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Flashcards in orthopedics Deck (142):

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



growth plate



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?

articular cartilage


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

impacted fx


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

stress fx


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

osteoid osteoma


• 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

ewings sarcoma


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


lateral epicondylitis


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


NSAIDs first

+/-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

patho phys



patho phys: 

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


dx, tx

ulnar nerve entrapment


cause: chronic pressure on it or hypertrophied muscle or trauma

dx; electromyelogram

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-


Burning tenderness

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

Physical examination

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


Differential Diagnosis

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?

Differential Diagnosis

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

Differential Diagnosis

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?


boutinneiere finger

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)



dequervain's tenosynovitis


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 

Fracture of the scaphoid (tenderness over the anatomic 

Intersection syndrome 

Superficial radial neuritis 

Wrist arthritis (pain with movement, evident on radiographs) 


Autosomal-dominant condition

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.



dupuytren's contracture



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

colle's fx


volar displaced distal fragment of radius

smiths fx


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 

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

PT, chiropractic

*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”

affects joints/disc


mechanical back pain


leg pain/radicular pain

cervical =myelopathy

dx: xray


Cate’s rule of activity dosing (pre dose and after dose to avoid having to use it all the time)

ROM exercises

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

Balloon Kyphoplasty/Vertebroplasty.

Surgical stabilization


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

management: surgery


hangman's fracture




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


odontoid fractures



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



jefferson fx




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

Unstable fracture

Ranges from rigid brace, halo, surgery

Like a life saver that breaks and shatters in a bunch of directions and you get the overhang


CAUDA equina






Spinal Stenosis (Lumbar)

Inflammatory conditions



Spinal infection


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


ankylosing spondylits




seronegative spondyloarthropathy (ie -RF,-ANA)

+HLA B-27

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

Rheumatology referral



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

 CT scan


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

• Trauma

• Unexplained weight loss >10% 3-6 mos

• Bony tenderness

• Multiple myotomal loss

• Thoracic pain

• Immuno-suppressed

Saddle anesthesia

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:

- cancer

- TB or other infections

- IV drug use

- long term steroid use: can cause bone fx


- osteoporosis


Also consider:

• 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)





Spondylolysis/fracture (athlete)

Scheuerman’s Disease



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

Surgical treatment


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)

L/E radiculopathy


Full axial spine MRI

Skeletal survey

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

Avoid smoking

Limit Alcohol to 2 drinks/day


Load bearing: anything on your feet

Weight training: muscle building

Often overlooked

Balance and Coordination


what ligaments keep the foot from rotating laterally?

Anterior talo-fibular


Posterior talo-fibular


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)

Non-weight bearing

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)


calcaneous fx:






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


talar fx:






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


Intense pain


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


metatarsal fx:





Stress fractures

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

Dx: xray


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

Statin-induced myalgias


Infection – UTI in elderly

Amyloidosis (elevated ESR)

Rarely- occult or metastatic malignancy


what disorder is polymyalgia rheumatica linked to?

giant cell arteritis


what dz?

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

polymyalgia rheumatica


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:

Malar Rash

Discoid Rash     

Photosensitivity(sun exposed places get overly burned with minimal exposure)

Oral ulcers




Serositis (pericarditis, pleuritis)


Neurologic disorder

Hematologic disorder

Positive ANA

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

Distal sclerosis)

diffuse: SCL 70 + 

Raynaud’s phenomenon

Lung involvement (interstitial lung disease)

Pulmonary hypertension

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?

adult dermatomyositis


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

straight-leg raise)

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-

articular swelling)

Tumor (pain, mass)