CM2 MSK overview 1 (UE)

stress fracture

normal, but excessively frequent force applied to normal bone

fatigue (traumatic) fracture

abnormal force applied to normal bone

pathologic fracture

normal force applied to focally diseased bone

insufficiency fracture

normal force applied to generally abnormal bone due to a disease state

epiphyseal location

end of long bone

metaphyseal location

b/w epiphyseal and diaphyseal

diaphyseal location

shaft

nondisplaced =

anatomic alignment

displaced =

not in alignment

angulated =

malaligned (not on the same axis)

bayoneted =

displaced but overlapping

distracted displacement =

physically separated

transverse fracture =

fracture straight across

comminuted fracture =

more than 2 fracture fragments

oblique fracture

angulated fracture line

segmental fractures

type of comminuted → free floating middle portion

spiral fracture

multiplanar and complex fracture line

intra-articular fracture

crosses the articular cartilage and enters the joint

buckle fracture

compressed and bulges → circumferential

torus fracture

incomplete buckle → seen in children

greenstick fracture

incomplete fracture with angular deformity

avulsed fracture

when bone is torn off by ligament

fracture healing - inflammatory phase*

 fracture hematoma and inflammatory response (1 week)

fracture healing - reparative phase*

 collagen, cartilage and bone start to form the callus to stabilize the fx site

→ soft callus (2-3 weeks) hard callus (4-16 weeks)

fracture healing - remodeling phase*

excess callus is reabsorbed and new bone is put in place along lines of stress (17 weeks and beyond)

why should you splint*

1. Reduces pain → keeps area stable

2. Reduces damage to soft tissues → prevents grinding of structures

3. Reduces changes of converting to an open fracture

shoulder immobilizer

for shoulder dislocation

arm sling is used in

conjunction w/ other splint

clavicle strap is used for

clavicle fracture → use sling/shoulder immobilizer instead

long arm gutter is for

elbow fracture/dislocation

→ 90 degree flexion 

short arm gutter is for

metacarpal or 4th/5th phalanx fractures

sugar tong is for

wrist/forearm fracture

→ prevents pronation/supination

thumb spica is for

scaphoid fracture

thumb fracture

knee immobilizer is for

meniscus tear

posterior ankle cast is for

ankle dislocation/fracture

ankle stirrup is for

ankle sprains or stable malleolus fracture

ortho referrals

1. Compartment syndrome → emergency → treat with fasciotomy 

2. Circulatory compromise → emergency 

3. Dislocation/subluxation → urgencies 

   1. Irreducible dislocation

4. Open fractures

trigger finger is?*

Thickening of flexor retinaculum due to injury

what causes trigger finger*

tendon nodule passing through constricted sheath at proximal flexor pulleyy at MCP

trigger finger s/sx*

1. Painful snapping of tendon on extension

2. Finger locks in flexion

trigger finger tx

1. Immobilize then stretching

2. NSAIDs, steroids injections

3. Surgery for refractory cases

what is mallet finger

Traumatic disruption of the terminal slip of the extensor tendon mechanism at the DIP joint

what causes wallet finger*

Rupture of the extensor tendon of the DIP or a bony avulsion of the distal phalanx occurs when there is forced flexion of an extended finger

Unopposed flexion leads to a fixed flexion deformity/extensor lag at the DIP joint if the injury remains untreated

mallet finger tx

1. Doral, volar or stax splint → to keep the DIP in full extension for 8 weeks 

2. Surgery → fail to improve after splinting

Boutonniere Deformity cause

disruption of the central slip tendon mechanism on the dorsal (extensory) aspect of the PIP

Boutonniere Deformity occurrence

Occurs if forcible flexion of the PIP joint occurs during active extension or if volar dislocation of the PIP joint occurs, leading the central slip tendon rupture

Displaced lateral bands + central slip

Boutonniere Deformity appearance*

Results in PIP flexion and DIP and MCP hyperextension

Boutonniere Deformity tx*

Splinting of the PIP in extension for 6 weeks

jersey finger definition*

rupture of the flexor digitorum profundus tendon from its distal attachment or from an avulsion fracture at the base of the DIP

jersey finger cause*

Occurs when a flexed DIP joint suddenly and forcefully hyperextended, leading to rupture of FDP tendon at insertion on distal phalanx

jersey finger PE*

1. Inability to flex the DIP joint actively indicated a rupture of the FDP tendon

2. PIP flexion and extension should be unaffected

jersey finger tx

1. Splint with the PIP and DIP joints slightly flexed → tendon could retract back into finger/hand

2. Surgery repair is necessary

gamekeepers thumb mechanism

1. hyperextension/hyperabduction of thumb MP joint w/ injury to the ulnar collateral ligament 

2. Repetitive motion injury

gamekeepers thumb presentation

1. Pain, tender in MP joint

2. Weak pincer grasp

3. Complete tear → >45 degrees of abduction with MP joint flexed

gamekeepers thumb tx

1. Thumb spica splinting 4-6 weeks

2. Referral to hand surgeon

Boxer Fracture definition

Fracture in 4th or 5th metacarpal neck due to direct trauma to a clenched fist

Boxer Fracture presentation

Dorsum of hand swollen

Bony tenderness

Sig. tenderness or ecchymosis on the palmar bony surfaces → highly suggestive of fracture

Boxer Fracture dx

Obtain x rays with PA, lateral, and oblique views

→ see fracture of pinky or ring finger

Boxer Fracture tx*

Ulnar gutter splint

RICE

cast after swelling goes down

Boxer Fracture - get surgery if?

Open fracture

Thumb fracture

Occupations/hobbies that require fine motor movement

Patients who prefer less angulation for cosmetic reasons

Dupuytren’s Contracture definition*

Fibrous contractures of the palmar fascia

Dupuytren’s Contracture RF

Hereditary and bilateral

Males

Dupuytren’s Contracture s/sx

1. Flexion contracture with adherence of overlying skin

2. Decreased ROM

3. Progresses ulnar to radial

4. Distal to proximal progression

Dupuytren’s Contracture tx

1. Refer to orthopedist for fasciectomy → full ROM post-operatively

2. Xiaflex → enzyme injected into the contracture that breaks down connective tissue

Colles Fracture definition*

fracture of distal radius

Colles Fracture mechanism

FOOSH (falling on outstretched hand) → sports injuries/falls

Colles Fracture s/sx

Dinner fork deformity → dorsal angulation at wrist

Pain, swelling, discoloration

Colles Fracture dx

X-Rays

→ 2 planes showing distal radius fracture with dorsal angulation +/- radial deviation

Colles Fracture tx

Manipulative reduction under hematoma block with post reduction x-ray

^ Repeat x-ray in 3-5 days then q 2 weeks until healing is complete

Sugar tong splint until swelling recedes → short arm case x 6 weeks

Colles Fracture - refer to ortho for?

Unstable fracture

Significant displacement or comminution

Other associated fractures or dislocation

Colles Fracture - emergent consult if?

Open fracture

Neurovascular compromise

smith’s fracture definition

Distal radius fracture with palmar/volar displacement

smith’s fracture mechanism

Falling on flexed wrist

buckle fracture is?

all the way around

torus fracture is?

an incomplete buckle

1 cortex only

Buckle and Torus Fracture is most common in

children

Buckle and Torus Fracture definition

on-angulated, incomplete compression fracture of the shaft of a long bone,

characterized by bulging of the cortex

Buckle and Torus Fracture cause

Result from trabecular compressed caused by and axial loading force along the long axis of the bone

→ FOOSH injury

Buckle and Torus Fracture tx

Splinting and a single ortho follow up

→ Cast immobilization for 3 weeks

Carpal Tunnel syndrome cause

compression of the median nerve by the transverse carpal ligament as it travels through the carpal tunnel

Carpal Tunnel syndrome first presentation s/sx

Bilateral CTS is common at first presentation

Carpal Tunnel syndrome s/sx

Pain or paresthesia in the median nerve distribution

Often awaken pts from sleep

Sensory symptoms often radiate proximally into the forearm (provoked w/ flexing/extending wrist or raise arm)

Carpal Tunnel syndrome PE

1. Tinel's Test → percussion over the median nerve (least sensitive)

2. Phalen's Test → full wrist flexion at 90 degrees

3. Nerve conduction studies highly sensitive

Carpal Tunnel syndrome conservative tx*

Splinting first

Oral or injected glucocorticoids

Nerve gliding exercises or electrical stimulation

Carpal Tunnel syndrome tx surgical

When symptoms are severe and conservative treatment fails

If there is evidence of motor weakness or muscle wasting

Scaphoid Fractures cause

FOOSH

Scaphoid Fractures PE

1. Pain with thumb grind test → tenderness in anatomical snuffbox

2. Tenderness to direct palpation in the anatomical snuffbox

Scaphoid Fractures dx

For symptomatic patients with negative x-rays

Immobilize in a short-arm thumb spica case for 7-10 days

Follow up xray in a week

Scaphoid Fractures tx

thumb spica splint/cast

Follow q 2 weeks with x-rays until definitive healing is seen

Follow cast with splint and OT

About 5-10% result in nonunion → surgical referral necessary

thumb spica splint duration w/ scaphoid fracture

if distal pole, 4-6 weeks (best blood supply)

waist = 10-12 weeks (most common)

proximal pole = 12-20 weeks (worst blood supply)

De Qervain’s Tenosynovitis definition

Tenosynovitis of the extensor pollicis brevis and abductor pollicis longus

De Qervain’s Tenosynovitis cause

Cumulative movement disorder due to chronic overuse

Direct trauma

De Qervain’s Tenosynovitis RF

Pregnancy

RA

DM

De Qervain’s Tenosynovitis s/sx

Pain at the radial side of the wrist during pinch grasping, gripping, thumb or wrist movement

(Tendon is rubbing over radial styloid)

Tender distal radial styloid

De Qervain’s Tenosynovitis PE

1. Pain on resisted thumb extension and abduction

2. Pain aggravated by Finkelstein maneuver → passive stretch of thumb tendons over the radial styloid with thumb in flexion 

3. Pain radiates to the forearm

4. Painful ROM of the thumb

De Qervain’s Tenosynovitis tx

1. Acute pain relief → ice and NSAIDs

2. Splinting

For persistent symptoms → corticosteroid injection

Surgical referral if more than 2 injections need in 1 year → decompression of the 1st extensor compartment has high success

Ganglion definition*

Chronic irritation of a tendon sheath, usually at the wrist, which causes an overproduction of joint synovial fluid

Ganglion presentation*

Soft-tissue mass in the hands and wrist

Mass can change size with movement

Most common on dorsum of wrist

Ganglion special studies/diagnostics*

Transillumination

U/S confirm cyst

Ganglion tx

1. No treatment needed unless symptomatic

2. Regress spontaneously