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

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