MSK CCC 1: DDX of Cervical Pain
Cervical Radiculopathy – directirritationof cervical nerve rootfrom:
Osteophyte,space occu...
Cervical Dermatomes/Muscle Groups
C5 – elbowflexors
C6 = wristextensors
C7 – elbowextensors
C8 - fingerflexors
T1 – small ...
Cervical – axial + sagittal + coronal withoutcontrast
Thoracic – not good due to pulsatingstructures
Lumar – cord,disc abn...
Tumors:gliomas,ependymomas,hemagioblastomas
Hydrosyringomyelia
Infection,Trauma
MSK CCC 3: BenignBone Tumors
Questionstoas...
~can be mistakenforchondrosarcoma
Tx: asymptomaticrequiresnotx,butneedtorule outprogressive
Non-ossifyingfibroma– nonneopl...
MSK CCC 4: Osteoporosis,Osteoarthritis
Osteoporosis
Indicationsthatacute back painmay involve underlyingconditions
 Patie...
Age Women Men
Puberty to mid-20s & 30s Bone mass increasesrapidly, reaching peak bone mass
Mid-30s to 40s A fewyears of st...
Calcitonin:hormonal inhibitorof bone resorption
Osteoarthritis/Degenerative Jointdisease =MC type ofarthritis
Layer of car...
Treatment:
OMT, PT, wt change,posture change,painmedicationswithlimitedusefulness
Inversiontable
Laminectomy
MSK CCC 7: No...
S/S:
X-rays: Notneeded
Tx: Avoidaggravatingfactors,US,local frictionmassage,NSAIDs
Corticosteroidinjectionevery6-8wks,spli...
Insidiousonsetof thickeningandcontracture of the palmar fasciawithisolatednodular
thickening skinondistal side drawnupint...
S/S: Vague achingwristpainwithstiffness,tenderness/swellingatlunate,painful ROM
X-rays: initiallynormal  eventuallycollap...
Tx: Protection
Aspiration(riskforsepsis),cultureif suspectedsepsis
Lateral pain
Epicondylitis“tenniselbow”
MOA: repetitive...
MOA: trappingof median nerve betweenheadsof pronatorteres
Racquetsports,throwing
S/S: Pain,paresthesias,reducedsensationin...
Antiphospholipidantibodiesfor hypercoagulability
*Anti dSDNA
*Anti SmithAbs
*+ abs confirma diagnosisof SLE
Treatment:
1st...
Patho:
Jointdestructionstartingwithcartilage  erode bone/ligaments/tendons=deformation
Fibroblasts/monocytessecrete prote...
Arthritis Common Deforming
Symmetry No Yes
Jointsinvolved PIP>MCP>wrist>knee MCP>wrist>knee
Synovial hypertrophy Rare Comm...
• Crystal-inducedarthritis
• Systemicrhemmaticillnesses
SLE
Systemicsclerosis
Systemicvasculitis
Polymyositis
Dermatomyosi...
Hangingcast Abductionpillow
ORIF(testquestion –indications)
Indications:DisplacedGTfx > 5mm, fx that involvesarticularsurf...
Type IV - AC jointdislocatedand clavicledisplaced posteriorly intoorthroughthe trapezius
muscle,seenonaxillaryview
Type V ...
RadiographicEvaluation:
X-rays:AP,Lat, Oblique
MRI: ligamentousinjury
Classification:3Typesincreasinginseverity –not respo...
Classification
DenisThree ColumnModel –to explaininjuries/guidetreatments
Columns:Anterior,middle*,andposterior
Instabilit...
Hyperflexion-Distractionof posteriorelements
Middle/posteriorcolumnsfail
S/S: Posteriortenderness,hematoma,interspinouswid...
Heal in a clockwise pattern
C - capitellum
R – radial head
I – internal/medial epicondyle
T - trochlea
O - olecrenon
E – e...
Radial Head/NeckFractures
MC 9-15 yrs old, more likelytofracture neck
70% have MCL injuryatelbow
MOI: FOOSH injury
Inspect...
Transverse fracturesof radius:
Colles’ –dinnerforkdeformity,dorsal displacementof distal fragment,mediann.damage
Smith– re...
VitaminDdeficiency  multiplebonydeformities
*Rachitisrosary alongchestwall – failure of bonestoharden
Harrisongroove or s...
If seeninthoracic – a late finding
HLA-B27, if seronegative worsenswithage
Inflammatorychanges+newbone formation
Beginswit...
Lumbosacral mechanics
Sacrum and lumbarspine move inoppositedirections
Lumbar flexion  sacral extension,etc.
Lumbar rotat...
Facet Syndrome – mimicsparsfx
Focusedpain,worse w/extension
Dx: Standing/seatedKemp’stest
Hyperflexiontest
Tx: therapeutic...
Grading:1 – 5 with5>100% slipand1 with0-25% slip
Riskfactors:
Athleticactivityes Congenital defects Age
MC inboys,but fema...
Femoral neckstressfracture Tendinosis
Acetabularlabral tear Referredpain
Osteoarthritisand inflammatoryarthritis –
 Both ...
Lateral Hip & ThighPain
CommonHipProblems
Hip Pointer
MeralgiaParethestica
IliotibialBandandTensorFasciaLatae Syndrome
But...
Rotational Deformities
Intoeing
Metatarsus Adductus
Clubfoot
Tibial Torsion
Medial Femoral Torsion
Outtoeing
AngularDeform...
PE! If abnormal  Ultrasound incoronal ortransverse planesorhipx-rays
Linesdrawn:Hilgenreiner,Perkins,Sheton(disruptionher...
CBC, ESR forinfection
AP,frog-legs
Bone scan to eval the bloodsupply
Tm:
Protecthipjoint! ↓wtbearing,keepfemurinAdduct/IRp...
B – dentinogenesisimperfectpresent
Both – blue sclera,inuterofractures,kyphoscoliosis,hearingloss,easilybruised,mild,
shor...
Withmalignancy – pain,pathologicfxs
May getcalcifiedovertime
Eval:
Xraysare modalityof choice
MRI andCT reservedforfurther...
Sanfilippo –deficiencyinheparinN-sulftase orglucosaminidase
MC MPS disorder,with4subtypes
Severe CNSinvolvementwithsevereb...
S/S: Lg jointsw/symmetricinvolvementof small jointsinhands/feet
Pain+ ↓ROMof cervical spine
Low grade fevers
Eval
Labs ESR...
Posterior tibial tendinitis
38-58 yearoldwomanwhostarts new exercise programandcomplainsof progressive,achypain
inmedial a...
Ddx for painin metatarsals/phalanges
Stress/true fx
Tendinitis
Infxn Tumor Synovitis
Metatarsal:
Metatarsalgia Interdigita...
MSK CCC 26: Traumatic foot,ankle
X-raysinvolvedinawork up:
Foot: AP/Lat/Oblique
Ankle: AP/Lat/Mortise view/Brodenviews
Fra...
Tendoninjuries
Flexortendons
Extensortendons
Complicationof misseddiagnosis:retraction
MSK CCC 27: Non-traumatic knee pain...
Tendonitis(chronicor acute)
Causative factors:changesinmechanical loadingorchangesinmuscle tendonextensibility
Intrinsicfa...
PatellarTracking– tilt,subluxationwithinvertedJsign,apprehensiontest,functional evaluation
Tx: relative restwithtemporaryc...
Trimming/contouringof tornsurface
Abrasion/microfracture inanattempttogrow fibrocartilage repaircartilage
Fillingacontaine...
Fx of base of 5th
metacarpal
Boxer’sFracture
Fx headof 5th
metacarpal withvolarangulation
MOI: punchinga person/wall
Fract...
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MSK CCC 1: DDX of Cervical Pain Cervical Radiculopathy – direct ...

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MSK CCC 1: DDX of Cervical Pain Cervical Radiculopathy – direct ...

  1. 1. MSK CCC 1: DDX of Cervical Pain Cervical Radiculopathy – directirritationof cervical nerve rootfrom: Osteophyte,space occupyinglesion,increasedstressortensioninforaminal area S/S: Arm pain Clumsiness PaininTrapezius,Paraspinal, Interscpularmuscles Dermatomal paresthesiasorhypesthesia Cervical Spondylosis– variousdegenerative diseasesof spine,ankylosisof adjacentvertebral bodies, degenerationof intervertebral discfrom: Age relateddegeneration,traumaorgenetics S/S: DecreasedROM Paininparacervical,trapezius,interscapularmuscles Painwithupwardgaze or rotationof neck,extensionof neck Progressionleadsto: Dehydrationof the disc,thinningof discspace,protrusionof disc Buckling/dysfunctionof intralaminarligaments Abnormal loadingandfxnof jointsurface CompensatoryChanges(ex.Osteophytes) PE: Spasmof cervical m.  knottyor firoustexture of muscles Loss of normal cervical lordosis Somaticdysfunction Cervical Degenerative JointDisease – degenerative/hypertrophicchangesinbone/cartilageof 1+ joints withprogressive wearingdownof opposingjointsurfaces=>distortionof jointposition DDX of non-traumatic cervical pain SomaticDysfunction Cervical Spondylosis/DJD Cervical Radiculopathy Visceral ReferredPain Mechanical Referredpain PathologicFracture Infection Diagnosis: X-rays:AP/lat/oblique views Myelogram EMG MRI CT Treatmentapproachfor cervical pain OMT, PT, Cervical traction,Medications,Surgical referral
  2. 2. Cervical Dermatomes/Muscle Groups C5 – elbowflexors C6 = wristextensors C7 – elbowextensors C8 - fingerflexors T1 – small fingerabductors Hintsfor PE:  If duringgross motiontesting,the headautomaticallysidebendsandrotates inopposite directions,thinkOA &/orSternocleidomastoid(SCM).  If duringgross motiontesting,the headautomaticallysidebendsandrotatesinsame direction, thinksingle SDs(perhapsafewof them).  If restrictioninflexion,thinktrapezius;restrictioninextensionSCM& strap muscles(muscles that connectto the hyoid).  If dysphagia(sensationof swallowingdifficulties),thinkstrapmusclesandhyoid.  If radiationof painto upperextremities,thinkentrapment(spondylosis,scalenes, firstrib dysfunction, herniateddisc).  If radiationof painto occiput - many muscles,occipital nerves.  If headache withpressure andtightheadbandsensation,thinksuboccipital andoccipitalis musclesandgreater& lessercranial nerves.  Anykindof symptom,thinksomatic dysfunction.  If dizzinessorsyncope,especiallyonheadturning,thinkcompromiseof carotids&/orvertebral arteries. BeCareful  In casesof respiratorydisease,thinkscalenes&sternocleidomastoid(secondarymusclesof respiration) andC3,C4,& C5 (attachmentof scalenesandoriginof phrenicnerves)  If radiationof painto the earor jaw,thinkSCMandstylohyoid MSK CCC 2: Imagingof spine Why imagine the spine? trauma,pain,disturbance insensation/movement,neoplasticdiseaseworkup Techniques: Plainradiographs Cervical:AP,lat,obliques,openmouth(c1-c2),swimmer’s(c7) Assesslinesonlateral (anterior,posterior,spinolaminar,posteriorspinous) Thoracic: AP,lat Lumbar: AP,lat,obliques,lateral sacrum Sacrum/coccyx:AP,lat, obliquesforSIjoints CT + CT thinsection - Betterfor bonystructures Neededformanythoraciccasesbecause of superimposedstructuresseenonxray Lumbar – disc or bone abnormality MRI - Bettersofttissue structures:cord,ligaments,discks,marrow
  3. 3. Cervical – axial + sagittal + coronal withoutcontrast Thoracic – not good due to pulsatingstructures Lumar – cord,disc abnormalities,bone contusion,ligamentousinjury Bone scan – lookformultiple areasof involvementorunsuspectedlesions Traumatic lesions– mostfrom blunttrauma Indicationsforimaging:pain,neurologicdeficit,distractinginjuries,alteredconsciousness,high riskMOI, vascularinjury Initial screen=plainfilms,thenfollow upwithaspiral CT Compression fracture –inthoracic/lumbarspine JeffersonFracture –inbonyring of C1 Densfractures(Type I,II, andIII) Flexionteardropfracture Burst fracture – of C3-C7 from axial compressioninjury,commontoinjure corddue toposterior displacementof fragments Signsof instability: Interspinous,interlaminarwidening >50% compressionof vertebral body >20° of kyphosis Interpediculate widening >2 mm of translation Dislocation Degenerativespinedisease –majorcause of neckand back pain Cervical betweenC5-6,C6-7 Dessication  diskbulge  protrusion  herniation  extrudeddisk Osteophytes Spondylolysis –defectof parsinterarticularis Showscollaron the scottydog Sondylolisthesis –anteriordisplacementof the uppervertebral body MC at L4-5 or L5-S1 Extradural processes: Disc protrusion/spondylosis Metastasis,B9, malignantneoplasms Infection,Trauma Intradural extramedullary: Meningiomas Schwannomas Embryonal tumors Infection,Trauma Intramedullar: Demyelinatingdisease
  4. 4. Tumors:gliomas,ependymomas,hemagioblastomas Hydrosyringomyelia Infection,Trauma MSK CCC 3: BenignBone Tumors Questionstoaskin a possible tumor: Age – certaintumorsfor certainage groups Durationof complaint Rate of growth Painassociated withthe mass – B9 are notpainful Historyof trauma Personal/familyhx of cancer Systemicsignsorsymptoms Tumorsare namedby tissue originandlocationwithinthe bone: Know:Tumorsthat recur and tumorsthat can become BAD Osteochondromafrom bone andcartilage “harmatomas” MC B9 bone tumor that arise nearthe endsof long bones 10-20 yearsof age Secondarymalignantchondrosarcomaarisesin10% X-rayshowsbonyoutgrowthfromcortex (mostof tumor isin cartilage cap soopacityon xrayis smallerthanthe massfeelsclinically) Tx: Necessaryif tumorisneara nerve,causespain(fxs),disturbsgrowthorbecomesmalig Hereditary multiple osteochondromatosis AD inheritance,lotsandlotsof tumors Riskfor chondrosarcomadevelopmentishigher FibrousDysplasia – defectinosteoblasticdifferentiationandmaturation Anybone can be affectedwithmedullarybone replacedbyfibroustissue Appears“ground-glass”onxray CT scan can showexpansionof the bone due tointramedullaryexpandinglesion *Monostoticis 7-10x timesmore commonthan polyostotic Associatedwithsystemicconditions(precociouspuberty/McCune-Albright/myxomas) Tx: conservative primarilytopreventdeformity Surgical indications:severe/progressive,nonunion,painful,fx Chondroma – uncommonB9 tumorwithinbone marrow thatforms mature cartilage Men in2-4th decade,asymptomatic–foundincidentallyaslyticlesionswithstippledcalcification whenx-raysare takenfor somethingelse ~small bonesof hand/feet usually
  5. 5. ~can be mistakenforchondrosarcoma Tx: asymptomaticrequiresnotx,butneedtorule outprogressive Non-ossifyingfibroma– nonneoplastic,asymptomatic Usuallyfoundinchildrenwith75% occurringin the 2nd decade Femur> Tibiaat juxtaepiphysealregion Larger lesionspresentsasa pathologicfracture Xraysshowlesionmigratingawayfromepiphysealplate withtime Normallyregressspontaneously –treatonlyif ithas a pathologicfx Chondroblastoma“Codman’stumor” Rare B9 tumor originatingfromcartilage See painwhereverthe tumoris,especiallyatendsof longbones People age 10-20 years X-ray: cyst containingspotsof calcificationthatmustbe excised Tx: sx,bone graft,PT – tumormay recur Chondromyxofibroma Rare,occurs before age 30 Locatednear endof longbones Xray: lyticlesionwithwell definedmarginsinthe metaphysicof leg Radiolucentarea is a giveaway Tx: excisionorcurettage Osteoidosteoma – MC benignosteoid-formingtumor Primarilyseeninlongbones (proximal femur),classicallycausespainatnight inyoungadults Xrays: newbone formationwithsometimesalucentspot Tx: NSAIDsforpain Benigngiant cell tumor – in epiphysesanderode bone intosofttissues,knowntorecur S/S: painat adjacentjoint,visiblemass,swelling,bonefracture,limitedROM,fluid accumulation Osteoblastoma– selflimitedproducingosteoidandbone Occurs invertebrae,metaphysic/diaphysisof longbones,sometimespelvis S/s: painof longduration, swelling/tenderness,tumorsof the spine Bonescan: increasedisotope uptakeonbone scan Endochondroma – B9 cartilage tumors Commonlyfoundintubularbonesof hand/foot thatmaycause unsightlyswelling/fx Be able torecognize the radiographsof this fortest. S/S: no symptomsbutcouldhave handpainif large tumor/fx
  6. 6. MSK CCC 4: Osteoporosis,Osteoarthritis Osteoporosis Indicationsthatacute back painmay involve underlyingconditions  Patientdemographics  Age > 70 yr  Historyof cancer  Glucocorticoidorimmunosuppressivedrugtherapy  Alcohol orI.V.drug abuse  Historical features  Weightloss  Fever  Painincreasedbyrest  Bowel orbladderdysfunction  Neurologicsymptoms  Saddle blockanesthesia  Progressive motorweakness OsteoporosisVertebral Fractures Acute or chronic? Varyin degree frommildwedgestocomplete compression Degree of compressiondoesnotcorrelate toamountof pain Some fracturescouldhave occurredgradually,andwill notcause acute pain Stable or unstable? Most are stable -- rest Diagnosedbyspinal radiograph  doa DEXA scan to confirmosteoporosis  kyphosisor height Treatment:NSAIDS,calcitonin,OMT,PT,Educaiton,supportgroups Surgeryto rebuildtheirspines: Vertebroplasty Kyphoplasty Osteopenia–weakbone that doesn’tnecessarilyfitthe osteoporosisrequirements T score < -1 but> -2.5 Osteoporosis –T-score < -2.5 Riskfactors: lowcalcium,smoking,alcoholism, meds
  7. 7. Age Women Men Puberty to mid-20s & 30s Bone mass increasesrapidly, reaching peak bone mass Mid-30s to 40s A fewyears of stability,then slowbone loss No risk factors bone loss 1% / yr Withrisk factors (smokers,i bone loss  6% / yr Mid-40s to 50s Menopause w/o estrogenreplacement,thenrapid bone loss  7% / yr for  7 yrs Mid-50s to late life Continuingbone loss of1% to 2% / yr Epidemiologyof OsteoporosisFractures:  Highprevalence  1.25 millionfemale &500,000 male hipfracturesworldwide (1990)  250,000 hip& 500,000 vertebral fracturesin U.S.annually Causesof Osteoporosis: *Estrogendeficiency Calciumdeficiency&secondaryhyperparathyroidism Androgendeficiency Changesinbone formation(gettingolder) Secondarycauses/meds(steroids,diuretics,heparin,etc.) Evaluation: BMD, assessforsecondarycausesof bone loss,biochemical markers BMD measure – bestpredictorof fracture if inlowestquartile DEXA – methodof measurement Treatment:PREVENT! Modifyriskfactors! Wt-bearingexercise –walking! Ca+2: 1200mg/day VitaminD:400-800 IUday regardlessof sunlightexposure Estrogenreplacement:worriedaboutside effects(PMS-likesyndrome),riskof endometrial/breastcancer Big difference betweennatural andequineestrogen. Bisphosphonates:stopsthe resorptionof bone Bad dentition! Donotgive! Cancause osteonecrosisof the jaw! SelectiveEstrogenreceptormodulators Preventosteoporosis Antagonistsinbreast/uterinetissue=lessriskof cancer development
  8. 8. Calcitonin:hormonal inhibitorof bone resorption Osteoarthritis/Degenerative Jointdisease =MC type ofarthritis Layer of cartilage breaksdownandwearsaway Degree of abnormalityonx-rayandclinical findings/symptomsdonotalwayscorrelate Spinal – intervertebral disks,vertebral bodies,posteriorapophysealjoints Nerve rootcompression=radicularpain Degenerativechanges: Apophyseal joint Spondylosis –degenerative DISKdisease Spondylolysis –classicOA change! Spondylolisthesis –one slipsforward Spondylitis Riskfactors: Age – olderyouget,higherthe risk Female –hand/knee Jointtrauma – more than likelydevelopDJDinthat joint Repetitive stress Obesity –highestcorrelationwithkneeOA Pathology: Most strikingchangesare seeninload-bearingareasof the articularcartilage Early stages:cartilage isthicker Progression:jointsurface thins,cartilage softens,integrityof surface isbreached Deepcartilage ulcersextendingtobone Treatment: Reduce jointloading,exercise,PT, intraarticulartherapy,sx,drugs Spinal stenosis Lumbar spine MC inmiddle-aged/eldery ClassicSyndrome:neurogenicintermittentclaudication Rule out:PVD bycheckingpulsesintheirfeet S/S:Dull to severe paininbuttocks Numbness,weakness,paresthesiasinlowerextremities Relievedbybendingforward,sitting,lyingdown. Gets worse whengoinguphills/stairs
  9. 9. Treatment: OMT, PT, wt change,posture change,painmedicationswithlimitedusefulness Inversiontable Laminectomy MSK CCC 7: Nontraumatic disorders of hand/wrist H&P Inspection Carryingangle – normally10-15° withF > M carrying angle Palpation MotionTesting Anatomy – bones:Some LoversTry PositionsThatTheyCan’tHandle Ganglioncyst Softtissue massof hand/wristusuallyattachedtoatendon sheathor joint MC scapholunate joint Liningherniatesoutof the ligamentousdefectcausinga“cyst” Full of jelly-like fluiddue toinflammation S/S: Vague wristpain,mildlytendermassthatmaybe reducible Fusiformmassfreelymobile,+transillumination,maybe mistakenforbonyprominence Commonhx of repetitive wristloading Tx: Alleviate symptoms/cause of problem Aspiration(seldomcurative) Injectionwithsteroid Surgery MalletFinger– DIP joint injury Flexiondeformitycausedbylossof continuityof extensormechanismtodistal phalanx Commonin4th /5th digits MOA: suddenforceful flexionof DIPjoint(bluntobject) S/S: Pain,swelling,lackof extensionatDIPjoint X-rays: Bonyavulsionoff dorsal proximal distal phalanx+volarjointsubluxation Tx: SplintingDIPinfull extension,encourage proximal jointmotionfor6-8weeks Surgeryif fracture fragmentinvolves>30% of articularsurface or volarsubluxation Trigger Finger Stenosingtenosynovitisdue torepetitive fingerflexioninanyfinger(MCthumb,middle,long fingers)
  10. 10. S/S: X-rays: Notneeded Tx: Avoidaggravatingfactors,US,local frictionmassage,NSAIDs Corticosteroidinjectionevery6-8wks,splintat night Gets worse – considersurgical releaseof sheath Thumb MCP – Ulnar collateral ligamentTear Tear of UCL of thumb= “gamekeeper’sthumb,skier’sthumb” Hyperabductionof thumbMCPjoint(aftera FOOSH) Cannotperforman effective pinch S/S: PainoverUCL area,weak/painful pinch Tenderness,swellingoverulnaraspectof thumbMCP X-rays: Fx associated? Stressx-rayshows>20 of instabilitycomparedwithcontralateral side,complete tearlikely Stenerlesion– occurs in complete UCLtears Cannotheal normally  residual instability Tx: ImmobilizationorfunctionalbracingwithMCPinslightflexionfor4-6wks Sx if completelytorn DeQuervain’sTenosynovitis Inflammationof the tendonsandsynovial sheaths,esp1st dorsal compartmentof wrist Commoninrepetitivemotionactivities S/S: Painin1st dorsal compartmentwithgripping/rotational motions + Finkelsteintest Tx: Splintinginthumbspica,avoidrepetitive activity,OMT,NSAIDs,steroidinjections*,Sx. IntersectionSyndrome (donot confuse withDeQuervain’s!) “Squeaker’swrist”–tendonmovementissometimesaudible Overuse injurydue torepetitivetwistingmotions  irritationof overlappingtendons Wt lifters,skiers,canoeists,raking,shoveling S/S: Painalongdorsoradial wristworseningwithgripping/twisintmotions Local crepituswithwristextension Tx: Avoidrepetitiveactivity,thumbspicasplit,NSAIDs,OMT,PT/OT,injections Rarelyneedsurgery Dupuytren’sDisease – NOT a consequence of activity!!!!
  11. 11. Insidiousonsetof thickeningandcontracture of the palmar fasciawithisolatednodular thickening skinondistal side drawnupintoa fold  fingersbecome progressivelyflexedat MCP/PIPjoints S/S: +Table top testof Hueston Tx: Hyperextensionexercisesof the fingers With30° contracture – considerSurgery Nerve entrapmentinjuries Carpal tunnel syndrome– mediannerve entrapment S/S: Tinglinginfingertips,nb/painatnightwakingthe patients  referredtoelbow/shoulder/neck +Tinel’s +Phalen’s +EMG +NCV Late findings:wknessof abductorpollicusbrevis,atrophyof thenareminence,l/osensoryin mediannerve distribution Tx: Correctionof MOA, splittingwristneutrally(atnight),NSAIDs,OMT,Injections,Sx Cubital Tunnel syndrome – ulnar nerve entrapmentinposterior-medialaspectof elbow MOA: repetitiveelbowflexionactivities S/S: Tendernessincubital tunnel + Tinel’stest +EMG/NCV Wk/sensorylossinintrinsic(ulnarnerve distribution) Tx: Avoidrepetitiveflexion,PT/OMM/Splinting/NSAIDs/Sx Guyson’sCanal Entrapment – ulnar nerve entrapmentmedial tocarpal tunnel Betweenpisiformandhookof hamate MOA: Repetitive trauma(masslesion,directtraumatohookof hamate,cyclists’palsy,jackhammer use) S/S: pointtenderness,sensorylossof ulnar1 ½ digits DDx: hookof hamate fracture Tx: rest,OMT, avoidance,NSAID,splint,sx Triangular Fibrocartilage Complex MOA: Fall on pronatedhyperextendedwrist Twistingw/palmarrotation Repetitive forcedulnardeviance Distal radiusfracture S/S: Ulnar sidedpain,clickingsensation X-rays: Ulnar variance (Positive) –lessspace soulnardeviance leadstomore trauma Tx: Injection* splint/cast,rest,NSAIDs,sx,reduce stressors Kienbock’sDisease (IdiopathicAvascular Necrosis) MOA: repetitive compressiveforcesaffectingthe bloodsupply Dominantwristinyoungermenandolderwomen
  12. 12. S/S: Vague achingwristpainwithstiffness,tenderness/swellingatlunate,painful ROM X-rays: initiallynormal  eventuallycollapseof lunate MRI: studyof choice forearlydiagnosis Tx: Conservative =symptomcontrol,immobilization Failedconservative =surgical intervention(lunate excision,fusion,revascularization) MSK CCC 8: Nontraumatic disordersof Forearm,Elbow, and Wrist pain H & P Inspection Normal carryingangle = 10-15° ElbowAnatomy Mediannerve passesthroughtwoheadsof the pronatorteres Ulnar nervesthroughcubital tunnel Radial nerve – dividesintosuperficial anddeepbranch DeepbranchpassesthroughArcade of Frohse (mostsusceptible toinjury) PE: ROM, DTRs, muscle testing,specialtests Elbow AnteriorPain BicepsTendonitis MOA: repetitiveoverloadingof biceps, resultof excessiveelbow flexion and supination S/S: Increased pain on resisted forearmsupination Anteriorelbowpainwithflexion/supination Wknesssecondarytopain,tenderbicepstendontopalpation DDX: Tx: Activity modification,stretching/strengthening/OMM Rest/ice,NSAIDs,bracing Posteriorpain Triceps Tendonitis MOA: Overuse due to overloadingtricepsbyrepetitiveextension(throwing/hammering) S/S: Painat posteriorelbow,tendernessat/above insertionof triceps Increasedpainwithresistedextensionof elbow X-ray: Couldsee:degenerativecalcification,hypertrophyof ulnar,tricepstractionspur DDx: Tx: activity modification,stretching/strengthening/OMM Rest/ice,NSAIDs,bracing OlecranonBursitis “miner’selbow,”“student’selbow” MOA: repetitive compression causesirritationtothe bursa S/S: Painless swellingof the elbow,noerythema DDX: Septicbursitis(infxn)
  13. 13. Tx: Protection Aspiration(riskforsepsis),cultureif suspectedsepsis Lateral pain Epicondylitis“tenniselbow” MOA: repetitiveoveruse of wristextensors,10Xmore frequentthanGolfer’selbow Risks: S/S: Achingoverlateral epicondyle Difficulty withwrist extension X-ray: Ca depositsinextensorsdue tobleedingfrommicrotears/chronicity Tx: Activity modification,stretching/strengthening/OMM Rest/ice,nsaids,bracing,steroidinjections,sx (last resort) Medial pain Epicondylitis“Golfer’selbow” MOA: repetitivetensionoverloadingof wristflexors S/s: Painful inflammationovermedial epicondyle,wknesssecondarytopain Tendernessatflexororigin - Tinel’s Increased pain withresisted wrist flexion and forearmpronation X-ray: Rarelydone,butif done negative exceptforsome calcificationsdue tomicrotears DDx: Tx: Activity modification,stretching/strengthening/OMM MCL (Ulnar collateral ligament) SPRAIN Mostimportantstabilizerof valgusstress MOA: repetitivevalgusstress  microtears/ruptures Pitching/throwing,racquetsports S/S: Gradual onsetof medial elbow painthatisrelievedbyrest Tendernessoverhumeroulnarjoint(at sublimetubercle) PE: valgusstress,movingvalgusstress,“milking”maneuver Tx: Strengthening/stretching,OMM Rest,NSAIDs,PT Fail rehab  reconstructanteriorbandof MCL Ulnar nerve entrapment(Cubital tunnel syndrome) MOA: repetitive elbowflexion S/S: +Tinel’s, Elbowpain radiating to wrist,4th /5th fingers, +EMG, +NCV Parethesiasonulnarside of hand,wkness/sensorylossinintrinsiclater Tx: Avoid repetitive flexion Rest,NSAIDs,OMT,PT, Splintinginflexionatnight,decompression Pronator syndrome – pure sensory
  14. 14. MOA: trappingof median nerve betweenheadsof pronatorteres Racquetsports,throwing S/S: Pain,paresthesias,reducedsensationinmediann.distribution Resisted pronation of forearmreproducessymptoms,- Phalens,+Tinels Tx: Modificationof activities,splinting, OMT,sx Anteriorinterosseoussyndrome – mostly motor MOA: strenuousorrepetitiveelbowmotioncompressingthe anteriorinterosseous(branch of median nerve) bythe deep head of the pronatorteres S/S: Wknessor lossof flexion of DIP jointof thumb index finger Tx: Dependsoncause,lifestylemodification,splinting,PT,OMT, NSAIDs,surgical decompression If advanced  osteophytescanformonthe olecranonandin the olecranonfossa MSK CCC 10: Lupus vs. RheumatoidArthritis SystemicLupus Erythematosus – chronic,recurrent,fatal multisysteminflammatorydisorder Clinical Findings: Migratory arthritisandarthralgiathat issymmetrical andpolyarticular *monoarticular – thinkinfxn* Predilectionforknees,carpal joints(PIPjoints) Morningstiffnessforminutes vshoursinRA Degree of pain> physical findings Tenosynovitis:epicondylitis,rotatorcuff tendinitis,Achillestendinitis,posteriortibialtendinitis, plantarfasciitis Diagnosis: No single diagnosticmarker Lupuspresentswith one orseveral of the following: Unexplainednonspecificsymptomssuchasfever,fatigue,wtloss,oranemia Photosensitive rash Arthralgia,arthritis Raynaudphenomenon Serositis Nephritisornephriticsyndrome Neurologicsymptoms(seizures orpsychosis) Alopecia Phelbitis Frequentmiscarriages Laboratory testing: CBC, creatinine,albumin,ESR,CRP,UA,24 hour urine ANA (negative makesitunlikely –goodfor rulingout,notfor positive diagnostic)
  15. 15. Antiphospholipidantibodiesfor hypercoagulability *Anti dSDNA *Anti SmithAbs *+ abs confirma diagnosisof SLE Treatment: 1st line forpain+ inflammation –NSAIDsor acetaminophen Contraindicatedinlupusnephritis(alsoCOX-2) Inflammation asprominentfeature =NSAIDs (ibuprofen,naproxen,nabumetone) Use withPPIif at riskfor NSAID-inducedGItoxicity Painwithoutinflammation=Acetaminophen Contraindicatedinliverdisease/alcoholism Hydroxychloroquine(antimalarial) –forjointsymptom relief,preventionof clinical relapse For articularmanifestations,rashes,andfatigue Corticosteroids –usedinfrequently,onlyforinflammation –not pain Riskof developingosteoporosis Goal – use for acute flare-upsbutgetdose reducedasquicklyaspossible Anakinra– IL1 receptorantagonist –for severe arthritispatients unresponsiveto otherrxs Methotrexate –resistantinflammatoryarthritis Methotrexate +prednisone =more effective thanpredalone Amitriptyline–TCADs– whenpainisunresponsivetoothermeasures RheumatoidArthritis – chronicsystemicinflammatorydisorderof unknownorigin *Causesinflammationof synoviumcausingchemicalstobe releasedtothickenthe synovium/damage the cartilage/bone oraffectedjoint inflammation  pain+swelling Clinical findings:Polyarticular,symmetrical,joints/tendonsinvolvedwith destruction +synovitis May be relapsing/remitting SymmetricJointsinvolved:shoulders,ankles,wrists,hands,elbows,MCPs Extraarticularfindings: Anemia Scleritis Fatigue Splenomegaly Sub-Qnodules Sjogren’ssyndrome Pleuritis Vasculitis Pericarditis Renal Disease Neuropathy
  16. 16. Patho: Jointdestructionstartingwithcartilage  erode bone/ligaments/tendons=deformation Fibroblasts/monocytessecrete proteinasesthatbreakdowncollagen/proteoglycans Diagnosis: At least4 of the followingcriteria: Morningstiffness>1hr, for > 6 wks Swellingof 3+ jointsforat least6 wks Swellingof wrist,MCP,PIPjointsforat least6 wks Symmetricjointswelling Hand x-raytypical of RA includingerosions/bonydecalcification Rheumatoidnodules(subQ) Rheumatoidfactor* Presentinmajorityof pts(w/oRF maybe seronegative,butcanstill have RA) Labs: RheumatoidFactor 70-80% of pts, alsofoundinCT disorders/endocarditis Anti-Citruline containingpeptides(CCP) Alsoseeninactive TB Complications: Jointdestruction Deformities Boutonniere’s Swanneck’s Ulnar deviation Rheumatoidnodules Tendonruptures Baker’s(popliteal) cyst Tenosynovitisof C1transverse ligamentproducingC1-C1instability/subluxation Treatment: Early diagnosis+earlyaggressive treatment!! -- keytominimizingdisability Immunosuppressing –be more aggressive intreatinginfxnsinthese folks! DMARDS (methotrexate,leflunomide,hydroxychloroquine) NSAIDs/Steroids TNF-alphaagents Physical/OccupationalTherapy Comparing Lupus to RA Feature Lupus Rheumatoidarthritis Arthralgia Common Common
  17. 17. Arthritis Common Deforming Symmetry No Yes Jointsinvolved PIP>MCP>wrist>knee MCP>wrist>knee Synovial hypertrophy Rare Common Synovial membraneabnormality Minimal Proliferative Synovial fluid Transudate Exudate Subcutaneousnodules Rare 35 percent Erosions Veryrare Common Morningstiffness Minutes Hours Myalgia Common Common Myositis Rare Rare Osteoporosis Variable Common Avascularnecrosis 5 to 50 percent,often at hip Uncommon Deformingarthritis Uncommon Common Swanneck 10 percent,reducible Common,notreducible Ulnar deviation 5 percent,reducible Common,notreducible *RA causesEROSIVEarthritis vs.SLE causing a NON-EROSIVEarthritis* DDX of inflammatory Arthritis: • Infections Bacterial (Lyme,bacterial endocarditis) Viral • Reative Rheumaticfever Reiter’s Entericinfections • Seronegativespondyloarthridities Ankylosingspondylitis Psoriaticarthritis Inflammatorybowel disease • RheumatoidArthritis • InflammatoryOsteoarthritis
  18. 18. • Crystal-inducedarthritis • Systemicrhemmaticillnesses SLE Systemicsclerosis Systemicvasculitis Polymyositis Dermatomyositis Still’sdisease Behcet’ssyndrome Relapsingpolychondritis • Othersystemicillnesses Sarcoidosis Familial Mediteraneanfever Malignancy Hyperlipoproteinemias MSK CCC 11: Trauma to shoulder/elbow Proximal Humeral Fractures Young highenergy&oldlowenergy 45% of all humerusfx,77% occur in female Consequences/associatedinjuries: LOM, LOreduction,AVN,heterotopicbone Associatedwith(rotatorcuff,nerve,vascular,scapulaandclavicularinjuries Anatomy: Proximal humerus –brokendownin4 parts Head,greater,lessertuberosity,shaft Bloodsupplytohumerus: Anteriorhumeral circumflex/*arcuate artery(ascendingbranch) Posteriorhumeral circumflex Nerve damage:TestQuestion Axillary,suprascapular,musculocutaneous(all frombrachial plexus) Muscle damage: Rotator cuff:supraspinatus,infraspinatus,subscapularus,teresminor Deltoid,pectoralis,longheadbiceps X-rayWorkup: Trauma Series:AP,Axillary,ScapularY(oblique views) CT: Articularfractures(impression,headsplit)&Glenoidfractures Tx: Closedtreatments Considerations –age,displacement,fxnaldemand,armdominance,abilitytosalvage with arthroplastylaterif needed Methods: Sling Sling+ Swath
  19. 19. Hangingcast Abductionpillow ORIF(testquestion –indications) Indications:DisplacedGTfx > 5mm, fx that involvesarticularsurface,surgical neckfx,displaced anatomical neckinyoungpt, displaced3-/4- partfractures Hemiarthroplasty - bestforelderly,headsplits,AVN Indications –young/middle age withsevere headsplitorextrudedanatomicneckORelderly Technique –beachchair positionwithdeltopectoral approach,retaintuberosityfragments, bone graft fromheadif necessary Ends upwithunpredictable resultsfromafunctional standpoint Complicationsof proximal humerusfracture Avascularnecrosis –due todisruptedarcuate artery Adhesive Capsulitis –almostalwaysdevelops,minimizedbyearlymotionandcontrolledPT May be fixedwitharthroscopicrelease AcromioclavicularJoint Injuries Anatomy Clavicle –S shapedbone SC joint,ACjoint,CCligamentswithmusclesattached:SCM, trap,pec major AC joint– betweenacromionandlateral clavicle stabilizedonall sides byligaments(superiorAC mostimportant) CC ligs– at distal clavicle (suspendUpperextremity) Trapezoid+ conoid= strongerthan AC,provide vertical stabilitytoACjoint MOI for AC joints Moderate/high-energytraumaticimpactstothe shoulder PE: Neurovascularexam(cervical roots) UE motor/sensation+ShoulderROM RadiographicEvaluation: AP,Zanca (orthogonal view) Axillary,Stressviews Typesof AC separations(fortest) Type I – ACligamentsprainedwithall ligaments/joint/musclesintact Type II – vertical displacement,withjointdisrupted Type III - AC jointdislocatedandthe shouldercomplexdisplaced inferiorly
  20. 20. Type IV - AC jointdislocatedand clavicledisplaced posteriorly intoorthroughthe trapezius muscle,seenonaxillaryview Type V - ACjointdislocatedandgrossdisparity between theclavicle and thescapula (100-300%) Type VI - AC jointdislocatedandclavicledisplaced inferiorto theacromion or the coracoid process Treatment Type I/II – conservative withrare surgeryfortype II Type III – may or may notneedacute surgery,conservative tx unlessanoverheadarmuser Type IV,V,VI - Surgery IndicationsforLate surgical Treatmentof ACinjuries(if aType I-IIIwastreatedandfailed) Pain,weakness,deformity Clavicle Fractures <5 mm – acceptable resultsat5 years >20 mmshorteningassociatedwithincreasedriskof nonunion,poorfunctional outcome Treatment Nonoperative–difficulttoreduce claviclefxsbyclosedmeans Theywill heal,butare theyhealingcorrect?May nothave unionof fxedends Simple slinguntilsignsof healing  ROMexercises Plate Fixation –ORIF(openreductioninternalfixation) For acute displacedfracturesand nonunions Plate appliedsuperiorlyorinferiorly newgoldstandard Neurological Complications Brachial plexussymptomstreatedbyreduction/fixationof fx,resectionof callus Radial Head Fractures Elbow Anatomy 3 joints:Humeral-ulnar, humeral-radial,proximal radial-ulnar ValgusElbowStability –fromMCL and radial head MOI – usuallyafall withaxial loadtoelbow + valgusforce Couldbe combinedwithhighenergyinjuries:elbow dislocation,coronoidfx,collateral liginjury PE: Neurovascular Valgusstress,PLRI(valgus,supination,axial load) Distal radio/ulnarjointstability Forearmrotation
  21. 21. RadiographicEvaluation: X-rays:AP,Lat, Oblique MRI: ligamentousinjury Classification:3Typesincreasinginseverity –not responsible forthese fortest Treatment:radial HeadFixation ORIFdifficulties: Communitionisworse thananticipated Fixationintothe headisdifficult Essex - Lopresti Lesions Definedaslongitudinal disruptionof forearminterosseousligament,usuallycombinedwith radial headfx and/ordislocation plusdistal radioulnarjointinjury Difficulttodiagnose Treatmentrequiresrestoringstabilityof bothelbow andDistal Radial UlnarJointcomponentsof injury. Radial headexcisioninthisinjurywill resultindisablingproximalmigrationof the radius. Complicationsof Tx: Improperly placedheadward Loss of fixation Posteriorinterosseousnerve injury ElbowStiffness MSK CCC 12: Thoracolumbar Spine Fractures 90% occur betweenT11 andL4, with60% betweenT12-L2 Majoritydue to MVA Biomechanics Burst Fractures – fromcompression Wedge Fractures – from Flexion Fracture Dislocations –from Rotation SeatbeltType Fracutres – fromshear Thoracic spine – stabilizedbyribs,MCflexion/compressioninjuries Thoracolumbarjunction–predisposedtorotation/axialcompressioninjuries B/wrigidthoracic and mobile lumbarspine TL experiencescompressionwhenTgoesintokyphosisandL goesto lordosis Lacks ribs,transitionpointbetweenAnteriorfacetsandinwardfacets
  22. 22. Classification DenisThree ColumnModel –to explaininjuries/guidetreatments Columns:Anterior,middle*,andposterior Instability=failure of 2+ columns Middle distinguishes4typesof spinal fractures 1st degree =mechanical 2nd degree =neurological 3rd degree =mechanical + neurological Imaging: Plainfilmseries –most importantwithlateral beingmostinformative Pedicle orTPsplaying Fracture on lateral Vertebral bodywidening Listhesis CT – bonyanatomy MRI – for spinal cord/ligamentanatomy Evaluation Hx – blunttrauma musthave spine cleared Exam – sans clothes,full neuroexam(rectal tone,perianal sensation),logroll forbruising,deformity, tenderness/crepitus,etc. Imaging X-rays– AP/Latforall spinal injuries(excludesthe mostdangerouspathology) CT – abdomen/pelvisfortraumamanagement,abdominalcanpickup TL fxs MRI – uponrequest,useful forsofttissue andcordinjuries Classificationof TLfractures: Flexion-Compression MC type,failure of anteriorcolumn,generallystable Tx: Hyperextensionorthosis,kyphoplasty,vertebroplasty,sx stabilization Burst Retropulse intocanal + fx of posteriorelements Failure of anteriorandmiddle columns=unstable Wideningof intrapediculardistance =decreasdbodyheight MC T10-T12 Tx: Decompress/stabilizewithneurological deficits Withoutneurodeficit –basedonstabilityof fracture SeatBelt/Chance
  23. 23. Hyperflexion-Distractionof posteriorelements Middle/posteriorcolumnsfail S/S: Posteriortenderness,hematoma,interspinouswidening+abdominal injuries Tx: Osseous – bracing Ligamentous - fusion Fracture-Dislocation All 3 columnsundercompression,distraction,rotation,orshearforces Types: A – flexion-rotation(3/4withneurodeficit) B – shear(all withneurodeficit) C – flexion-distraction(3/4withneurodeficit) Tx: Rapidmobilizationandrehab! Treatments One column= stable Two columns= mixed,if neuroinjury  surgery Three columns= surgery Decompressneurological elements(remove structurescausingcompression) Stabilize spine Spine fusion Corpectomywithretroperitoneal flankapproachtodecompress Kyphosplastyforstable compressionfractures –relievespain MSK CCC 13: PedsUE Disorders Pediatricsvs.Adults Overuse injuriesare common Bonesbendbefore theybreak Greenstickfractures, Plasticdeformity Torus fracture/Buckle fracture Pedsboneshave more collagen/cartilage–improvesresilience/reducedtensilestrength More metabolicallyactive =rapidcallusformation,rapidunionof fx,highpotential toremodel History – Age isveryimportantforDDX Lots of Falls Inspection Physical Exam ROM – supinate,pronate OssificationCentersof Elbow –growthplates Couldlooklike fracture patternsonx-ray,butmaybe growthplatesthathurt
  24. 24. Heal in a clockwise pattern C - capitellum R – radial head I – internal/medial epicondyle T - trochlea O - olecrenon E – external/lateral epicondyle Fat Pad Signs Anterior– anatomic Posterior– pathologic(75% chanceof occult fx) – maynot see anyboneysigns,butgoodchance theyhave a fracture MC occultfxs:Supracondylar> proximal ulnar>lateral condyle Salter-HarrisClassification –donot memorize fortest,butuseful forclinical years I and V oftenmissedonx-rays Little League ElbowSyndrome Overuse –due to excessive valgusstress,painatmedial epicondyle MC inbaseball, gymnastics MOI: Overuse/fatigue alteredbiomechanics  medial traction(valgusstress) lateral compression ->microtrauma overuse Tx: prevention! Rest,ice,NSAIDs,OMM,PT Radial HeadSubluxation/Dislocation “nursemaid’selbow” MC < 6 years/old, refusestouse armheldina flexedpositionagainstbody MOI: Suddentractiononextended+pronatedarm, radial headslipsunderannularligament Tx: Neverrequiressurgery,reduction,armsling  use astolerated,preventrecurrence Congenital Radial HeadDislocation MC congenital deformityinelbow,foundincidentallyorfollowinganinjury 60% have otherabnormalities Typically lose ability to supination/pronation Doesnot necessarilyneedtreatment
  25. 25. Radial Head/NeckFractures MC 9-15 yrs old, more likelytofracture neck 70% have MCL injuryatelbow MOI: FOOSH injury Inspection:Ecchymosis,swelling ROM: pain w/supination/promotion,↓ROM,crepitus X-rays:AP,lat,oblique,CT Mason Classification –do notneedfortest SupracondylarFracture MC children’selbow fracture (10% of childhoodfx overall) MOI: FOOSHinjury(extensioninjury) 10-20% alsohave neurologicinjury(anteriorinterosseousnerve isMCinjured) Can theymake the “OK” signwiththeirfingers?” S/S: Swelling,localizedtenderness,proximal depressionof triceps X-rays: AP,Lateral (lookforanteriorhumeral line,proximal radialline) GartlandClassification –NOTfor test Complications Neurovascular–nerve damage (median,anteriorinterosseous,radial,brachial artery) CompartmentSyndrome Malunion“gunstockdeformity” –due to mal-reductionattime of surgery,cosmetic>functional Lateral condyle Fractures MC 5-7 years/old MOI – FOOSHwithvarus force S/S: Pain,decreasedROM,localizedtenderness Medial Condyle Fractures MC 7-15 yrs MOI – acute valgusstress S/S: Ulnar n. injurycommon ForearmFractures – to shaftof radius/ulna(nightstickinjury) MOI: FOOSH Monteggia– proximal 3rd of ulnawithradial headdislocation Median/radial nerve injury,presents withobviousdislocation,verycomplex –needssx Distal fractures– 35-45% of all fracturesinchildren MOI: FOOSH
  26. 26. Transverse fracturesof radius: Colles’ –dinnerforkdeformity,dorsal displacementof distal fragment,mediann.damage Smith– reverse colles,volardisplacementof distal fragment,fallonflexedwrist Greenstick – clinical diagnosis,castwithpossible of recurrence Galeazzi – fx distal radiuswithdisruptionof radioulnarjoint Congenital Radio-UlnarSynostosis –donot rememberfortest MSK CCC 14: Disordersof Thoracic Spine,Claviclesand Rib cage ChestWall Costochondritis –chestpain,dull painworsenedby movement/respiration Tendernessalongcostochondraljoints,noswelling Tx: rest,nonsteroidal meds Tietze syndrome –rare formoftenat 2nd rib *Pectuscarinatum Pectusexcavatum – posteriorasymmetricdepressionof the sterum Normal 1st , 2nd manubrium May cause anteriorindentationof the heart,usuallycomeswithcongenitalcardiacdeformities PolandSyndrome –congenital anomaly,notverycommon Absence of hypoplasiaof unilateralpectoralismuscle withsyndactyl (fingersgrowntogether) Possible absence of associatedribs Barrel Chest– APdiameter>transverse diameter,seeninpatientswithemphysema Ribsbecome horizontal,sternumforward,senilekyphosis *Expiratoryphase inhibited(increased) RibFractures – trauma, osteoporosis,couldbe palpable Self-limited,lotsof pain4-6 weeksandthenpaindisappears Flail Chest– multipleribfractures *Developparadoxical movementof chestwall! Medical emergency,maybe associatedwithpneumothorax,severetrauma Atrophyof Myopathyof ChestWall Cicatrix of the Chest Burns mayseriouslimitchestexcursion=decreasedrespiratoryvolumes Rickets
  27. 27. VitaminDdeficiency  multiplebonydeformities *Rachitisrosary alongchestwall – failure of bonestoharden Harrisongroove or sulcusabove potbelly Ribnotching– due to collateral circulationintercostalsarterydilationfromcardiacproblems Dilationof arterieswearsawaythe ribs Coarctationof the aorta & Neurofibromatosis* Dock’ssign – due to collateral circulation4-8whichanastomose withthe internal mammary arterysupplyingthe descendingaorta= erosionof costal groove bydilated intercostalsarteries Sternal malformations Suprasternal Foramenwithcleft Cervical Ribs – anomalousaccessoribrib(eve’srib) From C7 transverse process Small or full ribthatcan cause impingementsyndromes,Thoracicoutletsyndromes(+Adson’s) 90% are asymptomatic Bifidribs – usuallynota problem Supranumeryribs (Gorillarib –13th ) Thoracic Spine Exam: observe,palpate,ROMtesting Thoracic Kyphosis –MC fromosteoporosis* No lateral curvative someone younger–metabolic/congenital,hyperparathyroidism,ankylosingspondylitis OsteoporosisandFractures Frequentlyinthoracicspine,MCcause of thoracic fx isosteoporosis *AnteriorWedgingof vertebral bodycontributestokyphosis,notalwaystrauma Scoliosis –couldcause restrictedlungdiseasesif severe WeirdAPdiameter Arthritis MC isOA RA – leadsto chronicrespiratoryfailure due tospinal problems Psoriatic AnklylosingSpondylitis
  28. 28. If seeninthoracic – a late finding HLA-B27, if seronegative worsenswithage Inflammatorychanges+newbone formation Beginswithsacroiliacare andprogressessuperiorly “pokerspine”and *bamboospine”– causingback pain b/c spine isencasedincalcium Othersymptoms:anterioruveitis,vascularproblems asit’saconnective tissue disease Clavicle *80% of fracturesoccur inthe middle thirdwhichlacksligamentoussupport Pay attentiontoLNs:supraclavicular(gastricca),infraclavicular AC JointDislocation –tearof coracoclavicularligament Complete dislocation=sx Clavicle Dysostosis –incompleteossificationof the clavicles=abnormalitiesof shoulders/ribcage CleidocranialDysostosis –lackof clavicle development MSK CCC 16: DDX Acute lumbar Pain Low back pain= pain affectingthe lumbarsegmentof the spine Acute < 3 months,Chronic>3+ months 14.3% of newpatientvisitsare forLBP, 13 millionforchronicLBP 60-90% of lifetime incidence,mostexpensive cause of work-relateddisability Onlya small %of pts will everexperience lumbarradiculopathyor sciaticaasa resultof LBP *Strongestpredictorforfuture backpainis a historyof prior back pain. Redflagsfor a patientwithbackpain: Major trauma mechanism Age >50 or < 20 Hx of cancer Cauda equine syndrome Atheroscleroticdisease Use of corticosteroids Hx of osteoporosis Constitutionalsymptoms PE No one test,lookabove/below,palpate,testROM,dosome provocative tests CLUES: painwithbackwardbending Radiationorreproductionof painwithcertainmaneuvers Differentiate betweenlumbar,sacrum, pelvis,andhipproblems Localize the problem: Standingflexiontest  seatedflexiontest Double legraise (SIvs.LS) Goldthwaite’stest–SLR + palpation(SIvsLS)
  29. 29. Lumbosacral mechanics Sacrum and lumbarspine move inoppositedirections Lumbar flexion  sacral extension,etc. Lumbar rotatesR  sacrum rotatesL Lumbar sidebendsR sacrum takeson an ipsilateral oblique axis LigamentsandFascia Stabilize,setmotionlimits(subjecttofatigue failure) SI ligamentshave mechanoreceptorstogauge strain Thoracolumbarfasciatransfersloadfromtrunkto legs PainGenerators: Discogenic Stenosis Facet Spondylolysis-listhesis Softtissue (muscle,ligament,tendon,capsule) Lumbar tests Nerve tensiontests: SLR Bowstring/cram Lasegue Braggard’s/Sicard’s Slump Nachlas Bonnet’s Buttock Malingeringtests Fliptest Hoover Axial compression Simulatedrotation Acute Lumbar Sprain “Mechanical back pain” Acute injurytosofttissueswithnoneurologiccomponent 85% of patients,neverwill IDthe paingenerator IliolumbarLigament Sprain Referspaintoanteriorthighor groin,easyto miss Palpate orinjectfordiagnosis Tx: Acute – OMT, active rest,SIbelt Chronic– prolotherapy,ablation,SIbelt,OMT
  30. 30. Facet Syndrome – mimicsparsfx Focusedpain,worse w/extension Dx: Standing/seatedKemp’stest Hyperflexiontest Tx: therapeuticexercise,PT,OMT,prolotherapy Lumbar somatic dysfunction Lumbar discherniation Usuallyprecededbyboutsof varyingdegreesanddurationof backpain Paineventuallyradiatestothe leg(shooting/stabbing) Dependentonlevel of nerve rootirritation: Higher(L3/L4)  groinor anteriorthigh Lower(S1)  calf or bottomof foot L5 – MC, lateral/anteriorthighandlegpain Eval:MRI, CT + myelograph Surgical indications:caudaequinesyndrome,progressive neurologicdeficit,persistent bothersome sciaticpaindespite convservative managementfor6-12 weeks. Contraindications:unrelentingbackpain,incompleteworkup,inadequate consertm Lumbar Discitis Infxnof the discpost surgeryor fromhematogenousspread Increasingpain/stiffness+fever Eval: MRI, Labs (CBC,ESR, CRP) Tm: Aggressive workup, surgical referral,longtermantibiotics Spondylolisthesis–defectinparsinterarticularisthatleadstotopvertebrae movingmore anteriorto the one belowit,MC at L5-S1, thenL4-L5 Type I: Congenital Type II: Isthmic– during1st /2nd decades MC occurs at time of adolescentgrowthspurt Focal back painand radicularpainwithlargerslips,some ptsare asymptomatic Tighthammies,lumbarmuscle spasm Larger slips:dermatomal weakness/radiculopathy Extension=provokedpain Type III:Degenerative F:M= 5:1, >40 yearsof age,MC at L4-L5 Insidiousonsetpainwithradiationtoposteriorupperthighs,chronic  progressive Extension=provokedpain,sometimesinvolvesreflex changes Type IV: Traumatic More likelytohave neurologiccompromisedue tosevere slipping Type V: Pathologic
  31. 31. Grading:1 – 5 with5>100% slipand1 with0-25% slip Riskfactors: Athleticactivityes Congenital defects Age MC inboys,but femalesthatgetitgetit worse andprobablywill needsurgery Youngerpatientsare at higherriskforprogression Do serial radiographsevery6months Highgrade slipsrequire surgerydue topain+ neurocompromise Imaging: Xrays– lookingforscottydog,bone scan, CT, MRI Tx: PT, Bracing,OMT (NOTinacute spondy), injections,surgery Lumbar Spondylolysis–defectinpars interarticularis Pars Interarticularis Fracture – pars fracture “collaron the scotty dog” onplainfilms Focusedpainthatis worse withextension Tx: active rest,brace/PT,OMT Lumbar Spinal Stenosis– neurogenicintermittentclaudication MC middle-aged,elderlypopulation Bonyencroachmentor nonosseousencroachmentbyligaments,discs,etc. S/S: begin/worsenwithambulationorstanding,relievedwithsitting/lyingdown Back pain1st  legfatigue,pain,numbness,wkness Eval: Pheasant’s/HomerPheasantsTest Bicycle Test(neural vs.circulatoryclaudication) Tx: normallysurgical decompression MSK CCC 17: DDX Hip, PelvicPain To developa DDX: List of possible diagnosis Know anatomyand physiology Appropriate hx PE to match the workingdiagnosis Choose furtherworkupbasedon the conditionsyouthinkare mostlikely Anteriorhippain OA Nerve entrapment InflammatoryArthritis Sportshernia Osteitispubis Muscle strains
  32. 32. Femoral neckstressfracture Tendinosis Acetabularlabral tear Referredpain Osteoarthritisand inflammatoryarthritis –  Both have gradual onset,morningsymptoms,worseningwithactivity,stiffness(gel phenomenon)  Osteoarthritis tendstohave decreasedmotiononinternalrotationandextension  Inflammatoryconditionsare associatedwithabnormalbloodtests(ESR),white blood cellsinthe jointfluidandotherjointinvolvement,perhapsskinorbowel symptoms (rheumatoidusually doesn’thitthe hips) ancer Some start withbone:osteoidosteoma,sarcoma Some metsTO bone:breast,prostate,lung,kidney,thyroid Associatedwithconstitutional symptoms,nightpain,original sitesymptoms Othercausesof GroinPain Intraabdominal disorders GU abnormalities Referredlumbosacral painfromlumbardiscdisease Hip Jointdisorders AvulsionFractures –such a forceful contractionthatsome bone ispulledoff CommonHipProblems Groin Strain Hernias IliopsoasBursitis SnappingHip Muscle Strainsand Tendinosis DelayedOnsetMuscle Soreness • Diagnosisisbyhistory24-48 hoursafter exertion. Musclesare sore. Nodistinctareasof painas inacute strains. Usuallybilateral (unlessaunilateral overuse –like arm-wrestling…) • Rhabdomyolysis– Canpresentlike delayedonsetmuscle soreness. Usuallyassociatedwith  Beingimmobilizedforaprolongedperiod  Acute dehydrationwithoveruse  Diagnosisiswitha bloodtest – lookingforelevationsof creatine phosphokinase (CPK) Trauma due to AnteriorHipPain GreaterTrochantericBursitis Labral tear AvulsionFxs
  33. 33. Lateral Hip & ThighPain CommonHipProblems Hip Pointer MeralgiaParethestica IliotibialBandandTensorFasciaLatae Syndrome Buttockand PosteriorThighPain Sciatica SI jointandLigaments Gluteal strain Gluteusmediusweakness –due to overuse,associatedwithSIdysfunction Hamstringstrain – due to acute overstretching,running,sprinting Local pain,deformity,poorROM& strength PiriformisSyndrome Dislocation –directblowwithhipabducted Posterior:shortleg,hipadducted,severe pain,inabilitytomove,footpointstootherleg Anterior:abducted,short,pointsawayfromotherleg Complications:Avascularnecrosis MSK CCC 18: Adult hippain – referto lecture slidesfor cases and answers MSK CCC 19: Congenital/PedDisordersofLumbar/Thoracic Spine Myelomeningocele –localizedfailure of the embryonicneural tube toclose properly Chiari IIMalformation TetheredCord Congenital Deformities of the Spine Congenital Scoliosis IdiopathicScoliosis Leg LengthDiscrepancy Infantand Juvenile scoliosis Congenital Kyphosis Congenital Lordosis Spondylolysis/Spondylolisthesis MSK CCC 20: PedsLE disorders
  34. 34. Rotational Deformities Intoeing Metatarsus Adductus Clubfoot Tibial Torsion Medial Femoral Torsion Outtoeing AngularDeformities Blountdisease FootDeformities Clubfoot CavusFoot CalcaneovalgusFoot PesPlanus Hip disorders DevelopmentalDysplasiaof the Hip SlippedCapital Femoral epiphysis Legg-Calve-PerthesDisease CoxaVara and Valga Toewalking MSK CCC 21: DDX Limpingchild withoutfever Developmental Dysplasiaofthe Hip –involve proximalfemur/acetabulum F/P: occurs in1.5% of neonates Risks:female,+FaHx,breechbirth,multiple gestation,1st prego,fatbaby,oligohydramnios, clubfoot,caucasian L hip > R hip Pathophys: earlydisruptionof relationshipb/w femoralheadandacetabulum, inadequate contact= neitherformsnormally Couldbe due to highlevelsof estrogen/relaxininfemales Clinical Findings: Ortolani maneuver–to reduce a dislocatedhip Barlowmaneuver–to determine if hipisdislocatable + Galeazzi/Allissign –shortenedthigh,decreasedadduction Typical dislocation –majority,ininfantsw/nootherproblems,adevelopmentaldisorder Teratologicdislocations –due to underlyingNMdisorder,occurinutero Eval:
  35. 35. PE! If abnormal  Ultrasound incoronal ortransverse planesorhipx-rays Linesdrawn:Hilgenreiner,Perkins,Sheton(disruptionhere suggestDDH) Tm: Restore normal relationshipb/w femoral head/acetabulum Paclikharnesstokeephipsinflexion/abductionuntilclinical/radiographsare normal (<6mos) >6 months – mayrequire a closedreduction SlippedCapital Femoral Epiphysis – Salter-Harristype 1 fx throughproximal femoral physisdue to stressaroundthe hip F/p: MC hipabnormalityinadolescence M > F, AA affectedmore Justafter puberty,associatedwithfatkids Risks: Skeletal immaturity malnutrition Overweight Priordx of DDH Chemotherapyuse Endocrine dx Irradiation Renal failure Pathophys: Fx is due to stressat growthplate,role inhormonesisstrongb/c thisoccurs exclusively duringpubertal growthspurt Clinical Findings: 50% presentwithhippain,25%presentwithknee pain Couldcomplainforweeks,watchforddx (acute muscle strain,Osgood-Schlatter,flatfeet) Outcome isrelatedtoseverityof the slip Eval: H & P,baseline radiographs(APof pelvis+lateral frog-leg) Obligate ERof hip,softtissue changesneariliaccrests TM: Stabilizationof the hiptoavoidfurtherdamage to the bloodsupply F/U: DJD inmiddle age, Legg-Calve-PerthesDisease –avascularnecrosisof the proximal femoral headdue tocompromised bloodsupply F/P: meanage 7, M>F, unilaterallymostof the time Risks: Trauma SCFE steroiduse sickle-cell crisis Toxicsynovitis DDH delayedbone age* short stature* Pathophys: Interruptionof bloodsupplytosecondaryossificationcentersdue torapidgrowth  joint prone to avascularnecrosis  replacementwithnew bonethatmayappearnormal on xray Clinical Findings: MC: painlesslimp,maypresentafterexertion Intermittentpainw/walkingoralteredgaitinchildrenbetween4-10, Referredpaintolateral thigh,contralateral knee,gluteal pain Painwithpassive ROM(IR andabduction) Eval:
  36. 36. CBC, ESR forinfection AP,frog-legs Bone scan to eval the bloodsupply Tm: Protecthipjoint! ↓wtbearing,keepfemurinAdduct/IRposition keepheadinside acetabulumbybracingorsx F/U: Short termprognosisisrelatedtoseverityof disease processorage at onset(older –worse) Long term- OA Transient Synovitis– arthralgiafrom inflammationinthe synoviumof the hip F/P: one of MC causesof joint paininpeds,M>F, between3-10y/o Pathophys: Non-specificinflammationof synovial membrane  synovial bulging/pain May have hx of trauma or hx of viral infectionprecedingthe jointpain Clinical Findings: Painwithwalking,fever,Hx of recentURT infection ↓ROMforAB and IR, hipistenderto palpation NO skinerythema Eval: Leg Roll Test – most sensitive +withmuscle guarding Examine knee AP/froglegfilmsshowincreasedjointspace ↑WBC,↑ESR – monitorforbacterial jointinfection Needle aspirationwithultrasoundguidance if:temp>99.5, ESR > 20, severe hippain/spasm Checkfor WBC, Gram stain,culture,↓glucose inaspirate Tm: Bedrest withnowt bearing,restrictactivities NSAIDs(ibuprofen,naproxen) Anymanipulationof the hipiscontraindicateduntil the diagnosisisconfirmed! F/U: Reeval in12-24 hours Resolvesspontaneouslyin2 wks,soif symptomsare still present –check forsomethingelse! Recurrence 4-17%, smrisk forOA MSK CCC 22: GeneticMusculoskeletal Disorders Osteogenesisimperfecta– defectsinType 1 collagen veryfragile,brittlebonesthatbreakeasily Freq/Pred: MC isType 1, IV,V and VIare reallyrare No knownracial/ethnicpredilection,nogenderpreference Pathophys: mutationsonloci encodingforalpha1/2chainsof type I collagen Clinical Findings: Type I - onsetininfancy A – dentinogenesisimperfectaabsent
  37. 37. B – dentinogenesisimperfectpresent Both – blue sclera,inuterofractures,kyphoscoliosis,hearingloss,easilybruised,mild, short stature Grow up normallyfunctioningdespitelotsof fractures Type II - onsetinutero,donot survive 1st year,most are stillborn Dentinogensisimperfecta,bluesclera,NOhearingloss,perinatallethality Small nose,CTfragility, 100% have inuterofractures,shorttrunk “beadedribs”onx-ray Type III - 50/50 infancyanduterowithfairlynormal life spanif theysurvive earlylife Dentinogenesisimperfect,nohearingloss,variable sclera 50% withinuterofractures Limbshorteningwithprogressive deformity PulmonaryHTN Triangularface,frontal bossing Type IV - onsetininfancy A – w/o dentinogenesisimperfecta,B – w/odentinogenesisimperfect Both – normal sclera/hearing,angulationof longbones,nobleedingdiathesis Type V and VI – variable onset Eval: Collagensynthesisanalysistodifferentiate OIfromchildabuse/geneticcounseling BMD (notproventobe sensitive) Chromosomal gene markers Prenatal testingviachorionicvillussampling Imagingof skull,chest,longbones,andpelvisassoonas diagnosisisthoughtof TM and Management: No medical therapyexistsbutsome experimental use of bisphosphonateshasbeentried Pamidronate,Clodronate –bothexperimental Surgical forsevere problems Intramedullaryrodding OMT, Geneticcounseling F/u: Educate.Achieve maximalmobilityandpreventfractures! Endochondroma/Enchondromatosis – B9 bone neoplasmsthatcancause pathologicfxsandpain Fre/Pred: Riskfor malignancywithmultipleenchondromas–seeninlong/flatbones Pathophys: Ectopic hyaline cartilage restinginintramedullarbone,replace normal bone with cartilage – looklyticor circularon x-ray Pathologicfxscanoccur due to “replacement”phenomenon MC malignanttumorassociated: Chondrosarcoma Clinical Findings: Asymptomaticandusuallyenchondromascause noproblems
  38. 38. Withmalignancy – pain,pathologicfxs May getcalcifiedovertime Eval: Xraysare modalityof choice MRI andCT reservedforfurtherdelineation Rare to use biopsyorbone scan Tx: No medical treatmentnecessaryunlesstheybecome malignantorcause fractures PREVENTION! Subtypes: Ollier–nonhereditarypresentingwithmultiple enchondromaswithunilateral distribution Good prognosis Maffucci – nonhereditarywithmultiplehemangiomasandmultiple enchondromas Metachondromatosis –multiple enchondromasandosteochondromas Mucopolysaccharidosis– resultof defective lysosomalenzymes,cellsaccumulate proteins/glycosaminoglycans Freq/Pred: Sanfilippois 80% of cases,all AR exceptHunterwhichisX-linked Pathophys: By-productsof incompletelysosomal processesbuildupintissue andaltercell function Diagnosisismade byseeingthese by-productsinthe urine Eval: Prenatal diagnosis UA showsexcessiveexcretionof GAGs Xrays– basisof diagnosisshowskeletal abnormalities HeadCT to r/o hydrocephalusandanechoto checkthe heart Tx and management: No cures – enzyme laronidase forMPSI Managementof symptoms,BMtransplantforsome F/U: Prognosisisbasedontype,butmost have a shortenedlifespan Subtypes: Hurler– deficiencyinalphaLiduronidase Normal at birth,dx @ 6-24 months Corneal clouding,skeletal dysplasia,coarse facial features,lgtongue,shortstature Developmentaldelay,hearingloss,hydrocephalus Deathby age 1 Hunter– deficiencyiniduronate sulfatase Pebblyskinlesionsonthe back,arms,thighs Mild:slowerprogressionwithnormal intelligence andhearingloss Severe:atage 2-4 y/o,progressive neurological involvement Retinal degeneration,MR,jointstiffness/deformities Deathby 10-15 years
  39. 39. Sanfilippo –deficiencyinheparinN-sulftase orglucosaminidase MC MPS disorder,with4subtypes Severe CNSinvolvementwithseverebehavioral disorders Mental deterioration,lghead,H/Smegaly,coarse hair,jointstiffness Deathby 2nd /3rd decade Morquio– deficiencyinacetyl galactosamine sulfatase orbetagalactosidase Orthopedicproblems:spondyloepiphyseal dysplasia Genuvalgum, shortstatus,scoliosis,odontoidhypoplasia,AA instability Mild:normal life span Severe:deathbyage 30 MSK CCC 24: Juvenile RheumatoidArthritis Freq/Pred 10-20 cases/100,000 kids Native Americanshave higherincidence AAsare olderwhendiagnosed,more likelytohave +RF Pauci/polyartmore commoningirls Pauci – earlychildhood,system –any age Pathophys: True etiologyisunknown Synoviumhasaninfiltrationof B-cells,plasmacells,monocytes=extrasynovial fluid=increased pressure = distentionof the jointcapsule =more inflammation Cytokines/proteasesdestroythe jointcartilage  breakdownof bone/jointinfrastructure Clinical subtypes: Systemiconset (Still’sDisease)–highspikingfeversseveral timesdailyfor2-3wk period, may/maynotaffectjoints S/S: Veryhighspikingfeverataboutthe same time everyday Notresponsive toantipyretics Pinkrash ontrunk/extremities Jointswellingdoesnotoccur,butarthralgiais common +/- Lymphadenopathy,+/- hepatosplenomegaly Definitive diagnosiscannotbe made until arthritisappears Pauciarticular – 4 or lessjointsinvolved,usuallythe largerjoints S/S: MC involveslarger,wt-bearingjoints Flexioncontracturesof the joints Morninglimpingw/knee involvement +/- Iridocyclitis/iritis *Include LCPdisease,transientsynovitis,SCFEandosteomyelitisindifferential *chronic involvement  atrophyof thigh/hamstringmuscles/ligaments Polyarticular – 5+ jointsaffected Subtypes:RHfactor + andRH factor – + group– arthritisissimilartoadultRA with+/- extensornodule presence
  40. 40. S/S: Lg jointsw/symmetricinvolvementof small jointsinhands/feet Pain+ ↓ROMof cervical spine Low grade fevers Eval Labs ESR CBC LFTs UA ANA RF HLA-B27 antigen For systemicJRA: total protein/albumin fibrinogen Imaging: X-raysof affectedjoints,bone scan,MRI,CT, echocardiogram Otherprocedures: Aspiration,synovialbiopsy,pericardiocentesis Slit lamp exam of eye inall childrenwithJRA symptomsof anytype DEXA scan to rule outosteopenia Treatment Nothingstandard,exactisdeterminedbydiagnosisandsymptoms Require teamapproachb/c thisinvolveslotsof systems/lifelongproblem Goals: Reduce jointpain,preservejointfunction,maintaingrowth,minimizemedsandside effectsandminimizeosteoporosis. Screenforiridocyclitistoreduce visionproblems andmaintain functionandself-esteem Meds: NSAIDs,etanercept(TNFinhibitor) F/U: No prevention,OMT,mayneedsx withaggressive arthritis,jointreplacement MSK CCC 25: Non-traumatic Foot,Ankle pain – Bolinassignments Medial FootPainDDX Bone Ligaments/fascia Nerve Tendon Somaticdysfunction Pescavus – higharch Pesplanus – low arch Arch Assessment: Inspection  Functional (forwardsquattest) Functional Archesof the Foot Lateral Medial Metatarsal Transverse
  41. 41. Posterior tibial tendinitis 38-58 yearoldwomanwhostarts new exercise programandcomplainsof progressive,achypain inmedial arch Exam: PainwithposteriortibialisMMT Unilateral pronation,PFandinversion Work up: Xray Tx: cast/bootwithorthotics Surgical consult Riskof DJD withrupture DDx forposteriorheel pain: Haglund’sdeformity(retrocalcaneal bursitis) Os trigonum/impingement Insertional tendinitis Retrocalcaneal fatpad Sever’sDisease True Achillestendinitis SomaticDysfunction AchillesTendinitis Paininposteriorheel thatisinsidiousinonset(stiffnesswithrunninandinAM) Swelling,nodule orboththat migratesproximallywithPF Affects18% of runners Risks: age,cavus feet,tibiavara,varusdeformities,overuse/jumping Tx: stretchingof gastroc/soleus Eccentric exercise AchillesTendonRupture Complicationof Achillestendinitis Hx of activitywitha suddenpop“like someoneshotme inthe back of the leg” Hx of fluoroquinoloneuse Dx: Thompsontest,palpation,MRI Tx: surgery DDX for Heel Pain: Fat pad syndrome Plantarfasciitis –morningsymptomsrelatedtofascial tension Painat medial insertion Windlassmanuever Foreignbody Medial plantarnerve entrapment Bone bruise/stressfx/fracture
  42. 42. Ddx for painin metatarsals/phalanges Stress/true fx Tendinitis Infxn Tumor Synovitis Metatarsal: Metatarsalgia Interdigital neuroma Turf toe Sesamoidpathology Friedberg’sinfarction Morton’s Neuroma Fibrosisof perineuralareaof commondigital nerve leadingtoentrapmentbetween3rd and4th metatarsal causingsharp,stabbing,lacinatingpain Worse whenwearingshoes(small toe box size) Dx: clinically,palpationof distal intermetatarsalspaces Mulder’ssign Laseague’ssign Workup: Xraysto lookfor osteophytes/masses Tx: Conservative  injections  surgery March Fracture 90% of all metatarsal stressfxs occurringat neckof 2,3,rth MT Verycommoninrunners,or 1st MT in dancers Dx: XRAY Tx: stiff shoe for4-6 weeks 5th Metatarsal Stress Fxs Distal  proximal = stress  Jones  Avulsion Dx: Clinical suspicion,xraysare usuallynegative,bone scanshowsbone turnover Tx: modifiedrest gradual reintroductionof sport Sesamoids Injuredduringrunning,jumping,typicallymedially Dx: Painon plantar1st MTP joint,painwithmaximal DFwith1st ray Inabilitytopushoff Bunion – Hallux Valgus Valgusdeformityat1st MTP jointassociatedwithshoeswithtightshoe box Tx: orthotics,wide toe box,sx whenconservative measuresfail Hallux Rigidus Limits1st MTP jointdorsiflexion
  43. 43. MSK CCC 26: Traumatic foot,ankle X-raysinvolvedinawork up: Foot: AP/Lat/Oblique Ankle: AP/Lat/Mortise view/Brodenviews Fracture Types: Transverse – across bone Oblique &spiral Comminuted - fragmented Compound – bone throughskin Fracture Healing: Hematoma softcallus+ newvessels  osteoblastslaydownnew bone (bonycallus) Talar Fractures – relativelyrare Taluscompressedwithinmortise (dorsaltoplantarshear) Neckfx is mostcommon,complicationisAvascularnecrosis Shepherd’sFracture – due to forceful plantarflexion(confusedwithostrigonum) Frequentlymissed(onxray)  complicationsare pain/tendinitis Tx: crutchesfor 6 weeks Talar dome fracture – injurytoarticular cartilage/subchondral bone Osteochondritisdissecans(loose bodyseparatesandfloatsinthe joint) Prolongedankle painafterasprain Tx: surgery,untreatedleadstoDJD Heel fracture – calcaneal mostcommon MOI: fall fromheight Dx: xrays,ct scan Tx: compression,elevation,footpumps,earlyROM,sx if displaced Lisfranc Fx/Dislocation MOI: “footfoldedbeneathme” S/S: pain,edema,ecchymosis,inabilitytobearweightorpushoff Dx: subtle dorsal disloationof firstMTT joint,wt-bearingxray Tx: short legcast or boot4-6 weeks >2 mm separationrequiressurgery Toe Fractures MOI: secondaryto“stub” or directimpact Tx: conservative with“buddytaping”
  44. 44. Tendoninjuries Flexortendons Extensortendons Complicationof misseddiagnosis:retraction MSK CCC 27: Non-traumatic knee pain 90% of these problemscanbe diagnosedwithgoodhx,physical andplainx-rays. MRIis seldomneeded. Hx alone can give diagnosisupto70% of pain. PE: Peri-patellarpalpation,patellargliding/ballotment,patellargrind Jointline palpation Varus/valgusstresstests McMurray’s test Lachman’s Anterior/posteriordrawer Pivotshifttest Osteopathiceval –“kineticchain” Pronation/supination Understand“real world”muscle fxn – econcentricfunction Influence of compensationandaccommodation Imaging:Onlyneededif H& P donot provide enoughinfo Plainfilms Functional standingxray –showstrue alignmentandjointspace narrowing Do at least4 views:standingAP,lateral,30°sunrise forpatellartracking,tunnel view) Assesforarthritis,fracture,growthplate injury,loosebody,jointeffusion,alignment Riskfactors forOveruse Injury: Biomechanical Age: Peds- rapid growth,usuallyinjurytothe apophysis(wheretendonattachestobone) Middle aged – inadequate conditioningandflexibility Senior– lookformedsor underlyingdisease process ExtrinsicFactors: Mechanical,coaching,environment,druguse,training Classification: Grade I – post activitypainonly Grade II – painwithactivity,doesnotrestrict Grade III – painwithactivity+ restrictioninperformance Grade IV – painwithactivity&rest
  45. 45. Tendonitis(chronicor acute) Causative factors:changesinmechanical loadingorchangesinmuscle tendonextensibility Intrinsicfactors:structural failure due tooverload,wkness,oracombo ExtrinsicFactors:impingementbybone orotherstructures “chokingthe tendon” PediatricandGrowthIssues Apophyseal injury– tractioninducedmicrotraumaat tendon-bone junction Physeal injuries– repetitiveloadingcausingmetaphysealischemicaandpoorgrowthinthe proliferative zone  wideningornarrowingof growthplate Osgood Schlatter’sDisease – commoncause of knee paininactive adolescents(M>F10-14 years) Diagnosis – localizedpain attibial tuberosity,noneedforradiographsbuttheycanconfirmyour suspicionandexludeothercausesof knee pain Patho– microtraumaat deepfibersof patellartendonatitsinsertiononthe tibial tuberosity “apophysitis” Usuallyself-limitedwithresolutionatskeletal maturity Tx – relative restandenhance strength/flexibility Popliteal (Baker’sCyst) – distendedbursainthe popliteal space MC bursainvolvedisbeneaththe medial headof the gastrocor semi-membranoustendon Presentwith complaintof achingpaininthe posteriorknee/proximal calf Diagnosis:AP,lateral,tangential X-raysof the knee Adults– usuallyassociatedwithintra-articularpathology Tx: children –may resolve withtime,occasionallyhave toexcise Adults– treatintra-articularpathologyfirst,if discomfrtstillremains  excise (rare) Lg, tense cystscan be aspiratedwithcommonrecurrence Sinding– Larsen – Johansson Syndrome – inflammationof patellaatitsinferiorpole atthe originof the patellartendon,“tractioninjury” S/S: swollen,warm,tenderbumpbelowthe kneecap Painw/activityespeciallywhenstraighteningthe legagainstforce orpostvigorous activity,if more severe –painwithanyactivity Tx: Ice,stretching,strengthening, exercises,modificationof activities Patellarband(brace b/wkneecap/tibialtubercleontopof patellartendon) Patellofemoral PainSyndrome Multifactorial:overuse/overload,biomechanical problems,musculardysfunction Pesplanus(pronation) Pescavus (high-archedfoot,supination) Q Angle – alignment(increased=knockedknees) Muscular causes
  46. 46. PatellarTracking– tilt,subluxationwithinvertedJsign,apprehensiontest,functional evaluation Tx: relative restwithtemporarychange tonon-impactactivity Quad strengthening,flexibility(addresskineticchain) Orthotics,icing,knee sleeve OsteochondritisDissecans – unknownetiology S/S: generalizedpainwithswelling/achingpostactivity Intermittentpain/mildswellingthatjustdoesn’tgetbetter(kneesprainforever) MC foundonmedialfemoral condyle weightbearingsurface Diagnosis: Tunnel viewx-raywithradiolucentdefectonfemoral condyle,confirmonMRI Tx: Rest,periodof non-weightbearingorsx if necessary MSK CCC 28: Traumatic Knee Pain Bone Trauma PatellaFracture Tx: ORIF> 2mm articulardisplacement Tibial Plateaufracture (wtbearingsurface of proximal tibia) Tx: >3-5mm, surgeryrequired Knee jointunstable,fx isopen,compartmentsyndrome  surgery Alsofix meniscusinjurythatmayhave occurred Lateral fx can be arthroscopicallyreducedandtreatedwithlegscrews Medial fx require abuttressplate andscrews Distal Femoral Condyle FxsandSupracondylarFemurFractures Avulsionof Tibial Spine or“bicycle”fracture inchildren Soft Tissue Trauma – rare to occur inchildren Knee LigamentTears Internal:ACL/PCLwill notheal ontheirown(ACLmore commonlyrepaired –mustdo a graft) Recoverytakes6 months External:MCL/LCL – heal ontheirown MeniscusTears – require majortraumaat youngages,but minimal twisting/squattingif >35 years S/s: Painalongjointline,stiffness,mildswellingorknee withorwithoutlocking/catching Audible poppingwithflexion/extension Repairisone of the top 3 orthopedicsurgical proceduresdone inUS Repairedwithsewing/staplingif the tearisinthe rightlocation Transplantcadavermenisci butunprovenefficacy ArticularCartilage Damage Poorhealingpotential,nearlyalwaysleadstoarthritis Repairtechniques:
  47. 47. Trimming/contouringof tornsurface Abrasion/microfracture inanattempttogrow fibrocartilage repaircartilage Fillingacontaineddefectwithcartilage andbone graftsfromelsewhere Growingautologouscartilage cellsintissueculture andimplantingthem Combosof the above + Knee Dislocation PatellarTendonRupture Suturingtendonbackto patellawithlarge andstrongsutures – verysuccessful if done acutely MSK CCC 30: Bone,joint infections – Palmieri Reviewcases MSK CCC 31: Traumatic injuriesto wrist/forearm Dislocation –bonycomponentsof jointare no longerincontact withone another/completedisruption Incomplete fx –GreestickorTorus Subluxation –bonycompartmentsare partiallyincontactwithone another/partial disruption Description: Directionof fx line Transverse Diagonal/oblique Spiral Relationshipof fragments Displacement/Translation –sidewaysmotionof afx Angulation –amt of bendat a fx line Shortening–amt a fx hascollapsed/bayonet opposition Rotation # of fragments 2 – simple 2+ - comminuted Communicationwithatmosphere(bestevaluatedclinically) Closed Open Gustiloclassificationusedforprognosis Treatment: Immediate Debridementof skin,muscle,bone,tendon Colle’sFracture Of the distal radiuswithdorsal angulation Jones’Fracture
  48. 48. Fx of base of 5th metacarpal Boxer’sFracture Fx headof 5th metacarpal withvolarangulation MOI: punchinga person/wall Fracturesin Children Salter-Harrisclassification(kidsfx thatinvolve the growthplate) I: across the physiswithnometaphysical/epiphysial injury II: across the physiswithextendsintothe metaphysis III:across the physiswhichextendsintothe epiphysis IV:fx through metaphysic,physisandepiphysis V: crushinjuryto the physis Supracondylar Humerus Fxs Distal Radius Fxs Commonwithhighpotential forfunctional impairmentandfrequentcomplications Most oftenresultfroma FOOSH Dx: Xrays– lookfor dorsal/volarrim,lookfordie-punchlesions of scaphoid/lunate Tx: Closedreduction

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