Orthopaedics

Fractures-Principles

Factors that influence healing favorably:

Skeletal Immaturity (young patient) Inherent stability (e.g., ulna fx with intact radius, pelvis, one rib) Adjacent bone for support (e.g., fingers can be used for buddy splint) Transverse fractures (vs. oblique)

Worse Prognosis

Older patient Comminuted or markedly displaced Both bones of forearm or leg Inclusion of articular surface Oblique or spiral fracture Cervical/lumbar vs. thoracic spine

Referral Considerations

Dubious compliance Open or irreducible fractures Suspicion of compartment syndrome Avascular areasscaphoid, lunate, hamate, femoral/humeral heads Associated dislocation or tendon injury Nerve injury, Multiple fractures

Casting

Extra padding for high pressure/bony prominences, minimum around fracture to allow for maximal immobilization Avoid pinching/excessive molding Make a window to monitor any skin wound Monitor for iatrogenic compartment syndrome

Fractures in Children

Salter-Harris/Peterson Classifications of physeal injuries Refer if Fx includes epiphysis, or if physis is crushed or displaced from metaphysis Closed management OK if only metaphysis or with minimal widening of physis Monitor for growth arrest/bone bars
Adapted with permission from Eiff, MP, Hatch, RL, Calmbach, WL:Fracture Management For Primary Care.Philadelphia, PA WB Saunders, 1998.

Ortho 6

Hand/Wrist

Boutonnire deformity
Tear of the central portion of the extensor tendon at the PIP joint PIP joint is flexed due to unopposed pull of flexor tendons Treatment Splint in extension - 3-6 weeks

Ortho 7

Adpated with permission from Anderson W, Gorusuch WL, Jennings CD, Hand and Wrist, in Snider RK, Essentials of Musculoskeletal Care, AAOS Rosemont, IL.

Hand/Wrist (Contd)

Mallet finger

Most common extensor tendon injury Rupture of extensor tendon at insertion on base of distal phalanx Avulsion Treatment
Splint with DIP in extension 6-8 weeks
Adpated with permission from Anderson W, Gorusuch WL, Jennings CD, Hand and Wrist, in Snider RK, Essentials of Musculoskeletal Care, AAOS Rosemont, IL.

Ortho 8

Hand/Wrist (Contd)

Trigger Finger

Inflammation of flexor tendons Patient complains of catching or locking Early treatment with steroid injection Surgical release for failures

Ganglion cyst

If asymptomatic no treatment required Cyst aspiration with steroid injection may be helpful but recurrence is common Surgical removal also has high recurrence rates

Hand/Wrist (Contd)

Scaphoid fractures

Fall on outstretched hand Tenderness over snuff box High risk of non-union Early x-rays may be negative Splint and re-xray in 2 weeks if concerned Or bone scan/CT

Boxers fracture

Fifth metacarpal neck fracture Reduction is seldom retained but usually not a functional problem Ulnar gutter splint for 4 weeks with early return to motion

Hand/Wrist (Contd)

De Quervain Tenosynovitis

Finklesteins Test

Inflammation of extensor and/or abductor policis longus due to repetetive overuse Finklesteins test NSAID immobilization steroid injection
Adpated with permission from Anderson W, Gorusuch WL, Jennings CD, Hand and Wrist, in Snider RK, Essentials of Musculoskeletal Care, AAOS Rosemont, IL.

Treatment

Ortho 11

Hand/Wrist (Contd)

Gamekeepers (Skiers)Thumb

Damage to the ulnar collateral ligament of MP joint of the thumb Traditionally associated with a stretch of ligament from chronic use causing an unstable thumb Now usually a ligament rupture secondary to trauma

Treatment

NSAID immobilization steroid injection Surgical repair for complete tears or unstable thumb

Distal Radius Fracture

Fall on outstretched hand Colles (dorsal displacement of distal fragment) is most common type Check all three nerves, radial artery Double-sugar tongs splint to stop rotation Closed rx if reduction maintained:

Intra-articular step-off <2mm Dorsal angulation < 5 degrees Radial inclination < 15 degrees No overlap of cortex

Refer for fx-dislocation, both bones fx

Carpal Tunnel Syndrome

Entrapment of the

median nerve Pain, paresthesia, sometimes paralysis Risk factors include repetitive trauma, RA, pregnancy, thyroid dysfunction Paresthesia - thumb, index, middle, and half of ring finger

Thenar wasting Night pain Phalen Test, Tinnel test - little diagnostic value Hand diagram, hypalgesia, thumb abduction strengthhelpful

Hand Diagram - Patient Draws Areas of Involvement

Classic Pattern

Symptoms involve 2 of the 1st three digits Permits symptoms in 4th and 5th digits, wrist pain, and radiation of pain proximal to the wrist No palmer or dorsal hand involvement

Probable pattern

Same as classic but palmar symptoms allowed unless confined solely to the ulnar aspect

Carpal Tunnel Syndrome

NCV has 5-10% false
negative rate, also some false positives X-ray not generally helpful Treatment:
Wrist splinting NSAIDs for mild disease Physical therapy

Steroid injections may be useful for failed initial therapy Ergonomic modification Pregnancy induced usually resolves post-partum Operative management for atrophy and weakness

Elbow

Nursemaids elbow

Radial head subluxation Sudden longitudinal traction Reduced by supination of the forearm+pressure on radial head +flexion of elbow

Supracondylar Fractures

High morbidity Neurovascular status may be compromised Anterior/posterior fat pad sign Early surgical stabilization

Elbow (Contd)

Olecranon Bursitis

Epicondylitis

Chronic vs acute (trauma/infection/go ut) If inflamed aspiration with culture/gram stain/fluid analysis Compression/ice Steroids if no infection

Medial (Golfers), lateral ( Tennis) Pain over medial/lateral epicondyle Related to over use Activity modification NSAIDs/ice

Radial Head Fracture

Commonly missed; associated with wrist fx, radioulnar dissociation, medial tendon injuries Fall on outstretched arm; tenderness or crepitus on palpation/ROM radial head Sail-shaped anterior fat-pad sign. Normal-no fluid density between fat and bone Refer if displaced; non-displaced can be treated with sling, early active ROM Aspiration of hemarthrosis/instillation of local may reduce pain and enhance early AROM

Shoulder

Acromioclavicular separation

Conservative treatment type 1, 2 and most 3 Types 4-6 require surgery but are uncommon
Adpated with permission from JohnsonTR,Shoulder, in Snider RK, Essentials of Musculoskeletal Care, AAOS Rosemont, IL.

Ortho 20

Shoulder (Contd)

Impingement Syndrome

Compression of rotator cuff and overlying structures May be 1- usually repetitive use or structural Or 2 to instability of the shoulder Painful arc - 90120 abduction

Minimal weakness on rotator cuff testing Rehabilitation NSAIDs steroid injection Consider surgical referral for no improvement 3-6 months Chronic symptoms may lead to rotator cuff tear

Shoulder (Contd)

Rotator cuff tendonitis/tear

Except for acute trauma- spectrum of the same disease Usually supraspinatus tendon Inflammation may cause impingement syndrome

Full thickness tears uncommon in < 40 yrs MRI - only if diagnosis is questioned and/or surgery considered Only patients who fail rehabilitation should be considered for surgery

Shoulder (Contd)

Frozen Shoulder - Adhesive Capsulitis

Loss of both passive and active ROM Most common 40-60 yrs old No gender preference Type I DM a risk factor May be idiopathic or related to other conditions, I.e. prolonged immobilization Rehabilitation steroid injections

Shoulder (Contd)

Shoulder instability

Uni/multi-directional Anterior most common 2 main types

Traumatic Atraumatic congenital vs chronic use, I.e. swimmers, pitchers

TUBS - Traumatic, Unidirectional, Bankart lesion, surgery AMBRI -Atraumatic, Multidirectional, Bilateral laxity, Rehabilitation , Inferior capsular shift if surgical procedure needed

Shoulder (Contd)

Clavicle Fractures

Most common bony injury Most commonly middle 1/3 Non-union rare Figure-of-8 splint or sling 3-4 weeks < 12 yrs, 4-6 weeks adult Fractures with posterior dislocation require surgical consultation

Stinger/Burner (Brachial Plexus plexopathy)

Transient injuries to upper trunk (C5/6) Common in football traction on neck Return to play when asymptomatic

Neck

Cervical Sprain

Usually self-limitedlonger course with whiplash Muscle injury of neckxray (if done for trauma) negative Pain worse with motion Tenderness/ spasmtrigger points Neuro exam normal, no deformity in neck Ice/NSAIDs, early mobilization/return to activity Physical therapy if continued symptoms

Neck (Contd)

Neck Trauma

Fracture or ligamentous injury can result from high energy trauma Spine precautions for any patient with neck pain and mechanism, distracting injuries,or altered mental status, intoxication even without pain X-rays -AP, Lateral, and odontoid view standard Adequate film must have top of T1 (must see C7 clearly) CT scan if questions on x-ray

Neck X-ray Rules

High riskage >65, dangerous mechanism, neurologic symptoms Low risksimple rear-end collision, sitting in ER, ambulatory at any point since injury, delayed onset of pain, OR absence of midline tenderness If low risk, and patient can actively rotate neck 45 degrees to left and right, no xray needed

Compression Fractures

Traumatic

High energy trama Burst fracture (posterior 1/3 of vertebra) more common Rotation indicates instability Main goal is to rule out/prevent neurologic injury

Pathologic

Minor or no injury Most osteopathic in nature Consider multiple myeloma, metastatic disease Goals: Relieve paincalcitonin; ? role of vertebroplasty Prevent future fxs Minimize functional impact with early non-weightbearing exercise

Low Back Pain

Acute < 1 month

Usually sprain or overuse, injury often trivial X-ray if trauma Conservative Rx if no neurologic findings Early return to work Exercise when pain has diminished

Chronic > 3 months

Pain with movement X-ray, CBC/sed rate Conservative Rx if no neurologic findings: Support, NSAIDs, antidepressants, exercise, smoking cessation

Red Flags in Low Back Pain

Loss of bladder/bowel function; hematuria/dysuria Fever/weight loss/night sweats Neurologic findings Abdominal pain History of cancer Night pain with sleep disturbance Avoid narcotics and be willing to re-think your diagnosis

Hip

Dislocation

High energy trauma Most commonly posterior Sciatic nerve injury common Shortened, hip flexed, adducted and internally rotated Reduction ASAP

Lateral Femoral Cutaneous Nerve Syndrome

Numbness, burning of the lateral thigh Causes - obesity, tight clothing, tool belts, scar tissue Remove irritation, weight loss, operative release

Hip (Contd)

Snapping hip

Snapping or popping sensation with hip movement pain Commonly iliotibial band subluxation Reassurance, stretching, surgery for persistent pain

Trochanteric Bursitis

Pain and tenderness over the greater trochanteric bursa May radiate distallysimulates sciatica NSAIDs and stretching Steroid injection relieve 90% of cases

Osteoarthritis of Hip

Loss of articular cartilage Gradual onset of pain in groin or anterior thigh, limp Loss of internal rotation Standing x-ray to demonstrate joint space narrowing Treatment:

Conservative: Non weight-bearing exercise, acetaminophen first line, then NSAIDs, cane in opposite hand, heat/cold Surgical: total hip replacementolder patient, more severe symptoms

Knee

Anterior Cruciate Ligament (ACL) Tear

Usual injury hyperextension or twisting More common in women Patients report a pop effusion immediate Hemarthrosis but tap rarely indicated Lachmans more sensitive than anterior drawer

Segond fracture on Xray pathognomonic of ACL - avulsion fx of the lateral tibia Surgery indicated for most young, active patients Bracing may for older and less active individuals

Knee (Contd)

Posterior Cruciate Ligament

Commonly associated with other injuries Posterior force on proximal tibia Auto accident -knees into dashboard Posterior drawer test Surgical repair

Collateral Ligaments

Varus/Valgus force Tearing sensation Graded by joint space opening Grade 1 < 5mm Grade 2 - 6-10mm Grade 3 > 10mm

Knee (Contd)

Medial Collateral Ligament (MCL)

Conservative Rx for all gradeshinged brace for grade 3 Watch for unhappy triad
Injury to the MCL, ACL and medial meniscus

Lateral Collateral Ligament (LCL)

Conservative treatment for grades 1&2 Grade 3 LCL usually requires surgical repair due to posterolateral capsule injury

Knee (Contd)

Meniscal tears

Twisting injuries Insidious onset of swelling and stiffness Mechanical symptoms of locking, catching, and popping Pain along joint line most sensitive test

McMurray test- positive = painful click with flexion circumduction of the affected knee Rest,Ice,Compression, Elevation (RICE) Surgical repair or removal for persistent symptoms and pain MRI - useful if diagnosis is in question

Ottawa Knee and Ankle Rules for Acute Trauma

Ottawa Knee Rules

X-ray only if Age >55 or Tenderness head of the fibula Isolated patella tenderness Inability to flex to 90 or Inability to bear weight acutely and in office/ER

Ottawa Ankle Rules

Injuries < 10 days X-ray for acute ankle injury if pain near malleoli and Inability to bear weight acutely and in office/ER Bone tenderness at post. edge or tip of either malleolus

Ankle

Ankle sprain

Usually inversion Anterior Talofibular Ligament most commonly injured Deltoid ligament (medial) stronger High sprain = syndesmosis injury Xray -use Ottawa rules

RICE NSAIDs Early compression wrapping decreases swelling and hastens return to function Weight bearing as tolerated in air stirrup brace Proprioceptive

Foot

Ottawa Foot rules X-ray of foot for pain in the mid-foot area and:

Hallux Valgus

Tenderness at the navicular bone or Base of the 5th metatarsal or Inability to bear weight acutely and in the office/ER

Lateral deviation of the great toe Bunion formation Education + shoe modification- wide forefoot No treatment if asymptomatic Surgery for failed conservative treatment

Foot (Contd)

Plantar Fasciitis

Most common cause of heel pain in adults Degenerative tear in the fascial origin Not inflammatory Pain with first step in the morning Tenderness over the plantar medial calcaneal tuberosity

Heel spurs develop in 50% of patients but are not the cause of pain Stretching, ice, massage, heel pads steroid injection Surgical release consider for 6-12 months of conservative therapy

Pre-Participation Eval

General-vaccine update, Rx, previous head injuries, get info from parent and student athlete CV-FH of sudden death < 50, exercise Sx especially syncope Murmur of hypertrophic cardiomyopathy increases from supine to standing Focus musculoskeletal exam according to sport (e.g., football-neck,knee and ankle) Females-h/o amennorrhea; Males-PE for hernias, missing testicles

Drugs and Doping

AsthmaCromolyn, anticholinergics OK, inhaled steroids and inhaled Beta-2 agonists can enhance performance and must be declared by athlete Ask about roidsanabolic/androgenic steroid use is common, risky, and forbidden Ask about street drugsthey will be detected on most tests in use Doping with erythropoeitin to raise hemoglobin may cause stroke, HTN, seizures

Female Athletic Triad

Features: Amenorrhea, anorexia/bulimia, and osteoporosis All amenorrheic athletes should be screened for eating disorders Bone loss is lifelong effect Infertility, stress fractures, cardiac arrhythmias, sudden death

Findings suggesting eating disorder:

Excess dieting, weigh-ins,or concern about details of diet Disturbance of body image; food hoarding Evidence of self-induced vomiting Use of laxatives, diet pills, and diuretics Disproportion between weight, caloric expenditure and reported diet

Concussion

Multiple guidelines. Main concern is increased risk with repeated injuries

Mild: No LOC, no amnesia, brief confusionreturn to play after 20 minutes of no symptoms Mild-moderate: Confusion + amnesia less than 24 hours, no LOCmay play if no symptoms 1 week Moderate-severe: brief LOC + post-traumatic amnesiaoff one full month, then can play if well for at least 1 week Severe: LOC exceeds 2-3 minutesoff as above but must be well at least 2 weeks to return More severe injuries/repeated injuries require several months without sx before return to play