Rad Lecttony 3 Extremities
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Rad Lecttony 3 Extremities Rad Lecttony 3 Extremities Presentation Transcript

  • Diagnostic Imaging Lecture 3 Musculoskeletal
  • Musculoskeletal Injuries
    • Musculoskeletetal problems commonly occur as a result of both serious athletic pursuits and activities of daily living .
    • Most sports and recreational injuries are the results of:
      • contusions,
      • sprains (ligamentous injuries),
      • strains (musculotendinous injuries),
      • meniscal injuries,
      • bursitis,
      • fractures, and
      • dislocations.
    • Physical therapy is an important adjunct to the management of these disorders
  • Skeletal Imaging
    • Majority by plain radiograph
    • AP and Lateral projections
    • Oblique views for trauma involving joints, hands and feet
    • CT - fine bone structure ( skull,spine and pelvis)
    • MRI - evaluation of soft tissue
    • Nuclear medicine - bone metastases, differentiate cellulitis from osteomyelitis and occult trauma (stress fractures)
  • Skeletal Imaging
    • Most bone lesions are obvious on clinical history
    • >95 % bone films are obtained for:
      • Evaluation of trauma
      • Eval. Arthritis
      • Eval. Degenerative conditions
      • Metastases
  • Sprains
    • Sprains are ligament injuries .
    • Ligaments attach bone to bone
    • Ligaments are like strong cords, tough and elastic , and provide stability and strength between joints , but when pulled or stretched to their limit they can tear or rupture.
    • Depending on the amount of ligament tearing, a sprain can be mild, moderate, or severe.
    • An alternate classification is; a first-degree , second-degree or third-degree sprain.
  • Sprains 1rst degree - joint pain / tenderness - no laxity 2nd degree - joint laxity present - pain and tenderness 3rd degree - ligament broken - unstable joint
  • Sprains
    • Most sprains are associated with varying degrees of pain, swelling and impairment of range-of-motion or weight bearing.
    • The most commonly involved areas are the shoulder, the elbow, the knee and the ankle .
    • Knee and ankle sprains are among the most common of all sports injuries.
    • If the physical exam is difficult to perform or damage to other intra-articular structures is suspected, an MRI can help determine the full extent of injury.
  • Strains
    • A strain is the tearing of a muscle-tendon unit.
    • termed tendonitis
    • acute or chronic
    • caused by overuse or a single episode of overactivity
    • pain results from minor tears in the tendons , from accumulated injuries ( repetitive micro-trauma ) that outpace the body’s ability to repair itself.
  • Strains
    • may result in pathologic changes of the soft-tissue and bones:
      • tendon degeneration, osteophytes, stress fractures, or nerve entrapment .
    • also graded as mild, moderate or severe.
    • Severe strains are characterized by rupture of any part of the tendon complex e.g biceps, patella or Achilles.
  • Terminology
    • Fracture is a break or loss of structural continuity in a bone.
      • it is important that fractures be described in a precise and detailed manner.
    • Dislocation and Subluxation alters the normal relationship between joint surfaces.
      • Dislocation : the normally apposing joint surfaces completely loose contact
      • Subluxation : those surfaces are only partially separated .
  • Fractures are described
    • Description
  • Fracture
    • displacement
  • Fracture
    • Angulation
    • dorsal volar
  • Fracture
    • Rotation
  • Fracture
    • Bayoneting
  • Fracture
    • Distraction
  • Fracture
    • Oblique
  • Fracture
    • Greenstick
  • Fracture
    • Transverse
  • Fracture
    • Comminuted
  • Fracture
    • Spiral
  • Fracture
    • Dislocation
  • Fracture
    • Nonunion Malunion
  • Fracture
    • Avulsion
  • Fractures
    • Fractures are open or closed .
    • Open : break in the surrounding skin or mucosa that allows the fracture to communicate with the external environment.
    • Open fractures are graded 1-3, with 3 being the most severe , and having the highest incidence of complications (e.g. osteomyelitis and nonunion).
  • Open fractures
    • Grade 1: wounds < 1cm in length
    • Grade 2: wounds > 1cm in length
    • but clean w/o devitalization of tissue
    • Grade 3: wounds > 1 cm in length,
    • grossly contaminated,
    • associated with comminuted fractures and vascular injury.
    • Open fractures - surgical emergencies
    • debrided , irrigated
    • (parenteral antibiotics within 6 hours)
  • Fracture Description
    • Fra ctures are further described based on:
      • Location
      • Pattern
      • Displacement
    • When describing location ,
      • the bone affected is identified
      • as well as the specific part of the bone involved ( proximal or distal epiphysis,etc .)
    • Fracture location has implication for healing.
      • Fractures of metaphyseal or cancellous bone usually heal quite rapidly in contrast to cortical or diaphyseal bone, which heals more slowly due to differences in blood supply and bone turnover rate.
  • (Physis)
  • Fracture Pattern
    • The fracture pattern relates to fracture geometry, which suggests the type and amount of kinetic energy the bone has been subjected too .
      • A transverse fracture is a low-energy injury , usually the result of either a direct blow to a long bone or a ligament avulsion.
        • An example is a “night stick” fracture, which involves the ulna and occurs when the forearm is used to defend against an assault.
    • Stress and pathologic fractures usually have a transverse pattern .
  • Fracture Pattern
    • Spiral or oblique fractures result from a rotatory or twisting injury.
      • These fractures have a tendency to displace after reduction and immobilization.
      • Spiral or oblique fractures typically require ORIF.
    • A fracture with two or more fragments is termed comminuted .
      • Subtypes are called butterfly fragments and segmental fractures.
  • Fracture Pattern
    • An impacted fracture is commonly seen in metaphyseal bone, such as the femoral neck , the distal radius or tibial plateau fractures.
      • These (impacted) are low-energy injuries in which two bone fragments are jammed together .
    • Fractured bone fragments can be displaced due to the force of the injury, gravity, or muscle pull.
    • Displacement is described in terms of angulation, rotation and length .
  • Salter-Harris (Growth Plate) Fractures
    • Growth plate fractures in children are based on the Salter-Harris classification of injuries.
    • Growth plate injuries, no matter how trivial, have the potential to cause growth disturbance of the involved bone.
    • These fractures are classified as type I-V .
  • Salter-Harris Classification Type I - through the physis . Type II - through the physis and metaphysis. Type III- through the physis and epiphysis . Type IV- through the physis, metaphysis and epiphysis . Type V - crush injury to the physis .
  • Principles of fracture management:
    • Patients with fractures should be managed as trauma patients.
    • always check for associated injuries ( ABC’s ).
    • Next, assess the neuro-vascular status .
    • Remember to check :
      • distal pulses and capillary refill.
      • sensory and motor function
      • (distal to the fracture )
  • Fracture management
    • The three principles of fracture care involve:
      • 1) Reduction of deformity
      • 2) Maintenance of reduction
      • 3) Rehabilitation of function
  • Closed reduction
    • Reduction
      • Closed
      • Open
    • Closed reduction: involves the manual manipulation of the fracture into a functional position.
      • traction is applied
      • deforming forces are reversed
      • realign the bone fragments .
  • Open reduction
    • open reduction
      • fracture is surgically exposed
      • bone fragments are manipulated directly (ORIF=open reduction and internal fixation).
    • Open reduction indicated when:
      • closed reduction methods fail
      • with intra/articular fractures (joint surface must be aligned anatomically to prevent the development of posttraumatic arthritis.
  • Maintaining alignment
    • Maintaining alignment requires
    • Immobilization :
      • include casting , splinting , traction , functional bracing , and internal or external fixation.
    • The type of immobilization depends upon fracture stability or its propensity for displacement.
    • Splints and casts immobilize and support the injured extremity and thereby reduce pain
    • prevent injury to structures in the proximity of a fracture , and maintain alignment after reduction .
    • Splinting and casting are also used postoperatively to provide additional stabilization when fixation is tenuous .
  • Splinting and casting
    • Splinting and casting accomplished with plaster or synthetic materials such as fiberglass.
    • Splints differ from casts in that splints are not circumferential and thus allow swelling of the extremity without a significant increase in pressure within the splint.
    • Swelling within the cast increases pressure, potentially resulting in a compartment syndrome or pressure sores.
  • Splinting and casting
    • Many of the fundamental rules of splinting and casting are identical.
    • Ideally, at least one joint proximal and one joint distal to the injury are immobilized .
    • Prior to immobilization, fractures are reduced , and, as much as possible are placed in a position of function .
    • The extremity and bony prominences are padded to prevent pressure sores and neurovascular compression.
  • Complications
    • Common complications of musculoskeletal injuries:
      • ARDS (fat embolism)
      • DVT
      • Atelectasis
      • Nerve compression
      • Osteomyelitis
  • Shoulder
  •  
  • Normal
  • Acromioclavicular (AC) separation (separated shoulder)
    • Mechanism of injury- fall onto point of shoulder
    • If there has been significant disruption (or a fracture to the clavicle itself), the area will appear swollen and deformed compared with the other side.
    • The patient will avoid movement, due to pain.
    • Gently have the patient move their arm across their chest while you palpate in the AC region.
      • This will cause pain specifically at the AC joint if there is separation.
    • Tenderness is felt at the junction, or the site of the AC (acromioclavicular) joint .
  •  
  • AC separation (cont)
    • Grade I:
      • AC ligament sprained , but joint remains intact
    • Grade II:
      • Rupture of AC ligamen t and joint separation
    • Grade III:
      • Coracoclavicular and AC ligaments ruptured with wide separation of joint
    • Tx:
      • Grade I-II: sling, ice x 2 wks then ROM
      • Grade III: sling, ice x several wks until pain subsides, then ROM & strengthening vs. surgical repair
  •  
  •  
  •  
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  • Anterior Glenohumeral Dislocation “Shoulder dislocation”
    • Mechanism of injury:
      • From external rotation & abduction force on humerus
      • From a direct posterior blow to proximal humerus
      • From a posterolateral blow on the shoulder
    • Exam:
      • Space underneath acromion where humeral head should lie
      • Palpable anterior mass representing humeral head in anterior axilla
    • Tx:
      • Closed reduction
      • Immobilization in internal rotation
  • Shoulder dislocation
  •  ------Normal
    • Shoulder dislocation->
  •  
    • Anterior dislocation
      • (Much more common than posterior dislocation)
    • Posterior
    • dislocation
  • Anterior Glenohumeral Dislocation Complications
    • 2 lesions with recurrent dislocations:
      • Bankhart Lesion :
        • Anterior capsular injury assoc with a tear of the glenoid labrum off the anterior glenoid rim
      • Hill-Sachs Deformity :
        • Compression fracture of the articular surface of the humeral head posterolaterally that is created by the sharp edge of the anterior glenoid as the humeral head dislocates over it
  •  
  • Hill-Sachs Deformity
  • Clavicle fracture
    • Most common bone fractured
    • Weakest aspect is junction of middle/distal thirds
    • Look for “ Tenting ” of the skin
    • Class A (middle third fractures) (80%) :
      • Treat with sling immobilization.
      • Some prefer using a figure-eight clavicular splint, especially for displaced fractures.
    • Class B (distal third fractures) (15%):
      • Treat type I (nondisplaced) and type III (articular surface) fractures with sling immobilization.
      • Immobilize type II (displaced) fractures in a sling and swathe.
      • These may require orthopedic surgical fixation.
    • Class C (proximal third) (5%):
      • Treat nondisplaced fractures with sling immobilization.
      • Displaced injuries may require orthopedic referral for surgical reduction.
      • Neonatal fractures generally heal spontaneously in several weeks without special treatment.
  • Normal--- 
    •  -----Normal
    • Fracture---- 
  •  
  • Shoulder Fractures
    • Proximal Humerus Fractures :
      • Neer classificaton:
        • Non-displaced fractures:
          • are displaced less than 1cm or angulated <45 degrees, regardless of the fracture pattern or # of fragments
        • Displaced fractures:
          • 2 part fx’s are fractured either through the anatomical neck, surgical neck, greater tuberosity or lesser tuberosity
          • 3 part fx’s are fx’s of the surgical neck with fractures of either the greater tuberosity or lesser tuberosity
          • 4 part fx’s are fxs of the anatomic neck & fractures of the greater and lesser tuberosities
  • Proximal Humerus Fracture
    • The vascularity is at risk with anatomical neck fractures
    • Most common mechanism of injury= FOOSH
    • Signs & symptoms:
      • Pain, swelling, tenderness
    • Tx:
      • For nondisplaced fx’s= sling, begin ROM exercises
      • 2 part/3 part fx’s= closed reduction, sling, possible ORIF
      • Absolute indication for hemi-arthroplasty: 4 part fx’s, non-reducible 3 part fx’s
  • Midshaft Humerus Fractures
    • Signs & Symptoms:
      • Arm pain, swelling, deformity
      • The arm is shortened with gross motion & crepitus on gentle manipulation
    • XR:
      • AP/lat c shoulder & elbow
    • Tx:
      • Coaptation splint
        • Carefully molded plaster slab placed around medial & lateral aspects of arm, extending from axilla around elbow & over deltoid & acromion x 2 wks
      • Change to Sarmiento brace @ 2 wks
      • May require ORIF with plate/screw or intramedullary nailing
  • Midshaft humerus fx
  • Elbow Fractures
    • Monteggia Fracture
      • Usually a fx of the proximal Ulna with anterior dislocation of the radial head
      • MOI:
        • Forceful pronation or direct blow to dorsum of ulna
      • H&P:
        • Pain & h/o trauma, may have obvious deformity
      • XR:
        • AP/lat/obliq
      • TX:
        • Hematoma block, reduction, long arm cast or splint
        • May require ORIF
  •  
  •  
  • Galeazzi Fracture/dislocation
    • involving distal radial shaft fracture with associated dislocation of the distal radioulnar joint (DRUJ), which disrupts the forearm axis joint.
    • &quot;fracture of necessity&quot; refers to the adult Galeazzi fracture not being amenable to treatment by closed means, necessitating surgical stabilization.
  • Galeazzi (Reverse Monteggia)
  • Galeazzi
  • Radial Head Fracture
    • MOI:
      • Fall forward with elbow extended, forearm pronated
    • Pain localized to radial head
    • XR:
      • AP/lat/obliq
      • If fracture is subtle, look for “fat pad, or sail sign’s”
    • TX:
      • Types I, II, & III without mechanical block are treated with a sling and AROM x 3 wks
      • After 3 wks d/c sling & begin aggressive PT
      • Fx’s with elbow instability or mechanical block are treated operatively with either reduction & fixation of head, excision of head, or ligament repair
  • Normal Elbow
  • Radial head fx
  •  
  •  
  •  
  • Olecranon Fractures
    • Pain @ elbow with h/o trauma
    • XR:
      • AP/lat/obliq
    • Management
      • Initial: sling for comfort
      • Definitive:
        • non-displaced fx’s can be managed with posterior splint @ 90 degrees flexion x 2 wks
        • Other fx’s are managed with ORIF or percutaneous pinning & early motion post-operatively
  • Olecranon Fractures
  •  
  • Olecranon Fractures
  • Distal Humerus Fracture
    • Supracondylar fx’s of the Humerus:
      • Characterized by dissociation b/t diaphysis & condyles of distal humerus, frequently extended distally & involves articular surface
      • Caused by FOOSH or direct blow
      • PE:
        • + deformity, instability, crepitus
      • XR:
        • AP/lat/obliq
      • Management:
        • Initial: alignment, immobilization, ice, long arm splint
        • Definitive: ORIF, early motion
    • (Other fx’s: transcondylar, medial condyle, lateral condyle)
  •  
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  • The Wrist-Eight Carpal Bones
    • S ome L overs T ry P ositions T hat T hey C annot H andle
        • Proximal / Distal row from radial to ulnar position
      • S caphoid , L unate , T riquetrum , P isiform ,
      • T rapezium , T rapezoid , C apitate , H amate
    + Radius and Ulna
  • Movements at the wrist
    • Radial deviation (abduction)
    • Ulnar deviation (adduction)
    • Flexion
    • Extension
    • Supination
    • Pronation
    • Combination of all of the above
  • Wrist Dislocations
    • Perilunate, and Lunate dislocations are variations of the same injury
      • Caused by hyperextension of the wrist (FOOSH)
    • Exam:
      • Note areas of ecchymosis, active ROM, neurovascular status
      • When dislocated, wrist appears shortened with a fullness over the dorsum or in the carpal tunnel
      • Any movement produces pain
      • Swelling varies from barely perceptible to significant
  • Wrist Dislocations
    • XR:
      • Minimum 4 views: AP neutral, AP ulnar deviation, oblique, lateral
    • Tx:
      • Reduce ASAP to minimize risk of median nerve injury
      • Axillary block or IV regional block provide adequate muscular relaxation.
      • Apply traction for 5-10 min using finger traps
      • Reduce & place in thumb spica plaster splint with wrist in neutral or slight palmar flexion
      • Post reduction films are required
      • May Require surgery for adequate reduction
  • Perilunate dislocation Perilunate dislocation
  • Lunate dislocation
  • Distal Forearm Fractures
    • 1. Extension fractures:
    • Colles Fracture
      • Fx distal radius with dorsal angulation of distal fragment and associated fx of the ulnar styloid
      • Usually 2* to FOOSH
      • Exam:
        • swelling wrist, decreased ROM secondary to pain
      • XR:
        • AP/true lateral/obliq- radius will be shortened
  •  
  • Colles fx
  • Colles’ fx
  • Distal Forearm Fractures (cont)
    • Colles Fx (cont)
      • Tx:
        • Hang in finger traps
        • Hematoma block:
          • Using an 18 gauge needle & 20cc syringe with 10cc 1% lidocaine, enter fx site & aspirate hematoma (blood will flow into syringe)
          • After aspirating hematoma, inject lidocaine into fx site
        • Wait several minutes until pain is decreased & reduce fx
        • Place in long arm cast (LAC) with wrist @ 20-30 degrees of flexion & ulnar deviation
      • Post reduction films are necessary
      • Ice, elevate above level of heart, NSAID’s, analgesia
  • Distal Forearm Fractures (cont)
    • 2. Non-displaced Distal Radius Fx’s
      • Require short arm cast (SAC) in neutral, ice, elevation, NSAIDS, analgesia
    • 3. Other common fx’s:
      • Smith’s fx
        • Reverse Colles fx
        • Fracture of the distal radius with palmar (volar) displacement of the distal fragment.
      • Die Punch Fx
        • Intra-articular distal radius fx with impaction of the dorsal aspect of the lunate fossa
      • Barton’s Fx
        • Displaced intra-articular lip fx of the distal radius
        • May be assoc with carpal subluxation
        • May be dorsal or volar configuration
        • Extends into radio-carpal joint
  •  
  •  
  • Smith’s fx
  •  
  • Smith’s Fx
  • Scaphoid Fractures
    • MC fx’d carpal bone
    • There is no direct blood supply to the proximal portion of the scaphoid
    • Therefore, scaphoid fx’s have a tendency to develop delayed union or avascular necrosis
    • Remember the more proximal the fx line is in the scaphoid injuries, the greater the likelyhood of avascular necrosis
    • Mechanism of injury
      • Forceful hyperextension of the wrist
  • Scaphoid Fractures
    • Exam:
      • + snuffbox tenderness,
      • radial deviation of wrist will probably elicit pain
    • XR:
      • Obtain AP/lat/obliq/scaphoid views
      • Initial plain xray may not demonstrate fx for up to 4 wks
      • If xrays are still negative at 10-14 days & pt is symptomatic, obtain bone scan for definitive diagnosis
      • A bone scan will show an increase in uptake in fracture area
    • Tx:
      • Initially in ER:
        • Thumb spica (*always tx snuffbox tenderness, even if xr neg)
      • Definitive:
        • Long arm thumb spica cast x 4-8 wks.
        • If scaphoid is displaced, may require ORIF
  •  
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    • A. Thumb B. Index C. Middle finger D. Ring finger E. Little fingerI-V. Metacarpal bones1,4. Distal phalanx 2. Middle phalanx 3,5. Proximal phalanx 6. Sesamoid bones 7. Distal interphalangeal joint (DIP) 8. Proximal interphalangeal joint (PIP) 9. Metacarpophalangeal joint (V.) 10. Carpometacarpal joints 11. Trapezium 12. Trapezoid 13. Capitate 14. Hamate 15. Scaphoid 16. Lunate 17. Triquetrum 18. Pisiform
    • 19. Radius 20. Ulna
  • Game Keeper’s Thumb Skier’s Thumb
    • Injury to the ulnar collateral ligament of the MCP joint of the thumb
    • Destroys joint stability
    • Impairs ability to pinch
    • Evaluation:
    • Stress ulnar aspect of the MCP joint by forcing thumb into radial abduction
      • If there is <15 degrees of side to side difference (one thumb compared to the other) or an opening > 45 degrees at the ulnar aspect of the MCP joint, surgical repair is required
      • Closed tx with a thumb spica cast or splint with the thumb slightly adducted may allow for healing of an incomplete tear
  •  
  •  
  • Distal Phalangeal Fractures
    • 1. Closed:
      • Splint, Ice, Analgesia
    • 2. Open:
      • Digital block c 1% lido local anesth.
      • Irrigate
      • ? Rongeur
      • Sterile repair (suturing) of nailbed, place nail as biological dressing
      • Xeroform gauze (betadine/petroleum imbedded gauze) & sterile gauze dressing
      • Splint
      • Antibiotics
  •  
  •  
  • Middle & Proximal Phalanx Fractures
    • Stable, non-displaced , impacted, transverse fx’s with no rotational deformity of the finger may be either buddy taped or splinted with mcp joints flexed @ 50 degrees & PIP joints flexed @ 15-20 degrees
    • Fx’s with rotational deformities may require closed or ORIF & casting/splinting
    • Unstable fx’s may require casting or percutaneous pinning with Kirschner (K) wires
      • More recently these fx’s are being internally fixed with plates & screws from small fragment sets
  •  
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  • Finger dislocation
    • Reduce
    • Splint
  •  
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  • Metacarpal Neck Fractures
    • Most frequently occur at the 5 th metacarpal ( Boxer’s fx ) as a result of a direct blow delivered to the hand or by the hand to a solid (animate or inanimate) object while the hand is held in a fist
  •  
  • Other Metacarpal Fx’s
  •  
  • Bennett’s
  •  
  • Rolando’s
  • Lower Extremities
    • Second Part
  • Knee
    • Standard Xray projections:
      • AP – eval.joint space narrowing / calcifications
      • Lateral –eval.Patella / effusions
    • Special views
      • Sunrise / merchant view
        • Tangential / knee flexed/from top-down
      • Tunnel view
        • Knee more flexed, looking through the “tunnel created by the femoral condyles
  •  
  • Knee
    • Most common reasons to order Knee
    • X rays are:
    • - trauma
    • - DJD ( X rays findings)
    • MRI – soft tissues
    • - tendons, ligaments, menisci, and cartilage
  • Knee
  • The Knee
    • Ligaments:
      • Anterior Cruciate Ligament (ACL)
      • Posterior Cruciate Ligament (PCL)
      • Medial Collateral Ligament (MCL)
      • Lateral Collateral Ligament (LCL)
  • Knee
    • Knee effusion:
      • Best seen on Lateral view
      • Superior to Patella
      • Anterior to distal femur
      • Water or blood
      • Same density as muscle
      • Look for anterior displacement of fat line
      • Clinical examination superior to X ray
  • Knee soft tissue injuries
    • Most common:
      • Cruciate ligaments: Xrays NL. Dx made on clinicals
      • and the menisci : plain film shows degree of joint space narrowing and possible loose body within the joint
    • MRI only if PE inconclusive
    • ACL- originates in front of the intercondylar eminence of the tibia and inserts on the posteromedial aspect of the lateral femoral condyle.
      • Lateral  medial
    • The ACL prevents anterior
    • translation of the tibia
    • PCL-Originates on the medial femoral condyle and inserts on the tibia.
      • Medial  lateral
    • The PCL prevents
    • posterior translation
    • of the tibia
  • Medial Collateral Ligament (MCL)
    • Originates on the medial femoral epicondyle and inserts on the proximal tibia
    • The MCL
    • prevents
    • valgus angulation
    • of the knee
  • Lateral Collateral Ligament (LCL)
    • Originates on the lateral femoral epicondyle and inserts on the lateral aspect of the fibular head.
    • It prevents varus
    • angulation of the knee
  • Menisci
    • Crescent shaped fibrocartilagenous structures that are triangular in cross section.
    • Only the peripheral 20-30% of the menisci are vascularized
    • These structures deepen the articular surface of the tibial plateau adding stability to the joint
  •  
  •  
  • Meniscal Tear
    • Most Common injury to the knee requiring surgery
    • Medial meniscal tears occur 3x more frequently than lateral meniscal tears
    • From acute trauma or chronic long term wear and tear
    • Locked knee requires urgent intervention
  • Meniscal Tear Diagnosis
      • History:
        • Locking, clicking sound
        • catching episodes / giving way episodes
        • pain with squatting / Swelling
      • Physical Exam:
        • + effusion
        • + joint line tenderness
        • + McMurray’s sign
  •  
  • Meniscal Tear
    • Treatment:
      • Meniscal repair may be achieved arthroscopically by suturing the torn meniscus
        • This may be an option if tear occurs in an area with blood supply
      • Partial meniscectomy
        • Arthroscopic removal of the torn meniscus
  •  
  • Ligament Sprains
  • Ligament sprains
  • Medial Collateral Ligament (MCL) Sprain
    • Caused by valgus force to knee
    • Diagnosis:
      • + tenderness along MCL (Grade I-III)
      • + opening of medial joint line with valgus stress when knee is @ 30 degrees of flexion (Grades II-III)
      • (Posterior Cruciate Ligament is most responsible for medial-lateral stability when knee is fully extended)
    • Tx:
      • Ice
      • NSAIDS
      • Physical Therapy
      • Grade III sprains may require surgical repair
  • Lateral Collateral Ligament (LCL) Sprain
    • Caused by varus force to knee
    • Uncommon
    • Dx:
      • + tenderness along LCL (Grade I-III)
      • + opening of lateral joint line with varus stress when knee is @ 30 degrees of flexion
    • Tx:
      • Non-operative:
        • Ice
        • NSAIDS
        • Physical therapy
  • Anterior Cruciate Ligament (ACL) Sprains
    • Caused by twisting of knee while foot is firmly planted on ground
    • Hx:
      • Patient hears a “pop” feels a tear and acute pain in knee
      • Knee may feel unstable with weight bearing
      • Acute swelling at time of injury
  • Anterior Cruciate Ligament (ACL) Sprains
    • Dx:
      • + Lachman (20-30 degrees flexion, pull tibia anteriorly)
      • + anterior drawer (90 degrees)
      • + pivot shift with anterolateral instability
      • Arthrocentesis reveals hemarthrosis
      • MRI >90% accurate
    • Tx:
      • Physical therapy (pre/post op)
      • Open vs. Arthroscopic surgical reconstruction with patella tendon or hamstring tendon autograft; allograft (cadaver); xenograft (another animal)
      • CPM (continuous passive motion machine) and hinged knee brace post-op
      • If stable = no surgery nec.
  • ACL tear
  • Posterior Cruciate Ligament (PCL) Sprain
    • Caused by hyperextension of knee or direct blow to anterior aspect of flexed knee (Dashboard)
    • Dx:
      • + posterior drawer
      • MRI >90% accurate
    • Tx:
      • Physical therapy
      • Surgical reconstruction in patients who have high demand knees (athletes) and severe instability
  • Unhappy Triad
    • This is the term given to an injury where the ACL, MCL and Medial Meniscus are all three torn. 
    • The mechanism for this injury is usually a lateral blow to the knee with the foot fixed. 
    • 1. ACL tear
    • 2. MCL tear
    • 3. Medial meniscus tear
  • Patellar Tendon Rupture
    • Most frequently in patient <40 y/o
    • Exam:
      • Patient cannot actively extend knee
      • Palpable defect inferior to patella
    • Xray:
      • + patella alta
    • Tx:
      • Surgical repair
      • Weight bear as tolerated (wbat) with knee in extension
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    • Patella tendon rupture
      • Notice superior appearing patella
    Normal Knee
  • Patella Dislocation/ Subluxation
    • Lateral displacement of patella
    • Acute vs. recurrent
    • Reduction occurs with knee in extension
    • + patella apprehension test
    • Tx:
      • mobilization and strengthening exercises
      • Vs.
      • Immobilization in cylinder cast x 6 wks
      • Vs.
      • Surgical repair
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  • Patellar fractures
    • Direct blow to patella – fall
    • Dark lines across the bone
    • Sharp corners and edges
    • Repair by fixation pins and wire
  • Patellar fracture
  • Chronic Knee Pain
    • DJD – OA vs RA -
    • PE
      • Decreased ROM
      • No systemic symptoms
      • Plain radiographs for initial workup (standing)
    • X ray findings
      • joint space narrowing (Medial common)
      • Spurs
      • Sclerotic bony margins
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    • Loose body: disruption of cartilage , single broken piece.
    • If multiple pieces – synovial chondromatosis
    • Chondrocalcinosis : calcification within articular cartilage of the joint (DJD, hypercalcemia, pseudogout) linear calcifications
  • Knee Replacement
    • Indicated for severe DJD
      • Femoral condylar component
      • Proximal tibial component
      • Patellar component
    • AP- may look like components are not touching – plastic component not seen on Xray
    • Infection and loosening
    • Both look as lucent space around screws and base of the implant
  • Foot
    • Bones of the foot:
      • 7 tarsals
        • Talus
        • Calcaneus
        • Navicular
        • Medial Cuneiform
        • Intermediate Cuneiform
        • Lateral Cuneiform
        • Cuboid
      • 5 metatarsals
        • “ rays of the foot”
      • 14 phalanges
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  • Plantar Fasciitis
    • Plantar fasciitis is the #1 most common foot problem.
    • It is caused by activity, overuse and aging.
    • Plantar fasciitis is an inflammation due to repeated overstretching of the plantar fascia ligament (fat pad of the foot), usually at the point where the fascia is attached to the calcaneus.
    • Pain is most severe in the morning and stepping down onto foot, decreases as day goes on
  • Plantar Fasciitis
    • Contributing factors are:
      • flat (pronated) feet
      • high arches (supinated feet)
      • increasing age
      • sudden weight increase
      • sudden increase in activity level
      • running in sand
      • hereditary factors
    • Xray: May reveal bony spur at same site
  • Plantar Fasciitis
    • Tx:
      • Achilles stretching (tennis ball)
      • massage
      • Rest from activities
      • NSAIDS
      • Shock absorbing heel cups
      • Ankle orthosis (AFO) for recalcitrant cases
      • Avoid cortisone injections
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  • Hallux Valgus
    • Most common deformity of the foot
    • Results in excessive valgus angulation of the big toe
    • Splaying of the forefoot with varus angulation of the first metatarsal predisposes
    • The anatomical deformity consists of:
      • Increased forefoot width
      • Lateral deviation of the hallux
      • Prominence of the first metatarsal head
    • Clinical features
      • More common in women
      • Often bilateral
    • Symptoms result from
      • A bursa over metatarsal head = bunion
      • Osteoarthritis of the first MTPJ
  • Hallux Valgus
    • Xray:
      • Bilateral weight bearing AP/ lateral/ oblique foot
    • Initial Tx:
      • Shoewear education/ modification (sneakers)
    • Surgical Tx:
      • Distal metatarsal osteotomy +/- internal fixation for mild deformity
      • 1 st tarsal metatarsal arthrodesis (fusion) for hypermobile 1 st ray
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  • Lisfranc Injury
    • Fracture and lateral dislocation of 2 nd , 3 rd ,4 th and 5 th metatarsals relative to the tarsal bones
    • MOI: falling out of a saddle, foot caught on stirrup, or stepping into a hole with twisting of the foot
    • Exam:
      • + tenderness at Lisfranc joint
      • + swelling dorsally
    • XR:
      • AP/ lateral/ oblique foot (weight bearing when possible):
      • May reveal widening at joint
    • Tx:
      • Reduced & treated with screw fixation
      • NWB x 6-8 wks
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  • Jones Fracture/Dancers fracture
    • Transverse fracture of the 5 th metatarsal at the junction of the proximal metaphysis & diaphysis
    • PE:
      • + tenderness lateral aspect of foot
      • + swelling
      • +/- ecchymosis
    • XR:
      • AP/ lat/ obliq
    • Tx:
      • Short leg cast (SLC)
      • Non-wt bearing (NWB) x 6wks
    • Frequently fail to heal when treated non-operatively, especially in smokers
    • Surg:
      • ORIF
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  • Jones fx
  • Avulsion Fracture of the base of the 5 th Metatarsal
    • Pseudo-Jones fx / dancer fx/ tennis fx
    • Occurs when the insertion of the peroneus brevis is avulsed during forced inversion of the forefoot
    • Exam:
      • + tenderness
      • + swelling at base of 5 th metatarsal
      • +/- ecchymosis
    • XR:
      • AP/lat/obliq
    • Tx:
      • Short leg walking cast (SLWC) x 6 wks
  • Pseudo-Jones Fracture Dancer Fracture Tennis Fracture Avulsion Fracture
  • Pseudo-Jones Fracture
  • Comminuted Fracture of proximal and/ or distal phalanx of great toe
    • XR:
      • AP/lat/obliq
    • Tx:
      • Splint
      • Hard sole shoe
      • Ice
      • Buddy tape
  • Fractures of phalanges of lesser toes
    • XR:
      • AP/lat/obliq
    • Tx:
      • Buddy tape
      • Ice
      • NSAIDS
  • March Fracture
    • Stress fracture usually of the middle of the shaft of the 3 rd metatarsal (or 4 th )
    • History of having gone on long walk/march with no clear h/o trauma
    • Also seen in females with eating/exercising disorders
    • Exam:
      • + tenderness midshaft of the involved metatarsal
      • Pain with increased flexion or extension of toes
      • Pain subsides with rest
  • March Fracture
    • Initial XR:
      • AP/lat/obliq weight bearing foot will be negative
    • Follow up XR:
      • In 2 wks will show callus formation
    • Tx:
      • Symptomatically with crutches or if patient’s occupation requires prolonged standing or ambulation
      • SLWC x 3-4 wks
  • Stress fx
  • Calcaneus Fractures
    • May be intraarticular or extraarticular
    • h/o fall or twisting injury & pain localized to hindfoot (tarsal)
    • XR:
      • AP/lat/obliq/ axial heel/ Broden’s view (lateral xray with foot passively dorsiflexed/ supinated & internally rotated)
    • Should have CT scan to review extent of fx
    • Also do Xray of Lumbar spine due to associated fx’s
    • Initial management:
      • Splint
      • Ice
      • Elevation
  • Calcaneus Fracture
    • Tx:
      • Non-displaced intraarticular fx= NWB 4-6 wks
      • Displaced intraarticular fx= ORIF, NWB x 6-8 wks, early motion
      • Minimally displaced tuberosity fracture= NWB 3-6 wks
      • Displaced tuberosity fx= internal fixation, NWB 4-6wks
      • Sustentaculum tali= SLWC x 4-6 wks
      • Non-displaced anterior process fx= SLWC x 4-6 wks
      • Displaced anterior process fx = ORIF
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  • The Ankle
    • Bones
      • Tibia
      • Fibula
      • Talus
    • Obtain AP/lat/ obliq to r/o fracture
    • Anterior fat line displacement with effusion (Lateral view)
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  • Ankle sprains
    • Inversion injury= MC mechanism of injury / injures lateral structures of ankle
    • MC ligament sprained=
      • 1. Anterior talofibular ligament (front) - tears first
      • 2. Posterior talofibular ligament (back) - tears second
      • 3. Calcaneofibular ligament (middle) - tears last
    • Tx:
      • Ice x 20min several x/day
      • Elevation
      • NSAIDS
      • WBAT c crutches prn
      • Early ROM
      • strengthening
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  • Ankle fractures
    • Most common:
    • Medial or Lateral malleolus
    • Severe trauma – trimalleolar fracture
      • When severe associated ligament damage and subluxation of distal tibia over the talus
    • Stress views when NL Xray (standard) and high clinical suspicion of trauma
  • Bi - Malleolar fracture
    • Ankle inversion injury:
      • Horizontal fibular fracture and oblique medial malleolus fracture
    • Ankle eversion fracture:
      • Horizontal medial malleolus fracture with oblique fibular fracture
  • Bimalleolar fracture-inversion injury
  • Foot Fractures
    • Can involve any bone
    • Talus fractures are rare - MVAccident
    • Calcaneous fracture hard to see in standard views – order calcaneal view
    • Place foot on film and shooting down along the back side of the ankle
  • Achilles Tendinitis
    • Pain at achilles tendon, increased by running decreased by rest
    • Pain is often worse following activity, rather than during
    • Often palpable thickening over tendon or peritendinous tissues
  • Achilles Tendon Rupture
    • Occurs most commonly at narrowest portion of tendon approx. 2 inches superior to point of attachment to calcaneus
    • Mechanisms of injury:
      • 1. extra stretch applied to taut tendon
      • 2. forceful dorsiflexion with ankle in relaxed state
      • 3. direct trauma to taut tendon
  • Achilles Tendon Rupture
    • C/O acute pain in lower calf & difficulty ambulating
    • +/- palpable defect or mass in post. calf
    • + Thompson test
      • squeeze calf, foot should plantarflex, if no plantarflexion then achilles tendon is out
    • Tx:
      • 1. surgical repair
      • 2. equinus walking boot x 8 wks followed by 2.5 cm heel for another 4 weeks
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  • Tibial Shaft Fractures
    • Mechanisms of injury
      • 1. direct trauma: MVA, skiing, (boot top)
      • 2. indirect trauma: assoc with rotary & compressive forces as from skiing or a fall
    • Exam:
      • Pain, swelling, deformity
    • XR:
      • AP/lateral tibia fibula
  •  
  • Tibial Plateau Fractures
    • Involve proximal articular surface of tibia
    • Exam:
      • Pain localized to proximal tibia, +/- swelling
    • Imaging:
      • AP, lateral knee
      • CT scan
  • Tibial Plateau Fracture Classification
  •  
  • Hip
    • Xray views
    • AP and “frog legs” (abducted)
    • Lateral views hard to interprete
    • Evaluate the relationship of femoral head to the acetabulum
    • Look for cortical discontinuities
    • Look at trabecular pattern
  • Hip dislocations
    • From M V Accidents
    • Most common posterior dislocation
      • On AP - head of femur located superiorly and laterally displaced
    • Anterior dislocation: inferior and medial
    • Look for associated fracture fragments from the acetabulum
  •  
  • Hip dislocation Posterior dislocation: Head of the femur superior and laterally located Anterior dislocation: Head of femur located inferiorly and medially to the acetabulum
  •  
  • Hip fractures
    • 90% of hip fracture either at:
    • Femoral neck - Osteoporotic
        • Unable to walk after a fall
        • Little deformity
    • Intertrochanteric - post traumatic
        • Shorter leg in internal rotation
    • Stress frx dificult to detect in elderly
    • Nondisplaced frx better seen
        • MRI
        • Bone scan ( may take several days to show)
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  • Open Book fx
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  • Intertrochanteric frx
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  • Hip Fx
    • Hip fracture classifications most often are based on their anatomic locations: head, neck, intertrochanteric, trochanteric, and subtrochanteric
  • Hip & Proximal Femur Fx’s
    • Femoral head fractures
      • These usually are associated with hip dislocations. Superior femoral head fractures normally are associated with anterior dislocations, while inferior femoral head fractures are associated with posterior dislocations.
      • Type 1 - Single fragment fractures
      • Type 2 - Comminuted fractures
    • Femoral neck fractures
      • Type 1 - Stress fractures or incomplete fractures
      • Type 2 - Impacted fractures
      • Type 3 - Partially displaced fractures
      • Type 4 - Completely displaced or comminuted fractures
    • Intertrochanteric fractures
      • Type 1 - Single fracture line; no displacement; considered stable
      • Type 2 - Multiple fracture lines or comminution; displacement; unstable
    • Trochanteric fractures
      • Type 1 - Nondisplaced fractures
      • Type 2 - Displaced fracture; greater than 1 mm displacement for greater trochanteric fractures and greater than 2 mm displacement for lesser trochanteric fractures Subtrochanteric fractures
      • Stable - Bony contact of medial and posterior femoral cortices
      • Unstable
    •  Femoral Head
    • Femoral Neck 
     Intertrochanteric fx Trochanteric fx 
  • Hip & Proximal Femur fx
    • Leg shortened and externally rotated
  •  
  • Hip Dislocation
    • MC is posterior dislocation
      • Due to dashboard
  • Aseptic necrosis hips
    • Xray changes
    • Flattening, irregularity, sclerosis of superior aspect femoral head(late)
    • Early findings on MRI/bone scan
    • Caused by trauma and chronic steroid use
  • Aseptic necrosis of the hips
  • Slipped Capital Epiphysis
    • Cause unknown
    • Does not occur before age 9 yo
    • Overweight teenage male
    • Radiographic dx
    • Thickened epiphyseal plate
    • Medial displacement of the femoral head relative to the femoral neck
    • Lateral and frog leg views used for dx
  • Slipped Capital Epiphysis
  • Osgood - Schlatter disease
    • Traumatic tibial lesion in children
    • Avultion fracture of the anterior tibial tuberosity
    • Frequent in active boys paticipating in sports
    • Pain present
    • Age 10-15 yo
    • Heals with rest
  • Osgood - Schlatter disease
  • Legg-Perthes disease(aseptic necrosis of the femoral head)
    • Boys more than girls
    • Limp + pain + limited ROM of the hip
    • Irregularity , sclerosis and fragmentation of epiphysis
    • Resulting deformity with OA after a few decades
  • Legg-Perthes disease(aseptic necrosis of the femoral head)