Musculoskeletal System/Rheumatologic

Upper Extremities

Bursitis ▪ Causes: injury or trauma; prolonged pressure; overuse or

strenuous activity; crystal-induced arthropathy; and inflammatory arthritis

▪ Swelling, pain ▪ ↓ Active ROM, Full passive ROM ▪ NSAIDs ▪ ***The two main indications to aspirate a bursa are to rule out

infection, and to aid in the diagnosis of a microcrystalline disorder like gout.

Tendinitis ▪ NSAIDs & Rest (ice, compression, elevation) ▪ PT/OT or brace may be useful ▪ Achillis tendinitis is a common injury, particularly in sports that

involve lunging and jumping ▪ Patellar tendinitis is a common among players with a lot of

jumping and landing

Fractures – wrist ▪ Colle’s Fracture (outward) – wrist gets bent backwards ▪ Smith’s Fracture (inward) – wrist gets bent forwards ▪ Results from a fall onto the hand ▪ Pain, deformity, MOI

o Colles – most common injury of the wrist – distal radius fracture w/ dorsal angulation

▪ Dx Xray ▪ Tx Cast immobilization after reduction ▪ *** Radius & ulna fractures comprise the largest proportion

of fractures (44%) ▪ Most affected group 5-14 years (26%)

Strain/sprain – wrist ▪ Sprain – ligaments ▪ Strains – muscles, tendons ▪ Acute – athletes, laborer, weekend worrier ▪ Chronic – overuse, repetitive use at work, sports ▪ Swelling, pain, tenderness, discoloration of skin, may hear a

“popping” or tearing inside wrist ▪ Clinical dx Xray or MRI to confirm ▪ Tx

o Protection splint o Rest o Ice through splint o Compression Ace wrap o Elevation above heart

▪ *** If left untreated, can become a SLAC wrist (scapho-lunate advanced collapse)

Rotator cuff injuries ▪ ***“SITS” muscles: Supraspinatus, Infraspinatus, Teres

minor, Subscapularis ▪ **Supraspinatus most commonly injured ▪ Rare to have an isolated tear of other muscles ▪ Usually tear from abduction and rotation ▪ Acute shoulder pain, night pain ▪ 90% of acute injuries are exacerbations of a chronic RTC tear ▪ Inability to abduct arm, externally rotate arm against

resistance ▪ Drop arm test is “+” ▪ Diffuse atrophy of shoulder musculature ▪ Dx Xrays helpful to r/o tendonitis, tumors, arthrosis

o Arthrography or MRI may be used to dx tears ▪ Tx

o pain meds, ice, ortho referral, prevent frozen should or adhesive capsulitis if possible

o Want to repair within 3-4 months ▪ Usually >40 y/o

Impingement syndrome ▪ Anything that entraps RTC muscles under acromion ▪ HPI: repetitive overhead work or fall on hand ▪ pain at greater tuberosity, lateral shoulder ▪ Pain and difficulty abducting arm ▪ Positive Neer impingement and Hawkins signs ▪ Dx clinical (MRI to r/o RTC tear if not improving w/ tx) ▪ Tx: rest, ice, NSAIDs, PT, steroid injections ▪ If not better after 6-12 wks, may consider surgery

Adhesive capsulitis ▪ Inflammatory process that may follow injury to the shoulder

or arise on its own ▪ Characterized by pain and restricted gleno-humeral

movement ▪ Often preceded by insignificant injury ▪ Decreased shoulder ROM, especially abduction and flexion ▪ Passive ROM limited by firm resistance ▪ Dx

o Arthrograthy may show decreased volume of the joint capsule and capsular contraction

▪ Tx o Aggressive home exercise program and PT o Passive ROM, NSAIDs o Operative manipulation when exercises fail o Not a permanent loss of motion!

▪ *** More common in women and diabetics o If they have this on top of an RTC tear, need tear to

clear before address this

Lateral Epicondylitis (“tennis elbow”) ▪ Overuse, repetitive supination and wrist extension ▪ Most common overuse injury of the elbow ▪ Point tenderness over lateral epicondyle ▪ Pain on resisted wrist extension ▪ Clinical diagnosis

o x-ray to r/o arthritis, may show osteophytes overlying lateral epicondyle

o MRI may be useful in demonstrating tendon disruption

▪ Tx o Rest (at least 6 wks), Ice, NSAIDs o counter force strap (counterbalance brace) o Steroid injection, a few may require surgery

▪ ***Extensor muscles attach to the lateral epicondyle

Medial Epicondylitis (“golfer’s elbow, baseball elbow”) ▪ Affects the flexor-pronator muscles ▪ Point tenderness over medial epicondyle ▪ Pain on resisted wrist flexion or pronation ▪ Clinical diagnosis (x-ray to r/o arthritis or loose body) ▪ Tx

o Rest, ice, NSAIDs o Steroid injection, stretching/strengthening

▪ *** Flexor muscles attach to the medial epicondyle

De Quervain’s ▪ A stenosing tenosynovitis – most common tendonitis in wrist ▪ Age: 30 – 50, women & diabetics

o Lifting your child repeatedly involves using your thumbs as leverage

o Jobs or hobbies that involve repetitive hand and wrist motions

▪ Painful condition involving tendons on thumb side of wrist ▪ difficulty moving thumb/wrist when grasping or pinching ▪ Pain/tenderness/swelling near base of thumb ▪ Radiation of pain up forearm is common ▪ Dx

o Swelling and thickening of tendon sheath may be appreciated

o Finkelstein test!

o Imaging (xrays) generally NOT needed to diagnose

▪ Tx o Brace/thumb splint o NSAIDs, PT/OT o Cortisone injection/surgery if needed

Olecranon bursitis ▪ Caused by acute injury or repetitive trauma to olecranon

bursa; less frequently from skin breaks w/ septic cause (S. aureus)

▪ May be painful, may also look reddened and appear like cellulitis

▪ Dx Clinical dx (imaging not usually indicated unless suspicion of fracture)

▪ Tx o Sling/pain meds/ice o Ace wrap (compression) o Drain if infectious (yellow joint fluid) o Abx if infectious

▪ *** ROM usually preserved

Carpal tunnel syndrome ▪ Compression of the median nerve under the transverse

carpal ligament ▪ Can be precipitated by premenstrual fluid retention, early RA,

acromegaly, trauma, pregnancy, repetitive flexion/extension of wrist, alcohol abuse

▪ Diabetes or metabolic disorders that make nerves more susceptible to compression are at higher risk (lupus, RA)

▪ Sx Pain, night pain, numbness/tingling (paresthesia) in hand & wrist (spare little finger)

▪ Dx o Durkan’s test: reproduction of symptoms with

carpal tunnel compression o Phalen’s sign: reproduction of symptoms with wrist

hyperflexion o Tinel’s sign: reproduction of symptoms with

percussion over carpal tunnel o Flick sign: patient reports shaking of the hand

provides relief ▪ Tx NSAIDs, volar splint in neutral position

o Surgical intervention may be needed to decompress nerve – 99% curative – most common and successful operative tx of peripheral nerves

▪ ***Most common mononeeuropathy

Ganglion cyst ▪ Noncancerous mass, often on tendons or joints of wrist/hands ▪ Round, small, fluid-filled masses, usually painless (unless

compressing nerve) ▪ Clinical diagnosis ▪ Tx

o Observation & rest - often resolves on its own with rest

o Immobilization o Aspiration or surgery if it painful or disabling

▪ *** Most common mass/lump of hand

Gamekeeper’s thumb (Thumb Sprain) ▪ Sprain or tear of the ulnar collateral ligament of thumb ▪ Usually a hx of sprained thumb or fall on hand ▪ Ligamentous laxity of the ulnar collateral ligament, with

instability and weakness of pinch ▪ Clinical dx MRI if unstable on exam ▪ Tx

o Immobilization with splint o Surgical repair of UCL if complete rupture

▪ Stenner lesion – absolute indication for surgery

Shoulder Dislocation ▪ Usually anterior ▪ Pt will support affected arm with the other arm ▪ May have loss of sensation over shoulder due to axillary nerve

entrapment ▪ Management Manual relocation, can resolve

spontaneously after a few weeks

Clavicle Fracture ▪ Usually a pediatric fracture ▪ MOI: direct force to lateral shoulder, fall or sporting injury ▪ Affected extremity held close to body ▪ Shoulder is slumped downward, forward, and inward ▪ Management Immobilization in figure 8 dressing

Scapula Fracture ▪ MOI: direct violent trauma ▪ May also have injury to ribs, chest wall, or shoulder girdle ▪ Shoulder is adducted and arm is held close to the body ▪ Immobilization with sling and swathe dressing

Humeral Shaft Fracture ▪ Typically from trauma in the elderly ▪ Extensive bruising of upper arm ▪ Wrist drop from radial nerve damage ▪ Wrist splinting and casting over site of break

Supracondylar Fracture ▪ Pediatric fracture ▪ Usually involves distal humerus ▪ Limb ischemia if branchial artery is damaged ▪ X-ray showing posterior sail sign, anterior humeral line drawn

will not bisect the capitate ▪ Assess neurovascular involvement, check radial pulses!

Radial Head Fracture ▪ MOI: FOOSH ▪ Decreased ROM in elbow ▪ Difficult to see on x-ray, may see displacement of fat pad,

elbow effusion

Colles Fracture of Distal Radius ▪ MOI: FOOSH posterior displacement of wrist (“dinner fork

deformity”) ▪ Casting alone if nondisplaced ▪ Closed reduction followed by casting if slightly displaced ▪ ORIF & short arm cast if displaced

Scaphoid Fracture ▪ FOOSH ▪ Fullness or pain in the anatomical snuffbox ▪ Possibly negative x-ray (4 view x-ray - repeat imaging in 10-14

days if negative) ▪ Management Immobilize in thumb spica ▪ ***Risk of AV necrosis due to poor blood supply

Smith Fracture of Distal Radius ▪ MOI: opposite Colles = fall on back of hand

Boxer’s Fracture of Distal 5th Metacarpal ▪ MOI: blow of closed fist against another object ▪ Splinting vs percutaneous pinning

Lower Extremities

Ankle Sprain

• Patient with a history of ankle inversion

• PE will show pain and swelling

• Imaging will show partial or complete tearing of ligaments

• Most commonly injured anterior talofibular ligament (ATFL)

• Treatment is RICE therapy

• Comments: Ottawa Rules to determine imaging

OTTAWA RULES: Do ANKLE xray if there is pain in the malleolar region with any of the following:

▪ Bone tenderness @ posterior edge of lateral malleolus ▪ Bone tenderness @ posterior edge of medial malleolus ▪ Inability to bear weight for at least 4 steps

Do FOOT series if there is pain in the mid-foot region with any of the following:

▪ Bone tenderness @ navicular bone ▪ Bone tenderness @ the base of the fifth metatarsal ▪ Inability to bear weight for at least 4 steps

ANKLE SPRAIN CLASSIFICATION: Grade 1 minimal tenderness & swelling (micro tears), treatment = weight bear as tolerated & PT Grade 2 moderate tenderness & swelling, decreased ROM, possible instability (complete tears or some), treatment = immobilize with air splint & PT Grade 3 significant tenderness & swelling, instability (complete rupture of ligament), treatment = immobilize, PT, possible surgical reconstruction

Meniscal injuries ▪ Cartilage injury ▪ Medial & lateral menisci most common knee injury ▪ Occurs with excessive rotational force (twisting or slipping) ▪ Sx Effusion (past or present)

o -delayed swelling (overnight) o +/- locking or clicking (inability to fully extend) o “knee giving way”, difficulty w/ stairs

▪ Dx + McMurray test & + Apley test (Clinical dx) o Confirm with MRI prior to surgery

▪ Tx o Rest, ice, elevation o NSAIDS o Quad strengthening (PT)

▪ *** Medial meniscus injured most often

Slipped Capital Femoral Epiphysis ▪ MOI: occurs when femoral head is displaced from the

femoral neck ▪ Patient will be an obese male 12 - 16 years old ▪ Complaining of a progressive limp and knee pain ▪ PE will show loss of hip internal rotation ▪ African American ▪ Left hip > right hip ▪ Limp, hip or groin pain

o Affected leg turns out and appears shorter ▪ AP/lateral X-ray of bilateral hips

o Xray will show "scoop of ice cream slipping off an ice cream cone"

▪ Abnormal Klein line ▪ Non-weight bearing ▪ An orthopedic emergency, requires surgical repair

Acute and chronic lower back pain ▪ 80% of US population will have episode of back pain, caused

by overuse, heavy lifting/twisting ▪ Low back pain that may radiate to buttock or leg (sciatica) ▪ Worse with periods of long standing ▪ Tenderness over paraspinal muscles, sciatic n. palpation, and

decreased lumbar ROM ▪ Neuro exam will be normal ▪ Dx: Clinical Xray to r/o other causes if sx persist ▪ Tx

o Rest, ice/heat, NSAIDs o PT, education o Narcotics + muscle relaxants for short time (~3d)

Plantar fasciitis ▪ Most common cause of heel pain ▪ Caused by microscopic tears in plantar fascia ▪ Often seen with recent increase of activity ▪ Pain with first steps in morning then improves ▪ Tender along plantar fascia ▪ Clinical dx ▪ Tx

o Rest/decreased activity o Stretch PF & calves o NSAIDS, ice, massage o Heel cushion, night splint injection, surg last resort

▪ *** Common in runners and overweight pts

Pediatric Fractures ▪ Bowing and greenstick fx are unique to kids due to their

skeletal immaturity ▪ Growth plate fx are classified by Salter-Harris ▪ Most fx only require closed reduction ▪ Kids heal faster due to more active periosteum and higher %

cartilage

Fractures Associated with Child Abuse ▪ Metaphyseal corner fx: child abuse until proven otherwise ▪ Posterior rib fx: child abuse until proven otherwise ▪ Any fracture in a child under 1 ▪ LE fracture in a non-ambulatory child ▪ Multiple fractures in various stages of healing ▪ Sternal or scapular fx: high impact mechanism such as MVC

required or else it may be child abuse ▪ Spinous process fracture

Hip Fractures ▪ Typically occurs in elderly females (mortality 20-35%) ▪ Extracapsular:

o Does not affect blood supply to femoral head = complications of nonunion are rare

o Stable vs unstable (detached fragment of lesser trochanter)

o Tx with Internal fixation ▪ Intracapsular:

o Can affect blood supply to femoral head, especially if displaced nonunion and avascular necrosis

o Internal fixation if no displacement o Hemiarthroplasty often the treatment of choice due

to high risk of avascular necrosis

Ankle Fracture ▪ Involves lateral, medial, or posterior malleolus ▪ MOI: eversion or lateral rotation on the talus ▪ Foot fracture (Involves talus, calcaneus, metatarsals, or

phalanges) ▪ Sx Tenderness in these areas suggests fracture vs strain or

sprain (Ottawa ankle rules) ▪ Workup Ottawa ankle rules help determine need for x-ray

o Standard AP and lateral views on x-ray (plus AP view with 15° internal rotation if suspecting ankle fracture)

▪ Management & Prognosis Elevation and ice, short leg cast

Knee Fractures (patella/tibial plateau) ▪ Sx Knee pain, difficulty walking, swelling and bruising

o Aspiration will show hemarthrosis with fat globules o Point tenderness

▪ Management o Lower extremity immobilization and no weight

bearing

Complications of fractures ▪ Most commonly DVT or PE ▪ Compartment syndrome ▪ Avascular necrosis ▪ Nerve injury ▪ Malunion, nonunion, or delayed union ▪ Complex regional pain syndrome form injury to sympathetics

(burning pain, skin changes, swelling, excessive sweating at site of injury)

Other

Osgood‐Schlatter Disease ▪ Inflammation over insertion point of patellar tendon in tibial

tuberosity (avulsion due to overuse) ▪ -Most common in boys age 10-15 ▪ Signs & symptoms

o Pain/tenderness & tibial tuberosity o Anterior knee pain that increases gradually o Worse with kneeling, jumping, squatting, or stairs o Relieved by rest

▪ Workup o X-ray to rule out fracture

▪ Management o Self-resolving o Rest & NSAIDs

Henoch‐Schonlein Purpura (AKA immunoglobulin A vasculitis) • Small vessel vasculitis in which complexes of IgA are

deposited in the blood vessels

• Children 4-12 years old

• Follows URI

• Arthritis + purpura + GI sx

• May have heme positive stool, microscopic hematuria or proteinuria

• Complications: nephropathy, intussusception

• Rx: supportive care (symptomatic relief, can be treated with steroids)

Kawasaki Disease ▪ medium-sized arteries ▪ Patient will be a child < 4 years old ▪ With a history of high fever for 5 days ▪ Complaining of conjunctivitis, rash, adenopathy, strawberry

tongue, hand/feet edema, fever ▪ Treatment is IVIG + aspirin ▪ Comments: #1 cause of pediatric acquired heart disease, risk

for coronary artery aneurysm ▪ Mnemonic:

CRASH and burn: Conjunctivitis, Rash, Adenopathy, Strawberry tongue, Hand/feet edema, Fever

▪ Cardiac Manifestations: o 25% of untreated patients go on to develop coronary

artery aneurysm ▪ Treatment

o IVIG – IV infusion of gamma globulin lowers risk of coronary artery complications

o Aspirin - High doses of aspirin may help treat inflammation. Aspirin can also decrease pain and joint inflammation, as well as reduce the fever.

▪ High dose in acute stage ▪ Low dose for months until labs normalize

▪ Prognosis Kawasaki disease is usually treatable, and most children recover from Kawasaki disease without serious problems.

Osteoporosis ▪ Decline in bone mass with aging → ↑ bone fragility + ↑

fracture risk (F > M) ▪ Risk factors: alcohol, steroid use, whites, Asians, cigarettes,

meds (depo, anticoags, GnRH agonists), low body weight o Most common fracture: vertebral body

compression fractures ▪ DEXA scan Screen women of average risk >65 ▪ Screen women younger if they have risk factors

o If osteopenia (1.0-2.5), screen again 1-5 yrs later o T-score ≤ -2.5

▪ Prevention: weight-bearing exercises, calcium, vitamin D, smoking cessation Pharmacologic rx: bisphosphonates

▪ Bisphosphonates MOA: inhibit bone resorption o Alendronate, resideronate, ibandronate o Must take on empty stomach and sitting upright o AEs: hypocalcemia, dysphagia, esophageal

inflammation, gastric ulcer, visual disturbance, arthralgia, HA, myalgia, fever after first dose

o Possible atypical femoral fx = take break every 5 years

o Possible osteonecrosis of the jaw in cancer pts receiving IV treatment

o Contraindications: inability to sit upright for 30 min, esophageal strictures, hypocalcemia

▪ VitD = 800-1000 IU daily ▪ Calcium = 500-600 mg BID

Costochondritis

• An acute and temporary inflammation of the costal cartilage

• Common cause of chest pain

• Often resolves on its own

• Etiology o Most cases = unknown o Physical trauma, scoliosis, RA, OA o Viral: Costochondritis commonly occurs with viral

respiratory infections because of the inflammation of the area from the viral infection itself, or from straining from coughing

o Bacterial: Costochondritis may occur after surgery and be caused by bacterial infections.

o Fungal – rare

• Sx Tenderness to palpation, affects multiple ribs, worsened with coughing, deep breating, or physical activity

• Tx NSAIDs, opiates if needed, can do corticosteroids to unresponsive cases

Overuse syndrome

• Tendon thickening and chronic, localized tendon pain

• Not typically associated with inflammation

• Risk factors o Advancing age and increased overall volume or

intensity of tendon load pose the greatest risk for developing overuse tendinopathy

• The major clinical features associated with tendinopathy are pain with palpation of the affected part of the tendon and pain with tendon loading

Rheumatologic Disorders

Gout

• Patient will be a middle-aged man

• Complaining of acute onset of pain in the first MTP (Podagra)

• Labs will show needle-shaped crystal with negative birefringence

• Most commonly caused by uric acid crystals

• Treatment is:

• Acute: NSAIDs (indomethacin)

• Chronic: allopurinol or colchicine

• Comments: can be triggered by loop and thiazide diuretics

Pseudogout

• M=F, >50 years old

• Slower onset than gout

• Positively birefringent, rhomboid-shaped, calcium pyrophosphate crystals

• Knee

• Rx: NSAIDs

Rheumatoid Arthritis ▪ Women in 20s/30s ▪ Autoimmune destruction of synovial joints ▪ Morning stiffness lasting > 30 minutes ▪ Fatigue ▪ MCP, PIP ▪ Bilateral ulnar deviation at MCP ▪ Baker's cyst, swan neck deformity, boutonniere deformity ▪ Symmetrical, bone errosions on xray & joint space narrowing ▪ Systemic sx

o Lung: interstitial fibrosis, effusions o Spine: atlantoaxial joint subluxation;

cord/vertebral artery compression o Anemia

▪ Labs RF, ESR, CRP ▪ NSAIDs, glucocorticoids, DMARDS (MTX), TNF inhibitor Consider polymyalgia rheumatica if (+) ESR & CRP (though not required) and (-) RF

Polymyositis ▪ Inflammatory muscle disease proximal weakness of the

skeletal muscles ▪ Caused by killer T-cells attacking muscle cells expressing

MHC class I (slow fibers) ▪ May be triggered by certain cancers ▪ Sx Insidious onset, proximal muscle weakness (can’t get

up from chair), muscle atrophy, low-grade fever, peripheral lymphadenopathy

▪ Workup LDH, LFTs, ANA, EMG, muscle bx ▪ Management High dose steroid taper

o DMARDS for patients unresponsive to steroids

Fibromyalgia

• Patient will be a woman

• Complaining of widespread musculoskeletal pain for > 3 months, non-restorative sleep and generalized fatigue

• PE will show tenderness at > 9 of 18 anatomic sites (“trigger points”)

• Labs will be normal

• Diagnosis is made clinically

• Treatment is education, antidepressants, avoid opioids

Antiphospholipid Antibody Syndrome

• Patient with a history of lupus or other rheumatic diseases

• Complaining of repeated spontaneous abortions

• Labs will show thrombocytopenia

• Most commonly caused by autoimmune

• Treatment is anti-coagulation

Systemic lupus erythematosus

• African-Americans, females

• Malar rash

• Arthritis

• Renal disease

• Cardiac: fibrinous pericarditis, Libman-Sacks endocarditis

• CNS: HA, stroke, seizures

• Drug induced: Hydralazine, INH, Procainamide, Phenytoin, Sulfonamides (HIPPS)

• Antinuclear antibodies (ANA): 100% sensitive, not specific

• Anti-dsDNA antibodies: 100% specific, poor prognosis

• Anti-Smith antibodies: 100% specific, not prognostic

• Antihistone antibodies: sensitive for drug-induced lupus

• NSAIDs, steroids, immunosuppressants, hydroxychloroquine

Scleroderma ▪ Excessive collagen deposition ▪ F > M ▪ Raynaud's phenomenon ▪ GI: dysmotility, dysphagia ▪ Pulmonary: pulmonary

hypertension, interstitial fibrosis ▪ Renal: malignant HTN,

arteriosclerosis ▪ CREST: Calcinosis, Raynaud

phenomenon, Esophageal dysmotility, Sclerodactyly, Telangiectasia

▪ Systemic: anti-SCL-70 antibody, ANA

▪ anticentromere antibody, ANA

Polymyalgia rheumatic

• More common in women > 50 years old

• Pain, stiffness in shoulders and hips (~1 month)

• Fever, malaise, weight loss common

• No weakness

• Lab findings: ↑ ESR, ↑ CRP, normal CK

• Temporal (giant cell) arteritis

• Rx: steroids (prednisone)

Sjogren’s Syndrome:

• Characterized by dry eyes (keratoconjunctiva sicca), and dry mouth (xerostomia)

• Destruction of lacrimal and salivary glands

• Can be associated with RA or on its own

• Why It’s Important: o 9x more common in women o INCREASED RISK FOR B-CELL LYMPHOMA (44x)

• Diagnosis: o Need ocular symptoms, oral sx o Autoantibodies (Ro-SSA or La-SSB, ANA, or RF) o Parotid enlargement (usually bilateral)

• Clinical Presentation: o Dry eyes, mouth, skin, vagina o Salivary gland enlargement (30-60%, usually bilateral) o Skin: vasculitis purpura, raynaud’s

Reactive Arthritis (Reiter’s)

• Patient with a history of recent GI or Chlamydia infection

• Complaining of acute asymmetric arthritis

• PE will show conjunctivitis, arthritis, urethritis

• Labs will show HLA-B27

• Treatment is NSAIDs

• Comments: “Can’t see” (uveitis), “can’t pee” (urethritis), “can’t climb a tree” (arthritis)

• ***Can be associated with immune response to enteric or GU organisms (shigella, salmonella, Yersinia, chlamydia)

Osteoarthritis ▪ Progressive destruction of articular cartilage by proteolytic

enzymes, remodeling of subchondral bone ▪ Stiffness worse w/ activity, relieved with rest ▪ Hard, bony swollen joints ▪ Typical finger joints: DIPs, CMCs of thumbs ▪ Heberden (DIP) & Bouchard (PIP) nodes ▪ Osteophytes ▪ Limited movement, crepitus, joint effusion ▪ Thinned cartilage, bone ends rub together ▪ Labs: typically normal ESR & RF ▪ Clear viscous synovial fluid w/ WBC <2k ▪ Tx:

o Weight loss, PT, joint protection, physiotherapy (heat, cold), orthotics

o NSAIDs, Tramadol, Intraarticular corticosteroids o Arthroscopic irrigation or synovectomy, arthroplasty, o Artificial joints

Osteosarcoma ▪ Osteosarcoma is the most common primary malignancy of

the bone ▪ Bimodal age distribution with peaks in early adolescence

and in adults over the age of 65. o 10–20 years old, > 65 years old

▪ Sx pain and swelling ▪ Dx X-ray: Codman's triangle, sunburst pattern ▪ Can be caused by ionizing radiation for treatment of

childhood solid cancers (example retinoblastoma) ▪ More common in the long bones with the most frequent

sites in descending order being femur, tibia, and humerus ▪ Most common malignant bone tumor

Septic arthritis

• Age <35: N. gonorrhea

• S. aureus most common overall

• Hematogenous spread

• Fever, pain, ↓ ROM

• Knee (most common)

• Arthrocentesis (WBC >50,000 with >75% PMNs)

• IV ABX, surgical washout

Acute/Chronic Osteomyelitis

Ankylosing Spondylitis

• HLA-B27

• Sacroiliac joints and spine

• Low back pain: worse in the morning, improves with exercise

• X-ray: bamboo spine

• ↑ ESR

• Uveitis, aortic regurgitation

• NSAIDs, MTX, physical therapy, spinal fusion

Avascular Necrosis

• Causes: corticosteroids (most common), alcohol

• Most common site: femoral head

• MRI

Peripheral Neuropathies

• Sciatic: buttock injury, hip dislocation, ↓ knee flexion, foot drop, rx: ankle splint

• Common peroneal: proximal fibula injury, footdrop, rx: ankle splint

• Radial: crutches, wrist/finger drop, rx: wrist splint

• Ulnar: elbow injury, ↓ finger adduction/thumb grasp, 4th/5th digit paresthesias

• Lateral femoral cutaneous: inguinal ligament entrapment, upper thigh dysesthesia/numbness

Pelvic Avulsion Fracture

• Powerful contraction of lower leg muscle on a developing apophysis

• Most common type ischial tuberosity avulsion

• Diagnosed with AP and frog leg radiographs

• Treated with rest, crutch use and pain control

• Surgical pinning rarely required

Multiple Myeloma

• Single clone plasma call malignancy

• Elderly

• CRAB: hyperCalcemia, Renal insufficiency, Anemia, lytic Bone lesions/Back pain

• X-ray: lytic lesions

• Monoclonal antibody spike

• PBS: Rouleaux formations

• SPEP: M spike

• UPEP: Bence-Jo

Osteogenesis Imperfecta (“Brittle Bone” Disease)

• Patient with a family history of similar symptoms

• Complaining of hearing loss, easy bruisability, or multiple fractures

• PE will show blue sclera, increased laxity of joints and skin, short stature, scoliosis, basilar skull deformities

• Most commonly caused by autosomal dominant mutation in collagen

Polyarteritis nodosa

• Proximal myalgia and weakness

• Skin ulcers

• Nephritis

• Mesenteric ischemia

• Spares pulmonary vasculature

• Hepatitis B seropositivity

• DX: biopsy, mesenteric angiogram

• HBV testing

• Rx: steroids, cyclophosphamide

Lisfranc Injury

• Definition: any fracture or dislocation of the tarsal-metatarsal joint

• Plantar ecchymosis

• Fleck sign (pathognomonic): avulsion fracture of the medial aspect of the base of the second metatarsal

• Weight-bearing films may be necessary

• Treatment:

• Nondisplaced: non-weight bearing casting

• Displaced: surgery

Fractures @ growth plate

-Salter Harris fractures

Genusvarum -Bow-legged -Normal until 2yrs

Genuvalgum -Knock knees -Normal until 8yrs

Osgood Schlatter’s Disease

-Stresses on tibial tuberosity causes microevulsion -Benign, resolves once child stops growing, resting from sports can provide comfort from pain but will not speed up resolution

Clavicular Fractures -Common in newborns – breech, macrosomic, Vit D deficiency -Can be detected w/asymmetric Moro reflex

Development Hip Dysplasia

-Barlow and Ortolani screening tests, f/u US (can’t do XR no ossification until 4-6mo) -US recommended all females born breech, all females w/FHx, questionable exam -“Lollypop on a stick” -Pavlic harness: for babies up to 6mo; harness leaves baby in position that allows hip to grow into correct placement -Short leg spica cast: cast that keeps baby in abducted position -If older than 18mo pelvic Dega osteotomy (open reduction cut into hip bone and make place for femur)

Legg-Calve-Perthes Disease

-Avascular necrosis of head of femur -Best seen on MRI -Cannot internally rotate -More common in younger children

Slipped Capital Femoral Epiphysis

(SCFE)

-Kline’s line should go through head of femur to hip -“Head of ice cream falls of the cone” -Surgical reduction to put pin through and hold in place -Has significantly higher lifetime risk than LCP (during teenage years with growth spurts)

-Considered Salter Harris fracture

Limping -Trauma -factures, stress fractures, toddlers fractures, soft tissue contusion, strain/sprain -Infection – osteomyelitis, Lyme dz, cellulitis, gonorrhea, post-infectious reactive arthritis, septic joint -Malignancy – bone spinal cord tumors, lymphoma, leukemia -Inflammation – JIA, transient synovitis, SLE -Congenital – DDH, sickle cell, club foot -Developmental – osteochondritis, LCP, SCFE

Limping: All ages Septic arthritis, osteomyelitis, cellulitis, stress fracture, neoplasm, NSM

Limping: Toddlers (1-3yo)

Septic hip, DDH, occult fractures (child abuse), leg-length discrepancy

Limping: Child (4-10yo)

LCP, SCFE, transient synovitis, JIA

Limping: Adolescent

(11-16yo) SCFE, LCP, gonococcal arthritis (3% disseminated in untx), overuse injuries

Metatarsus Adductus

-Adducted forefoot -Midfoot and hind foot normal (differentiates from club foot)

Idiopathic Talipes Equinovarus

-Aka “club foot” -Hypoplastic tarsals and foot bones, atrophy of calf muscle -Varus (goes inward) -Serial casting tx -25% risk if parent or sibling -More common in M, bilateral 50%

Nursemaid’s Elbow -Annular ligament – rubber band that goes over head of radium -Gets pulled up and gets stuck, radial head gets sublaxed (trapped) -Supinate and flex to fix

Greenstick Fracture -Bone angulated -Fall on tension side, bend deformity on compression side

Buckle Fracture (torus)

-Fall on an outstretched hand -Occurs in metaphysis

Bucket Handle Fracture

-Fragmentation by distal end of the bone only accomplished by shear forces -Suggestive of child abuse call child services

Other fractures suggestive of child

abuse

-Bones that are hard to break sternum, scapula, 2nd rib, spine -Posterior ribs -Different stages of healing -Certain skull fractures multiple “eggshell” fractures, occipital impression fractures, fractures crossing sutures -Diaphyseal fractures and spiral fractures -If fracture does not match mechanism of injury

Supracondylar Fracture

-Very common in kids -Elbow hyperextends -Fall on an outstretched hand -Surgical emergency neurovascular compromise (brachial artery, median nerve), risk for compartment syndrome (Bulkman’s contracture) -Posterior fat pad abnormal, large anterior fat pad

Spondylosis -Defect in pars interarticularis -Most commonly 5th lumbar vertebra -Lower back pain numbness, tingling, stiffness

Spondylolysis -Worsening of spondylosis

Spondylolisthesis -Slippage and herniated disc

MUSCULOSKELETAL EMERGENCIES

Crush Injuries

-Really a result of acute traumatic ischemia -Rhabdomyolysis from sarcolemma failure permeability of muscle membranes leak of myoglobin and K+ out of cell with leak in of water, Ca, Na -Also have local vasoconstriction and platelet aggregation ischemia -Compartment syndrome from increased pressure within muscle compartments muscle, tissue, and nerve death

Signs & Symptoms -Fractures -Evident soft tissue injury -Dysrhythmias and EKG changes (peaked T waves, loss of P waves) from electrolyte imbalances -Red-brown urine Compartment syndrome: tight, shiny, pain out of proportion to exam,

pain, pressure or poikilothermia, paralysis, paresthesia, pallor, pulselessness

>30mmHg indicates need for surgical decompression

Workup -Electrolytes: hyperkalemia, hyperphosphatemia, hypocalcemia -High myoglobin -Elevated CK (officially rhabdo if > 5x ULN) -Elevated Cr due to AKI from trying to clear myoglobin Management -ABCs -Cardiac monitoring -Fluid resuscitation -Pain management

Management -Can give bicarb before extrication to shift K+ intracellularly -Can give Ca carbonate for K+ cardiac membrane stabilization post-extrication (different IV from bicarb!) -Give insulin with D50W to shift K+ intracellularly -Albuterol to raise insulin level more intracellular K+ shift -Kayexalate to reduce K+ via GI tract (slower onset of action) -Remove any constrictive clothing, jewelry, or splints -Avoid large boluses of fluid if pt is hemodynamically stable -Mannitol: a non-osmotic diuretic to help wash myoglobin out of renal tubules to protect kidneys -Compartment syndrome: fasciotomy, hyperbaric oxygen Prognosis -Degree of physiologic dysfunction is not related to time elapsed before extrication

Fractures Pediatric Fractures ▪ I: S (Slipped epiphysis)

▪ II: A (fracture Above physis), most common

▪ III: L (fracture beLow physis) ▪ IV: T (fracture Through physis) ▪ V: R (wRecked physis) ▪ I/II rx: nonoperative ▪ IV/V rx: surgery required ▪ Negative radiographs do not r/o a Salter I

fracture

General Information

-Greenstick fx = one side broken, other bent -Buckle / Torus fx = compression fx -Growth plate fx are classified by Salter-Harris -Most fx only require closed reduction -Kids heal faster due to more active periosteum and higher % cartilage Fractures Associated with Child Abuse -Any fracture in a child under 1 -LE fracture in a non-ambulatory child -Multiple fractures in various stages of healing -isolated diaphyseal fx -rib & skulls fractures -Metaphyseal corner fx: child abuse -multiple or bilateral fractures -Sternal or scapular fx: high impact mechanism such as MVC required or else it may be child abuse -Spinous process fracture -Lower specificity: clavicular fx, long bone fx *osteogenesis imperfecta may be confused w/ abuse

Presentation -Will always cause pain -Tender, swollen, and with mobility at the fracture site -Loss of limb function Workup -All suspected fx need at least 2 views for radiographs: AP, lateral -CT for subtle stress fractures or for inability to detect on x-ray but with high suspicion -MRI: T1 for new fractures, T2 for older fractures Complications -Most commonly DVT or PE -Compartment syndrome -Avascular necrosis -Nerve injury -Malunion, nonunion, or delayed union -Complex regional pain syndrome form injury to sympathetics -burning pain, skin changes, swelling, excessive sweating at injury site

Upper Limb Fractures and Dislocations Shoulder Dislocation -95% anterior, 5% posterior

-anterior d/t external rotations or excessive abduction or extension -posterior d/t seizures, electric shocks, direct blow to anterior shoulder

-Pt will support affected arm with other arm -Shoulder may appear flattened -Prominent acromion -Displaced greater tuberosity and unusual subclavicular bulge -nerve injuries uncommon with anterior dislocations but most common nerve injured is axillar n. see sensory loss over lateral aspect of shoulder & weakened abduction -must document nerve exam d/t axillary nerve injuries

standard xray views: AP, transscapular, axillary view

Can resolve spontaneously Tx: closed reduction w/ traction + scapular manipulation traction-countertraction stimson technique May use conscious sedation or intra-articular block

AC Separation MOI: fall on outstretched hand, fall on affected shoulder with the arm adducted S/sx: swelling with tenderness over AC joint, gross deformity w/ higher degree injury, pain with upper extremity movement Standard xray view: AP view of both clavicles Sprain = Sling, Torn = Surgery

Scapula Fracture MOI: direct violent trauma (MVA) Shoulder is adducted and arm is held close to the body Common areas of scapula fractured = glenoid, body, neck

Consider lung injuries, rib fx, shoulder injuries, chest wall injuries

Immobilization with sling and swathe dressing

Humeral Shaft MOI: proximal humeral fx is a common fx in the elderly population

-Extensive bruising of upper arm -Wrist drop from radial nerve damage

Complications: *adhesive capsulitis, axillary n. injury, AVN of humeral head

Wrist splinting and casting over site of break

Clavicle Fracture Usually a pediatric fracture MOI: direct force to lateral shoulder from a fall or sporting injury

Affected extremity held close to body Shoulder is slumped downward, forward, and inward

Immobilization in figure 8 dressing

Supracondylar Fracture

-Pediatric fracture -Usually involves distal humerus -MOI: fall on outstretched hand extension fx*: distal humeral fx is displaced posteriorly flexion fx: displaced anteriorly Assess neurovascular involvement, check radial pulses!

AP & lateral xray of elbow posterior fat pad sign (aka sail sign) is highly suggestive of occult fracture displacement of anterior humeral line (does not bisect the capitate) alteration of Baumann angle

Complications: -AIN neuropraxia -radial nerve palsy -ulnar nerve palsy (flexion-type) Non-op management = long arm posterior splint Operative = open vs. closed reduction with percutaneous pinning

Lateral Condylar Fracture

-MOI: FOOSH with extended elbow, traction forces, or acute varus stress Lateral epicondyle of distal humerus articulates w/ capitellum

Nondisplaced or minimally displaced fx immobilize with sling or cast in 90d flexion Displaced fx ORIF

Medial Epicondyle Fracture

-MOI: fall on outstretched arm, elbow dislocations, traumatic avulsion (overthrow), acute valgus sress during FOOSH, posterior stress, chronic muscular traction (throwing), -Associated with elbow dislocation or subluxation -Medial epicondyle of distal humerus articulates w/ trochlea

Hand / Wrist / Finger Injuries Boxer’s Fracture Metacarpal neck fx of the 5th +/- 4th digit

MOI: punch with a clenched fist Most are unstable Operative intervention if: any rotational deformity, significant angulation, neurovascular compromise

Management: Splinting vs percutaneous pinning

Mallet Finger Disruption or laceration or the extensor tendon at the DIP MOI: blow against tip of extended finger with sudden forced flexion

Management: Xray to distinguish soft vs. bony fracture If no associated fx, can splint DIP in extension If fx, may either splint or pin the fragment Complication if untreated: swan neck deformity

Colles Fracture Transverse fx of metaphysis of distal radius, with dorsal displacement of distal portion MOI: fall on an outstretched hand (wrist gets bent backwards) Median nerve associated with colles fx

-Coaptation splint -Casting alone if nondisplaced -Closed reduction followed by casting if slightly displaced -Displaced: ORIF & short arm cast

Smith Fracture Transverse fx of metaphysis of distal radius, with volar displacement of distal fragment MOI: fall on back of hand (wrist gets bent inward)

-ORIF & short arm cast

Scaphoid Fracture Most commonly injured carpal bone MOI: fall on outstretched hand S/Sx: Fullness or pain in the anatomical snuffbox Referred pain to anatomic snuff box w/ compression of thumb

Xray: lateral & AP view +/- scaphoid view Repeat imaging in 10-14 days if negative, normal radiograph does not r/o scaphoid fx, may require f/u MRI Immobilize in thumb spica Displaced fx often require ORIF Risk of scaphoid AVN, non-union, malunion

Galeazzi Fx Distal radial shaft fx with an associated distal radioulnar joint dislocation Tx: ORIF

Monteggia Fx Fracture proximal 1/3 of ulna + dislocation of radial head

Radial Head Fracture -MOI: FOOSH -Decreased ROM in elbow

-Difficult to see on x-ray, may see displacement of fat pad, elbow effusion

Ankle and Foot Fractures

Ankle Fracture Malleolar fx lateral, medial, posterior MOI: caused by eversion, inversion, or lateral rotation; inability to bear weight Pain, swelling, ecchymosis, instability Pain will be over bone vs. ligament Check proximal fibula for tenderness (they may have broken this as well), Check peroneal nerve (foot drop) Tenderness in these areas suggests fracture vs strain or sprain (Ottawa ankle rules)

Ottawa ankle rules help determine need for x-ray Standard AP and lateral views on x-ray (plus AP view with 15° internal rotation if suspecting ankle fracture) -Deltoid ligament determines surgery or not -Isolated lateral malleolus fracture casting vs. boot for 6 weeks -Bimalleolar goes to surgery, ORIF because of instability (more ankle instability) -Bimalleolar equivalent fx of fibula / lateral malleolus ----Deltoid ligament involved ends up in surgery because instability - ORIF vs. cast depending on stability

Foot Fracture Involves talus, calcaneus, metatarsals, phalanges Jones fx = 5th metatarsal transverse fx at proximal aspect MOI: load applied to the ball of the foot laterally Lisfranc fx = midfoot injury = metatarsal bones displaced for tarsus MOI: compression, rotation, axial load

pain, ecchymosis, edema over affected bone xray AP, lateral, oblique non-displaced = protected vs. non weight-bearing displaced = ORIF great toe fx = ORIF Lisfranc = may require ORIF

Leg & Knee Injuries Patellar

Fracture & Dislocation

MOI: direct blow to patella Often a transverse fx Lateral patellar dislocation most common *knee dislocations are considered orthopedic emergencies consider arteriogram & immediate relocation by longitudinal tracton

-Knee pain, difficulty walking -Swelling and bruising -Point tenderness -Pain on extension of knee -Aspiration will show hemarthrosis with fat globules

Lower extremity immobilization and no weight bearing -Nondisplaced – immobilization in full extension -Wide displacement – often requires surgical intervention

Pelvic & Hip Injuries Pelvic fractures Major nerve roots in pelvis: lumbar & sacral Structures that may be damaged with injury to lower pelvis: -nerve roots, bladder/urethra*, colon, rectum, anus Leading causes of pelvic fx = MVA, falls, crush injuries

Hip dislocations Posterior dislocation: leg often shortened, adducted, internally rotated associated with sciatic nerve injury Anterior dislocation: limb is adducted, externally rotation, extended associated with femoral nerve injury Primary concern = AVN

Extracapsular -Does not affect blood supply to femoral head = complications of nonunion are rare -Stable vs unstable (detached fragment of lesser trochanter)

-H/o fall or trauma -Leg may be shortened and externally rotated if displacement is present -May also have fx at another site, usually proximal humerus or distal radius -Rarely neurovascular injury, but can have sciatic nerve injury

-Internal fixation

Intracapsular -Can affect blood supply to femoral head, especially if displaced = commonly complications with nonunion and avascular necrosis

-Internal fixation if no displacement -Hemiarthroplasty often the treatment of choice due to high risk of avascular necrosis

Toddler Fracture Tibia

-Spiral fx of distal tibia, Typically in 1-3 year olds, Salter-Harris classification

-X-ray: may show subtle fracture only on 1 view

-Long-leg casting

Neck & Spine Injuries Spinal Cord Injuries 3 main spinal cord pathways:

Dorsal column position & vibration Spinothalamic pathway pain & temperature Corticospinal pathway movement Complete SCI = irreparable damage w / no discernible motor, sensory, or electrical function Incomplete SCI = some preservation of sensory and/or motor Posterior cord injury loss of position & vibration Anterior cord injury loss of bilateral motor, temp, pain Central cord injury loss of pain, temp, & motor (arms>legs)

Cauda Equina Syndrome

Cauda equina syndrome is defined by a constellation of symptoms that result from terminal spinal nerve root compression in the lumbosacral region Etiologies: disc herniation*, spinal stenosis, trauma, tumors, spinal epidural hematoma, epidural abscess *true emergency emergent MRI *can be associated with DVTs

Bilateral leg pain Saddle anesthesia Bowel & bladder dysfunction (retention overvlow incontinence) Lower extremity sensory motor changes Tx = urgent surigical decompression within 48hrs (discectomy, laminectomy)

Spondylolysis -Stress fx of pars interarticularis, usually L5 -Seen in gymnasts, football players, weight lifters -Pain adjacent to midline, aggravated with extension & rotation -May be asymptomatic

X-ray showing scotty dog with collar

-Modification of activities -Core strengthening

Disc Herniation S/sx: Back pain, radicular pain, cauda equine Dx: typically no need to image, but MRI if red flags: infection (IV drug user, h/o of fever and chills) tumor (h/o or cancer) trauma (h/o car accident or fall) cauda equina syndrome (bowel/bladder changes) Tx usually conservative and non-operative (usually resolves in 4-6wks) Rest, PT, NSAIDs, muscle relaxants, oral steroid taper, steroid injections Laminectoy, discectomy

Low Back Pain Differential -Muscle strain -Osteoarthritis -Herniated disc -Spinal stenosis -Sciatica -Sacroillitis -Rheumatoid arthritis -Metastatic cancer -Compression fracture -Osteomyelitis -Epidural abscess -Cauda equina tumor -Ischial bursitis -Piriformis syndrome -Fibromyalgia -Aortic aneurysm -Duodenal ulcer -Kidney stones -Pyelonephritis -Pancreatitis -Prostatitis -Hip osteoarthritis

Red Flags for Serious Etiology -Trauma -Unexplained weight loss -Age > 50 or h/o osteoporosis or prolonged corticosteroids -Unexplained fever -History of urinary or other infx -Immunosuppression or DM -H/o cancer -IV drug use -Age > 70 -Focal neuro deficits or progressive or disabling symptoms -Duration > 6 weeks -Prior surgery -Nighttime pain -Bladder dysfunction -Saddle pattern anesthesia Physical Exam -Inspect gait and spinal motion -Spinal palpation -Straight leg raise test -Peripheral pulses -Focused neuro exam -Testing of L5 and S1 nerve roots via reflexes and sensation

Workup -Judicious use of irradiation, especially in younger patients -Imaging indicated in first 4-6 weeks of symptoms only for:

• progressive neuro sx

• constitutional sx

• h/o traumatic onset

• h/o malignancy

• age > 50 years

• infectious risk

• osteoporosis -If symptoms > 4-6 weeks, then plain AP and lateral views of lumbosacral spine are indicated -CT or MRI (preferred modality) indicated for progressive neuro deficits or high suspicion of cancer or malignancy and only for those with > 12 weeks of symptoms Management -Up to 90% of patients with back pain that don’t have systemic symptoms or sciatic will improve rapidly without any intervention -Acute low back pain: minimal activity modification with return to usual activities ASAP, short term NSAIDs ± muscle relaxants -Chronic pain: opioids only for acute exacerbations, no muscle relaxants, PT referral, acupuncture -Neurosurg or ortho consult for cauda equina, suspected cord compression, or progressive/severe neuro deficit -Neuro or PT consult for neuromo tor deficits persisting after 4-6 weeks of conservative therapy, persistent sciatica/sensory deficit

• Night pain, weight loss: malignancy

• Back pain + fever + neurological deficits: epidural abscess

• Acute bony tenderness: fracture

• Young, morning stiffness: seronegative spondyloarthropathy

• Urinary retention: cauda equina syndrome

• Pain with extension, relief with flexion: spinal stenosis

• Image if red flags present

Soft Tissue Injuries & Infections Osteomyelitis

Infection of bone characterized by progressive inflammatory destruction and apposition of new bone Pain, erythema, edema, tenderness, fever risk factors: recent trauma, surgery, immunocompromised, IV drug use, poor vascular supply, systemic conditions (DM), peripheral neuropathy S. aureus is most common agent in adults Work up: WBC, ESR, CRP, blood cx, sinus tract cx, bone biopsy* (gold standard for anti-biotic coverage) Xray (bone loss must be ~35% to be evident): often shows a lytic region surrounded by an area of sclerosis Tx: IV or oral abx for 4-6wks, may need surgical irrigation & debridement

Septic Joint Usually acute presentation with single swollen and painful joint Pain, swelling, warmth, restricted movement S. aureus (>50%) is most common, N. gonorrhea (20%), gram negative bacilli (10% - elderly, neonates, immunocompromised pts, IVDU) Etiologies of bacterial seeding; bacteremia, direct inoculation (surgery, trauma), contiguous spread (from adjacent osteomyelitis) DDx: gout, pseudogout, cellulitis, bursitis Imaging studies likey show joint effusion Dx: CRP >5, ESR >30, WBC >10k w/ left shift, joint fluid aspiration = gold standard, saline fluid load test Tx: IV abx, operative irrigation and drainage of joint

Avascular Necrosis Disruption of blood supply leads to death of cells in bony matrix Pain, decreased ROM, crepitus, weakness MRI is preferred imaging modality Tx: pain meds, activity modification, PT, core decompression, arthoplasty

Volkmann’s Ischemia Compartment syndrome of the upper extremity leading to deformity and contractures

Fat Emboli Syndrome Symptoms usually occur 1–3 days after a traumatic injury high index of suspic predominantly pulmonary (shortness of breath, hypoxemia), neurological (agitation, delirium, or coma), dermatological (petechial rash), and haematological (anaemia, low platelets)

Strain

stretching or microscopic tearing of a muscle and/or tendon (tendon = muscle to bone, ligament = bone to bone) Severity Grade I (mild) = muscle stretched and painful but not torn --no hematoma Grade II (moderate) = muscle intact w/ some tearing and bruising --hematoma, typically treat non-operatively Grade III (severe) = complete tear including fascia, rupture is palpable --Requires repair (ex: quads rupture off patella)

Sprain

injury to ligament when joint is carried thru a range of motion greater than normal Typically found in the knee, ankle, hand (example: ACL) Severity Grade I (mild) – ligament stretched but not torn Grade II (moderate) – partial tear of ligament Grade III (severe) – complete tear of ligament

Rotator Cuff Tendonitis/Bursitis /Tear

Shoulder pain, weakness, difficult w/ overhead activity Tendonopathy Pain with active abduction beyond 90 degrees (ie, painful arc sign) suggests rotator cuff tendinopathy. The test is most useful when combined with other rotator cuff tests, such as the Neer and Hawkins tests Neer & Hawkins tests – indicate impingement Tx: RICE, NSAIDs, PT Tear Likely tear if: active painful arc test, drop arm test, weak external rotation Weakness may help differentiate tendonitis vs. tear Xray, musculoskeletal ultrasound, MRI Bursitis joint protection, NSAIDs, glucocorticoid injections

Biceps Tendonitis/Rupture

Action: supination and flexion of forearm Speed’s test – elbow extended, arm supinated, forward flexion of shoulder against resistance Yeargeson’s test – patient flexes elbow 90d, pronates arm; pateint attemt to supinate against resistance of clinical holding hand Popeye deformity A visible or palpable mass is often present near the elbow or in the mid-upper arm in cases of biceps tendon rupture

Patella Tendon Bursitis/Tendonitis

Bursitis: local tenderness over bursa, pain on motion & at rest, ocassional loss of active movement, swelling, erythema, warmth Tendonitis (jumper’s knee): infrapatellar pain, difficulty weight-bearing, popping sensation (suggests tendon rupture)

ACL & PCL Tears (Cruciate Ligaments)

ACL MOI: non-contact pivoting injury Often associated with a meniscal tear S/Sx: pop, pain in knee, immediate swelling, hemarthrosis, effusion Lachman’s test traction for anterior displacement of tibia Anterior Drawer test – bend knee and full anteriorly

PCL The “sag sign”, posterior drawer test

MCL & LCL Tears (Collateral Ligaments)

MCL Action: valgus stabilizer MOI: valgus and external rotation force to lateral knee S/sx: pop, medial joint line pain & tenderness, ecchymosis, effusion, difficuly moving Tests: valgus stress test MRI is modality of choice, can also order xray

LCL MOI: excessive varus stress, external tibial rotation, and/or hyperextension S/Sx: lateral joint line pain & swelling, instability near full knee extension, difficulty ascending/descending stairs Tests: varus stress test MRI is modality of choice

Achilles Tendon Rupture

MOI: traumatic injury, sudden forced plantar flexion, violent dorsiflexion in a plantarflexed foot S/sx: pop, weakness, difficulty walking, pain in heel, palpable gap Thompson test = lack of plantar flexion when calf is squeezed