Study of the musculoskeletal system: bones, ligaments (bone to bone for stability at joint) , joints, muscles, tendons(muscle to bone causing action)
Sub-specialty in internal medicine and pediatrics, devoted to the diagnosis and therapy of rheumatic diseases- medical specialty, not surgical
pathogenesis of major rheumatological dzs
disorder of purine/ protein metabolism with uric acid crystallization in synovial fluid, inflammatory & provokes immune system
name of erythema and swelling on a toe with gout
5 function of the ms system
Movement Structural support Organ protections Storage of minerals Hematopoiesis
end portion of bone
phalanged portion of bone
living unit of bone; help build bone tissue, break down bone tissue
osteocytes, osteoblasts, osteoclasts
which part of a joint doesn't have its own blood supply and heals poorly?
freely mobile joints and examples
diarthrodial: ball and socket, hinge, saddle, pivot, condyloid
joints that allow some movement and examples
amphiarthrodial/fibrocartilaginous: pubis symphysis, costosternal, acromioclavicular
joints that don't move and examples
synarthrodial, cranial sutures
bowlegged): distal extremity is inward
(knock-kneed): distal extremity is outward
occurs when joint between two bones separates Usually from excessive tension to or disruption of supporting ligaments
acute injury of partial dislocation, or can be a chronic problem
stretching of ligaments from excessive force
stretching or partial tearing of the muscle-tendon unit from excessive force
why do joint injuries and fxs bruise?
there are micro tears that cause bleeding from blood vessels under the skin
buckling of the cortex –almost exclusive to peds patients
torus fracture (buckle)
caused by a tendon or ligament pulling a piece of bone off- cause instability of a joint
fx usually a result of normally minor injury - should be suspicious of osteoporosis/osteopoenia
if any air is found in an X-ray of a bone/joint, what do you do?
immediate surgical consult b/c this signifies an open fx and surgical emergnecy
fx caused by caused by non-traumatic, cumulative overload on a bone –usually a chronic axial force like running, chronic flexion of naturally curved bones like the plantar arch
through the physis- low risk of growth arrest, treat like a normal fracture
salter harris I
through the physis with extension ot Metaphysis- can be easily viewed on Xray
salter harris II
through physis with extension to epiphysis- can disrupt the joint surface itself, risk of premature/post-traumatic arthritis
salter harris III
hrough Metaphysis, physis, and epiphysis- bone fragment can break off and die, joint will collapse on one side
salter harris IV
impaction/crush injury to the physis- Xray can show normal physis, use a contralateral Xray to compare, highest risk of growth arrest so treat aggressively- completely non-weight bearing, refer to ortho
salter harris V
what should you include when describing an X-ray of a fx of limb/joint?
view, R or L anatomy, where fracture indicated, what distance along bone, what type of fracture, relationship of fragments (simple v comminuted) displacement or angulation, communication with atmosphere, whether growth plate is involved
Elevated pressure in a closed muscle compartment due to injury- commonly crushing component or repetitive stress which releases blood/inflammatory cells and causes swelling: most common areas?
anterior tibial and volar forearm
7 P’s of compartment syndrome
pain, pallor, paresthesias, paresis (weakening), poikiolothermia, pressure, pulseless
The standard radiographs for musculoskeletal trauma. how many views needed?
plain films, views needed at 90 degree angles
More sensitive delineation of fractures than plain film; Evaluation for bone tumors May help guide operative planning
best for soft tissue injuries like ligaments, etc and occult fx
• Developmental defect with no bone at growth plate • Usu in kids and teens • XR shows “soap bubble” in metaphysis • Bone does not enlarge beyond growth plate • Heals spontaneously • Watch for fractures • Tx: steroids, observe, surgery
unicameral bone cyst
• Kids and teens • Cortex destroyed by periosteal rxn and bone balloons out • Proximal fibula usu • Can be aggressive but not malignant • High recurrence rates • XR shows fluid/fluid levels on CT/MRI • Tx: curettage
aneurysmal bone cyst
what are examples of benign bone- forming tumors?
Paget’s disease – old, bone enlarged fibrous dysplasia – young, bone enlarged osteopetrosis – “marble bone”, no marrow space melorheostosis – candlewax fractures! osteoma – “bone island”, cancellous, pelvis osteoid osteoma/osteoblastoma…
• A benign cartilage-capped outgrowth, connected to bone by a stalk • The marrow cavity of the stalk is in continuity with the parent bone marrow and grows away from the joint • The cap is slow growing cartilage. Marrow is continuous into it. • As the cap thickens, it outgrows its nutrition, becomes calcified, and then is mineralized. • A cartilage cap > one cm in thickness, is thought to be malignant. • Grows during growth spurts • Presentation: +/- limited ROM, pain from lump • XR: no periosteal rxn, continuity of stalk with canal. • Tx: excise if sx. If multiple :HMO
• Benign but painful, especially at night. • Pain often relieved by ASA. • Can be found just about anywhere, including hip, spine, tibia, foot, etc • The nidus stimulates hypertrophic bone.. • The nidus is hypervascular and needs to be removed or destroyed to stop the pain. • Can be done with radiofrequency ablation. • night pain, NSAIDs (ASA) help • younger patients (2cm, spine, cystic
• Cartilage within bone marrow space • Starts from epiphysis to metaphysis • May calcify later in life • Esp in metacarpals and feet • May be painful or incidental finding • Can be alarming due to size. • Should not cause any endosteal (internal) scalloping of the cortex- lesion is growing and creating pressure on inside of bone. If scalloping, or increase in pain or size, consider malignancy. • Should not be especially hot on bone scan. • Should not occupy more marrow than one can see on the xray • Dx: XR with bagel sign, well marginated, periosteal rim • Tx: observe
• Seen in teens or adults with Paget’s disease. • Often pretreated with chemo before surgery to shrink the soft tissue mass. • Used to have >80% mortality, usually from lung metas. • Prognosis improved with aggressive chemotherapy protocols. • Limb salvage possible in some cases. • Not sensitive to irradiation treatment. • Presentation: minimal sx, pts not sick. • Imaging: metaphyseal and expansile mass. Eats away bone, no sclerotic rim. Lucent areas not yet calcified. “sunburst appearance. • Tx: bx, staging. Also get CXR, chest CT, bone scan, MRI. Pre-op chemo to shrink, wide resection, post-op chemo, surveillance with alk phos.
what are examples of benign cartilage forming tumors?
• osteochondroma • enchondroma
what are examples of malignant bone forming tumors?
what are examples of malignant cartilage forming tumors?
• Note the well-defined border of the hole. • 20% of population • Implies slow growth. • Tumor remains within the bone of origin. • Looks like it might be healing. • Somewhat scalloped appearance internally. • May heal spontaneously- name is a misnomer- can heal in children • These lesions are eccentric in metaphyseal bone. • Well marginated. • May heal spontaneously if observed long enough. Treatment of NOF • Observation- annually if they remain asymptomatic until healing assured. • Curettage and grafting with a bone-graft substitute for a large painful lesion. ORIF- occasional pathologic fracture may require internal fixation.
non ossifying fibroma
benign but locally aggressive and high recurrence rates grows rapidly in pregnancy spans epiphysis and metaphysis XR: large, expansile, well-defined, lytic lesion, expands up to subchondral bone rarely metastasizes after excision treatment: curettage, radiation sensitive
giant cell tumor
malignant,lytic lesion rarely isolated middle-aged adults painful – out of proportion to degree of bone destruction rule out mets or myeloma (primary rare – 1%) treatment: radiation and chemo (no OR)
• Cancer of the plasma cells in bone • Usually seen in adults >50yrs. • X-ray may be solitary lytic, permeative, or soap bubble-like, osteoporosis, punched out lytic lesions or osteoblastic • Solitary lesions can be treated with moderate doses of XRT. • Plasma and urine electrophoresis used to diagnose • SPEP/UPEP, bone scan, BM biopsy
• neuroectodermal tumor • Usually in preteens or teens, caucasians • C/O bone pain, +/- fevers, increased ESR (necrosis) • Associated soft tissue swelling. • May mimic osteomyelitis because of pattern of bone destruction. • X-ray pattern varies from onion skin periosteal reaction, to permeative destruction. • Usu metaphyseal with assoc soft tissue mass • Dx: BM bx • Tx: treatment: chemo and resection, ?radiation • 5-year survival 63% (80% if local and
what does the fat pad sign suggest?
occult supracondyllar fracture in kids or occult radial head fracture in adults.
Usu presents as direct pain on lateral epicondyle. May present as a dull ache on outer aspect of the elbow that increases with grasping, twisting and resisted extension of the wrist or fingers
Very local, focal tenderness over insertion of extensor tendon on lateral elbow (on the bone)
Increasing pain with (resisted) extension of wrist- hold on to wrist and push down on hand while patient resists
Increasing pain with (resisted) supination of wrist- try to shake patient’s hand
Pain will cycle in 12-18 month periods
Rest, avoid aggravating activities like gripping
Ice if acute or rep. injury
?Compression, ace wrap. Beware of tennis elbow bands b/c they can be put on too tight. Idea is that bending elbow transmits force to band
Massaging may make it feel better for them
+/-Injection with steroid and
pain on medial elbow:
Tender to palpation on the medial epicondyle
-Increased pain with resisted flexion and pronation of the wrist
Microtrauma to the flexor carpi radialis tendon insertion on the medial epicondyle
Flexor-pronator wad of muscles attach to medial epicondyle
Treatment—more aggressive like an acute injury
Rest, avoid aggravating activity
PT for iontophoresis, throwing eval
Referral for resistant cases- but typically resolve after a few weeks
Use significant caution when considering injection- Ulnar nerve
-don’t do it if you don’t do it on a regular basis
pain and swelling over the olecranon process.
dx: olecranon bursitis
causes: trauma, infection, inflammatory conditions, gout
how to make dx:
X-ray if trauma or suspicion of foreign body and +/- gout
CBC for white count if suspicious of infection
ESR, CRP and serum uric acid if suspicious of gout
Aspiration is controversial, consider specialist consultation
Avoid temptation to poke b/c secondary iatrogenic infections are common
Nothing for non infectious- Typically will resolve spontaneously in 2-4 weeks
Rest-avoid direct trauma
Elbow padding might be effective
NSAIDs if pain is present
Aspiration (orthopedist or hand surgeon only)
If for some reason they ask you to aspirate—use good sterile technique, if looks like uric acid don’t put in formalin or it will degrade. Leave in syringe or put in saline.
Gram stain and culture
>5000 WBC per ml indicates infection (Staph Aureus is most common)
-high white cell and low glucose usu means there is an organism in there
-if no organism and low WBCs probably just traumatic
Do not inject steroids unless you are absolutely sure there is no infection. Some literature says steroids help bursitis go away faster, but if there is even 1% chance there is an infection that steroid is stuck in there for about 3 months and infection gets worse.
Close follow up after steroid injections
usu resolves spontaneously in 2-4 weeks
Paresthesias in the ulnar side of the ring finger and small fingers
Weakness and atrophy of the ulnar innervated intrinsic muscles of the hand- lumbrical muscles and Hypothenar muscle EXCEPT THENAR muscles of thumb unaffected, most evident at web space between thumb and second finger
Weakness of adduction of 5th digit—the pink will drift out
ulnar nerve entrapment
cause: chronic pressure on it or hypertrophied muscle or trauma
tx: splinting elbow in extension; NSAIDS, poss. surgery
Wrist Drop (weakness of extension) and loss of sensation in dorsal web space between thumb and index finger
Usually from extrinsic compression of axilla and radial nerve entrapment
Usu fell asleep on arm or feel asleep with arm over a chair
“Saturday night syndrome” b/c usu pass out/sleep hard in that position after etoh or other medical conditions
dx: radial nerve palsy
Cock-up splint for wrist
Orthopedic follow-up, OT
benign, temporary paralysis/injury of nerve
usu get a flicker of extension in their fingers, then wrist, etc.
Claw hand in non-resolving cases
Actually compression of posterior interosseous nerve in forearm.
Hypertrophy of extensor muscles from repetitive movements or extrinsic compression-
If using tennis elbow strap that is cinched down with lots of tightness
radial tunnel syndrome
Arm usually held in slight flexion and pronation against body
usu does not hurt at time of dislocation
Child will not want to use arm to grab a toy, candy, etc. can test and see if they will grab it
X-ray first if any question of fracture
subluxation of radial head
x ray if suspicious of fradcture
reduce, reexamine, follow up xrays, sling if still bothering them
how does a supracondylar fracture develop and what do you have to examine closely?
happens by falling backward on an hyperextended elbow
Be suspicious for vascular compromise, especially of the brachial artery
Be suspicious for nerve injury of median, ulnar or radial nerve
FOOSH- fall on an outstreched hand
Radial head driven into capitellum
Elbow pain, +/- swelling
Inability to completely extend
Pain on pronation and supination (occurs at radial head) +/- crepitus
Tenderness over radial head
Limitation of motion, especially in extension and pro-supination
AP, lateral and oblique x-ray series.
There are specialized radial head views if necessary
Positive fat pad sign - fluid in the anterior joint capsule
radial head fracture
Sling for comfort- immobilize
Ice for swelling, pain
Analgesics like oxycodone etc especially during sleep, avoid NSAIDS in fractures- inhibit prostaglandins
Encourage early AROM
Follow x-rays at interveals wk. 1,3,6 to make sure things not displacing further, not necessarily looking for healing which will be mostly clinical via lack of pain, etc.
At 6 weeks usu pain is gone and you can “turn em loose”
ddx of radial head fx
Elbow dislocation (clinical deformity and diffuse pain)
Hemarthrosis of the elbow (present with radial head fracture
or with other bony or soft-tissue injury)
Olecranon fracture (pain and tenderness over the posterior tip
of the elbow)
Supracondylar fracture of the humerus (location of pain,
tenderness, and deformity)
what's in the ddx for lateral epicondylitis?
Cubital tunnel syndrome (compression of the ulnar nerve, paresthesias in little and ring fingers)
Fracture of the radial head (radiographs should differentiate; pain and tenderness over the radial head that are exacerbated by passive pronation and supination)
Lateral plica (patient describes locking episodes and loss of elbow extension)
Osteoarthritis of the radiocapitellar portion of the elbow joint (radiographs should differentiate; similar examination to radial head fracture but without a history of acute trauma)
Osteochondral loose body (medial or lateral joint line pain, symptoms of locking)
Radial tunnel syndrome (compression of the posterior interosseous nerve, tenderness typically approximately 5 cm distal to lateral epicondyle)
Synovitis of the elbow (swelling, palpable effusion)
Triceps tendinitis (tenderness above the olecranon)
ddx for olecranon bursitis
Fracture of the olecranon process of the ulna (evident on radiographs)
Gouty tophus or rheumatoid nodule (a tophus or nodule generally will be smaller and more discrete than an inflamed olecranon bursa)
management of "fight bites"
Usually polymicrobial (from mouth and skin) and require urgent surgical I&D.
Presentation: laceration on mP joint +/- swelling, cellulitis, pain
Beware of occult extensor tendon injury from laceration
Infection can spread through extensor tendons to elbow
patient presents with Flexion deformity of the PIP with a secondary hyperextension of the DIP joint after an injury. what is it and how do you tx?
A rupture, usually traumatic, of the central slip of the extensor tendon mechanism on middle phalanx
Extensor mechanism then slides to the sides of the PIP joint instead of on top of knuckle
strict splinting for 8-10 weeks
what's in ddx for carpal tunnel
Arthritis of the carpometacarpal joint of the thumb (painful motion)
Cervical radiculopathy affecting the C6 nerve (neck pain, numbness in the thumb and index fingers only)
Diabetes mellitus with neuropathy (history)
Flexor carpi radialis tenosynovitis (tenderness near the base
of the thumb)
Hypothyroidism (abnormal results on thyroid function tests)
Pronator syndrome (median nerve compression at the elbow)
(tenderness at the proximal forearm)
Ulnar neuropathy (first dorsal interosseous weakness, numbness of the ring and little fingers)
Volar radial ganglion (mass near the base of the thumb above the wrist flexion crease)
Wrist arthritis (limited motion evident on radiographs)
swelling or stenosis of sheath that surrounds abductor pollicis longus and extensor pollicus brevis
=tendon and synovial tissue are both hypertrophied and hurts when pass under retinaculum
Affects women eight to 10 times more often than men.
Pain on radiostyloid, tender to palpation
Forced /repetitive radial deviation of wrist- enlarged tendons in tenosynovium causing friction and pain
Idiopathic, triggered by overuse, a direct blow to the thumb, repetitive grasping, and inflammatory conditions like RA (impacts synovial tissue)
Conservative treatment: rest, ice, anti-inflammatory medications and splinting in a thumb spica splint.
Spica splint prevents wrist from ulnar deviating and thumb from extending
Tell them to wear the sprint and pick up the baby in a different way
PT for tendon gliding exercises and iontophoresis may be helpful.
Corticosteroid injection into the first dorsal extensor compartment if frequently helpful and may be curative.
surgery if refractory
ddx of dequervain's tenosynovitis
ddx: Carpometacarpal arthritis of the thumb (swelling over the joint, pain with joint compression)
Dorsal wrist ganglion (palpable mass)
Flexor carpi radialis tendinitis (pain and swelling over the tendon)
Fracture of the scaphoid (tenderness over the anatomic snuffbox)
Superficial radial neuritis
Wrist arthritis (pain with movement, evident on radiographs)
Usually on ulnar side of hand
It’s not a tendon problem but a skin problem
When you move digit the tendon won’t slide, it’ll stay stiff
Localized formation of fibrosis of palmar fascia - starts with bump on palm may get dimpling/pitting of skin
As it progresses, more of the fascia becomes thickened and shortened- not painful
Dimpling and puckering of the skin over the area eventually occurs.
Ultimately contracture of the MP joints occurs, DIP joints involved later
More common in men over age 40 and in people of northern European descent.
Tx: observe it, have them put their hand down on the table, if they can’t do that, it’s a good idea to refer them on
don’t have them try to manipulate it, it can make it worse, leave it alone and go about their normal business
Treatment is usually conservative until patient is unable to put hand flat on table top, then surgical fasciectomy is indicated
dupuytren contracture ddx
flexion contracture secondary to join or tendon injury (no cords or bands) or locked trigger finger (no assoc nodules)
animal bite microorangism. how can the infection manifet itself?
Pasteurella Multocida, it can present with ascneidng lymphangitis
typical pathogens in paronychia
staph aureus and strep epidermidis
dorsally displaced distal radius from fOOSH
volar displaced distal fragment of radius
what's in the ddx for ganglion and mucus cysts?
Arthritis (evident on radiographs)
Bone tumor (evident on radiographs)
Intraosseous ganglion (evident on radiographs)
Kienböck disease (collapse of the lunate)
Soft-tissue tumor, benign or malignant (solid mass on palpation, rare) Hand and Finger
Dupuytren disease (presence of cords or bands)
Epidermal inclusion cyst (history of laceration and repair)
Giant cell tumors (different locations, but usually about the phalanges)
Lipoma (larger in size, often in the palm)
how to manage a snuff box tenderness
For a patient who has the correct mechanism of injury (scaphoid injury),
has pain in the snuff box and normal x-rays:
Treat the injury as if they had a fracture
TSS (thumb spica splint)
No NSAIDS- block prostaglandins that help fracture heal
Smoking cessation b/c that affects microvasculature
F/U 7-10 days for repeat x-ray
Maybe do specialized scaphoid views or advanced imaging
Still tender in snuff box with normal x-rays- consider advanced imaging (CT- bone)
acute low back strain/sprain:
Occurs when the muscles surrounding the spine are asked to stretch too far, lift to much weight, or move in such a way that they sustain very small tears. “weekend warriors”
Because of the tearing of the muscles, small microscopic bleeding occurs which in turn results in pain and muscle spasm
dx :symptoms: pain stiffness, local tenderness, shifted
pain worse with bending, sitting, twisting, coughing, lifting. Gets better as they go throughout the day
resolves in 2-6 weeks
self limiting problem
Rx: ice, modified activity, NSAIDS, mm relaxants*, oral steroids*, resume activity as tolerated.
narcotics have limited short term benefit, avoid benzos
*X-ray: A/P lateral spine standing (debatable)
no MRI unless red flag symptoms (i.e. hx of cancer), follow up
90% improve within 4 weeks, but re injury is common.
Once healing occurs, high level strength, conditioning and body mechanics training for lifting.
where is the most common area for a herniated disc? how do you tx?
Most common location is in the lumbar spine; L4-5 or L5-S1
Usu in corner of disk=weakest area
85-90% of first time disk herniations will resolve within the first 6 weeks to 3 months of onset of symptoms w/ without any treatment modalities.
Initially treated with short term bed rest for 1-2 days with gradual return to normal activities.
Anti inflammatories, ice, heat
Other conservative modalities include: physical therapy, chiropractic, acupuncture, pilates, yoga- work into it
Surgical treatment is warranted when all conservative measures fail or neurologic deficit is present like weakness
Degenerative process of the spine. “Arthritis of the spine”
Defect that occurs in the posterior aspect of the spine known as the pars interarticularis
Essentially a stress fracture in the vertebral body.
most common age of spondylolysis
Usu in adolescence age 10-15
Common cause of low back pain in children.
5% of the general population has this condition with the vast majority being asymptomatic.
Most common in football lineman and young gymnasts with det lift or clean and jerks with hyperextension
Typical symptoms include low back pain especially when involved in activities that place the spine in an extended position from hip or hamstring
findings: hamstring tightness, paraspinal spasm and guarding, pain with palpation, + standing extension test (stork test)
tx: Initial treatment is rest and possible bracing with hopes of the fracture healing. (since most kids won’t rest the whole time—she knows kids)
positive scotty dog sign= ?
fracture of pars interarticularis: area where superior articular process and transverse process attach to spinous process
symptoms: back and leg pain( radicular)
hip pain, often mistaken for bursitis
mechanical pain when getting up from chair
pain with standing and walking
pain worse with extension, better with pulling knees to chest.
Treatment: PT, injections,NSAIDS, surgery
Natural degenerative process “arthritis”
mechanical back pain
leg pain/radicular pain
Cate’s rule of activity dosing (pre dose and after dose to avoid having to use it all the time)
Core muscle exercise
Pool ex’s if not land tolerant
Facet injections/Rhizotomy in some cases, epidural steroid shots if radicular pain.
If primary back pain and mechanical in nature its all about management.
If stenotic/radicular pain then surgery
vertebral compression fractures:
vertebral compression fractures: Fracture of the vertebrae. Causes may include osteoporosis, trauma, infection and tumors.
Compression fractures affect 25% of postmenopausal women.
Only 33% of fractures in elderly women are diagnosed. Often misdiagnosed as “arthritis”
presentation:Typical presentation is an elderly female with acute onset of mid back pain. This may be traumatic or non-traumatic.
plain x-ray studies. Other imaging studies may include: MRI, CT, Bone Scan
Majority of mild to moderate compression fractures are treated with immobilization in a brace or corset for 6-12 weeks
Surgery: see PP
most common mets to spine are from where?
lung, breast, prostate
what sign is pathopneumonic for spinal stenosis?
the grocery cart sign:
tx of spinal stenosis:
Avoid activities or motion that put the spine in extension or backward bent positions
NSAIDS or other oral analgesics.
Epidural steroid injections, no more than 3/ year.
Physical therapy should consist of exercises that emphasize “flexion” type exercises and pelvic tilts
Surgical decompression of the stenotic neuro- aliments. Goal of surgery is to “take the pressure off the nerves”
Fortunately, surgical intervention for spinal stenosis is successful and rewarding
where do most c spine injuries occur? who should you contact first?
Most fractures occur at 2 areas: 1/3 from C2, over ½ occur at C6 or C7.
Most fatal injuries occur at C1-2
After assessment of airway and medical stability, always consult spine or neurosurgery regarding management.
This is a medical emergency- prompt evaluation and treatment is essential.
tx of cervical fractures:
Initially- complete immobilization of the cervical spine.
Various forms of diagnostic imaging is warranted including: X-RAY, MRI, CT.
Minor fractures may require simple soft collar bracing with observation.
Severe fracture/dislocations may require halo traction and surgical stabilization
Two type of meds: 1)antiresorptive medications that slow bone loss and 2)anabolic drugs that increase the rate of bone formation.
Antiresorptive:Bisphosphonates, calcitonin, denosumab, estrogen and estrogen agonists/antagonists. (Fosamax, Boniva, Actonel)
Anabolic: Teriparatide (Forteo) a form of parathyroid hormone, increases the rate of bone formation
flexion teardrop fx
flexion teardrop fx
Flexion injury with compression force
Involves ligament disruption
High incidence of cord injury
Most common level C5-6
Diving into a pool
Traumatic bilateral par’s interarticularis fracture of C2
Hyperextension and distraction injury
High speed auto, dashboard injury, falls in elderly
Neurological injury 25%
managemetn: rigid bracing or surgery
h/o slip and fall but doesn’t hurt right away but gets worse and worse
Lateral and open mouth view
management: type 1: soft collar
type 2: fx thru base: halo +/- surgeyr
type 3: fx thru c2, rigid collar +/- surgery
cause Cause: hyperextension/axial falls, playground falls, mva, diving
sx Neck pain, rarely neurological issues, horner's syndrome
managment: open mouth view, CT,
Overhang of C1 lateral mass over C2
Ranges from rigid brace, halo, surgery
Like a life saver that breaks and shatters in a bunch of directions and you get the overhang
Spinal Stenosis (Lumbar)
Usu d/t central disk herniation, can start as a smaller disk herniation and then got worse, they may say all of a sudden they wet themselves
Tell patient if you start losing control of bowel and bladder you need to call me right away
Weakness, Saddle-anesthesia, Incontinence are common
low back pain, pain radiating into both legs, numbness or paralysis in the legs, saddle anesthesia, and bowel and bladder incontinence or retention.
With rectal exam there should be some sphincter tone resistance, and an anal wink if poked, and ask if they have sensation when they wipe
Medical emergency requiring surgical decompression
Failure to recognize = BAD, PERMANENT DEFICITS
Innervate B&B- lifetime incontinence
how should scoliosis be managed?
always refer b/c there are many different kinds and curves and there is no "one way" to measure
seronegative spondyloarthropathy (ie -RF,-ANA)
males>females mid 20s.
symptoms: pain and stiffness, relieved with movement/activity, they can get to sleep but are awaken with night pain
Inflammatory sacroilitis,enthesis, autofusion from SI to cervical (play video)
By the time this shows up on xray, they’ve probably had it for 7-10 years
Early diagnosis is key
mobility exercises, yoga, posture
Important: ***If a patient with known AS falls, and has pain, it is a fracture until proven otherwise. Need to get CT scan for them
what are red flags with back pain?
Red flag symptoms
• Severe unremitting pain
• Unremitting night pain—pain that waxes and wanes or you can reproduce it is less concerning
• Night sweats
• General malaise
• Unexplained weight loss >10% 3-6 mos
• Bony tenderness
• Multiple myotomal loss
• Thoracic pain
Bowel or bladder retention or incontinence ,gait disturbance—need to do a rectal exam
Bandlike pain (herpes zoster—it can happen up to 3-4 weeks before zoster’s finding)
Can’t lie supine
Pins/needles both hands and feet: MS, diabeters
More red flags
• PMH of:
- TB or other infections
- IV drug use
- long term steroid use: can cause bone fx
• age - < 20 or > 55 (kids don’t complain of back pain—if they do check on it!) and scoliosis usu doesn’t call pain
• any previous surgery
don’t complain of back pain
Rare compared to adults
Must be evaluated
Painful scoliosis is a red flag
(scoliosis is typically not painful)
Osteoporotic or senility fracture
malignant spinal cord compression: def and tx
Spinal mets can cause MSCC
5% of all patients with cancer present with MSSC
First symptoms are pain
Reduced control of legs, ataxia and vague weakness are other signs often overlooked
Can present with radicular pain due to compression
MRI gold standard
MRI whole axial spine(emergent)
Biopsy and labs
Oncology work up
Source primary lesion
most common primary malignant spinal cnacer
Most common primary malignant spinal cancer
White count, platelets and hemoglobin go down but calcium goes up
Results in bone being resorbed secondary to excessive plasma cells which produce abnormal quantities of immunoglobulins
Early diagnosis reduces risk of spinal cord compression.
Average age 65
Male 2:1 over female
Looks like moth eaten bone or punched out
Bone pain, lumbar spine, pelvis, ribs
Tired, fatigues easily(anemia)
Bruise easily (thrombocytopenia)
Associated fractures (apendicular)
Full axial spine MRI
Full body bone scan ?
Bone marrow biopsy
Urinalysis: Bence Jones Protein
osteo porosis prevention
Get enough Calcium and Vitamin D and eat a balanced diet
Get regular exercise that includes weight bearing and strengthening
Limit Alcohol to 2 drinks/day
Load bearing: anything on your feet
Weight training: muscle building
Balance and Coordination
what ligaments keep the foot from rotating laterally?
where can you find the plantar flexors?
Pass posterior to medial malleolus- at end of tibia and wrap under foot
Tom, Dick and Harry tendons
where can you find the peroneals or evertors of the foot?
Pass posterior to lateral malleolus and wrap under foot
Peroneal brevis- inserts on base of 5th metatarsal
what is usually assoc with a deltoid ligament sprain?
usu also fibular fx b/c of force requ'd to forcibly evert the foot like that
which ligaments are most often sprained in the foot?
>90% of the time the lateral ligaments are sprained
Lateral ligaments tear in sequence, anterior to posterior- most anterior is anterior talo-fibular >90%, bad sprains can involve 2+ ligaments (calcaneofibular or posterior talofibular)
managment of ankle sprains
rest, Ice, compression, elevation
Immobilize with plastic or plaster splint- stabilize ankle so the ligament can rest and heal, should be able to bear weight. Fits inside their shoe and usually they can walk with that
Consider crutches if moderate-severe or difficulty bearing weight with splint
Third degree sprains may need surgery (rare)- all ligaments torn so it won’t heal on its own
Usually takes 4-6 weeks to heal
If still not healed, unstable, refer to ortho b/c they might need surgery
achilles tendon tear:
Usually due to forced dorsiflexion of ankle- initiating sprint, slipping on stair
Also seen with direct trauma- blow to taut tendon, laceration
Hx: were doing something, then sudden pain like a “gunshot wound”
Patient may have heard a “snap”
Difficulty stepping off or walking, won’t want to push off on foot
Swelling of distal calf
Palpable tendon defect
Difficulty bearing weight
Weak plantar flexion (if asked to press foot down on hand like pressing down on a gas pedal) b/c of tom dick and harry tendons
May still be able to flex toe flexors, tibialis posterior, peroneal- not indicative of injury
dx: thompson test
Initial, splint in equinus- aka plantar flexion so no tension on achille tendon (dorsi flexion puts tension on it)
Refer to ortho: they need to decide tx: casting vs. surgery
Conservative: casting x8 weeks, PT
Surgical: recommended for younger, athletic patients
Achilles tendinitis or tendinosis (thick, tender Achilles tendon or crepitus may be noted on palpation)
Deep vein thrombosis (no history of injury, negative Thompson test)
Medial gastrocnemius tear (pain on palpation over the medial head of the gastrocnemius-soleus complex)
Plantaris rupture (pain but little loss of function)
Stress fracture of the tibia (constant pain over a localized area
of the tibia)
what are the ottawa ankle rules?
criteria to determine if Xray required. Cost effective and well validated. Need xray if any of the following are positive:
Bony tenderness along distal 6 cm. of tibia or fibula—push on medial and lateral portions.
Bony tenderness at base of 5th metatarsal (b/c peroneal brevis can pull off a piece of that 5th metatarsal in inversions)
Inability to bear weight, both immediately after injury and in ED
ddx of arthritis of foot
Charcot arthropathy (history of diabetes mellitus, swelling that is disproportionate to symptoms)
Gout (redness and swelling)
Tendinitis (normal radiographs)
tx of hallux rigids
Rx: rocker-soled shoes that help walking without bending MTP joint, NSAIDs, surgery possible (joint replacement vs. fusion)
Req a lot of force; mechanism usually due to compression- ie fall from height or in head on collision in car accidents
Usu assoc with other issues b/c of force req’d
10% associated with lumbar fx- axial load distributed to spine
26% associated with other extremity injury
Needs a good head to toe PE b/c of distraction pain
Clinical- swelling, pain located at heel, ecchymosis over calcaneus
Xray- standard foot films usually demonstrate (AP and lateral)
Calcaneal view- more elongated view of the calcaneus, can get if if doesn’t show up on AP or lateral but you suspect fx
Treatment- surgical by a foot specialist to restore anatomy b/c comminuted
Bilateral calcaneus fractures are common
Px: can be really devastating. Often they might have a limp for the rest of their life even if they get surgery by the best foot surgeon
Usually due to foot hyper-plantar flexion
Drives talus into tibia, maybe from running and you catch your foot
Fracture may involve dome, neck, or body
Important b/c Talus covered by cartilage, its blood supply tenuous and can be disrupted
1% may lead to avascular necrosis if not recognized and treated appropriately
Inability to bear weight
Localized tenderness and swelling- anteriorly, where foot meets ankle
May have loss of normal foot contour: instead of nice 90 degree angle it will be softened
Caution “ankle sprain” misdiagnosis- pt says they have ankle pain, get xray and often you can miss them on ankle xrays. usually the CC
Diagnosis with foot xrays
Ice, elevation, immobilization
Nonsurgical, if non-displaced minor chip fracture of dome
Surgery if displaced fracture of neck or body
Stress fractures of midshaft metatarsals
Usually 2nd and 3rd MTs which are relatively fixed compared to mobile 1,4,5- take more of the impact from physical activity
Due to excessive stress over time (i.e. training for marathon)
May not appear on xray for 2-3 weeks b/c at that point you start to lay down calcium (a white line) at fx site
If suspected and need to know right now: bone scan (with isotopes—goes to area of fx), repeat xray in 2-3 weeks
But this doesn’t change tx—the only way it will heal is to stop running, etc
No one wants to hear that…but its what they have to do or it will get worse
Rx: rest, possibly immobilize- can turn into complete bone fracture
proximal 5th metatarsal fx
Most common metatarsal fracture
Often occurs with lateral ankle sprain
Usually due to inversion/avulsion of proximal bone by peroneus brevis tendon- can pull part of the bone off
Always check for tenderness at base of fifth metatarsal when evaluating ankle sprain- second Ottawa ankle rule
Ankle xrays must visualize this area
If can’t see 5th metatarsal with ankle xray get a foot xray
Rx: Usually conservative, Immobilize, Crutches
At right: Jones fx vs. proximal 5th
broken toe: mOI, presentation, sx, dx, tx
Phalanges (toe fractures) –forefoot fracture
Common, often see fracture-dislocation
Usually due to direct trauma or hyper-extension or crush
Exam: pain/swelling, deformity if dislocated, ecchymosis
Reduce fracture and/or dislocation
Immobilize with dynamic splinting- “buddy taping” to toe next to it
Tell them to wear the stiffest-soled shoes that they have
Great toe bears 1/3 of body weight on that side, may require walking cast, may want to refer them to orthopedist to see if they need something else to get it to heal
If unable to reduce, may require internal fixation (rare) surgery
plantar fasciits: presentation, dx, tx
Usually an overuse injury: runners, standing occupations, RA and gout
Strain of fascial fibers, friction causes periostitis of calcaneus
Plantar fascia runs along bottom of foot and attaches to calcaneous
Pain over plantar surface or at insertions of fascia on calcaneous
Increased with walking or running, relief with rest
Tender to palpation over anterior calcaneus
Pain with passive dorsiflexion (strains fibers)
Rest, NSAIDs- stretch facial fibers gently
Heel and arch supports
If refractory, steroid injection- may last months without resolve
Takes time, sometimes months. Can be frustrating.
ddx of Ra
Hepatitis (abnormal liver function tests)
Lyme disease (serology, rash, anemia)
Seronegative arthropathies (human leukocyte antigen [HLA]
tests, abnormal radiographs, urethritis)
Systemic lupus erythematosus (antinuclear antibodies,
peripheral blood smear)
ddx of OA
Charcot joint (primarily foot and ankle, diabetic neuropathy)
Chondrocalcinosis (crystals in joint aspirate)
Degenerative changes secondary to inflammatory arthritis
(positive rheumatoid factor)
Epiphyseal dysplasia (short stature)
Hemochromatosis (abnormal liver function studies)
Hemophilia (bleeding tendency)
ddx of seronegative arthopathies
Achilles tendinitis or plantar fasciitis (no associated symptoms)
Degenerative disk disease (no associated symptoms, normal skin distraction on flexion of the spine)
Rheumatoid arthritis (positive rheumatoid factor, peripheral joint involvement)
ddx of fibromyalgia
AIDS (blood test)
Bursitis or tendinitis (usually single joint or extremity)
Complex regional pain syndrome (usually a single extremity)
Hypothyroidism (abnormal thyroid function tests)
Lyme disease (serology test)
Multiple sclerosis (abnormal MRI of the brain)
Polymyalgia rheumatica (elevated erythrocyte sedimentation
Polymyositis (skin rash)
Rheumatoid arthritis (positive rheumatoid factor)
Systemic lupus erythematosus (antinuclear antibodies,
elevated erythrocyte sedimentation rate)
Tenosynovitis (single focus, associated with tendon motion)
ddx for polymyalgia rheumatica (aka what you need to exclude)
Rotator cuff disorders
DJD, neck, shoulders, hips
Large Joint RA
Infection – UTI in elderly
Amyloidosis (elevated ESR)
Rarely- occult or metastatic malignancy
what disorder is polymyalgia rheumatica linked to?
giant cell arteritis
70-95% with shoulder pain
50-70% with hip involvement
Systemic sx in 1/3
Occasionally a red, hot swollen joint (somewhat related to RA somehow—need more studies to understand)
MRI shows subdeltoid and subacromial bursitis as most frequent lesions in PMR; frank synovitis less common.
Distal swelling of UE with pitting edema in 8% (extensor tenosynovitis) not tender (pseudogout is tender)
usu acute onset, not as fast as gout
MRI below shows inflammation of bursa
what blood tests are specific for lupus activity?
anti double stranded DNA and complements
which autoimmunity extractable nuclear antigens is specific for sjogens? SLE MIXED ctd? inflammatory myophaty? systemic scleroderma/
sjogens SSA and SSB, SLE anti smith MIXED ctd U1-RNP inflammatory myophaty Jo-1 systemic scleroderma Scl-70
what are the criteria req'd for SLE?
ACR Revised Classification Criteria
4 of 11 criteria required:
Photosensitivity(sun exposed places get overly burned with minimal exposure)
Serositis (pericarditis, pleuritis)
Other positive antibodies (Smith, DNA antibody, antiphospholipid antibodies, etc)
what manifestations are seen in limited scleroderma? how about diffuse scleroderma?
limited=centromere antibody, distal sclerosis, and CREST (
Calcinosis, Raynaud’s, Esophageal dysmotility(swallowing issues/strictures), Sclerodactyly (tightening of skin), Telangectasia
diffuse: SCL 70 +
Lung involvement (interstitial lung disease)
Renal (hypertensive, renal crisis)
Upper or lower GI (reflux, dysphagia, decrease peristalsis, bacterial overgrowth)
with which AI rheumatic disorder should you always check for other malignancies?
what are the dx criteria for takayasu's arteritis?
age <40, claudication of extremities, decreased brachial artery pulse, BP difference >10 mm hg between arms, bruit oversubclavian, arteriogram abnormality: occlusion or narrowing in aorta or main branches (need 3/6)
what are the classifications for polyarteritis nodosa?
weight loss >4kg, livedo reticularis, testicular pain or tenderness, myalgias/weakness/leg tenderness, mononeuropathy or poyneuropathy, mononeuropathy or polyneuropathy, diastolic BP >90, elevated BUN or creatinine, hep B, arteriographic abnormality, bx of small or medium artery containing PAN
what are the criteria for churg strauss syndrome?
asthma, eosinophilia >10% WBC, mononeuropathy or polyneuropathy, transitory pulmonary infiltrates, paransal sinus abnormality, bx with extravascular eosinophils
what are the criteria for vasculitis with polyangitis (wegener's):
nasal or oral inflammation (oral ulcers or bloody nasal drainage), abnormal chest radiographs (nodules, fixed infiltrates, cavities), urinary sediment (>5 RBc) granulomatous inflammation on biopsy
ddx for ACL tear
Fracture (tenderness over the bone, evident on radiographs)
Meniscal tear (continued tenderness along the joint line, pain
or trapping with circumduction) (may occur with ACL tear)
Patellar dislocation/subluxation (positive apprehension sign
when displacing the patella laterally)
Patellar tendon or quadriceps rupture (inability to perform
Posterior cruciate ligament tear (positive posterior drawer test,
firm end point on Lachman test)
ddx of OA of knee
Herniated L3 or L4 disk with radiculopathy (diminished knee reflex, numbness)
Meniscal tear (history of trauma and/or locking and catching) (may be concomitant)
Osteonecrosis of the femur or tibia (patient older than 50 years, female, history of steroid use, blood dyscrasia)
Pigmented villonodular synovitis (unexplained recurring hemarthrosis)
Primary hip pathology (dermatomal referred pain to the knee, limited range of hip motion)
Septic arthritis (fever, malaise, abnormal joint fluid)
Tendinitis/bursitis (tenderness directly over a tendon or bursa)
ddx of bursitis in knee
Inflammatory arthritis (multiple joint involvement, abnormal laboratory studies)
Medial meniscal tear (catching, locking, effusions)
Osgood-Schlatter syndrome (preadolescent patients)
Osteoarthritis of the knee (intra-articular effusion,
Patellar fracture (intra-articular hemarthrosis, history of
Patellar tendinitis (jumper’s knee) (tenderness at the inferior
pole of the patella)
Saphenous nerve entrapment (numbness over the medial shin,
Septic arthritis of the knee (effusion of the joint but the
patella can be palpated in its subcutaneous position, knee held
in more flexion)
Septic knee (flexion contracture, pain with knee motion, intra-
Tumor (pain, mass)