: across the physis with no metaphysical/epiphysial injury
II: across the physis with extends into the metaphysis
III: across the physis which extends into the epiphysis
IV: fx through metaphysic, physis and epiphysis
V: crush injury to the physis
Supracondylar Humerus Fxs
Distal Radius Fxs
Common with high potential for functional impairment and frequent complications
Most often result from a FOOSH
Dx: Xrays – look for dorsal/volar rim, look for die-punch lesions of scaphoid/lunate
Tx: Closed reduction
