CAM I - MSK Missed Concepts (Not on Upper Cohort Quizlets)

Nursemaid's elbow (pulled elbow)

Most common in 1-4 yo's, results from sudden "jerk" of the arm - pulling arm motion

Arm flexed

forearm pronated

no deformity, eccymosis, swelling, or bony tenderness

What are the clinical manifestations of nursemaids elbow?

clinical (can do x-ray- not often needed, obtain if deformity, ecchymosis, swelling, or concerns of fx)

How do you diagnose nursemaids elbow?

bedside reduction (hyperpronation or supination/flexion)

How do you treat nursemaids elbow?

Pediatric elbow

Most common in peds, typically a condylar fracture

posterior fat pad and/or anterior sail sign

occult fracture - pain, swelling, tenderness over radial head/proximal ulna

What are the clinical manifestations of pediatric elbow?

lateral x-ray (presence of posterior fat pad)

How do you diagnose pediatric elbow?

long arm splint, refer to peds ortho (if available - if not, general ortho)

How do you treat pediatric elbow?

elbow dislocation

Majority of posterior dislocations - FOOSH injury

Essential to assess NV status

pain/significant swelling at elbow

elbow at 45 degree flexion, severely restricted ROM

What are the clinical manifestations of elbow dislocation?

AP x-ray (medial and lateral displacement of ulna/radius)

lateral x-ray (both ulna/radius displaced)

How do you diagnose elbow dislocation?

REDUCTION

Assess NV, post reduction x-ray, long arm splint, close ortho follow up

How do you treat elbow dislocation?

Shoulder dislocation

Displacement of the humeral head from the glenoid fossa

ANTERIOR - MOST COMMON (95%) - arm abducted and externally rotated

Posterior - often due to seizures, electrocution, or trauma

inferior - rare

visible deformity

"squared off" shoulder

prominent acromion

arm held in slight abduction and external rotation

numbness/tingling if nerves involved (axillary nerve injury is most common - deltoid numbness, once popped back into place - numbness should go away)

What are the clinical manifestations of shoulder dislocations?

x-ray (AP, axillary, scapular Y views)

before and after reduction

How do you diagnose a shoulder dislocation?

reduction techniques

immobilization in sling

PT for rehab

Surgery (if recurrent or associated injury)

How do you treat a shoulder dislocation?

recurrent dislocations

Bankart (labral injury) and Hill-Sachs lesions (fracture)

RTC tears

Nerve or vascular injury

What are some complications of a shoulder dislocation?

paronychia

Infection of the lateral or proximal nail fold (usually more superficial)

acute or chronic

staph aureus (nail biting)

what causes acute paronychia?

often candida or irritant exposure (wet work)

what causes chronic paronychia?

redness

swelling

tenderness around the nail

possible pus collection (fluctuance)

nail changes in chronic cases

What are the clinical manifestations of a paronychia?

clinical diagnosis

How do you diagnose a paronychia?

mild cases:

warm soaks (3-4 times day)

topical antibiotics (ex: mupirocin)

More severe cases:

I&D if abscess present

oral antibiotics if cellulitis (ex: cephalexin)

How do you treat acute paronychia (<6 weeks) mild vs severe?

topical steroids

reduce water exposure

How do you treat chronic paronychia (>6 weeks)?

persistent droop

swan-neck deformity if left untreated

what are some complications of a paronychia?

mallet finger

Injury to the extensor tendon at the distal interphalangeal (DIP) - causing inability to extend finger tip

sudden forceful flexion of an extended finger (ex: ball striking the tip - common in sports)

What causes mallet finger?

DIP joint held in flexion

inability to actively extend fingertip

swelling/tenderness at the dorsal DIP joint

What are some clinical manifestations of mallet finger?

x-ray (rule out avulsion fracture or joint subluxation)

How do you diagnose a mallet finger?

splinting DIP in full extension for 6-8 weeks

surgery (only if large fracture fragment or joint subluxation)

How do you treat a mallet finger?

Gamekeeper's Thumb (Skier's Thumb)

Injury to the ulnar collateral ligament (UCL) of the thumb or the thumb metacarpophalangeal (MCP) joint

forced abduction or hyperextension of the thumb (common in skiers, falls with thumb caught on object)

What causes gamekeepers thumb?

pain/swelling over ulnar aspect of MCP joint

weak/painful pinch grip

instability with vagal stress

What are some of the clinical manifestations of gamekeepers thumb?

Physical exam - valgus stress testing

x-ray (rule out avulsion fracture or Stener lesion)

MRI (if diagnosis is unclear - or high suspicion)

How do you diagnose game keepers thumb?

partial tear: thumb spica splint/cast vs brace (4-6 weeks)

complete tear or Stener lesion: surgery

How do you treat game keepers thumb?

chronic instability

weak pinch grip

early arthritis if not treated

What are some complications of game keepers thumb?

Cervical Dystonia (Torticollis)

spasmodic torticollis or wryneck - an acquired issue in adults

trauma or injury (can be minor/severe)

burn - scaring

can be congenital (children)

How does cervical dystonia occur?

severe/sudden muscle spasm (sternocleidomastoid)

muscle often "locked" in spasm

neck muscle pain

"constant involuntary spasms"

twisting of neck (abnormal position of the chin)

head tilt

What are some clinical manifestations of cervical dystonia?

clinical

if trauma: +/- neurological sx.- MRI may be warranted

How do you diagnose cervical dystonia?

NSAIDs

muscle relaxants

rest

PT - stretching

botox injections (administered directly into muscle)

How do you treat cervical dystonia?

cauda equina

A surgical emergency caused by compression of the cauda equina (nerve roots below conus medullaris)

large central disc herniation (most common)

tumor

trauma

abscess

spinal stenosis

hematoma

How does cauda equina occur?

1. saddle paresthesia

2. bladder and bowel dysfunction

3. severe bilateral leg pain

4. decreased lower extremity reflexes (especially achilles reflex)

5. decreased anal sphincter tone DRE

What are some clinical manifestations of cauda equina?

MRI of lumbar spine (TEST OF CHOICE)

hx and physical exam:

neural deficits, urinary retention, and saddle anesthesia

DRE:

decreased anal sphincter tone

URGENT NEUROSURG CONSULT!

What are some clinical manifestations of cauda equina?

EMERGENT SURGICAL DECOMPRESSION!! (best outcome with early intervention)

delay - increases risk of permanent paralysis, incontinence, and sexual dysfunction

How do you treat cauda aquina?

always assess saddle sensation and urinary function in patients with new back pain + neuro symptoms

(cauda equina = back pain + bowel/bladder dysfunction + saddle anesthesia = MRI stat)

What are some clinical pearls for cauda equina?

septic arthritis

monoarthritis characterized by intra-articular infection and joint destruction (S. Aureus - including MRSA - most common)

where: native and prosthetic joints (ex: dental work)

how: most cases result from hematogenous seeding

How/where does septic arthritis happen?

hip and KNEE - 80% of cases (large joints > small joints)

What are the clinical manifestions of septic arthritis?

joint aspiration promptly (quickest and most crucial step if infection suspected) - cell count, gram stain, culture, etc.

CBC

ESR

CRP

cultures

how do you diagnose septic arthritis?

irrigation and debridement followed by IV antibiotics

How do you treat septic arthritis?

hip dislocation

Posterior dislocation is the most common (90%)

risk of vascular damage and nerve injury

weak hip flexion, knee extension, ankle dorsiflexion (common perineal nerve)

can lead to avascular necrosis/osteoarthritis

traumatic - high energy, MVC, falls

nontraumatic - can occur after hip replacement

How does a hip dislocation occur?

posterior: leg shortened, internally rotated, ADDucted, hip/knee slightly flexed (likely to cause pelvic fracture)

anterior (much less common): leg shortened, externally rotated, ABDucted

What are the clinical manifestations of a hip dislocation?

x-ray

CT

neurovascular assessment: check sciatic nerve (post) or femoral nerve (ant)

check for motor function, sensation, and pulses

How do you diagnose a hip dislocation?

put the hip back into place

How do you treat a hip dislocation?

developmental dysplasia

"ball and socket" do not form properly, shallow socket - uncovering femoral head and can lead to dislocation

female > males, first born, breech presentation, tight swaddling, and + fam hx

What are the risk factors for developmental displasia?

asymmetry in thigh/gluteal folds

leg length discrepancy

limited hip abduction

What are the clinical manifestations of hip dislocation?

barlow

developmental dysplasia: moves hip posteriorly either subluxation or dislocation

ortolani

developmental dysplasia: moves hip anterior reducing dislocated joint

Galeazzi sign

developmental dysplasia: done in older infants - apparent leg-length discrepancy when hips and knees are flexed

<6 months: ultrasound (femoral head is CARTILAGENOUS until 6-months)

>6 months: x-ray

How do you diagnose developmental dysplasia?

pavlik harness, closed vs open reduction with casting if severe

How do you treat developmental dysplasia?

labral tears

early onset OA

gait abnormalities

need for hip replacement - if severe

what are some complications of developmental dysplasia?

Slipped Capital Femoral Epiphysis (SCFE)

OBESE CHILDREN (teens and preteens)

adolescents

F: 10-14 yo

M: 12-16 yo

GROWTH SPURTS!

What is Slipped Capital Femoral Epiphysis (SCFE) associated with?

EXTERNAL ROTATION OF AFFECTED LEG +/- LEG LENGTH DISCREPANCY

Pain (groin, hip, knee)

altered gait

worse with activity

decrease ROM (abduction and internally rotated)

inability to bear weight

What are the clinical manifestations of Slipped Capital Femoral Epiphysis (SCFE)?

x-ray (Klein Line) - ICE CREAM FELL OFF THE CONE

Widened/displaced physis

how do you diagnose Slipped Capital Femoral Epiphysis (SCFE)?

surgery - in situ fixation

What is the treatment for Slipped Capital Femoral Epiphysis (SCFE)?

Legg-Calve-Perthes Disease

AVN of the hip

Kids: 3-12 yo

Boys > girls x 4

no, idiopathic (unknown cause)

Do we know the cause of Legg-Calve Perthes Disease?

pain groin/hip, worse w/ activity

What are the clinical presentations of Legg-Calve Perthes Disease?

doesnt say? (x-ray since we have an x-ray picture on slides?)

How do you diagnose Legg-Calve Perthes Disease?

conservative tx - casting, bracing, NSAIDs

refer to peds ortho

potential surgical involvement

How do you treat Legg-Calve Perthes Disease?

Salter Harris

Fractures involving the growth plate (epiphyseal plate) in children and adolescents - can affect bone growth and development - leading to potential deformities if untreated

Slipped or straight across (Type I)

Above or away from joint (Type II)

Lower (Type III)

Through or transverse or together (Type IV)

Ruined or rammed (Type V)

How do you classify the types of Salter Harris fractures? (remember SALTR)

pain to palpation at epiphysis/growth plate

What are the clinical manifestations of Salter Harris fracture?

x-ray typically

(type 1 fracture may not show on x-ray, but still treat if pain at epiphysis)

MRI if more detailed evaluation is needed

How do you diagnose Salter Harris fractures?

non-surgical tx w/ cast or splint

What is the treatment for Type 1 and 2 fractures?

May require reduction and immobilization

What is the treatment for Type 3 and 4 fractures?

often requires surgical intervention for realignment

What is the treatment for Type 5 fracture?

Compartment syndrome

MOST COMMON IN ANTERIOR COMPARTMENT OF LEG

Increased pressure within a closed fascial compartment - compromises circulation and tissue perfusion

trauma fracture (especially tibial fracture)

crush injury

reperfusion after trauma

What is the mechanism of injury for compartment syndrome?

pain with passive stretch (moderate swelling and tightness of skin)

"wood like" feeling on palpation

P's:

pain out of proportion

parasthesias

pallor

pulselessness (late)

paralysis (late)

What are the clinical manifestations of compartment syndrome?

do not delay for imaging if suspicion is high

LABS MAY SHOW RHABDO (INCREASED CK, MYOGLOBINURIA) IF SEVERE

How do you diagnose compartment syndrome?

EMERGENT FASCIOTOMY OF ALL AFFECTED COMPARTMENTS

(infection risk since leaving wound open but pros > risk)

How do you treat compartment syndrome?

talipes equinovarus (clubfoot)

Congenital foot deformity characterized by:

plantar flexion

inversion

adduction

unknown cause - genetic factors may play a role, fam hx increases risk

How does talipes equinovarus occur?

xrays or ultrasound (severe cases - if there is uncertainty about the extent of the deformity)

How do you diagnose talipes equinovarus?

non-surgical (preferred approach):

Serial casting (gradually correct position)

achilles tenotomy

bracing

PT

Surgical:

severe or nonresponsive cases (tendon lengthening, realignment of bones, etc.)

How do you treat talipes equinovarus?

pes cavus

Often associated with neuromuscular conditions (ex: Charcot-Marie-Tooth)

"high arches"

congenital

How does pes cavus occur?

rigid high arch

frequent ankle sprains or lateral foot pain

calluses on heel/ball of foot

may have claw toes

What are the clinical manifestations of pes cavus?

physical exam

x-rays (increased calcaneal pitch)

How do you diagnose pes cavus?

shoe modification (rigid high arch support, wide toe box)

orthotics

PT

surgical correction (severe or progressive)

How do you treat pes cavus?

Pes planus

Can be flexible (common in children) or rigid (pathologic in adults)

"flat foot"

congenital

How does pes planus occur?

foot fatigue

arch/heel pain

medial ankle bulging

overpronation when walking

What are the clinical manifestations of pes planus?