PANCE: MSK, (10%) →↑↓

Elbow anatomy--nerve MC injured in epicondyle injury

ulnar (funny bone)

Complex regional pain syndrome

(formerly known as reflex sympathetic dystrophy) Autonomic dysfx following bone or soft tissue injury (ex wrist fx) Stage I: Pain out of proportion to injury sx: swelling, extremity changes color, Stage II: waxy, pale skin, brittle nails, loss of hair' Stage III: joint atrophy & contractors Tx: (prevent) w *Vit C prophylaxis after fx* -*anesthetic blocks*, PT, PO steroids, NSAIDs (surgical sympathectomy or cutting of sympathetic nerve)

shoulder (MC direction of dislocation, MC nerve damaged)

*AA: Anterior disloc, Axillary nerve* anterior (95%) (usu the result of fall on outstretched hand--FOOSH) axillary nerve is in close proximity to the glenohumeral joint, thus making it vulnerable to injury during a shoulder dislocation -Closed Reduction as soon as poss

Rules for Metatarsal Fracture Referral

*All first metatarsal fractures*--ortho referral -All OPEN fractures In non-athletes, indications for orthopedic referral include: -multiple metatarsal fractures, -intra-articular fractures, -*1st metatarsal fracture*, -or 2nd-5th metatarsal fracture displaced > 3-4 mm. This includes first metatarsal fracture with 1 mm displacement, should receive an orthopedic referral. Metatarsal fractures are the second most common type of foot fractures in adults, behind toe fractures. Eti: Direct blows and twisting injuries are the most common mechanisms of metatarsal fracture. Greater force is typically needed to fracture the first metatarsal due to its larger size. RF: osteoporosis, diabetes, and decreased physical activity. Patients with metatarsal fractures usually present with acute onset of foot pain and difficulty walking. Physical exam is often notable swelling and ecchymosis. Point tenderness is common, but swelling may make localization difficult. The tarso-metatarsal joint should be palpated to evaluate for Lisfranc injury. Dx: Three-view plain radiographs are recommended as initial diagnostic imaging. Initial management for minimally displaced involves a posterior splint, non-weight-bearing status, elevation, and ice. Healing typically occurs within 6 weeks in the majority of adults with metatarsal fractures.

Scaphoid fracture

*ScaFoid Fractures* FOOSH (MC carpal) SNUFFBOX TENDERNESS** *XR (may not show for 2 wks)* Tx: If non-displaced→ Thumb Spica cast Or if displaced→ORIF surgery (open-reduction internal fixation) most commonly FRACTURED carpal bone

Bone Cancer (Peds)

"Dallas! The *benign Osteo-Com-Drama* where smelly *Onion-peels* like j.r.Ewing actually "DIEaphyses". And others like brother Bobby "METAphyses" from death to *sunburst* and *Codman* rise from *Osteo-star-comas*" *Osteochondroma*: *MC benign* bone tumor (esp ages 10-20y) MC in males. Dx: often pedunculate and grows away from growth plate *Osteosarcomas*: *MC bone malignancy* (10-20yo, however also MC in elderly); *metaphyseal* of the long bones XRay: *sun ray/burst*, hair on end, *Codman's triangle* MC METS to lungs Tx: limb-sparing resection or amputation (neovascular), Chemo as adjunct *Ewing sarcoma*: (5-25yo), (2nd MC bone malignant in kids) *diaphyses* of long bones, ribs, flat bones Xray: *onion peel* Tx: chemo, surgery, radiation Epiphysis--ends of long bone Metaphysis--narrow transition Diphysis--shaft Sx: Associated w Malignancy: Night pain, painful mass attached to bone can be non painful) -Severe pain preceded by dull, aching pain may indicate pathologic fx *Systemic sx:* fever, weight loss, anorexia, fatigue Red flags: -Non-articular bone pain -Back pain on presentation -Bone tenderness -Severe constitutional sx -Night sweats -Ecchymoses/bruising -Features atypical of rheumatologic dz

radial head subluxation

"Nursemaids anterior RADIAL tires need annual replacement" *Elbow is MC dislocated joint in kids* Def: subluxation of the radial head caused by excessive longitudinal traction RF: < 4yo Path: the radial head slips ANTERIORLY out of the ANNULAR ligament Though it occurs incidentally, Consideration should be made *possible abuse* in this injury PE: forearm fully PRONATED slightly flexed and held tightly to side Dx: AP & lateral films to r/o fx Tx: "SUPLEXing the forearm POSTER pressure. place thumb of proximal hand over radial head while fully SUPinating and fLEXing the forearm AND applying posterior pressure. A "screwing" action. -------------- (nursemaid's elbow) lifting, swinging, pulling a child. Sx: arm slightly flexed, refuses to use arm. Tenderness of radial head Dx: XR if needed Tx: reduction, XR if still can't use

Sjogren's syndrome

"Slow sad jogger" (dry mouth, eyes, thyroid dysfx) Eti: Slowly progressive autoimmune dz causing *lymphocytic infiltration* of exocrine glands (esp. lacrimal and salivary) *SSa ("Ro") and SSb ("La") Antibody* RF: Mean dx age is 50, F>M 9:1 RARE in kids. Sx: dry mouth (xerostomia) dry eyes (keratoconjunctivitis sicca) 1/3: Do well with minimal symptoms 1/3: Arthralgias, Fatigue 1/3: Very aggressive: Risk for inflammatory lung dz, autoimmune hepatitis, lymphoma Dx: Schirmer's test: lacrimation (+) RF, ANA, Anti-Ro, Anti-La Tx: eye drops, water

Scleroderma (systemic sclerosis)

"Thickened skin"--systemic connective tissue d/o char by collagen deposited on skin (and sometimes heart, lungs, kidneys, GI) RF: F>M, age 30-50, child-bearing years, Sx: (3 types) LOCALIZED: just skin; steroids, methotrexate LIMITED: (CREST symptoms)--MC type C-Calcinosis cutis (ext of elbow, pre-patellar, hands) "cutis"=cutaneous R-Raynauds Phenomenon (red/white/blue hands) E-Esophogeal Motility Dz S-Sclerodactyly (claw hand) T-Telangectasia (dilation of capilaries) DIFFUSE: "Above the elbows/knees, it's prob diffuse dz", Raynauds, Interstitial Lung Dz, renal disease, pulm HTN Dx: POL3 Tx: No cure. Poor prognosis. - Tx is aimed at organ-specific disease processes (ie. PPIs for reflux dz, ACE inhibitors for renal dz, avoidance of triggers and tx with CCB for Raynaud, and immunosuppressive drugs for pulmonary HTN)

Osteogenesis Imperfecta

("Brittle Bone" Disease) Patient with a family history of similar symptoms Complaining of hearing loss, easy bruisability, or multiple fractures PE will show blue sclera, increased laxity of joints and skin, short stature, scoliosis, basilar skull deformities Most commonly caused by autosomal dominant mutation in collagen

Polymyositis/Dermatomyositis

*Inflammatory dz* of striated muscle affecting the *proximal limbs*, neck and pharynx. Eti: Cause is unknown, but strong assoc w occult malignancy RF: M>F Sx: PROGRESSIVE SYMETRICAL (and usu PAINLESS) PROXIMAL muscle WEAKNESS; dysphagia, skin rash (malaria or heliotrope), polyarthralgias; muscle atrophy *When skin affected (dermatomyositis)* Other organs: joints, heart, lung, GI Dx: *Anti-Jo 1 Ab*; *Elev Muscle Enzyme*s: *CK* (creatinine kinase) and *aldolase* Muscle biopsy--myopathic inflam changes Tx: High-dose steroids, methotrexate, azathioprine until sxs resolve

lunate dislocation

*Lunate reLocates* *perilunate disl*: no luntate articulate w capitate, but yes to radius *lunate disl*: no luntate articulate w capitate or radius Dx: "piece of pie" or "spilled teacup" sign Tx: ORIF lunate is the most commonly dislocated carpal bone. It is usually displaced anteriorly by rotation on its proximal, convex surface (where it articulates with the radius). The displaced bone may compress the median nerve in the carpal tunnel, leading to pain, sensory loss, and/or paralysis

septic arthritis

*Most dangerous* form of acute arthritis---medical EMERGENCY (destroys joint quickly) Def: INFECTION in the JOINT cavity (usually BACTERIAL) Eti: Hematogenous spread, direct inoculation (trauma, puncture, sx), contiguous spread (ex from OA) RF: extremes of age, immxsupp drugs, chronic debilitating dz, IVDA, prostetic joints, chronic arthropathies (RA, OA, gout) MC: S.aureus (59%) N. gonorrhea (sexually active young adult); streptococci; Neonates: GBS, S.aureus, H.influ Sx: *Joint*:MC single, swollen, warm, painful joint (↓ROM) *Constitutional*: fevers, chills, sweats, myalgias Dx: Arthrocentesis (joint fluid aspirate is definitive diagnosis) -*WBCs >50K* (primarily PMNs) -gram stain, cx Tx: ABX (Kaplan says dx as septic then tx empiraclly until cx) [GRAMposCocci]: -If G+ Staph, Strep or Enterococci then NAFCILLIN (Vanco if MRSA). (Vanco or Clinda if PCN allx) [GRAMnegCocci]: -If G-, Neisseria gonorrhea, meningitits, M catarrhalis, or H.influenza then CEFTRIAXONE (Cipro if PCN allx) [GRAMnegRod]: -If G-rod, Escherichia coli (E. coli), Salmonella, Shigella, and other Enterobacteriaceae, Pseudomonas, Moraxella, Helicobacter, THEN Ceftrixone + anti-pseudo (Gentamicin) -------- SUMMARY: Sx: fever, monoarticular pain with decreased ROM Dx: Labs will show WBC > 50,000 with > 75% PMNs Diagnosis is made by arthrocentesis MC: Age < 35: N. gonorrhea, S. aureus overall Tx: is IV ABX, surgical washout

Posterior Glenohumeral Shoulder Dislocation

*Newsflash: The ANT was ABDUCTED by EXTERNAL forces; POSThumously he was ADDed to INTERNAL obituary*. PE: arm adducted and internally rotated Eti: usu assoc w *seizures, shocks* Dx: Axillary and "Y" view to determine if ANT or POST. *More difficult to see on Xray* Tx: Reduction

Jones Fracture

*Transverse* fracture through *diaphysis of 5th metatarsal* (avulsion is psedo-Jones/Tennis) Tx: NWB x 6-8weeks Frequently requires ORIF

positive ANA (A) suggests a

*mixed-connective tissue disease*: -rheumatoid arthritis, -systemic lupus erythematosus, -scleroderma, -polymyositis or -Sjogren's syndrome, All of which typically display skin and/or digit abnormalities.

tendonitis tenosynovitis

-tendonitis is inflammation of the tendon -tenosynovitis is inflammation of the sheath enclosing the tendon Sx: often occur together, causing pain w movement, swelling and impaired fx. Tx: Ice, rest, stretching, NSAIDs for pain (does not treat tendon inflammation acutely 2' to inadequate penetration) --may resolve over several weeks corticosteroid injection beside the tendon (+ local anesthesia) may alleviate primary pathology (*NO intratendon injection*) risk of rupture

Acute Lower Back Pain RED FLAGS

1. Cauda Equina: new onset of (urinary *retention*/incontinence w saddle anethesia, *bilateral* leg weakness, *bilateral* sciatica, decreased anal sphincter tone) 2. Infection (fever, UTI or skin infection, Immxsup, IDU) 3. Malignancy (Cancer Hx, wt. loss, >50) 4. Compression Fx (>70, female, corticosteroid use, Hx osteoporosis, trauma) 5. Lumbar radiculopathy

Low back sprain

?

Anterior cruciate ligament

ACL: MC injured; MOI: non-contact pivoting injury Sx: "I heard it pop" or "give out" during activity Dx: *Lachman's Test* (ACL laxity) but also Anterior drawer test Tx: Contreversial: Therapy (bracing, crutches, PT) vs. surgical repair (consider age and activity goals)

Ottawa Rules

ANKLE Radiograph: (Malleolar Zone) -Pain along *POSTERIOR* tip of *LATERAL malleolus* -Pain along *POSTERIOR* tip of *medial malleolus* OR -inability to bear weight both immediately after AND in the ER for 4 steps. FOOT Radiograph: (Midfoot Zone): -Pain over the navicular bone -Pain over the base of the fifth metatarsal, or -inability to bear weight for 4 steps immediately after AND in ER. ANKLE Sprain: -ankle inversion -pain and swelling Imaging will show partial or complete tearing of ligaments *MC-anterior talofibular ligament (ATFL)* TX: RICE therapy Comments: Ottawa Rules to determine imaging

ankle sprains (types and classification)

Anterior talofibular ligament (ATFL) most commonly sprained Grade I: microscopic tear, Grade II: incomplete tear, Grade III: complete tear RICE 3 grades of Ankle Sprains Grade 1: *Partial tear WITHOUT laxity* and only mild edema. Grade 2: *Partial tear WITH mild laxity* and moderate pain, tenderness, and instability. Grade 3: *Complete rupture* resulting in considerable swelling, increased pain, significant laxity, and often an unstable joint. Ankle sprain involves stretching or tearing of the ligaments of the ankle. There are three grades of ankle sprain as determined by the extent of ligamentous injury. MC cause of morbidity in the general population. 85% of all ankle sprains occur on the -*lateral aspect of the ankle*, -involving the *anterior talofibular ligament and calcaneofibular ligament*.

spinal stenosis (back pain)

Arnorld!!! What did you do to my back! Eti: Narrowing of spinal canal w impingement on nerve roots & cauda equina Sx: -Better: leaning forward, flexion *SHOPPING CART SIGN* -Worse: walking uphill/extension; MC >60yo *hyperreflexia* Stocking/glove sensory changes, vibration and proprioception changes, electric shock pains Dx: *MRI* Tx: *STEROID injection* of lumbar epidural (if no neuro sx) Surgical decompression laminectomy, fusion (by a SPINE surgeon)

Smith fracture

Bruce SMITH FLEXES! but these days GARDENs. Def: distal radius w/anterior angulation (over-flexion of wrist) (less common other radius fx) Sx: Ventral deformity ("garden spade" deformity) Dx: XR Tx: Sugar tong splint/cast if stable; surgery if unstable

Herniated disc (nucleus propulsus)

Classic: Radiculopathic back pain (sciatica) +/- low-back pain; Eti: MC: *L5-S1* - Pain in a *dermatomal pattern*, - increased pain when coughing, straining, bending, sitting Sx: Sciatica: Back pain *RADIATING to the thigh/buttock*→ lower leg down L5-S1 dermatome PE: Positive STRAIGHT LEG RAISE , +cross over test, + strength reflex Sensory/Motor/Reflex L4: ant thigh/ dorsaflex/(pointing to) knee L5: lat thigh/ bigtoe/ none S1: postleg/ plantarflex/ ankle Dx: R/o RED FLAG symptoms then tx supportively. Imaging generally unneccesary. ONLY after 6 weeks, then consider MRI Tx: NSAIDs and short-term (<2d) bed rest (most recover wo additional intervention) +/- muscle relaxants -fitness program -If not improved after 6-12 weeks, consult surgery Kaplan: Majority of patients with simple herniated lumbar discs *do not need any imaging* because the majority of these patients will improve with conservative care. If the patient fails to respond to conservative care or develops red flag symptoms, herniated lumbar disc is best confirmed by MRI. Surgical intervention is needed if neurologic deficits are progressing. Emergency intervention is required if there is a cauda equina syndrome

Osteoporosis

Compromised bone density → decreased strength and frxs RFs: female, Asian, Caucasian, low body weight, tobacco, EtOH Primary: Type 1: post-meno estrogen def and accelerated bone resorption Type 2: later, d/t decreased bone formation and decreased Vit D Secondary: - Meds, endo, genetic, immune Estrogen promotes clast apoptosis and increases blast growth factor Normal: T-Score > -1 SD *Osteopenia*: -1 to -2.5 SD Osteoporosis T-Score < -2.5 + frx Tx: PREVENTIVE: Exercise, fall prevention, calcium, Vit D, PHARM: - *Bisphosphonate (1st line)*: inhibit resorption - Hormone Replacement Therapy - SERM: Raloxifen -Calcitonin: max 6 months

Nerve responsible for "foot drop"

DEEP PERONEAL DERVE -arises from the common peroneal nerve (L4-S2). -responsible for dorsiflex (extend) the foot. -one of it's branches innervates the skin between 1st-2nd toes.

Lumbosacral strain

Def/Eti: acute strain or tear of paraspinal muscles esp w twisting/lifting injury Sx: POINT TENDERNESS; back muscle spasms, dec ROM, no neurologic changes (no pain below knee) Tx: NSAIDs/analgesics +/- muscle relaxants; BRIEF bedrest <2d should improve in 6 weeks (if not then consider imaging)

*Legg-Calve-Perthes Disease (Avascular necrosis of the proximal femur)

Def: *results from interruption of blood supply to the bone*; Femoral head ischemia results in the death of marrow and osteocytes and usually results in the collapse of the necrotic segment Sx: Classic: initially an "atraumatic, *painless limp*", now w pain in thigh; may be mild or intermittent hip, groin, thigh or knee; Patients have "delayed bone age" Dx: Xray: -sclerosis and radiolucency of femoral head (FH), -reduction in size of FH, -flattening/ fragmentation of affected FH Tx: usu self-limited disorder followed by pediatric orthopedist; Observation. Pain control. *Bed rest* (to contain FH c/n acetabulum). Restore ROM

*Slipped capital femoral epiphysis

Def: Displacement of the femoral head due to weakening or disruption of the epiphyseal growth plate Eti: Unknown RF: *obese male adolescents (10-16y)* w delayed skeletal maturation OR tall, lanky, thin kids after *growth spurt* (also assoc w hypo/hyperthyroidism) Sx: gradual onset, *painful partial limp* with hip or referred KNEE/thigh pain (external rotation of affected leg) *cannot rotate leg INTERNALLY* Dx: lateral X-ray show posterior and medial displacement of epiphysis (back and in) Assess w patient in *frog-leg lateral pelvis* Tx: ORTHO Emergency; pinning in situ (percutaneous screw) ORIF (open reduction internal fixation)

Gout

Def: Inflammatory arthritis 2ry to Uric acid deposition in the soft tissue, RF: >30 yo, M>F, purine-rish foods (ETOH,oily fish,yeasts) Meds (THIAZIDES, HCTZ; Loop, furosemide,) Sx: Abrupt excruciating painful red & swollen joint (wake from sleep) commonly in 1st MCP (big toe), [acute-monoarticulat, Chronic-polyarticular] Dx: MSU crystals, YELLOW when parallel, strongly NEGATIVE birefringent , NEEDLE shaped crystals X-ray: "punched out" erosions Acute: 1st: NSAIDs (*indomethacin* and naproxen are NSAIDs) (if normal renal fxn), Colchicine Chronic: 1st-Allopurinol

Compartment Syndrome

Def: Muscle/nerve ischemia (decrease tissue perfusion) MC compartment *"anterior compartment of the leg"* (leg=calf) in association w *tibia fracture* MC fx'd long bone--tibia--kids & adults Etio: trauma, MC after *fracture* of Long bones, *crush injuries*, tight cast or thermal burns *ALSO, prolonged ischemia (drunk* on park bench for 12h) Sx: Pain out of proportion to injury 5 Ps: -pain on PROM, -pallor -paresthesia, -pulselessness, -poikilothermic Dx: Increased intracompartmental pressure >30-45mm HG (or pressure diff >30) Tx: Fasciotomy

Fibromyalgia

Def: Widespread muscular pain, sleep/memory problem, Increased in pain perception Epi: MC Middle aged WOMEN Diffuse pain, extreme fatigue, stiffness, sleep disturbances Sx: Diffuse pain in 11 out of 18 trigger points > 3 months Neuro, vision, skin, stomach Dx: Biopsy: moth eaten appearance Tx: Exercise, TCAs, Pregabalin, gabapentin -------- Patient will be a woman Complaining of widespread musculoskeletal pain for > 3 months, non-restorative sleep and generalized fatigue PE will show tenderness at anatomic sites ("trigger points") Labs will be normal Diagnosis is made clinically Treatment is education, antidepressants, avoid opioids

Ankylosing spondylitis

Def: a seronegative spndyloarthropathy that progresses to fused spine; *I SEE the BAMBOO says Bomber-27 (uveitis, HLA-B27)* chronic systemic inflammatory dz of sacroiliac joints and spine; *MC Complication: Anterior Uveitis*, also IBD *Kyphosis* RF: males, 15-40 y/o Sx: *morning back stiffness*, nocturnal pain, *improves with exercise*, buttock pain, *SI tenderness (SACROILIAC)*, decreased spinal mobility Dx: Lumbar Spine XR *(*"bamboo spine"*-*squaring of vertebral bodies*)* *(+) HLA-B27 Inc ESR,* (-) ANA, (-) RF Tx: 1st Line: *NSAIDs*, rest PT if failed *Infliximab* then steroids

Osgood-Schlatter Disease

Def: apophysitis of tibial tubercle caused by trauma or overuse; RF: 8-15 yo males Sx: anterior knee pain w localized pain and swelling over tibial tubercle Dx: Xray may be necc to r/o infection, tumor or avulsion fracture Tx: Rest and activity modification; pain meds and icing can help; Sx can last 1-2 years. (an inflammation of an outgrowth, projection, or swelling, especially a bony outgrowth that is still attached to the rest of the bone. Apophysitis occurs due to excessive traction or stress)

Pseudogout

Def: calcium pyrophosphate deposition in the joints and soft tissue -> inflammation and destruction of the bone RF: OA, DM, hyperthyroidism, > 60 yo, female Sx: Red, swollen, painful joint MC knees, also wrists, MCP joints, elbows, MTP (resembles RA) Dx: arthrocentesis (POSITIVELY charged RHOMBOID shaped crystals BLUE in PARALLEL) Tx: Corticosteroids (1st line), NSAIDs, Colchicine (prophylaxis)

Systemic Lupus Erythematosus (SLE)

Def: chronic systemic, multi organ autoimmx d/o of connective tissue; RF: 20-40 yo, Fem, AA/Hisp/N.Amer Drug induced: procainamide, hydralazine, INH, quinidine SOAP BRAIN MD Serositis: pericarditis, pleuritis Oral ulcers (lip cracking) Arthritis Photosensitivity/retinopathy Blood (CBC thrombocytopenia, hemolytic anemia) Renal (glomerulonephritis) *Anti-ANA Ab (best initial test* Immune (Anti-Smith, Anti-DS DNA) Neuro (seizures, psychosis) Malar rash (butterfly--*SPARES nasalabial folds*) Discoid rash Tx: 1) regular exercise & sun protection, 2) NSAIDs or acetaminophen (for arthritis) 3) hydroxychloroquine (for skin--antimalarials), 4) Corticosteroids 5) Methotrexate at low doses (Rosh: Treatment is NSAIDs, steroids, immunosuppressants, hydroxychloroquine) Comments: Drug-induced SLE (HIPPS): Hydralazine, INH, Procainamide, Phenytoin, Sulfonamides (HIPPS). False-positive test for syphilis

costochondritis

Def: inflammation of the cartilage that connects a rib to the breastbone (sternum). can mimic that of a heart attack Sx: sharp, achy, pressure-like, usu leftsided, worse w cough/deep breath Eti: usu no apparent cause. Tx: easing your pain self-resolve (weeks or longer) Chostochodral Junction involvement Tietze syndrome - 2nd/3rd costochondral joints; men and women equally affected Costochondritis - 3rd-5th costochondral joints; women affected more than men

Cauda Equina*

Def: serious complication of herniated lumbar disc when massive herniation compresses several roots of caudal equina (*neurosurgical emergency*); Sx: *NEW ONSET* -*URINARY/BOWEL Dysfx* (*retention*/incontinence) W SADDLE ANESTHESIA -decreased *ANAL SPHINCTER TONE* on rectal exam; Dx: MRI Tx: Call surgeon ASAP! Emergent May need steroids to immediately dec. inflammation

Adhesive Capsulitis

Dterm-30ef: frozen shoulder d/t inflammatory process RF: DM, hypothyroid Sx: shoulder pain/stiffness 18-24 mos, dec ROM (especially abduction + external rotation) resistance to passive ROM. // As opposed to SITS team which ROM might Strength can be normal (as opposed to SITS tear which will have dec strength// Tx:*PT*, NSAIDs, steroids // (cortisone injection into the subacromial & glenoidhumeral joint) //, heat

Developmental Dysplasia of the Hip

Dx: *Limited hip abduction* is reliable sign of developmental dysplasia in children older than 2-3 months. Def: spectrum of abnormal hip development d/o that range from acetabular dysplasia to irreducible dislocation. Mild physiologic hip laxity is common during the newborn period but resolves without treatment. The left hip is more likely to be affected than the right hip and both hips are affected in 20% of patients. Female infants are at increased risk for DDH due to an increased susceptibility to maternal relaxin. Swaddling is another risk factor because it places the hips in a limited adducted and extended position. American Academy of Pediatrics Screening: -first few days of life -every routine visit until the child is walking. Infants <3m: The Barlow and Ortolani maneuvers -Barlow maneuver attempts to dislocate the hip -Ortolani maneuver reduces the dislocated hip. >3 months: hip abduction limitation is the most reliable sign of DDH. US is the first-line imaging technique for evaluating the infant hip. Hip instability: Orthopedic surgeon referral Braces--Pavlik harness: maintain the hip in an abducted and flexed position are the mainstay of DDH treatment.

superior labral tear from anterior to posterior)

Dx: O'Brien Test The O'Brien test (also known as the active compression test) is performed with the patient standing. The patient holds his shoulder in 90 degrees of forward flexion with the elbow extended. The arm is then adducted 10 degrees. The patient is instructed to internally rotate his arm, pointing his thumb to the floor. The patient should hold his arm in this position against resistance while the examiner pushes the arm towards the floor. The examiner then applies the same force with the patient's arm externally rotated. The test is considered positive if the patient has pain or popping in the internally rotated position and the pain is eliminated in the externally rotated position. The test is thought to be sensitive for a SLAP (superior labral tear from anterior to posterior) lesion if the patient reports deep, diffuse glenohumeral joint pain. SLAP lesions can be secondary to an acute injury or chronic overuse, such as in overhead athletes. Patients may complain of clicking or mechanical symptoms, especially when the arm is the in cocked position of throwing or serving.

MC stress fracture bone(s) in foot

PAEasy says 2nd metatarsal Pearls says 3rd metatarsal

ganglion cyst

Eti: Tumors of the hand, benign Outpouching of synovium (MC--dorsum of the wrist at the *scapholunate joint*, but may occur at any joint or tendon sheath) Sx: cystic swelling overlying a joint or tendon sheath +/- pain -can be "white and translucent" & *jelly-like fluid* can be aspirated from the lesion -MC on hands esp. dorsal wrist; (less often the knee, shoulder, spine) -Extensor carpi radialis (common site) Dx: clinical Tx: Observation OR joint aspiration, -Only if other measures fail, surgery

Knee Fx/Dislocation

Eti: Patellar Fracture: MC direct blow (fall on flexed knee + forceful contraction) MC in young patients Sx: Pain, swelling deformity, limited knee extension Dx: sunrise view xray Tx: non-displaced (knee immobilizer cast 6 wks); displaced (surgery) Patellar dislocation: Valgus stress, MC females, Usually laterally PE: + *apprehension sign* Tx: closed reduction, knee immobilizer 3-6w Knee dislocation: Severe limb Threatening emergency (*popliteal artery rupture*) Sx: gross deformity, may reduce by itself Tx: ORTHO consult NOW!

Posterior cruciate ligament

Eti: *"dashboard injury"*; blow to front of knee Sx: anterior bruising esp anteromedial aspect of tibia; large effusion Dx: Posterior Drawer Test (MRI used as adjunct) Tx: RICE, NSAIDS Therapy: bracing , crutches, PT Surgical repair in multiple ligament

Rheumatoid Arthritis

Eti: Chronic infl dz targeting synovium of symmetric jts, *Rheum is Wrists*, MCP & PIP RF: smoking Joints: Wrists, MCP, PIP Joints soft, warm, BOGGY, tender Sx: - Morning joint stiffness (rest hurts), -AM stiffness >60m Xray: osteopenia, Symmetric joint narrowing Labs: (+) RF, (+) anti-CCP Ab, (+) ESR, (+) CRP Systemic sxs BS flexed PD Boutonniere flexed @ PIP Swan neck flexed @ DIP; (ulnar deviation) Dx: Initial: (+) Rheumatoid Factor (Most sens) Confirm: (+) anti-CCP (most spec)* ESR Tx: DMARDS & biologics (MTX, sulfasalazine, rituximab, plaquenil) NSAIDs for pain Anti-citrullinated protein antibodies (ACPAs) are autoantibodies (antibodies to an individual's own proteins) that are directed against peptides and proteins that are citrullinated. Cyclic citrullinated peptides (CCP) are frequently used to detect these antibodies in patient serum or plasma (then referred to as anti-citrullinated peptide antibodies)

Hip Fx/Dislocation

Eti: Elderly pts--falls, osteoporosis Common: Femoral neck, intertrochanteric Young pts—stress,trauma non-displaced, falls, MVA - subtrochanteric, isolated troch *POSTERIOR MC* DISLOCATION: shortened, ADDucted, INTernally rotated FRACTURE: shortened, ABDucted, EXTernally rotated Sx: H/o fall or trauma c/o pain in upper thigh, groin, hip, knee PE: R/O pelvis frx esp in trauma, monitor for hypovolemic shock, be sure to due distal neurovasc exam Dx: *ANY pain—get x-ray FIRST* Tx: Call ortho! If pt is ambulatory--treat aggressively aka surgery, pain control Surgery: total hip arthroplasty (THA) repair with screws or plates Recognize non-op pts Delirium, elevation of bed for aspiration https://www.uptodate.com/contents/geriatric-trauma-initial-evaluation-and-management?search=hip%20fracture%20elderly%20protocol&source=search_result&selectedTitle=6~150&usage_type=default&display_rank=6

Humeral shaft fracture

Eti: FOOSH blow Dx: Check radial nerve (possible wrist drop) Tx: Sugar tong splint Ortho f/u 24-48 hours Proximal humerus (Metastatic breast CA)

Supracondylar humerus fracture

Eti: FOOSH w hyperextended elbow; MC 5-10; Sx: swelling, tender elbow Dx: XRay *POSTERIOR FATPAD is ALWAYS ABNL* (+) *Anterior FAT PAD Sign*→ -In *kids: supracondylar* fx; In *adults: radial head* fracture Tx: nondisplaced →posterior splint displaced →ORIF surgery

Osteoarthritis→

Eti: Loss of articular cartilage: damage & degeneration; RF: Aging, OBESITY Joints: DIP, thumb (WEIGHT bearing-knees, hips, spine) Joints HARD & BONY; *FIRST to go, INTERNAL-ROTATION of hip* - Evening joint stiffness (rest helps), AM stiffness <60 MIN Xray: osteophytes (spurs), Asymmetric joint narrowing Labs: (-) RF, (-) anti-CCP Ab, (-) ESR, CRP No systemic sxs (BH osteophytes PD) - Bouchard's node (osteophytes @ PIP) Heberden's node (osteophytes @ DIP) Dx: X-ray: asymmetric jt narrowing; osteophytes Tx: *Acetaminophen* If unsuccessful try NSAIDs (bleed risk) corticosteroid injections.

Clavicle fracture

Eti: MC in kids, teens, newborns at birth. Impact, M>F Sx/PE: pain w ROM, deformity, crepitus, arm against chest Dx: mid clavicle MC Tx: Mid 1/3 (80%) & Lateral 1/3 (15%) → arm sling 4-6 wks, figure 8 sling kids; If mid-shaft and displacement > 1,5 cm, may require sx (increased pain and reduced ROM); also consider comminuted wedge frag displaced vertically and assoc skin tenting (Schoch--Unicorn) --poly-trauma. Proximal 1/3 (5%) → ortho consult

Medial collateral Lateral collateral

Eti: MCL-valgus stress +/- rotation; LCL-varus stress +/- rotation; Sx: localized pain, swelling, stiffness, instability Dx: MCL-Valgus test*; LCL-Varus Test* to elicit laxity Tx: Conservative: RICE, bracing, PT; If instability and impacting lifestyle, consider surgery (though less common)

rotator cuff injuries →↑↓

Eti: chronic erosion +/- trauma (repeated overhead movements) S.I.T.S. //supraspinatus: abduction; infraspinatus: external rotation; subscapularis: internal rotation & adduction\\ *supraspinatus*: empty can (think Will Smith, Hancock): -infraspinatus -teres minor -subscapularis: liftoff test (skyscraper liftoff) *MC torn is supraspinatus* Sx: Anterior deltoid pain w ↓ROM, can't sleep on that side weakness, atrophy, continuous pain MC w tears Dx: Impingement Tests (of subscapular nerve/supraspinatus) *Hawkins* (flexed elbow/shoulder c internal rotation) *Neer test* (arm pronated, thumb down, w pain during forward flexion) *Drop Arm Test* Tx: physical therapy (strengthen shoulder musculature), subacromial steroid injection arthroscopic surgery if the above measures fail TRY NOT TO LET CONFUSE YOU: -this is not worth the point if it becomes cumbersome to memorize: -*supraspinatus*: empty can (think Will Smith, Hancock): suprascapular nerve--arm abduction from 0-30 deg. -infraspinatus (also suprascapular nerve) -teres minor (axillary nerve which also innervates the deltoid) -subscapularis: liftoff test (skyscraper liftoff)

Ulnar Fracture

Eti: direct blow, Sx: localized pain and swelling Dx: XR ND distal 1/3→short arm cast; ND mid/prox 1/3 →long arm cast Or if displaced →ORIF surgery

olecranon fracture

Eti: direct blow, fall on flexed elbow Sx: inability to extend elbow Cx: Ulnar nerve dysfx Tx: Nondisplaced: splint (90deg flex) Displaced: ORIF

elbow dislocation

FOOSH w hyperextension. *MC posterior*. Sx: elbow flexed, marked olecranon prominence Dx: XR, *MUST R/O brachial artery, nerve injury Tx: emergent reduction, posterior splint. Surgery if unstable

Boxer's Fracture

Fx @ neck of 5th metacarpal (+/-4th) MOI: punch w clenched fist (always ck for bite wounds) Tx: ulnar gutter splint ABX for bite/mouth wound/abrasion:

Seronegative Spondyloarthropathies

HLA-B27: PAIR J -*P*: psoriatic arthritis, -*A*: ankylosing spondylitis -*I*: inflammatory bowel dz -*R*: reactive arthritis (Reiter's syndrome) (Chlamydia!!!!) -juvenile rheumatoid arthritis

Scoliosis

Lateral curvature of spine >10 degrees Associated w kyphosis (humpback of thoracic spine) and lordosis (sway back lumbar spine) Dx: Cobb's angle Tx: Observation (<20) Brace (20-40 deg) Surgery > 40deg

Osteomyelitis

Infection of the bone by pyogenic organism (S.aureus-MC, salmonella -SCD, S.epidermis, pseudomonas) RF: Sickle Cell Dz, Diabetes, Immxcomp, joint dz, URI in kids Acute vs Chronic: ACUTE: *MC in kids (S.aureus MC)*, also GABHS, & in (*Sickle Cell Dz: Salmonella*) Chronic: *MC in adults 2ry inj./sx, S.aureus* MC the metaphysis of distal femur & proximal tibia Sx: gradual onset (days→weeks) Sx of Bacteremia (↑fever, chills, malaise) Inflammation/infection *REFUSAL to bear weight (MC the HIP in kids)* Dx: *↑WBC, ↑ESR* (if not then unlikely), +/-↑CRP *MRI is most sensitive early* (bone scan 24-48h) Xray (level of bone involve-can be 2w behind) *Gld Std: Bone Aspiration, biopsy * culture* Tx: Chronic: Surgical debridement + Cx (& ABX) Acute: Cx & IV ABX (4-6w) +/-debridement Newborn-4m-GBS: Nafcillin + Ceftriaxone >4m MSSA: Nafcillin or MRSA: Vanco Sickle Cell (Salmonella: 3rd Gen Ceph or FQ) Puncture Wound: Pseudomonas: Ciprofloxacin

bursitis

Inflammation of the fluid-filled pads (bursae) that act as cushions at the joints Eti: trauma/overuse Sx: pain, swelling, tenderness Tx: avoidance of precipitating factors, rest, NSAIDs, and steroid injections

Colles Fracture

KOHL's EXTENDS their sale! Gonna be late for DINNER Def: distal radius w posterior angulation, FOOSH (over-extension of wrist) Sx: dinner fork deformity*** Dx: XR Tx: Sugar Tong splint*/cast if stable; if not, surgery

Knee Dislocation (Tibiofemoral)

MC Knee Displacement HYPEREXTENSION: limb-threatening emergency -multiple ligamentous tears due to hyperextension -posterior force to the anterior tibia, or force to the femur or fibula. -*instability in multiple directions* -Hemarthrosis or significant ecchymosis MC: *motor vehicle collision*, but also *sports injuries*, falls or even spontaneously in very obese patients. Because of the severe ligamentous damage, many tibiofemoral dislocations will spontaneously reduce prior to presentation. Check neurovascular check, -ankle-brachial index -motor exam -sensory exam. Tx: *Immediate Manual Reduction*. Serial neurovascular checks should follow, as damage to neurovascular structures are common.

Fat embolism syndrome (FES)

MC assoc w long bone and pelvic fractures closed >> open fractures. MC cx'd long bone: tibia Fat emboli may be the result of fat globules entering the bloodstream through tissue that has been disrupted by trauma or alternatively via production of the toxic intermediaries of plasma-derived fat. Sx: Classic triad: -hypoxemia (dyspnea/tachy) -neurologic abnormalities -petechial rash (Upper body; only 20-50% of cases) also: In the brain, multifocal petechiae in the white matter represent the most common pathologic change; Dx: made when the *pathognomonic petechial rash* occurs in an appropriate clinical setting. Preventive strategies: corticosteroids, early operative intervention, early mobilization following sx, and limitation of the intraosseous pressure during orthopedic procedures. Tx: Supportive care alone Most patients with FES fully recover.

Anterior Glenohumeral Shoulder Dislocation

MC direction is ANTERIOR (95%) *Newsflash: The ANT was ABDUCTED by EXTERNAL forces; POSThumously he was ADDed to INTERNAL obituary*. Eti: Usu from fall on outstretched hand (FOOSH) PE: arm abducted and externally rotated "Squared off shoulder" Dx: Axillary & "Y" View XRAY: Humeral head is ANTERIOR and INFERIOR to glenoid (much easier to observe on Xray) Tx: Closed Reduction Must r/o *axillary nerve* injury (pinprick over deltoid) Ortho within 1 week

Ankle sprain (MC direction of spare and ligament injured)

MC mechanism of ankle sprains is INVersion stress of a plantar-flexed foot, while the most frequently injured ligament is the ANTERIOR-TALOFIBULAR-LIGAMENT (ATFL) #2 CalcaneoFIBULAR lig.

Henoch-Schonlein Purpura (HSP)

MC systemic vasculitis in kids Sx: *rash LE & butt* (palpable purpura) arthritis, abdominal pain, and renal involvement. Eti: unknown, Associated with an antecedent bacterial or viral infection. RF: boys >> girls, ~5-years-old. *Gastrointestinal involvement* is typically seen during the acute phase of illness and may precede the rash. It is thought to be due to small vessel involvement and usually presents as gastrointestinal colic but may lead to ischemia (heme positive stools) and *intussusception*. When intussusception occurs, it is usually ileoileal, unlike the more common ileocolic, and is more difficult to diagnose and reduce by barium or air contrast enema. Renal involvement will usually present early and can range from microscopic hematuria to nephrotic syndrome. Additionally, up to 15% of males can have scrotal involvement with epididymitis, orchitis, torsion, and scrotal bleeding. The musculoskeletal involvement is periarticular and does not involve the actual joint. It tends to affect the lower extremities, especially the ankles and knees. It can be very painful but *does not leave any permanent joint damage*. Treatment is supportive.

mallet (baseball) finger

MOI: Avulsion of extensor tendon Sx: unable to straighten distal finger (flexed at DIP) Tx: splint DIP in extension for 6 weeks vs. surgical pinning

Achilles tendon

MOI: overuse injury, sprinter Sx: kicked in the back of the leg, *"snap, crack or pop"*, swelling, stiffness, nodule Dx: *Thompson Test* (weak or absent *PLANTAR FLEXION* (toes down), MRI is definitive Tx: Surgical repair; Medical: RICE, NSAIDs, Nitric Oxide Patch, PT, stretch;

Carpal Tunnel Syndrome

Median; *Tinel's Typmany, Phalen's flexing; Voltron Cast* MOI: median nerve entrapment/compression Sx: parasthesias & pain of palmar 1st 3 and 1/2 of 4th digits esp @ night Thenar muscle wasting Dx: *Phalen's (wrist flexion 30-60s)* (more important than Tinel) Tinel's (percussion on median n.) Tx: Volar splint, NSAIDs, Sx if refractory

Spinal Disc Anatomy

Nucleus pulposus Disc annulus Bulging versus herniation

juvenile rheumatoid arthritis

Onset must be < 16 years of age and symptoms persist > 6 weeks. RF is negative (98%) however, -HLA-B27 is commonly positive 3 main subtypes: systemic (Still's disease), pauciarticular, polyarticular (MC) Unknown etiology Dx: clinical Rx: NSAIDs, *methotrexate*, steroids, specialist referrals

Review Patellar dislocation Anterior cruciate ligament tear Medial collateral ligament tear Medial meniscal tear Patellofemoral pain syndrome

Patellar dislocation is commonly seen with a history of twisting of the torso when the foot is planted. The positive apprehension sign, in conjunction with the X-ray findings, are diagnostic for this disorder only. Anterior cruciate ligament tear is incorrect; there would be increased anterior laxity with Lachman test, which was negative. Medial collateral ligament tear is incorrect; there would be pain and laxity with valgus testing, which was negative. Medial meniscal tear is incorrect; the McMurray test was negative, and it would have elicited pain at the medial joint line. Patellofemoral pain syndrome is incorrect; it does not include instability or dislocation of the patellar, which is evident on X-ray.

Patellar tendonitis

Patellar tendonitis or jumper's knee, -caused by repetitive activities such as jumping, running (especially uphill), squatting or standing from sitting. It results in anterior knee pain at the proximal portion of the tendon.

injury to radial nerve. Injury to the median nerve Injury to the ulnar nerve

RN: The characteristic sign of injury to the radial nerve is *wrist-drop*: the inability to extend the wrist and the digits of the metacarpophalangeal joints. MN: would result in loss of flexion of the PIP joints in digits 1 to 3. *benediction hand* or *ape hand* UN: can result in sensory loss in the hand, and patients may have difficulty making a fist because they cannot flex their fourth and fifth digits at the DIP joint. *claw hand*

Reactive Arthritis (Reiter syndrome)

Reactive Writer (Reiter) arthritis writing campfire tales. *"Can't pee, can't see, can't climb a tree, CLAM!"* Def: inflammatory arthritis occuring after or during a bacterial infection *Recent GI* or *chlamydia infection* shigella, salmonella, campylobacter, yersinia RF: age 20-40 yo Sx: Can't pee (urethritis), can't see (conjunctivitis), can't climb a tree (Arthritis) Dx: **(+)HLA-B27 (80%), Synovial fluid WBCs (1-8K)** Tx: 1st: NSAIDs, +/-abx, Should resolve in 2-6 months DMARDs if no response (methotrexate, sulfasalazine) Seronegative spondyloarthropathy

Polyarteritis nodosa

Response to Inflamatory process: (FEVER, MALAISE, WEIGHT LOSS) Fibrin deposit in the arteries → reduced blood flow → : ischemia, necrosis PAIN in EXTREMITIES & w organs: RENAL failure. ARNOLD HELPP!!!!! Peter Pan is tired, febrile and in severe pain after the gator ate his hand and leg off giving him pain and weight loss. Eti: systemic vasculitis of small and medium artery → necrotizing inflamatory lesions; inflammation involving the skin, kidney, peripheral nerves, muscle and Gut Cause unknown but *Hep B* assoc. 30% RF: M:F, 3:1; 40-60yo Sx: Renal: HTN, renal failure Const: Fever, wt loss, & pain, arthralgia, arthritis, CNS: (neuropathy) Derm: livedo reticularis (pic), purprua, ulcers, gangrene skin lesions (inc palpable purport and livedo reticularis) Dx: Vessel biopsy or angiography ↑ESR, ↑CRP; HBsAg (Hep B Surface Antigen) and proteinuria may be present as well as Possible: Antineutrophil cytoplasmic antibody (ANCA) Tx: HIGH dose corticosteroids "Affects the skin, heart, kidneys, and central nervous system; associated with fever, weight loss, muscle and joint pain as well as anemia; very rare, though the symptoms can be similar to those of other types of vasculitis; some cases may be linked to hepatitis B or C infections"

Patellofemoral Syndrome

Runner's knee or Female athletes Knee pain worse after prolonged sitting, bending motions -*Patella compression test*: patella compression into femoral groove → pain, crepitus -*Apprehension test*: patella pushed laterally → quadriceps contracts involuntarily -↑ Q angle "Sunrise View" on Xray Rx: NSAIDs, quadriceps-strengthening exercises

Salter-Harris Classification of Fxs

S: Same. Fx occurs growth plate A: Above. Fx occurs above GP L: Lower. Fx occurs below GP T: Through. Fx occurs through GP R: Rammed. Compression fx. Worst. I: S (Slipped epiphysis) II: A (fracture Above physis), most common III: L (fracture beLow physis) IV: T (fracture Through physis) V: R (wRecked physis) I/II rx: nonoperative IV/V rx: surgery required Negative radiographs do not r/o a Salter I fracture

Acromioclavicular Dislocation

Separated shoulder (Romeo failed CLeAVIng to wall to see Juliet and fell on shoulder) --Direct blow to ADDUCTED shoulder Sx: pain w lifting arm or unable to lift arm @ shoulder Dx: usu clinical +/- "bump" deformity (Xray taken w weights) Grades: I. AC ligament sprain (nl xray) II. AC ligament disruption + coracoclavicular (CC) ligament sprain III. AC and CC disrupted, clavicle displaced IV. Clavicle displaced posteriorly V. Clavicle displaced superiorly and anteriorly VI. Clavicle displaced inferiorly Obtain bilateral AP radiographs Tx: Type I-III: sling, orthopedic referral Type IV-VI: sling, orthopedic referral, surgery likely necessary ----my old---above is Rosh---- Type I: nl xray--ligaments sprained Type II: AC lig torn, coraclavicular lig sprained Type III: Both ligs torn Tx: SLING immobilization; ice, analgesics, AND Ortho Follow-up Type III Sling +/- Ortho for possible surgery Type IV-VI: need surgery

gamekeeper's (skier's) thumb

Skier's: Acute version Gamekeeper's: chronic version ULNAR collateral ligamental injury of thumb, 1st metacarpal is MC Instability of MCP joint MOI: forced HYPERABDuction Tx: Thumb spica * ref to hand surgeon

Nerve responsible for foot "eversion

Superficial peroneal nerve -conveys sensory information from most of the dorsal surface of the foot.

Meniscus Tear

Tear of one of two crescent-shaped fibrocartilaginous structures that cushions the knee; One *MEDIAL (MC torn)* and one lateral menisci MOI: *Sudden or excessive rotational force of femur on the tibia* RF: Trauma, Repeated squatting, Aging, Prior ligamentous injury Sx: Intermittent pain along the joint line Mechanical Symptom: "catching", "clicking", "locking" or "giving way"**, swelling/edema, Restricted ROM *Dx: MCMURRAY'S Test, Apley Test. , MRI for formal diagnosis* (occasionally arthroscopy), X-Ray usually negative Tx: Conservative: RICE (rest, ice, compression, elevation) NSAIDs, analgesics, Quad strengthening, Activity modification, Time, Chronic Injury or Irreducible Locking: Arthroscopy

Radiculopathy due to nerve root compression occurs most commonly at which nerve root within the brachial plexus?

The C7 nerve root is affected the most often (approximately 45-60%). This radiculopathy can result from foraminal encroachment of the spinal nerve, cervical disk herniation, tumor, and multiple sclerosis. C7 radiculopathy can present with weakness in the triceps, which cause elbow extension, and finger flexion and extension. C6 is another common site of radiculopathy. C6 radiculopathy can present with weakness in the biceps, brachioradialis, and wrist extensor muscles. Cervical radiculopathy at the C5, C8, and T1 are less common, but still possible. C5 radiculopathy can present with deltoid and biceps muscle weakness. C8 radiculopathy can present with finger flexor weakness and T1 radiculopathy with finger abduction weakness.

Weber Classification of Lateral Malleolus

The Weber ankle fracture classification (or Danis-Weber classification) is a simple system for classification of lateral malleolar fractures, relating to the level of the fracture in relation to the ankle joint. It has a role in determining treatment. Classification *type A below the level of the talar dome usually transverse* *tibiofibular syndesmosis intact deltoid ligament intact* medial malleolus occasionally fractured usually stable if medial malleolus intact *type B* distal extent *at the level of the talar dome; may extend some distance proximally usually spiral* tibiofibular syndesmosis usually intact, but widening of the distal tibiofibular joint (especially on stressed views) indicates syndesmotic injury *medial malleolus may be fractured deltoid ligament may be torn,* indicated by widening of the space between the medial malleolus and talar dome variable stability, dependent on the status of medial structures (malleolus/deltoid ligament) and syndesmosis; may require ORIF Weber B fractures could be further subclassified as 9 B1: isolated B2: associated with a medial lesion (malleolus or ligament) B3: associated with a medial lesion and fracture of posterolateral tibia type C *above the level of the ankle joint tibiofibular syndesmosis disruption with widening of the distal tibiofibular articulation medial malleolus fracture or deltoid ligament injury often present* fracture may arise as proximally as the level of fibular neck and not visualized on ankle films, *requiring knee or full-length tibia-fibula radiographs (Maisonneuve fracture) unstable: usually requires ORIF* Weber C fractures can be further subclassified as 6 C1: diaphyseal fracture of the fibula, simple C2: diaphyseal fracture of the fibula, complex C3: proximal fracture of the fibula fracture above the syndesmotic result from external rotation or abduction forces that also disrupt the syndesmosis usually associated with an injury to the medial side

Carpal Bones

The lunate is in the proximal row and articulates with the scaphoid laterally (this being the most lateral of the proximal row). The lunate is the most commonly dislocated carpal bone. It is usually displaced anteriorly by rotation on its proximal, convex surface (where it articulates with the radius). The displaced bone may compress the median nerve in the carpal tunnel, leading to pain, sensory loss, and/or paralysis. The capitate: carpal bone in the distal row. It articulates with the hamate (the most medial of this row). The *scaphoid: MC fractured* carpal bone, is the most lateral bone of the proximal row. Patients who have scaphoid fractures have an increased risk for avascular necrosis. The trapezoid is a carpal bone of the distal row and articulates with the most lateral of this row (trapezium). The triquetrum although in the proximal row of carpal bones, is medial to the lunate. Review The proximal carpal bones (from radial to ulnar) are: Scaphoid Lunate Triquetrum (dorsal) Pisiform (volar) The distal carpal bones (from radial to ulnar) are: Trapezium Trapezoid Capitate Hamate

Giant Cell Arteritis (temporal arteritis)

aka Temporal arteritis Systemic INFLAMMATORY condition of MEDIUM/LARGE vessels RF: >50y and hx of polymyalgia rheumatic (pain in shoulder and pelvic girdle) Most freq involves TEMPORAL ARTERY and other extracrainal branches of cared CAN CAUSE BLINDNESS if not treated (d/t anterior ischemic optic neuritis) Sx: unilateral temporal *HA* also: scalp tenderness, *jaw claudication*, throat pain, *vision disturbances* amaurosis fugax (diplopia) *constituational sxs* (fatigue, wt loss, fevers, night sweats) Aortic aneurysm (thoracic) Dx: *↑ESR >100, ↑CRP* normochromic normocytic anemia & thrombocytosis *Definitive Dx*: Temporal Artery BIOPSY Tx: High-dose Prednison (1-2 mos) & Aspirin DO NOT DELAY TREATMENT!

MC fracture in kids and adolescents

clavicle Fx -FOOSH and up to 30% of live births -look for brachial plexus injuries (pain, weakness, reflex, sensory abnormalities)

Morton's Neuroma

degeneration/proliferation of plantar digital nerve -painful mass near tarsal heads MC women 25-50y, high heels Sx: lanciating pain esp w ambulation (MC 3rd, metatarsal head +/- 4th) +/- numbness Tx: wide shoes, glucocorticoid injection if fails, surgery but can = permanent numbness

Kyphosis

excessive outward curvature of the spine, causing hunching of the back.

polymyalgia rheumatica

geriatric inflammatory disorder of the muscles and PROXIMAL joints characterized by pain and stiffness in the *neck, shoulders, upper arms, and hips* and thighs Eti: Cause is unknown; assoc w giant-cell (temporal) arteritis (30%) Epi: Women 2x more, >50y Sx: INFLAMATORY causing SYNOVITIS, BURSITIS, TENOSYNOVITIS that leads to ACHING/STIFFNESS in PROXIMAL joints (esp in MORNING and after rest) Amaurosis fugax (AF), transient loss of vision in one or both eyes, seen in giant cell arteritis. Polymyalgia rheumatica is seen in about 50% of patients with giant cell arteritis. MSK sxs are bilateral, proximal, symmetrical -Closely related to Giant Cell must be ruled out Dx: Clinical; *↑ESR, ↑CRP* *(ESR is markedly elev (>50 mm/hr)* BIOPSY (definitive dx >2.5cm) Tx: Low-dose corticosteroid (up to 2 years and slowly tapered) OR High-dose therapy (1-2mo) Higher doses are required if giant cell arteritis is present. Tx should not be delayed while awaiting biopsy Giant Cell: (which presents w scalp tenderness, jaw claudication, HA, temporal artery tenderness poss leading to vision loss)

medial epicondylitis lateral epicondylitis

golfers (wrist flexion-medial) tennis (wrist extension/forearm pronation-lateral) Tx: RICE, NSAIDs, physical therapy; steroid injections (if no improvement following PT)

thoracic outlet syndrome

idiopathic compression of brachial plexus Nerve compression (parasthesias to the forearm, arm and ULNAR side of hand Vascular compression: swelling, discoloration PE: (+) Adson: loss of radial pulse w head rotated to affected side Dx: MRI Tx: Controversial: PT-1st line, Ortho +/-sx

MC fractured upper extremity bone

radius

Corticosteroids are often used in the management of SLE, Complications include:

osteoporosis, weight gain, aseptic necrosis, Cushing syndrome, infection, hypertension, hyperglycemia, and cataracts. With regard to osteoporosis, bone loss is most significant with the first 6 months of treatment with corticosteroids. To prevent this bone loss, calcium and vitamin D and bisphosphonates are utilized

Prepetellar bursitis

overuse pain syndrome of the anterior knee caused by repetitive kneeling on hard surfaces. -housemaid's knee, -carpet-layer's knee, or -nun's knee. Eti: prepatellar bursa becomes inflamed and the range of motion of the knee may become restricted. PE: The space anterior to the patella is tender to palpation and there may be an effusion over the lower pole of the patella. Tx: conservative with heat, rest, and nonsteroidal anti-inflammatory drugs.

HLA-B27 diseases

seronegative spondyloarthropathies: -ankylosing spondylitis (spine and sacroiliac pain), -reactive arthritis (conjunctivitis, urethritis, arthritis), -psoriatic arthritis (skin and nail findings) and -enteropathic arthropathy (history of Crohn's or ulcerative colitis)

Dequervain's Tenosynovitis

tenosynoovitus of abductor pollicus longus (APL) & extensor pollicus brevus (EPB) sx: pain at radial wrist (golfer's, clerical workers, "mommy") Dx: Finkelstein Test Tx: Thumb spica splint

MC fractured long bone in both adults and children

tibia