FAA Ortho Class 2 2025

Introduction to Orthopedics

• Overview of previous classes:
  • Discussed fractures, low back pain, and neck pain.
• Current focus: Shoulder pain (Chapter 52).
• Importance of a good understanding of diagnostic and management practices in orthopedics.
• Minimal examination questions yet necessary to know key concepts for clinical application and patient communication.

Shoulder Pain

• Anatomy of the Shoulder Joint:
  • Components:
  • Humerus (head articulates with glenoid cavity of scapula)
  • Acromion (part of the scapula)
  • Clavicle (collarbone)
  • Acromioclavicular joint (connects acromion and clavicle)
  • Subacromial bursa located underneath the acromion, acts as a cushion to reduce friction during shoulder movement.
  • Key Muscles:
  • Supraspinatus muscle (critical for initiating shoulder abduction, specifically the first $15^ ext{o}$)
  • Deltoid muscle (major muscle providing shoulder shape and power for abduction after the initial $15^ ext{o}$)

Causes of Shoulder Pain

• Common causes include:

  • Arthritis of the shoulder joint (e.g., osteoarthritis, rheumatoid arthritis).
  • Tendon tear (e.g., rotator cuff tear).
  • Tendon inflammation (tendonitis), often due to overuse.
  • Bursitis (inflammation of the bursa, typically the subacromial bursa).

• Key Movements and Associated Tendons:

  • Abduction: Supraspinatus (initial $15^ ext{o}$), Deltoid (remaining range)
  • Internal Rotation: Subscapularis
  • External Rotation: Infraspinatus, Teres Minor
  • Adduction: Pectoralis Major / Latissimus Dorsi

Rotator Cuff Muscle Group

• Four primary muscles that stabilize the shoulder:
  • Supraspinatus
  • Infraspinatus
  • Subscapularis
  • Teres Minor
• Importance of understanding their functions and pain implications:
  • Limited abduction often indicates a supraspinatus issue.
  • Weakness in internal rotation points to a subscapularis problem.
  • Weakness in external rotation suggests issues with infraspinatus or teres minor.

Rotator Cuff Tendinopathy

• Definition:
  • Inflammation or degeneration of a rotator cuff tendon, most commonly the supraspinatus.
• Patient symptoms:
  • Shoulder joint pain; may radiate down the lateral aspect of the arm to the elbow.
  • Constant throbbing pain, often with a history of repetitive overhead activity (e.g., lifting, sports).
  • Difficulties with overhead activities like dressing (reaching behind the back) or combing hair.
  • Pain often worse at night, especially when lying on the affected side.
• Management:
  • Initial: Pain relief with paracetamol.
  • If ineffective: NSAIDs and physiotherapy focusing on range of motion, strengthening, and posture correction.
  • Surgical intervention (e.g., arthroscopic debridement or repair) considered if symptoms persist after several months of conservative treatment.

Rotator Cuff Tear

• Presentation:
  • Significant weakness in abduction and external rotation.
  • Impingement signs noted through:
  • Empty Can Test: Patient abducts arms to $90^ ext{o}$ in the scapular plane, internally rotates shoulders (thumbs down), and resists downward pressure. Weakness or pain indicates supraspinatus pathology.
  • Drop Arm Test: Patient actively abducts arm to $90^ ext{o}$ and then slowly lowers it. Inability to smoothly lower the arm or a sudden drop suggests a rotator cuff tear (often supraspinatus).
• Confirmation Tests:
  • Initial high-resolution ultrasound is often used as a first-line imaging.
  • If inconclusive or for detailed assessment of tear size and retraction, MRI is used to differentiate partial vs. full-thickness tears.

Subacromial Bursitis

• Definition:
  • Inflammation of the subacromial bursa, often due to overuse or direct trauma.
• Symptoms:
  • Localized tenderness on the lateral part of the shoulder, just below the acromion.
  • Severe pain on direct pressure or during abduction, especially with overhead activities.
  • Pain with passive and active range of motion, particularly at the end range of abduction.
• Diagnostic Tests:
  • Ultrasound for confirmation, showing fluid accumulation in the bursa.
• Management:
  • Initial pain relief with paracetamol and NSAIDs.
  • Steroid injections (e.g., corticosteroid with local anesthetic) into the bursa if symptoms persist, often guided by ultrasound.

Adhesive Capsulitis (Frozen Shoulder)

• Definition:
  • Inflammation of the glenohumeral joint capsule leading to fibrotic scarring and significant loss of both active and passive range of motion.
• Phases of Capsulitis:
  • Freezing phase: (2-9 months) Characterized by severe, diffuse shoulder pain that worsens progressively, with gradual loss of motion.
  • Frozen phase: (4-12 months) Pain may decrease, but stiffness and significant loss of movement are paramount. Both active and passive ranges of motion are severely restricted.
  • Thawing phase: (12-42 months) Gradual, spontaneous return of motion, though full range may not always be recovered.
• Management:
  • Focus on physiotherapy (gentle stretching, pendulum exercises, range of motion within pain limits), medications for pain relief (NSAIDs).
  • Corticosteroid injections (intra-articular) may help reduce pain and inflammation, particularly in the freezing phase.
  • Surgical options like arthroscopic capsular release can be considered for severe cases unresponsive to conservative treatment.

Pain in the Arm and Hand (Chapter 53)

Pulled Elbow

• Common: In children aged 2-5.
• Mechanism: Dislocation of the radial head (nursemaid's elbow) due to longitudinal traction on a pronated and extended arm, often from pulling a child by the hand or wrist.
• Symptoms:
  • Child avoids using the arm, keeps it flexed and pronated, often crying or holding the arm still.
  • No swelling or deformity typically observed.
• Treatment:
  • Reduction of the radial head through a specific maneuver (e.g., supination and flexion of the forearm).

Tennis Elbow (Lateral Epicondylitis)

• Condition:
  • Overuse or repetitive microtrauma to the extensor muscles of the forearm, particularly the extensor carpi radialis brevis, leading to pain at the lateral epicondyle of the humerus.
• Symptoms:
  • Pain when gripping, extending the wrist, or lifting objects.
  • Tenderness over the lateral epicondyle.
  • Pain exacerbated by resisted wrist extension with the elbow extended.
• Management:
  • Rest, NSAIDs, physiotherapy (stretching, strengthening, eccentric exercises), elbow support band (counterforce brace).
  • Steroid injections are an option.
  • Surgery (e.g., debridement) as a last resort after prolonged symptoms.

Olecranon Bursitis

• Definition:
  • Inflammation of the olecranon bursa at the posterior aspect of the elbow.
• Presentation:
  • Characterized by swelling (sometimes described as a "golf ball" sensation) and pain at the olecranon area.
  • Can be septic (infection) or aseptic (trauma, gout, rheumatoid arthritis).
• Management:
  • Rest, pain relief (NSAIDs), and possible steroid injections for aseptic cases.
  • Important to rule out septic bursitis if symptoms worsen, with signs like redness, warmth, fever, or purulent drainage, requiring aspiration and antibiotics.

Carpal Tunnel Syndrome

• Definition:
  • Compression of the median nerve as it passes through the carpal tunnel in the wrist.
• Symptoms:
  • Pins and needles (paresthesia) or numbness in the thumb, index, middle fingers, and radial half of the ring finger (sparing the little finger).
  • Symptoms often worse at night or after repetitive hand use.
  • Weakness or atrophy of the thenar muscles in severe cases.
• Diagnostic Tests:
  • Tinel's sign: Tapping lightly over the median nerve at the wrist elicits tingling sensations in the median nerve distribution.
  • Phalen's maneuver: Sustained wrist flexion (e.g., for $30-60$ seconds) reproduces symptoms in the median nerve distribution.
  • Two-point discrimination for sensory assessment.
  • Nerve conduction studies are the definitive diagnostic test to confirm median nerve compression.
• Management:
  • Rest and splinting (especially night splints) for mild cases.
  • Steroid injections into the carpal tunnel for moderate cases.
  • Surgical release (carpal tunnel release) for severe cases or those unresponsive to conservative treatment.

Trigger Finger (Flexor Tenosynovitis)

• Definition:
  • Inflammation and thickening of the flexor tendon sheath, often at the A1 pulley, leading to restriction of tendon gliding.
• Symptoms:
  • Finger locks in flexion, particularly during gripping, and then suddenly releases with a painful "pop" or "click" sensation (triggering).
  • Pain and tenderness at the base of the affected finger.
• Management:
  • Rest, pain relief (NSAIDs).
  • Corticosteroid injection into the tendon sheath is often effective.
  • Surgical release of the A1 pulley for persistent symptoms.

Dupuytren's Contracture

• Definition:
  • Progressive thickening and shortening of the palmar fascia, leading to flexion deformity of the fingers (most commonly ring and little fingers).
  • Presents with palpable nodules and cords in the palm.
• Treatment options:
  • Collagenase injection to dissolve the collagen in the cords for limited contracture.
  • Surgical options (e.g., fasciectomy) for significant contracture that impairs hand function.

De Quervain's Tenosynovitis

• Definition:
  • Inflammation and thickening of the synovial sheath enclosing the abductor pollicis longus and extensor pollicis brevis tendons in the first dorsal compartment of the wrist.
• Symptoms:
  • Pain at the base of the thumb and radial side of the wrist, especially with grasping or pinching movements.
  • Tenderness over the radial styloid.
  • Finkelstein's test: The patient makes a fist with the thumb tucked inside, then ulnar deviates the wrist. Severe pain along the radial wrist is a positive test.
• Management:
  • Rest, splinting (thumb spica splint), NSAIDs.
  • Corticosteroid injections into the tendon sheath are often very effective.

Mallet Finger

• Definition:
  • Injury to the extensor tendon at its insertion into the distal phalanx, often from a blunt force to the fingertip (e.g., basketball hitting the tip of the finger), causing an inability to actively extend the distal interphalangeal (DIP) joint.
• Symptoms:
  • Drooping of the distal phalanx.
  • Inability to extend the distal phalanx actively.
  • Pain and swelling at the DIP joint.
• Management:
  • Finger placed in continuous hyperextension using a splint (e.g., stack splint) for several weeks ($6-8$ weeks) to allow tendon healing.

Hip and Buttock Pain

• Focus on common conditions and their diagnostic and treatment paradigms.

Important Conditions in Children

• Developmental Dysplasia of the Hip (DDH):

  • Risk factors: Female gender, firstborn, breech delivery, family history, oligohydramnios.
  • Screening: Via Ortolani and Barlow tests performed by pediatricians or orthopedists. A positive Ortolani sign is a clunk indicating reduction of a dislocated hip. A positive Barlow sign is a clunk indicating dislocation of an unstable hip.
  • Confirmation: Through ultrasound (preferred for infants under 6 months as cartilage is not ossified).

• Perthes Disease:

  • Definition: Avascular necrosis of the femoral head, typically affecting boys ages $4-8$, of unknown etiology but involves disruption of blood supply to the femoral head.
  • Symptoms: Unilateral hip pain (often insidious onset), limping (antalgic gait), limited range of motion (especially abduction and internal rotation).
  • Diagnosis: Via X-ray, which may show early stages of increased density or later fragmentation and reossification of the femoral head. Urgent referral to pediatric orthopedics required.

• Transient Synovitis:

  • Definition: Common, self-limiting inflammatory condition of the hip joint, typically in children after a viral infection.
  • Treatment: Includes rest and pain management (NSAIDs). Must rule out septic arthritis vigorously via ultrasound (showing effusion) and blood tests (e.g., C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), white blood cell count (WBC)) to differentiate.

• Slipped Capital Femoral Epiphysis (SCFE):

  • Common: Between ages of $10-20$, often in obese or rapidly growing adolescents.
  • Mechanism: The femoral head (epiphysis) slips posteriorly and inferiorly relative to the femoral neck through the growth plate.
  • Symptoms: Hip pain, often referred to the knee or thigh, and limping (antalgic or external rotation gait).
  • Confirmation: Via X-ray (AP and frog-leg lateral views are crucial). Requires urgent orthopedic intervention for management, typically in-situ pinning to stabilize the growth plate.

• Osteoarthritis (In Elderly Patients):

  • Definition: Degenerative joint disease affecting the articular cartilage of the hip.
  • Presents with: Mechanical hip pain that worsens with activity and is often relieved by rest in the early stages.
  • Features: Morning stiffness typically less than $30$ minutes, pain after prolonged inactivity (e.g., "start-up" pain).
  • Initial management: Analgesics (e.g., acetaminophen, NSAIDs), physiotherapy for strengthening and flexibility, weight management.
  • Hip replacement (arthroplasty) as a last resort for severe cases with significant pain and functional impairment.

Leg Pain Pathophysiology

Vascular Problems:

• Intermittent Claudication:
  • Definition: Cramping pain, aching, or fatigue in the calf, thigh, or buttock due to peripheral artery disease (reduced blood flow), which is consistently brought on by exercise or walking a predictable distance and promptly relieved by rest.
  • Treatment: Lifestyle changes (e.g., smoking cessation, exercise program), medications (e.g., antiplatelets, statins), and potentially surgical intervention (e.g., angioplasty, bypass surgery) in severe cases.

Neurological Problems:

• Neurogenic Claudication:
  • Definition: Pain, tingling, or weakness originating in the back and radiating to the legs, caused by compression of spinal nerves due to spinal canal stenosis (narrowing).
  • Features: Worsens with standing or walking (lumbar extension), relieved by sitting or leaning forward (e.g., "shopping cart sign"). Pain is often less position-dependent than vascular claudication and may not be relieved by immediate rest.

Conclusion

• Reinforces the understanding of key orthopedic conditions and clinical management strategies through detailed symptom presentation, diagnostic approaches, and treatment paradigms.
• Highlights