*for deletion* Procedures Term 1

5th metatarsal base fracture

5th metatarsal base fracture Left image - The fracture line passes transversely across the bone Right image - A normal unfused 5th metatarsal base apophysis is aligned more longitudinally along the bone

Thumb Spica - indications? Position?

ndications Scaphoid fx - seen or suspected (check snuffbox tenderness) De Quervain tenosynovitis Notching the plaster (shown) prevents buckling when wrapping around thumb Wine glass position

Tenosynovitis

(trigger finger) Inflammation of the thin inner lining of a tendon sheath Impairs movement or gliding of the tendon

Trigger finger

(stenosing flexor tenosynovitis - sheath is inflammed) Inflamed MCP pulley with swelling of the flexor tendon Rest/immobilize 6 wks Steroid injection if persists

AnkLe Injury Tests - Talar tilt test

(or inversion stress maneuver): To assess integrity of the calcaneofibular ligament Compare to unaffected side

Assessment of fingers for ring removal

- S/s of ischemia - Cyanosis, ischemic pain, lack of 2 point discrimination, decreased capillary refill, mottling - Indication of fracture - Trauma hx, deformity, x-ray findings - Laceration distal to ring location - Evaluate the material of the ring and the sentimental value to the patient. - Pt cognition: are they mentally competent Sentimental value of ring vs. finger

Boxer's fracture

- 2 examples The transverse fracture on the left is easy to see The fracture on the right is more subtle - close observation shows an oblique fracture Both examples show soft tissue swelling - often a useful sign of a finger fracture

Hip dislocations

- Account for 10-15% of all dislocations posterior most common (90%) - A well documented neurovascular exam is mandatory → 15% will involve sciatic nerve - 50% fracture elsewhere - Prompt, closed reduction under general anesthesia - 50% will develop post-traumatic arthritis

Femoral Neck and Intertrochanteric Fractures

- Common fracture in elderly d/t low-energy falls and issues with the bone itself (ie OA) - Incidence increases with age (peak 70-80) with women five times more than men - Young—d/t high energy trauma - Cause the most problems with vascular disruption and repair - Morbidity approximately 25-50% w/in a year and mortality 1:5 (typically from hip fx complications and mobility)

Carpal Tunnel: Treatment

- Evaluate for common co-morbidities—ie thyroid, DM - Remove irritant when possible: what are ergonomics of work set-up? - Consider OT (hand specialist best), PT would be second - Wrist splint -neutral position, limits exacerbating movements incl hs hyperflexion (ie at night or at work) - Possible benefit - Stretching techniques; Aerobic fitness (not just wrist) ; Wrist-specific Yoga - Steroids—oral or injection—may also help predict if surg beneficial - Surgery—long-term success rate about 60% - Ultrasound - Massage and/or nerve glide techniques No proven benefit Nonsteroidal anti-inflammatory drugs (NSAIDs) and/or diuretics Vitamin B-6 or B-12 supplements Laser

Knee exam

- Gait - normal or antalgic? - Deformity - present or absent? Example: bony hypertrophic changes, Baker's cyst Leg lengths - equal or unequal? - Inspect alignment (Q angle) - Patellar tracking - what happens to the patella when they move their leg? - Vastus medialis obliquis (VMO) tone - Evaluate biomechanics (feet to low back) - Check for effusion - Does the patella ballot? If I push on it, does it move down? - Patellar mobility - Alignment - normal, varus or valgus? Active & Passive ROM - Normal or limited? - Pain? - Crepitus? - Tenderness to palpation and/or with movement?

Digital Block of Fingers & Toes: Avoiding Complications, Minimizing Pain

- Intradermal vs. subcutaneous - techniques you should play with - Accidental piercing through intact skin on opposite side - try not to put your finger on the other side. - Too rapid injection: SLOOOOOWWW! She says it hurts more but if things take too long. Try 10 seconds vs like 1 second. - Needle too large: Use 25g or smaller (higher guage and smaller diameter). 30g will not come in a 1.5 inch bc it is not really a stable needle. - Acidic anesthetic solution - want to reduce the acidity: Use 1ml NaHCO3: 10ml Lidocaine. You can use that to reduce the pain with injection - Cold anesthetic solution increases pain : Keep in warmer

Knee injury:

- Is there a single event with a definable mechanism of injury? If so, are there videotapes or eyewitnesses who can describe what happened? - Where is the pain? - Are there mechanical symptoms (eg, locking, popping, or catching)? - Can you bend and straighten the knee all the way? - If there is swelling, when did it begin after the injury? - Is there a sense of instability (ie, "giving way") or functional limitation (eg, is the athlete able to bear weight without pain)? - Is there a history of previous knee injury? If so, how was it evaluated and treated? - Is there history of any chronic pain or illness prior to the acute injury? - Was there any fever or limp prior to the injury that suggests an underlying chronic condition not related to knee trauma?

Ligamentous Injuries to Knee

- Knee is largest synovial joint in body - Surrounded by static and dynamic stabilizers - Injury to medial aspect is most common - Static stabilizers classified according to location—medial, lateral, anterior, posterior - Common mechanism: valgus or varus stress while weight bearing on fixed foot and flexed knee with some degree of rotation - "Pop" or "snap", pain, rapid swelling and hemarthrosis - might need to get imagery - H&P

Digit dislocation: Specialty consultation rather than reduction ??

- Pt or provider preference - Associated digit fracture - Open joint dislocation - Digital neurovascular compromise (unless orthopedic or hand surgery consultation is not emergently available) - Interphalangeal joint dislocation of the great toe (hallux) - Multiple metatarsophalangeal dislocations - Any joint dislocation with tendon rupture - Digit dislocation that is irreducible - Unstable joint after attempted dislocation reduction - Patients who remain in a significant amount of discomfort after reduction (occult fracture?)

Standard Procedure for Digital Block (a.k.a. Infiltrative anesthesia)

- Review anatomy and choose an anesthetic technique - Discuss the procedure with the patient, including what they can expect and the possible complications; obtain signed informed consent as needed - Evaluate the surrounding area and areas distal to the injection site for signs of neurovascular compromise and infection - Choose and label the appropriate anesthetic agent based on the technique and clinical situation; warm and buffer solutions as indicated - Cleanse the injection site (for intact skin, alcohol wipes are as effective as chlorhexidine [Peridex] or povidone/ iodine)—earlier if betadine d/t time needed efficacy - Rapidly introduce the needle (27- to 30-gauge) through the skin into the subcutaneous layer, using distraction techniques as necessary; consider aspiration before injection - Slowly and steadily inject small volumes of anesthetic while withdrawing the needle - Wait appropriate amount of time** then test the area for adequate anesthesia because you have psychologic doubt. Go do something for a 2-3 minutes and then test the area - Test for PAIN not pressure. Poke them with something sharp.

Places that sprains might occur

- Shoulder - AC/acromioclavicular - Elbow - Collateral Ligaments - Wrist - DRUJ/distal radio-ulna joint and TFCC/ triangular fibrocartilaginous complex - Hip - Knee - Collateral Ligaments or Cruciate Ligaments - Ankle - ATFL or CFL Foot - Lisfranc

Plaster of Paris—Splinting Materials

- Stockinette - protects skin, looks nifty (often not necessary) cut longer than splint 2,3,4,8,10,12-in. widths - Padding - Webril 2-3 layers, more if anticipate lots of swelling Extra over elbows, heels Be generous over bony prominences Always pad between digits when splinting hands/feet or when buddy taping Avoid wrinkles Do not tighten - ischemia! Avoid circumferential use - Ace wraps - Scissors

Ceruminosis Prevention or Treatment: Ceruminolytics

- Used to treat & prevent Helps prevent build up by keeping cerumen soft Improves irrigation success - Some options—not much difference in efficacy Depends on your and pt preference OTC formulations (Debrox, Audax) Docusate (stool softener) Water or saline - Pre-irrigation needed?: use 15-30" before or 3-4 days before irrigation—no difference

Finger Fractures: Clinical Presentation

- Usually crush injury for Distal Phalangeal fracture or high velocity hyperextension→ avulsion fracture - Nail bed lacerated or subungal hematoma - Check two point discrimination - Check motion: active and passive flexion and extension of DIP - Most heal well with splinting 3-4 weeks - Refer to hand specialist with: Transverse or angulated fractures: may need surgery Failed closed reduction Non unions Persistent symptoms after 6 months: refer.

Pediatric fractures

- What makes kids bones different when it comes to fractures - Decreased bone mineral density→Compression/buckle fx - Relatively stronger ligaments and tendons →avulsion fx (when the ligament attaching bone to bone, instead of ligament taearing, it breaks off a part of the bone - greater bone flexibility →greenstick fx (AKA 'plastic deformation') - Growth plates, periosteum→Salter-Harris fx - Need to be aware of patterns of abuse - esp with repetitive injuries - Femur fracture would be something that you would be suspecious of

Pittsburgh Knee Rule

-- recommends a radiograph for anyone with a fall or blunt-trauma mechanism, AND anyone <12 years or >50 years Inability walk 4 wt bearing steps in clinic/ED

Anterior humeral line and proximal radial line

-Anterior humeral line: a line drawn parallel to the anterior humerus should pass through the middle third of the capitulum. -Proximal radial line: a line along the longitudinal axis of the radius should pass through the center of the capitulum in all projections

Assessing the Anterior Cruciate Ligament (ACL) - list of tests

Lachman's Test Anterior Drawer Test Pivot stress test

Digital Block of Fingers & Toes: Potential Anesthesia Toxic Reactions

-Vasovagal (neruocardiogenic syncope - would see a decrease in BP) vs. pain and anxiety related to epi. Anxiety would see increased pulse and BP. CNS stimulation vs. IV injection of epinephrine - avoid anesthetic via IV, especially epi. - Seizures vs. overdose or IV injection - Lidocaine toxic dose (1%= 10mg/ml) - if using appropriate doses you shouldn't get anywhere near toxic doses. Sometiems people get pseudo-seizures which is anxiety related. Plain: >4mg/kg (70kg pt would need >28 ml) With epi.: >7mg/kg - Anaphylaxis: rare - Epinephrine??!: Not with digital blocks "Local anesthetics are to be used without epinephrine in some cases to avoid vasoconstriction of adjacent arteries, which may lead to ischemia or infarction of local tissues. " Digital block (numbing the whole finger) Injury that results in a very ragged and irregular laceration. On the tip of the nose or penis ("hose, nose, toes") Despite studies that have shown epinephrine to be safe in these circumstances, epinephrine is traditionally avoided in the digits

Apprehension test

90° of abduction Examiner applies slight anterior pressure to humerus and externally rotates arm Positive test = patient expresses apprehension

Maisonneuve fractures - definition

A 'Maisonneuve fracture' is a fracture of the proximal fibula associated with injury to the medial side of the ankle and disruption of the distal tibiofibular syndesmosis. The medial ankle injury may be either a visible medial malleolus fracture or an invisible injury of the medial ligaments.An isolated fracture of the medial malleolus, or widening of the ankle joint with no visible fracture seen on ankle X-ray, should raise the suspicion of an associated fracture of the fibula. If this is not visible in the distal fibula then further X-rays of the proximal fibula should be performed. Imaging of the proximal fibula should also be considered in the setting of any severe ankle injury or if the proximal fibula is tender to palpation.

Comminuted fractures

A bone injury that results in more than 2 separate bone components is known as a comminuted fracture. Some comminuted fractures have specific names such as 'butterfly fragment' or 'segmental fracture'. this could include shattering of bone, etc

Normal variants of the knee

A fabella and a bipartite patella are 2 common normal variants that should not be mistaken for a fracture.

Fracture-dislocation

A fracture combined with a dislocation is called a fracture-dislocation.

'Irregular bone' fractures

A fracture of a short, flat or irregular bone requires a description determined by its direction through the bone. Useful terms include - horizontal, vertical, coronal, sagittal and axial.Often a fracture can be seen to pass in more than one direction, in which case a more detailed description may be needed.

Clavical fracture

A fracture of the clavicle characteristically leads to inferior displacement of the distal component - weighed down by the whole arm.

Distraction and impaction

A fracture resulting in increased overall bone length, is due to distraction (widening) of the bone components.If there is shortening of bone without loss of alignment, the fracture is impacted. The bone substance of each component is driven into the other.

Periprosthetic fracture

A periprosthetic fracture occurs at the site of orthopaedic metalwork.

Sesamoid

A sesamoid bone is a bone that ossifies within a tendon. The largest is the patella. Sesamoids are also common at the first metatarsophalangeal joint (big toe) and the first metacarpophalangeal joint (thumb).

Toddler's fracture

A toddler's fracture is a spiral tibial fracture seen in young children. This fracture is associated with a twisting injury, and may present with refusal to weight-bear. Often there is little or no displacement and the fracture line is very subtle. Some toddler's fractures are not visible on the initial X-rays but cause a periosteal stress reaction which becomes visible on follow up.

Digital Block of Fingers & Toes: Contraindications

Absolute contraindications: patient refusal - children cannot concent, remember! infection at injection site Documented allergy to all available anesthetic If allergic to amide-type anesthetic, use esther-type If allergic to preservatives/methylparaben—used in multi-dose vials Using single-dose vials avoids preservatives, that might be an option Additional Alternative Agents: Diphenhydramine (Benadryl): 1% 50mg in 4cc NS Use non-preservative type solutions Normal saline? - might provide pressure on the effective nerve, resulting in blockage of the nerve pathway to the brain. Relative contraindications: Coagulopathy preexisting neuropathy of the target nerve Pain of block exceeds pain of procedure needing to be done? Will the area hurt after? Compromised circulation of digit

Accessory ossicles

Accessory ossicles (small bones) are considered normal, but are not present in all individuals. They should not be mistaken for fractures. The best clue is that they have a dense fully corticated edge, whereas the edge of a fracture will not be corticated.It should be remembered that although usually innocent, accessory ossicles and their surrounding soft tissues can be injured, and become symptomatic.

Osgood-Schlatter's Disease (traumatic tibial apophysitis)

Active, adolescent males> females Repetitive injury to tibial tubercle apophysis leading to avulation/separation Swelling and increased pain with forceful leg extension Tx symptomatic Analgesics PT Sx usually resolve once epiphyseal plates close, this might be bc males get it more commonly Complications uncommon

Management of knee pain &/or injuries

Acute injuries: - RICE - Rest—24-48 hours after acute injury - Ice - Compression - only if people find it helps. - Elevation Brace, splint and/ or crutches if concern of fracture or instability - NSAIDS/analgesics—acute and chronic - choose based on risk factors. - Imaging - Referral vs watch and wait: Ortho prn (FYI that ortho is hard to get in to, so if there are significant concerns, you should send them to the ED bc they will see ortho there) PT if chronic knee issues Can help with OA and wt loss

Splinting - advantages vs disadvantages

Advantages 100% restriction Stabilization Prevention trauma Allows adjustment to accommodate swelling Disadvantages Bulky Can't use prophylactic measures Over or misused Skin irritation Expensive

Taping - advantages vs disadvantages

Advantages Limits movement, but does not completely restrict - pro and a con Possible return immediately to sport Less bulky Prevention further aggravation of chronic injury - less for an acute injury Disadvantages Loosens w/in 10" application Requires provider skill Skin irritation Less effective joint immobilization

Essential Components of History

Age Sport Chief Complaint Mechanism Length Descriptive Symptoms (where exactly) Exacerbating/Alleviating Symptoms Dx and Tx w/u to date

Essential Components of History for MSK Injury

Age Sport Chief Complaint Mechanism Length Descriptive Symptoms (where exactly) Exacerbating/Alleviating Symptoms Dx and Tx w/u to date

Cerumen removal pearls for all techniques

All Techniques: Pull auricle up and back to straighten canal (down back in young kids) Never use a candle

Fracture treatment

All fracture treatment starts with appropriate resuscitation and care of the patient with consideration of the full clinical context.Immobilisation of a fracture is usually required to allow long term healing. If a fracture is displaced then 'reduction' (returning the bones to an anatomical position) may be required prior to immobilisation. Placement of metal stabilisation devices may be required if simple methods of immobilisation are unsuccessful.X-rays play an important role in assessing bone position following the treatment of a fracture or dislocation. Two or more views are usually required to accurately assess bone position after any treatment procedure.

AnkLe Injury Tests - Prone anterior drawer test

Also tests for ligamentous instability

Apophysis

An apophysis is a normal developmental outgrowth of a bone which arises from a separate ossification centre, and fuses to the bone later in development. An apophysis usually does not form a direct articulation with another bone at a joint, but often forms an important insertion point for a tendon or ligament. Occasionally an apophysis can persist into adult life and if injured may become symptomatic. The many apophyses in the body have variable appearances and are often mistaken for fractures.

Elbow X-ray

An awareness of normal X-ray appearances of the elbow is essential for the identification of elbow injuries. Elbow injuries often have characteristic radiological appearances, which may only be detected by the presence of soft tissue abnormalities.There are important considerations when dealing with elbow injuries in children. Elbow injuries have characteristic appearances Soft tissue abnormality is often the only evidence of bone injury An awareness of elbow development is essential when considering paediatric elbow injuries Order of elbow ossification centre development C - Capitulum (or Capitellum) R - Radial head I - Internal epicondyle (or medial epicondyle) T- Trochlea O - Olecranon L - Lateral (or external epicondyle) Mnemonic = C R I T O L

Ring Removal: Pearls

Anesthesia prn— Digital block may be necessary Children may not be able to cooperate→procedural sedation Open wounds or fracture→ need to cut ring off Glove technique may be exception If lacerations—cover wound/protect from metal shavings metal filings→foreign body reaction and/or chronic synovitis. PPE—eye protection with saw for pt and provider Manual ring cutter--Not usually effective for removing hardened steel rings (eg, steel nuts, washers). All ring cutters→Heat from friction may necessitate periodic cooling with cold water or ice. ICD-10 Coding: W49.04 "Ring or other jewelry causing external constriction"

Anterior Drawer Test:

Anterior Drawer Test: Assesses for ACL tear. Have the patient flex the knee 90 degrees with the foot flat on the exam surface. Sit on the patient's foot and grasp the lower leg at the proximal tibia, pulling forward. Positive Test: Absence of a firm end point when pressure is applied is suggestive of a torn ACL. No need to do both of these tests as they are so similar—do one or the other!

Tests for Glenohumeral instability

Anterior Glenohumeral Instability Apprehension test Relocation test Anterior release test

Shoulder Dislocation: Types

Anterior dislocations are far more common than posterior dislocations Four types of anterior dislocations account for 96-98% of all shoulder dislocations Subcoracoid - occur 3x more frequently than all others combined Subglenoid Subclavicular Intrathoracic Only Subcoracoid reductions are recommended for non-orthopedic specialists.

Standard views of femoral fractures

Anterior-Posterior (AP) and Lateral.

Standard views for ankle

Anterior-Posterior (AP) and Lateral. The AP or 'mortise' view is not a true Anterior-Posterior projection but rather at an angle to optimise visualisation of the ankle joint without being overlapped by the fibula.

Standard views for hip dislocation

Anterior-Posterior (AP) pelvis and Lateral hip

Toe fx - when to refer

Any time it is an articular surface Great toe > lesser toes role in weight bearing, balance, and pedal motion Unstable, open Not responding to conservative tx Consider if fx of Great toe involving > 25% intra-articular surface (the upper image would qualify) Arthritis

Carpal Compression/Durkan Test

Application of firm pressure directly over the carpal tunnel, usually with the thumbs, for up to 30 seconds to reproduce symptoms. Reports indicate that this test has a sensitivity & specificity also variable between 64-96%.

Plaster of Paris - application of the splint

Application of the splint Submerge the dry splint material in the bucket of water until bubbling stops Remove splint material and gently squeeze out the excess water until plaster is wet and sloppy Smooth out the splint to remove any wrinkles and laminate all layers Place the splint over the webril cast padding and smooth it onto the extremity An assistant (or a cooperative and willing patient) may be required to hold the splint in place while you adjust the splint Fold back the edges of the stockinette and cast padding over the ends of the splint Secure the splint with an elastic bandage Place the extremity in the desired position and mold the splint to the contour of the extremity using the palms of your hand. (Avoid using your fingers to mold in order to decrease indentations in the plaster which can lead to pressure sores) Hold the splint in the desired position until it hardens

Shoulder internal and external rotation

Arm at side, elbow flexed to 90° and held at waist Examiner externally or internally rotates arm

Shoulder abduction

Arm straight Hand - palm up (arm supinated) ROM measured in degrees as for forward flexion

Shoulder forward flexion

Arm straight and brought upward through frontal plane, and move as far as patient can go above his head 0° is defined as straight down at patient's side, & 180° is straight up

Scapula fractures

Associated with high velocity impact. Car accident or high fall. Relatively uncommon: <1% Often associated with head, thoracic, and extremity injuries Treatment with sling immobilization Ortho management?? based on severity of fracture and displacement

Cerumen removal pearls for curettage

Avoid touching canal Look for opening and approach from there Brace on pt head to minimize trauma if move Involuntary cough d/t vagal nerve stimulation Consider otic antibiotics if tears epithelium prophylaxis against otitis externa. Consider topical anesthetic (antipyrine, benzocaine, glycerine=Auralgan): 5-10 ml Efficacy is questioned

milch

Based on the principle of recreating the injury The patient can be positioned supine or seated, with the provider on the affected side The provider places a hand on the superior aspect of the injured shoulder and uses a thumb to stabilize the humeral head in a fixed position while the arm is abducted Once the arm is fully abducted, gentle longitudinal traction is applied, and the humeral head is manipulated with the thumb over the glenoid rim Success rates ranging from 70% to 100% have been reported

Places that strains occur

Biceps Rotator Cuff Muscles Forearm Quadriceps Hamstrings Gastrocs or Calf

Bone grafting

Bone graft material can be used to help treat an ununited fracture, or to give long term additional support to internally placed metalwork.

Ottowa Ankle Rules

Bone tenderness at the posterior tip of lateral malleolus (A) Bone tenderness at posterior tip of medial malleolus (not shown) Inability to bear weight immediately or 4 steps in the clinic/ED

Vascular/nutrient lines

Bones are highly vascular structures that are penetrated by nutrient vessels. These appear as low density black lines which often mimic fractures. Characteristically they pass obliquely through the cortex and may have a visible corticated edge. They are not associated with loss of alignment of bone as seen in genuine fractures.

Cortical outline

Careful scrutiny of the bone cortex is required because a check that is too brief will lead to incorrect or incomplete diagnosis.In the context of trauma the clinical features of a significant injury may be masked by other injuries. Remember to be systematic, and if you spot one abnormality, do not stop until you are sure you have focussed on all areas of the anatomy shown.

Joint anatomy - knee

Certain peri-articular soft tissues such as ligaments and tendons, or even cartilaginous structures such as the meniscus, can be seen on X-ray If there is narrowing of a joint - this implies abnormal thinning of cartilage

Cerumen

Cerumen (AKA earwax)—naturally occurring, protective Usually extruded automatically from canal Individual rates of cerumen production (oft genetic) If becomes builds up, may block canal resulting full sensation, decreased hearing, pain or infection (otitis externa) Often, hearing loss is so gradual, pt isn't aware of how much has lost until removed

After All Splints

Check for neurovascular compromise Check for discomfort or pressure points Apply tape along the sides of the splint to prevent elastic bandages from rolling or slipping, (avoid circumferential tape to allow for swelling) Provide sling or crutches as needed Crutches: Pt needs to demonstrate safe use Not everyone can use them Can be more dangerous than the original injury Steps?? Slide on derrier if unable to do it Before you rx crutches, you need to have them show you how to use them. If no one is going to show you how to do it, that is a big deall **MAKE SURE YOU TELL THEM TO LOOSEN BANDAGES IF UNCOMFORTALBLE

Humerus fx

Classified to amount of angulation and displacement Most commonly seen in elderly women 80% are one-part/uncomplicated fractures and can be managed with sling and early mobilizations Humoral head or neck fractures require surgery if present in abduction should be splinted in that position to avoid neurovascular damage Shaft fractures should be splinted in sugar tong with ortho follow up Important to check neurovascular status carefully radial & ulnar arteries function of the radial, median, and ulnar nerves. Most common associated injury is radial-nerve palsy

Clavicle fractures - management

Clavicular Fx at risk for non-union and require orthopedics referral/may be surgical candidate: Displacement greater than one bone width Shortening (> 1.5 cm) Distal clavicle fx Elderly A traditional sling can be used for immobilization. Figure of eight braces, once thought to be superior to traditional slings, have fallen out of favor due to brachial plexus injuries and patient discomfort. Gentle ROM should be encouraged early to prevent adhesive capsulitis.

Hip dislocations Clinical Presentation

Clinical Presentation shortened, internally rotated, and adducted (posterior, which is 90%)

Knee fx clinical presentation

Clinical Presentation→ pain, swelling, deformity, effusion, instability, crepitus and hemarthrosis Neurovascular injury is uncommon but must be excluded

Femoral Neck and Intertrochanteric Fractures Assessment

Clinical assessment : shortened, externally rotated, and abducted Treatment : pain meds, immobilize, surgery 24-48 hours is optimal Non-surgical risks incl aseptic necrosis, immobility (PE)

Greater Trochanteric Pain Syndrome (a.k.a. Trochanteric Bursitis) - Common antecedents

Common antecedents: Play or work activities that cause overuse or injury to the joint areas. Such activities might include running up stairs, climbing, or standing for long periods of time Injury to the point of the hip. This can include falling onto the hip, bumping the hip into an object, or lying on one side of the body for an extended period.

Plantar fasciitis

Common cause of plantar foot pain >1 mil/yr Risk factors Obesity Excessive foot pronation excessive running prolonged standing Poor foot wear, high heels Dx—typically H&P

Radial head fracture

Commonly involve articular surface Capitellum fractures and medial collateral ligament injury are commonly associated (many fractures can be occult and not seen on initial xrays!) Can be treated in sling or long posterior splint Might need ORIF Olecranon fractures Commonly result of direct blow to olecranon Examination of ulnar nerve is key

Frame fixation

Complex bone injuries or injury to small bones may not be amenable to plastering or internal fixation. In these cases external fixation may be achieved with the use of a frame device.

Elbow Injuries & Relevant Anatomy

Complex joint involving the distal humerus, radius and ulna allowing for flexion/extension (primarily) Common presentation: •Pain (can be acute or chronic) •Swelling and/or deformity •Decreased range of motion

Scaphoid Fracture

Consider with all hand & wrist injuries Palpation of the anatomical snuffbox just distal to the radial styloid Most common fractured carpal bone Occur as result of forced hyperextension of wrist 15-25% not seen on initial x rays AVN is common due to poor blood supply to proximal portion Recommend splint & consult if + snuffbox tenderness Some splint 7-10 d and re-evaluate sx and xray What is con of this approach? Worry about this bc of avascular necrosis.

Fiberglass (Orthoglass) - what are the relative benefits?

Cure rapidly (20 minutes) Doesn't require additional padding--Layers of fiberglass between polypropylene padding Less messy Stronger, lighter, wicks moisture better Less moldable you won't get as tight of a fit Expensive If re-sealed incorrectly, ruins entire roll---common!

Ring Removal w/o Cutting: Surgical Glove Technique

Cut a finger from a surgical (can't be a rubber glove bc of the tighter fight is surgial) glove and cut the tip off so it is sleeve. Gently put it on the finger and tuck the proximal end under the ring. Grip tightly and pull the proximal end of the sleeve distally, working the ring off. Slow and steady to avoid ripping glove...This may take some time. Advantage— Relatively painless can be used with finger fx or soft tissue injuries

Greater Trochanteric Pain Syndrome (a.k.a. Trochanteric Bursitis) - dx

DX: Based on hx and physical Local tenderness to palpation of the greater trochanter, most marked at its superoposterior facet (posterior corner) Doesn't usually require imaging or labs except to r/o fx or suspected underlying pathology

Tendonitis/Tendinosis/Tenosynovitis

DeQuervain's Trigger Finger Rotator Cuff Biceps Achilles Quadriceps Gluteus / Hip Flexors & Extensors Posterior Tibial Peroneal Patella

Tendinosis (tends to be older)

Degenerative process from high intensity or high frequency mechanical load

Tape vs. splint

Depends on type injury Time of injury (acute or delayed) Previous Hx injury to same joint Severity of injury (grade II-III) Physical exam findings Ability to return to work, sport

Thessaly Test

Designed to elicit pain when patient rotates on a weight bearing knee at 20% flexion Studies initially revealed high sensitivity/spec (90%tile) later tests reveal similar to other maneuvers (like McMurray') Use with caution if instability concerns or a lot of pain— Use non-wt bearing

Scaphoid fracture Info

Despite these additional views 30% of scaphoid fractures remain occult on any image taken at the time of injury. The long-term consequences of not treating a scaphoid fracture can be significant. There is a high risk of non-union, with or without avascular necrosis of the proximal fracture component. It is therefore essential that patients clinically suspected to have a scaphoid fracture are treated as such, even if a fracture is not visible on the X-ray. These patients should then be followed up clinically with repeat X-rays if still tender.In many departments MRI is performed if there is persistent pain/tenderness with no visible fracture on X-ray at 10 days. Local protocols must be adhered to.

Diastasis

Diastasis is a term used to describe the separation of 2 normally adjacent bone parts, either at a ligamentous joint, or at a growth plate.

Dislocation injury

Dislocation is an injury resulting in loss of anatomical congruence of bones at a joint. Joint dislocations are described in terms of the position of the distal bone in relation to the proximal bone. This means that distal bones can dislocate from proximal bones, but not vice versa.Subluxation is a term which may be used to describe incomplete dislocation.

Monteggia Fracture

Displaced proximal ulnar fracture with radial head dislocation Radial nerve injuries common Less common, more complciated

Fracture displacement

Displacement of fractures is defined in terms of the abnormal position of the distal fracture fragment in relation to the proximal bone. Types of fracture displacement include - angulation, rotation, change of bone length, and loss of alignment.The severity and nature of displacement are key factors when considering fracture management.

Digital Block of Fingers & Toes: Anatomical considerations

Dorsal and palmar/plantar digital nerves as well as arteries Fingers and Toes Basically approached the same way except thumb and great toe Toes (except 1st) single needle insertion

Standard Views of the foot?

Dorsal-Plantar (DP) and Oblique - are standard projections of the forefoot. If only a phalangeal fracture is suspected then DP and oblique views of the toe(s) can be acquired. Lateral views can also be helpful.

Drop arm test

Drop Arm Test Purpose: This test indicates tears in the rotator cuff, primarily of the supraspinatus muscle. Method: The athlete abducts (or examiner passively abducts) the arm as far as possible and then slowly lowers it to 90º. Patient slowly lowers arm to waist May be able to lower arm slowly to 90° (this is mostly deltoid function) Arm will then drop to patient's side if rotator cuff tear Findings: A positive sign is that the athlete will be unable to lower the arm further with control. If the athlete is able to hold the arm at 90º, pressure on the wrist will cause the arm to fall.

Bursitis Diagnosis - differentials

Dx: History-don't be fooled—oft presents as simple Exam Tophi (gout)? Abrasion? Inflammation (infection)? Neighboring joint affected? Back or knee issues→trochanteric Pes planus/flat feet→ what kind? Testing—not typically needed - to rule out tohi or infected/septic joint When, why, and what would normally do? As bursae are not radio-opaque, they are not evident on plain radiographs of the joints Both ultrasonography and MRI are equally useful in the diagnosis of deep bursal syndromes. We prefer ultrasonography since this imaging technique permits dynamic assessment of the bursa in motion. Further, ultrasonography can be used simultaneously to guide needle aspiration of the bursa.

Peri-lunate dislocation

Normal alignment of the radius - lunate - capitate on the left for comparison The right image shows dorsal dislocation of the capitate which should be congruous with the cup of the lunate

When to Refer?

Emergency Department/ Orthopedic referral Suspect certain types of fracture Varies according to... Open injury Sprains accompanied by soft tissue compression Unstable joint Injury could cause potential loss of limb or function Derangement ligaments Persistent pain Injury not resolved Persistent joint instability *First thing you need to know is what kind of fracture it is and what grade, the amount of displacement and type of bone will tell you if you need to be referred. Use book resources around when to refer bc a lot of this has not changed in many many years.

Ring Removal w/o Cutting: Wrap Technique (Undertaker method)

Equipment: elastic band from O2 mask, penrose drain, 0 size suture. Anything binding, elastic is better. Start at DIP and wrap tightly moving proximally towards the ring, slightly overlapping the band Work end of band under ring, may use hemostat for grip. Pull end of band, it will naturally slide circumferentially around the ring as you pull. May have to attempt this multiple times to successfully push down edema and remove the ring.

Shoulder ROM

Evaluate active ROM If movement limited by pain, weakness, or tightness, assist passively Lack of full ROM with active and passive exam is found in adhesive capsulitis and arthropathy Evaluate bilaterally for comparison

Splinting Complications, Prevention & Management: Joint stiffness and Muscle Atrophy

Expected to some extent after any immobilization of a joint Avoid prolonged immobilization if possible

Extracapsular fractures

Extracapsular fractures of the proximal femur include intertrochanteric (between the trochanters) and subtrochanteric (distal to the trochanters). These fractures do not involve the neck of the femur.

Calcaneus

Falling from height can lead to severe calcaneal fractures, which may be accompanied by axial loading fractures of the spine.Calcaneal fractures due to a fall from height are often comminuted and intra-articular. The extent of injury is easily underestimated by X-ray appearances.Low impact trauma or twisting injuries of the calcaneus can result in subtle X-ray changes Severe calcaneus fractures often result in loss of Bohler's angle Calcaneus fracture often result from falling from height but may be due to more trivial injury

Bones of the hand - Normal X-ray (PA)

Finger bones articulate at the metacarpophalangeal joints (MCPJ), the proximal interphalangeal joints (PIPJ) and the distal interphalangeal joints (DIPJ) The fingers each have 3 phalanges - proximal - middle and distal The thumb has only 2 phalanges - proximal and distal - joined by the interphalangeal joint (IPJ)

Finger dislocation

Finger dislocation is usually evident clinically. X-ray can be used to check for underlying bone injury and to reassess following reduction of the dislocation. In this image, The proximal phalanges are dislocated at the 4th and 5th MCPJs

Assessing for Carpal Tunnel Syndrome: Tinel's Sign

Firmly tap over the median nerve on top of the carpal tunnel. Positive sign: Pain and/or paresthesias in the fingers during this maneuver is indicative of CTS. Sensitivity and specificity controversy.

Tendonitis: Management

First line - Activity & ergo modification—requires good hx - Eccentric & heavy load exercise: (PT usually, esp for chronic) - Slow w/ gradual increase wt - Stretching—best when warm, no > 30 sec Controversies relating to treatment: - NSAIDS -best if acute. Less if acute - Joint immobilzation - Ice vs heat (ice first then heat) - Glucocorticoids - Counterforce bracing

Boutonniere

Flexion at PIP with hyperextension of DIP Caused by rupture of central slip of PIP May have delayed manifestation after blunt trauma Treat by splinting PIP in full extension, assuming it is acute

Mallet Finger/Extensor tendon injury of the distal interphalangeal joint

Flexion posture of the DIP Caused by avulsion of extensor tendon Treat by splinting in full extension Uninterrupted for 8 weeks! Not even taking off for shower. Hold in place if you need to change the splint. Surgical consult: Inability to achieve full passive extension of the DIP joint Full laceration of the extensor tendon Volar (palmar) subluxation of the distal phalanx Fracture involving greater than 30 percent of the joint surface (aka interarticular surface) controversial→evidence suggests conservative tx may be equal to surgery

Foreign bodies

Following traumatic breach of the skin X-rays can be used to identify and locate residual foreign bodies. Materials which are radio-opaque such as glass or metal are usually seen easily. Other less dense substances such as wood are not readily detected with X-rays.The requester should inform the radiographer acquiring the image that the purpose of performing the X-ray is to identify a foreign body. This is so that specific image settings can be used, and views acquired depending on the nature and site of injury. At least 2 views are required with an external metallic marker to indicate the point of skin entry.As well as locating foreign bodies within soft tissues, X-rays can show if a foreign body is lodged within bone. Antibiotics may be appropriate in this scenario to prevent bone infection.

Tibia and fibula

High force impact is required to fracture the tibia. Injuries are often obvious both clinically and radiologically, but a careful check should be made for undisplaced fractures.Occasionally a history of chronic tibial pain is due to a stress fracture. Stress injuries are due to repeated low force trauma to a normal bone - unlike a pathological fracture which is the result of minor injury to an abnormal bone.

Pathological fractures

High force is required to fracture a normal bone, but diseased bones may fracture as a result of low impact trauma. A fracture arising within abnormal bone is termed 'pathological.'Osteoporosis is the commonest cause of pathological fractures.Pathological fractures may also occur in bone weakened by benign or malignant, primary or secondary bone tumours.

Forearm muscles

Forearm flexors→medial epicondyle Forearm extensors→lateral epicondyle

Speed's test

Forward flex shoulder against resistance while maintaining elbow in extension and forearm in supination Positive test = tender in bicipital groove (bicipital tendinitis)

Galeazzi Fracture

Fracture of radius with radio-ulnar separation Emergent operative repair

Trauma X-ray - Foot

Fractures and dislocations of the forefoot (metatarsals and phalanges) are usually straightforward to identify, so long as the potentially injured bone is fully visible in 2 planes. The contour of the bone cortex of all bones must be checked carefully. Key points Carefully check the cortical edge of all bones on all views available Always check for alignment of bones at the mid-forefoot junction (tarsometatarsal joints) Injury to the Lisfranc ligament may not be visible on initial X-ray - follow up may be necessary Metatarsal stress fractures are subtle and may not be visible on the initial X-ray

Knee fx

Fractures are uncommon: - Patella - Proximal Tibia Associated with ligamentous and/or meniscal injuries Mechanism→ severe valgus/varus stress, falls, "bumper fender" Goal is restoration of articular surface and joint stability

Femoral shaft fractures

Fractures of the femoral shaft usually result from high force impact such as in a road traffic crash. Injury often results in highly displaced fractures which are easily recognised both clinically and radiologically.If there is a fracture of the femoral shaft without a history of high force trauma then the possibility of a pathological fracture should be considered.

Humerus fractures

Fractures of the humerus are common at the surgical neck. A fracture line may extend into the humerus head with separation of the tubercles.Fractures of the humerus shaft are not uncommonly due to a pathological lesion.Distal fractures are considered with the elbow.

Patellar injury views

Fractures of the patella may only be visible on 1 of the 2 standard views, more often the lateral view.

Tibial plateau fractures

Fractures of the tibial plateau can be subtle with little displacement, or can be widely displaced, with varying degrees of comminution. There may be depression of the plateau surface, displacement of a fracture fragment, or a combination of both.Not infrequently the formation of a lipohaemarthrosis is the only radiological sign. Lipohaemarthrosis is a layered effusion of fat and blood which has 'leaked' from the bone following a fracture.

Radial splint

Fractures, phalangeal & metacarpal, & soft tissue injuries of index & long fingers

General principles/pearls for splinting

Frequently assess neurovascular status; before & after splint application Apply material firmly Avoid skin irritation Remove splint 4x/day & gentle ROM

Taping Indications

Grade I & II strains Tenosynovitis Plantar fasciitis

Metacarpal Fractures: Treatment

Gutter splint Less frequently-- surgery for malunions or non unions Carpometacarpal/CMC joints 2-3rd CMC—no room for movement. High possibility for complications 4-5th CMC—have compensatory mobility -

Finger dislocations - hx questions? Physical exam focus? Imaging?

HX: Age, closed epiphyses? Mechanism and time of injury/Digit position during injury (flexed versus extended) Dominant hand, Occupation Prior hand conditions, injuries, or interventions Physical exam focus: Site of injury (eg, maximal pain and swelling) Neurovascular exam, especially distal to injury Presence of open wounds adjacent to the injury Range of motion Imaging: Xray: AP, oblique, & true lateral

knee dislocations

High energy trauma→Dislocations ortho emergency with 40% involvement of popliteal artery Basis of tibial movement in relation to femur with anterior being most common with highest incidence of vascular problems Immediate reduction is key Must get early angiography/operative exploration

Ankle fracture

High incidence of associated ligamentous damage Most are intra-articular Clinical Presentation→ pain, swelling, deformity; weight bearing ability determines stable vs. unstable Treatment→ stable usually requires no reduction; unstable requires ortho referral and either closed reduction or ORIF

Hip disorders

Hip Anatomy : A strong fibrous capsule which is weakest posteriorly Tenuous vascular supply to the femoral head

Hip dislocation

Hip dislocation (dislocation of the femoral head from the acetabulum) is most frequent following total hip replacement (THR). Dislocation is usually in a posterior direction which clinically leads to leg shortening, with flexion and internal rotation at the hip (note - hip fractures usually cause external rotation).Hip dislocation may be accompanied by fracture of the acetabulum, or significant soft tissue injuries not visible with X-ray.

Cerumen impaction: hx and exam

History: Hearing loss (unilateral vs. bilateral), tinnitus Otalgia, fullness in ear, discharge from ear Cough, fever Vertigo, dizziness Trauma, foreign body Occupation (dusty environment) Ear hygiene (use of Q-tips) Use of hearing aids, ear plugs, tympanostomy tubes Ototoxic medications (i.e. aminoglycosides) Physical exam: Inspect, palpate pinna and post-auricular skin Whisper test to assess hearing Otoscopic exam to directly visualize cerumen

Digital block of finger: Web Space Block

Hold the syringe perpendicular to the digit and insert the needle into the web space, just distal to the metacarpal-phalangeal (MP) joint After insertion, withdraw to ensure not in artery --

Signs of Annular ligament displacement

Hx: Although a traction force is the most common mechanism of this injury, often no definite history of a typical pull or fall can be obtained. child is reported to resist moving his or her arm and is found to be holding it against the body and slightly flexed. Not typically in pain when left alone and the arm is not being manipulated. No swelling at injury site Holding arm in "nursemaids position" (slightly flexed and pronated) and not using it

Swan neck

Hyperextension (beyond the normal plane) of PIP with flexion of DIP Often associated with old mallet finger injury that did not heal properly, Rheumatoid arthritis , PIP volar plate injury

Mallet finger injury

Hyperflexion of the DIP joints may result in avulsion of the distal phalanx base on the dorsal side. More commonly there is tearing of the extensor tendon which is an injury not directly visible with X-ray.If there is a clinically evident mallet deformity, but no bone injury, do not make the mistake of thinking there is no significant injury

Hamate fracture

If a carpal bone injury is suspected and not visible on the PA or lateral image, then a request for other views can be made. For example, a hamate fracture is often poorly visualised on the standard views and may be best seen on an oblique view. Like many other carpal injuries this fracture can have significant long term clinical consequences if not identified. In this image, Fracture line through the hamate This injury was only visible on this view

Joint Line Palpation

If a patient has joint line tenderness, it could be indicative of medial or lateral meniscal injury. To assess for joint line tenderness, have the patient slightly flex his/her knee. Find the joint space along the lateral and medial margins (perpendicular to tibia) and palpate. Positive Sign: Pain may suggest an underlying meniscal damage. Perform maneuvers (McMurray's or Apley Grind) to assess further.

Open reduction and internal fixation

If manipulation and use of external immobilisation devices is not successful or not appropriate, then open surgical reduction with placement of internal fixation metalwork such as plates and screws may be required.

Raised fat pad sign - definition

If the anterior fat pad is raised away from the humerus, or if a posterior fat pad is visible between triceps and the posterior humerus, then this indicates a joint effusion. In the setting of trauma this is due to haemarthrosis (blood in the joint) secondary to a bone fracture. This is often the only X-ray sign of a bone injury.A post-traumatic effusion without a visible bone fracture usually indicates a radial head fracture in an adult, and a supracondylar fracture of the distal humerus in a child.If there is a joint effusion but no history of trauma, an inflammatory cause should be considered.

TIBIAL PLATEAU FRACTURE

If they are intra-articular. These will cause more problems

Compare with other side

Images of the asymptomatic contralateral side to a suspected abnormality are not routinely acquired for assessment of all bones or joints.If an old image of the contralateral side is available, or if the other side is included as standard (for example hip/pelvis) then comparison between symptomatic and asymptomatic appearances can be very helpful.

Immobilization Primer:

Immobilize the digit based on the location and type of dislocation: - DIP dorsal or lateral finger dislocation: Splint the DIP in full extension while allowing full range of motion of the PIP joint. - PIP dorsal or lateral finger dislocation: Apply a dorsal splint with the PIP in 20 to 30 degrees of flexion. - Volar finger dislocation: Splint the PIP and DIP in full extension. - DIP or PIP toe dislocation: Buddy tape the affected digit to its neighbor.

Special impingement tests

Impingement tests Neer's sign Hawkin's test

Adhesive capsulitis

Important to be aware of as very difficult and prolonged recovery—oft years Preventable in some cases —gentle shoulder ROM ASAP (TT theory) Get moving as soon as possible Get PT involved prn Associated with: Prolonged immobility Traumatic injury Diabetes, thyroid increase risk No identifiable precipitants—"idiopathic" Peak in 5th decade < 40 rare Women> men Non-dominant shoulder > dominant Characterized by severe shoulder pain & global limitation of shoulder motion Gradual development -oft several months No radiographic findings (except possible osteopenia) Exam—difficult to perform as reduced ROM

Skyline view

In knees, A 'Skyline' or 'Sunrise' view is rarely indicated in the context of trauma. This view is only necessary if the standard views are normal and a patellar fracture is still suspected, or to assess patellar dislocation. A skyline view can only be acquired if the patient can tolerate knee flexion.

New v old

In old xray, there is evidence of lytic bone disease

Bone texture

In some bones a fine matrix of fine white lines (trabeculae) is seen. Occasionally bone injury or disease will result in abnormality of this texture This image is normal .

2 views

In the context of trauma at least 2 views of the body part in question are usually required. If looking for specific disease entities, for example erosions in rheumatoid arthritis, this may be less important. In some cases, such as possible scaphoid injury, more than 2 images are required. This image only shows the fracture in the lateral view

Cerumen Removal: Contraindications

Inability to adequately restrain uncooperative pt Clinician unfamiliarity of anatomy Pt with distorted canal &/or hx of surgery which complicates removal Possible cholesteatoma Affected ear only hearing ear Known or suspected perforation—only if irrigating

Forearm sugar tong - indications

Indications Distal radius and ulnar fx Prevents pronation / supination & immobilizes elbow

Posterior ankle splint

Indications Distal tibia/fibula fx Reduced dislocations Severe sprains Tarsal / metatarsal fx Adding a coaptation splint (stirrup) to the posterior splint eliminates inversion / eversion - especially useful for unstable fx & sprains

Double sugar tong

Indications Elbow and forearm fx - prox/mid/distal radius and ulnar fx Better for most distal forearm & elbow fx limits flex/extension & pronation / supination

Digital Block of Fingers & Toes: Indications

Lacerations Nail bed injuries Paraonychia Felon Nail avulsions - think about whether or not is to think about whether or not you need to do further procedures Foreign body removal Dislocations

Long Arm Posterior splint - indications? Limitations?

Indications Elbow and forearm injuries Distal humerus fx Both bone forearm fx Unstable proximal radius or ulna fx (sugar-tong better) Doesn't completely eliminate supination / pronation -either add an anterior splint or use a double sugar-tong if complex or unstable distal forearm fx

Ulnar gutter

Indications Fractures, phalangeal & metacarpal, & soft tissue injuries of the little & ring fingers.

Stirrup splint

Indications Similar to posterior splint Less inversion /eversion and actually less plantar flexion compared to posterior splint Great for ankle sprains

Forearm Volar splint or "cock up"

Indications Soft tissue hand / wrist injuries - sprain, carpal tunnel night splints Most wrist fx, 2nd -5th metacarpal fx Most add a dorsal splint for increased stability - 'sandwich splint' (B) Not used for distal radius or ulnar fx - can still supinate and pronate

Bursitis - causes?

Inflammation of the sac in between tendon and bone or skin and bone. Causes Overuse & Repetitive Stress Injury Hardware irritation especially along the hip

Tendonitis

Inflammation of the tendon substance. Injury related

Finger dislocation: Reduction - steps

Informed consent •Inadequate or delayed reduction may cause an unstable, deformed, or stiff joint •Reduction attempts may lead to fracture •The joint may become dislocated again if immobilization is not maintained •Swelling &/or stiffness up to mos despite appropriate treatment Analgesia, distraction Post-reduction Check ROM Xray (incl true lateral) Immobilize Followup

Ulnar collateral ligament injury (AKA Gamekeepers or Skier's Thumb)

Injury to the ulnar collateral injury (metacarpal and proximal philange) Treat with thumb spica splint and follow up with hand surgery. Would need specilist referral

Physical Exam for Ortho Injury

Inspection Palpation Example: C-spine, para-scapular muscles, supraspinatus, infraspinatus, subacromial, AC joint, and biceps tendon. ROM - active and passive Strength Testing Special Tests "The most important aspect of the physical exam is exposure." - can I see the whole area? The joints above and below. Examine bi-laterally

Patient Education - splints

Instructions--verbal and written RICE Rest Ice decrease swelling and pain Not directly on skin no > 15-20" minutes at a time during the first 24-48 hours after injury to Compression Elevation x 48 hours→ minimize swelling and decrease pain Avoid getting the splint wet; removable vs plastic bags over while bathing Discuss s/s infection, neurovascular compromise: Teach back RTC if damaged/broken or wet splint Follow-up plan

Intra-articular fractures

Intra-articular fractures have a worse prognosis and are often the most difficult to see. Check all views available. If a fracture is not visible and there is sufficient clinical suspicion of bone injury then a request for further views may be helpful.

Intracapsular fractures

Intracapsular fractures include subcapital (below the femoral head), transcervical (across the mid-femoral neck), or basicervical (across the base of the femoral neck). These injuries may be correctly termed fractures of the 'neck of femur' (NOF).

Intracapsular v extracapsular fractures

Intracapsular v extracapsular The capsule envelopes the femoral head and neck Subcapital, transcervical and basicervical fractures are intracapsular hip injuries Intertrochanteric and subtrochanteric fractures do not involve the neck of femur

Cerumen removal pearls for irrigation

Irrigation water body temperature to prevent vestibular reflex (dizzy, nausea) Direct stream aimed high on canal wall, NOT at TM Don't use high pressure Don't insert tip > 1 cm Air bubbles make it more noisy Not appropriate if known or suspected TM perforation or cholesteatoma

Assessing for Meniscal Injury: tests

Joint Line Palpation McMurray's Test Apley Grind Test

Other splinting devices

Knee Immobilizer - can be under or over clothes Semirigid brace, many models Fastens with Velcro Worn over clothing AirCast/ Airsplint Resembles a stirrup splint with air bladders Worn inside shoe Hard Shoe Used for foot fractures or soft tissue injuries

Knee splints

Knee Immobilizer / Bledsoe Bulky Jones Posterior Knee Splint

Lachman's Test

Lachman's Test: The patient's knee is flexed 15-30 degrees. Place one hand just below the knee joint while placing the other on the anterior aspect of the femur (just above the knee). Lift up on the lower leg while applying downward pressure on the upper leg.

Ligamentous Injury to Ankle

Leading cause of ED visits 80% from inversion and rotation High incidence of complications Lateral most common Lateral support ligaments→ anterior talofibular, calcaneofibular, posterior talofibular Medial support → medial collateral /deltoid (four separate ligaments) Classify sprains as 1,2nd or 3rd degree. Grade 3 would be a complete tear. Stress testing with xrays very helpful in differentiation between second/third degree Treatment→ RICE + time compressive dressing or air cast vs. splinting vs. surgery depending on degree of sprain

Splinting Complications, Prevention & Management: Compartment Syndrome - presenting s/s?

Less common in splints than with circumferential casts (that is one of the points, allows for given). constricting cast padding or elastic bandages →increased pressure within a closed space on an extremity→ inadequate tissue perfusion & loss of muscle, vascular & nerve function Presenting signs and symptoms: pain in the extremity tenderness over the involved compartment significant pain with passive stretching of ischemic muscle tissue diminished distal pulses and sensation delayed capillary refill, and pale cool skin.

Toe fracture

Lesser toe fx 4x>great toe Xray AP, lateral, & oblique RICE - usually Buddy tape hard soled shoe, seen to the left Reduction lesser toes within scope of primary care Refer if unstable (can't maintian w/o splinting)

Lisfranc Fracture/dislcocation

Lisfranc Fracture/dislcocation → most common midfoot fx. Disrupted tarsal-metatarsal joint and fx of base of 2nd metatarsal Commonly missed initially (up to 20%) Emergent Ortho Consult needed

Elbow/Forearm (name)

Long Arm Posterior Double Sugar - Tong

'Long bone' fractures

Long bone fractures are described with reference to the direction of the fracture line in relation to the shaft of the bone. For example, a fracture passing perpendicular across the bone shaft is described as 'transverse'.Other fractures passing across a long bone include, 'oblique' and 'spiral' fractures.If a fracture passes along the shaft of a long bone then it can be described with reference to the plane in which it passes, for example coronal or sagittal.

Plaster of Paris—Part 1 - What is it made of? How long to set?

Made from gypsum - calcium sulfate dihydrate Strips or rolls of various width made from crinoline-type material impregnated with plaster which crystallizes or "sets" when water is added Exothermic reaction when wet - recrystallizes (can burn patient bc it gets hot) Warm water - faster set, but increases risk of burns Fast drying - 5 - 8 minutes to set Extra fast-drying - 2 - 4 minutes to set - less time to mold Can take up to 1 day to cure (reach maximum strength) Upper extremities - use 8-10 layers Lower extremities - 12-15 layers, up to 20 if big person (increased risk of burn!)

Mallet finger injury X-ray

Mallet finger injury X-ray Dorsal avulsion of the distal phalanx base Soft tissue swelling In this case the extensor tendon is intact

Soft tissue injury complications

Many bone fractures are complicated by a significant soft tissue injury that the X-ray may or may not show. Soft tissue injuries may be threatening to life or limb, and for this reason thorough clinical examination is required BEFORE obtaining the X-ray. For example, it is essential to check for neurological and vascular compromise, which may mean immediate fracture reduction is appropriate prior to imaging.An 'open fracture' is any fracture complicated by breach in the adjacent skin. This is evident clinically and often difficult to appreciate on X-rays.A 'closed fracture' (no break in skin) that is clinically complicated by soft tissue injury is correctly termed a 'complex fracture'.The soft tissue injuries associated with complex and open fractures are usually more evident clinically than on X-ray.

Reduction of acute dislocation of shoulder

Many techniques-- all apply gentle and persistent tension on the spasmodic chest wall muscles, to elongate them, and to reestablish the mobility of the humeral head Allows for the humeral head to track or be gently manipulated back into the glenoid fossa No clear evidence exists supporting the superiority of any one of the many methods used to reduce anterior shoulder dislocations depends on clinician preference and the patient's condition A technique that is quick, simple, and requires neither significant force nor intravenous medication is ideal Clinician should not attempt more than two reduction procedures If second attempt is unsuccessful, the resultant muscle spasm will likely prevent closed reduction in a safe manner → call orthopedic surgeon

McMurray's Test

Medial Meniscus: With the patient supine, grasp the heel and flex the knee. Place the other hand on the knee joint, rotating the lower leg internally and externally to loosen the joint. Turn the foot outwards while rotating the leg externally and extending it. Lateral Meniscus: With the patient in the same position as for the medial meniscus, turn the foot inwards while internally rotating and extending the leg. Positive Test: A click or a pop along the joint with stress, rotation, and leg extension suggests a probable tear of the meniscus.

Carpal Tunnel - define

Median nerve entrapment at wrist - transverse carpal ligament Ennervates thumb, index, long & half of ring finger high carpal tunnel pressures exist in patients with CTS→ pressure, edema, and ischemia →numbness, paresthesias, and pain in the median nerve distribution

Metatarsal fractures - Def

Metatarsal fractures are usually easily recognised, but are often only visible on one view.Fractures of the 5th metatarsal base are a common injury. The normal 5th metatarsal apophysis should not be mistaken for a fracture.

Splinting Complications, Prevention & Management: Infection

More common with open wounds, but may occur with intact skin Clean and debride wounds well prior to splint application Consider using a removable splint for periodic wound checks

Bone anatomy - diaphysis? - epiphysis? - epiphyseal line?

Most bones develop from cartilaginous ossification centres to form a diaphysis (shaft), or epiphysis (end). During bone growth the diaphysis and epiphysis are separated by the epiphyseal line (growth plate) which fuses later in life. The zone adjacent to the growth plate on the diaphyseal side is called the metaphysis.

Clavical fractures

Most commonly fractured bone in children Careful neurovascular exam must be done to r/o brachial plexus or vascular injury Fractures most common in middle third of bone (80%) Medial clavicle fractures may have associated thoracic injury

Displacement combinations

Most displaced fractures result in more than one type of displacement.

Joint anatomy

Most joints are synovial and comprise two articulating bones lined with hyaline cartilage and contained by a synovial lined capsule. Although soft tissues such as cartilage and capsular structures are of low density, and therefore less well-defined on X-ray images, it is a mistake to think they are not visible.

Carpometacarpal Joint Dislocations

Much less common than MC dislocation (<1%) Caused by high force blows, clenched fist or MVA Swelling can obscure the deformity Requires fixation - Refer

Annular ligament displacement: Pearls and Red Flags

Multiple repeated attempts to reduce should be avoided Remember... There may or may NOT be a palpable click Voluntary use of the arm will return in less than 15 minutes in almost 90% of patients. Younger children usually take longer to begin reusing the arm. Many clinicians relate experiences with "failed" reductions in children whose arms are better the following morning. Radiographs are indicated when the reduction maneuver has failed after appropriate repetition. Consider giving them time...go to waiting room while parent observes their play Longer duration of subluxation does not appear to be associated with delayed return of function. If disuse of the arm persists and radiographs are normal, a sling should be placed and the child should be seen in follow-up by an orthopedist

Wrist bones - Normal X-ray (Lateral)

Multiple wrist bones overlap The scaphoid (red) is difficult to see clearly on this view IMPORTANT NOTE: This view is essential to check for alignment of the radius, lunate and capitate (blue)

Irrigation - cons

NO—if known or suspected tm perforation or tympanostomy tubes messy, noisy potential for triggering dizziness Especially common if water is not body temperature

Shoulder dislocation physical exam

Need to rule out neurologic or vascular deficits 6Ps: pain, pallor, pulselessness, parasthesia, paralysis and perishing in cold Check for vascular compromise (temperature and color of the skin over the fingers and palpation of the distal pulses). Concerns about impingement. Assess axillary nerve or brachial plexus General nerve testing—check sensation from the point of the shoulder to the fingers and simple motor function testing Testing axillary nerve specifically-assess sensation over lower deltoid and on dorsum of hand to rule out Neck: assess cervical spine for range of motion to rule out potential injury, examining for nerve root impingement along cervical spine Extremities: for evaluation of instability assess for rotator cuff injury, especially in older patients palpate shoulder girdle and upper extremity for tenderness assess for range of motion and motor strength evaluate both limbs for stability in anterior, posterior, inferior directions assess for presence and size of sulcus sign (degree of separation between humeral head and acromion)

Post Annular ligament reduction care

No additional treatment or activity restriction is necessary Because it is so common, the reduction of the displaced annular ligament is an essential procedure for all pediatric caregivers to learn. The maneuver is easily performed. It is also gratifying to produce such immediate relief. The procedure has even been taught to parents over the telephone.

Osteopenia and Sudeck's atrophy

Normal bone formation is influenced by mechanical stress. Occasionally fractures requiring prolonged immobilisation will result in osteopenia due to disuse.Reduced bone density may also result from Sudeck's atrophy, also known as 'reflex sympathetic dystrophy' or 'complex regional pain syndrome'. This is a painful syndrome which is poorly understood, but thought to be caused by dysfunction of the autonomic nervous system and regulation of blood supply.

Normal elbow X-ray - 10 year old

Normal elbow X-ray - 10 year old The red ring shows the position of the External or 'Lateral' epicondyle (L) which has not yet ossified All the other centres of ossification are visible C = Capitulum R = Radial head I = Internal epicondyle T = Trochlea O = Olecranon

Shoulder ROM

Normal is between 0-180 abduction Watch for symmetrical even motion Is the decrease motion because the patient cannot or won't? (active and then passive) Do shoulders have equal elevation throughout

Curettes conts

Not recommended in difficult to restrain pt. Canal pain TM or canal trauma or bleeding TM much less common

Documentation for splints

Note the indication for the splint CPT code Based on location & type of splint Describe any wounds & their location under the splint Document the neurovascular exam findings before & after splint placement Describe the type of splint applied, area immobilized, and materials used to make the splint Indicate what follow-up is planned for re-assessment of injury

Shoulder dislocation hx

OLDCARTS, PQRST,--whatever helps you be thorough In suspected acute dislocation ask about recent injuries or traumatic events ask about numbness, paresthesias, or motor weakness to rule out associated nerve or vascular injury In cases of recurrent dislocation or instability frequency and duration of any past instances of instability, dislocation, or subluxation arm positioning that causes pain history or repetitive overhead activity Family history of joint laxity

Metatarsal shaft fracture

Oblique fracture of the 5th Metatarsal shaft Fracture more clearly visible on the oblique image

Avascular necrosis (AVN)

Occasionally a bone will not heal because its internal blood supply is compromised. This may result in AVN - the death of bone cells through lack of blood supply.

Osteochondral fractures - definition

Occasionally ankle trauma causes a fracture of the talus bone surface. These 'osteochondral' injuries are often subtle and so this area should be assessed carefully on all post-traumatic ankle X-rays.

Shoulder pain in primary care

Often chronic with acute exacerbations Subacromial impingement syndrome and rotator cuff tears are the most common disorders encountered. Onset may be acute, following an injury, or insidious, particularly in older patients, where no specific injury occurs The history and physical are keys to the majority of shoulder pain diagnosis. Most history and physical techniques are better for ruling-out not ruling-in a diagnosis. [Today we are focusing on acute trauma]

Palpable elbow processes

Olecranon process Olecranon fossa Medial and lateral epicondyles Radial head Cubital Tunnel—Ulnar N

Normal elbow X-ray appearances

On the lateral image there is often a visible triangle of low density lying anterior to the humerus. This is the anterior fat pad which lies within the elbow joint capsule. This is a normal structure. Anterior humerus line A line extending from the anterior edge of the humerus should pass through the capitulum with at least one third of the capitulum seen anterior to it. Radiocapitellar line A line taken through the centre of the radius should extend so it passes through the centre of the capitulum.

Ottowa Knee rules

Ottowa Knee Rules--recommends X ray if Patient > 55 yrs Not established for peds but studies support validity with kids Tenderness at head of fibula Isolated Patellar tenderness Inability to flex to 90 degrees Inability to transfer weight for 4 steps immediately after injury and in ED

Plaster of Paris - splinting pt 1

Padding Apply stockinette to extremity to extend several cm beyond edges of plaster, so that it may be folded back over the edges of the splint after plaster is applied to create a smooth edge Roll on two to three layers of cast padding evenly and smoothly (but not too tight) over the area to be splinted. Extend the padding out beyond the planned area to be splinted so that it can be folded back with the stockinette over the edges of plaster to create smooth edges. Each turn of the webril/cast padding should overlap the previous by 25-50 % of its width. Place extra padding over bony prominences to decrease chance of creating pressure sores An alternative to circumferential stockinette and cast padding is to place 2-3 layers of padding directly over wet plaster, and then apply this webril-lined splint over the area to be immobilized and secure it with an elastic bandage

Sprain

Partial or Complete Tear of a Ligament - Ligaments connect Bone to Bone

Achilles Tendon Rupture

Partial or complete Often partial -sx may not evident until 'cooled down' the next day Middle aged "athlete" (weekend warrior) 4-5 cm above calcaneus Misdiagnosed 20-30% - confused with calf muscle tear/strain Mechanism→ direct trauma to taut tendon vs. forceful dorsi flexion with ankle relaxed; Excess supination on daily basis Agonizing pain preceded by "snap" Weakness with "push off" Soft tissue gap Sudden sharp pain in calf

Greater Trochanteric Pain Syndrome (a.k.a. Trochanteric Bursitis) - pathophys

Pathophys—unclear: repetitive overload tendinopathy of the gluteus medius /minimus muscles (role in hip abduction +pelvic stabilization in walking, running, and standing) Similar to rotator cuff shoulder

Anterior release test

Patient in supine position, arm abducted 90° Examiner performs Relocation Test, then releases downward pressure Positive test = patient expresses pain or instability when the humeral head is released

Chair reduction

Patient is seated sideways in a chair with the affected arm hanging over the backrest The clinician holds the supinated forearm stationary and the patient slowly stands A 73% success rate was reported in the original description of this technique Success rate of 97%, and anesthesia was not required in 110 of 118 reductions (93%)

Fast, reliable, and safe (FARES)

Patient lies supine with the provider standing on the affected The patient holds the arm adducted, with the elbow extended and the forearm in neutral rotation. Axial traction is applied without countertraction A short-range oscillating, vertical movement is rapidly performed throughout the reduction maneuver The arm is slowly abducted At 90° of abduction, the arm is gradually externally rotated while continuing abduction and vertical oscillation Reduction typically occurs at 120° of abduction

Spaso

Patient positioned supine The provider stands adjacent to the affected arm, holding it in 90 of for- ward flexion Gentle vertical traction is applied to the arm, followed by slight external rotation The medial border of the scapula must be kept in contact with the bed to stabilize the glenoid Reduction should occur spontaneously after several minutes of traction or the humeral head may be manually pushed toward the glenoid fossa Success rates ranging from 68% to 88% have been reported

Impingement - Neer's Sign*

Patient seated with arm at side, palm down (pronated) Examiner standing Examiner stabilizes scapula and raises the arm (between flexion and abduction) Positive test = pain

Palpation of bicipital groove

Patient sitting, beginning with the arm straight Patient actively flexes biceps muscle while examiner provides supination and ER Examiner palpates the bicipital groove for pain

Labral Tear (SLAP) - O'Brien's Active Compression Test

Patient standing Arm forward flexed 90°, adducted 15° to 20° with elbow straight Full internal rotation so thumb pointing down Examiner applies downward force on arm - patient resists Patient externally rotates arm so thumb pointing up Examiner applies downward force on arm - patient resists Positive test = Pain or painful clicking elicited with thumb down and decreased or eliminated with thumb up

Hawkins test

Patient standing Examiner forward flexes shoulder to 90°, then forcibly internally rotates the arm Positive test = pain in area of superior GH joint or AC joint *The Hawkins' test is another commonly performed assessment of impingement. It is performed by forward flexing the patient's arm forward to 90 degrees while forcibly internally rotating the shoulder. The drives the greater tuberosity farther under the coracoacromial ligament, reproducing impingement pain. Pain with this maneuver suggests subacromial impingement or rotator cuff tendonitis. One study found Hawkins' test more sensitive for impingement than Neer's test.

Stimson reduction

Performed with the patient prone on the stretcher, and the affected arm hanging over the edge Downward traction is applied with weights, starting with 5 lbs Alternatively, the elbow may be flexed 90° to relax the biceps tendon, and the provider may apply manual traction with a gentle rocking motion. Reduction should occur within 15 to 20 minutes. Advantages of this method include the relative ease of reduction and avoidance of large amounts of force. Disadvantage is the difficulty providing sedation with the patient in the prone position

Pivot stress test

Pivot stress test Flexion of the knee while the lower leg is internally rotated and a valgus stress is applied Positive Test: subluxation of the tibia occurs indicating an ACL injury

Cutting a ring

Place the guard palmar aspect (less bony tissue to contend with) Apply the saw blade to the ring using the lever (large arrow) and turn the wheel of the blade using the handle (lines). Once cut through, pull apart with hemostats or cast spreader Two cuts may be necessary

Knees and imaging

Plain radiography?— Ottowa vs Pittsburgh rules CT if significant trauma and suspect fracture but plain radiography is negative or inconclusive MRI: If suspect meniscus or ligament injury Obtain only if conservative measures fail Do NOT obtain initially unless knee is unstable

Differential Diagnosis for an Immobile Arm in Children

Possible differential to consider: Fracture of the clavicle, humerus or forearm Always consider abuse as possible underlying factor in pediatric fx we may be their only advocate! Soft tissue injury Can't miss: Septic arthritis Complicated fracture or dislocation Osteomyelitis Necrotizing cellulitis Stroke Tumor

Ankle splints

Posterior Ankle Stirrup Need to get a 90 degree angle. If you don't do this, there will be a shortening of achilles. Check it. Double check it. Keep pushing it.

Assessing the Posterior Cruciate Ligament (PCL):

Posterior Drawer Test Assesses for PCL tear. The patient is positioned the same as for the anterior drawer test. Grasp the lower leg and push posteriorly on the tibia. Positive Test: A "soft" or absent end point indicates a tear in the cruciate ligament.

Elbow Dislocations

Posterior more common Present with marked swelling and joint with 45 degrees flexion Reduction with posterior stabilization of distal humerus, steady traction at wrist and elbow moved into flexion Ulnar nerve and brachial artery are common complications Radial head subluxation—see "procedures presentation - more of a ligamentous issue Ulnar nerve and brachial artery injury complications to be aware of

Procedure/Technique for splinting

Prepare the patient Don't forget the ring for upper extermeties. Even if you don't think that swelling will impact. Even if you don't think you need to...ounce of prevention! Cover patient with sheet or gown if using plaster to protect clothing Inspect skin for wounds and soft tissue injuries Clean, repair and dress wounds as usual prior to splint application

Plaster of Paris - splinting pt 2 - how many layers?

Prepare the plaster splint material Ideal length and width of plaster depends on body part to be immobilized in the splint Estimate the length by laying the dry splint next to the area to be splinted Be generous in estimating length, the ends can always be trimmed or folded back Width should be slightly greater than the diameter of the limb to be immobilized Cut or tear the splint material to the desired length Choose thickness based on body part to be immobilized, patient body habitus, and desired strength of splint Average of 8-12 layers Less layers (8-10) for upper extremities More layers (12-15) for lower extremities More layers may be needed for large patients Fill a bucket with cool water, deep enough to immerse the splint material into Using cool water decreases the chances of thermal burns, but takes longer for the splint to dry

Splinting Complications, Prevention & Management: Pressure sores

Pressure Sores Uncommon with short term splinting D/t stockinette wrinkles irregular wadding of padding, insufficient padding over bony prominences indentions in plaster form using fingers to mold splint If suspected, remove, check & revise

Complications Prevention & Management: Compartment syndrome

Prevention avoid wrapping bandages too tightly or making circumferential splints elevate the extremity to decrease swelling apply topical cold packs no weight bearing early (24-48 hour) follow-up for high-risk injuries If suspected-emergent referral

Reduction

Prior to immobilisation, reduction of a fracture can be achieved by manipulation under anaesthetic. X-rays are useful to assess the success of this procedure.

Irrigation - pros

Pros: Safe, gentle, relatively painless If pain--Stop Important water is body temperature—not hot or cold Rare pain—stop

Carpal Tunnel: Exam and Provocative Maneuvers

Provocative maneuvers: - Tinel sign - Phalen maneuver - Carpal compression test/Durkan Exam findings: - Thenar eminence atrophy—more severe - Weakness of digits innervated - Decrease in 2-point discrimination Testing: labs if suspect secondary causes (DM, TSH) - esp in women or family hx EMG/electrophysiological testing as appropriate

Fracture classification of hips

Proximal femoral fractures either involve bone which is enveloped by the ligamentous hip joint capsule (intracapsular), or involve bone below the capsule (extracapsular).

Shortening

Proximal migration of the distal fracture component results in shortening of the overall bone length. An oblique fracture is more readily shortened than a transverse fracture, which would need to be fully 'off-ended' before it can shorten.

Defer, Referral for ring removal?

Pt preference--If transient swelling expected, no evidence of vascular compromise, and pt requests that the ring not be removed This assumes pt is considered mentally competent Explain concern of vascular compromise (pallor, cyanosis, or pain) elevate, apply cool compresses. Return if the circulation does become compromised because of the possible risk of losing his finger. Be clear & DIRECT in communication! Document the patient's request and your directions. Fracture Ischemia laceration unstable pt.

Problems with PIP

Swan neck and Boutonniere Trigger finger

Management of dislocation

Radiographs should be obtained Standard three-view shoulder series to confirm diagnosis and rule out associated fractures (anteroposterior, lateral and axillary views) Reduction should be performed promptly if radiographs confirms dx and NO fracture

When to Xray?? (a.k.a. when to suspect fracture) Annular ligament displacement

Radiography is not indicated if hx and exam correspond with ALD Xray if H&P indicative of fracture risk: Hx of significant trauma including fall from substantial height Point tenderness of the structures** Swelling &/or deformity Evidence of neurovascular compromise Supracondylar fractures 2nd most common elbow injury in this age group **swelling and localized tenderness of the distal humerus Other less common fractures: Monteggia injury→ALD and ulnar fx; floating elbow, radial head &/or ulnar fx.

Avulsion injury

Range of movement at a joint is normally limited by ligaments or tendons which may withstand injury better than the bone to which they are attached. Excessive movement at a joint, may result in a bone fragment being pulled off, or 'avulsed', by a tendon or ligament.A fracture arising in this way is called an 'avulsion fracture'.

Post reduction care

Reassess neurovascular status Post-reduction film if uncertainty regarding reduction Post-reduction Splinting debate: Traditionally includes immobilization with arm in internal rotation for 3-6 weeks followed by rehabilitation More data showing early mobilization is needed to limit joint stiffness Age 20-40 yrs → immobilized 1-2 weeks Older than 60 yrs → less than 1 week of immobilization PT--Goal of rehabilitation is to regain maximum ROM while retaining stability Pain management Persistance of pain, decreased ROM or weakness 2-3 weeks after→obtain MRI (assess for possible rotator cuff injury) High incidence of recurrent dislocation → early surgical intervention may provide better outcomes

Curettes pros

Recommended if: Known or possible TM perforation or tubes Tinnitus or dizziness (irrigation may exacerbate) Less messy, faster

analgesia for shoulder reduction

Reduction can frequently be obtained without analgesia in patients with anterior dislocations that are recent (ie, less than 24 hours), recurrent, or relatively nontraumatic narcotics or Procedural sedation and analgesia (PSA)—requires monitoring reduce spasm in the muscles of the rotator cuff If patient is unable to relax because of pain → intra-articular block Wait 15-20 minutes before performing the procedure

Ring Removal w/o Cutting: Elastic tape (or string wrap) method

Reduction of edema allowing ring to be removed #1 Inflate BP cuff to 100 mm Hg #2 Tightly wrap penrose drain or tourniquet—start at tip and work proximally #3 Elevate digit high above heart 15" #4 Assess edema reduction Redo steps #2-4 prn if more edema reduction needed Maintain BP cuff inflation at 100 mm Hg throughout Do not keep on for > 2 hours

Contraindications to reduction in primary care

Refer immediately to ED for orthopedic consult if: A shoulder dislocation, other than a subcoracoid, anterior dislocation Any fracture dislocation of the shoulder Dislocations are more than a few days old (higher risk of vascular injury) Other fractures of the shoulder, neck, ribs, or upper extremity Prior orthopedic surgery for chronic or recurrent shoulder dislocations Provider with inadequate training Shoulder dislocations in children (if ossification centers are not fused, there is usually an associated Salter-Harris fracture)

Ring Tourniquet—Initial Management

Remove ring ASAP—going forward, we will assume no longer an option Elevate! Elevate! - the higher above the heart, the better Ice (while elevated) Lubricate and twist—pull skin taught Liberal use of soap and water, Windex Obtain Xray prn

Plantar fasciitis management

Rest & analgesics Arch support Added to shoes; get shoes with good arch Stretching essential, PT if needed Myofascial massage—anecdotal evidence Night splints help prevent plantar flexion in the night. Can be used alone. Injections Podiatry consult

Traumatic Wrist Injuries - Extension Fx Radius/Colles Fracture

Result from fall on an outstretched hand, Dorsal angulation of distal fracture fragment Median nerve injury can be seen 60% associated with ulnar styloid fractures Any profound angulation, intrarticular involvement should be referred to ortho

Traumatic Wrist Injuries -Flexion Fx Radius/Smith's Fracture (reverse Colles fracture)

Result from fall on fully flexed wrist Much less common than Colles Volar angulation of distal fracture fragment

Metacarpal Fractures: Clinical Presentation

Results from direct impact such as punching ("Boxer' fracture) 2nd - 5th Metacarpal 5th metacarpal most commonly injured Exam findings to look for: Tender along dorsal aspect MCP depressed Malrotation of fingers Examine hand for bites,

Rotation

Rotation of a long bone fracture may be internal or external.

Special rotator cuff tests

Rotator cuff Drop arm test

Cholesteatoma

S/S: Painless otorrhea Conductive hearing loss Dizziness -less common

Scapula fractures

Scapula fractures are relatively uncommon. Careful attention should be paid to the standard shoulder views as scapula injuries are often found when not suspected clinically.Subtle fractures are easily missed if care is not taken

Scapular manipulation reduction

Scapular manipulation is performed by internally rotating and medializing the scapula The patient is placed prone, with the arm hanging over the edge of the stretcher Once gentle traction is applied, the clinician stabilizes the superior aspect of the scapula with the thumb and applies medial force on the inferior angle of the scapula with the other thumb Reduction is often extremely subtle and may be missed Success rates ranging from 79% to 96% have been reported Major draw back is steep learning curve

Soft tissues

Scrutinising the soft tissues can often provide helpful information.Not uncommonly an abnormality of soft tissues is more obvious than a bone injury, or may even imply a bone injury that is not visible at all. The fracture in this image is on the left hand side

Bohler's angle

Severe injury may result in flattening of the calcaneus. This results in a reduction of 'Bohler's angle'.On a lateral view this angle is formed by the intersection of two lines. The first line is drawn from (1) - the upper edge of the calcaneal body posteriorly to (2) - the upper edge of the posterior articular facet of the calcaneus at the subtalar joint. From this point another line is drawn to (3) - the upper edge of the anterior process of the calcaneus.Bohler's angle is normally between 28-40 degrees.

Inspection of shoulders

Swelling, asymmetry, muscle atrophy, scars, ecchymosis and any venous distention Note posture (e.g., shoulder protraction) Deformities Squaring of shoulder - anterior dislocation Scapular "winging" - shoulder instability and serratus anterior or trapezius dysfunction Atrophy - supraspinatus or infraspinatus - consider rotator cuff tear, suprascapular nerve entrapment or neuropathy

Shoulder dislocation

Shoulder dislocation is a term often used loosely to indicate dislocation of the head of the humerus from the glenoid of the scapula.The shoulder can dislocate posteriorly, but anterior dislocation is approximately 50 times more common.Anterior dislocations are usually associated with trauma with the arm abducted and in external rotation. Posterior dislocations are associated with electric shocks and epileptic seizures.

Labral tear - crank test

Shoulder elevated to 160° in the scapular plane A gentle axial load is applied through glenohumeral joint with one hand, while other hand does IR and ER Positive test = pain, catching, or clicking in the shoulder

Shoulder Dislocation: Background

Shoulder joint has the greatest range of motion of any joint in the body Glenohumeral dislocations are quite common, most commonly dislocated joint In 90% of cases anterior shoulder dislocations affects young individuals, 21-30 y.o., many of whom are athletes Peak incidence in 2nd & 6th decades of life Men>women Classified as either atraumatic (indirect) or traumatic (direct) 96% are traumatic

Hyperpronation in Annular ligament displacement

Slightly higher success rate and less painful (Meckler and Spiro, 2008) Support the arm at the elbow, placing moderate pressure with a finger on the radial head. With the other hand, hyperpronate the distal forearm. If reduction is successful→click is sometimes felt over the radial head.

Finger shaft injuries

Some finger fractures are easy to identify, but others are more difficult to spot because of overlying bones or soft tissues.The most common metacarpal fracture is the 'boxer's' type injury.

Special bicepts tendon tests

Speed's test Biceps tendon

Finger splints - indications?

Sprains - dynamic splinting (buddy taping). Dorsal/Volar finger splints phalangeal fx Gutter splints probably better for proximal fxs

Palpation of shoulders

Sternoclavicular joint Clavicle Acromioclavicular joint Subacromial bursa Coracoid process Bicipital groove Greater tuberosity Lesser tuberosity Scapula (spinatus muscles)

Immobilisation materials

Strapping, plaster or metal wires can be used to immobilise many fractures. Following the positioning of these materials X-rays are used to assess the position of bones. Comparison should be made with the pre-treatment X-rays.Some immobilisation materials will obscure detail of bone injuries, but usually assessment of bone alignment can still be made.

Metatarsal stress fractures - def

Stress fractures of the metatarsals are common in athletically active individuals. These may not be visible on initial X-rays but follow up images show periosteal stress reaction. This has the appearance of fusiform bone expansion.

Strain

Stretching or tearing of a muscle and/or tendon Tendon=muscle to bone Can lead to full rupture or complete tear

Bursitis Locations

Subacromial Olecranon Pes Anserine Greater Trochanteric Pre-Patellar Retrocalcaneal

Lift off test

Subscapularis Lift off test - Patient rests dorsum of hand on back in lumbar area Patient attempts to push examiner's hand away In one study, the investigators noted that only a few of the patients with confirmed subscapularis ruptures actually demonstrated a positive result on the lift-off test; the remainder could not complete the test because of pain. Modified version for patients who can't put their arm behind their back - patient places hand of affected arm on abdomen and resists examiner's attempts to externally rotate arm

Supination/flexion in Annular ligament displacement

Support the arm at the elbow, placing moderate pressure with a finger on the radial head. Hold the distal forearm and gently pull, while supinating the forearm and then flexing the elbow. If reduction is successful→click is sometimes felt over the radial head

Empty can test

Supraspinatus Empty can test - Patient sitting with arms straight out, elbows locked, thumbs down, and arm at 30 degrees in scapular plane. Patient should attempt to abduct his arms against the examiner's resistance.

Ring Removal w/o Cutting: String Pull Technique

Suture or floss Work string under ring, can grasp with hemostat for grip If using 2 strings, alternate pulling each side of the ring to pulley off If using 1 string, pull gently while rotating location of string circumferentially around the ring

Greater Trochanteric Pain Syndrome (a.k.a. Trochanteric Bursitis) - symptoms

Symptoms: Non-radiating pain at the greater trochanteric region of the lateral hip Pain when lying on the affected side—can interfere w/ sleep Pain that gets worse during activities such as getting up from a deep chair or getting out of a car. Pain with walking up stairs. Focal tenderness over greater trochanter

Carpal Tunnel: Symptoms

Symptoms: intermittent, associated with certain activities (eg, driving, reading the newspaper, crocheting, computer). along median distribution though can feel like entire hand Nighttime symptoms that wake the individual, oft relieve symptoms by shaking the hand/wrist. (d/t nocturnal hyperflexion) Bilateral CTS is common, although the dominant hand is usually affected first and more severely than the other hand. Weakness/clumsiness - Loss of power in the hand (particularly for precision grips involving the thumb) usually d/t loss of sensory feedback and pain than is loss of motor power

Cerumen removal indications

TM or canal sx: Important to include in ROS Sx: Pain, dizziness, tinnitis Decreased hearing--30-40 dB Otitis externa d/t cerumen "Need to know" basis— Evaluation of fever without known etiology possible AOME Before hearing testing

Splinting Indications

Temporary immobilization decrease pain & discomfort decrease blood loss reduce the risk for fat emboli minimize the potential for further neurovascular injury associated with: - Fractures - Sprains; mild grade II or III - Reduced dislocations - Tendon lacerations - Deep lacerations across joints - Painful joints associated with inflammatory disorders(tenosynovitis)

Lisfranc injury - definition and image

The 'Lisfranc' ligament stabilises the mid-forefoot junction. Loss of alignment of the 2nd metatarsal base with the intermediate cuneiform indicates injury to this important ligament.Every post-traumatic foot X-ray must be checked for loss of alignment at the midfoot-forefoot junction (tarsometatarsal joints).

Normal shoulder joint

The 'shoulder' joint is more accurately termed the glenohumeral joint.In the context of trauma there are 2 standard views used to assess this joint. These are the - Anterior-Posterior (AP) view, and the lateral or 'Y-view'.If the patient can tolerate holding the arm in abduction, an 'axial' view is an alternative to the Y-view. AP and Y-views are the standard views in the context of trauma Anterior dislocation is much more common than posterior dislocation Anterior dislocation results in the humeral head lying anterior to the glenoid and inferior to the coracoid process

Intracapsular fracture severity - Garden classification

The Garden classification system is a traditional means of assessing severity of neck of femur fractures. The system broadly corresponds with prognosis - the more displaced, the more likely the blood supply to the femoral head is compromised. In reality the distinction between the classes can be difficult.

Xray of knees - standard views

The Horizontal Beam Lateral view allows identification of a knee joint effusion or lipohaemarthrosis (fat and blood in the joint) Tibial plateau fractures can be very subtle and lipohaemarthrosis may be the only visible sign

AC joint

The acromioclavicular joint can be assessed with standard shoulder X-rays.Loss of alignment of the inferior surfaces of the clavicle and acromion indicates disruption of the acromioclavicular ligaments at the acromioclavicular joint (ACJ).Minor ligamentous disruption may not be detectable on a plain radiograph as alignment is not lost.More severe injury can result in additional disruption of the coracoclavicular ligamen Disruption of the acromioclavicular ligaments results in loss of alignment of the clavicle and acromion inferior surfaces Additional disruption of the coracoacromial ligament results in separation of the entire scapula from the clavicle Low grade ligament injury may not be visible on a plain X-ray

Unfused apophysis

The apophysis of the 5th metatarsal base is often mistaken for a fracture. Here the normal apophysis is orientated nearly longitudinally to the bone. A fracture at this site will typically be perpendicular to the length of the bone shaft.Another clue is that the bones of an aphophysis will have a rounded and corticated edge. The edge of a fracture will be angulated with no cortication. Left is normal. Right is a fracture

Assessing for Carpal Tunnel Syndrome (CTS): Phalen's Maneuver

The backs of the hands are held together, causing forced flexion of the wrists. Hold in front of chest. Positive sign: Tingling or pain in the median nerve distribution is induced by full flexion (or full extension for reverse Phalen) of the wrists for up to 60 seconds 68%-90+% specificity>sensitivity

Clavical

The clavicle is the most proximal bone of the upper limb, and provides leverage and support for the shoulder girdle structures.

Hip X-ray anatomy - Normal Lateral

The cortex of the proximal femur is intact The Lateral view is often not so clear because those with hip pain find the positioning required difficult

Ottawa Rules --Midfoot

The foot radiograph guidelines are midfoot pain and one of the following: 1) Inability to bear weight both immediately and in the ED/clinic (four steps). 2) Bone tenderness at the navicular or the base of the fifth metatarsal.

Hand/fingers

The hand comprises the metacarpal and phalangeal bones. Fractures and dislocations are usually straightforward to identify, so long as the potentially injured bone is fully visible in 2 planes.Finger joints commonly dislocate and are susceptible to avulsion injuries.Standard views are posterior-anterior (PA), oblique and lateral. Finger injuries visible on X-ray include bone fractures, dislocations and avulsions

Subcoracoid anterior shoulder dislocation

The humeral head has been pulled out of a joint and is then held anteriorly and medially by spasm of the anterior chest wall muscles Usually occurs when an abducted, extended, and externally rotated upper extremity takes a major jolt Resulting lever forces the proximal humerus anteriorly out of the glenoid socket Usually presents to the clinician in extreme pain with a non-functional arm Loss of the normal rounded shoulder contour, with a step-off where the deltoid muscle used to be prominent

Carpal dislocation

The most common dislocations of the wrist involve the lunate.'Lunate dislocation' is a term used to describe dislocation of the lunate from the radius, usually with accompanying dislocation of the capitate from the lunate.'Peri-lunate dislocation' is a term used to describe dislocation of the capitate from the lunate.

Scapholunate ligament injury

The most commonly injured carpal ligament is the scapholunate ligament. Tearing of this ligament results in widening of the scapholunate space to greater than 2mm on an X-ray, or such that it is obviously wider than the other intercarpal spaces. This injury is best seen when the wrist is stressed in ulnar deviation.If scapholunate ligament injury is suspected then orthopaedic/hand surgeon referral is required.

Apley Grind Test

The patient is prone and the affected leg flexed to 90 degrees. Place your knee on the patient's posterior thigh to stabilize it while grabbing the foot, applying pressure on the heel, and rotating the foot in a "grinding" motion. This squeezes the menisci between the femur and the tibia. Positive Test: Pain with this maneuver is positive for a meniscal injury. Location of the pain distinguishes medial vs. lateral.

External rotation reduction

The patient is supine or seated, with the arm fully adducted and external rotation performed by a clinician Reduction should occur at 70° to 110° of external rotation This method is atraumatic and easy to perform, with reported success rates ranging from 78% to 90% and >80% of patients requiring no anesthesia

Wrist bones - Normal X-ray

The pisiform and triquetrum overlap The other carpal bones partly overlap

Hippocratic technique

The provider places a foot in the patient's axilla while applying traction to the affected arm with alternating internal and external rotation to disengage the humeral head This method is largely historical and has been abandoned because of the high rate of traction injury to the brachial plexus A less traumatic alternative is to use a folded sheet held by an assistant

Elbow dislocation - def

The radial head may dislocate from the capitulum of the humerus on its own or in combination with dislocation of the ulna from the trochlea. The latter is usually straightforward to identify, but radial head dislocations may be more subtle. The rule to remember is that the midline of the radial shaft, the radiocapitellar line, should pass through the middle of the capitulum.

Standard Wrist X-ray

The standard wrist views are Posterior-Anterior (PA) and Lateral. In certain circumstances (such as scapphoid injury) further views are helpful so that the 8 overlapping bones are more easily seen.The wrist comprises the scaphoid, lunate, triquetrum, pisiform, trapezium, trapezoid, capitate and hamate bones. The radiocarpal, distal radioulnar and carpometacarpal joints can also be considered part of the wrist.When assessing the wrist it is important to assess the bones and the joint spaces separating them.

Loss of alignment - 'displacement'

The term 'displacement' is often used as a specific term to describe loss of bone alignment along its long axis. Loss of alignment, or displacement, is usually accompanied by some degree of angulation, rotation or change in bone length.

Intra-articular fracture example - Bennett's fracture

The thumb metacarpal base intra-articular fracture is much more easily seen on the oblique image This injury is termed a 'Bennett's' type injury - as in this case there is invariably a degree of subluxation/dislocation of the metacarpal base

Traction-countertraction

The traction-countertraction method uses longitudinal traction to disengage the humeral head. The patient is placed supine. A sheet wrapped around the patient's chest and within the axilla is pulled away from the affected side by an assistant while the affected limb is pulled inferiorly and laterally at a 45° angle Slight external rotation of the humerus may aid the humeral head in clearing the anterior glenoid rim Once the humerus is disengaged, slight lateral traction on the proximal humerus may be necessary

Contraindications for Annular ligament reduction :

There are few risks or contraindications against this procedure, unless the patient's history and presentation do not fit the criteria for annular ligament displacement. If the presenting history and exam do not fit the picture for Nursemaid's Elbow, an X-ray is often useful to determine if a fracture or dislocation is present. Billing and coding: ICD-10 Nursemaid's elbow, right elbow, initial encounter S53.031A Nursemaid's elbow, left elbow, initial encounter S53.032A CPT: Closed treatment of radial head subluxation in child, nursemaid elbow, with reduction Code: 24640

Wrist joints

There are numerous joints of the wrist, named according to their relative bones. These joints should be uniform in width and similar to that of the carpometacarpal, radiocarpal, and distal radioulnar joints. The intercarpal, radiocarpal, distal radioulnar and carpometacarpal joint spaces are aligned closely and evenly

Fracture mimics

There are numerous normal anatomical features which may mimic fractures. Careful correlation of X-ray findings with clinical features are often useful to eliminate significant injury.Some fracture mimics have characteristic features. Here are some examples: unfused growth plates unfused apophysis accessory ossicles bvascular/nutrient lines harris lines

Eponymous fractures

There is great variance in understanding of the defining features of many eponymous injuries. For example, there is no common agreement on the definition of a 'Colle's fracture'.Eponyms may be useful in some settings, but if there is any doubt about the nature of an injury, then it is best to avoid using an eponymous term and describe the injury more specifically.

Bony Bankart' fracture

There is often injury to the glenoid cartilage as a result of shoulder dislocation. This is known as a 'Bankart' lesion and is not visible on X-rays. Occasionally there is visible injury to the bony glenoid - often called a 'bony Bankart' lesion.This fracture is most often seen on an X-ray taken following reduction of a glenohumeral joint dislocation.

Ankle

Three bones form the ankle joint - tibia, fibula and talus. Ankle fractures are usually bony injuries involving the distal tibia (medial malleolus) or distal fibula (lateral malleolus). Occasionally the articular surface of the talus can be injured. Ankle injury may involve bones or ligaments - or a combination of the two The talar dome surface should be carefully viewed following ankle trauma

General Exam of Musculo-tendinous unit

Three techniques to exam almost ANY muscle/tendon unit Direct palpation Tissue intersections are point of failure Active resistance Use against increasing force Passive stretch Create the opposite motion of the muscle

Angulation

To describe fracture angulation the direction of the distal bone and degree of angulation in relation to the proximal bone should be stated.Medial angulation can be termed 'varus', and lateral angulation can be termed 'valgus'.

Thompson's and Matle's Tests

To test achilles rupture The patient lies in prone, active or passively flexing the knee to 90° with both feet and ankles in a neutral position. + test: absence of plantar flexion is observed rupture → more dorsal flexion.

Unfused growth plate

To the uninitiated eye the growth plate in a young patient with an unfused skeleton can mimic a fracture.

Tendonitis: Diagnosis basics

Typically via hx and exam - can palpate tendon. If it hurts, that gives you info. Duration—oft > 3 mos (→more difficult to tx) Exam: pain with palpation of affected tendon(s) tendon loading - when you move the muscle the tendon is attached to Superficial tendinopathies (Achilles) → observable tendon thickening Imaging not typically recommended US, MRI, Xray, but can confirm

Jones fracture

Transverse, diaphyseal fracture of the proximal 5th metatarsal Linear fx that does NOT involve articular surface - there is a high incidence of non-union (up to half, whcih is why they need consult) high incidence of nonunion/delayed union (30-50%) Do not confuse with Pseudo-jones/dancers fracture ortho consult. NWB (non-wt bear) usually 6-8 weeks

Treatment of achilles ruputure

Treatment → splint vs. surgery (partial vs. complete) Rest—non-wt bearing w/ crutches or walkers. Have them crutch walk with or for you. Ice—15-20" at time - using beyond that, will reverse. Take a break for at least an hr Analgesics—tyl or nsaids Immobilize—usually posterior splint in some plantar flexion Referral to Ortho

Simpleposterolateral dislocation of elbow

Treatment: Closed Reduction Long arm splint/cast x 2 weeks Progressive ROM Protect terminal extension x 6wk Major Complication→Extension Loss

Triquetrum fracture

Triquetrum fractures are often only seen on the lateral image. Soft tissue swelling can provide an important clue to the presence of fractures such as this, or elsewhere in the wrist.

Greater Trochanteric Pain Syndrome (a.k.a. Trochanteric Bursitis) -tx

Tx: NSAIDs Intra-bursal injection of corticosteroids and anesthetics physical therapy/stretching Rest/ stop possible offending activity application of ice

How to identify an anterior subcoracoid dislocation:

Typical presentation is of a patient who has experienced a recent trauma to an extended and externally rotated arm. The humeral head will be located anteriorly and medially. The patient will have loss of normal function and contour with a "step-off" where the deltoid used to be. A hollow can be found beneath the acromion process, where the humeral head used to be.

Hand/Fingers Splints (name)

Ulnar Gutter Radial Gutter Thumb Spica Finger Splints Neutral or position of function, Hand in the "beer can" position (which may have contributed to the injury in the first place) wrist slightly extended (10-25°) with fingers flexed as shown. When immobilizing metacarpal neck fractures, the MCP joint should be flexed to 90°. Have the patient hold an ace wrap (or a beer can if available) until the splint hardens. For thumb fx, immobilize the thumb as if holding a wine glass

Normal scapholunate space - ulnar deviation view

Ulnar deviation view (wrist stressed towards the ulnar side) The normal scapholunate space (arrowheads) is similar in width to other normal intercarpal joints (arrows)

Scapholunate widening

Ulnar deviation view (wrist stressed towards the ulnar side) Widening (arrowheads) of the scapholunate distance >2 mm - the space is obviously wider than the other intercarpal spaces (arrows) This results in the 'Terry Thomas sign' - in homage to the well known British actor Widening if the scapholunate space indicates a tear injury of the scapholunate ligament

LOCAL ANESTHESIA: Pearls for reducing pain

Use a smaller needle (> 25 gauge) Inject slowly Anesthetics at body temp—can keep in warmer if available Distract!! Don't show the needle (or other scary objects) get them talking (& deep breathing)! Keep it light but honest!—it will hurt but do NOT focus on it. Pinch or vibrate near site of injection, causing an overwhelming of the nerves to the brain. A skin wheel, topical cream or 'cold freeze' at the point of needle insertion.

Elbow exam

Usually done with the shoulder exam or the wrist and hand exam Palpation Range of motion Strength testing Special Tests Resisted Flexion - C5-C6 Resisted Extension - C7-C8 Resisted Supination - C5-C6 & Lateral Epicondylitis Resisted Pronation - C6-C7 & Medial Epicondylitis

Assessing the Medial Collateral Ligament (MCL)

Valgus Stress Test The patient is supine and the knee is slightly flexed, with the thigh 30 degrees to the side of the table. Place one hand against the lateral knee and the other around the medial ankle. Push medially against the knee and pull laterally at the ankle, opening the knee joint on the medial side. Positive Test: Pain or a gap in the medial joint line is suspicious for a ligamentous laxity or a tear of the MCL.

Assessing the Lateral Collateral Ligament (LCL)

Varus Stress Test The patient is in the same position as for the Valgus Stress Test. Place one hand on the medial surface of the knee and the other around the lateral ankle. Push laterally at the knee and push medially at the ankle to open the knee joint on the lateral side. Positive Test: Pain or a gap in the lateral joint line is positive for ligamentous laxity or a tear of the LCL.

Sternoclavicular joint Dislocations

Vary from minor sprains to complete dislocation Anterior dislocations (85%) are more common Posterior dislocations may be associated with vascular or pulmonary compromise. Prompt reduction required!

Ring Cutting: Difficult-to-Cut Rings

Very thick rings, stainless steel, titanium are more challenging Usually can cut with high-speed dremel Tungsten carbide may NOT be cut with any rotary tools, even high speed Brittle→may be shattered Use of ring pincer or plier or small electric saws may be needed

Forearm/wrist splints (name)

Volar Forearm / Cockup Sugar - Tong

Full vs Partial ligament tear vs fracture??

Want to see amount of edema and ecchymosis.

Five questions for orthopedic injuries

What is the function or purpose of the structure? Is the structure normal in location, size, and appearance. How can it be made to fail or tested for abnormal function and pathology? What portion of the exam reproduces the patient's pain or other symptoms? How do the exam findings correlate with the symptoms and history?

Stress fracture

Whereas a pathological fracture can arise from a single minor trauma to an abnormal bone, a stress fracture is the result of repeated low impact trauma to a normal bone.The 'march' fracture is a common stress fracture of a metatarsal bone. This is not only seen in soldiers who march, but also as the result of other repetitive weight-bearing activities.

Harris lines

You may see thin sclerotic lines passing transversely across the shaft of long bones. Although it is important not to overlook a genuine impacted fracture, these commonly seen lines are not pathological, and are considered developmental. The harris lines can be seen at the bottom half of each image

Shoulder reduction techniques

With all techniques gain the patient's confidence by holding the arm securely, asking them to relax Tell them there will not be a sudden movements and that if any pain occurs, you will stop and let them get comfortable before starting again Positioning is more important than strength for relocation

Kocher reduction

With the patient supine or seated, the operator grasps the patient's forearm on the affected side and flexes the elbow 90 The patient adducts the affected arm and actively externally rotates to 70 to 80 until resistance is felt The provider forward flexes the arm and reduction of the humeral head occurs. This technique has a reported success rate of 81% to 100%

Scaphoid fracture - (Ulnar deviation view)

Wrist stressed towards the ulnar side Transverse fracture of the scaphoid waist

Elbow Injuries

X ray Findings - Fat Pad sign: Displacement of anterior fat pad or presence of a posterior fat pad suggests a possible fracture or dislocation of below - Anterior humeral line usually transects the capitellum in it's middle third (failure indicates distal humeral fracture) - A line drawn through the shaft of the radius will bisect the capitellum (radiocapitellar line) Failure indicates radiocapitellar dislocation

Bone injury complications

X-rays are commonly used to diagnose fracture complications visible in the bones themselves, or complications arising from treatment.Success of bone healing is affected by the location and type of injury, and is influenced by factors such as underlying bone disease and systemic illness.'Malunion' is a complication that arises if a fracture is allowed to heal in an abnormal position. Failure of bone healing following a fracture is termed 'non-union'.

Fat pad or Sail Sign

atraumatic sail sign implies intraarticular fluid of an inflammatory nature posterior fat pad is never normal and always signifies fluid in the intraarticular space. Again, in the setting of trauma, this strongly implies fracture of an articular surface

Pseudo-jones fracture

avulsion fracture of the 5th metatarsal styloid Assoc forcible inversion 90% of fx at base 5th mtatrsl Pseudojones can d/c home with hard sole shoe

Annular ligament displacement

common pediatric joint injury ages 6 months to 5 y.o. peak between 2-4 y.o. Girls>boys Left>right preferred and more anatomically correct term annular ligament displacement A.K.A. subluxation of the radial head nursemaid's elbow Typical cause--traction force applied to a pronated arm. →annular ligament to slip over the head of the radius →rest in the radial-humeral joint between the radius & capitulum →becomes entrapped.

Splinting Complications, Prevention & Management: Heat Injury

d/t drying plaster To reduce risk→use cool water to wet the splint material, keep splint thickness <12 sheets of plaster

General Exam of Musculo-tendinous unit

hree techniques to exam almost ANY muscle/tendon unit Direct palpation Tissue intersections are point of failure Active resistance Use against increasing force Passive stretch Create the opposite motion of the muscle