What are mechanisms for fractures?
Acute - Sudden impact of large force exceeding strength of the bone Stress - From repetitive submaximal stresses Pathologic - From normal forces to diseased bone
Fracture history (Acute vs Chronic)
Acute - Sudden Blow!
Chronic - Repetitive activity, increase in activity duration, intensity or frequency
Deformity - Bleeding +/- fragment => suspect open fracture => orthopedic emergency & needs to be surgically washed out ASAP
Bony point tenderness
Pain with loading bone - Indirect loading especially useful
Fracture indirect loading tests
Immobilization (in generals)
Avoidance of NSAIDs: Some animal studies & models show NSAIDs interfere with bony healing via PGs
Bones with "vulnerable" blood supply
Watershed - Central (tarsal) navicular
Retrograde - Scaphoid, talus, femoral head (adults)
- Radial nerve
- Cephalic vein
- Radial artery
- Scaphoid bone
Common cause: Fall on outstetched hand with impact on thenar eminence
Clinical feedings: Pain, tenderness and swelling in anatomical snuffbox
Vascular issues: Nutrient arteries only enter distal half of scaphoid, so fracture results in osteonecrosis of proimal half
Type of femoral head fractures
Type I: Impacted fracture
Type II: Nondisplaced fracture
Type III: Partially displaced
Type IV: Displaced fracture
What is the blood supply of the femoral head?
Chiefly the medial circumflex femoral artery
Fracture can result in osteonecrosis of femoral head
Artery of ligament is usually insignificant
Arthritis history & exam findings
- Stiffness - especially after rest
- Worse after prolonged used
- Joint line tenderness
- Mild swelling
- Symptoms with both passive & active motions
What is capsulitis?
What are the causes/risk factors?
What are the phases of capsulitis?
Capsular thickening: Inflammation and scarring
Can be idiopathic or post-injury, risk factors include injury, disabetes, thyroid disease
- Freeze phase: Painful early with decreasing ROM
- Frozen phase: Non-painful stable, decreased ROM
- Thawing phase: Non-painful with improving ROM
What are the exam findings for capsulitis?
Decreased ROM, gradually tightening endpoint, otherwise consistent with underlying etiology
Educate & set expectations
Maintenance of ROM
Biceps brachii rupture
Long head rupture from superglenoid of scapula, only marginally affects muscle strength
Results in the popeye sign
Can be treated with surgery (attachment onto coracoid process), but usually observation of physical therapy is sufficient
What are the key components to selecting treatment of musculotendinous ruptures?
Impact of absence of muscle
Presence of alternative muscles
Functional requirements of patient
Enthesopathy - Disorder of muscular or tendinous bony attachment
Tendinitis - Technically acute inflammation of tendon (Traumatic: Blow or pull)
Tendinosis - Chronic degenerative condition of tendon
Many injuries may be acute on chronic
What is a strain?
What are its symptoms?
Muscle fiber damage from overstretching due to eccentric loading (lengthening during fire)
Symptoms: Stiffness, bruising, swelling, soreness
What is the etiology?
What is the presentation?
Etiology - Most common fall directly onto shoulder
Presentation - Pai with overhead motions, deformity of superior shoulder
Findings on exam
- Pain and deformity at AC joint
- Pain with cross body adduction of arm
- Painful arc of abduction over 150 degrees
AC Injury Grading
Grade I - AC ligament injury
Grade II - AC ligament tear & coracoclavicular (CC) ligament stretch
Grade III - Complete AC and CC tears
What is a sprain and what are it's symtpoms?
Ligamentous damage from overloading
Symtpoms: Instability or laxity, swelling
Grade I: Microscopic damage - No increased laxity, but pain with stress on exam
Grade II: Partial tear - Increased laxity & pain on exam
Grade III: Complete tear - Significant laxity
Most common shoulder dislocation is.....
Anterior shoulder dislocation (90%)
What is the most effective passive stabilizer of the glenohumeral joint?
Joint stability terms:
Dislocation - Complete displacement
Subluxation - Transient, partial displacement
Laxity - Normal variant in joint looseness
What is the etiology of a shoulder dislocation?
What are findings on examination?
Etiology - Forced extension, abduction & external rotation of arm or direct blow to posterior shoulder
Examination - Arm held by opposite hand in slight abduction & external rotation
Alteration of shoulder contour including: Prominent acromion, humeral head anterior to acromion & adjacent to coracoid
Check sensation of axillary & musculocutaneous nerves
Positive apprehension test - feeling of instability with stress
Carpal tunnel syndrome
What are the signs?
What is the mechanism?
Symptoms: Thenar wasting (chronic) and parasthesias in 3.5 radial digts (acute)
Mechanism: Impingement of median nerve
Clavicular fracture types
Type I - Fracture with no disruption of ligaments, no displacement
Type II - Fracture with tear of CC ligament and upward displacement of medial fragment
Type III - Fracure through acromicoclavicular joint, no displacement