Musculoskeletal SG – Fall 2020

1. Know fracture terminology, definitions, typical findings, and who they present in.
2. Physical exam findings associated with neurovascular injury with the various fractures
3. Sports medicine- the various injuries that you may see, presentation, and treatment.
Orthopedic Terminology
 Abduction (Varus)
o Movement going away from the body
o Think – Alien Abduction – going away from home
 Adduction (Valgum)
o Movement going toward the body
 Hands and feet
o Carpal (carpo): Refers to bones of the hands and the wrists
o Phalanges: Fingers and toes singular form of the term is “phalanx”
o Tarsal (tarso): Refers to bones of the feet or ankle
 Fractures
o Open (compound)
 There is an open wound or break in the skin near the site of the broken bone
 Higher risk and require prompt repair; more emergent
 Gustilo Classification of open fractures:
 Type I
 Open fracture with a skin wound <1cm in length and clean
 Type II
 Open fracture with a laceration >1cm in length without extensive soft tissue damage, flaps,
or avulsions
 Type III
 Open segmental fracture wound with extensive soft tissue injury
 IIIa: Adequate soft tissue coverage
 IIIb: Significant soft tissue loss with exposed bone that requires soft tissue transfer
to achieve coverage
 IIIc: Associated (Cardio) vascular injury that requires repair for limb preservation
o Closed
 bone breaks but there is no puncture or open wound in the skin (skin intact)
 Can still be an emergency based on neurovascular status at site
o Nondisplaced Fracture: The bone fragments/segments remain aligned
o Displaced fracture: The bone fragment/segments are no longer in line
o Types of fracture lines
 Transverse fracture
 a straight break right across a bone
 at a right angle to the long bone of the axis
 Oblique fracture
 a fracture that is at an angle across the bone's long axis.
 Longitudinal fracture
 Fracture occurs along the axis of the bone
 Butterfly Fracture
 When two oblique fractures meet and cause a wide, large wedge between the two proximal and
distal fracture pieces.
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  Spiral fracture
 Fracture that occurs while in motion which causes torsion and the fractures is around the bone.
 a fracture where at least one part of the bone has been twisted.
 Comminuted fracture
 A break or splinter of bone into two or more fragments
 Segmental fracture
 Composed of at least two fracture lines that come together to isolate a section of bone. Usually
diaxis fractures
 Impacted fracture
 One of the bone fragments is driven into the other fracture
 Stellate Fractures
 Where the lines of break radiate from a point of injury
 Avulsion Fracture
 Injury to the bone where a tendon or ligament attaches to the bone and causes a piece of bone to
be pulled off by the injured tendon or ligament
 Compression (crush) fracture
 generally, occurs in the spongy bone in the spine. For example, the front portion of a vertebra in
the spine may collapse due to osteoporosis.
 Pathological fracture
 when an underlying disease or condition has already weakened the bone, resulting in a fracture
(bone fracture caused by an underlying disease/condition that weakened the bone).
 Stress fracture
 more common among athletes and in lower extremities. A bone breaks because of repeated
stresses and strains (like running). Can also occur in the elderly
 Greenstick fracture
 Incomplete fracture. Bone partly fractures on one side but does not break completely because the
rest of the bone can bend. Usually seen in children.
 Torus (buckle) fracture
 bone deforms but does not crack. More common in children. It is painful but stable.
 Dislocation
 Disruption in the normal relationship of the articular surfaces of a bone making up a joint
 Mal-union: healing but not in a satisfactory position
 Non-union: not healing
 Subluxation: partial (incomplete) dislocation or out of place
 History of injury
o Mechanism (ex: did pt fall on out stretched hand)
o Localization and characteristics of symptoms
 Any dysfunction in the area
 Guarding, pain
o Past injuries or surgeries (makes injury worse)
o Concomitant injuries
o Chronic conditions
 Or medications that could have led to injury
 Bone softening (prednisone)
o Allergies
o Last meal (may need surgery)

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 Assessment:
o NV check
 Palpate distal pulses
 Check capillary refill
 Motor function and sensation testing
 2 point discrimination distal to the site (can they tell that they’re being touched in 2 separate spots at the
same time)
o Findings:
 Pain over fx site
 Deformity
 Crepitus
 Swelling and ecchymosis

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  Decreased ROM distal to the fx
 Diagnostics
o Scans
 AP and lateral films
 Always want at least 2 views (1 view = no view)
 Oblique views
 For complex fractures of the femur, humerus, or ankle
 Mortis view
 AP film with the foot internally rotated at around 10%
 Looks at the talus with ankle fxs
 Inlet and outlet views
 For pelvic fractures
 CT
 Especially for pelvis and spinal fxs
 Advanced imaging recommended when radiographic findings do not match clinical findings
 MRI
 Spinal cord injuries
 Swimmers view
 For odontoid (C2) fxs
 Dexa
 To evaluate for osteoporosis
o Labs
 Leukocytosis  Left shift
 H&H  blood loss
 UA  look for myoglobin as blood
 Electrolytes, lactate, CPK  especially potassium from cell death
 Coags  coagulopathies, OR
 Type and crossmatch
 EKG with crush injuries
 NS instead of LR in crush injuries (do not need electrolytes)
 Arteriogram for diminished or absent pulses
 Fracture Care
o Cover open wounds with Saline
 They need Sx and debridement and ABX for about 24 hrs
 Tetanus vaccine
o Early reduction is best
o Immobilization
 Splinting
 General rule of thumb is to splint the fracture where it lies
 Exception: limb is not neurovascularly intact
 Goal: Pain relief, stabilization, decrease other injuries
 Stabilize the joint both above and below the point of injury
 Do not attempt to correct any deformity until imaging  unless there is vascular compromise
 Only place cast/splints on patients to have access to follow up care in case there is an emergency
o Pain control
 Expected for weeks, beyond that could mean complications
 Increasing pain after application of a cast or splint needs urgent assessment
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  Acetaminophen, NSAIDS with narcotics

Upper Extremity Injuries

 Subacromial impingement syndrome
o Collection of diagnosis that can cause inflammation of the subacromial space
o R/T muscle strength imbalances, poor scapula control, rotator cuff tears, subacromial bursitis, and bone spurs
o Shoulder injury may present differently depending on the patient’s hand dominance.
o Baseball pitchers may complain of pain while throwing, while older adults may not complain of any pain because
of lower demand on the joint
o Presentation/Exam-
 Pain with overhead activities, nocturnal pain from sleeping on shoulder, or pain with internal rotation
 possible atrophy in the supraspinatus or infraspinatus fossa
 can have mild scapula winging or “dyskinesis.”
 rolled-forward shoulder or head-forward posture
 tenderness over the anterolateral shoulder at the edge of the greater tuberosity
 Decreased active ROM but preserved passive ROM
 Maneuvers: Neer impingement sign, Hawking’s impingement sign
o Xray:
 4 views: AP scapula, AP acromioclavicular joint, lateral scapula (Y view), and the lateral axillary scapula.
 The AP scapula view can rule out glenohumeral joint arthritis.
 The AP acromioclavicular view evaluates for inferior spurs.
 The scapula Y view evaluates the acromial shape
 axillary lateral view visualizes the glenohumeral joint as well and for the presence of os acromiale
 Will not show tendon issues but will show narrowing and space changes
o MRI: may demonstrate full- or partial-thickness tears or tendinosis.
o Ultrasound: may demonstrate thickening of the rotator cuff tendons and tendinosis.
 Tears may also be visualized; more difficult to identify partial tears from small full thickness than on MRI
o Treatment
 Education, activity modification, and PT
 Rotator cuff muscle strengthening can alleviate weakness or pain, unless the tendons are seriously
compromised, which may cause more symptoms
 Corticosteroid injections for short-term symptom relief
 arthroscopic acromioplasty with coracoacromial ligament release, bursectomy, debridement, or repair
 When to refer:
 Failure of conservative treatment over 3 months
 Young and active patients with impingement due to full-thickness rotator cuff tears
 Rotator cuff tears
o Mechanisms:
 related to falls on an outstretched arm/Hand (FOOSH) or pulling on the shoulder.
 chronic repetitive injuries with overhead movement and lifting.
 Partial rotator cuff tears are one of the most common reasons for impingement syndrome
 Most common tendon affected = Supraspinatus
o Symptoms
 Same as impingement syndrome
 Pain with overhead movement
 Night pain

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  full-thickness rotator cuff tears are more symptomatic - may be more obvious with weakness noted with
light resistance testing.
o Findings (see question 4 for description):
 Open can test (supraspinatus tendon strength)
 Resisted shoulder external rotation (infraspinatus and teres minor)
 Lift off or belly press test (subscapularis strength)
o Xrays- same as for impingement
 AP scapula – degenerative changes can appear between the acromion and greater tuberosity.
 Axillary lateral view – Superior elevation of the humeral head in relation to the center of the glenoid.
 Supraspinatus outlet view – evaluation of the shape of the acromion.
 High-grade acromial spurs are associated with a higher incidence of rotator cuff tears.
 AP acromioclavicular joint view – evaluates for the presence of acromioclavicular joint arthritis, which can
mimic rotator cuff tears. Also evaluates for spurs that can cause rotator cuff injuries
o MRI is the best method for visualizing rotator cuff tears
 Can show partial or small tears <1cm
o Treatment:
 Partial rotator cuff tears
 PT and muscle strengthening
 40% will progress to full thickness in 2 years
 Full thickness tears
 Do not heal well and tend to enlarge
 Young and active pts require sx
 Old or sedentary pts or those with atraumatic degenerative rotator cuff tears can treat with
PT unless this avenue fails
 Shoulder Dislocation
o When the bone is out of its normal location within the joint
 Subluxation = partial dislocation (wrist, spine, ect)
o Mechanism
 Anterior (Most common)
 Usually are caused by a fall on an outstretched and abducted arm, externally rotated
 Ex: blocking a basketball shot
 Rotator cuff tears occur in about half of pts over 40
 Posterior
 Usually associated with traumatic blow on the anterior portion of the shoulder, falls from a height,
seizures, or electric shocks
 Can be associated with other injuries such as a humerus fx
 Atraumatic shoulder dislocations are usually caused by intrinsic ligament laxity or repetitive microtrauma
leading to joint instability. This is often seen in swimmers, gymnasts, and pitchers as well as other
athletes involved in overhead and throwing sports
o Presentation/Exam
 Acute pain that is improved with reduction
 Pts will resist all movements
 Obvious deformity - Arm will be abducted and externally rotated while displaced
 Check pulses and axillary nerve injuries (see below)
 Test for shoulder instability include the apprehension test, the load and shift test, and the O’Brien test
(see question 4)
o Diagnosed with xray
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  AP and axillary lateral scapula (glenohumeral) views to determine the relationship of the humerus and
the glenoid and to rule out fractures
 Orthogonal views are used to identify a posterior shoulder dislocation
 For chronic injuries or symptomatic instability, these are helpful to identify bony injuries and Hill-Sachs
lesions (indented compression fractures at the posterior-superior part of the humeral head associated
with anterior shoulder dislocation)
 MRI for soft tissue injuries and rotator cuff tears
 3D CT to determine bone loss
o Treatment: Shoulder reduction
 Nerve and vascular damage can happen with dislocation and reduction
 Most commonly affected is the axillary nerve
 More common in elderly pts
 More common when traction is used on the abducted arm to relocate the joint
 Managed conservatively
 4wks post injury, EMG and nerve conduction studies are performed
 If sx is required, 3-6 months post injury to limit damage
 Tested by rubbing on the outside of the arm for sensation
 Brachial Plexus, redial, ulnar, and musculotaneous nerve injury is less common
 PT with recovery in 3-4 months
 Axillary arterial injury can occur but is rare
 More common in older pts with chronic dislocations
o Follow up care
 Immobilization
 Abducted and internally rotated in sling for 2-4weeks with pendulum exercises
 Early PT to maintain ROM
 Avoid active and risky sports
 Orthopedic surgeon within one week
 Sx is the only tx that has been shown to decrease recurrence
 Watch for recurrent dislocation
 should be managed with PT and a regular maintenance program, consisting of scapular
stabilization and postural and rotator cuff strengthening exercises
 Adhesive Capsulitis (Frozen Shoulder)
o Very painful shoulder – triggered by minimal or no trauma
o Pain out of proportion to clinical findings during the inflammatory phase.
o Stiffness during the “freezing” phase and resolution during the “thawing” phase.
o More commonly seen in women than men, patients with endocrine disorders – diabetes or thyroid, and
following breast cancer care (mastectomy).
o Presentation/Exam:
 Pain, limited ROM with both passive and active movements.
 Limitation of movement of external rotation with the elbow by the side of the trunk (See Current table
41-1)
 Strength usually normal, can appear diminished when the patient is in pain.
 Three phases:
 Inflammatory phase: 4-6 months, painful shoulder without obvious clinical findings.
 Freezing phase: 4-6 months, shoulder becomes more stiff over time but the pain is improving.
 Thawing phase: Can take up to a year. Shoulder slowly regains motion.

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  Total duration of idiopathic frozen shoulder is usually 24 months. Can be longer for pts who have trauma
or an endocrinopathy.
o Imaging:
 Standard AP, axillary, and lateral glenohumeral radiographs.
 Useful to rule out glenohumeral arthritis – can also present with limited active and passive ROM.
 Rule out calcific tendinitis – acute inflammatory process where calcifications are visible in the soft tissue.
 Adhesive capsulitis is usually a clinical diagnosis – does not need an extensive diagnostic workup.
o Treatment:
 NSAIDs and physical therapy for the “freezing” phase.
 Short-term benefit from intra-articular corticosteroid injection or oral prednisone.
 Anti-inflammatory medication is not as helpful during the “thawing” phase.
 Sx rarely indicated, but may include manipulation under anesthesia and arthroscopic release.
o When to refer:
 Not responding after more than 6 months of conservative treatment.
 No progress or worsening of range of motion over 3 months.
 Humerus Fxs
o Mechanism
 frequently occur in elderly women with a hx of osteoporosis
 Falls or FOOSH.
 Midshaft fx usually from direct trauma
o Presentation/ Exam Findings
 Proximal fxs
 Mod-sever shoulder pain with movement
 Deformity at shoulder
 Tend to hold arm abducted against the side
 Swelling, bruising, focal tenderness
 Midshaft Fx
 Severe pain midarm
 May have referred pain elsewhere
 Swelling/ecchymosis
 Possible crepitus at exam site
o NV Complications
 Proximal fx
 Distal pulses and nerve function
 Assessment is often limited to pain
 Axillary nerve
 test over deltoid region for sensation
 deltoid weakness (can be difficult with acute injury)
 Suprascapular nerve
 Super/Infraspinatus muscle weakness - Weakness with initiation of
abduction/external rotation
 Midshaft
 Arteries - Radial and ulnar, brachial artery lies in proximity to the distal humeral shaft
 Nerves - Radial (most common), median and ulnar
 Especially spiral fxs
 Test for weakness of the wrist, finger, thumb extension, elbow supination
 Wrist drop = redial nerve dysfunction

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  Test dorsum of hand at the web space between the thumb and index finger for
sensory loss

o Treatment
 Conservative treatment
esp. in elderly
 splint, sling, and swath,
or sling and swath alone,
 6-12 week healing time
 Ortho follow up 3-4
days
 Exception here is young
patients, displacement of shaft…
may need ORIF
o Complications
 Most common in proximal humerus fxs – adhesive capsulitis – frozen shoulder
 Discontinue sling w/I 2-4 weeks of injury and perform passive ROM with arm swings
 Elbow Fxs
o Mechanism
 Direct blow to elbow
 FOOSH with hyperextension of the elbow
 High risk for injury to medial, ulnar, and radial nerves as well as brachial artery injury
o Presentation/Exam Findings
 Holding arm in flexion with swelling (mod amount) and pain
 Inability to flex = increased risk for fracture
o NV
 Ulnar nerve
 Sensation on the palmar surface of the 5th digit
 Motor fxn of interossi muscles of the hand
 Palm flat on table, hold paper between 2nd and 3rd digit then try to pull paper away
 brachial nerve injuries w/ severe fxs = pain on finger extension
o X-rays  Always look for the presence of fat pads. A small anterior fat pad can sometimes be normal; however,
the presence of a posterior fat pad is abnormal and should alert the clinician to a fracture
 Olecranon fractures
o Mechanism
 Direct blow or fall
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  less commonly by contraction of the triceps while the elbow is flexed
o Presentation/Exam
 Pain, limited range of motion, a palpable defect, or crepitus
 inability to extend the elbow against force
o Dx with plain xray
o Tx
 long arm posterior splint with the elbow at 90 that includes the fingers to prevent wrist flexion and sling
 Ortho follow up
 Ulnar nerve injury or displaced fx >2mm = acute ortho consult
 Radial Head Fxs
o Mechanism
 FOOSH (more common) or direct trauma
 More force = more injury
 More risk for comminuted dislocations depending on the amount of force
 Can have concomitant soft tissue injuries
o Presentation/Exam
 Usually will present w/i 48hrs of injury
 Pain on supination or pronation, and with limited ROM
 Joint tenderness over the radial head
 Elbow extension may be limited by joint effusion
o Diagnosis
 X-ray
 the presence of a fat pad (especially posterior) should raise suspicion for an occult fracture
o Treatment
 Simple radial head fractures  tx conservatively with analgesics and a immobilization with simple sling
and ortho follow up
 Ortho consult for comminuted radial head fxs
 Elbow Dislocation
o Generally, the radius and ulna are displaced together and the dislocation is described as the relationship of the
ulna to the humerus, such as posterior (which is most common), anterior, medial, or lateral
o 2nd most commonly dislocated major joint
o Mechanism
 Fall
 Frequently associated fractures
 Nursemaid’s elbow (common in children)
 Radial head subluxation
 Radial, ulnar, humeral joint  Which happens usually due to FOOSH
 Radial head dislocation
o S/S
 The patient often holds the elbow in 45° of flexion
 deformity at the olecranon is usually visible
o NV
 Brachial artery and median nerve at risk
o Diagnosis
 Plain films
 Look for associated fxs
o Treatment
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  If neurovascular compromise is present, reduction ASAP
 Reduction of posterior elbow dislocation by applying manual traction on the forearm while an assistant
stabilizes the humerus. If radial or lateral displacement is present, it must be corrected before reduction
is completed by flexion of the elbow
 long arm splint with the elbow in flexion and sling
 Pain control and ortho follow up and education on signs of vascular impairment
 Lateral and Medial Epicondylosis
o Mechanism
 Tendinopathy
 chronic repetitive overuse causing microtrauma
 Acute injury if tendon is strained due to excessive loading
 Lateral
 involves the wrist extensors, especially the extensor carpi radialis brevis.
 This is usually caused be lifting with the wrist and the elbow extended
 Medial
 involves the wrist flexors and most commonly the pronator teres tendon
o Presentation/Exam
 Lateral (more common)
 Lateral elbow pain
 pain with the arm and wrist extended, Ex shaking hands, lifting objects, using a computer mouse,
hitting a backhand in tennis (“tennis elbow”)
 Medial
 Medial elbow pain
 pain during motions in which the arm is repetitively pronated or the wrist is flexed AKA “golfer’s
elbow”
 For either, tenderness directly over the epicondyle is present
o Imaging
 Often normal (Small spur in chronic cases)
 Diagnostic investigations are usually unnecessary, unless the patient does not improve after up to 3
months of conservative treatment
 MRI or US for tendinosis or tears
o Treatment
 Conservative
 Activity modifications and Ice/NSAIDS
 Good stretching followed by strengthening exercises
 PT
 Severe  Steroid injections, Platelet-rich-plasma (PRP) injections
o When to refer
 Not responding to 6 months of conservative tx  injection procedure (PRP or tenotomy), sx
debridement, or repair of the tendon
 Severe pain or dysfunction
 Bursitis
o Mechanism
 Inflammation of bursae—the synovium-like cellular membranes overlying bony prominences - where
friction occurs
 trauma, infection, or arthritic conditions such as gout, RA, or OA
 Most common sites: Olecranon & Prepatellar
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 o Presentation/Exam
 focal tenderness and swelling
 Does not affect ROM
 More common in septic bursitis: Tenderness, erythema and warmth, cellulitis, a report of trauma, and
evidence of a skin lesion
 Septic bursitis can be afebrile
o Image
 unnecessary unless there is concern for osteomyelitis, trauma, or other underlying pathology.
 Rule out DVT which can be mimicked by ruptured baker cyst
o Treatment
 Aspiration if the patient is either febrile or has prebursal warmth
 WBC > 1000 indicates inflammation from infection, rheumatoid arthritis, or gout
 Chronic stable bursitis does not need aspiration
 Septic Bursitis Fluid characteristics:
 Purulent drainage
 fluid-to-serum glucose ratio less than 50%
 WBC > 3000 with PMNs>50% positive
 +gram stain
 S. Aureus most common
 Rest, heat, NSAIDs, Steroid injections, ABX for septic joint
 Elbow pads to protect from trauma
 Sx only for repeated infections
 Forearm fractures
o Mechanism
 Direct Blow or FOOSH
o Presentation/Exam
 Proximal
 Swelling and inability to flex or extend the elbow
 Midshaft
 Some swelling or tenderness on pronation and supination
 Distal
 Deformity around the wrist with the inability to flex or extend the wrist
 Assess redial, medial, and ulnar nerves and check distal pulses
o Treatment
 Nondisplaced fxs tx conservatively with:
 sugar-tong (U-shaped)
 Ulnar shaft fx ulnar gutter splint
 Radius shaft fx  thumb spica splint
 orthopedic follow-up
 Displaced fxs need ortho consult for open/closed reduction
 Hand and Wrist Injuries
o Assessment
 Dominant hand, Occupation, Mechanism of injury, Time since injury, Place of injury
o Hand injuries = high risk medically/legally
 Carpal Tunnel syndrome
o Mechanism
 Entrapment neuropathy
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  compression of the median nerve between the carpal ligament and other structures within the
carpal tunnel
 fluid retention of pregnancy, history of repetitive use of the hands, or following injuries of the wrists
 RA and other rheumatic disorders (inflammatory tenosynovitis), myxedema, amyloidosis, sarcoidosis,
leukemia, acromegaly, and hyperparathyroidism
o Presentation/Exam
 pain, burning, and tingling in the distribution of the median nerve (the palmar surfaces of the thumb, the
index and long fingers, and the radial half of the ring finger)
 Most bothersome during sleep (at first)
 Worse with manual activity and extremes of volar (the palm) flexion or dorsi flexion
 may radiate into the forearm and occasionally shoulder and over the neck and chest
o (Electromyography) EMG testing
 Standard for diagnosis
o Screening test (See #4 for description)
 Tinel’s Sign (least sensitive)
 Phalen Sign (more sensitive)
 Carpel Compression test (Most sensitive)
o Treatment
 Trial of Neutral position wrist splinting, NSAIDS
 May require carpal tunnel release sx if EMG testing is positive
o When to refer
 For EMG testing when symptoms are persistent
 Failing consertative treatment
 Urgent referral If thenar muscle (eg, abductor pollicis brevis) weakness or atrophy develops
 Lunate and peri-lunate dislocations
o Mechanism
 FOOSH
o S/S
 Wrist swelling, pain and tenderness
o Imaging
 AP lateral for diagnosis
o Treatment
 Watch for median nerve injury
 Splinting and pain control with ortho referral
 Carpal Bone Fractures
o Often missed
o Mechanism of injury
 FOOSH
o Presentation
 Wrist/hand swelling + decreased mobility and pain
 Check NV status
o Imaging
 Snuff box tenderness  obtain scaphoid views
 Splint and treat like fx even if xray is clear
 AP views
 Consider CT and follow up xrays in 1-2 weeks  Some fxs will not show up until there is remineralization
of the bone
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 o Treatment
 Even if you don’t see a fx on xray, you should treat as a fx if there is a high clinical suspicion due to risk of
long-term complications such as avascular necrosis (common in scaphoid or lunate fxs)
 Scaphoid fx = Thumb spica splint
 Other fxs = volar wrist splint
 Displaced fx = Sugar tong splint (prevent wrist movement)
 Metacarpal fractures
o Mechanism
 Boxers Fx (most common)
 Fx through the neck of the 5th finger usually due to direct trauma
o Presentation
 Dorsal surface pain, tenderness to affected area
 Assess to rotational injury  open and close the fist
 NV injury is rare but assess for sensation, abduction/adduction, cap refill
 Phanlyx fx
 Finger pain, deformity, limited ROM
 Digital block before manipulation and reduction
 Splint with aluminum finger splint
o X-ray
 diagnosed
o Treatment with splint
 2nd-4th finger injuries = Volar splint
 5th finger injury = ulnar gutter splint
 Bennett fx (intra-articular fracture at the base of the first metacarpal that extends into the joint)
 Thumb spica splint and ortho follow up (most likely will need sx)
 Dupuytren Contracture
o Mechanism
 Benign fibrosis of the palmar fascia
 Can lead to limited hand function
o Presentation
 Tightness in the digit
 Inability to extend the finger
 Nodular or cord like thickness in the hand at the 4th or 5th digit
o Treatment
 Can inject transalone or collagenase into the nodules
 Refer when one or more digits are affected or when contractures interfere with activity

Lower Extremity Injuries

 Hip Fractures
o described anatomically, may occur through the femoral neck, intertrochanteric, or subtrochanteric locations
o Groin pain. Shortening of the affected leg, with abduction and external rotation, is common but may not be
obvious in cases of nondisplaced fractures
o Femoral neck fractures
 Mechanism
 Old pts
 More frequent in elderly who fall directly onto their hip
 Can happen from twisting while the foot is planted
Page 14 of 39
  Sudden fatigue or stress fractures which then causes a fall
 Young pts
 Trauma – MVAs
 Presentation/ Exam findings
 Sudden onset of pain with inability to walk
 Tho some can walk
 Displaced
 Groin pain with shortening and external rotation of the limb
 Little ecchymosis due to the capsular nature of the injury
 Large amts of blood can be lost without actually seeing the loss
 Diagnosis
 AP and lateral views
 If you do not see a fx but have a high clinical suspicion, obtain CT or MRI
 If CT is normal, may proceed to MRI if necessary
o Intertrochanteric fractures
 Mechanism
 Old (fall); young (major trauma)
 Presentation/Exam findings
 Hip pain (esp. in elderly)
 Swelling
 Lots of bruising because this is an extracapsular break
 External rotation and shortening if is displaced
 Tenderness over trochanter area
 High association with other injuries
 Important to ask “why did pt fall”
 Diagnosis
 AP and lateral
 Consider CT/MRI if high clinical suspicion outweighs your findings
o Trochanteric Fractures
 Usually avulsion fxs due to a muscle contraction in the greater and lesser trochanter
 Mechanism
 Old
 Usually from falls but consider pathologic fxs R/T cancer
 Presentation/ Exam findings
 Groin pain
 Knee or posterior thigh pain that is worse with flexion
 Diagnosis
 AP and Lateral xrays
o Treatment
 Sx within 1st 24hrs
 Increased risk for complications: PMN, DVTs, pressure ulcers
 Femoral neck fractures
 ORIF or arthroplasty or pinning
 If displaced: will need hip replacement with arthroplasty
 If not displaced: pinned
 Non-operative management if severely debilitated or hospice
 Prolonged bed rest 6-12 weeks (will usually have complications and die)

Page 15 of 39
  Intertrochanteric fractures
 Ambulatory pts needs sx
 Non-ambulatory pts needs pain control and nonoperative management
 In practice, most will get sx
 Trochanteric fractures
 Most do well non-op unless displaced
o Prevention
 Bone density screening
 Identify osteoporosis and osteopenia and treat (outpatient)
o Hip Testing (See question 4)
 Tredelenberg test to assess for weakness or instability
 Hop or jump test
 Internal rotation
 Femoral Shaft Fractures
o Mechanism
 High energy trauma
 Fx with minimal trauma – possibility of pathologic fx
 Associated with other innuries
o Presentation/ Exam findings
 3 L of blood can be lost in the thigh
 tenderness and deformity of the thigh
 NV status – ACS
 Assess for soft tissue swelling and perform serial exams
o Diagnosis
 AP and lateral views with visualization of knee and hip as associated fxs are common
o Treatment
 Pain control
 Fluid resuscitation if necessary
 Traction (external or skeletal) to decrease muscle
spasms
 Ortho Consult for ORIF, IM rod
o Distal Femur Fxs
 Same as femoral shaft except associated with patella
and hip injuries with hemarthrosis common
 Traction or knee immobilization with ORIF or IM nailing
 Osteonecrosis of bone
o Mechanism
 Trauma
 Non-traumatic: steroids, ETOH, decompression disease,
Sickle cell, Lupus, and prior trauma
o Presentation
 Groin pain
 Thigh and buttock pain
 Femoral head pain
 Some pts may be asymptomatic
o Exam findings
 Non-specific
Page 16 of 39
  Decreased ROM
o Diagnosis
 Clinical
 MRI is gold standard
o Treatment
 Surgical depending on the stage of necrosis
 Patella injuries
o Patella fractures
 Mechanism
 Falls and indirect forces
 Most common, transverse fracture, and can be caused by a direct blow or a powerful contractile
force from the quadriceps.
 Presentation / Exam findings
 Tenderness over patella
 Joint effusion
 Patella displacement
 Defect may be palpable
 Diagnosis
 Plain radiographs including anteroposterior, lateral, and sunrise views
 CT scanning or MRI may be necessary to identify occult injuries
 Bipartite or multipartite patellae are congenital findings that may be confused with acute fracture
 Treatment
 Ortho consult
 Simple fx – immobilization
 Complex or displaces - Sx
o Patella dislocations
 Mechanism
 direct forces or a hyperflexion injury, and it almost always displaces laterally
 Presentation/Exam
 Tenderness
 Deformity
 May or may not have Joint Effusion
 Tested with the Ballottement Test
 Bulge Sign
 Xray findings  Plain radiograph for dx
 Treatment
 Closed Reduction
 Immobilization, crutches, ortho referral
 Recurrent subluxations/dislocations my need sx
 Cruciate ligament injury
o Anterior
 Pop with buckling, swelling, instability with lateral movements and down stairs
 Anterior drawer and Pivot test
 MRI is best for Dx
 If young and active, will need sx
 Old and sedentary will need PT
 Ortho consult
Page 17 of 39
  Instability in an injury older than 6months should be refered
o Collateral
 Valgus or varus blow, pain and instability on affected area with limited ROM
 Valgus/varus test
 Isolated MCL injuries do not need MRI
 Posterior or LCL need MRI
 Protected weight bearing and PT
 Ortho referal
o Posterior
 Trauma of the anterior tibia, knee may be freely dislocated
 1/3 NV compromise!
 Difficulty with ambulation
 Multi ligament injuries
 Sag sign and posterior drawer test
 MRI needed
 Immobilize knee with urgent ortho follow up
 Meniscus Injuries
o Mechanism
 Not always associated with actual injury
o Presentation/Exam
 Antalgic gate or difficulty squatting
 Difficulty with extension
 MRI – risk for internal derangement
 Complaints of catching or locking
 Swelling, Effusions, tenderness
 McMurray
o Imaging
 MRI best for dx
o Treatment
 Initially: NSAIDS, Ice, Elevation
 Repair especially in younger pts
 Conservative treatment in degenerative tears in older pts
 PT
 Urgent referral for inability to extend the knee
 Patellofemoral pain
o Mechanism
 Starts after trauma or a repetitive activity
 Runners knee
o Presentation
 Pain in the anterior knee with bending and moving that is less so in full extension
 Pain right under the knee cap
o Physical exam
 Palpate patella surfaces looking for abnormal/excessive movement beyond a quarter of the knee cap
o Diagnostics
 Most useful in older patients to assess for OA or those failing conservative treatment
o Treatment
 Rest, Ice, NSAIDS
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  If they have hypermobility, may need PT for quad strengthening
 Knee exam
o Lachman
o Anterior drawer test
o Pivot shift
o Valgus stress
o Varus stress
o Posterior drawer test
o McMurray
 Knee dislocation
o Mechanism
 high or low velocity
o Presentation/ Exam findings
 Hemarthrosis, ecchymosis
 Pain often limits exam
 May see a dimple sign with a posterior lateral dislocation
 These cannot be manually reduced
 Associated with injuries to ligaments and meniscus
 Assume dislocation with gross instability of the knee (hyperextension >30 when lifted by the heel)
o Treatment
 Many spontaneously self-correct
 Conscious sedation and reduction
 Ortho consult, maybe vascular surgery
 Distal pulses after reduction
 Any questions with pulses – arteriography
 Immobilized after relocation with 15-20 of flexion
 Xrays to confirm reduction
 If no arteriography, admit with serial NV checks
 Tibial Plateau Fracture
o Mechanism
 Axial loading and varus/valgus forces
 Lateral is most common
 High risk for other ligament injuries
 Risk for popliteal and perineal nerve injury
o Presentation/Exam
 Pain and tenderness
 Hemarthrosis/effusion
o Diagnosis
 AP and lateral xrays
 CT/MRI to delineate extent of injury
 Arteriogram if vascular injury is suspected
o Treatment
 Immobilize the knee
 Non-weight bearing
 Ortho consult
 Tibia/fibula fxs are high risk for ACS
 Tibial Shaft Fractures (highest risk for ACS)
Page 19 of 39
 o Mechanism
 Low energy, high energy rotational
 Most common long bone fx
 Occur with fibula involvement
o Presentation/Exam
 Swelling, pain, and inability to bear weight
 AP and lateral with view of joint above and below
o Treatment
 Nondisplaced – long leg posterior splint with ortho follow up
 Displaced/open/comminuted – urgent sx
 Monitoring with access to care 24hrs a day in case they need to have splint/device removed for ACS
 Isolated Fibula fxs
o Usually associated with tibia fxs
o Presentation/Exam
 Pain and tenderness
 Palpable deformity
 Not a weight bearing bone so pt can generally ambulate
 Proximal fibula Perineal nerve injury possible
 Look for foot drop
o Diagnosis
 Xrays
o Treatment
 Splints or compressive dressings for comfort
 Maisonneuve fracture – considered an unstable
ankle fracture
 Ankle Joint Injuries
o Lateral Malleolar Fractures
 Mechanism
 Inversion injury
 Range from Avulsion fx – disolaced fxs
 Presentation/exam findings
 Point tenderness, swelling, difficulty
ambulating
 Xrays for Dx
 Treatment
 Simple fxs – posterior leg splint with stirrup,
crutches, non-weightbearing, ortho follow-
up
 Open fx – ortho consult
o Medial Malleolar Fractures
 Mechanism
 Eversion injury
 Often associated with deltoid ligament
injury
 Presentation/exam findings
 Pain, swelling, difficulty ambulating

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  Palpate proximal fibula to check for Maisonneuve fx
 Treatment
 Similar to lateral malleolar with longer rehab with deltoid ligament injury
o Inversion ankle sprains
 Mechanism
 Inversion of the plantar flexed foot
 Most common out patient sports injury
 Presentation/Exam
 Pain and swelling of the lateral ankle with limping
 Difficulty bearing weight
 Perceived instability of the ankle
 Ecchymosis or swelling over the lateral aspect of the ankle
 Testing
 Anterior drawer
 Subtalar tilt test
 Xray
 OTTAWA rule
 Treatment
 MICE
 Early motion is essential
 Refer to PT
 NEVER apply plaster case due to the risk of swelling
 Air cast commonly used
 Ortho referral for associated fxs or recurrent sprains or fail to improve with 3 months of
conservative therapy
o Eversion ankle sprains
 Mechanism
 Anterior tibial/fibula ligament most common
 Foot often turned out and inverted (ex. Tackled)
 Presentation/Exam
 Severe prolonged pain of the anterior ankle and the anterior tibial/fibula ligament
 Worse with weight bearing
 Palpate the proximal fibula to rule out Maisonneuve fx
 Often have limited ROM
 Diagnostics
 AP, Mortis, Lateral views
 Treatment
 Cast or walking boot for 4-6 weeks
 Protected weight bearing until pain free
 PT early to regain ROM and strength
 Urgent Referral for widening of the joint space and asymmetry of the joint (may need sx)
 Achilles tendon injuries
o Mechanism:
 Middle aged and older adults participating in sports
o Presentation/exam
 Report feeling/hearing a “pop”
 Localized weakness in plantar flexion and weakness

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 o Clinical dx
 MRI to dx
o Treatment
 Temporary long leg or stirrup splint with consultation
 Calcaneal fractures
o Mechanism
 Axial loading with associated vertebral fx from fall or jump from a height
o Presentation/PE
 Severe pain, inability to bear weight +/- deformity
o Diagnostics
 AP, Lateral, axial views
 Boehler’s angle can help
 Because calcaneal fracture lines are often subtle
to visualize on foot radiographs, Boehler's Angle is
used to determine if the normal anatomic
relationships of the calcaneal bony prominences
have been disrupted. The normal angle is 28–40°
and with fracture from an axial load, the angle is
reduced to less than 20
o Treatment
 Posterior leg splint, crutches, non-weight bearing
 Ortho consults to determine operative or not
 Intraarticular, Comminuted, displaced = urgent referral
 Talar fractures
o Mechanism
 No muscle attachment and a tenuous blood supply – potential for avascular necrosis
 Risk for infection, Arthritis, Problems healing
 Plantar or dorsiflexion forces
 Inversion forces
 High energy trauma with associated injuries
o Presentation/Exam
 Pain, swelling
o Diagnostics
 X-rays (AP, mortis, lateral) but often need CT/MRI due to subtle fxs
o Treatment
 Splinting and non-weight bearing for simple fx
 ORIF for major fxs and prolonged immobilization
 Tarsal injuries
o Metatarsal Fractures
 Mechanism
 Crush or twisting
 Base of 5th metatarsal most common
 Presentation/exam
 Visible deformity with pain, swelling, and tenderness
 Diagnostics
 xrays
 Treatment
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  Avulsion fx of the tuberosity of the proximal 5th metatarsal can be splinted or pt use a hard-sole
shoe
 Immobilize fx of the metaphysis of the proximal 5th metatarsal – high risk of complication
 Referred to ortho
o Phalangeal injuries
 Mechanism
 5th phalanx fx
 Presentation/exam
 Pain, swelling, deformity
 Diagnostics
 xray
 Treatment
 Buddy tape
 If needed, digital nerve block and reduction
 Simple fx = no follow up; complicated fx or dislocation = ortho referral
o Sesamoid injuries
 Mechanism
 Hyperextension of the great tow
 Presentation
 Localized pain
 Diagnosis
 Often unexpected finding
 Treatment
 Immobilization
 Weight bearing as tolerated
 No follow up needed

4. Know the tests that can be performed in MSK testing in relation to injury and what the test may tell
you. (anterior drawer, McMurry, pivot, Trendelenburg, Ballottment) to name a few).

 Open Can Test (supraspinatus tendon strength)

o Perform resisted shoulder abduction at 90 degrees with slight
forward flexion to around 45 degrees to test for supraspinatus
tendon strength (“open can” test), or with shoulder abduction at
30 degrees and flexion to 30 degrees (“empty can” test).
o Hold arms out in front and tip them over as if they were
emptying a can then rotate out 45 and apply downward
resistance

Page 23 of 39
  Weakness = concern about supraspinatus tendon strength

 Resisted shoulder external rotation (infraspinatus and teres minor)

o The patient resists by externally rotating the arms with elbows at his or her side

 Lift off or belly press test (subscapularis strength)

o A positive “lift-off” test is the inability of the patient to hold his or her
hand away from the body when reaching toward the small of the
back. The clinician pushes the patient’s hand toward the back while
the patient resists. A positive lift-off indicates subscapularis tendon
insufficiency
o A positive “belly-press” test is the inability to hold the elbow in
front of the trunk while pressing down with the hand on the
belly. A positive belly-press test indicates subscapularis tendon
insufficiency

 Neer Impingement Sign

o Perform by having the clinician flex the shoulder maximally in an
overhead position. The test is positive when pain is reproduced
with full passive shoulder flexion.

 Hawkins Impingement Sign

o Perform with the shoulder forward flexed 90 degrees and the elbow
flexed at 90 degrees. The shoulder is then maximally internally rotated to
impinge the greater tuberosity on the undersurface of the acromion. The
test is considered positive when the patient’s pain is reproduced by this
maneuver

Page 24 of 39
 Apprehension Test
o With persistent anterior instability or a recent dislocation, the
patient feels pain or guards when the shoulder is abducted and
externally rotated at 90 degrees. With posterior instability, the
patient is apprehensive with the shoulder forward flexed and
internally rotated to 90 degrees with a posteriorly directed force.

 Load and Shift Test

o Perform to determine shoulder instability by manually translating
the humeral head anteriorly and posteriorly in relation to the
glenoid. However, this test can be difficult to perform when the
patient is not relaxed.

 O’Brien Test
o Performed to rule out labral cartilage tears that often occur
following a shoulder subluxation or dislocation. The test involves
flexing the patient’s arm to 90 degrees, fully internally rotating the
arm so the thumb is facing down (palm down), and adducting the arm to 10
degrees. Once positioned properly, the clinician applies downward force
and asks the patient to resist. The test is then repeated in the same position
except that the patient has his arm fully supinated (palm up). A positive
O’Brien test for labral tear is pain deep in the shoulder with palm down
more than the palm up. The O’Brien test can also be used to identify AC
joint pathology. The patient would typically complain equally of pain directly
over the AC joint with the palm down or up

 Tinel Sign
o Tingling or shock-like pain on volar wrist percussion.
The carpal compression test, in which numbness
and tingling are induced by the direct application of
pressure over the carpal tunnel, may be more
sensitive and specific than the Tinel and Phalen
tests.
 Phalen Sign (more sensitive)
o Pain or paresthesia in the distribution of the median
nerve when the patient flexes both wrists to 90
degrees for 60 seconds.

Page 25 of 39
 Carpel Compression Test
o Performed by applying direct application of pressure over the carpal tunnel

 Lachman test – ACL

o Performed with the patient lying supine, and the knee flexed
to 20-30 degrees. The examiner grasps the distal femur from
the lateral side, and the proximal tibia with the other hand
on the medial side. With the knee in a neutral position,
stabilize the femur, and pull the tibia anteriorly using a
similar force to lifting a 10-15-pound weight. Excessive
anterior translation of the tibia compared with the other
side indicates injury to the anterior cruciate ligament.
o Attempt to pull the tibia forward relative to the femur while
the knee is slightly flexed. Any increase in laxity compared
with the uninjured knee signifies injury

 Drawer Sign (Anterior = ACL) (Posterior = PCL)

o Performed with the patient lying supine and the knee flexed to 90
degrees. The clinician stabilizes the patient’s foot by sitting on it
and grasps the proximal tibia with both hands around the calf and
pulls anteriorly. A positive test finds anterior cruciate ligament
laxity compared with the unaffected side.
o Rupture of the posterior cruciate ligament is a likely diagnosis
when the tibia of the injured knee sags posteriorly below the distal
femur when the legs are held flexed 90° at the hip and knee

 Valgus stress – MCL

o Performed with the patient supine. The clinician should stand on the outside of
the patient’s knee. With one hand, the clinician should hold the ankle while the
other hand is supporting the leg at the level of the knee joint. A valgus stress is
applied at the ankle to determine pain and laxity of the medial collateral
ligament. The test should be performed at both 30 degrees and at 0 degrees of
knee extension.
 Varus Stress – LCL
o The patient is again placed in supine. For the right knee, the clinician should be
standing on the right side of the patient. The left hand of the examiner should
be holding the ankle while the right hand is supporting the lateral thigh. A Varus
stress is applied at the ankle to determine pain and laxity of the lateral
collateral ligament. The test should be performed at both 30 degrees and at
degrees of knee flexion

Page 26 of 39
 o Varus and valgus stress tests for rupture of the medial and lateral collateral ligaments of the knee. More laxity
than in the uninjured knee or lack of a firm endpoint constitutes a positive test. Pain and muscle guarding may
make interpretation difficult.

 Thessaly test – Meniscus

o Performed with the patient standing on one leg with knee slightly
flexed. The patient is asked to twist the knee while
standing on one leg. Pain can be elicited during twisting
motion.

 Pivot test - ACL, LCL, posterolateral capsule, arcuate complex

o Used to determine the amount of rotational laxity of the knee. The patient
is examined while lying supine with the knee in full extension. It is then
slowly flexed while applying internal rotation and a valgus stress. The
clinician feels for a subluxation at 20–40 degrees of knee flexion. The
patient must remain very relaxed to have a positive test.

 Trendelenburg test – weakness of hip abductors

o The patient balances first on one leg, raising the non-standing knee toward
the chest. The clinician can stand behind the patient and observe for
dropping of the pelvis and buttock on the non-stance side primarily the Gluteus Medius

 Hop or Jump test –

o asking the patient to hop or jump during the examination. If the patient has a
compatible clinical history of pain and is unable or unwilling to hop, then a
stress fracture should be ruled out. The back should be carefully examined in
patients with hip complaints, including examining for signs of sciatica

 Internal Rotation – most sensitive test to identify intraarticular hip pathology

 Ballottement test – knee or wrist effusion

Page 27 of 39
 o apply downward pressure towards the foot with one hand, while pushing the patella backwards against the
femur with one finger of the opposite hand. A "milking" motion is used
with the downward pressure. If a bogginess around the joint occurs,
then the test is positive for ballottement.

 McMurray Test
o Performed with the patient lying supine. The clinician flexes the knee
until the patient reports pain. For this test to be valid, it must be flexed
pain-free beyond 90 degrees. The clinician externally rotates the
patient’s foot and the extends the knee while palpating the medial
knee for a “click” in the medial compartment of the knee or pain
reproducing pain from a meniscus injury. To test the lateral meniscus,
the same maneuver is repeated while rotating the foot internally

 Modified McMurray Test

o Performed with the hip flexed to 90 degrees. The knee is then flexed
maximally with internal or external rotation of the lower leg. The knee
can then be rotated with the lower leg in internal or external rotation
to capture the torn meniscus underneath the condyles. A positive test
is pain over the joint line while the knee is being flexed and internally
or externally rotated.

5. Characteristics, physical exam findings, and treatment options

for OA, RA, and gout.
6. Risk factors for the various diseases including OA, RA, gout, osteoporosis.

Osteoarthritis (OA)
 What is it?
o a degenerative disorder with minimal articular inflammation: degeneration of cartilage and hypertrophy of the
bone at the articular margins
o Disease of AGING
o NO systemic symptoms
o Pain relieved by rest
 Morning stiffness may be seen but it is BRIEF
 Risk Factors:
o Obesity increasing changes of knee arthritis
o Gender (women>men)
o Competitive sports increase risk
 Patient Presentation:
o Insidious onset
o Joint stiffness
o HALLMARK: Worse by activity and better with rest
o Symptoms worsen with age
 Exam Findings:
o Small, proximal & distal joints
o OA spares the wrist & metacarpophalangeal joints
o RA involves wrist and spares the distal phalangeal joints
o Asymmetrical pattern
Page 28 of 39
 o Flexion
o Contractures
o Crepitus common @ knee
o Burris bow legged deformity (knee)
o Heberden Nodes
 Swelling of the distal interphalangeal joint
o Bouchard Nodes
 Swelling of the proximal interphalangeal joint
 Laboratory Results:
o Negative ESR
o Arthrocentesis: normal
 Imaging:
o 90% of people of evidence of OA by age 40 in weight bearing joints
o Osteophyte formation
o Narrowing of the joint spaces
 Primary
 Distal and proximal interphalangeal joints
 Carpo/metacarpal joint of the thumb
 Hip/knee
 Metatarsal phalangeal joint of the big toe
 Cervical & lumbar spine
 Secondary
 Any joint of articular injury which results from intraarticular causes (RA) or extraarticular causes
(fractures, metabolic disease)
 Prevention:
o Weight loss
o Vitamin D
 Treatment:
o Exercise o Topical Capsaison
o Weight loss o Intra-articular joint injections
o Acetaminophen (not 1st line) o Surgical Option
o NSAIDS (more effective but greater risks)

Gout
 What is it?
o Uric Acid deposits
o Acute, monoarticular arthritis
o 1st MTP often
o Polyarticular involvement in longstanding disease
o Urate crystals in joint fluid is diagnostic
o Chronic Gout leads to joint damage
o Often spares hips/knees
 Risk Factors:
o Men over 30
o Post-menopausal women
o Diseases

 Plasma cell myeloma  Hemoglobinopathies

 CKD  Hypothyroid
 Psoriasis  Sarcoidosis
Page 29 of 39
 Alcoholism
o Medications:
 Diuretics
 ASA
 Cyclosporine
 Niacin
 Patient Presentation:
o Podagra
 Exam Findings:
o Acute Phase:
 HOT
 Tender
 Red
 Systemic fever
o Recovery Phase:
 Pruritis
 Laboratory Results:
o Uric Acid Level
o Leukocytosis
o Sodium Urate Crystal on Arthrocentesis
 Calcium Pyrophosphage
 Imaging
o Early Disease: no change
o Later Disease: punched out erosion with overhanging rim of cortical bone called “rat bite”
 Differential Diagnosis:
o Pseudogout
o Cellulitis
o Bacterial Infection
 Treatment:
o NSAIDS, Colchicine, Corticosteroids
o Medication changes, diet
o Colchicine Prophylaxis
o Reduction of Serum Uric Acid
Pseudogout
 What is It?
o Acute rarely chronic
o Looks like Gout except that you find calcium pyrophosphate crystals on arthrocentesis
o Affects knees and wrist the most
 Who?
o 60 or older
 Treatment:
o NSAIDS
o Colchicine

Rheumatoid Arthritis (RA)

 What is it?
o Insidious onset with morning stiffness and pain
o Symmetric polyarthritis that tends to affect SMALL JOINTS
o RF and anti-ccp are present in 70-80% of all cases
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 o Multiple extra-articular manifestations
 Who?
o Women more than men (3:1)
o Any age can be affected
o Women peaks 40-50
o Men peaks 60-80
 What?
o Polyarthritis that usually affects small joints
 Differential Diagnosis:
o OA
o Pseudogout
o Gout
o Spondyloarthropathies
o Chronic Lyme
o Acute Viral Infections
 Presentation:
o Prolonged AM stiffness
o Pip of the fingers, MCP joints, wrists knees,
Rheumatoid Nodules
ankles, and MTP are most involved

 Laboratory Findings:
o Antii-ccp and Rheumatoid factor
o ANA
o ESR
o CRP
o Anemia
o Septic Arthritis
 Imaging:
o Most specific regarding testing for RA
o 1st 6months: normal
o Later: joint narrowing and erosions develop
 Treatments:
o Corticosteroids
o DMARDS:
 Methotrexate
 Sulfasalazine
 Leflunomide
 Antimalarials
 Tofacitinib
 Biologic DMARDS

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  TNF inhibitors

7. Testing and indications for spinal disease

 C5 – T1
o Test radial power for strength extension and sensation in the webspace between the index finger and thumb
 C8 – T1
o Innervates the ulnar area
 Abduction of the small finger and check sensation of the tip of the small finger
 C5 – T1
o Innervates the Median nerve
 Check the thumb, index finger and half of the ring finger
 OK sign
 Low Back Pain: pain in the lower back causing discomfort, limiting range of motion, neurological symptoms
o Causes: strain, obesity, trauma, twisting, bending, lifting, Herniated lumbar disk, Spondylolysis,
Spondylolisthesis, degenerative disk disease,
o Cervical dz
 Red flags: shock pharasethias with neck flexion --> midline disk herniation or intermedullary pathology
 fever, chills, weight loss, cancer, immunosuppression, IV drug use --> infection of epidural space
 Antecedent events: not usual
o Lumbar dz
 Red flag: indicate infection malignancy, or cauda equina
 pain radiation, neurogenic or pseudo claudication
 Cauda equina syndrome: leg weakness, perineal pain, saddle anesthesia, loss of Bowel and B, sexual
dysfunction (s2-4)
o Testing:
 Straight leg raise test: The patient lies supine and the clinician elevates the patient's leg.
 A positive test for sciatica pain is classically described as "electric shock"-like pain radiating down
the posterior aspect of the leg from the low back. Cross-over pain, where sciatica symptoms occur
down the opposite leg during a straight leg raise, usually indicates a large disk herniation.
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  One-leg standing extension test: Assesses for pain as the patient stands on one leg while extending the
spine.
 positive test can be caused by pars interarticularis fractures (spondylolysis or spondylolisthesis) or
facet joint arthritis
 Check: reflexes, motor strength, and sensation
 Compare bilaterally
 Check while sitting, standing, and prone
 Standing check strength, reflexes, and sensation
 Supine: eval hip for ROM and straight leg raise test
 Prone: palpate vertebrae for tenderness

 Imaging tests:
 Cervical: MRI is preferred,
 Lumbar: for progressive or severe defect, red flags for infection, neoplasms, abscesses, Cauda
equina
 red flag: awaken at night with pain
 MRI-preferred
 CT Myelogram - rarely done, but best test to visualize spinal nerve roots
 Herniated disk: bulging or protrusion of the spinal nucleus through the annulus of the intervertebral disks
o Diagnosis:
 Pain with back flexion or prolonged sitting.
 Radicular pain into the leg due to compression of neural structures.
 Lower extremity numbness and weakness.
o L5-S1 is most commonly affected
o Symptoms:
 Discogenic pain typically is localized in the low back at the level of the affected disk, worse with activity
 significant disk herniation can cause numbness and weakness, including weakness with plantar flexion of
the foot (L5/S1) or dorsiflexion of the toes (L4/L5)
 L5- MOST COMMON
 acute pain and radiating down lateral leg
 Decreased strength in foot dorsiflexion, toe extension, foot inversion, and foot eversion
 lateral sensory leg (lower and foot dorsum)
 S1
 weak planter flexion, Weakness of leg extension and knee flexion
 decreased lateral foot and posterior leg
 Spinal Stenosis: narrowing of central canal
o Diagnosis:
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  pain is usually worse with back extension and relieved by sitting.
 Occurs in older patients over 50
 May present with neurogenic claudication symptoms with walking (symptoms are worse with walking
and relieved with sitting).
 Caused by: OA, compression, herniation,
o Testing: Neurovascular

 Sciatica
o Diagnosis:
 Often acute on chronic flare-ups of pain.
 Radiation of pain in radicular fashion along the distribution of the sciatic nerve.
 Positive straight- and crossed-leg raise tests.
o Symptoms:
 Shooting, stabbing, worse with cough or sitting or Valsalva
 Radicular pain that is below the knee
o Causes: herniated disk, tumor, infection, stenosis of lumbar
o Testing
 L5: foot drop, loss of dorsiflexion of the great toe, and pain in the great toe.
 S1: heel pain, decreased plantar flexion of the great toe, and decreased ankle jerk.
 Epidural Compression Syndrome
o Diagnosis
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  Bowel or bladder incontinence.
 Saddle anesthesia, decreased or absent rectal sphincter tone, lower extremity deficits.
 EMERGENCY
 RED FLAGS: urinary retention marked by overflow incontinence, saddle anesthesia, decreased rectal
tone, and bilateral motor and sensory deficit
 Check PVR: <100 ml rule out cauda equina
 Other red flags = epidural compression syndrome
 Causes: disk herniation, tumors, trauma, epidural abscess, and hematomas.
 Spinal infection
o Diagnosis:
 Usually occurs in patients with predisposition for infections: diabetic patients, intravenous drug users,
transplant patients, cancer patients.
 Fever and back pain are the hallmarks.
o Usually abscesses and osteomyelitis with Staph. Aureus
o RED FLAGS: night pain, pain with coughing, night sweats, fever, and an elevated erythrocyte sedimentation rate
and C-reactive protein
o Appear 10-14 days after onset on x ray
 Neoplasms:
o Metastatic tumor most common with multiple myeloma as second
o Bone loss evident on x ray
o RED FLAGS: weight loss; night pain in the absence of day pain; and a history of insidious and progressive pain
that has not responded to conservative
o Labs: elevated erythrocyte sedimentation rate, significant anemia, proteinemia,

8. Compartment syndrome (ACS) diagnosis and care

 Risk factors/Causes
o Men under 35
 Related to likelihood of traumatic injuries
o Long bone fractures
 Tibia/Fibula
 Arms and legs are always at risk
 Can occur in abdomen
 Comminuted fxs have a higher risk
 Open and closed reduction can cause CS
 Vascular injury with bleeding into an enclosed space, reperfusion injury
o Non-traumatic causes
 Soft tissue injury without fx
 Burns
 Crush injuries
 Constrictive bandages
 Iatrogenic causes – infiltrated IVs, ABG punctures
 Pathophysiology
o Compromised blood flow due to an increased hydrostatic
pressure in a closed tissue space.
o Ischemia develops due to an inability to meet catabolic
demands in the surrounding tissue.
 This causes the compartment pressure to rise
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  Causes the venous return that leads blood away from the compartment to decrease
 Decreases the arterial venous pressure gradient which eventually leads to shunting of blood away from
this internal compartmental tissue
 Eventually you get arterial collapse when tissue pressure exceeds arterial pressure and increased venous
drainage results in edema and increased interstitial pressure
o Hypotensive patients are at higher risk
o If patient has a difference in diastolic blood pressure and compartment pressure ( pressure) of  30 = concern
for ACS and decreased extremity perfusion
 Signs and Symptoms
o Exam findings
 Pain (most important finding)
 Pain with passive stretching is worrisome
 Pain out of proportion to findings
 Pallor
 Rubor 1st (redness) then pallor
 Pulselessness
 Bounding pulse early (limb trying to compensate) pulselessness is a late and ominous sign
 Paresthesia’s
 Sensory nerves are affected more rapidly than motor nerves when compartment pressures are
elevated; two-point discrimination is an important physical finding.
 Feelings of heaviness I limb
 Paralysis – nerve damage
 Poikilothermia – cold extremity
o Serial evaluations are important – 1,2,3,4…
 Looking for changes or rapid progression
 Tense/painful muscle compartments
 Delays in recognition of compartment syndrome are more likely to occur in sedated patients or in those
with head injuries than in other patients due to altered mental status
o Lab findings
 CBC -  WBC
  CK
 Myoglobinuria (W/I 4 hours of onset of ACS)
  LDH due to cell damage
 elevated systemic inflammatory markers
o Diagnostics
 MRI
 Adjunctive tool to see compartments
 Diagnosis
o Compartment pressure
 Diastolic blood pressure – compartment pressure (AKA delta pressure)
  30 = ACS
 Normal compartment pressure is 0-8; Levels above 30 mm Hg are abnormal and lead to necrosis
of nerve and muscle
 Capillary compromise
 When tissue pressure is within 25-30 mmHG of MAP
 Ischemia
 Tissue pressure approaches diastolic pressure
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  Bladder pressures for IACS
 Management
o Surgery (consult when suspicion is high)
 Fasciotomy – definitive tx
 (Currents) Intra-compartmental pressures greater than 30 mm Hg generally require immediate
intervention with fasciotomy, preferably by a surgeon
 May perform fasciotomy based on clinical signs only
o Decrease restriction – remove restrictive dressings/coverings
o Limb positioning
 At the level of the heart and never dependent or elevated, make it as easy as possible to get blood flow
to extremity as possible
o be conscious of possible rhabdomyolysis and renal failure
o Pain control
o Oxygen
o Treat hypotension with isotonic saline
o Perform frequent NV checks
o Amputation is a possibility and could be needed

9. Risk factors for osteonecrosis

 Corticosteroid use  Gout
 Alcoholism  Sickle cell disease
 Trauma  Dysbaric syndrome (“The Bends”)
 SLE (Lupus)  Knee meniscectomy
 Pancreatitis  Infiltrative disease such as Gaucher disease

10. Basic treatment for fractures and soft tissue injuries

 Upper Extremity

 Volar: wrist sprain, triquetral fracture, lunate dislocation, or 2nd-5th metacarpal head fracture.
Extends from the Volar aspect of the forearm proximal to the radial head.

 Ulnar Gutter: fractures to the ulnar aspect of the hand, including 4th and 5th phalanges and
metacarpals. Extends from distal interphalangeal joint of the little finger to the proximal forearm.

 Thumb Spica: fractures of the scaphoid and lunate, 1st metacarpal, and thumb. Extends from the
tip of the thumb to the proximal forearm.

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  Long-Arm: Fractures of the proximal forearm and elbow. May also stabilize intraarticular fractures
of distal humerus and olecranon prior to surgery. Extends along the posterior arm from the wrist
to the proximal humerus.

 Sugar-Tong: Fractures of the wrist and distal forearm. Extends from the metacarpophalangeal
joints to the dorsum of the hand, along the forearm, around then elbow, and back to the volar
aspect of the mid-palmer crease.

 Lower Extremity
 Posterior-Leg: Fractures of the distal leg, ankle, and foot.
Extends from the metatarsal heads to just below the fibular
head.

 Posterior-Leg w/ Stirrup: More stability for fractures near

ankle. Extends from the tibial tuberosity to wrap around the
foot and end just below the fibular head.
 Pain Control
o Adequate pain control w/ opioids
o Avoid NSAIDs with increased risk of rhabdomyolysis, crushing injuries
 Revaluation
o Cast/splint integrity
o Cast/splint damaged, intact?
o Neurovascular assessment
o ROM, motor function, paresthesia?
o Circulation
o Skin integrity

11. Synovial fluid findings based on disease

 Osteoarthritis-Clear, yellow fluid with a normal WBC count (less than 100,000/mm, glucose levels that approximate
patient’s serum glucose
 Rheumatoid arthritis-Yellow, turbid have fluid with friable mucin clot; elevated WBC up to 100,000/mm, normal
glucose
 Gout-Urate crystals seen under red lamp in the laboratory
 Soft tissue injury
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o WBC-inflammation or infection
o RBC- bleeding into joint
o Crystals-gout

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