Muskuloskeletal quiz 1

10-12 weeks

How long should you manage a forearm fracture?

Monteggia fracture

dislocation of the radial head and fracture of the proximal ulnar shaft
-may see NV injury, fractures of the radial head and coronoid process
-FOOSH mechanism

XR of the elbow and wrist

workup for Monteggia fracture

closed reduction and long arm cast

treatment of Monteggia fracture in kids

surgery

treatment of Monteggia fracture in adults

Galeazzi fracture

fracture of the distal radius and dislocation/disruption of the distal radioulnar joint
-often with displacement of the ulna
-deformity, shortened radial forearm (curved), prominent ulnar head, edema

surgery

treatment of Galleazzi fracture

buckle fracture (torus)

classic pediatric fracture with a buckling of the cortex
-may see a slight outward bulge of the cortex

greenstick fracture

classic pediatric fracture
-bone is bent but fracture only on one side

immobilization

treatment of greenstick fracture

child abuse

pediatric pt presents with fractures of the long bones in diff stages of healing
-see periosteal reaction and calluses
-esp be concerned in children that are not yet mobile

skeletal survey

What should be done if child abuse is suspected?

distal radius fractures

one of the most common fractures across all age groups
-younger pts, older pts with osteoporosis
-usually due to FOOSH or high energy trauma
-often seen with carpal fractures
-Colles, Smith, Barton, Chauffeur

AP/lateral XR

imaging for distal radius fractures

splint/cast immobilization for 4-6 weeks

treatment for nondisplaced distal radius fractures

ORIF

treatment for displaced or intra-articular distal radius fractures

Colles fracture

transverse fracture of the distal radius with *dorsal angulation* and displacement of the fragment
-most common
-FOOSH with wrist extended
-may also see comminution, ulnar styloid fracture, disrupted radioulnar joint, medial nerve injury, radiocarpal osteoarthritis

closed reduction, surgery

treatment for Colles fracture, Smith fracture

Smith fracture

"reverse colles fracture"
-fracture of the distal radius with *volar displacement* and fragment displacement
-younger pts with high-energy trauma from a fall on the flexed wrist

classic Barton fracture

shear fracture of the distal articular radial surface with *dorsal displacement* of the radiocarpal joint
INTRA-ARTICULAR

reverse Barton fracture

shear fracture of the distal articular radial surface with *ventral displacement* of the radiocarpal joint
INTRA-ARTICULAR

surgery

treatment for Barton fracture

Hutchinson (chauffeur fracture)

oblique, intra-articular fracture of the distal radius
-radial styloid process and radial collateral ligament in the fragment
-often sen intercarpal ligamentous injuries ex. scapholunate ligament

surgery

treament of Hutchinson fracture

scaphoid fracture

most common carpal fracture, most commonly unidagnosed fracture of the UE
-FOOSH
-risk of avascular necrosis

scaphoid fracture presentation

pt presents with TTP in the anatomical snuffbox, painful ulnar deviation, radial risk pain with thumb axial loading, painful grip and ROM

AP, lateral, oblique XR, CT, MRI if suspicious

imaging for scaphoid fractures

immobilize for 2 weeks with long arm thumb spica splint, refer

treatment for scaphoid fractures

MRI

What is the best imaging to detect a scaphoid fracture, as well as to investigate avascular necrosis?

ORIF

treatment for scaphoid fractures with displacement \>1mm

lunate dislocation

uncommon but requires prompt management, most common carpal dislocation
-from FOOSH for forceful wrist dorsiflexion

lunate dislocation presentation

pt presents with pain and volar wrist swelling, numbness/tingling in the median nerve distribution

urgent reduction

treatment of lunate dislocation

lunate fracture

usually seen with other injuries/fractures
-standard radiograph views are diagnostic
-perilunate dislocation and avascular necrosis can occur

Kienbock disease

avascular necrosis of the lunate
-can be due to repeated trauma ex. young men in construction with constant jarring
-pt has pain and tenderness at the radiolunate joint, effusion/edema over radiocarpal joint, decreased ROM and grip strength

NSAIDS, immobilization

treatment of Keinbock disease in minimally symptomatic pts

pinning, bone grafts, decompression, wrist fusion, wrist arthroplasty

treatment of Keinbock disease in operative pts

immobilization 10-12 weeks

treatment for lunate fracture

scapholunate dissociation

disruption of the radioscaphoid and scapholunate ligaments
-pt presents with unstable wrist, "about to give way"
-widening of the scapholunate interval \>4mm

cortical ring sign (signet ring sign)

seen with scapholunate dissociation
-scaphoid appears shortened on PA XR

dynamic imaging

imaging for scapholunate dissociation

immobilization, surgery

treatment for scapholunate dissociation

Bennet's fracture

intra-articular fracture and dislocation of the *volar ulnar aspect* of the thumb base
-caused by axial loading of flexed thumb metacarpal
-may affect pinching and opposition
-pt has swelling and pain at the thumb base, decreased ROM

XR, CT

imaging for Bennet's fracture

thumb spica cast, surgery

treatment for Bennets fracture

Rolando fracture

similar to Bennet fracture, with comminution of the bone in a T or Y pattern

Bett and Robert view XR

imaging for Rolando/Bennet fracture
-visualize trapeziometacarpal joint

Boxer's fracture

fracture of the 5th metacarpal (pinky side)
-punching inanimate objects with a closed fist, usually young men with anger issues
-metacarpal appears shortened, deformity of angulation

ulnar gutter splint, surgery

treatment for Boxer's fracture

Gamekeeper's thumb

aka skier's thumb
-injury/rupture of the ulnar collateral ligament of the thumb which causes instability at the 1st MCP joint (thumb side)
-pt has swelling, pain, tenderness on ulnar thumb side (inside)

XR, MRI

imaging for gamekeeper's thumb

Stener lesion

avulsion fracture seen with gamekeeper's thumb

thumb spica, surgery

treatment for gamekeeper's thumb

phalangeal fractures

common and easily recognized fractures with displacement and angulation
-PIP injuries are the most common

AP and lateral XR

imaging for phalangeal fractures

mallet finger

flexion deformity of the DIP as a result of avulsion of the extensor tendon from the distal phalanx

splint DIP for 6 weeks

treatment for mallet finger

flexor tendon injuries

rupture of the FDS from the middle phalanx, rupture of the FDP from the distal phalanx
-due to sports injuries (Jersey finger), trauma, spontaneous
-test active flexion of PIP and DIP on exam

XR, MRI

imaging for flexor tendon injuries

clean and repair superficial wounds, splint, surgical repair of the tendon

treatment for flexor tendon injuries

Dupuytren's contracture

hyperplasia of the palmar aponeurosis with painless nodules and cords
-slow, progressive, affects ring and pinky fingers
-due to repetitive trauma, alcoholism, diabetes, epilepsy, pulm disease, smoking
-men \>50yo, northern Europeans

stretching, injections, needle aponeurotomy, open fasciotomy

treatment for Dupuytren's contracture

trigger finger

tenosynovitis of the flexor tendon sheath
-F\>M, DM, RA, hand strain
-proximal pulley of the flexor tendon becomes stenotic, *locking or snapping* of MCP joints with nodules

rest, splint, NSAIDs, steroid injections, surgery

treatment for trigger finger

Bowler's thumb

compression of the ulnar/digital nerve on the inside of the thumb from repetitive grip trauma ex. bowling ball or tool
-scar tissue around the nerve leads to a tender nodule and decreased sensation of the ulnar thumb

rest, NSAIDs, splint, surgery

treatment for Bowler's thumb

De Quervain's tenosynovitis

inflammation of the tendons and sheath on the thumb side of the wrist which constricts the tendon as it glides in the sheath
-pain, tenderness, thickening of the radial styloid area (near snuffbox)
-due to trauma, pregnancy, DM, etc
-image to rule out radius/carpal fracture

Finkelstein's test

PE for De Quervains tenosynovitis

thumb spica splint, NSAIDS, steroid injections, surgery

treatment for De Quervains tenosynovitis

pyogenic flexor tenosynovitis

infection of the synovial sheath that surrounds the flexor tendon
-due to penetrating trauma, direct spread form, felon, septic joint, deep space infection
-diagnose with Kanavel signs

Kanavel signs

1. pain on passive extension
2. sausage finger
3. digit flexed
4. pain on the flexor sheath distribution

urgent irrigation and debridement of flexor tendon sheath with IV antibiotics

treatment of pyogenic flexor tenosynovitis

carpal tunnel syndrome

*most common mononeuropathy*
-compression of the median nerve under the transverse carpal ligament
-F\>M, repetitive trauma, obesity, DM, alcoholism, RA, acromegaly

carpal tunnel presentation

pt presents with pain, numbness/tingling in the 1st three digits and maybe 4th digit
-symptoms often worse at night
-hand weakness can occur
+Tinel's, +Phalen's signs on PE
-thenar atrophy

Phanel test

wrist flexion to reproduce the symptoms of carpal tunnel syndrome

Tinel test

Percussion on medial nerve reproduces pain associated with carpal tunnel

EMG/NCS

testing for carpal tunnel syndrome

modify activity, cockup splints, NSAIDs, steroid injections, surgery

treatment for carpal tunnel syndrome

ganglion cyst

most common soft tissue mass of the hand, arises from the tendon sheath due to trauma
-cyst filled with synovial fluid
-often on the dorsal of the wrist
-can be asymp or cause pain with grasping, impede movement, can break open and drain clear jelly-like fluid

transillumination test

PE for ganglion cyst

reassurance, aspirate (high rates of recurrence), surgery

treatment of ganglion cysts

paronychia

infection of tissue around the fingernail, usually due to staph aureus
-pain, redness, swelling

topical antibiotics, warm water or antiseptic soaks, antibiotic therapy if nonresponsive

treatment of non-abscess paronychia

I&D with antibiotics

treatment of paronychia with abscess

herpetic whitlow

pain, pruritis with vesicle formation that may present as paronychia
-medical and dental personnel at increased risk

saline soaks, wound care, analgesics, antivirals

treatment for herpetic whitlow

felon

digital pulp abscess with throbbing pain that develops over 12-24 hours
-can cause necrosis or osteomyelitis of the distal phalanx

I&D distal finger, IV antibiotics

treatment of felon

pasturella multocida

What is the most common pathogen from animal bites?

clean and irrigate site, Augmentin for 5-7 days

treatment of animal bites

human bites

contain greater amounts of bacteria than animal bites
-staph aureus and alpha-hemolytic strep most common pathogens
-treat the same as animal bites

Cephalexin

antibiotic to treat human bites

shoulder arthritis

destruction of the cartilage within the joint space
-pts \>50yo, can be due to OA, RA, post-trauma, infection, spondyloarthropathies, osteonecrosis

shoulder arthritis presentation

pt presents with generalized, diffuse, deep, gnawing pain that is aggravated by repetitive movement or strenuous activity
-pain at rest, pain at night, pain with any movement
-decreased ROM, ADL probs
-PE shows TTP, crepitus, muscle atrophy

AP and axillary XR

What imaging would you order to evaluate shoulder arthritis?

NSAIDs, acetaminophen, heat/ice, PT, glucosamine and chondroitin (trial), steroid injections, total shoulder replacement

treatment for shoulder arthritis

rotator cuff

SITs muscles: *supraspinatus*, infraspinatus, teres minor, subscapularis
-provide a covering around the humeral head, rotate arm and stabilize the humeral head around the glenoid

rotator cuff syndrome

pathologies affecting the rotator cuff
-subacromial impingement syndrome, bursitits
-rotator cuff tendonitis
-tears

impingement syndrome

inflammation of the subacromial bursa and RCTs between the humeral head and acromial arch
*usually supraspinatus involved*
-edema and hemorrhage leads to inflammation and fibrosis, tendon failure, tendon tears

impingement syndrome presentation

pt presents with gradual onset anterior/lateral shoulder pain exacerbated by overhead activity
-night pain on affected side
-pain on the greater tuberosity, subacromial bursa, bicipital groove and anterior acromion *no weakness on exam*
-decreased ROM and crepitus
-NEER SIGN AND HAWKINS SIGN