MSK Re-Up #5 (Arm & Elbow)

Question 1

A supracondylar humerus fracture occurs due to __________. It is MC in what population?

What is seen on radiographs to diagnose a displaced supracondylar humerus fracture?

Answer 1

-FOOSH
-MC in 5-10 year olds

-Displaced anterior fat pad sign or posterior fat pad sign (hemarthrosis) is suggestive of fracture

Question 2

What is one other thing to remember about radiographs and what is seen with supracondylar humerus fractures?

Answer 2

Look at the radiocapitellar line. The radial head should dissect the capitellum. If not, it is likely displaced.

Question 3

What are some complications of a supracondylar humerus fracture that you should be aware of?
-There is a specifically named one
-And another one

Answer 3

-Median nerve and brachial artery injury may lead to Volkmann ischemic contracture (claw like deformity from ischemia with flexion of the wrist)
-Radial nerve injury

Question 4

Treatment for a supracondylar humerus fracture if:
-Nondisplaced
-Displaced

Answer 4

-Nondisplaced: long arm posterior splint followed by long arm casting
-Displaced: closed reduction and pinning

Question 5

A radial head fracture, usually also from a FOOSH, usually the patient presents with …

What is present on radiographs for a radial head fracture?

Answer 5

-Inability to fully extend the elbow

-Displaced anterior fat pad sign (hemarthrosis)

Question 6

Cubital Tunnel Syndrome is compression of which nerve at the cubital tunnel along the medial elbow?

The patient has paresthesia and pain along the nerve distribution that is worse with…

Answer 6

-Ulnar Nerve Compression

-Elbow Flexion

Question 7

What are some physical tests you can do to diagnose cubital tunnel syndrome?

Answer 7

-Tinel’s at the elbow
-Froment Sign (holds paper and compensates with flexion of IP joint –pinching effect – to evaluate adductor pollicis)
-Decreased sensation to fifth and ulnar side of fourth finger

Question 8

Treatment for cubital tunnel syndrome

Answer 8

-Wrist immobilization with sleep
-NSAIDs
-Steroid injections if chronic

Question 9

What are some etiologies of olecranon bursitis?

How does this present?

Answer 9

-Repetitive trauma or pressure
-Gout, inflammation
-Infectious (Staph A) after injury to skin

-Goose egg boggy swelling to posterior olecranon process area
-Usually painless
-Full ROM
-Infectious: erythema, warmth, tenderness with painful, limited ROM

Question 10

Usually olecranon bursitis is a clinical diagnosis; however, if inflammatory cause is suspected, aspirate bursa to evaluate for septic bursitis or gout.

If septic bursitis, Staph A is the cause. What are some ABX treatment options?

Answer 10

-Dicloxacillin or Clindamycin

Question 11

Lateral Epicondylitis (Tennis Elbow) is inflammation of the __________ muscle due to repetitive pronation of the forearm and wrist extension.

What is the symptom you should remember with this?

Answer 11

-Extensor carpi radialis brevis

-Lateral elbow pain with wrist extension and gripping

Question 12

Treatment for Tennis Elbow

Answer 12

-RICE, activity modifications, NSAIDs, physiotherapy, steroid injections, volar splint (palm side)

Question 13

On the other hand, medial epicondylitis (golfer’s elbow), is inflammation of what TWO muscles from overuse and stress?

The pain is worse over the medial epicondyle and worse with what motions?

What is the treatment

Answer 13

Pronator teres-flexor carpi radialis muscles

-Wrist flexion against resistance with elbow extended

Activity modification, RICE, NSAIDs, steroid injections

Question 14

Radial Head Subluxation (Nursemaid’s Elbow) occurs when the radial head is wedged into the stretched __________. It is MC in what population?

How does this occur?

Answer 14

Stretched annular ligament

MC in kids 2-5 years old

Lifting, swinging, or pulling a child while the forearm is pronated and extended

Question 15

What is one thing the child will be doing to the arm if the radial head is subluxed?

Answer 15

-Arm slightly flexed and child refuses to use the arm
-Tenderness of radial head (lateral elbow)

Question 16

Management for Nursemaid’s Elbow (Radial Head Subluxation)

Answer 16

-Closed reduction: pressure on radial head with supination of elbow followed by flexion of elbow.
-Hyperpronation technique
-No immobilization. Observe for 15 minutes.

Question 17

What is the difference in a pediatric forearm fractures… Greenstick Fracture vs a Torus (Buckle) Fracture?

What do they occur from?

What should you do?

What should you be aware of if the MOI doesn’t match the injury?

Answer 17

-Greenstick: incomplete fracture with periosteal tearing on convex side of fracture (bowing)
-Torus: Incomplete fracture with wrinkling or bump of metaphyseal-diaphyseal junction due to axial loading

-FOOSH

-Closed reduction, long arm cast

-Child abuse!

Question 18

Salter-Harris Classification of Fractures is for growth (epiphyseal plate) fractures. What is the pneumonic to use and what do they mean?

Answer 18

-SALTR
–Same, Above, Lower, Through, Rammed

-Type I: Isolated growth plate fracture
-Type II (MC type): Type I + fracture of metaphysis
-Type III: + fracture of epiphysis
-Type IV: fx extending across metaphysis, growth plate, and epiphysis (needs reduction)
-Type V: growth plate compression injury

Question 19

What is a Nightstick Fracture?

Treatment?

Answer 19

Fracture of middle portion of ulnar shaft

Short arm cast vs long arm cast.
-If displaced, ORIF

Question 20

A Monteggia Frature is ….

What is a complication of this?

Answer 20

-Fracture to proximal 1/3 of ulnar shaft + radial head dislocation

Radial nerve injury (may develop a wrist drop)

Question 21

On the other hand, a Galeazzi Fracture is

What is the management for this?

What is a complication of this type of fracture?

Answer 21

-Mid-distal radial shaft fracture with dislocation of distal radioulnar joint

ORIF (unstable fracture)

Anterior interosseous nerve injury: loss of pinch between thumb and index finger

Question 22

What is the acronym to use for Monteggia and Galeazzi Fractures?

Answer 22

-GRUesome MURder
–Galeazzi: Radial shaft fracture with dislocation of RadioUlnar joint
-Monteggia: Proximal 1/3 of ulnar shaft fracture + radial head dislocation

Question 23

MC type of elbow dislocation?

What is seen on physical exam with an elbow dislocation?

Answer 23

-Posterior

Flexed elbow, marked olecranon prominenence, inability to extend elbow

Question 24

Treatment for elbow dislocation?

Answer 24

-Emergent reduction with posterior splint at 90’ and ortho follow up

Question 25

What is the pathophysiology of osteogenesis imperfecta?

What are some symptoms and clinical manifestations of this condition?

Answer 25

Autosomal dominant disorder leading to defects in gene that codes for Type I collagen

-Severe premature osteoporosis: multiple recurrent spontaneous fractures
-Presenile deafness
-Blue-tinted sclerae *****
-Brown teeth

Question 26

Complex Regional Pain Syndrome (CRPS) is autonomic dysfunction following bone or soft tissue injuries (30% have no history of injury, though). What are symptoms of this condition?

Answer 26

4 main symptoms after initiating event:
-Sensory: Pain, hyperalgesia out of proportion
-Motor/Trophic Changes: decreased ROM, increased hair and nail growth initially
-Edema: Or sweating changes
-Vasomotor: temperature and skin color asymmetry

Question 27

What is the management for CRPS?

Answer 27

-NSAIDs initially, PT or OT
-Oral corticosteroids, TCA’s
-Electric nerve stimulation

Question 28

What should be given to patients with fractures to reduce the incidence of CRPS?

Answer 28

Vitamin C prophylaxis

Question 29

What is the cause of osteoporosis (pathophysiology)?

Answer 29

-Loss of bone density over time to imbalance of increased bone resorption > formation of new bone

Question 30

Primary osteoporosis has causes such as…

Secondary osteoporosis, due to disease or medications, has causes such as…

Answer 30

-Primary: Postmenopausal and senile

-Secondary: Glucocorticoid use, Cushing’s Syndrome, Heparin, Phenytoin, Lithium, Levothyroxine, DM, Low estrogen

Question 31

What are other risk factors for osteoporosis?

What are some symptoms that would make you think osteoporosis?

Answer 31

-RF: Caucasians, Low BMI (thin body habits), corticosteroid use, smoking, CKD, alcohol, physical inactivity, low calcium and Vitamin D intake

-Symptoms: usually asymptomatic, pathologic fractures (vertebrae MC), spine compression (loss of vertebral height, shortening of stature, kyphosis AKA hunchback, back pain)

Question 32

What is the best diagnostic test for osteoporosis?

Explain the T scores and what each means.

Answer 32

-DEXA scan (bone densitometry)

-Normal: 1.0 or greater
-Osteopenia: -1.0 to -2.5
-Osteoporosis: -2.5 or less

Question 33

Who should you screen for osteoporosis?

Answer 33

-DEXA scan in patients 65 years or older

Question 34

Management for osteoporosis?

Answer 34

-Lifestyle modification: Vitamin D, Calcium supplements, weight bearing exercise, smoking cessation
-Bisphosphonates: inhibit osteoclast turnover
-Denosumab: RANKL inhibitor that is used if unresponsive to other therapies

Question 35

Osteosarcoma is the MC primary bone malignancy in Children and young adults. It MC occurs in what bone?

Where are the METS MC to (this is the MCC of death).

Answer 35

Distal femur (long bones)

MC mets to the Lungs

Question 36

Symptoms of an osteosarcoma

Answer 36

-Localized bone pain, worse at night
-Joint swelling without systemic symptoms
-Palpable soft tissue mass (may be tender to palpation)

Question 37

Radiographs are usually done first for osteosarcoma, what is shown on them?

What is the definitive diagnostic for this?

Answer 37

-hair on end or sunburst appearance due to tumor spicules of calcified bone radiating in right angles.

-Biopsy is definitive

Question 38

Treatment for osteosarcoma?

Answer 38

-Chemotherapy + surgical removal with possible amputation of limb

Question 39

On the other hand, a chrondrosarcoma is …..

What is seen on radiographs?

What is the treatment?

Answer 39

-Cancer of the cartilage. MC in adults 40-75.

Punctate or ring and arc appearance calcification

Surgical resection +/- chemotherapy

Question 40

A Ewing Sarcoma, the second MC primary bone malignancy in children and young adults, occurs due to a translocation between what two chromosomes?

Whats the MC site for mets?

MC location for this condition?

Answer 40

Chromosomes 11 and 22

Lungs

Femur or Pelvis MC

Question 41

Symptoms of a Ewing Sarcoma

What is shown on Radiographs for this condition?

Answer 41

Localized bone pain and swelling with systemic symptoms (fever, malaise, weight loss)

Periosteal reaction (onion skin appearance), lytic lesions with moth-even appearance

Question 42

What is seen on histology for a Ewing Sarcoma?

Answer 42

-sheets of monotonous small round blue cells

Question 43

Treatment for Ewing Sarcoma?

Answer 43

-Chemotherapy with limb-sparing resection when possible

Question 44

In benign bone tumors, osteochrondroma is the MC type. It occurs in 10-20 year old males MC and what symptoms does it have?

What is shown on radiographs?

Treatment?

Answer 44

-Painless, palpable mass.

-Pedunculated (narrow stalk) that grows away from the growth plate and involves the medullary tissue.
-Biopsy is definitive.

Observation if asymptomatic. Marginal resection if painful or location in pelvis.

Question 45

An osteoid osteoma, a benign bone tumor characterized by small radiolucent nidus, MC presents in the second decade of life. what does the nidus produce?

What are symptoms of this condition?

Answer 45

-Nidus produces high levels of prostaglandins.

-Progressively increasing pain that is worse at night and unrelated to activity. Pain is relieved within 20-25 minutes of NSAID administration (prostaglandin inhibition)
-May develop a limp, decreased ROM

Question 46

Treatment for Osteoid osteoma

Answer 46

-NSAIDs with serial X-rays every 6 months