Pain from overuse causing bony breakdown faster than repair
Stress fractures ( Pain worsens through activity)
Common Location for stress frx
Common locations – tibia, metatarsals Locations with slow healing (& high non-union rates) – navicular, femoral neck, anterior tibia, tension side of femoral neck
Abnormal bony metabolism and remodeling. c. Most common locations: pelvis, femur, skull and lower lumbar vertebrate
Pagets has what type of effect on bone: both function and structure
May cause affected bone to be structurally weak, painful, misshapen and /or arthritic.
Teenager comes in with pain and swelling in her knee, it sometimes will lock. Has been going on for a few months... No history of trauma. Dx?
Osteochondritis dissecans (OCD)
Who is usually affected by OCD?
a. Occurs mostly in children & adolescents (although it may not become symptomatic until adulthood in some patients.
Tx options for Osteochontritis Disease
Most common locations knee, elbow and joints e. Treatment in young patients –relative rest for 2-4 months i. Surgery for loose fragments and large fragments in older patients
Cause of Osteochondritis Disease
Theoretical etiology – interruption of blood supply to a bony segment of causes it to separate from the surrounding area. This may result in bone section and the cartilage covering it begin to crack and loosen
Young man comes in comes in with pain in his finger. He can't flex it at the DIP. He was play capture the flag with some 'bros' at the park and things go a little rough as he explained he was 'accidentaly' grabbing at someones shirt to try and get the flag. Dx?
Finger injuries Jersey finger: Traumatic avulsion of flexor digitorum profundus from distal phalanx
Mechanism of a jersey finger injury?
Mechanism of injury (MOI) - forced passive extension of dorsal interphalangeal (DIP) joint during active flexion of DIP joint
Tx for avulsion of flexor digitorum profundus at distal phalanx?
Treatment – surgical repair
Woman comes in with pain and swelling in the DIP of her index finger. She can no longer actively extend her finger: Pt states she was playing basketball and as she was going up for a rebound and her finger got jammed. What is the Dx?
Mallet finger Traumatic avulsion of terminal extensor tendon from distal phalanx
Mechanism of Injury in a mallet finger?
MOI - forced flexion of the DIP during extension (e.g. ball jamming fingertip)
Tx for mallet finger?
iv. Treatment – immobilization; large displacement or joint involvement may require surgery
Central extensor slip insertion ruptures/Boutonniere deformity Initially causes: Chronically causes:
-loss of full active PIP extension -adjacent lateral band tendons migrate palmarly resulting in characteristic boutonniere deformity – PIP flexion and DIP hyperextension
Patient with history of RA comes to clinic. You are on rotations and you Attending points out that the patient has a Boutonnier deformity of her middle finger. She asks you to explain the tendon and joint involvement and what is the cause:
Disruption of central extensor slip insertion at the base of middle phalanx PIP flexion and DIP hyperextension
What do you see on exam with a pt that has central extensor slip?
With finger bent over table at the PIP and the proximal phalanx held down, the patient attempt to extend finger; normally DIP can be passively extended; abnormal test cannot extend finger and decreased passive DIP flexion
MOI of central extensor slip insertions
iv. MOI – forced passive PIP flexion against active extension (commonly from dorsal PIP dislocation) – resulting in avulsion of central slip
TX options for central extensor slip/Boutonneir deformity
Treatment 1. Closed injury - early PIP splinted in I extension with active DIP exercises 2. Laceration – surgical repair
Common causes of swan necking in fingers:
ii. Usually caused by volar plate disruption iii. Often related to rheumatoid arthritis
Pt comes in with hyperextension of proximal joint and flexion of distal joint (mostly PIP and DIP respectively) DDx
Volar plate disruption/Swan neck deformity
Pt has tingling from the proximal to medial malleolus and issues with ankle dorsiflexion (tibialis anterior). Suspected level of lumbar radiculopathy?
Pt has tingling from the proximal to medial malleolus and issues with ankle dorsiflexion (tibialis anterior). What reflex would you expect to see issues with?
Patellar reflex (L4)
Pt with a weak patellar refelx and issues with ankle dorsiflexion would have suspected disc herneation btwn?
L3/L4 L4 would be impinged --> Patellar reflex
Pt comes because her back has been bothering her. On exam, you noted weakness during extension of her toes (extensor hallicus longus and ext digitorum brevis). She also has a tingling sensation over the 1st web of her foot. Suspected level of lumbar radiculopathy?
Pt comes because her back has been bothering her. On exam, you noted weakness during extension of her toes (extensor hallicus longus and ext digitorum brevis). She also has a tingling sensation over the 1st web of her foot. What movement with her thigh would you also expect to see issues with?
Hip ABduction Signs point to L5 radiculopathy. Extensors of toes involved as well as Hip ABduction!!!
Pt cannot ABduct her hip and has weakness when extendig her toes, what is the suspected level of nerve impingement?
L4/L5 L5 is affected nerve
Suspected reflex issues with L5 radiculopathy
Traditionally –“none” Tibialis posterior reflex or medial hamstring reflex
While performing a musculoskeletal exam you notice your pt has a diminished achilles reflex with tingling over his posterolateral heel. She states she's had recent low back pain. Suspected lumbar radiculopathy?
Expected muscle involvement (weakness) on a L5/S1 impingement
Gastrocsoleus (plantar flexion), peronei (foot eversion), gluteus maximus (hip extension)
Spurs/irregular shape of femoral head are called: They can cause:
Cam Hip impingement – bony irregularities of the femoral head and acetabulum may result in joint irritation especially at extremes of motion and may potentially interfere with motion block motion .
spurs on acetabulum are called: Can lead to:
b. Femoral acetabular impingement (FAI) – Hip impingement – bony irregularities may result in joint irritation especially at extremes of motion and may potentially interfere with motion block motion.
What types of muscle are at high risk for tear?
Muscles that transverse two joints at higher risk of injury (gastroc, quad, hamstring)
A runner comes into clinic complaining of pain in her feet when she wakes up in the morning but it gets better once she moves around. What is a common anatomical finding on these pts?
Individuals with pes planus (flatfeet) are at increased risk (plantar fasciitis)
Etiology of plantar fasciitis
pain & irritation of plantar fascia origin-- due to overuse
A dancer comes to you office with right foot pain. She complains that she can no longer perform point and that two days ago she landed 'funny' on her right foot.She ahs Acute mid-foot swelling. Dx?
Lisfranc sprain (tarsometatarsal sprain)
What is a concern with a chronic Lisfranc sprain?
mid-foot pain (up to 20% missed on initial evaluation)
Where would a pt with a Lifranc sprain have pain? What would we do on physical exam? What type of imaging would we want?
pain at Lisfranc joint To palpation, squeeze, distraction of adjacent metatarasals X-ray - wt. bearing views
Pt was diagnosed with a Lifranc sprain. She has a <2mm metatarsal diastasis. How would you tx this patient?
Grade I & II < 2mm metatarsal diastasis - cast with arch support x 4-6 wks or walking boot w/ arch support x 4-6 wks
Tx options for a Grade III Lifranc sprain Chronic Lifranc sprain?
Grade III - surgery Chronic - orthosis or surgery
5th metatarsal gets fucked up alot. What do we see with an avulsion frx here (name tendon)
Avulsion – 5th MT base @ peroneus brevis insertion
5th metatarsal gets fucked up alot Describe a jones frx
Trauma to METAPHYSEAL-DIAPHYSIS jnx
5th metatarsal gets fucked up alot: Pseudo Jones is different from a Jones because:
Stress fs to PROXIMAL DIAPHYSEAL while Jones is metaphyseal/diaphysis jnx
5th metatarsal gets fucked up alot: Describe a Dancers fx:
spiral frx mid to distal diaphysis
What types of 5th metatarsal frx are d/t trauma?
Trauma - avulsion, dancer’s & Jones
Overuse and stress of the 5th metatarsal may result in :
2. Overuse/stress - especially “psuedo-Jones”
Pt has point tenderness over the fifth metatarsal as well as pain with resisted for eversion. Dx?
Avulsion fx - 3. Dancer’s & Jones - axial loading, vibration & squeeze (+)
Pt has point tenderness over the firth metatarsal as well as pain during axial loading, vibration and squeeze test. Dx?
Dancers OR Jones frx Dancers = spiral fx from mid to distal diaphysis Jones = Metasphyseal-diaphyseal frx **tell apart by x-ray
Tx option for avulsion frx?
symptomatic or ankle brace
Tx option for Dancers frx?
Dancer’s - cast shoe or rigid orthosis
Tx for Jones frx?
walking boot, cast or surgery
Tx for pseudo Jones frx?
(prox. diaphyseal) – Non-weight bearing cast or surgery