msk pathologies

difference between osteoarthritis and rheumatoid arthritis

OA: cartilage breakdown

RA: synovial membrane pannus

what is the #1 cause of nonfatal injuries ages 0-14

unintentional falls

mortality rate after hip fractures in the older population

18-33%

who has a higher fracture rate after a fall and why

females - lower bone density after menopause

when should you recommend imaging to a Pt

try conservative care/PT first, imaging if no response

difference between acute and overuse injuries

acute: trauma - sprain, strain, fracture

overuse: excessive stress to msk tissue causing breakdown, can cause acute

what structure is likely affected in an overuse injury

tendon

who more commonly gets overuse injuries

athletes - where tendons attach to bone (elbow, hip, knee)

adolescents - lower muscle strength and rapid growth

do acute or overuse injuries have better outcomes? why?

acute - tissue is already healthy, repairing healthy tissue

overuse - atrophy likely already occurred, harder to heal

when do overuse injuries commonly occur

sudden drops or spikes in workload

symptoms of tendon injuries

aching and tightness at rest, tenderness, swelling, slow developing pain

sharp sensation during eccentric to concentric transition

risk factors of tendon injuries

obesity, poor metabolic health, steroid meds

management of tendon injuries

strengthen everything around it - treat the donut not the hole

why should you strengthen a tendon when healing it? how do you strengthen it

collagen forms over lesion, wild/not parallel → causes discomfort

isometric to eccentric loading - (isometric for remodeling, eccentric for strengthening/remodeling)

when can an epidural hematoma occur? what structure is at risk?

direct blow to pterion - middle meningial artery

when can a subdural hematoma occur? what happens?

shearing/concussion, alcoholism - brain shrinks, veins tear, slower bleed

how do contusions happen? how do they present?

bruise - direct trauma - ecchymotic (local hemorrhage) purple to brown to yellow as blood is reabsorbed

what are hematomas? how is it treated

large painful hemorrhage from pressure on nerve endings, pain worsens with pressure - elevation and cold compress, may require aspiration

what are lascerations? how are they treated?

tear in skin - wound closure after cleaning, irrigation to limit infection

skin may be left open during healing to prevent anaerobic bacteria from fluorishing

how should antibiotics be used and why

prescribed for the shortest possible time, use bottle even if you feel better, avoid separate treatments close together in time - overuse may lead to superbug/antibiotic resistance

what does prophylactic mean

preventative

when are limb sutures removed and why

7 to 10 days - less ROM available the longer sutures are in

when are facial sutures removed? when are scalp sutures removed?

facial: 3-5 days

scalp: 7-10 days

what is a capsular shift? what should you prioritize in treatment?

capsule is loose, tighten by removing excess and attaching two parts closer - prioritize ROM in treatment

difference between strain and sprain

strain: stretching injury to muscle, tendon, or m/t junction

sprain: stretching injury to ligaments, swelling subsides far slower

what kind of action are strains attributed to? give example

high load eccentric - bicep: pronated, extended elbow and shoulder

strain grading

I: minimal strength loss, pain and tenderness, 3 week recovery, prone to reinjury if load is not modified

II: significant tearing of muscle fibers, pain and strength loss, 8-12 week recovery, ecchymosis, discomfort

III: loss of continuity of muscle, complete rupture of muscle belly or m/t junction, may require surgical fixation

how to treat a strain when fibers are still intact

low grade isometric exercises to guide where body needs to orient fibers

what is compartment syndrome

bleeding into compartment/fascial space around muscle

what is the most commonly sprained joint?

ankle

what imaging would a sprain appear on

MRI, CT, ultrasound

what is an osteochondral defecit? what can be observed with it?

cartilage over bone chips off - crunching/crepitus

what is crepitus and when is it abnormal

creaking/grinding - abnormal if painful

what symptoms are associated with loose bodies

painful catching and locking of joint - remove to protect integrity of articular surface

where do separations and dislocations occur

separation: AC joint

dislocation: synovial joints

what is a subluxation

partial dislocation, bone ends are still in partial contact

what should you check first when you suspect a dislocation

pulses and sensation (arterial supply and innervation)

what are congenital, traumatic, and pathological dislocations

congenital: often in hip and knee

traumatic: after falls, blows, rotation - often recurrent from ligamentous laxity after initial dislocation - less force required each time

pathologic: result from infection, paralysis, arthritis

what structure is at risk with knee dislocation

popliteal artery and nerve

first thing to perform after knee dislocaiton

ABI - ankle brachial index (pulse of ankle/arm) (doppler ultrasound gold standard)

what is a normal, severely abnormal, incompressible ABI level

normal: 1.0-1.4

abnormal: <0.40

incompressible: >1.4

what is a bankart tear

anterior labrum tears due to humeral head dislocation

what is a hill-sachs lesion

posterior humeral head lesion due to impact with glenoid, strong pulling force from relocation

use techniques that involve relaxation

what are the 2 most common techniques to reduce a dislocated shuolder

FARES and stimson

what direction does patellar maltraction/dislocarion usually occur? how do you relocate it?

lateral - slow knee extension

should you return to sport immediately after relocated patella? why/why nont?

no. will dislocate again bc MPFL is likely torn

what muscle is commonly used for MPFL reconstruction

gracilis or semitendinosus

what is the apprehension sign? when do you test it?

Pt has anxiety/fear when laterally translating patella, feel inherent stabiluty, will contract quad for protection or tell you to stop - only test after patella is reduced

AC joint injury grading

I: partial AC ligament tear

II: complete AC tear, CC sprain

III: complete tear of AC and CC ligaments

what is a history of AC joint separation associated with

osteoarthritis - less control over elevation

how to conservatively treat a shuolder separation

sling immobilization, rest, physical therapy

when may a surgical fixation be needed for a shoulder separation

clavicle displaced >2cm

when can a shoulder separation occur

direct blow to point of shoulder

what is a radial head subluxation

nursemaid’s elbow - annular ligament no longer holds radial head in place

how do people get nursemaid’s elbow - how is it managed and how do you know if it worked?

lifting, swinging, pulling a child with pronated and extended arm - radial pressure with supination and flexion of elbow, works if child uses it/stops protecting it

what happens in a lunate dislocation? what is at risk?

lunate loses artoculation with capitate and radius - imaging ASAP because the longer it is dislocated, the higher the risk of avascular necrosis, followed by ORIF

which shoulder bone is most commonly fractured with a fall

clavicle

what structure may be affected with a subacromial impingement

subacromial bursa (sebdeltoid and subcoracoid), long head bicep, supraspinatus

what is a subacromial decompression? why can this be bad?

surgically remove bursa - increased friction on supraspinatus → increased risk of rotator cuff tear

what motions do each of the rotator cuff muscles do

supraspinatus: first 15 degrees abduction, ER, flex, stabilize

infraspinatus: ER

teres minor: ER at 90 degrees

subscapularis: IR

what rotator cuff muscle is most commonly torn

supraspinatus

signs of a rotator cuff tear

pain at night, with overhead activity, at point of deltoid,

lose AROM, proximal migration of humeral head

gold standard to confirm rotator cuff tear

MRI

what special test is used to test a full thickness tear

drop arm test

what special test is used for supraspinatus

empty can

what special test is used for infraspinatus

ER lag sign

what special test is used for teres minor

hornblowers

what special tests are used for subscapularis

belly press, lift off, IR lag sign

when can you treat a rotator cuff tear conservatively

0-1cm, no evidence of retraction, improves with loading

what is considered a massive cuff tear

>5cm, 2+ tendons

difference between tenotomy and tenodesis? what are results of each intervention?

tenotomy: release/cut biceps tendon → popeye deformity

tenodesis: cut and reattach biceps tendon → cannot use biceps for shoulder flexion

what needs to happen if there is a massive cuff tear with fatty infiltration

reverse total shoulder arthroplasty

what is a SLAP tear and when does it occur

superior labrum tears anterior to posterior - from fall or catching a heavy object

when is the MCL torn

valgus movement

is the LCL commonly torn? why/why not?

no - strong, supported by biceps femoris

what leads to osteoarthritis

age, knee injuries, damaged capsule and cartilage

major predictor of OA

past surgery

which meniscus is more commonly torn? why? what symptoms can present?

medial

attaches to MCL → limited mobility

popping, locking

how is a meniscal tear diagnosed

MRI, mcmurray sign (bend knee, push, ER foot and tibia - positive if painful)

what is a thessaly’s test

test meniscal lesion - plant affected leg, brace with hands on table, quickly rotate

difference between a meniscectomy and a meniscus repair?

meniscectomy: remove meniscus after tear, WBAT after surgery → less cushion, higher impact forces, increase OA rate

meniscus repair: suture torn meniscus, prolonged NWB and ROM limitation

what kind of imaging is better to see a fracture

CT scan

which collateral ligament in the knee is most commonly sprained/torn

MCL

what do the MCL and LCL resist?

MCL: valgus movement

LCL: varus movement

what muscle should you strengthen to correct valgus landing

glute med → abduct femur

collateral ligament graded management

I and II: conservative, bracing to prevent stretching, PT

III: likely surgical, extensive bracing

ACL tear mechanism of injury

knee valgus, hip IR, tibia ER, ankle pronation

what part of a tendon is used for an ACL reconstruction? what kind of graft has a higher retear rate

central third - allograft/cadaver

recent evidence supports ___ and spontaneous healing for an ACL tear. why?

copers - improve stability of the knee through muscle support

retear rate is 25-30%…bad!

describe the clinical tests for an ACL tear

lachman test: foot elevated, eliminate hamstrings → >2mm shift is positive

anterior drawer: foot is planted, pt may contract hamstrings

ligamentous laxity is strangely associated with ___ in ACL tears

menstrual cycle

what is the terrible triad

ACL, MCL, medial meniscus commonly torn together

what is BEAR

bridge enhanced autologous repair - bridge placed to support ACL, sponge around it with plasma and rbcs

RULE OF 9s!!!

-never return to sport before 9 months

-need 90% strength (isokinetic, tindeq)

-need at least 90% LEFS/ACL-RSI (functional questionnaire)

-90% on return to sport test and hop testing

when do PCL tears commonly happen

dashboard (car accident, direct blow to tibia), maybe fall onto flexed knee

clinical presentation of a PCL tear

sulcus sign, posterior drawer laxity

PCL tear management is primarily ___

conservative - surgery only indicated for notable instability/secondary

risk factor for tendon rupture

steroid use, chronic infection → weakened ligaments

how does a patellar tendon rupture present and how is it repaired

patella alta, autograft within 7-10 days - immobilization, PWB, slow return to full ROM

what is chondromalacia patella

patellofemoral pain syndrome - abnormal lateral tracking from IT band → friction between patella and femur → breakdown of articular cartilage