Clin Med 1 Unit 2 L1

what type of joint is the knee joint

synovial joint with joint capsule and articular cartilage

ACL goes from where to where

posterior lateral side goes to anterior medial site

sac of synovial fluid, ease action of the joint, allow muscles and tendons to glide over each other, can become inflamed and infected

bursae

ball and socket, rotary movement, hip and shoulder

spheroidal joint

flat, planar, slightly curved, gliding motion in a single plane, flexion/extension of digits

hinge joint

rotates around single axis, C1 around dens of C2, radial head and ulna

pivot joint - uniaxial

articulating surfaces are convex or concave, flexion/extension/rotation in coronal plane, MCPs, radiocarpal articulation

condylar - biaxial

articulating bones fit together like a rider on a saddle, thumb joint

saddle joint - biaxial

cartilaginous, slightly moveable

intervertebral joint

immovable, suture, syndesmosis, gomphosis

fibrous joint

differential diagnosis structures to consider

joint (synovia, meniscus), ligaments, tendons, bursae, bones, muscles, nerves, blood vessels, functional deficits, differential diagnosis

functional deficits

range of motion, strength, sensation

differential diagnosis

traumatic, orthopedic, rheumatologic, systemic, infectious

mechanism of injury

• traumatic (injury) vs atraumatic (overuse, degenerative)

• acute or chronic

• localized or diffuse

• inflammatory vs noninflammatory

• what is the functional limitation

• systemic signs and symptoms

timing of pain

rapid or slow, progressed or fluctuated, how long does pain last, what does it feel like over the course of a day

other questions

what aggravates, what alleviates, reproduceable, past problems in the affected area, past treatment and effect?

inspect

observe the joint while patient attempts normal activitiy, deformity/malalignment, shortened leg, skin lacerations or bleeding, foreign bodies, compare for symmetry, scars, atrophy, hair distribution

palpate

be specific, look for warmth, crepitus, deficits in bone/tendon, tenderness, palpate joint above and below, make patient point to spot of pain

assess range of motion

perform passive ROM if active is limited or causes pain, assess ROM of joints proximal and distal to affected area, note limitations or ligamentous laxity (what does joint normally do, what can’t the patient do, what limits the patient)

grinding when moved - think bone, may be a sign of a fracture, also seen with OA

crepitus

found with dislocations or severe ligament disruptions, range of motion with caution

gross instability

suggests internal structural issue (meniscus)

locking or clicking

vascular and neurologic assessment distal to injury/pain

sensation (light touch, sharp/dull, two point discrimination), reflexes, rectal tone, cap refill, pulses

stress testing (excluding fracture/dislocation)

stress test of joint for pain or instability, deformity suggests fracture, dislocation or subluxation, or get an x-ray), performed to evaluate the stability of an injured joint (ligamentous injury)

stressing

passively opening joint in a direction usually perpendicular to the normal ROM (painless laxity likely means complete ligamentous tear)

red flags

obvious fracture/dislocation, open fracture, severe pain not relieved by common analgesics (pain out of proportion to injury/exam), suspected compartment syndrome, neurovascular compromise (tingling, numbness, cold or paralysis)

open joint overview

50-90% of open joint injuries involve the knee

open joint etiology

usually involve the knee

open joint presentation/exam

injury - knee capsule extends 3-4cm above the superior pole of the patella, laceration, difficult to determine if there is communication with internal knee structures

open joint diagnosis

saline loading test with and without methylene blue, CT scan for all joints concerned

open joint tx/management

consult ortho, IV antibiotics (cefazolin q8 to start + update Td)

imaging tests used in diagnosis of MSK disorders

xrays, DEXA, CT, MRI, ultrasound, bone scan, arthroscopy, fluoroscopy

xrays use

if fracture or dislocation suspected, used to identify fractures, tumors, bone injuries, infections, deformities congenital or arthritis, include at least 2 views (AP and lateral)

what to not use xrays for

soft tissue injuries (muscles, ligaments, bursae, tendons, nerves)

dual energy x-ray absorptiometry for bone density, used for osteopenia/osteoporosis

dexa

may be used to detect fractures that are not visible on xrays, further evaluate previously identified fracture (pelvic fractures), soft tissue issues (foreign body, necrotizing fasciitis, intramuscular abscess, myositis, pyomyositis, osteomyelitis), CT uses radiation, takes less time, costs less than MRI

computed tomography

best images muscles, ligaments, tendons, may be used to detect fractures which are not visible on xray (occult fracture), bone bruises, osteochondral fractures, stress fractures, used if patient is still unable to use joint/bear weight despite conservative treatment

MRI magnetic resonance imaging

can identify inflammation/fluid in and around joints, can identify tears or inflammation of tendons and muscles, soft tissue foreign bodies, abscesses, joint effusions, can be used to guide a needle into a joint, can be used to evaluate nerves (specialized)

ultrasound

used to detect fracture, infection, tumor, uses IV radioactive technetium 99m is absorbed by healing bone

bone scan

fiberoptic scope is placed into joint, can perform biopsy, surgical repair, used in cases on synovitis; ligament tendon, or cartilage repairs, remove loose pieces of bone or cartilage

arthroscopy

xray in real time shows movement, c-arm, uses fracture reduction management, removal of foreign bodies

fluoroscopy

what do ligaments connect

bone to bone

what do tendons connect

muscles to bone

tears in ligaments

sprains

tears in tendons or muscles

strains

sprain MOI

twisting, jamming, or stretching of joint in a direction or degree it wasn’t meant to go

patient presentation sprain

tenderness, swelling, ecchymosis, instability? loss of fx?

sprain diagnosis

lack of fracture or hemarthrosis on x-ray, should be able to ambulate >3 steps

grade 1 sprain

stretched ligament

grade 2 sprain

partial ligament tear with some laxity or instability

grade 3 tear

complete ligament tear, causing instability of the joint

treatment for grade 1 sprain

RICE, rehabilitation

treatment for grade 2 sprain

RICE, rehabilitation, immobilization (foam splint or air cast)

treatment for grade 3 sprain

immobilization with cast vs surgery, need ortho consult

sprain management

early mobilization and return to normal function is advocated for grade 1 and grade 2 sprains, follow up within 5-7 days swelling will worsen within 24 hrs and decrease over 2-4 days, may take up to 6 months for full strength/stability

partial tendon tear

may be due to single trauma or repeated stress (tendinopathy), ROM usually intact, often progress to full tears, can heal on own over time

complete tendon tears

rupture, motion produced by the detached muscle is lost, may require surgery

first degree strain (mild)

minimal; fibers are stretched but intact, or only a few are torn, minimal pain/swelling, sx may be delayed until next day, no loss of fx or strength, no joint laxity, healing takes 1-3 weeks

second degree strain (moderate)

partial some to almost all fibers are torn, significant pain and swelling, obvious loss of strength and function, may have joint laxity, healing takes 2-3 months

third degree strain (severe)

complete, all fibers torn, acute, severe pain and swelling - often after a pop, complete loss of strength and function, deficit on palpation, instability on exam, healing takes 6+ months with probable surgery

strain management

mild, moderate: RICE, NSAIDs, severe: RICE, NSAIDs, splint/immobilization, may need IV pain management/observation, ortho consult

delayed onset muscle soreness (pains)

result of mechanical damage to muscle and surrounding connective tissue (result of new or different pattern of exercise), type 1 strain, occurs 12-48 hrs after exercise, lasts 4-12 days

signs and symptoms of delayed onset muscle soreness (pains)

tenderness to palpation, stiffness, pain with movement

delayed onset muscle soreness (pains) tx

ice, stretching, active rest

what is general term for pain and swelling of a tendon

tendinopathy

what was a popular term for an acute inflammatory process and is generally replaced by tendinopathy

tendinitis

what is a chronic tendon injury with cellular level damage

tendinosis

what is pain and swelling of a tendon and the tendon sheath + / - tendinosis secondary to lubrication system within the sheath failing

tenosynovitis

what is a tendon that does not smoothly glide along it’s path

tendon entrapment

what is a complete separation of two ends of tendon

tendon rupture

what causes tendonitis/tendinopathy and tendinosis

repetitive or prolonged activity, forceful exertion or localized mechanical stress causing tendon fibers to tear apart, triggers inflammatory response which results in thickened, bumpy, and irregular tendons

• decreased inflammatory cells

overloading, inadequate rest, poor ergonomics, inadequate equipment, new activities, repetitive vibration, awkward or static postures

examples of tendinopathy

epicondylitis, biceps tendinosis, achilles, quadriceps, rotator cuff, tibial

two examples of epicondylitis

tennis elbow, golfer’s elbow

tendinopathy where extensor carpi radialis brevis, maybe extenssor digitorum, and EC ulnaris affected

tennis elbow

tendinopathy where FC ulnaris, FC radialis, palmaris longus, FDS, and pronator teres are affected

golfer’s elbow

signs and symptoms of tendonitis/tendinopathy/tendinosis

gradual to subacute onset, pain with activity - generally repetitive, improved pain with passive movement or rest/joint compression, point tenderness over structure but minimal localized tenderness over the joint line, + / - swelling no effusion, pain at night, difficulty sleeping

tendonitis/tendinosis/tendinopathy tx

quinolones, correct reason for overuse, rest, ice, splint or support, pt, antiinflammatory medication (oral or injected corticosteroids), surgery as last resort

bursitis

inflammation of the bursae

bursitis signs and sx

swelling and tenderness

bursitis tx

rest, ice, otc pain medications, bursal aspiration but should cover with compression bandage or it will refill, surgery

plantar fasciitis

most common cause of heel pain in adults, due to degenerative disease in the origin of the plantar fascia on calcaneus, gradual onset

plantar fasciitis signs and sx

pain to palpation along plantar fascia, pain with dorsiflexion of toes

plantar fasciitis tx

heel pad, stretching exercises, ice

septic joint/arthritis signs and sx

hours to days onset, hot, red, swollen, tender, difficult to ambulate, significant decrease in ROM, normal vitals or fever/tachycardia

reasons for septic joint/arthritis

RF: immunosuppresion/DM, injection drug use, elderly, prosthetic joint, previous joint injury

Gonococcal: prodrome of migratory arthritis and tenosynovitis prior to setting in one joint

diagnosis of septic joint/arthritis

xray, joint aspiration, culture/gram stain/wbcs and crystals

differential diagnosis of septic joint/arthritis

gout, pseudogout, rheumatoid arthritis, tumor, Lyme dz, systemic lupus erythematosus (SLE)

septic joint/arthritis tx

IV ABX (intravenous antibiotics), admission, orthopedic and ID consult (infectious disease)

disruption in the break of the cortex of a bone

fracture

clinical features of a fracture

pain and point tenderness, loss of function depending on site/pain tolerance, + / - deformity, crepitus, abnormal mobility, + / - neurovascular injury, radiographic findings

dislocation

complete separation of two bones that form the joint, obvious deformity/seen on x-ray, need to diagnose ASAP if limb is ischemic, within 4 hrs, must reduce

subluxation

partial separation of bones, may need reduction

acute complications of msk injuries

bleeding, vascular injuries, nerve injuries

bleeding acute complication

any bleeding over ortho injury should raise suspicion for open fracture

vascular injury acute complication

significant swelling or decreased distal perfusion

usually in open injuries, do not heal spontaneously, most serious form of nerve damage

neurotmesis (torn nerve)

axon is injured but myelin sheath is not, can regenerate over weeks to years

axonotmesis (crushed nerve)

nerve conduction is blocked but nerve is not torn, leads to temporary motor/sensory deficits which typically return to normal in 6-8 weeks

neurapraxia (bruised nerve)

long term complications of msk injuries

instability (buckling of a joint), stiffness and impaired ROM, chronic pain

what can buckling of a joint lead to

osteoarthritis