Diagnosis and Treatment of Orthopedic Disorders

1. Discuss the significance of the elements of history for orthopedic complaints and correlate injury or condition to
history of trauma
Age
Observation- gait, posture, disrobing, facial
expressions (not always dependable)
Sex
Inspection- alignment, deformity, swelling,

Occupation
erythema, symmetry, skin color, atrophy
Socio-economic background
Palpation- pain, masses, defects, muscle

Family history
tone/bulk
Past medical history (PMHx)
Motion- compare to uninjured side for range,
DM, infection, trauma
crepitus
HOW, WHY, WHEN, WHERE
Strength/Stability- muscle groups and isolated
PQRST
joints
Character
Nerves
When first noticed and by whom
Median tea drinking
Association with known injury or disease
Ulnar Intrinsics
Increasing
Radial Wrist extensors
Extent of disability
2. Explain the indications, contraindications, positive findings, and
limitations of the following studies:
a. Plain radiographs, tomography, and contrast radiography
a.Fracture assessment, soft tissue abnormalities
b.Anterior/Posterior(AP)+Lateral= minimal views
c. Oblique-sometimes useful, not always necessary
b. Ultrasound scanning
a.DVT, Masses, newborn hip dysplasia. Good for identifying superficial tissue problems, including
tendinopathy and synovial problems
c. Radioisotope scanning
a.Bone scan-technetium-99 (Occult/stress fxs)
b.Tagged WBCs- indium-111 (infxn)
d. Computerized tomography
a.delineation of fractures with or without contrast dye. most effective method for visualizing any
bony pathology, including morphology of fx.
e. Magnetic Resonance Imaging
a.Soft tissue imaging, joint fluid with or without contrast dye. Good for looking at ligaments,
cartilage, and soft tissues
f. Nerve conduction study
a.Movement d/o, numbness, paresthesias
g. Electromyography
a.Movement d/o, numbness, paresthesias
h. Arthroscopy
a.An arthroscope is inserted through one of three small incisions made in the patient's skin. The
arthroscope contains a small lens and lighting system to allow illumination and magnification of
structures inside the joint. The arthroscope can be attached to a television so the images are
larger and more clearly visible. With arthroscopy, the surgeon detects injury or damage and can
then decide if surgical repair is possible through the other accessory incisions that were made
to accommodate other surgical instruments.
i. Hematological and biochemical studies
a.CBC-infxn, anemia
b.Chemistry- Ca, Alk Phos, Potassium, Inc ALP when you have destruction of bone:osteomalacia,
pregnancy, hyperparathyroid, rickets
c. Serum proteins-myeloproliferative disorders
d.CRP, ESR-inflammatory markers
e.Urinalysis- rule out metabolic disorders (Bence Jones protein)
f. Histology of tissue biopsy (aspiration, needle, punch)
g.Joint aspiration (synovial fluid)- the gout, infxn
h.Wound cultures- organism ID and abx sensitivity
j. Biopsy
a.Performed to remove tissue or cells from the body for examination under a microscope. A bone
biopsy is a procedure in which bone samples are removed (with a special biopsy needle or
during surgery) to determine if cancer or other abnormal cells are present.
k. Myelogram

a. type of radiographic examination that uses a contrast medium to detect pathology of the spinal
cord, including the location of a spinal cord injury, cysts, and tumors. The procedure often
involves injection of contrast medium into the cervical or lumbar spine, followed by several Xray projections. A myelogram may help to find the cause of pain not found by an MRI or CT.
b.Myelography has been largely replaced by the use of CT and MRI scans.
l.

Arthrogram
a.An arthrogram is a series of images, often X-rays, of a joint after injection of a contrast medium.
The injection is normally done under a local anesthetic
b.Patients who are allergic to or sensitive to medications, contrast dyes, local anesthesia, iodine,
or latex should not have this procedure
m. PET scan
a.Useful in identifying metastatic malignant lesions
b.A positron emission tomography (PET) scan is an imaging test that uses a radioactive substance
called a tracer to look for disease in the body
n. Arthrocentesis
a. To rule out infxn
b.CI if INR>3.0
3. List the six common non-operative methods of treatment of orthopedic conditions and correlate one clinical
scenario to each treatment modality
a. Modification of activities , Ice, Compression, Elevation (RICE)
b. Medications- PO, Injectable- tendinitis
c. Therapy- adhesive capsulitis
d. Immobilization
a.Braces, splints, appliances- carpal tunnel syndrome
b.Casts- plaster, fiberglass- broken bones
e. Traction- shortened, closed fx of metacarpal
f. Massage- sore muscles
g. Acupuncture
h. Osteopathy
4. Define the following surgical interventions and list two indications and complications of each:
a. Synovectomy
d. Arthroplasty
a. Surgical removal of synovial
a.Joint replacement or reshaping
membrane of a synovial joint.
b. Used in severe arthritis
b.Used in arthritis that is
e. Bone grafting
refractory to medications
a.Autograft-self,
b. Osteotomy
homograft=allograft/xenograft,
a. A bone is cut to shorten,
heterograft-different species
lengthen, or change its
f. Tendon grafting
alignment
a. Replacement of torn tendon in
b. Used in Hallux valgus
ACL tear.
c. Arthrodesis
g. Equalization of leg strength
a.Fusion of a joint
a. Strengthening of leg that hasn't
b. Used to treat pain caused by
been used for example in a
the motion or instability of the
Knee replacement
spine
h. Biopsy
a.To check for cancer in bones
5. Discuss the indications for rehabilitation following orthopedic surgery.
a. To restore muscle strength and mobility. To increase blood flow to areas and to promote healing.

General Orthopedic Disorders

1. Discuss the differences between congenital and acquired deformities
a. Congenital= abn dev present at birth.
Occurs from:
b. Acquired= arising after birth and may or
i. Embryonic development
may not be progressive
ii. Uterine malposition
i. Medications
iii. Medications
ii. Genetic defects
iv. Genetic defects
iii. Environmental influences
v. Environmental influences
iv. Combination of above
vi. Combination of above
2. List the top 4 types of bone dysplasias and malformations
a. Clubfoot
iv. Tx=serial casting, bracing, surgical
i. Most common (1/800 births)
release
ii. 10% genetic
b. Metatarsus Adductus
iii. males >females
i. Frequently mistaken

ii.

for clubfoot
Tx=none

c.

Hip dysplasia
i. Dislocation due to
Under development
ii. Females>males
iii. D/L may occur after birth
iv. Tx= reduction, Pavlik brace,
casting
d. Spina bifida
i. 1-2/1000 births
ii. Laminar defect

iii.

Tx= surgical closure if

myelomeningocele present, shunt
for hydrocephalus, supportive care

e. Others
i. Osteogenesis imperfecta
1. Brittle bone disease
2. Tx=bisphosphonates, fx
management, prevention
of fx
ii. Polydactyly (extra digits)
1. Tx= ligation, surgery
iii. Syndactyly (fused digits)
1. Tx=ligation, surgery

ORTHOPAEDIC INFECTIONS (BOARDS)

Bizz-buzz Bugs
Vibrio vulnificus: Katrina calf
Mycobacterium marinum: fish tank granuloma
Sporothrix: rose thorn injury
Pasturella multocida: dog and cat bite with rapid evolution
Salmonella (non-typhi): reptile bites and exposures
Salmonella osteomyelitis: Sickle cell disease
Erysipelothrix rhusiopathiae: fish mongers hand (fins slice your webspace)
Bartonella Henselae: cat scratch dz
Eikenella c: human bite
STAPH & STREP: most common!
Acute / Chronic Osteomyelitis
o Essentials of Dx (Acute):

Fever and chills associated with pain and tenderness of involved bone

Dx usually requires culture of bone biopsy

ESR often extremely high (>100mm/h)

Radiographs early in course are typically negative

o Definition/Etiology:

Infection of bone that leads to tissue destruction and often debility

Bacterial causes:

S. aureusmost common

P. aueruginosa, E. coli, M. tuberculosis

Fungal causes: Candida, Coccidioides, Histoplasma, and Aspergillus

Organism reaches bone through:

Hematogenous dissemination of bacteria (bacteriema d/t endocarditis, seeding from abscesses, boils,
vascular devices, etc.)

Invasion from contiguous focus of infection (prosthetic joint replacement, decubitus ulcer, neurosurgery,
and trauma)

Skin breakdown in setting of vascular insufficiency (DM patientsfoot and ankle most commonly affected)
o Chronic:

Characterized by formation of necrotic bone (sequestrum) harboring colonized bacteria

Typically due to untreated infection or untreated trauma > 2 wks

Nontyphoidal salmonaellae may cause chronic infection of long bone in sickle cell patients

Cierny and Mader classification:

Type 1: Endosteal or medullary lesion

Type 2: Superficial osteomyelitis limited to surface

Type 3: Localized, well-marked lesion with sequestration and cavity formation

Type 4: Diffuse osteomyelitis lesions

o Clinical Symptoms:

History of prosthetic joint implants, stabilization devices, or injury

Acute vs. chronic

Acute:
Long bone (kids)
Abrupt onset of fever
Fatigue, Irritability, or Malaise
Vertebral (adults)
Hx of acute bacteremic episode
May be associated with contiguous vascular insufficiency

Chronic: Chronic fatigue

Findings:
Guarding and limited use of affected limb
Focal bone tenderness over area of infection
Acute vs. chronic

Acute:
Local edema, erythema, calor (warmth), and tenderness
Long boneRestriction of movement
VertebralFailure of young child to sit up normally

Chronic:
Non-healing ulcer
Sinus tract drainage
Increased local pain
Lab/ Radiologic Evaluation- Findings:

CBC w/WBC and differential

X-ray (AP and lateral)important to r/o other conditions

Can confirm w/ bone scan, indium scan, MRI or CT

Needle aspiration

Culture of wound swablimited use with bacterial causes

Bone biopsy required unless hematogenous osteomyelitis with + blood cultures

ESR to test S. aureus infections

Treatment:

Empiric ABX for S. aureus or Streptococcus and adjust as necessary for definitive

ABX therapy usually 4-6 weeks (IV), followed by oral for 6-8 wks

Chronic osteomyelitis may require frequent interval of long-term ABX

Surgical Tx:

I & D of necrotic bone and avascular, devitalized tissue + ABX

Adequate soft tissue coverage with split thickness skin graft or muscle flaps

Restoration of blood supply

Hyperbaric oxygen therapy can promote collagen production, angiogenesis and healing in ischemic or
infected wound

May lead to amputation if severe

PE

TUMORS

Osteochondritis? I think this means osteochondritis dissecans. It is below. Page 22 or so

o Epidemiology
o Radiographic
o Histologic
Osteoid osteoma
o Epidemiology
benign bone tumor that arises from osteoblasts.
demographics

5-30 years (mostly in the second decade of life)

2:1 male to female ratio

location

50% in diaphysis or metaphysis of long bones of lower extremity (tibia, femur)

proximal femur > tibia diaphysis > posterior elements of the spine > fingers and carpus > feet

the most common location is the proximal femur

the most common intra-articular location is the hip joint

the most common locations in the hand are the scaphoid and proximal phalanx
Symptoms

pain that
increases with time
worse at night and with drinking ETOH (aching night pain)
relieved by NSAIDS (Aspirin!)
may be adjacent to joint and mimic arthritis

hand lesions may present with painless swelling

Physical exam

joint effusions

contractures

limp

muscle atrophy

may present as painful nonstructural scoliosis

as a result of paravertebral spasm
osteoid osteoma is located on the concave side at the apex of the curve
Radiographic
intensely reactive bone around radiolucent nidus

nidus is < 1.5 cm (otherwise osteoblastoma)

nidus may be difficult to see on plain xray
because intense periosteal reaction may obscure the nidus
CT = study of choice = to identify nidus surrounded by a sclerotic rim

Bone scan = Always hot with intense focal uptake

Histologic
Characterized by

distinct demarcation between nidus and reactive bone

nidus contains uniform osteoid seams of immature osteoid trabeculae (woven bone) with a sharp
border of osteoblastic rimming

uniform plump osteoblasts have regularly shaped nuclei with abundant cytoplasm

reactive bone seen in region of sclerotic border

similar appearance to osteoblastoma

no pleomorphic cells, and does not infiltrate surrounding bone

Benign cystic changes- WTF
o Epidemiology
o Radiographic + Histologic

Bone Cancers
Definition/Etiology:
o Classified as either benign or malignant, differentiated histologically
Benign:
o > 200 types; much more common than malignant
o Non-aggressive with diminished tendency for recurrence or metastasization
o Most common types: Osteoid osteoma, Enchondroma, Osteochondroma, Giant cell tumor of bone
Malignant:
o ~ 90 types; much more rare
o AKA Osteosarcoma, Multiple Myeloma or synovial cell sarcoma

Multiple Myeloma: most common primary bone cancer

Labs: Bence-Jones protein, hypercalcemia, proteinuria

M-Spike

Mnemonic: CRAB
Ca2+ hypercalcemia
Renal Failure
Anemia
Bone pain
o High risk in patients previously w/ retinoblastoma
o Aggressive tumors which invade nearby tissues, have destructive growth patterns and metastasize to other
organs
o Most common primary malignant neoplasm: Osteosarcoma, Chondrosarcoma, Ewing sarcoma, Lymphoma of
bone
o Develop through dysfunction of oncogenes, tumor suppressor genes, and other genes that contribute to cell
proliferation or apoptosisresults in tumor formation
o Classified as primary (originates in bone) or secondary (metastasized from another location)
Clinical Symptoms:
o Persistent skeletal pain, swelling, and tenderness
o Ewings seen in pelvis OR diaphysis of long bones
o Pain may occur with or without limiting ROM in nearby joint
o Spontaneous pathological fractures
o Suspicious areas of bony enlargements or deformities
PE Findings:
o asymp or present w/msk pain in affected area
o Some tumors highly correlate in occurrence with specific age groups

Benign = younger patients

Malignant = older patients

Pain typically deep and dullacute more likely malignant; chronic more likely benign
Pain initially intermittent, but can be constant
Mass may be palpated over area of concern
If painless usually benign
Increasing size may affect bone strength, nerve impulses, and displace nearby tissues
Rapid growth= malignancy
Surrounding redness, warmth, and evaluation of surrounding lymph nodes aids in Dx
Systemic symptoms (paroxysmal night pain, fever, wt loss, anorexia) require further evaluation for cancer
metastasis
Lab/ Radiologic Evaluation- Findings:
o Plain X-ray with AP & lateral views is diagnostic

Distinct borders typically benign

Poorly defined edges or a moth eaten appearance typically malignant

Classic findings of various tumors:

Punched out skull = multiple myeloma
Sun burst appearance = osteosarcoma
Metaphysis of Long Bones
Age 10-20
Onion peel effect = Ewing sarcoma
Age 5-25 y/o
o Isotope bone scanningassess degree of osteoblastic activity

Very sensitive; preferred over skeletal surveys. Also, monitor progression of therapy
o CT best for small tumors involving cortical structures
o MRI best for BM involvement and on-calcified soft tissue lesions
o Bone biopsy = gold standard for Dx

Performed after PE & XRAY

Treatment:
o Medication:

Neoadjuvant chemotherapy PRN

70% survival rate at 5 years IF NO METASTASIS for both

NSAIDs = pain assoc w/osteoid osteomas

Chemical cauterization w/Phenol

Procedures:

Surgical resection

Interstitial laser photocoagulation

Cartilage curettement

Cortical windowing

Bone grafting or Radiation

o
o
o
o
o
o
o
o

Inflammatory soft tissue lesions

a.

Soft tissue tumors

Soft tissue sarcoma
a) Types
i) synovial sarcoma
ii) liposarcoma
iii) rhabdomyosarcoma
iv) fibrosarcoma
v) leiomyosarcoma
vi) angiosarcoma
b) Sx
i) Enlarging painless mass
c) PE
i) Palpable soft tissue mass
ii) Size >5cm in cross section is a poor prognostic factor
d) Imaging
i) Obtain radiographs in 2 planes
ii) MRI- diagnostic in Lipoma, neurilemoma (schwannoma), intramuscular myxoma.
iii) If MRI=diagnostic, can remove mass without biopsy.
iv) If MRI is indeterminate or suggestive of sarcoma, do a core needle or open biopsy
e) Tx
i) Based on a tissue diagnosis unless images are diagnostic
ii) Operative- radiation therapy & wide surgical resection.
(1) Indications

(a) Standard of care in most cases

(2) Radiation
(a) Adjunct to surgery decreasing local recurrence.
(b) Radiotherapy must be given pro- or post- operatively.
(3) Chemo
(a) Controversial for soft tissue sarcoma
(4) Surgical resection
(a) Must confirm border free of disease with histology.
iii) Recurrence
(1) Following resection the most common location for recurrence of a low grade, soft tissue sarcoma is
locally.
Arthritis (Osteoarthritis)
Histological findings
o Lymphocytes, plasma cells, macrophages, increased colonies of regenerating cartilage cells. basically an
immune reaction.
Radiographic findings
o Narrowed joint space
o Osteophyte formation
o Increased density of subchondral bone
o Bony cysts
Heberdens nodes or Bouchards nodules

Fractures
1. Diagram the following fracture classifications
and list the mechanism of injury and required
for each fracture type:
a. Closed/Open
i. Bone protruding though the
skin/ bone not protruding. Can
occur with any trauma such as
motor vehicle accident.
b. Transverse
i. Broken straight across the
bone, result of sharp direct
blow, or may be a stress
fracture from prolonged
running
c. Oblique
i. Fracture in which the line runs
obliquely to the axis of the
bone. Caused by falls, or other
trauma
d. Spiral
i. Occurs when torque is applied
along the axis of a bone,
planes perpendicular to this
axis are not affected.
e. Comminuted
i. A bone injury that results in
more than 2 separate bone
components. May have a
"butterfly" fragment. From high
impact injury
2. Fracture pattern
a. Angulation
i. Bone broken at angle. Usually
long bones.
b. Displacement
i. Fracture with loss of bone
alignment along its long axis.
Can also cause shortening of a
long bone.
c. Rotation
i. Fracture that causes the bone
to rotate on itself.
d. Varus/Valgus
i. Varus=bowlegged. Part of bone
past joint (knee in this case)
goes "inward"
ii. Valgus=knock-knee. Part of
bone past joint (knee in this
case) goes "outward"

3. Site
a.
b.

c.

Diaphyseal
i. Break along shaft of a long
bone. MVA or sports collision
Metaphyseal
i. Break in area between
diaphysis and epiphysis.
Usually occurs in kids <2 from
jerking or swinging motion.
Epiphyseal
i. Fracture of growth plate.
Weakest area of skeletal
muscle. "Salter" fracture
ii. SALTR (slip, above, lower,
through, ram)
iii. Epiphyseal plate is weak and
can give way before the bone
in an immature skeleton
iv. Potential for growth
disturbance increases as
you go up in the
classification (very
bad with LE injuries)
worse w/ SH IV and V
v. SH II is the most common
vi. SH V rare (1-2%)
vii. SH V and I can have normal
x-rays

4. Other
a. Compressions
i. Fracture occurring from trauma
(ejecting from an ejection seat)
or weakening of the vertebra,
for example in osteoporosis
b. Avulsion
i. Occurs when a fragment of
bone tears away from the main
mass of bone as a result of
physical trauma
c. Greenstick
i. Usually when a young bone
bends and partially breaks.
This occurs due to thick fibrous
periosteum of immature bone.
d. Pathologic
i. Broken bone from disease
leading to weakness of bone.
Most commonly from falls and
osteoporosis

5. List 5 common treatments for fractures and for each method list the most common type of fracture it is used
for, its risks and benefits, and the possible complications of the therapy
a. Support (splinting or bracing) - Used for minor fractures or smaller fractures such as a non
complicated finger fracture.
b. Casting - to protect patient from moving to allow healing. Low risk of infection since it is not invasive.
c. Traction - used to return long bone to original shape. Used to lengthen a long bone after an angulated
fracture.
d. External fixation - Used to repair broken bones with rods and pins outside of the skin. Limited duration.
Risks include patient may not take proper care of wires or pins. Indicated in severe open fractures.
e. Internal fixation- Plates or other objects used under the skin. Don't need to be taken out. Used in
serious fractures such as comminuted or displaced fractures or in cases where the bone would otherwise
not heal correctly with casting or splinting alone. Risks include bacterial colonization of the bone,
infection, stiffness and loss of range of motion.
Important Fracture Notes

Child abuse
o Bucket handle or Corner Fractures
o Posterior rib fractures
o Bruises NOT over bony prominences
o Bruises or fractures not consistent with the childs level of mobility

Compartment Syndrome
5 Ps: pain, paresthesias, pallor, paralysis, pulselessness
Fracture risk:
o Pediatrics: supracondylar humeral fracture
o Adults: tib-fib fracture

HIP
Degenerative arthritis OSTEOARTHRITIS
Clin features
o Bouchard nodes pip
o Heberden dip
Labs and films
o No crystals, no wbc, no uric acid, normal cbc.
o Narrow joint spaces. Peripheral osteophytes, chondral irregularity. Chondral irregularity. Boney cystic changes
Tx
o Wt loss. Exercise. Heat/cold therapy. Tylenol. NSAIDs. Injection (steroid vs Synvisc)
o Surgical

Hemiarthroplasty of one compartment

Total joint arthroplasty if two or more compartments of the joint

o NSAIDS
o Cox 2 inhibitors safer for GI. Celebrex
o Tx is pain control
Avascular necrosis
Loss of blood supply. Chronic limp and hip/groin pain. Pain may radiate to knee.
Causes
o Steroids, injury/dislocation, sickle cell dz, alcohol abuse, pancreatitis, bends (bubbles of nitrogen obstructing
the flow).
Tx
o May result in TOTAL HIP replacement. Hold off as long as possible if you can.
o Protect weight bearing
Trochanteric bursitis

Clinical points
o Swelling of bursa around trochanter, may be due to repetitive microtrauma caused by dynamic use of the
muscles that insert on the greater trochanter
o Inflammation or irritation of the bursae surrounding the hip may lead to symptoms.
Sx = Tenderness to palpation over the tip of the lateral or posterior aspects of the greater trochanter
Dx = MRI will show increased signal in bursa due to inflammation on T2 sequence
Tx
o Nonoperative

NSAIDS, stretching, PT including modalities, corticosteroid injections

Indications = first line treatment is always conservative

o Operative

open vs arthroscopic trochanteric bursectomy

indications = is done only after conservative measures fail

Hip dislocation
o 98% are posterior.
o Typical position= (internally rotated) IR + flexed. Knee vs dashboard and falls. Relocate ASAP to avoid AVN.
Post column fx common. Procedural sedation required.
Hip fracture (intertrochanteric and femoral neck)
o Neck fx-old ladies
o Intertrochanteric fx=most common
o Subtrochanteric fx= high forces MVC
o Repair can be a quick 2-3 screws if NOT displaced neck, or require ORIF if displaced or more serious. If needed
CT or MRI(better)
o Comorbidities require admission to internal medicine doc for elderly pts w/neck fx
o Complications

Infection

DVT

Pulmonary embolism

o Dx tests: CT or MRI (MRI better)

Snapping hip
o Snapping that occurs as the iliotibial band subluxes over the greater trochanter or the iliopsoas tendon
subluxates over the pectineal eminence of the pelvis. Most common in women, especially women athletes
o Sx

Occurs with ambulation or rotation of the hip. Some may have pain at the trochanteric bursa. Pain when
moving from a flexed to an extended position.
o Exam

Have patient stand, adduct, and rotate the hip. The snap is palpated over the lateral hip as the iliotibial
band subluxates over the trochanter
o If suspect intraarticular problem. do Xray

Xray is usually normal. MRI arthrogram if you suspect a labral tear

o TX

Activity precautions. Phys therapy. NSAIDS. Steroid injection.

Femur fx
o High forces MOI. Compartment syndrome is rare. Midshaft is most common.
Pelvic Fractures
o Stable

Tx: typically heal with rest

o Unstable

Blood loss is big issue: 1-2L typically

Most bleeding is venous

Tx: pelvic binders vs. surgery vs. angio

Resuscitate, Type and Cross, Stop bleeding

Developmental dysplasia of the hip
o The neonatal hip is relatively unstable, which may lead to sub-luxation or dislocation; lack of concentric
positions for the acetabulum and femoral head may lead to dysplasia
o Incidence is <1 per 1000 per year, less common in African American children and more common in some North
American Indian tribes; increased risk in patients with family history, breech presentation, female gender,
large fetal size, and first-born infants
o Infant is asymptomatic
o Physical exam shows positive Ortolani or Barlow test;

in the Ortolani test, the hip is out and pops in with abduction and anterior force;

the Barlow test is the oppositethe hip pops out with adduction and posterior force
o Radiographs are not helpful in the newborn but become useful at 46 mo when the ossific nucleus of the
femoral head appears; ultrasound may be useful but clinicians must be careful of false- negative results
before 10 wk
o Treatment

Infants aged 06 mo: Pavlik harness may induce spontaneous reduction of the hip; a 1-mo trial is
warranted

Infants 615 mo: perform gentle closed reduction under anesthe- sia followed by spica cast application

Children 15 mo to 2 y: open reduction of the hip is necessary, and femoral shortening may be required,
followed by spica casting

Older children require significant surgical interventions to achieve and maintain a reduction of the hip;
these vary from case to case
Legg-Calve-Perthes Disease
o Avascular necrosis of the hip in children aged 410 y

Avascular necrosis may be a result of thrombosis from thrombophilia

o Considered as a pre- osteoarthritis and prognosis depends on level of damage.
o Stages (radiographic findings evolution)

Initial = shrinkage of ossific nucleus

Next = fragmentation (there are areas of both radiolucency and radiodensity within the capital femoral
epiphysis, generally during the first 6 to 9 months)

Re-ossification or healing of femoral head

Areas of increased radiodensity are seen in regions that were radiolucent, along with changes in the
shape of the femoral head, neck, and acetabulum.

Residual deformity; permanent changes in morphology

o More common in males than females; self-limited and usually unilateral

If bilateral hip involvement, will see similar changes in wrists and knees.
o Affected children are usually small for age
o Child usually presents with a painless limp; if pain is present, it may be referred to the thigh or knee
o PE shows hip flexion contracture of 030 degrees, with decreased abduction and internal rotation
o Imaging

Radiographs are normal early in the disease course, with progressive fragmentation, irregularity, and
eventual collapse of the femoral head.

A subchondral fracture (crescent sign) may be identified on the frog lateral.

Bone scans and MRIs are of little value

Labs

Commonly performed in children who present with a limp, including a CBC with a differential, ESR, and
CRP.

Additional studies such as Lyme titer, RH, antistreptolysin O titer, and ANA
Treatment

Children with bone age <5 y and minor involvement do not need treatment

Bracing or surgery is recommended for older children and those with more advanced disease

Poor prognostic signs are age 8 y, abduction <15 degrees (stiff- ness), >50% of head involvements, and
subluxation or lateral calcification

Treatment has no effect on outcome if patient has a chronologic age 8 y at onset of the disease

Slipped capital femoral epiphysis (SCFE)

o Etiology

Etiology may involve several factors.

Idiopathic

Hypothyroidism

Hypopituitarism

Progressive displacement of the upper portion of the femur relative to the capital femoral epiphysis.

Weakening of epiphyseal plate of the femur resulting in displacement of femoral head.

o Essentials

The condition most commonly occurs in adolescent boys (Age 12-14)

Common in African Americans and Asians

When affected, girls are often younger than boys.

Pain in the groin, anterior thigh, or knee. (Present with painful limp for 1-3 months)

Inability to bear weight

Can be acute (painful, prevents walking), chronic (over several months), or acute on chronic

Classified as stable vs. unstable

Unstable risk of avascular necrosis. Poor outcome d/t premature joint degeneration.

Typical patient is overweight and in early prepuberty

o Diagnosis & imaging

Evaluation of the hip is necessary in any child aged 915 y with knee pain; children with SCFE have loss of
internal rotation of hip and obligatory external rotation with flexion of the hip (diagnostic)

Radiographs are diagnostic in most cases; frog lateral view is most helpful because the slip is always
posterior

If a Klein line drawn along the lateral femoral neck (AP view) or anterior femoral neck (lateral view) does
not intersect any portion of the epiphysis, the child has SCFE
o XRAY findings

X-rays demonstrate slipped epiphysis

First sign is widening of the physis

Later can note displacement of head posteriorly (most of the time)

o Treatment

Consists of pinning the hip in situ with 12 pins

Reduction of the slip, even in acute SCFE, risks causing avascular necrosis of the epiphysis; another
complication, which may be iatrogenic from pin penetration, is chondrolysis of the articular surfacesthe
higher the degree of slip, the earlier osteoarthritis will develop

Most cases are idiopathic, but endocrine abnormalities should be considered (ie, hypothyroidism)

KNEE
Ottowa Knee Rule- acute pain/injury Knee Xray indications
Age >/= 55
Isolated patella tenderness
Tenderness at head of fibula
Inability to flex knee 90 degrees
Inability to bear weight (4 steps) immediately after injury and in emergency department
Lesions of the meniscus
Clicking and locking. May have effusion acutely. Exam > MRI for lateral meniscus. Apley's grind test. McMurray's
test. Arthroscopic repair possible.
Discoid meniscus
o Abnormal dev of the meniscus leads to hypertrophic and discoid shaped meniscus.
o AKA popping knee syndrome
o Classes

Type 1-complete

Type 2-incomplete

Type 3- Wrisberg (lack of posterior meniscotibial attachment to tibia)

o Presentation

Pain, clicking, mechanical locking.

Often becomes symptomatic in adolescence

o Physical exam

mechanical symptoms most pronounced in extension

o Radiograph

widened joint space due to widened cartilage space (up to 11mm)

MRI = Dx can be made with 3 or more 5mm sagittal images with meniscal continuity.
o Tx

Nonoperative

Observation = indicated for asymptomatic discoid meniscus without tears

Operative

partial meniscecetomy and saucerization

indications
pain and mechanical symptoms
meniscal tear or meniscal detachment
technique
obtain anatomic looking meniscus with debridement
repair meniscus if detached (Wrisberg variant)
Meniscal tears
o Definition

Meniscal tears occur on one of the two fibrocartilaginous pads atop the tibial plateau, which act as shock
absorbers between the femoral condyles and the tibial plateau. There is a medial and lateral meniscus.
o Etiology

Meniscal tears are often the result of a twisting injury, particularly in younger patients

Older patients with more degenerative menisci may have little or no trauma.
o PE

A history of a twisting injury (in younger patients) or a minor injury in older patients

Knee swelling and pain may develop over the next 24 to 72 hours following the injury.

Patients may note mechanical symptoms, such as locking or catching or a painful popping.

Motion may be limited, and patients often report pain at night, especially if the knees touch when lying on
their side.

Tenderness over the medial or lateral joint line

Knee effusion

Loss of full extension or loss of flexion

Positive McMurrays test or positive Apley grind test

o Dx

AP and lateral and axial patellofemoral knee x-rays to rule out fracture or patella subluxation

MRI to determine if there is a torn meniscus

o Tx

In the case of a degenerative tear initial treatment should be rest, ice, compression, and elevation (RICE)

Non-narcotic oral analgesics to reduce initial pain

Degenerative tears that do not respond to conservative treatment should be considered for arthroscopy.

Patients will require physical therapy to restore motion, strength, and stretching.
o Complications

Older patients with degenerative tears may find that their symptoms become recurrent and that the only
definitive treatment will be arthroscopic evaluation and treatment.
Osteoarthritis may be a late complication of subtotal or partial menisectomy.

Pseudogout
Calcium pyrophosphate dihydrate crystals. mimics gout.
Big crystals. Rhomboid.
Sx
o Acute onset joint tenderness, warm red joint. knees and wrists common
PE
o red, monoarticular arthritis. tender
Imaging
o may see calcification of fibrocartilage structures
Tx
o ACUTE nonoperative. NSAID. Splints for comfort
o CHRONIC nonoperative. intraarticular yttrium-90 injections. Colchicine (0.6mg PO bid for recurrent cases).
prophylactic colchicine can help to prevent recurrence
Baker cyst
Normal anatomic structures that represent a bursal sac between the semimembranous and medial head of the
gastroc
May inc in size in the presence of meniscal tears or degenerative arthritis.
Sx
o fullness and mild pain
o ruptured cyst may cause pain and swelling in the calf from fluid leakage
Dx
o Found on MRI or US
Tx
o None if asymptomatic
o Can aspirate or inject with cortisone
o May recur
o Generally resolves spontaneously if intra-articular pathology assessed
o Rarely requires surgical excision
ACL Tear
Definition= An ACL tear results most often from a rotational force or hyperextension placed on the knee that
exceeds the strength of the ligament.
Happens in active, young adults.
Clin Hx
o Sudden onset of pain following a twisting or hyperextension injury to the knee.
o 1/3 of patients hear an audible pop
o Swelling occurs after the injury usually due to a hemarthrosis
o If meniscal injuries occur, they will continue to cause pain and intermittent swelling
PE
o The Lachman test is performed by flexing the knee to 25; while the femur is stabilized, the tibia is gently
pulled forward. The most important element of the test is not how much anterior translation one feels, but how
it compares to the normal side.
o Anterior drawer is not as sensitive
o Check for injury to MCL and Menisci
Dx
o Lachman test MOST SENSITIVE for determining ACL instability
o R/O fracture with x-ray
o History and physical exam can usually confirm the diagnosis but an MRI, if needed, is able to demonstrate an
ACL tear
Tx
o Initially, RICE, partial weight bearing, and a knee immobilizer
o Aspiration if effusion
o Early ROM exercises
o Surgery = Definitive treatment of an ACL tear is arthroscopically assisted surgical reconstruction of the ACL,
using autograft or allograft.
o Following surgery use of knee immobilizer, then ACL brace and PT.
Complications
o Untreated, and if instability and buckling occurs, the patient risks suffering a second and more devastating
knee injury creating a multi-ligamentous unstable knee.Prognosis
o Untreated and with continuing instability, patients also risk developing traumatic arthritis of the knee.
o Use of ACL brace is important in the post-operative phase until adequate strengthening has occurred.

Prognosis
o Good if treated adequately

Medial collateral ligament tear

MOI
o Injury to the knee, usually the result of a valgus stress, which produces a force great enough to tear the medial
collateral ligament (MCL)
o The mechanism of injury to produce an MCL tear or strain is generally a valgus (abduction) force without a
rotational component.
o Can occur with ACL tear
Clin hx
o Able to ambulate after injury and may return to play for the rest of activity.
o Some localized swelling
o Ecchymosis
o Locking, popping, or frank instability usually does not occur with this injury
PE
o Swelling+ ecchymosis
o palpate MCL for tenderness best done with the leg in the figure 4 position
o Grade 3 tears open >10mm on the affected knee and grade 2 tears open >5mm
Dx
o AP and lateral x-rays to rule out other fractures and occasionally a small avulsion fracture from the origin of
the MCL on the distal femur
Tx
o Isolated MCL tear treated conservatively
o Grade I strains resolve spontaneously in a few weeksrest, ice, compression, elevation (RICE)followed by
crutches to protect the knee.
o Grade II tears require use of a hinged brace until a gradual return to full weight bearing is tolerated.
o Grade III tears require the use of a hinged brace with a gradual return to full weight bearing over a period of 4
to 6 weeks.
o Grade III injuries will need 3 to 4 months of protected bracing before a return to unrestricted activities.
o Physical therapy requires an early range of motion activities (bicycling) and quadriceps and hamstring
strengthening.
complications
o Patients should be advised as to the importance of physical therapy post-injury, particularly if they plan to
return to high-demand activities. prognosis
o It is important to fully evaluate patient and avoid missing associated diagnoses (ACL tear, meniscal tear).
Lateral collateral ligament sprains
MOI
o Force that pushes the knee sideways. Often contact injuries.
o Not as common as medial injuries. A sprain occurs when a joint is overstretched.

First degree sprain - is a tear of only a few fibers of the ligament.

Second degree sprain - is a tear of part of a ligament, from a third to almost all its fibers.

o Third degree sprain - is a complete tear of the ligament.

PE
o Pain. swelling, bruising. decreased ability to move the limb.
Dx
o Made by PE. Xray may be used to make sure other fractures are not present. If a tear in the ligament is
suspected, then an MRI or arthroscopy is obtained. MRI is usually ordered after swelling has subsided and can
readily identify the presence of a ligament injury
Tx
o RICE. The joint should be exercised fairly soon.
o NSAIDS may help
o Avoid weight bearing at first then increase it gradually.
complications
o Prolonged immobilization delays healing of a sprain. It leads to muscle atrophy and a stiff joint.
prognosis
o Prognosis is good

Posterior cruciate ligament tears

o MOI

Direct blow to proximal tibia with flexed knee (dashboard injury)

Noncontact hyperflexion with plantar-flexed foot

o Clin hx

dashboard injury. hyperflexion athletic injury.

o
o

PE

Posterior drawer test.

Dx

Radiographs

AP and lateral

kneeling stress radiographs of knee

MRI

Classification based on posterior subluxation of tibia relative to femoral condyles (with knee in 90 flexion)

Grade I
1-5mm posterior translation of tibia

Grade II
6-10 mm posterior translation of tibia

Grade III
>10 mm posterior translation of tibia
Tx

Nonoperative

protected weight bearing & rehab

indications = isolated Grade I and II injuries
technique
follow with quadriceps rehabilitation
can return to sports within ~4 weeks

extension brace for 2-4 weeks

indications = isolated Grade III injuries
technique
followed by quadriceps rehab
may choose surgery if bony avulsion or a young athlete

Operative

PCL repair or reconstruction (ORIF for bony avulsion)

indications
combined ligament injury (PCL injury with with ACL or PLC injury)
isolated grade II or III with bony avulsion
postoperative rehabilitation
immobilize in extension early and protect against gravity
early motion should be in prone position
follow with quadriceps rehabilitation

high tibial osteotomy

indications = chronic PCL deficiency
technique
consider medial opening wedge osteotomy to treat both varus malalignment and PCL deficiency
when performing a high tibial osteotomy in a PCL deficient knee, increasing the tibial slope helps
reduce the posterior sag of the tibia

Surgery techniques

Arthroscopic repair
transtibial from front to back
risk of popliteal vessels
fix graft in flexion

Open (tibial Inlay)

used for ORIF of bony avulsion
uses posterior-medial approach between medial head of gastroc and semimembranosis
biomechanic studies show less graft attrition and failure

Two bundle technique

may be utilized in both arthroscopic and open techniques
leads to improved stability in flexion and extension
anterolateral graft tensioned in 90 of flexion
posteromedial tensioned in 30 of flexion
Complications

Popliteal artery injury

popliteal artery lies just posterior to the insertion of the PCLon the tibia, separated only by the posterior
capsule. Therefore care must be taken when drilling the tibial tunnel
Disorders of the extensor mechanism I looked for this a lot but all I found was that "extensor mechanism injuries"
were quadriceps tendon rupture. Which is under Rupture of the extensor mechanism below

Chondromalacia patella
Anterior knee pain due to softening and degeneration of the articular cartilage of the patella
may have knee effusion, tenderness on the undersurface of the patellar crepitation.
Plain xray of the knee. most helpful views are standing AP, lateral, and merchant or sunrise views.
TX
o conservative
o muscle strengthening activities
o occasionally patella taping helpful

patella bracing helpful

injection helpful

symptoms may be refracted in therapy, especially in the young, active patient

Recurring patellar subluxation/ patellar instability
MOI
o The kneecap slides up and down a groove on the end of the thigh bone as the knee bends.
o patients who experience an unstable kneecap have a kneecap that does not slide centrally within its groove
o Instability of the patellofemoral joint covers a range of pathologic conditions of the knee, ranging from
malalignment of the patella and its relation to the distal femur to recurrent subluxation and dislocation of the
patella.
Clin hx
o Causes

Wider pelvis

A shallow groove for the kneecap

Abnormalities in gait
o Dislocation or subluxation results in severe knee pain; often patients will report hearing or feeling a pop and
will see a deformity of the patella with dislocation.
o With a frank dislocation, the patient maintains the knee in a flexed position.
o The patella often reduces spontaneously with some degree of relief.
o Marked swelling of the knee
PE
o If the patella has not spontaneously reduced, there will be a lateral deformity of the knee.
o Marked apprehension signs with any attempts by the examiner to move the patella laterally.
o Reduced range of motion in extension and flexion due to pain
o Tenderness along medial patellar border if the medial retinaculum was torn
Dx
o AP, lateral and axial patellofemoral x-ray views are needed
o With malalignment, there will be chronic lateral tilt of the patella.
o Axial computerized tomography (CT) may better demonstrate the relationship of the patella, patellofemoral
joint, and the trochlear.
Tx
o Protective compressive dressing with the a knee immobilizer maintaining the knee in extension
o If the effusion is sizeable, consider aspiration.
o Oral analgesics, rest, ice
o Eventually physical therapy can begin and advance slowly, emphasizing gentle quadriceps strengthening,
patellar taping techniques.
o Orthopedic referral
o If medical treatment fails, surgery to address extensor mechanism realignment
complications
o Chronic instability can lead to patellofemoral arthrosis
Acute dislocation of the patella
Minor issue. it'll pop back in. teenagers. Usually relocates easily (extend). Happens in people with "lax" joints
Dislocation of Knee
Major. Vascular injuries are common. Some CT angiogram(CTA) all dislocated knees to R/O popliteal injury. Most
relocate spontaneously. Bi-cruciate ligamentous instability means a dislocated knee occurred.
Open knee
Needs to go to OR and get washed out. Methylene blue arthrogram or Saline arthrogram (150-200cc). Need ORIF.
Osgood-Schlatter disease
Osteochondrosis or traction apophysitis of tibial tubercle.
Stress from extensor mechanisms
Self limiting but does not revolve until growth has halted
Sx
o pain on anterior aspect of knee

o exacerbated by kneeling
PE
o Enlarged tibial tubercle
o tenderness over tibial tubercle
o Pain on resisted knee extension
Radiographs
o lateral radiograph of the knee
o Irregularity and fragmentation of the tibial tubercle.
MRI
o Not essential for diagnosis
o diagnosis can be made based on history, presence of tender swelling and radiographs alone
o Soft tissue swelling
o thickening and edema of inferior patellar tendon
o fragmentation and irregularity of ossification center
Tx
o Nonoperative

NSAIDS, rest, ice, activity modification, strapping/sleeves to decrease tension on the apophysitis and
quadriceps stretching

Indications = first line of treatment

Outcomes = 90% of patients have complete resolution

cast immobilization x 6 weeks

indications = severe symptoms not responding to simple conservative management above

o Operative

ossicle excision

indications = refractory cases (10% of patients) OR

in skeletally mature patients with persistent symptoms

Rupture of the extensor mechanism

Quadriceps tendon rupture
Eccentric loading of the knee extensor mechanism. often occurs when the foot is planted and knee is slightly bent.
In younger patients the mechanism is usually direct trauma
Rupture is either partial or complete
S/S = Pain
PE
o Tenderness at site of rupture. palpable defect usually within 2cm of superior pole of patella. unable to extend
knee against resistance.
o can't perform straight leg raise with complete rupture
o Extensor lag
AP and lateral view of knee recommended = Findings will show patella baja
MRI
o when there is uncertainty regarding diagnosis
o helps differentiate b/w a partial and complete tear.
Tx
o Primary repair of acute rupture

approach

midline incision to knee

repair

longitudinal drill holes in patella

nonabsorbable sutures in tendon in a running locking fashion with ends free to be passed through
osseous drill holes

retinaculum is repaired with heavy absorbable sutures

ideally the knee should flex to 90 degrees after repair

postoperative care

initial immobilization in brace, cast, or splint

eventual progressive flexibility and strengthening exercises

o Primary repair of chronic rupture

approach

midline to knee

repair

often the tendon retracts proximally

ruptures >2 weeks old can retract 5cm

repaired with a similar technique to acute ruptures but a tendon lengthening procedure may be
necessary
Codivilla procedure (V-Y lengthening)

auto or allograft tissue may be needed to secure quadriceps tendon to patella

Osteochondritis dissecans

Pathologic lesion affecting articular cartilage and subchondral bone with variable clinical patterns.

Most common joint is knee

Juvenile

age 10-15 while physis is still open

lesions in lateral femoral condyle

Adult

Worse prognosis

cause is thought to be vascular

usually symptomatic and leads to DJD if untreated

Sx

pain, activity related pain that is vague and poorly localized

recurrent effusions of the knee

PE

Localized tenderness, stiffness, swelling

Wilson's test = Pain with internally rotating the tibia during extension of the knee between 90 deg and 30 deg,
then relieving the pain with tibial external rotation.

Imaging

Radiographs- weight bearing anteroposterior, lateral radiographs.

Obtain tunnel (notch) view

knee bent between 30 and 50 degrees

MRI
useful for characterizing
size of lesion
status of subchondral bone and cartilage
signal intensity surrounding lesion
Presence of loose bodies

Tx

Nonoperative
restricted weight bearing and bracing
indications

stable lesions in children with open physes

aysmptomatic lesions in adults

outcomes = 50-75% will heal without fragmentation
Operative
diagnostic arthroscopy
indications

impending physeal closure

clinical signs of instability

expanding lesions on plain films

failed non-operative management

microfracture
indications = stable lesion seen on arthroscopy
outcomes

leads to formation of fibrocartilagenous tissue

improved outcomes in skeletally immature patients

fixation of unstable lesion
indications

unstable lesion seen on arthroscopy or MRI >2cm in size

outcomes = 85% healing rates in juvenile OCD
chondral resurfacing
indications = large lesions, >2cm x 2cm
knee arthroplasty
indications = patients > 60 years

Loose bodies
free floating piece of bone, cartilage, or a foreign object in a joint. The knee is the most common site for loose
bodies
Causes
o OA

o Chip fx
o Torn piece of cartilage
Sx
o locking of the knee that comes and goes
o pain and swelling of the knee that comes and goes
o feel the loose body by touching the knee
Imaging = Xray, CT, or MRI to find loose body
TX = May include surgery for removal and repair of the kneecap if causing symptoms

Osteonecrosis
caused by reduced blood flow to the bones and joints.
Bone starts to die and may break down
Sx = Joint pain that becomes more severe.
Tx
o NSAIDS
o non-weight bearing
o ROM exercises
o Electrical stimulation
o Surgery

Core decompression surgery-lower press inside bone to inc blood flo

Osteotomy- reshapes the bone to reduce the stress on the damaged joint.

Bone graft. takes health bone from one body part to the bad part.

Total joint replacement. replaces the joint with a manmade one.

Bursitis
Chronic friction or trauma leads to inflammation or infection and thickening of the bursa
2 most common at the knee
o Pes anserine bursitis

Medial knee where the conjoined hamstring tendons insert to the tibia.

Seen in OA and obesity

Sx = Pain with rest and worse at night. Antalgic gait

PE
Tender on palpation of medial tibial flare

Xray eval for a stress fx

Tx = Heat/ice, nsaids, injection, hamstring stretching

o Septic prepatellar bursitis

Housemaids knee. Direct trauma causing an abrasion common as well,

Common pathogen is S aureus

Sx
Sudden severe pain, stiffness, warmth, effusion of bursa

PE
Erythema, edema, and dome shaped effusion.

Be sure to differentiate a septic joint (intra-articular findings)

From a septic bursa

Dx
o Xray normal except for anterior soft tissue edema.
o CBC and Diff
o CRP
o Aspirate bursa for CBC, gram stain, C&S
Tx
o IV abx. I&D.
o Ancef 2grams unless culture demonstrates other organism
Tendonitis
MOI
o Sometimes the tendons become inflamed for a variety of reasons, and the action of pulling the muscle
becomes irritating
Clin hx
o Mostly an overuse injury.
PE
o Tendonitis is almost always diagnosed on physical examination. Findings consistent with tendonitis include:

Tenderness directly over the tendon

Pain with movement of muscles and tendons

Swelling of the tendon

Dx

Studies such as x-rays and MRIs are not usually needed to make the diagnosis of tendonitis. While they are not
needed for diagnosis of tendonitis, x-rays may be performed to ensure there is no other problem, such as a
fracture, that could be causing the symptoms of pain and swelling. X-rays may show evidence of swelling
around the tendon.

Tx
o Rest and protection of the area.
o Avoid aggravating movements.
o NSAIDS may help
o If symptoms are present, steroid injection may help.
o Achilles tendon is not usually injected due to risk of rupture.
o Physical therapy
complications
o Tendonitis due to underlying conditions such as arthritis and gout are more difficult to treat and recur more
frequently. The best management in these situations is to do your best to avoid flare-ups of gouty attacks or
arthritic episodes, and to avoid activities which you have learned cause tendonitis.

Fractures of the knee

MOI
o Fractures about the knee are classified as supracondylar or condylar; the latter involving either the medial or
lateral condyle. Fractures of the knee involving the tibia are classified as tibial plateau fractures.
o In younger patients these fractures result from a high energy trauma and are often associated with other
injuries, while in older patients they can result from relatively low energy trauma in the presence of
osteoporosis.
Clin hx
o Immediate onset of pain and swelling with difficulty weight bearing
PE
o Swelling is usually significant due to the bleeding that occurs within the joint.
o Inspect the skin for skin integrity and the possibility of an open fracture.
o Evaluate for concomitant injuries specifically to the superficial or deep peroneal nerves, posterior tibial nerve,
and check distal pulses.
Dx
o AP and lateral x-rays of the knee and, if surgery is planned, oblique views

Look for air in joint indicates OPEN KNEE

o If distal pulses are compromised, obtain an ultrasound
o Saline vs. Methylene Blue arthrogram to assess OPEN vs CLOSED
Tx
o displaced or minimally displaced fractures require
o Open fractures, intraarticular fractures, vascular injuries, or compartment syndrome all require immediate
surgical intervention.
o Patients with large hemarthroses can obtain significant relief with aspiration of the joint under sterile
technique.
Complications = Intraarticular fractures, even in the best of hands, increase the risk of traumatic arthritis in the
future.
Tibial plateau
High forces. Auto vs pedestrian is classic. Bumper into knee. Get plateau views or obliques. Once known, CT is
becoming standard to describe fx preop.
o Tx: ORIF is virtually always needed

Worry about popliteal artery

Patella tendonitis
Overuse or overload of the extensor mechanism at the infrapatella tendon
Common in athletes (Jumpers knee) and in obesity.
Known as Osgood-Schlatters disease when present at the tibial tubercle physis in the growing adolescent
SX
o Ant knee pain. pain when sitting, squatting, or kneeling. pain with climbing stairs.
PE
o Point tenderness at patella tendon. Pain on knee extension against resistance
Xray should be normal.
TX = Rest. NSAIDS. PT (Ultrasound Phonophoresis helpful) DO NOT INJECT. Cho-Pat Strap
Tibial eminence fracture
MOI
o A fracture of the bony attachment of the ACL on the tibia
Epidemiology
o rare injuries
o most common in ages 8-14

traumatic
o rapid deceleration or hyperextension of the knee
o same mechanism that would cause ACL tear in adult
Clin hx = Trauma
PE
o Immediate knee effusion
o Limited ROM secondary to pain
o Positive anterior drawer.
Dx
o Radiographs = recommended views = standard knee radiographs
o CT = useful for pre-operative planning
o MRI = better at determining associated ligamentous/meniscal damage than CT or radiographs
o Classes

Type 1 nondisplaced

type 2 minimally displaced with intact posterior hinge

type 3 completely displaced

Tx
o Nonoperative

closed reduction, evacuation of hemarthrosis, immobilization in 0-20 degrees of extension

indications = non-displaced type I and reducible type II fractures

o Operative

ORIF vs. all-arthroscopic fixation

Indications = Type III or Type II fractures that can't be reduced

complications
o Arthrofibrosis (more common with surgical reconstruction)
o Growth arrest
o ACL laxity

incidence

10% of knees managed surgically

20% of knees managed non-operatively

often not clinically significant

Traumatic dislocations of the knee

MOI
o Devastating injury resulting from high or low energy
high-energy

usually from MVC or fall from height

commonly a dashboard injury resulting in axial load to flexed knee

low-energy

often from athletic injury

generally has a rotational component

morbid obesity is a risk-factor

Clin hx
o history of trauma and deformity of the knee
o knee pain & instability
PE
o No obvious deformity.
50% spontaneously reduce before arrival to ED
o Obvious deformity
do not wait for radiographs.
Dx
o Radiographs
may be normal if spontaneous reduction

look for asymmetric or irregular joint space

look for avulsion fxs (Segond sign - lateral tibial condyle avulsion fx)
osteochondral defects

MRI

Required to evaluate soft tissue injury (ligaments, mensicus) and for surgical planning
obtain MRI after acute treatment

Treatment
Initial Treatment
o reduce knee and re-examine vascular status

considered an orthopedic emergency

splint knee in 20-30 degrees of flexion
confirm reduction is held with repeat radiographs in brace/splint
vascular consult indicated if

if arterial injury confirmed by arterial duplex ultrasound or CT angiography

pulses are absent or diminished following reduction

Nonoperative indications = limited and most cases require surgical stabilization
Operative = emergent surgical intervention

indications

vascular injury repair (takes precedence)

open fx and open dislocation

irreducible dislocation

compartment syndrome

technique = vascular intervention

perform external fixation first

excision of damged segment and repair with reverse saphenous vein graft

always perform fasciotomies after vascular repair

delayed ligamentous reconstruction/repair
o indications

generally instability will require some kind of ligamentous repair or fixation

patients can be placed in a knee immobilizer for 6 weeks for initial stabilization

improved outcomes with early treatment (within 3 weeks)

o technique

PLC = recommend early reconstitution

PCL = reconstruct prior to ACL reconstruction

Postoperative = recommend early mobilization and functional bracing

o complications

Stiffness (arthrofibrosis)

is most common complication (38%)

more common with delayed mobilization

Laxity and instability (37%)

Peroneal nerve injury (25%)

most common in posterolateral dislocations

poor results with acute, subacute, and delayed (>3 months) nerve exploration

neurolysis and tendon transfers are the mainstay of treatment

Vascular compromise

in addition to vessel damage, claudication, skin changes, and muscle atrophy can occur
o prognosis

complications frequent and rarely does knee return to pre-injury state

Pediatric Orthopedics
Draw the Salter classification of epiphyseal fractures and state the prognostic significance of the classifications
1) Epiphyseal fractures
a) AKA growth plate fractures
b) Classified by SALTER CLASSIFICATION
c) Injuries to the growth plate heal quickly (3-4 weeks) with significant remodeling. To avoid deformity, early
diagnosis and treatment is pertinent.
d) Physical findings
i) Swelling and tenderness over the physis are the common findings when fractured.
ii) Comparison films may be helpful and should be obtained as part of any pediatric fracture workup.
e) Treatment
i) Type I, nondisplaced type II: careful observation, closed treatment with cast or splint
ii) Displaced type II: percutaneous fixation is indicated for significantly displaced fractures; it may be difficult
to obtain an anatomic closed reduction in type II fractures due to interposed periosteum
iii) Types III and IV: these intra-articular fractures, if displaced, require open treatment
iv) Types I and V: may be difficult to see on radiographs; a high index of suspicion is necessary to warn the
family of potential complications affecting the growth process
f) Salter Harris classification (MNEUMONIC = S A L T R)
i) I S = Slip (separated or straight across). Fracture of the cartilage of the physis (growth plate).
(1) Not a displacement. Splint/cast will recover in 3 weeks. (when press on line = no pain = healed)
ii) II A = Above. The fracture lies above the physis, or Away from the joint.
(1) Splint/cast and follow up and several weeks.
iii) III L = Lower. The fracture is below the physis in the epiphysis.
(1) Crack below the epiphysis
(2) Worse than the previous because getting near joint line (articular surface).
iv) IV T = Through. The fracture is through the metaphysis, physis, and epiphysis.
(1) Bad prognosis. Will have growth defects/deformities
(2) V R = Rammed (crushed). The physis has been crushed

Define the four common spinal deformities in children and review their clinical presentations, radiographic findings,
and treatment methods
http://www.emoryhealthcare.org/pediatric-orthopedics/conditions/spinal-deformity.html
a. Pediatric scoliosis
a. Increased S shaped curvature of the spine
b. Especially in girls during growth spurts
c. Cause is unknown, congenital, genetic, or neuromuscular disease induced.
d. The vertebrae at the apex of the curve are used for its description. Right thoracic curves (T7 or T8)
are the most common, followed by the double major (right thoracic, left lumbar), left lumbar, and
right lumbar
e. Signs & symptoms
i. Uneven musculature on one side of the spine
ii. Uneven hips, shoulders, or legs (asymmetry of shoulder & iliac height)
iii. Difference in the chest or breast area
iv. Gait and neurologic examine normal (most of the time).
1. Slowed nerve action (if severe but rarely)
f. Imaging
i. Lateral xray
g. Treatment

i.
ii.

Minor = spinal bracing and casting

Severe = require surgery to prevent long term problems with the spine, lungs, or other
organs.
iii. Surgery options include growing spine instrumentation such as growing rods or the Vertical
Expandable Prosthetic Titanium Rib (VEPTR) in younger patients or spinal fusion in older
teenagers and young adults.
1. These procedures are designed to stop the scoliosis from progressing, decrease the
size of the curvature, and get patients back to their activities as quickly as
possible. The majority of patients who have scoliosis surgery are able to get back
to their normal activities, including athletics, in just a few months.
b. Pediatric kyphosis
a. Spinal curve that results in an abnormally rounded back usually thoracic region.
b. X-rays will measure the degree of the kyphotic curve. A kyphotic curve that is more than 50 is
considered abnormal.
c. Hyperlordosis is associated
d. Progressive kyphosis (seen with Potts disease or TB)
e. Types of Kyphosis:
i. Postural
ii. Scheuermanns
1. Most common.
2. Idiopathic osteochondrosis of thoracic spine.
iii. Congenital
f. Treatment
i. Surgical rods to straighten and stabilize vertebra.
ii. Curvature greater than 60 wear Milwaukee brace.
iii. Surgery if refractory.
c. Pediatric spondylolysis
a. Bone growths (osteophytes or spurs) as a result of joint degeneration,
b. If severe can compressed nerve roots leading to radiculopathy (pain, paresthesia, and muscle
weakness).
c. See spine section
d. Pediatric spondylolisthesis
a. Hyperextension leads to stress fractures. (Anterior slipping go PARS body leading to Pars fracture)
i. Some sports, such as gymnastics, weight lifting, and football
b. If the stress fracture weakens the bone so much that it is unable to maintain its proper position,
the vertebra can start to shift out of place.
c. If too much slippage occurs, the bones may begin to press on nerves and surgery may be
necessary to correct the condition.
d. Signs and symptoms and findings
i. Pain usually spreads across the lower back and may feel like a muscle strain.
ii. Spondylolisthesis can cause spasms that stiffen the back and tighten the hamstring
muscles, resulting in changes to posture and gait.
iii. May have lower leg pain
iv. If the slippage is significant, it may begin to compress the nerves and narrow the spinal
canal
1. Nerve compression = positive straight leg test and bowel/bladder sxs
2. REQUIRES MRI
v. CT is best to delineate the anatomy of PARS defect.
e. Treatment
i. TLSO braces for 6-4 weeks (if no neuro sx)
ii. Surgical repair of PARS if fractured. Surgery required with neuro deficits.
1. State the hallmark sign of child abuse and which fracture patterns are most associated with this condition
a. Long bone fractures in children <2 y with a questionable history are considered abuse until proven
otherwise
b. History of delay in seeking treatment
c. Findings may include limb deformity, swelling, ecchymosis, and multiple healing fractures of various ages
seen on radiographs
d. Provide pain control and fracture treatment, by casting or splinting
e. Contact Child Protective Services in suspicious cases
f. Fracture patterns = see chart below
2. Define metatarsus adductus and discuss its clinical presentations
a. Most common foot deformity in the newborn; may be unilateral
b. May cause apparent in-toeing in children
a. In toeing does not require treatment; just reassurance and close monitoring.
c. Forefoot is held in adduction and inversion, usually mild and flexible; hindfoot is normal
a. Adduction of the forefoot with normal hind foot. Lateral foot border is convex and not straight.

d.
e.
f.

b.
In severe cases, an oblique groove is noted on the medial side of the foot
Physical exam
a. Measure hip rotation
b. Measure rotational status of lower leg and foot
Treatment
a. Generally no treatment is needed as the condition frequently resolves by 1218 mo of age
b. Stretching exercises and, in resistant cases, short-leg casting will accomplish correction
c. Surgical release is necessary for older children with residual metatarsus adductus and pain or
trouble fitting shoes; medial capsulotomy and abductor hallucis lengthening are performed

Hand and Wrist

a.

b.

Carpal tunnel syndrome (CTS)

1. Most common mononeuropathy
2. Compression of median nerve in the carpal tunnel (space on palmar aspect of wrist bounded by
scaphoid, trapezium, capitate, hook of hamate, pisiform, and transverse carpal ligament)
3. USUALLY DUE TO: overuse phenomena and trauma.
4. Common in middle aged women
5. Diagnosis via clinical presentation mostly.
6. Specific disease association: hypothyroidism, pregnancy, and diabetes
ii. Symptoms:
1. Numbness in the median nerve distribution; pain awakens patient from sleep; wrist-flexed
activities are uncomfortable and elicit symptoms
2. Tinel sign (tapping volar aspect of wrist), Phalen wrist flexion test (negative after 1 min), weak
opposition, or thenar atrophy may be present
3. Most sensitive test is carpal compression (direct compression over carpal tunnel for 60 s); sensory
exam is very helpful
iii. Imaging
1. Obtain radiographs, including a carpal tunnel view, to r/o bony causes of CTS
2. EMG/NCS can help differentiate from other entities but findings are often normal in early CTS
3. Atrophy of thenar muscles is a sign of advanced disease
iv. Treatment
1. Administer NSAIDs. Begins with splinting in slight extension and evaluation of causes other than
idiopathic; If conservative treatment fails, consider steroid injections in the carpal tunnel can help
reduce symptoms for a period of time
2. Work-related CTS may benefit from ergonomic aids.
3. CTS of pregnancy usually resolve after delivery.
4. Surgical treatment is reserved for fixed sensory loss, thenar weakness, or intolerable symptoms.
5. Surgical treatment is indicated when conservative therapy is unsuccessful; the transverse carpal
ligament can be divided by open surgery or by endoscopic surgery; success rates are high
v. COMPLICATIONS = Permanent loss of sensation, hand strength, and fine motor skills.

Ganglion cyst of the wrist

i. Most common cause of soft tissue mass on hand and wrist (USUALLY NONTENDER)
1. Cysts may develop at joints, tendons, or nerves.
2. Wrist joint cysts arise most commonly dorsally from the region of the scapholunate ligament (Fig.
51.2). These dorsal cysts account for approximately 60% to 70% of all ganglion cysts of the hand
and wrist.
3. Ganglions are slightly moveable but have a pedicle or stalk, which leads to adherence of the cyst
to the joint capsule
4. IF the dorsal wrist ganglion cysts are not palpable, but is tender. Can affect median nerve and
induce carpel tunnel syndrome.
5. In evaluating a volar radial wrist cyst, it is important to perform an Allen test to determine patency
of the radial artery.
ii. Cysts contain thick, gelatinous material.
iii. The cysts most commonly occur in the second to fourth decades of life.
iv. Women are three times more likely than men to develop a ganglion cyst.
v. Most ganglion wrist cysts are asymp and are often present for months to years prior to evaluation.
vi. Treatment
1. Some spontaneously resolve
2. Aspiration and injection with cortisone (High rates of reoccurrences)
3. Recurrences can be removed surgically (must remove the stalk of cyst)
a. Dorsal ganglion wrist will not affect neurovascular structures
b. Volar radial wrist cyst is adjacent to radial artery and venae comitantes (caution)
2. List the physical exam finding distinctions between osteoarthritis and rheumatoid arthritis of the hand
a. Osteoarthritis
i. A common, chronic, noninflammatory arthritis of the synovial joints (e.g., DIP joints).
1. Characterized by deterioration of the articular cartilage and osteophyte and subchondral
bone formation at the joint surfaces. Risk factors include a + family history, obesity, and a
history of joint trauma.
ii. HISTORY/PE
1. Presents with crepitus; ROM; and initially pain that worsens with activity and weight
bearing but improves with rest. Morning stiffness lasts for < 30 minutes. Stiffness is also
experienced after periods of rest (gelling).
iii. DIAGNOSIS
1. Radiographs show joint space narrowing, osteophytes, subchondral sclerosis, and
subchondral bone cysts. Radiograph severity does not correlate w/ symptomatology.
2. Synovial fluid shows straw-colored fluid, normal viscosity, and a WBC count < 2000
cells/L.

b.

iv. TREATMENT
1. Physical therapy, weight reduction, NSAIDs. Intra-articular corticosteroid injections may
provide temporary relief. Consider joint replacement (e.g., total hip/knee arthroplasty) in
advanced cases.
Rheumatoid arthritis
i. Symmetric joint destruction
ii. PIP ENLARGEMENTS (bouchard)
1. DIP usually spared (heberden nodes = osteoarthritis )
iii. Note the boutonniere deformities of the digits, ulnar deviation of the fingers, MCP joint
hypertrophy, and severe involvement of the PIP joints.
iv. Extra-articular manifestations, including subcutaneous nodules, pulmonary nodules, vasculitis,
pericarditis, or episcleritis, may be detected.
v. Physical findings
1. Symmetrical swelling in the MCP joints (Can involve the PIP and the thumb later)
2. Morning stiffness lasting more than 1 hour
3. Chronic inflammation leads to deformity of ulnar drift, swan neck, and boutonniere
a. Swan neck = PIP hyper extension (DIP hyper flex)
b. Ulnar drift = fingers point to pink (slanted)
c. Boutonniere = PIP hyper flex (DIP hyper extend)
4. Usually associated with carpal tunnel syndrome
5. X-rays show early notching in the periarticular area
6. MRI sensitive for bone erosions
vi. Labs = Rheumatoid factors and antibodies to citrulline-containing peptides (CCP) are helpful for
diagnosis, while acute phase reactants are helpful in monitoring disease activity
vii. Treatment = DMARDS

3. State the physical exam findings and treatment of Dupuytren contracture and De Quervain tenosynovitis
a. Dupuytren contracture
1. Progressive fibrosis (nodular thickening) on the fascia of the palmar surface of the hand;
a. Genetic association with Peyronie disease (penile fibrosis) or Ledderhose disease
(plantar foot fibromatosis)
b. Alcohol, smoking, and diabetes
2. More common in men, with usual age of onset 4060 y; predisposition in patients of
northern European ancestry and occasion- ally Asians
3. Causes gradual contracture of the palmar fascia, resulting in (MCP) and (PIP) joint
contractures; usually the little finger is worst
ii. Symptoms of finger(s) catching in pockets, cosmetic complaints, shaking hands, and
occasionally, with severe cases of contracture, hygiene of the finger creases
iii. Treatment
1. Nonoperative treatment is efficacious in milder forms of the disease when joint flexion
contractures are small
2. Surgical treatment is indicated to remove the fascia (fasciectomy) causing the
contractures; joint contracture of 30 degrees at the MCP or any contracture at the PIP joint
is the indication for surgery
3. In severe, neglected cases or cases with neurovascular compromise or extreme stiffness,
amputation of the little finger may be necessary
4. Surgery is risky because neurovascular structures are intimately adherent to the nodular
fascia in Dupuytren contractures
5. Early surgery prevents severe contractures but has high rate of recurrence of dz
b. DeQuervains tenosynovitis
1. Is a stenosing tenosynovitis occurs at the radial styloid and involves the abductor pollicis
longus and extensor pollicis brevis
2. Inflammation is under the retinaculum of the first extensor compartment
3. More common in females >30 yo and diabetics
4. Can occur from injury, inflammatory disease = rheumatoid arthritis, degenerative joint
disease, or wrist fracture.
5. De Quervain tenosynovitis may be accompanied by a symptomatic ganglion, or triggering
of the tendons in the compartment, or both.
ii. Physical exam
1. Patient has a history of pain at the radial side of the wrist with activities in which the
thumb is abducted or the wrist is ulnarly deviated.
2. Pain and tenderness occur at the wrist and base of the thumb and may radiate up
shoulders.
3. Swelling and thickening of the tendon sheath upon examination.
4. Palpation elicits pain at the site of the retinaculum at the radial styloid)
iii. Signs
1. Finkelstein test: thumb is put in the palm and enclosed by the fingers; the wrist is
abruptly deviated ulnarly; positive test results in pain at the radial side of the wrist

2. + Hitch hikers sign (abduct thumb radially against resistance)

a. + Brunelli test = performed by having the patient actively radially abduct the
thumb with the wrist in radial deviation
3. 1st dorsal extensor compartment (snuff box) is tender upon palpation
iv. Treatment
1. Splinting does not cure the problem but provides symptomatic relief
2. Steroid injection into the first extensor compartment is successful in most patients, but as
many as 25% need a second injection to get relief, probably because the 2 tendons have
separate compartments and the abductor has variable numbers of accessory tendon slips
3. Surgical release of the retinaculum is indicated for patients who do not respond to
conservative therapy
4. Define trigger finger and Keinbock disease and discuss their treatments
a. Trigger finger
i. Stenosing flexor tenosynovitis results from localized tenosynovitis of the superficial and deep flexor
tendons adjacent to the A1 pulley at the metacarpal head. This inflammation causes hypertrophy
of the A1 pulley, which leads to discrepancy between the tendon and the tendon sheath
ii. Types
1. Diffuse = with thickening of the entire flexor tenosynovium (more commonly seen in
rheumatoid arthritis)
2. Nodule = with thickening of the tendon on the distal edge of the A1 pulley
iii. Congenital (at birth = children) vs. acquired
1. Acquired = adults
2. More common in women and > older than 40 yo.
iv. It can affect any digit but most commonly affects the ring finger, thumb, and long finger.
v. It is associated with medical conditions such as diabetes mellitus, hypothyroidism, gout, renal
disease, and rheumatoid arthritis.
vi. Patients who develop trigger digits are more likely to be affected by carpal tunnel syndrome and
de Quervain stenosing tenosynovitis.
vii. S/S + Physical exam
1. On examination, can feel tender nodule trigger on flexion and extension of the finger at the
A1 pulley
2. Patients typically present with a tender nodule located on the palm at the metacarpal head
and the inability to smoothly extend or flex the digit. Their complaints are sometimes
vague, consisting of aching in the palm and morning stiffness of one or more digits. As the
flexor tenosynovitis becomes more severe, patients have increased pain at the nodule and
increased triggering that occurs during flexion or prevents them from fully extending the
finger.
viii. Treatment depends on severity
1. Early stages of tenosynovitis, NSAIDs + massage + heat + splint
2. Moderate/refractory = Corticosteroid injection into tendon sheath (very successful)
a. Water-soluble steroids such as betamethasone sodium phosphate and acetate
suspension are preferred because they do not precipitate, leaving a residue.
b. Complications such as depigmentation, fat necrosis, flare reaction, and
hyperglycemia should be discussed with patient. Injections are less likely to be
successful in patients with triggering for >6 months, diffuse tenosynovitis, and
diabetes mellitus.
3. Surgical release of tendon pulley for failures of injection
b. Keinbock disease
i. Kienbck's disease is a condition where the blood supply to one of the small bones in the wrist, the
lunate, is interrupted. Resulting in osteonecrosis.
ii. Damage to the lunate causes a painful, stiff wrist and, over time, can lead to arthritis.
iii. Cause is unknown. May be as a result of previous wrist fx or injury that disrupts blood flow.
iv. Common 15-40 yo OR people with short ulnas
v. Severity varies with extent of damage.
vi. Classified into 4 stages
1. Stage 1 = symptoms of wrist sprain. Normal XRAY or fracture. MRI better to show blood
supply.
2. Stage 2 = the lunate bone begins to harden due to the lack of blood supply during
(sclerosis). In addition, the lunate will appear brighter or whiter in areas on x-rays, which
indicates that the bone is dying. To better assess the condition of the lunate, your doctor
may also order either MRI scans or computed tomography (CT) scans.
a. The most common symptoms during this stage are wrist pain, swelling, and
tenderness.
3. Stage 3 = the dead lunate bone begins to collapse and break into pieces. As the bone
begins to break apart, the surrounding bones may begin to shift position.
a. During this stage, patients typically experience increasing pain, weakness in
gripping, and limited wrist motion.

4. Stage 4 = If the condition progresses to Stage 4, the surfaces of the bones surrounding the
lunate also deteriorate, and the wrist may become arthritic.
vii. The most common symptoms of Kienbck's disease include:
1. A painful and sometimes swollen wrist.
2. Pain that radiates to the forearm, wrist stiffness, swelling or tenderness over the lunate,
and decreased grip strength.
3. Limited ROM in the affected wrist (stiffness); Pain or difficulty in turning the hand upward
4. Tenderness directly over the bone (on the top of the hand at about the middle of the wrist)
viii. Treatment
1. Early stages = ibuprofen + 2-3 weeks of splinting or casting to relieve pressure from lunate
2. If cause is short ulna, surgical shortening of radius.
3. Surgical stage 1 + 2 = revascularization
4. Joint leveling with bone grafts to reduce form on lunate and prevent progression
5. Proximal row carpectomy. If the lunate is severely collapsed or broken into pieces, it can be
removed. In this procedure, the two bones on either side of the lunate are also removed. To
relieve pain and maintain partial wrist motion.
6. Fusion of nearby wrist bones (with plate, screws, and pins) to make one solid bone in
severe arthritic wrist. Relieves pain and retain some wrist motion. Wrist motion is
eliminated in a complete fusion, but forearm rotation is preserved.
5. Discuss the etiology, physical findings, mechanism of injury, and treatment for mallet finger and boutonniere
deformity
o Jersey Finger

Rupture of Flexor Digitorum Profundus tendon

MOI: forceful hyperextension

S/S: inability to actively flex the DIP joint

Tx: aluminum splint in slight flexion

o Mallet finger

Loss of full, active extension of the distal interphalangeal (DIP) joint, resulting in unopposed flexor
digitorum longus action to pull the distal phalanx into flexion. (resulting in full flexion of DIP)

can be due to avulsion of the tendon with or without a fragment of bone, or rupture or laceration of the
tendon inserting on the distal phalanx

Traumatic (except for rheumatoid arthritis)

Patient often presents late, weeks after the injury

Radiographs are necessary to determine if an intra-articular fracture is present

Treatment

Injuries are usually closed and can be treated with continuous splinting of the DIP joint in full extension
for 8 wk

Articular fragments if small (ie, <33% of the joint surface) can be ignored and treated as if ligament
injuries

Single large fracture fragments can be treated operatively to reduce the fracture

Joint is usually pinned in extension

Chronic mallet finger can often be successfully treated with splinting; if splinting is unsuccessful and
the amount of finger flexion is unacceptable, finger fusion is an option

Surgical management is reserved for patients who cannot work with a splint in place or those who
have large fragments or dislocated joints.
o Boutonniere deformity

PIP hyperflexion and DIP hyper extend secondary to central slip disruption on the middle phalanx
(laceration, closed rupture, synovitis of PIP joint).

Basically locks the PIP joint in flexion, resulting in contracture

Subluxated lateral bands and unopposed flexor digitorum profundus are the main deforming forces

Commonly seen RA (MCP + PIP) and Osteoarthritis (PIP + DIP)

Treatment

Treat an acutely lacerated central slip with direct repair and pin- ning of the joint in full extension for 3
6 wk

Treat acute, closed ruptures of the central slip by splinting the PIP joint in full extension for 6 wk

Delayed treatment: prolonged splinting with Capener splint, or Joint Jack splint versus serial casting;
patients with delayed diag- nosis may develop fixed flexion contracture of PIP joint
o Gamekeepers Thumb

S/S: weakness of pinch

Tx: thumb spica cast vs surgical repair

6. List the etiology, organisms, physical findings, and TX for human bites, paronychia, and tendon sheath infxn
o human bites

often from fist striking tooth; penetrates skin, subcutaneous tissue, extensor tendon, and capsule of
metacarpophalangeal (MCP) joint

may lead to osteomyelitis if untreated


bites distal to wrists are more at risk for malignant infections due to superficial spaces
Consider Eikenella corrodens, viridans streptococci, group A streptococci, S aureus, Bacteroides,
Fusobacterium, Actinomycetes, spirochetes

Kanavals Sign: (Flexor tendon sheath)

S/S: severe pain on passive extension, redness/pain along flexor tendon

Tx: surgical I&D and Abx

Treatment

Incision and drainage arthrotomy if MCP involve- ment is suspected; begin broad-spectrum IV
antibiotics followed by oral penicillin, ampicillin, amoxicillin-clavulanate, and tetanus prophylaxis as
indicated

Tetanus required

NOTE* GUEST LECTURES TREATMENT OF CHOICE

Augmentin
If penicillin allergic, Bactrim/Levaquin + clindamycin
Paronychia

inflammation of nail folds

caused by nail cosmetic service or prolonged water immersion

infections can be acute or chronic

acute = staph aureus as cellulitis > leads to abscess formation

chronic = candida (associated with nail biting)

Treatment

Treatment for acute infection begins with warm soaks and oral antibiotics
Staph = Bactrim or nafcillin

Incision and drainage is required after an abscess forms

Partial nail removal may be necessary to decompress the abscess

Treatment of chronic infection includes antimicrobial agents and maintenance of dry hands, and may
require nail removal
6 weeks antifungals
Tendon sheath infections

Synovial infection of flexor tendon sheath

May or may not require I&D, monitor closely, rest, and antibiotics

7. State the mechanism of injury, physical findings, radiographic findings, treatment and complications of the
following fractures:
o Shaft of the ulna fracture

AKA nightstick fracture (direct blow)

Occurs more often in males, generally as a result of an altercation, fall, contact sports, or MVA

Presence of pain, localized swelling, and crepitus

Fracture of the ulnar shaft can be assoc. w/ dislocation of the radial head (Monteggias lesion)

Radial or posterior interosseus nerve injuries are common, especially in the Monteggias variant

Displaced ulna fractures usually mean a disruption of the distal or proximal radioulnar joints, if the radius is
not fractured.

Treatment

Nondisplaced fractures can be treated closed

Open fractures or those displaced >50% of the diaphyseal diameter or angulated >10 degrees require
operative intervention
o Shaft of radius fracture

Causes: direct trauma or blow to the radius, or a fall onto an out- stretched hand

Fracture of the proximal two thirds of the radial shaft may be considered isolated

Fracture of the distal one third of the radial shaft is likely associated with distal radial ulnar joint (DRUJ)
disruption

Treatment

Isolated proximal radial shaft fractures: if nondisplaced and non-angulated, may be treated nonoperatively with casting

All displaced and angulated radial shaft fractures should be treated open to restore the natural radial
bow
o Galeazzi Fracture and dislocation

Radial shaft fracture with distal radial ulnar joint (DRUJ) disruption

Presence of pain, swelling, and often bruising in the area

Patients with Galeazzi fractures also have wrist (DRUJ) pain, instability, or both

Require open anatomic reduction of the radius and internal fixation (fractures of necessity)

o
o

Galeazzi Fx: distal radio-ulnar joint injury + radius fx

*Tx: ORIF
Monteggia Fx: ulnar fx + radial head dislocation
*Tx: ORIF
Essex-Lopresti Fx: crush to radial head w/ DRUJ dislx
*Tx: ORIF

Colles fracture

Silver fork deformity = Fracture of distal radius leading to dorsal angulation

Tx: typically closed reduction, may require ORIF

Triquetral fracture (90% of FOOSH fracture)

Dorsal chip fracture due to FOOSH

Scaphoid fracture

Bone most common fractured on the wrist. HX of a fall on an outstretched hand.

Blood supply is from radial artery from lateral and distal branches. Proximal pole of scaphoid has poor
blood supply; untreated can lead or prone to nonunion or avascular necrosis.

Complications

Include nonunion of the fracture or development of avascular necrosis. In avascular necrosis,

radiography may reveal a ground-glass appearance of the proximal pole or an increased bone density.

Clinical presentation

#1 SX = pain over snuff box and has ecchymosis

Symptoms include pain and swelling on the radial side of the wrist.

Image

Initially XRAYs are not diagnostic. AP, lateral, and scaphoid views should be ordered. Repeat xray 2-3
weeks

Bone scan, MRI, or CT may be helpful for acute injury

Diagnose based on symptoms (easily confused with wrist sprain)

Treatment

For nondisplaced fractures, long arm thumb spica cast with the wrist in neutral for 6 weeks. If after 6
weeks x-ray shows evidence of healing, replace long arm cast with a short arm thumb spica cast for
several more weeks, followed by a brace.

If no evidence of healing in follow-up x-rays or widening of the fracture line, consider surgical
intervention.

Displaced fractures and failed medical management, require intervention by a hand surgeon for further
treatment.
Bennets fracture

Intra-articular Fracture at Base of thumb

Intra-articular fracture of the base of the first metacarpal in which the small volar fragment remains
attached to the trapezium and the thumb and first metacarpal are displaced proximally and radially

Metacarpal shaft is displaced by the forces of the extrinsic thumb extensors and abductor pollicis longus
muscles.

Treatment

Must be reduced (require immediate X-ray) and fixated with percutaneous pins.

Thumb splint (spica) cast if closed fracture for 6 weeks.

If refractory, must perform open reduction and internal fixation.

Boxer fracture

See below

5th metacarpal neck fracture

Metacarpal fracture

divided into fractures of metacarpal head, neck, shaft

metacarpal neck fracture is most common (5th metacarpal fx = boxers fracture)

treatment based on which metacarpal is involved and location of fracture

acceptable angulation varies by location

no degree of malrotation is acceptable

Phalangeal fracture

Fractures of proximal and middle phalanges can be at the base, neck, shaft, or intra-articular.

Also be classified by open or closed.

Pain and swelling with decreased range of active motion, and possibly deformity, are reported after a
history of trauma

Tenderness to palpation; pain with passive motion

Swelling and ecchymosis may be present

Radiographic exam is diagnostic; comparison views may be helpful if the physes are open

Treatment

Undisplaced fractures can be treated with splinting, either a gutter splint (radial or ulnar, depending
on the fracture) or a short-arm cast with an outrigger to protect the digit; splinting for 12 wk can be
followed with buddy taping; healing occurs in 46 wk

Displaced fractures with angular, rotational, or especially intra-articular deformity require correction
of the deformity with either closed reduction (with or without pinning) or open reduction and internal
fixation; shortening or proximal migration of the distal fragment can also be an indication for more
aggressive treatment
10-20-30-40 Rule: angulation from index to ring finger

To avoid stiffness of the MCP joint in any hand fracture, immobilization should always place the MCP
joint at 7090 degrees of flexion (intrinsic-plus position).

SPINE AND PELVIS

Red flags: Care should be taken to ensure that constitutional symptoms are not reported, such as fever, chills, pain
that wakes the patient from sleep, weight loss, malaise, and the like; these warning signs can signify more
ominous conditions such as infection or malignancy. (REQUIRE MRI)
Cervical Spine
Cervical disc syndrome
o Herniated disc

Same as in lumbar occurs after traumatic episodes.

Most herniations occur between C5 and T1, and the most common location is the C5-6 disc space.

Nerve root compression (minor) = Patients present with biceps weakness as well as with pain and
numbness in the thumb and index fingers.

Spinal cord compression (severe) = Spinal cord compression symptoms include awkward or stumbling
gait, difficulty with fine motor skills in the hands and arms, and tingling or shock-type feelings down
the torso or into the legs.

Myelopathy = complain of weakness and clumsiness of the upper extremities as well as difficulty with
maintaining lower extremity balance. Certain physical findings such as clonus, hyperreflexia, and the
Babinski sign are present in patients with myelopathy.

Patients typically complain of frequent headaches and pain/numbness that radiates down an upper
extremity.

A thorough neurologic exam is necessary.

Spurling maneuver. The patients neck is extended and rotated in the direction of symptoms. A
compressive force is then applied as shown. This reproduces the symptoms of nerve root compression.

Cervical range of motion typically is limited.

MRI is the imaging study of choice.

Sagittal MRI. Image reveals a herniated disc protruding into the spinal cord.

X ray is not useful in herniation. More useful in degenerative disc disease.

NCS-EMG is especially helpful to differentiate cervical radiculopathy from confounding neuropathic

conditions such as ulnar nerve entrapment, carpal tunnel syndrome, and peripheral neuropathy

Treatment

Spine surgery is performed if a course of conservative treatment has failed. Surgery consists of disc
removal, placement of an intervertebral bone graft, and fusion. Plate fixation is generally used for
multiple levels of involvement. Patients are placed in a soft collar postoperatively for comfort and are
generally discharged the following day.

Spinal cord compression is more severe than nerve root compression. Will require more aggressive
treatment.
o Degenerative disc disease

Same as in lumbar

More common in lumbar than cervical. Occurs with aging (arthritis)

As we age disc lose water content. Normal but will worsen with age and form bone spurs to stabilize spine

Arm pain when have posterior bone spurs blocking foramina.

PE

Patients with cervical degenerative disc disease often complain of low-grade neck pain with stiffness
and inflexibility

Additional symptoms may consist of numbness, tingling, or even weakness in the neck, arms, or
shoulders as a result of nerves in the cervical area becoming irritated or pinched.

Cervical degeneration can become so severe that surrounding osteophytes may encroach on the spinal
canal, leading to spinal stenosis and myelopathy.
Symptoms of myelopathy include awkward or stumbling gait, difficulty with fine motor skills in the
hands and arms, and tingling or shock-type feelings down the torso or into the legs.

Imaging

Lateral x-ray of the cervical spine. X-ray reveals loss of lordosis, osteophyte formation, and a decrease
in disc space.

MRI can be utilized to determine whether there is nerve root compression or cervical stenosis in
patients who present with neurologic symptoms. Nerve root or spinal cord compression secondary to a
herniated nucleus pulposus, abscess, or tumor can be easily identified with MRI.

Treatment

Symptomatic = NSAIDs and PT for 6 weeks

if severe symptoms or inflammation, epidural steroid injections.

Spine surgery is performed if a course of conservative treatment has failed. Surgery consists of disc
removal, placement of an intervertebral bone graft, and fusion. Plate fixation is generally used for
multiple levels of involvement. Patients are placed in a soft collar postoperatively for comfort and are
generally discharged the following day.
Cervical strain

Pearl

Tissue inflammation as a result of whiplash.

Common mechanisms of cervical strain injury include rear-end automobile collisions, sports trauma
(e.g., football), and repetitive occupational injuries. Muscular and ligamentous structures of the
cervical spine are stretched beyond their physiologic capacity, generating inflammation within the
local soft tissues. Patients with cervical strain may present with a constellation of symptoms including
neck pain, persistent stiffness, trapezial pain, back pain, muscle spasm, headache, and limited range
of motion. These symptoms often begin acutely, hours after the injury.

d/t hyperextension followed by hyperflexion.

Cervical spine stability must first be verified before the diagnosis of cervical sprain can be made. Examine
appropriate C-spine series, including flexion and extension views.
o Symptoms:

Pain is the chief complaint (and minor = stiffness)

Local tenderness; decreased range of motion; headaches, typically occipital; blurred or double vision

Dysphagia, hoarseness, jaw pain, difficulty with balance, vertigo

Strain refers to muscle injuries; sprain, to ligamentous and capsular injuries

o Imaging

Therefore, clinical decision guidelines for the judicious use of cervical radiography have been developed
based on history, physical examination, and simple tests. Two decision-making tools were developed
independently: the National Emergency X-Radiography Utilization Study (NEXUS) Low-Risk Criteria (NLC)
and the Canadian C-Spine Rule (CCR).

X ray if older than 65 yo, paresthesia, major rear in collision, acute onset of pain with midline cervical
tenderness, and unable to rotate neck 45 degrees.
o Treatment

Initial therapy is rest with soft collar immobilization and NSAIDs. Encourage early progressive range of
movement.

Many patients have persistent symptoms.

o Factors associated with a poor prognosis include the presence of occipital headaches, interscapular pain,
reversal of cervical lordosis, and involvement in litigation or workers compensation claims; women have a
worse prognosis than men.
Cervical subluxation and dislocation
o Misalignment of vertebral body and symptoms depend on severity

Minor symptoms = nerve root impingement

Major symptoms = spinal cord compression

o Usually associated with trauma
o Spinal Cord Injury causes:

42% MVA

24% Violence

22% Falling

8% Sports
o
Great risks requires X-ray (to prevent neurologic dysfunction)
o
Most often treated with closed reduction
Cervical Fractures
o Mnemonic (95% of unstable C-Spine fractures)

Jefferson (Burst C1)

Bit (Bifacet dislocation/fracture)

A (Any fx dislocation)

Hangmans (middle and posterior elements of C2 can transect the cord and cause immediate death as
well)

Hyperextension injury

Tit (Teardrop Fx: usually flexion)

Rheumatoid arthritis (cervical vertebra)
o A systemic autoimmune disorder characterized by chronic, destructive, inflammatory arthritis with symmetric
involvement of both large and small joints synovial hypertrophy and pannus formation erosion of adjacent
cartilage, bone, and tendons. Risk factors include female gender, age 3550, and HLA-DR4.
o HISTORY/PE

Presents with insidious onset of morning stiffness for > 1 hour along with painful, warm swelling of multiple
symmetric joints (wrists, MCP and PIP joints, ankles, knees, shoulders, hips, elbows, and cervical spine) for
> 6 weeks.

Fever, fatigue, malaise, anorexia, and weight loss may also be seen.

Ulnar deviation of the fingers is seen with MCP joint hypertrophy.

Also presents with ligament and tendon deformations (e.g., swan-neck and boutonniere deformities),
Bakers cysts, vasculitis, atlantoaxial subluxation, carpal tunnel syndrome, rheumatoid nodules,
keratoconjunctivitis sicca, pulmonary nodules, inflammatory endocarditis, and Feltys syndrome (triad of
splenomegaly, leukopenia, and cutaneous manifestations).
o


Feltys syndrome is characterized by RA, splenomegaly, and neutropenia
Can have extra articular manifestations

Skin, eyes, lung, GI

o DIAGNOSIS

RF (IgM antibodies against Fc IgG) is seen in > 75% of cases.

ESR may also be seen.

Anemia of chronic disease.

Synovial fluid aspirate shows turbid fluid, viscosity, and an WBC count (300050,000 cells/L).
o Treatment

Radiographs:

Early: Soft tissue swelling and juxta-articular demineralization.

Late: Joint space narrowing and erosions.

TREATMENT

NSAIDs (can be reduced or discontinued following successful treatment with disease-modifying

antirheumatic drugs [DMARDs]).

DMARDs should be started early. First-line drugs are hydroxychloroquine, sulfasalazine,

methotrexate, and azathioprine. Second-line agents include rituximab (anti-CD20), and leflunomide.
Junior RA
o A nonmigratory, nonsuppurative mono- and polyarthritis with bony destruc- tion that occurs in patients 16
years of age and lasts > 6 weeks. Approximately 95% of cases resolve by puberty. More common in girls than
boys.
o Can be accompanied by fever, nodules, erythematous rashes, pericarditis, and fatigue.
o Subtypes:

Pauciarticular (+ANA)

Polyarticular

FEVER

Salmon colored rash

o No labs for DIAGNOSIS but commonly Elevated WBC, PLT, and ESR
o Treatment

NSAIDs or corticosteroids; methotrexate is second-line therapy.

ROM and strengthening exercises.

Ankylosing spondylitis
o A chronic inflammatory disease of the spine and pelvis that causes sacroiliitis and, eventually, fusion of the
affected joints. Strongly associated with HLA-B27. Risk factors include male gender and a + family history.
o HISTORY/PE

Typical onset is in the late teens and early 20s. Presents with fatigue, intermittent hip pain, and LBP that
worsens with inactivity and in the mornings.

spine flexion (+ Schober test), loss of lumbar lordosis, hip pain and stiffness, and chest expansion are
seen as the disease progresses.

Anterior uveitis and heart block may occur.

Other forms of seronegative spondyloarthropathy must be ruled out, including the following:

Reactive arthritis (formerly known as Reiters syndrome): A disease of young men. The characteristic
arthritis, uveitis, conjunctivitis, and urethritis usually follow an infection with Campylobacter, Shigella,
Salmonella, Chlamydia, or Ureaplasma.

Psoriatic arthritis: An oligoarthritis that can include the DIP joints. Associated with psoriatic skin
changes and sausage-shaped digits (dactylitis).
o DIAGNOSIS

HLA-B27 in 8595% of cases.

Radiographs may show fused sacroiliac joints, squaring of the lumbar vertebrae, development of vertical
syndesmophytes, and bamboo spine.

ESR or CRP is in 75% of cases.

Negative RF; negative ANA.

o TREATMENT

NSAIDs (e.g., indomethacin) for pain; exercise to improve posture and breathing.

Tumor necrosis factor (TNF) inhibitors or sulfasalazine can be used in refractory cases.
Cervical Spondylosis
o Spondylosis = Bone spurs (osteophytes) as a result of joint degeneration
o Generalized disease of the cervical spine related to disk degeneration; myelopathy, radiculopathy, or both may
occur.
o Occurs in elderly patients > 50 yo. Occurs more frequently in Men > women.
o Patients often present with complaints of shoulder, elbow, wrist, or hand pain and may report headache (if
upper cervical spine is affected) and stiff neck
o Multiple nerve roots may be involved in radicular symptoms, causing arm pain and distal paresthesias

Myelopathy may present with radicular symptoms but also loss of balance, broad-based gait, and lower
extremity weakness
o Reflexes are hypoactive in the upper extremity but hyperactive in the lower; possible Babinski reflex and
clonus
o Patients with severe cord compression may demonstrate a positive Lhermitte sign, where an electric-shock like
sensation radiates down the spine or extremities with certain movements of the neck, especially during flexion
and extension.
o Causes

The causes of spinal stenosis may be divided according to compression from anterior or posterior
structures.

Anteriorly, herniated disks

Ossification of the posterior longitudinal ligament (OPLL); and osteophytic spurs from the back of the
vertebral bodies, endplates, or uncovertebral joints are the common culprits of cord and root
compression
The ligamentum flavum is the main culprit causing posterior compression, losing its tension and
buckling into the canal as the disc degenerates anteriorly.
OPLL more common in asians
o PE

Some of the common ones include the Lhermitte sign, Babinski reflex, Hoffmann sign, Spurling sign, and
jaw jerk test.

+ Babinski sign is a poor prognosis. Measure upper motor lesions where upward movement of the great
toe is considered abnormal in adults when the sole of the foot is stroked.

The Hoffmann sign is an upper extremity counterpart of the Babinski reflex, and it can be elicited by
flicking the volar surface of the third distal phalanx of relaxed and slightly flexed fingers, which results in
pathologic flexion of the thumb and index finger (Fig. 10.1).

The jaw jerk test is not used to evaluate cervical stenosis but rather to differentiate cervical myelopathy
from the lesions in the brain. Tapping the lower jaw leads to abnormal opening of the mouth, which
indicate brain pathology.

Patients with root compression may have reproduction of their radicular symptoms when the neck is
rotated and the examiners hand presses down on the top of the head (positive Spurling sign)
o Imaging

Initially, Lateral X ray shows spinal stenosis. Normal space available for cord (SAC) is 17 mm and relative
stenosis <13 mm and absolute stenosis is <10 mm.

Measures of Posterior inferior aspect of vertebral body to the anterior aspect of spinous process of the
below vertebra.

MRI is the diagnostic tool of choice because it is not invasive but has multiple planes of view. Also, shows
the extent of damage and degeneration.

IF MRI is contraindicated, CT with myelogram is indicated. It is invasive.

o Treatment

Depends on symptoms (eg, neck pain alone, radiculopathy, or myelopathy); initial management is soft
collar, NSAIDs, and physical therapy; epidural steroids may be helpful

Consider surgical intervention if unresponsive to conservative therapy or if neurologic status deteriorates;

surgical decompression of cord through an anterior approach allows anterior fusion; cervical disk
replacement is probably not appropriate for the generalized disease occurring in spondylosis
Torticollis
o Aka wry neck or loxia
o Symptoms of abnormal/asymmetrical head or neck position AS A RESULT OF MUSCLE SPASMS. Head is tipped
to one side (affected side), while chin is turned to the other side. Shoulder is higher on one side.
o May be present at birth or due to damage of nervous system, spine, or muscles.
o Complications

Muscle swelling d/t constant tension

Nerve root compression.

Muscle may become hypertrophic due to constant stimulation and exercise.

o Image

CT of neck

MRI of brain

Electromyogram to localize most affected muscles.

o Treatment is dependent on cause.

If at birth, passive stretching and positioning during infancy. If does not resolve by preschool, then surgery.

Applying heat, traction to cervical spine, and massage may relieve pain.

Stretching and neck braces help muscle spasm.

Anticholinergic = baclofen

Botulinum injections every 3 months for temporary relief.

Surgery if torticollis is due to dislocated vertebrae. May require destroying nerves in neck muscle or brain
stimulation.
o

Thoracic Spine
Thoracic disc disease
o Herniated disc
o Degenerative disease
o see cervical and lumbar notes
Scoliosis
o Essentials

Adults who seek medical treatment complain of issues related to the spinal curve and/or pain.

Adults may have typical S-shaped or only single curves.

In general, women seek medical attention more often than do men.

A lateral curvature of the spine of > 10 degrees occurring in the thoracic and/or lumbar spine and
associated with rotation of the vertebrae and sometimes excessive kyphosis or lordosis.

Most commonly idiopathic, developing in early adolescence. Other etiologies are congenital or associated
with neuromuscular, vertebral, or spinal cord disease. The male-to-female ratio is 1:7 for curves that
progress and requires treatment.
o HISTORY/PE

Idiopathic disease is usually identified during school physical screening.

Vertebral and rib rotation deformities are accentuated by a forward bending test.

Patients with a history of scoliosis since childhood, who often have substantial thoracic curves, will often
complain of asymmetry of the scapulae and excessive prominence of the shoulder blades. Issues relating
to pain include back pain and/or radicular leg pain.

Chronic scoliosis since childhood= pain interscapular

De novo curvature (usually lumbar)= lower back pain.

Many older patients will complain of their back simply feeling tired with prolonged activity. Radicular leg
pain is common in those with an adult degenerative curve but is rare in those with a history of scoliosis
since adolescence.
o DIAGNOSIS

Radiographs of the spine (posterior, anterior, and full-length views).

Serial full-length spine films recommended.

CT + myelogram OR MRI if have radiculopathy or neural deficits.

o TREATMENT

Regular observation for < 20 degrees of curvature.

Spinal bracing for 2045 degrees of curvature. Curvature may progress even with bracing.

Surgical correction for > 50 degrees of curvature. COMPLICATIONS

Hypokyphosis the risk of restrictive pulmonary disorder.

Kyphosis
o Essentials

Flexion deformity of the spine

Normal thoracic kyphosis has a Cobb angle (the angle between lines drawn perpendicular to the endplates
of the most cephalad and most caudal vertebra of the curve on the lateral radiograph) that ranges from 25
to 45 degrees

Increased kyphosis can be congenital, or a result of trauma or progressive deformity secondary to

osteoporosis

Scheuermann kyphosis refers to 3 or more wedged vertebral bodies with endplate abnormalities and
kyphosis

Congenital kyphosis results from failure of vertebral body formation or segmentation

o Treatment

Bracing is indicated if kyphosis is >4555 degrees in a skeletally immature patient

Surgery is indicated if kyphosis increases despite bracing in a growing patient, or the Cobb angle is >70
degrees, or both
o Pearl

Orthotic treatment of adolescent kyphosis can obtain correction and maintain correction after skeletal
maturity.
Central Cord Syndrome
o MOI: Elderly patient fall
o S/S: Upper extremity weakness > LE weakness
Anterior Cord Syndrome
o S/S: pain and temperature deficient

Will still have proprioception

Posterior Cord Syndrome
o Associated w/ Syphilis, B Vitamin Deficiency (NOT TRAUMA)
o S/S: loss of proprioception
Lumbar Spine

Lumbar disc syndromes

o Herniated disc

Definition

A lumbar disc herniation is defined as a prolapse of the annulus fibrosis of the lumbar disc into the
spinal canal causing compression of the neural elements or frank rupture of the annulus fibrosis with
extrusion of nucleus pulposus material into the spinal canal causing compression of the neural
elements.

Chemical radiculopathy = nerve pain but not d/t compression. TX = sealing tear, exercise, PT, muscle
relaxants

Symptoms

Often preceded by days or weeks of back pain, indicating damage to annulus around disk; rupture
causes pain down leg into nerve root distribution (sciatica in 40% of patients); 90% are L5S1 or L4L5
disks.

Besides pain, common symptoms include numbness, pins and needles, and tingling.

Nerves compressed (L4, L5 or S1 nerve roots); this would typically cause pain that starts in the buttock
and goes down the posterior aspect of the thigh into the calf and into the foot. Many patients will note
that sitting is their most uncomfortable position and that standing and lying down are more
comfortable for them

Complications:

Very rarely, a massive disc herniation can compress all of the nerves in the spinal canal at that level,
including the lower sacral nerve roots; such a situation, known as cauda equina syndrome, will produce
severe pain down both legs, significant derangement in bowel and bladder function (incontinence or
retention), and saddle anesthesia (numbness in the buttocks around the anus and genitals and in the
inner aspects of the thighs). Severe weakness may also accompany this syndrome.
REQUIRE SURGICAL DECOMPRESSION!
Medical emergency

PE and lab findings

+ straight leg test (radiculopathy)

+ femoral stretch (laying on table prone with extension of affected leg)

Valsalva maneuver reproduces pain by increasing intraabdominal pressure.

Reflex tests
L4 compression = have weakness of ankle dorsiflexion, some difficulty walking on the heels, and a
diminished patella tendon reflex on that side.
L5 compression = unable to walk on heels
S1 compression = weakness of the gastroc-soleus muscle group with difficulty walking on the toes
or doing repeated toe raises; there may be a diminished Achilles tendon reflex.

Imaging
MRI shows high intensity zones when disc is dehydrated (appears black). Can produce lower back
pain.
Diagnosed by Discography
If MRI is contraindicated (pacemaker/obese), use CT + myelogram.
X ray is useful to rule out a structural abnormality of the spine such as scoliosis, spondylolisthesis,
or a fracture; it will not, however, show anything but the osseous structures and will therefore not
show a lumbar disc herniation.

Treatment

Most will spontaneously resolve within 4-6 weeks.

Symptomatic = NSAIDs, PT, short term oral steroids, or epidural steroid injections.

In severe cases (progressive neuro deficits/chronic pain/cauda equina), require surgery. The standard
operation for a lumbar disc herniation is a laminectomy-discectomy. This typically involves an incision
approximately 1.5 to 3.0 inches in length and takes approximately 1 hour.
o Degenerative disc disease

Definition

Lumbar disc disease is the drying out of the spongy interior matrix of an intervertebral disc in the
spine (d/t premature aging of IV disks).

Symptoms

The typical patient with degenerative disc disease will be in the third to sixth decade of life with
chronic low back pain that had been intermittent in nature and is becoming increasingly frequent and
painful.

Pain worsens with activity and may have minimal leg pain RARE (radiculopathy if severe)

Patient may complain of instability; feeling like their vertebra is moving back and forth. IV disks acts as
shock absorber and allows for spine stability.

Imaging

X ray initially to rule out fracture

Finally, suggestion of disc degeneration is often evident by loss of space between vertebra and
associated osteophyte formation, particularly in the anterior aspect of the vertebral bodies.

More accurate suggestion of degenerative disc disease is by way of MRI studies; sagittal T2-weighted
images are particularly useful to evaluate disc height and hydration
When disc degeneration is severe, changes within the endplates of the vertebral bodies may be
seen, with edema noted in the area of the endplates of the vertebral body (Modic changes).

Treatment

Mainstay is NSAIDS, steroid injections, and PT.

Surgery (benefits vs. risks)

Fusion of L5 and S1
Lumbar strain/Mechanical back pain
o Low back pain in younger adults (20-45 yo) due to sprain (if in older adults 45-60 yo d/t arthritis).
o No leg pain (radiculopathy nerve root impingement).
o ROM of lower back is diminished secondary to pain. PE shows tenderness/spasms of paraspinous muscles.
o Straight-leg testing may provoke back pain but will not cause radicular leg pain and is therefore considered
negative in these patients.
o Treatment

NSAIDS, PT, NO SURGERY

Imaging is not necessary.

Spondylolisthesis
o Definition = Anterior slip of one vertebral body onto another (usually lumbar) due to facet joint degeneration,
IV disc degeneration, or ligament laxity (hormonal changes).
o Essentials

Patients may be asymptomatic or have back or leg pain; young patients may have tight hamstrings and
flexed hip and knee gait

Radiographs show slip on lateral views and collar on Scotty dog on oblique views with pars defects
present

Degenerative spondylolisthesis most commonly occurs at the L4L5 level. There is greater stability at L5
S1, due to the transverse alar ligaments, and L5S1 is below the level of the iliac crest.

Sitting in positions that decrease lumbar lordosis (leaning forward) will open spinal canal and improve
symptoms.
o Imaging

Radiographs show degenerative changes that include disk space narrowing, facet hypertrophy, and
spondylolisthesis a narrowed spinal canal.

MRI or CT shows spinal stenosis.

o Two main types

Isthmic

Bilateral PARS defect and most commonly in L5

Congenital or acquired

Common in gymnast, athletes, football, or extension pain (bending back = get pars fracture from
repeated.) *facet joint is worn out.

Surgery is indicated for intractable pain

Degenerative

Occurs at L4-L5 and occurs in older patients d/t arthritic

Common with GRADE 1 OR 2

Treatment: PT, anti-inflammatory agents, and muscle relax.

Williams flexion routine most and Avoid extensions

Symptoms related to mechanical pain, leg pain due to foraminal narrowing

Present as radiculopathy from pinching nerve

o Treatment

Low grade or mild symptoms = NSAIDs, brace, PT, and activity modification

High grade or symptomatic = epidural corticosteroids for persistent / radiculopathy pain. Spinal insitu
fusion of affected area.
Spinal Stenosis
o Etiology:

Narrowing of the spinal canal or neural foramina, producing nerve root compression

Caused by combination of disc changes, facet enlargement, thickening of ligament

Must differentiate between neurogenic vs. vascular claudication

Vascular claudication will be relieved immediately with rest (sx d/t decreased BF)
o Essentials of DX:

Pain is usually worse with back extension and relieved by sitting (leaning forward)

Occurs in older patients (> 50 yo). Osteoarthritis (degenerative joint disease) causes narrowing of spinal
canal and compression of nerve roots.

Nerve compression can lead to leg numbness and weakness.

Lumbar disk herniation can cause stenosis and compression of neural structures or spinal artery resulting
in claudication symptoms WITH AMBULATION.
o Clinical presentation

Patient reports low back pain that worsens with extension. May present with neurogenic claudication
symptoms with walking.

Neurogenic claudication Pain is described as reproducible single or bilateral leg symptoms that worse
after walking several minutes and are relieved by sitting.

On examination, exhibit limited extension of lumbar spine, which may reproduce the symptoms
radiating down the legs.

Require thorough neurovascular exams.

In severe cases, may have cauda equina symptoms due to compression. Symptoms include bladder and
bowel incontinence.

Medical emergency requires surgical decompression.

o Imaging

Radiographs show degenerative changes that include disk space narrowing, facet hypertrophy, and
spondylolisthesis a narrowed spinal canal.

MRI or CT shows spinal stenosis.

o Treatment

Flexion based exercises with PT can relieve symptoms.

Spinal or facet joint corticosteroids injections can also reduce pain symptoms.

Mild to moderate: NSAIDs and abdominal muscle strengthening.

Advanced: Epidural steroid injections can provide relief.

Refractory: Surgical laminectomy may achieve significant short-term success, but many patients will
have a recurrence of symptoms

Fusion of spine if it is unstable post laminectomy or if in severe arthritis

Discitis
o Essentials

Patients report severe intractable back pain; tension signs may be present

Usually occur in old or immunocompromised patients > can lead to osteomyelitis

Pain with percussion, or paraspinal muscle spasm

CBC, ESR and CRP may be elevated. May present with fever

Radiographs may show endplate erosion and narrowing; bone scan is positive; MRI with gadolinium is
usually diagnostic

No gadolinium in renal dysfunction patients

CT-guided biopsy and cultures can help confirm the diagnosis

Aspiration is required if symptomatic.

o Treatment

Blood culture to find pathogen. If not, treat empirically w/ IV antibiotic for 6 weeks.

If unresponsive to IV abx or abscess formation will require surgical debridement.

Compression fractures
o Essentials

Typically, the patient affected by an osteoporotic vertebral compression fracture (OVCF) is a

postmenopausal white woman who likely is older than 50 years of age.

If young patients, d/t trauma.

Severity of pain varies. Most are asymptomatic and found incidentally with XRAY. Symptomatic (severe
acute pain) occurs with trauma, fall, or heavy lifting.

No radiculopathy (pain or numbness) or cauda equina symptoms.

Pain is aggravated with activity (flexion/leaning forward) and relieved with rest (or extension).

Many patients with an OVCF will exhibit tenderness about the spinous process of the vertebra that is
fractured
o Imaging

Initial X-ray; X-rays will often show a typical wedge-shaped fracture; however, this is not universally visible,
particularly early in the course of the OVCF.

Bone scan takes several days and is not specific for malignancies (hot spots).

MRI is the best will to show edema within vertebral bodies in acute fracture, malignancies, or infections.

Acute vs. chronic fx

Acute = increased uptake on bone scan and edema in MRI

Chronic = none

X ray can not determine age of fracture.

o Treatment

Conservative treatment with bed rest if not severe.

In severe cases, cement augmentation of OVCF

Vertebroplasty, involving the percutaneous injection of cement into the fractured vertebral body,
which, when hardened, will give immediate stability to the fracture.

Kyphoplasty (Fig. 6.3), which involves inflation of a percutaneously introduced balloon into the
vertebral body in an attempt to restore vertebral body height and prevent kyphosis, followed by
instillation of cement as in vertebroplasty.
Burst fracture
o Compression fracture with retropulsion of posterior elements
o 50% patients develop neurological deficits
o Better prognosis with surgical decompression and stabilization within 1 st 48 hrs

If pts have neuro sx/cauda equina

Pelvis and Sacrum

1) Osteitis Pubis
a) Inflammation of pubis symphysis and surrounding muscle insertions.
b) d/t trauma, giving birth, or urologic procedures
c) Pain with difficulty ambulation and waddling gait.
i) Low grade fever, elevated ESR, and milk leukocytosis.
d) Treatment
i) Pharmacologic therapy may include nonsteroidal anti-inflammatory drugs (NSAIDs), steroids (oral or
injected), or, possibly, prolotherapy with dextrose and lidocaine. Surgery is rarely warranted for osteitis
pubis and should not be a consideration during the acute phase.
2) Coccygodynia
a) Tailbone pain that worsens with when sitting or any activity that puts pressure on the bottom of spine.
b) More common in athletic women > man. Usually d/t athletic injury/trauma or giving birth.
i) Rarely caused by tumor or infection
c) To relieve pain, activity modification with pharmacotherapy needed.
i) If refractory or severe symptoms, coccygectomy is considered.
ii) Initially, rest with NSAIDS. If refractory, systemic steroids, rarely surgical therapy.
3) Pelvic Fracture
a) Most often occur in a fall from significant height, pedestrian accident, ski accident, or vehicular trauma
b) Three categories: anteroposterior (AP) compression injuries, lateral compression (LC) injuries, and vertical
shear (VS) injuries; most are closed injuries
i) Posterior ring fractures are revealed by pelvic instability associated with posterior pain, swelling,
ecchymosis, and motion
ii) LC injuries are usually stable, with impaction of the posterior structures but seldom any complications
iii) AP compression injuries demonstrate anterior instability, palpable ramus fractures, or pubic symphysis
gapping
iv) AP injuries are often accompanied by bladder, prostatic, or urethral injury
c) Gynecologic and rectal exams are mandatory because bony fragments can exit the vagina or rectum,
rendering the fracture as open and necessitating urgent irrigation and debridement
d) Treatment
i) External fixation for AP-type injuries with pubic diastasis >2.5 cm
ii) Immediate application of pelvic clamp for unstable posterior injuries
iii) Sheet or commercially available pelvic compression belt for immediate reduction of potential bleeding
space in AP-type fractures; an external fixator can also be used
iv) Definitive fracture fixation depends on specific fracture type
e) Pearls
i) Identification of posterior injury to the pelvic ring is essential to pre- vent associated significant
hemorrhage, neurologic injury, and mortality. Hemorrhage is rarely from pelvic arterial injuries (usually
internal iliac branches).

Ankle and Foot

1. Define flatfoot deformity and distinguish the clinical significance of flexible vs rigid deformities:

Physiologic variant consisting of a decrease in the medial longitudinal arch and a valgus hindfoot and forefoot
abduction with weightbearing.

Most of the time it resolves spont.

Hypermobile flexible pes planovalgus (most common)-familial ->associated with generalized ligamentous laxity
and lower extremity rotational problem, usually bilateral associated with an accessory navicular correlation is
controversial.

Flexible pes planovalgus -with a tight heel cord. Rigid flatfoot & tarsal coalition (least common): no correction of
hindfoot valgus with toe standing due limited subtalar motion.

Sx: usually asymptomatic in children, may have arch pain or pretibial pain. PE- foot is only flat w/ standing and
reconstitutes w/ toe walking, hallux dorsiflexion or foot handing; valgus hindfoot deformity; forefoot abduction.
Normal and painless subtalar motion; hindfoot valgus corrects to a varus position w/ to standing
2. Define talipes equinovarus and discuss it association with neurologic disease, and its age dependent
treatment in children:

Idiopathic deformity of foot, unclear etiology. Most common birth defect, highest prev in Hawaiians and Maoris;
more common in males. Its adduction of the forefoot, inversion of the heel and plantar flexion of the forefoot
and ankle. Neurologic problems associated with clubfoot include spina bifida/meningomyelocele and
hydrocephalus.

Tx: Nonoperative
o serial manipulation and casting (Ponseti method)
indications
there has been a trend away from surgery and towards the nonoperative Ponseti
method due to improved long term results
outcomes = Ponseti method has 90% success rate
Tx: Operative
o posteromedial soft tissue release and tendon lengthening
indications
resistant feet in young children
"rocker bottom" feet that develop as a result of serial casting
syndrome-associated clubfoot
delayed presentation >1-2 years of age
used to be gold standard but now largely replaced by Ponseti method
performed at 9-10 months of age so the child can be ambulatory at one year of age
outcomes
requires postoperative casting for optimal results
extent of soft-tissue release correlates with long-term function of the foot and
patient
o medial opening or lateral column-shortening osteotomy, or cuboidal decancellation
indications
older children from 3 to 10 years
o triple arthrodesis
indications
in refractory clubfoot at 8-10 years of age
contraindicated in insensate feet due to rigidity and resultant ulceration
o talectomy
indications

salvage procedure in older children (8-10 yrs) with an insensate foot

3. Define the calcaneovalgus entity and Kohler disease:

Calcaneovalgus foot
o is soft tissue contracture foot deformity characterized by: excessively dorsiflexed hindfoot, hindfoot
valgus and no dislocation or bony deformity. Usually a positional deformity caused by intrauterine
packaging.
o More common in females and first borns.
o Deformity is caused by spasticity of foot dorsiflexors/evertors (L4/5), weakness of plantar
flexors/inverters (S1/2) or muscle imbalance caused by an L5 spinal bifida.

Kohlers disease
o is avascular necrosis of the navicular bone of unclear etiology.

o
o

Occurs in young children (4-7), 4X more common in boys.

The blood supply of central 1/3 of navicular is a watershed zone.

Accounts for susceptibility to AVN and stress fx. Navicular is last bone to ossify; increases its
vulnerability to mechanical compression and injury. Kohlers dz often misdiagnosed as infection
(infxn).

4. Discuss the mechanisms of injury, classification, and treatment of ankle sprains:

result of injury to lateral ligamentous complex of ankle;

most common ligament injured is anterior talfibular lig (grade 1 sprain);

o if in addition the calcaneofibular lig is injured, its a grade 2 sprain.
o If all 3 ligs (posterior talofibular lig) are injured, pt has sustained grade 3 sprain.
o If injury to anterior tibiofibular lig, produces so-called high ankle sprain.
o More severe sprains involve subtalar jt (interosseous lig).
o queeze test (compress tibia and fibula over mid-calf) assess for high syndesmotic ankle sprain.
o External rotation test (dorsiflexion of foot w/ external rotation of foot)- if pain prod over distal
tibiofibular syndesmosis->high ankle sprain.

Treatment:
o phase 1 tx involves RICE + NSAIDs prn; brace or air stirrup used to provide support and promote
soft tissue healing, wt bearing as tolerated; severe sprains or in peds may req casting.
o Phase II begins when pt can wt bear w/out increased pain or swelling. It involves continued use of
brace or stirrup and exercises to increase peroneal and dorsiflexor strength. Achilles tendon
stretch.
o Once full rom and 80% normal ankle strength- begin phase III; begins about 4-6 wk after injury and
involves functional conditioning, proprioceptive activities, agility and endurance training. Pt may
be weaned from air stirrup or ankle brace. Phase 3 takes 2wks for low grade sprains or up to 2 mon
for higher grade. High demand athletes- functional brace or taping to reduce reinjury
5. Identify the clinical presentation, physical exam findings, and general treatment of the following
conditions:
Tarsal tunnel syndrome
Compressive neuropathy caused by compression of tibial nerve; May have prev trauma or surgery.
Sx: pain with prolonged standing or walking, often vague and misleading medial foot pain, sharp + burning pains
in foot. Also intermittent paresthesias and numbness in plantar foot.
PE- tenderness of tibial nerve (tinel's sign), sensory exam equivocal, pes planus, muscle wasting of foot intrinsicsabductor digiti quinti or abductor halluces, pain with dorsiflexion and eversion of the ankle, compression testplantar flexion and inversion of ankle, digital pressure over tarsal tunnel ( highly senstitive and specific).
Tx: Nonoperative
o lifestyle modifications, medications

indications = usually ineffective

medications

anti-inflammatory medications

SSRIs have been used

bracing

orthosis or foot wear changes to address alignment of hindfoot

can try a period of short-leg cast

Operative
o surgical release of tarsal tunnel

indications

after 3-6 months of failed conservative management and

compressive mass (ganglion cyst) identified
positive EMG
reproducible physical findings

outcomes

best results following surgery are in cases where a compressing anatomic structure (ganglion cyst) is
identified and removed /

traction neuritis does not respond as well to surgery

Subluxation of the peroneal tendon
o History - patients often report they felt a pop with a dorsiflexion ankle injury
o Symptoms- clicking, popping and feelings of instability or pain on the lateral aspect of the ankle
o Physical exam- swelling posterior to the lateral malleolus, tenderness over the tendons,
'pseudotumor'
over the peroneal tendons, voluntary subluxation of the tendons +/- a popping sound; apprehension tests-

o
o

the sensation of apprehension or subluxation with active dorsiflexion and eversion against resistance cause
subluxation/dislocation and apprehension ; compression test
pain with passive dorsiflexion and eversion of the ankle.
Tx: Nonoperative

short leg cast immobilization and protected weight bearing for 6 weeks

indications = all acute injuries in nonprofessional athletes

technique

tendons must be reduced at the time of casting

outcomes

success rates for nonsurgical management are only marginally better than 50%.
Tx: Operative
o acute repair of superior peroneal retinaculum and deepening of the fibular groove

indications

acute tendon dislocations in serious athletes who desire a quick return to a sport or active lifestyle

presence of a longitudinal tears

o groove-deepening with soft tissue transfer and/or osteotomy

indications

chronic/recurrent dislocation /

technique

less able to reconstruct SPR so treatment focuses on other aspects of peroneal stability

typically involves groove-deepening in addition to soft tissue transfers or bone block techniques
(osteotomies to further contain the tendons within the sulcus)

plantaris grafts can act to reinforce the SPR

hindfoot varus must be corrected prior to any SPR reconstructive procedure

o

Osteochondritis Desiccans of the talus

May be caused by trauma or repetitive microtrauma w/ no history of trauma.

Sx: pain, swelling and mechanical sx such as catching or locking.

PE- effusion. Medial talar dome- usually no hx of trauma, more common and posterior, larger and deeper vs lateral
lesions. Lateral talar dome- usually trauma hx, more superficial + smaller, more central or anterior, lower
incidence of spont healing, more often displaced + symptomatic.
Treatment

Nonoperative
o short leg cast and non weight bearing for 6 weeks
indications = nondisplaced fragment wiht incomplete fracture
Operative
o arthroscopy with removal of the loose fragment and drilling of the base
indications
chronic fractures
size < 1 cm
displaced smaller fragment with minimal bone on the osteochondral fragment (poor
healing potential)
o retrograde drilling and or bone grafting
indications
size > 1 cm with intact cartilage cap
o ORIF vs. osteochondral grafting
indications
size > 0.5 cm and displaced
rehabilitation
emphasize peroneal strengthening, range of motion, and proprioceptive training

6.
State the etiology, clinical signs and symptoms, physical exam findings, treatment and prognosis
for plantar fasciitis:
Plantar Fasciitis
Inflammation of aponeurosis at its origin on the calcaneus- a chronic overuse condition d/t repetitive over
stretching of plantar fascia. Abductor hallucis, flexor digitorum brevis and quadratus plantae share the origin on
medial calcaneal tubercle and may be inflamed as well. Risk factors: high BMI, decreased ankle dorsiflexion in nonathletic population, tightness of foot and calf musculature, wt bearing endurance activity (dancing, running).
Sx: sharp heel paininsidious onset of heel pain when first getting out of bed, worse at end of day after prolonged
standing, relieved by ambulation, warming up.

PE: tender to palpation at medial tuberosity of calcaneus, tight Achilles tendon (limited ankle dorsiflexion).
Tx:
o Nonoperative

night splinting & stretching programs

indications = first line of treatment

technique
plantar fascia-specific stretching
achilles stretching
pre-fabricated shoe inserts

outcomes
stretching programs have equally successful satisfaction outcomes at 2 years /
pre-fabricated shoe inserts shown to be more effective than custom orthotics in relieving
symptoms when used in conjunction with achilles and plantar fascia stretching /

shock wave treatment

indications = second line of treatment

technique = painful for patients

outcomes = efficacious at 6 month f/u

o Operative

surgical release with plantar fasciotomy

indications = refractory disease

technique
can be done open or arthroscopically
resection of heel spurs does not improve outcomes

outcomes = complications common and recovery can be protracted

7.
List the etiology, clinical features, physical examination findings, treatment and prognosis of the
following conditions:
Morton neuroma
Compression neuropathy of interdigital nerve.
Pathophys=compression/tension around the transverse intermetatarsal ligament , repetitive microtrauma,
excessive bursal tissue, endoneural edema; all the above can lead to neural fibrosis.
Sx: 60% of patients report pain radiating into toe distally, often pain elicited during push-off phase of running
athletes and demi-pointe position in dancers, shoes with narrow toe box or high heels can make symptoms
worse , patients often complain of feeling like there is a stone or similar under the ball of their foot. 40% reports
numbness or dysesthesia in plantar aspect of web space.
PE- plantar tenderness with palpation just distal to metatarsal heads, check sensation in affected region as it may
be altered in some patients, a bursal click (Mulder's click) may be elicited by squeezing metatarsals together, or
metatarsalgia and MTP synovitis or instability must be ruled out (use drawer test at MTPJ).
Tx: Nonoperative
o wide shoe box with firm sole and metatarsal pad

indications

first line of treatment

o corticosteroid injection

usually approached dorsal

nerve is below intermetatarsal ligament

avoid injection of MTPJ due to risk of iatrogenic instability

TX: Operative
o neuroma resection

indications

when nonoperative management fails

technique

dorsal incision used most commonly

resection of neuroma 2-3 cm proximal to deep transverse intermetatarsal ligament (incise transverse
intermetatarsal ligament)

bury proximal stump within intrinsic muscles

o neuroma decompression

alternative to resection, especially if adjacent neuromas

resection of adjacent neuromas will lead to complete numbness of toe

Metatarsalgia
Hallux valgus:
o Not a single deformity, but rather a complex deformity of the first ray; often accompanied by deformities and
symptoms in lesser toe.

o
o

o
o

Two forms exist - adult hallux valgus and adolescent & juvenile hallux valgus.
Pathoanatomy- valgus deviation of phalanx promotes varus position of metatarsal; the metatarsal head
displaces medially, leaving the sesamoid complex laterally translated relative to the metatarsal head;
sesamoids remain within the respective head of the flexor hallucis brevis tendon and are attached to the base
of the proximal phalanx via the sesamoido-phalangeal ligament; this lateral displacement can lead to transfer
metatarsalgia due to shift in weight bearing; medial MTP joint capsule becomes stretched and attenuated
while the lateral capsule becomes contracted; adductor tendon becomes deforming force; inserts on fibular
sesamoid and lateral aspect of proximal phalanx; lateral deviation of EHL further contributes to deformity;
plantar and lateral migration of the abductor hallucis causes muscle to plantar flex and pronate phalanx;
windlass mechanism becomes less effective; leads to transfer metatarsalgia .
Presentation-presents with difficulty with shoe wear due to medial eminence, pain over prominence at MTP
joint, compression of digital nerve may cause symptoms
Physical exam

Hallux rests in valgus and pronated due to deforming forces illustrated above /

examine entire first ray for

1st MTP ROM

1st tarsometatarsal mobility

callous formation

sesamoid pain/arthritis

evaluate associated deformities

pes planus

lesser toe deformities

midfoot and hindfoot conditions

Treatment - Adult Hallux Valgus:

Nonoperative:
shoe modification/ pads/ spacers/orthoses
indications = first line treatment
orthoses more helpful in patients with pes planus or metatarsalgia

Operative: surgical correction

indications
when symptoms present despite shoe modification
do not perform for cosmetic reasons alone
Technique
soft tissue procedure

indicated in very mild disease in young female (almost never)

distal osteotomy

indicated in mild disease (IMA < 13)

proximal or combined osteotomy

indicated in more moderate disease (IMA > 13)

1st TMT arthrodesis

arthritis at TMT joint or instability

fusion procedures

indicated in severe deformity/spasticity/arthritis

MTP resection arthroplasty

only indicated in elderly patients with low functional demands

Treatment - Juvenile and Adolescent Hallux valgus

Nonoperative:
o shoe modification
indications= pursue nonoperative management until physis closes
Operative:
o surgical correction
o indications
best to wait until skeletal maturity to operate
can not perform proximal metatarsal osteotomies if physis is open (cuneiform osteotomy OK)
o surgery indicated in symptomatic patients with an IMA > 10 and HVA of > 20
severe deformity with a DMAA > 20 consider a double MT osteotomy to correct orientation of MT head articular
cartilage
o technique
soft tissue procedure alone not successful
similar to adults if physis is closed (except in severe deformity)

Hallux rigidus (W/ DJD)o A condition characterized by loss of motion of first MTP joint in adults due to degenerative arthritis: osteophyte
formation leads to dorsal impingement.
o Pathoanatomy - primary etiology unknown, acute trauma and repetitive microtrauma predispose to arthritic
changes, anatomic variations of first metatarsal may play a yet unproven role in arthritic predisposition.
o Symptoms: first ray and 1st MTP pain and swelling worse with push off or forced dorsiflexion of great toe, shoe
irritation due to dorsal osteophytes and compression of dorsal cutaneous nerve may lead to paresthesias, pain
becomes less severe as the disease progresses.
o Physical exam=limited dorsiflexion, pain with grind test.
o Tx:
o Nonoperative:

NSAIDS, activity modification & orthotics

Indications = grade 0 and 1 disease

activity modifications

avoid activities that lead to excessive great toe dorsiflexion

types of orthotics

Morton's extension with stiff foot plate is the mainstay of treatment

stiff sole shoe and shoe box stretching may also be used
o Operative:
o joint debridement and synovectomy

indications = patients with acute osteochondral or chondral defects

o dorsal cheilectomy

indications

grade 1 and 2 disease (controversial)

pain with dorsiflexion is an indicator of good results with dorsal cheilectomy

shoe wear irritation from dorsal prominence and pain (ideal candidate)

contraindicated when pain located in the mid-range of the joint during passive
motion

technique

remove 25-30% of the dorsal aspect of the metatarsal head along with dorsal
osteophyte resection

the goal of surgery is to obtain 70% to 90% dorsiflexion intraoperatively

o Moberg procedure (dorsal closing wedge osteotomy of the proximal phalanx)

indications

runners with reduced dorsiflexion (60 is needed to run)

failure of cheilectomy to provide at least 30 to 40 degrees of motion

technique

increases dorsiflexion by decreasing the plantar flexion arc of motion

o Keller Procedure (resection arthroplasty)

indications

elderly, low demand patients with significant joint degeneration and loss of motion

contraindicated in patients with pre-existing rigid hyperextension deformity of 1st

MTP joint

technique

involves removing the base of the first proximal phalanx

risk of hyperextension (cock-up deformity), weakness with push-off, and transfer

metatarsalgia (decreased with capsular interposition)
o MTP arthroplasty

indications controversial

technique

capsular interpositional arthroplasty gaining popularity

silicone implants are not recommended due to poor long-term results

outcomes

silicone implants may have a good short term satisfaction rate

osteolysis and synovitis cause mid to long term pain and joint destruction
o MTP joint arthrodesis

indications

grade 3 and 4 disease (significant joint arthritis)

most common procedure for hallux rigidus

o outcomes

70% to 100% fusion rate

15% of patients experience degeneration of IP joint after surgery (mostly asymptomatic)

Congenital overlapping of the fifth toe:

A congenital deformity characteized by a 5th toe that overlaps the fourth -condition is usually bilateral.

May cause problems with shoewear

Treatment: Nonoperative -initial treatment is passive stretching and buddy taping

Operative : tenotomy, dorsal capsulotomy, syndactylization the the fourth toe (McFarland procedure)
Hammertoe:
Hammer deformity characterized by flexion of the PIP joint, extension deformity at DIP, deformity can be rigid or
flexible. Most common deformity of lesser toes.
More common in older women. Second toes usually affected.
Pathoanatomy -overpull of EDL , imbalance of intrinsics.
Sx: pain on dorsal surface with shoe, Push up test :flexible deformity is reducible with dorsal directed pressure on
the plantar aspect of the involved metatarsal-effect of over active extrinics is removed.
Tx: Nonoperative
o shoes with high toe boxes, foam or silicone gel sleeves

indications = pain and or corns on dorsal PIP

Operative
o flexor tendon (FDL) to extensor tendon transfer

indications = flexible deformity that has failed nonoperative management

o resection arthroplasty +/- tenotomy and tendon transfers

indications

rigid deformity that has failed nonoperative mangement /

o girdlestone procedure with flexor to extensor transfer

indications

MTP involvement

similar to claw toe treatment

o arthrodesis

indications = an option in rigid deformity

outcomes = high nonunion rate

corns and calluses- will finish

plantar warts- will finish

disorder of the toenail- will finish

8. Explain the difference between stable vs unstable ankle fractures focusing on their radiographic
findings and treatment
Stable fractures involve only 1 side of the ankle. Unstable involve both sides of the ankle (bimalleolar) or both
sides and posterior malleolus (trimalleolar).
o A fx of distal fibula in conjunction with tenderness over deltoid ligament medially is most likely an unstable
bimalleolar fx.
o Tx- stable distal fibula fractures (fx) can be treated w/ weight bearing cast or brace for 4-6 wks.
Unstable but non displaced fx req a non-wt bearing short or long leg case and longer immobilization. Unstable
displaced fx req closed or open reduction, but better alignment is obtained w/ open reduction and internal fixation.
Any dislocation needs to be reduced, along with ORIF.
9. Discuss the mechanisms of injury and treatment methods for the following conditions:
Calcaneal fractures- traumatic axial loading is primary mech of injury (fall from height, MVAs);
Treatment includes:
Nonoperative -cast immobilization with nonweightbearing for 6 weeks /
o indications
calcaneal stress fractures
cast immobilization with nonweightbearing for 10 to 12 weeks
o indications
small extra-articular fracture (<1 cm) with intact Achilles tendon and <2 mm displacement
Sanders Type I (nondisplaced)
anterior process fracture involving <25% of calcaneocuboid joint
comorbidities that preclude good surgical outcome (smoker, diabetes, PVD)
o techniques
begin early range of motion exercises once swelling allows
Operative
closed reduction with percutaneous pinning
o indications
tongue-type fxs or those with mild shortening
large extra-articular fractures (>1 cm)
early reduction prevents skin sloughing and need for subsequent flap coverage

techniques
lag screws from posterior superior tuberosity directed inferior and distal

ORIF

indications
large extra-articular fractures (>1 cm) with detachment of Achilles tendon and/or > 2 mm
displacement
urgent if skin is compromised
Sanders Type II and III
posterior facet displacement >2 to 3 mm, flattening of Bohler angle, or varus
malalignment of the tuberosity
anterior process fracture with >25% involvement of calcaneocuboid joint
displaced sustentaculum fractures
o timing
wait 10-14 days until swelling and blisters resolve and wrinkle sign present 10-14 days
no benefit to early surgery due to significant soft tissue swelling /
o outcomes
surgical outcome correlates with the number of intra-articular fragments and the quality of
articular reduction
factors associated with a poor outcome / / /
age > 50
obesity
manual labor
workers comp
smokers
bilateral calcaneal fractures
multiple trauma
vasculopathies
men do worse with surgery than women /
factors associated with most likely need for a secondary subtalar fusion /
male worker's compensation patient who participates in heavy labor work with an inital
Bhler angle less than 0 degrees
primary subtalar arthrodesis
o indications = Sanders Type IV
o techniques = combined with ORIF to restore height

Metatarsal fractures Mechs: direct crush injury (may have significant associated soft tissue injury); indirect mech- most common :
occurs with forefoot fixed and hindfoot or leg rotating.
Tx: Nonoperative
o stiff soled shoe or walking boot with weight bearing as tolerated
indications
first metatarsal
non-displaced fractures
second through fourth (central) metatarsals
isolated fractures
non-displaced or minimally displaced fractures
stress fractures
second metatarsal most common
look for metabolic bone disease
evaluate for cavovarus foot with recurrent stress fractures
Operative
o percutaneous vs open reduction and fixation
indications
open fractures
first metatarsal /
any displacement
no intermetatarsal ligament support
30-50% of weight bearing with gait
central metatarsals

sagittal plane deformity more than 10 degrees

>4mm translation
multiple fractures

techniques
antegrade or retrograde pinning
lag screws or mini fragment plates in length unstable fracture patterns
maintain proper length to minimize risk of transfer metatarsalgia
outcomes = limited information available in literature

Snowboarders Fracture
Lateral process of the Talus
MOI: eversion and axial loading
Other Fractures
Maisonneuve Fracture: medial malleolus OR deltoid ligament injury + proximal fibular fracture
Tillaux Fracture: S-H III of the distal 1/3 tibia joint (teenagers)
(Plafond) Pilon Fracture: talus splits ankle apart with distal tibia fracture +/- fibula fracture
Triplanar or Trimalleolar Fracture: fracture of the lateral malleolus, the medial malleolus and the distal
posterior aspect of the tibia (posterior malleolus);
o Tx: ORIF and non-weight bearing
Pilots Fracture: talar neck/body
Lisfranc Fracture: 2nd MT; unstable arch of foot
o Sometimes no fracture or small avulsion-like appearance
o X-Ray: Look for Fleck sign
o Tx: most need surgery
Dancers Fracture: avulsion fracture of the base of the 5th MT; cast
Jones

fracture
Hx of increased activity over short period of time or change in running surface;
most significant single MT fracture (the base of the 5 th MT fracture).
Tx: Jones fx requires ORIF to reduce the risk of either delayed union or non-union.
These fx occur in zone 3 of the 5th MT. They are much more serious than they look and req non-wt bearing
and surgical intervention to reduce risk of delayed union or non-union.

Phalangeal fractures
mech depends of age: 10-29 yoa sports is most common,

40-60 yo machinery is most common and >70 yoa- falls are most common.

Treatment of proximal phalanx fracture

o Nonoperative

buddy taping

indications
o extraarticular with < 10 angulation or < 2mm shortening and no rotational
deformity

3 weeks of immobilization followed by aggressive motion

reduction and splinting

indications
o most distal phalanx fx
o Operative

CRPP vs. ORIF

indications
o irreducible or unstable fracture pattern
o transverse fractures (all angulate volarly) with > 10 angulation or 2mm
shortening or rotationally deformed /
o long oblique proximal phalanx fractures

techniques
o crossed k-wires
o Eaton-Belsky pinning through metacarpal head
o minifragment fixation with plate and lag screws, or lag screws alone

lag screws alone indicated in presence of long oblique fracture /

Treatment of middle phalanx fracture

o Nonoperative

buddy taping

indications

extraarticular with < 10 angulation or < 2mm shortening and no rotational

deformity
technique
o 3 weeks of immobilization followed by aggressive motion
o

Operative

CRPP vs. ORIF

indications
o irreducible or unstable fracture pattern
o transverse fractures with > 10 angulation or 2mm shortening or rotationally
deformed

techniques
o crossed k-wires
o collateral recess pinning
o mini fragment fixation with plate and lag screws
Treatment of distal phalanx fracture
o Nonoperative

reduction and splinting

indications
o most cases
o nail matrix may be incarcerated in fx and block reduction
o Operative

remove nail, repair nailbed, and replace nail to maintain epi fold

indications = when distal phalanx associated with a nailbed injury

see nail bed injuries /

ORIF +/- bone grafting

indications = non-unions
Complications
Loss of motion
o most common complication
o predisposing factors include prolonged immobilization, associated joint injury, and extensive
surgical dissection
o treat with rehab, and surgical release as a last resort
Malunion
o malrotation, angulation, shortening
o surgery indicated when associated with functional impairment
corrective osteotomy at malunion site (preferred)
metacarpal osteotomy (limited degree of correction)
Nonunion
o uncommon
o most are atrophic and associated with bone loss or neurovascular compromise
o surgical options
resection, bone grafting, plating
o

Shoulder
1.Identify the anatomy and discuss the physical exam tests for the rotator cuff tendon:
Overview of Physical Exam of Rotator Cuff
Cuff Muscle

Strength Testing

Supraspinatus

Weakness to resisted elevation in Jobe position

Special Tests

Drop arm test

Pain with Jobe test

Infraspinatus

ER weakness at 0 abduction

ER lag sign

Teres minor

ER weakness at 90 abduction and 90 ER

Hornblowers

Subscapularis

IR weakness at 0 abduction

Excessive passive ER
Belly press /
Lift off /
IR lag sign

2. Distinguish between the following:

a) tendonitisb) rotator cuff tearso most often occurs at insertion of myo into greater tuberosity;
o acute tears present with sudden onset of pain related to acute injury,
o chronic tears present with no hx of injury in older pt.
o Difficulty w/overhead activities; grinding/grating/catching sensation w/ movt of shoulder; complaints of
nocturnal pain worse than daytime pain and difficulty sleeping on affected shoulder, pain localized to
deltoid region and rarely radiaties past elbow.
o PE- tenderness to palpation over greater tuberosity, pain w/ forced internal rotation and forward
flexion, presence of pain and weakness w/ empty can test, atrophy may be noted in posterior shoulder,
PROM may remain full but limitation in abduction to around 45deg with AROM; shoulder xr reveal
hooked acromion which predisposes to tears, shoulder xr in long term chronic tears may reveal loss of
subacromial space,
o MRI to confirm and assess extent of tear.
o NSAIDS for acute pain, PT for preserving rom, stretching, strengthening. Judicious use of corticosteroid
injections
c) calcific tendonitis3. Define adhesive capsulitis and discuss its physical exam findings, diagnostic evaluation, differential
diagnosis, treatment and prognosis
Tx: Codmans exercises: swing arm in pendulum motion with light handheld weights for five minutes 1-2x/day
4. Explain the mechanism of injury of glenohumeral dislocation and multidirectional instability and
discuss radiographic findings, treatment, complications and recurrence rate
Anterior: most common
o QB position, paddlers, rebounders, etc.
o Associated w/ greater tuberosity and proximal humeral fractures
Posterior: seizure patients
o Difficult to identify on xray
Imaging:
o AP x-ray and Y view

Hill-Sachs lesion: humeral head deformity found in recurrent dislocations

Bankarts lesion: tear of glenoid labrum (seen on MRI)

5. AC joint dislocations ligamentous injury causing disruption of AC joint; called shoulder separation; in higher grade tears also involve
coracoacromial lig.
o Grade 1 injuries= AC jt lig partially disrupted;
o Grade II- AC jt ligs completely disrupted and coracoacromial lig partially disrupted;
o Grade III- complete disruption of both AC and coracoacromial lig resulting in complete separation of
acromion from clavicle;
o Injuries most often occur from fall onto acromion.

o
o
o

presents with traumatic injury to acromion, pt usually supporting injured arm in adduction, motion esp
abduction of shoulder causes pain, pain over AC jt and pain when attempting to lift affected arm.
PE- tenderness over AC jt, grade 2- usually have small amt of deformity over AC jt; grade 3- have
marked deformity over AC jt. AC jt widening on affected side in grade 2 or higher. 10# wt strapped to
each wrist during XR may help enhance asymmetry.
Use sling for few days until improves, icing for first 48 hrs, analgesic prn, PT to reduce pain +restore
motion, return to high demand activities as tolerated in 4 wks

Will Finish the following later:

6.Explain the patient profile, radiographic and physical exam findings and treatment of degenerative
arthritis of the shoulder
7.Discuss the mechanism of injury, physical findings, treatment and complications of elbow and radial
head dislocation
8.Describe the mechanism of injury, radiographic findings, and treatments for radial head fracture,
olecrenon fracture, and Monteggia fracture
Osteoporosis
DEXA start at 65 y/o (females) or 75 y/o (males)
Repeat every 1-5 years depending on scores
Thoracic Outlet Syndrome
EAST/Adsons test (elevated arm stress test: one arm may become painful or pale)

ELBOW
Nursemaids Elbow
Seen in ages 2-5
Dx: Xray radial line misses capitellum
Tx:
o Reduction: supination/pronation with hyperflexion