Ortho Objectives!!!!

Hip dislocation

*True orthopedic emergency* -Trauma MCC -Complications: avascular necrosis, sciatic nerve injury, DVT, bleeding -Posterior=MC, anterior usually 2ry to forced hip abduction —————sx—————— -Leg is flexed, adducted, and IR'd -Hip pain is SEVERE -in skeletally mature athletes, often associated w/ acetabular and femoral neck fx ———-imaging—- -Hip radiographs and MRI or CT ———-tx———— -Immediate surgical consult and surgery -CLosed reduction commonly done -After reduction, protected weight bearing on crutches x 6 wks followed by another 6 weeks of ROM and strengthening exercises. Can return to competition in 3 months, when strength and ROM normal -Surgery can be necessary if: associated fx, labral tear, loose body, or if a concentric reduction cannot be achieved in a closed fashion.

Slipped Capital Femoral Epiphysis (Slippy)

- Orthopedic Emergency! -Occurs in obese children aged 11-16 yrs. If seen in children before puberyty, suspect hormonal/systemic disorders like hypothyroidism, hypopituitarism. ^ incidence in:African american and polynesians -RF's: endocrine disorders, obesity, coxa profunda (deep acetabular socket), femoral or acetabular retroversion. -Pathophys: physis weakened during times of rapid growing and is susceptible to shearing failure either actuely 2ry to traumatic injury or insidiously d/t chornic overload. *Head of femur usually displaced medially and posteriorly relative to femoral neck*. -Classified as stable or unstable. Considered stable if child is able to bear weight, unstable if unable to bear weight. ^ risk of avascular necrosis with inability to bear weight. ———-sx———— -Pts complain of groin, thigh, or medial knee pain and often have a limp -PE= painful ROM of hip, *limited IR*, often have a limp. Obligatory ER when hip is flexed ——-imaging——— -AP and frog-leg lateral films= widening of physis and epiphyseal slippage or displacement of femoral head relative to femoral neck. -*Klein's Line*: line drawn parallel to superior border of femoral neck. Epiphysis should project superiorly to the line. Should have equal sides of ice cream on both sides of the cone. ———tx——- -Immediate non-weight bearing and referral to ortho for ORIF. PT after surgery. Return to activity progressive over months -Complications: can result in permanent hip deformity and early arthritis

Metatarsus adductus

-*MC forefoot anomaly* (1-2/1000 live births, 10-15% associated with ddh) -Reults from intrauterine molding —-Manifestations—— -Inward deviation of forefoot: -Occurs at base of 5th metatarsal -Hindfoot and ankle are NORMAL ——TX——- -Flexible deformity: responds to stretching -Rigid deformity: requires manipulation and serial casting every 1-2 weeks, orthotic to maintain

Collateral Lateral ligament injury

-*MCL= MC injured ligament in the knee*. Usually injured w/ valgus stress to partially flexed knee. Can also occur w/ a blow to lateral leg -LCL= less commonly injured. *Varus* force to knee (medial force) ——-sx———— -Difficulty walking initially, but can improve when swelling decreases -Pain along course of the ligaments. May have limited ROM d/t pain, esp during first 2 wks following injury -(+) valgus stress test for MCL (do at 30 and 0 degrees) -(+) varus stress test for LCL (do at 30 and 0 degrees) ———Grades——- 1= Pt has pain w/ varus/valgus stress test but no instability 2= patient has pain, and the knee shows instability at 30 degrees of knee flexion 3- Marked instability and not much pain. Knee often unstable at both 0 and 30 degrees ———Imaging————- -Radiographs usually nondiagnostic except avulsion injuries. -*MRI= test of choice* ———TX for MCL——— -Grade 1 and 2= Conservative. bear weight as tolerate d with full ROM. Pain control, PT to restore ROM and strength. RICE, NSAIDs -Grade 3 = long leg braces to provide stability. MCL injuries rarely need surgery ——-TX for LCL———- -Usually assocaited w/ other ligament injuries (like ACL and PCL) -Do NOT recover well with nonoperative tx and usually require urgent *surgical* repair or construction

Odontoid Fracture

-15% of all C-spine injuries, creates instabliity at C1-C2 -MC presentation=complaint of severe neck pain after stirking head in a fall or after a traumatic event. -Presence of frontal/occipital contusion in elderly should raise a concern -CT scan for better detail Types 1= Fx through upper part= conservative management 2= Fx at the base... unstable and complicated by nonunion in over 50%= surgical mgmt 3= Fx through the body= conservative mgmt

Wedge fracture

-AKA wedge fracture -Osteoporotic compression of vertebral body -Failure of anterior aspect of the body under compression/flexion force -Posterior vertebral wall remains intact -Patients complain of localized pain w/o neurological sx -Imaging: Seperate card on radiology, CT if >50% compression of vertebra -TX= usually nonsurgical: pain managment, brace immobilizatoin, observation

Multi-Direction Instability (MDI)

-Abnormal translation of the shoulder, specifically with inferior laxity in conjunctino with anterior, posterior, instability or both. -More severe

Lumbosacral sprain/strain

-Acute strain or tear of paraspinal muscles, esp after twisting/lifting injuries or violent trauma like automobile accidents or athletic injuries -Manifestations: Back spasms, loss of lordotic curve, decreased ROM, No neurological changes (no pain below knee). Can cause lateral and midline pain over musculature -Pain often reproducible on exam w/ tenderness to palpation over the region. -TX: brief (</=2 days) bed rest if in moderate pain. NSAIDs/Analgesics +/- muscle relaxers

Scoliosis

-Assymetry of the spine: usually lumbar or thoracic -Types: 1)Idiopathic (80%): 8-10 yrs old, F>M.... 2)Congenital (5-7%)- failure of vertebrae to form or segment. 3) Neuromuscular 4)Syndromic -Congenital types: 1)Wedge vertebrae: partial unilateral failure of formation 2) Hemivertebra: Complete unilateral failure of formation 3)Congenital Bar: unilateral failure of segmentation 4) Block vertebra: bilateral failure of segmentation. ————Sx———— -If curve >30 degrees: Rib cage deformity or rib hump. Assymetrical waist line -If curvature >70 degrees= decreased pulmonary function in adulthood -No pulm inovvlment typically seen w/ cobb angle <35 degrees ——PE——— -Look at apperance of rib cage and waist line -Forward bending test: can detect curvatures <30 degrees -OBservation of back in standing position: levelness of pelvis observed 1st, any leg length discrepancies are corrected (compensatory scoliosis). -Adams test= slow forward bening. Used to assess symmetry. Observe from behind (thoracic area) and in front (lumbar area) ———Radiographic imaging——— -PA and lateral spine Measure Cobb Angle: Intersection of lines: -1 parallel to superior end plate of most cephalad vertebra in curve -1 parallel to inferior end plate of most caudad vertebra in curve ———-TX————- -Curvature <20 degrees= continue monitoring with serial x-rays. Treat only if curvature progresses -Curvature 20-40 degrees= Consider bracing in skeletally immature patient -Surgical intervention (Vertical expandable prosthetic titanium ribs and eventual fusion) indications= Curvature >40-60 degrees AND progressing curvature

Malleolar fractures

-Bony tenderness, swelling, ecchymosis, deformity -Ottawa Ankle rules (when to x ray: Tenderness at tip of medial or lateral malleolus, inability to bear weight, pain at the base of the 5th metatarsal, navicular (midfoot) pain, 5th metatarsal pain) -dx: X-ray -Tibial Plafond fracture: fx of distal tibia (posterior malleolus), from impact w/ talus (axial load) interrupting ankle joint space. Fx edtends into ankle joint. Posterior tibiofibular ligament. -Bimalleolar fx= fx of lateral and medial malleolli -Trimalleolar fx= Bimalleolar fx plus fx of posterior malleolus (^ risk of complication than bimalleolar fx and require surgical stabilization) ———Weber Classification————— -Weber A: Fibular (distal) Fx below syndesmosis, tibiofibular syndesmosis intact, deltoid ligament intact, usually stable. -Weber B: Fibular fx at level of syndesmosis (joint line and above), tibiofibular syndesmosis intact or mild tear. Deltoid ligament may be intact or torn. Can be stable or unstable. -Weber C: Fibular fx above mortis. Tibiofibular syndesmosis torn w/ widening of talofibular joint. Deltoid ligament damage or medial malleolar fx. ———TX—————— -Weber A: Conservative tx -Weber B: If stable, treat it weight bearing in boot, no surgery. If it's non weight bearing or inside= surgical -Weber C= Surgical— ORIF Bimalleolar and Trimalleolr= ORIF

Trigger Finger (stenosing flexor tenosynovitis)

-Caused by disparity in the size of the flexor tendons and the surrounding retinacular pulley system. Flexor tendon catches when it attempts to glide through a relatively stenotic sheath= *inability to smoothly flex or extend finger* Mechanical impingement leading to tendon entrapment. -W>M, MC in 5th-6th decade, ^ incidence in DM, RA, or condtiions that cause systemic protein deposition like amyloidosis. Occasionally seen in kids. —————-Sx————— -Pts usually describe painless snapping, catching, or locking of one or more fingers during flexion of the affected digit(s). This often progresses to painful episodes in which the pt has difficulty spontaneously extending the affected digit(s). Pain is localized over MCP joint and radiates to palm or distal finger. -Pt may rub over the tendon in the palm or demonstrate locking phenomenon when describing the condition. -Severe cases: finger(s) become locked in flexion requiring passive manipulation which can be painful. Reluctance to fully flex and extended finger can lead to secondary PIP contracture. ———————-dx—————- -Primarily based on hx of locking or clicking during finger movement. Have pt have hands palm up and have them actively flex and extend fingers to make this happen. Locking/clicking doesn't have to occur every rep. Also will possibly see tenderness or pain at base of finger, irectly over MCP, tender nodule (thickened tendon) may be present —ddx: Dupuytren's contracture is painless and loss of extension is fixed and chronic, while this condition can be painful and this condition is dynamic and episodic. ——-Tx————- -Initial presentation: conservative tx= activitidy modification, splinting, and/or short term NSAIDs (max duration of 2-4 wks). Glucocorticoid injection may be offered to pts whose sx haven't resolved with conservative tx. -If severe sx or frequent episodes of triggering= glucocorticoid injection at initial presentation -Surgical release generally reserved for pts who have failed conservative therapy and have not improved with 1 or 2 glucocorticoid injections.

Patellofemoral pain

-Causes: abnormal patellar tracking, ligamentous hyperlaxity, msucle strength/flexibilty imbalances, altered, hip/ankle biomechanics ———sx——— -Anterior knee pain w/ bending movements (flexion) and less commonly in full extension. -Pain localized under kneecap but can sometimes be refrred to posterior knee or over medial or lateral patella -Sx may begin after a trauma or repetitive PA. When maltracking, palpable and sometimes audible crepitus can occur -Apprehsnion sign= suggests instability of patellofemoral joint and is positive when pt becomes apprehensive when patella deviated laterally -Patellar grind test: reprdocution of pain or grinding being positive for chondromalacia . ————Imaging——— -More helpful in older pts, not much in younger pts. May show lateral deviation or tilting of patella -MRI may show thinning of articular cartilage but is not clinically necessary, except prior to surgery or exclude other pathology ———-Tx—— -Conservative: Ice, anti-inflammatorys, PT, McConnell taping -Surgery rarely needed, and is considered a last resort for patellofemoral pain

Spinal Stenosis

-Causes: can be d/t OA, large disk herniation, older age -Herniation can compress neural structures or spinal artery resulting in claudication sx with ambulation -Usually occurs in older pts, aged 50+ -------SX---------- -Pain usually worsens with back extension and relieved by sitting (flexion) -Pts describe reproducible single or bilateral *leg sx* that are worse after walking several mins and relieved by sitting (*neurogenic claudicatinon*) -PE: limited extension of lumbar spine, may reproduce sx radiating down the leg. -Thorough neurovascular exam recommended ———-Dx———- -Made by MRI ------Tx--------- -Exercises (PT) -Facet joint CS injections can also reduce sx -Surgical tx= spinal decompression, nerve root decompression, spinal fusion

Achilles Tendinitis

-Chronic inflammation of achilles tendon -Calcium deposition in substance of tendon -Caused by repetitive impact activities -At higher risk for rupture -Acute tendon pain generally develops when athletes abruptly increase their training intensity. Chronic tendon pain (>3 months) may result from sustained stress, poor running mechanics, or improper footwear. ——-dx——- -Typically a clinical dx -Radiographs can be used to r/o other patholgoy -May see a *"pump bump"* (Haglund's deformity) on xray= bony bump (also seen in calcaneal bursitis) ——-Tx——— -PT -Heel lift -NSAIDs -CAM boot -Surgery

Ankylosing Spondylitis

-Chronic inflammatory disease of the joints of the axial skeleton, manifested clinically by pain and progressive stiffening of the spine -Age of onset= ~teens or early 20's; M>F, sx more prominent in men with ascending involvement of spine more likely to occur ———————-Findings——————————- -Gradual onset, intermittent bouts of back pain that may radiate to butt -*Pain worse in morning and usually stiffness lasts hours* -Pain and stiffness improve w/ activity, in contrast to back pain d/t mechanical causes and degnerative disease which improve w/ rest and worsen w/ activity -As disease progresses, sx progress in cephalad direction, and back motion becomes limited, with normal lumbar curve flattened and thoracic curve exaggerated -Chest expansion often becomes limited, entire spine can fuse -Transient (50%) or persistent PERIPHERAL arthritis (MC knees, hips, shoulders) -*Enthesopathy= hallmark of sponyloarthropathies, can manifest as: swelling of achilles tendon at insertion, plantar fascitis, or sausage swelling of finger or toe (less common)* -*Anterior uveitis in ~25%, can be presenting sx* ———————-Labs—————- -ESR^ -(-): anti-ccip and anti-rheumatoid factor -Anemia of chronic disease may be seen but is mild -*HLA-B27* found in 90% of white pts, 50% of black pts, but not specific bc it can be seen in healthy population. Most helpful if intermediate probability of disease ————-Imaging————— -Earliest Radiographic changes usually in SI joints, may be only seen on MRI in first 2 yrs of disease process -Later, erosion and sclerosis of these joints often evident on plain radiographs; sacroilitis bilateral and symmetric -Inflammation where annulus fibrosus attaches to vertebral body initially causes sclerosis= *shiny corner sign* and then characteristic *squaring* of vertebral bodies -*Bamboo spine*= late radiographic apperance of the spinal column in which vertebral bodies are fused by vertically oriented, bridging syndesmophytes. *Basically calcified tendons that we can see on radiographs* -Fusion of posterior facet joints common too -Other radiographic findings= periosteal new bone formation of iliac crest, ischial tuberosits, and calcanei, and alterations of pubc symphysis and sternomanubrial joints -Radiologic changes in peripheral joints when present, tend to be assymtric and lack demineralization and erosions seen in RA ——————ddx———————- -Think this dx if onset of LBP prior to age 30 and inflammatory qualities of LBP (morning stiffness, pain improves with activity) -RA predominantly affects small peripheral joints of hands and feet, spares SI joints and only affects C-spine -Can see bilateral sacroilitis that is almost indistinguishable from this dx in IBD —————-Tx————— -1st line= NSAIDs and PT referral -TNF inhibitors (Enteracept, adaliumanb, inflidmab, a million other mabs) if resistant to NSAIDs -Sulfasalzine sometimes helpful for the peripheral arthritis, doesn't help with spinal and SI joint disease

Scapular Fracture

-Classified by anatomic location: body, neck, spine, acromion, coracoid, or glenoid -Often associated with other injuries like: subclavian vessel injury, aortic rupture, pneumothorax, other soft tissue injuries w/ high energy trauma. -Fx of acromion and coracoid rare. Glenoid needs to be evaled closely for step off -Fx may be caused by a blow on the should or FOOOSH -Imaging: AP sapula and axillary x ray. May be supplemented by axial view of scapular body and transscapular Y view. -CT may be helpful if surgery recommended -Tx: Most are nonoperative tx. -Surgical indications (controversial): displaced intraarticular fx involving >25% of articular surface, scapualr neck fractures >40 degree angulation or 1 cm of medial translation, scapular neck fx with an associated displaced clavicle fracture, acromion fractures that cause subacromial impingement, coracoid fx that cause functional AC separation.

Tibial fx

-Closed shaft fx MC long bone fx -MOI: high energy trauma (more likely to involve complex fx and complications or low energy trauma (falls, contact sports, distance running, other endurance/repetitive impact activities -Always do a neurovascular exam (be aware of compartment syndrome) -Imaging: Radiographs -Tx:immobilization, anlagesics, iceing, elevating

Subacromial impingement syndrome

-Collection of dx's that cause mechanical inflammation in subacromial space -Causes can include: muscle strength imbalance, poor scapular control, rotator cuff tears, subacromial bursitis, bone spurs - Impt to establish pt hand dominance, job, and recreational activities (pitchers etc;... ^ likeliness as getting older) —————————-Sx———————- -Classically presents w/ 1 or more: pain w. *Overhead activities, nocturnal pain w/ sleeping on shoulder, pain on IR* (putting on jacket/bra). Pt often has rolled forward shoulder posture or head forward posture. -PE: may be possible atrophy in supra or infraspinatus fossa. +/- mild scapular winging or "dyskinesis". Palpation: can have tenderness of anterolat shoulder at edge of greater tuberosity. Pt may lack full ROM -Tests: *+Neer and +Hawkins* -ddx: numbness and pain radiation below elbow usually d/t cervical spine disease ————Imaging——————————- -The following 4 radiographic views should be ordered ( in addition to MRI): AP of scapula, AP of AC joint, Lateral scapula (Spacular Y), axillary lateral. -Rationale: AP scapula can r/o glenohumeral joint arthritis, AP acromioclavicular evals AC joint for inferior spurs, Scapula Y evals acromial shape, axillary lateral visualizes glenohumeral joint as well as for presence of os acromiale. - *MRI of shoulder = imaging of choice*:: can demonstrate full or partial thickness tears or tendonitis -US: tears can be visualized on this too, but more difficult to identify partial tears from small full thickness than MRI, so stick to MRI —————————-TX—————- -1st line= conservative: education, activity modification, PT (muscle strenghtening, scapular stabilization, postural exercisers). No strong evidence supporting ice and NSAIDs as prolonged therapy. In a Cochrane review, corticosteroid injections produced slightly better sx relief than placbo. Most respond well to conservative tx -Surgical: arthroscopic acromioplasty with coracoacromial ligament release, bursectomy, or debridement or repair of rotator cuff tears ——————When to Refer————- -Failure of conservative tx over 3 mos -Young and active pt w/ impingement d/t full thickness rotator cuff tears.

Rotator Cuff Tears

-Common cause of shoulder impingement syndrome after age 40 -Can be caused by acute injuries related to FOOSH or by pulling on shoulder -Partial= MC reasons for impingment syndrome, full= more symptomatic and may require surgical tx -MC torn tendon= supraspinatus ——————Sx———————- -Most complain w/ weakness or pain w/ overhead movement (doing hair, putting on bra/jacket). Night pain also common -Similar sx as impingement syndrome except that full-thickness tears being present: may be more obvious weakness with light resitance testing of specific rotator cuff muscles. -Weakness, atrophy and continuous pain MC seen with teras. -Can hear characteristic "bone on bone", that may be palpable or audible with large tears as the humeral head contacts acromion -+ Neer and hawkins -+: empty can (supraspinatus), + resisted ER (infraspinatus and teres minor), + lift off or belly press (Subscap) -+ drop arm test: inability to lift arm above shoulder level or hold it. Or severe pain when lowering arm after should is abducted to 90. -Subacromial lidocaine test: may help distintinguish it from tendinopathy. Normal strength with pain relief= tendinopathy. Persistent weakness seen with large tears. ————Imaging—————- -Recommended radiographs: AP scapula (glenohumeral), axillary lateral, supraspinatus outlet, AP acromioclavicular joint views -AP scapula good for visualizng tears bc degnerative changes can appera between acromion and greater tuberosity. Axillary lateral views show superior elevation of humeral head. Supraspinatus outlet views allow eval of shape of acromion. AP acromioclavicular view evals presence of AC joint arthritis, which can mimiic tears and spurs that can cause rotator cuff injuries -*MRI= best method* -MR arthrogram can show partial or small (<1cm) tears. -For pts who can't do MRI or postop artifacts limit MRI evals= US ————-TX——————- -Partial tears= may heal w/ scarring. PT. 40% progress to full thickness in 2 yrs tho. -Full thickness= Fatty infiltration can occur. Most young active pts with acute full-thickness tears should be txed w/ operative fixation. Full thickness subscap tendon tears should undergo surgical tx as untreated tears usually lead to premature OA. -PT for atraumatic degenerative tears and success can be as high as 70% ———-When to refer——— -Young and active pts w/ full thickness tears -Partial tears >50% and significant pain -Older and sedentary pts w/ full-thickness tears who haven't responded to nonoperative tx -Full-thickness subscap tears

Dislocation of Patella

-Complete dislocations almost always dislocate laterally -Reccurent dislcoaitons MC in loose jointed ppl, esp aolescent girls. Factors that affect risk for recurrence= length of patellar tendon, depth of trochlear groove, position of patella to trcholear groove. -Pain=severe -Pt will present with knee slightly flexed, and an obvious bony mass lateral to knee joint associated w/ a flate area over anterior knee -Radiographic exam confirms dx -Tx= reduction—> extend knee and place slight pressure on patella while gentle traction exerts on leg. -For 1st time dislocation initial tx after reduction= nonoperative= PT -Surgery reserved for individuals w/ reparable osteochondral injuries, loose bodies, and recurrent dislocation following appropriate nonop therapy.

Osteonecrosis (Avascular necrosis of bone)

-Complication of CS use, ETOHism, trauma, SLE, pancreatitis, gout, sickle cell disease, dysbaric syndromes, knee menisectomy, infiltrative diseases, high impact femoral neck fracture. -MC affected sites= proximal and distal femoral heads= hip and knee pain -Bilateral in 80% -Other sites= ankle, shoulder, elbow -Can see in jaw thru bisphosphonate therapy, almost always when used for treating metastatic cancer or multiple myeloma rather than osteoporosis -Sx:*Pain=MC presenting sx*. Groin pain, thigh, buttt pain. Rest pain in 2/3, night pain in 1/3. Or can be asymptomatic. -Initial radiographs= normal. MRI, CT, bone scan all more sensitive. *Crescent sign* .....*Gold standard= Non contrast MRI* -Tx= avoidance of weight bearing on the affected joint for several weeks. -Surgical deompression may help young ppl who don't have advanced disease -Without successful surgical intervention, natural hx of this disease leads to significant joint dysfunction -*THA usual outcome for all pts who are candidates for it.*

Carpal tunnel syndrome

-Compression of median nerve b/t carpal ligament and other structures in carpal tunnel -Can be inherited or aquired (through repetitive wrist activities or even systemic diseases) -Commonly seen during pregnancy and in pts with DM or RA ——-Sx————- -Pain, burning, and tingling in median nerve distribution. -Aching pain may radiate proximally into forearm and occsaionaly into shoulder and over neck/chest. -Pain exacerbated by manual activity, esp volar flexion or dosriflexion of wrist. -Intially, most bothersome during sleep. -LAte: weakness or atrophy of thenar eminence ———Clinical tests——— -+ Tinel, + Phalen, + Carpal compresion test -Carpal compression may be more sensitive than tinel and phalen. Multiple resources have Phalen>Tinel ————-Imaging/tests———— -US can show flattening of median nerve. Sensitiviy of 54-98% lol -EMG and nerve conduction tests show sensory conduction delay before motor delay ——TX——— -Can try splinting in neutral position x 3 mos. -Others: Therpeutic US, exercises, ergonomic positiong -Oral CS or NSAIDs can be tried too. -Surgery (open approach or endoscopically)can be positive outcomes if: + electrodiagnostics, at least moderate sx, high clinical probability, unsuccessful nonop tx, and sx >12 mos.

Posterior tibial tendon dysfunction

-Condition typically affects middle aged women (and Me) and is progressive ——-Hx——— -Pain on posterior-medial aspect of ankle -Pain in dorsal medial midfoot -Loss of medial longitudinal arch (Flatfoot) -Increase pain w/ weight bearing ——-PE——— -Edema -Tender over posterior tibial tendon -Pain, difficulty, or inability to perform single or double limb heel rise -Hindfoot valgus deformity -Pain w/ inversion against resistance ——-Tx——- -PT -Orthotics/bracing -Surgery

Out-Toeing

-Definition: Feet and toes point away from midline -MC etiologies= External tibial torsion, femoral retroversion, external rotation contraction of hip (2ry to intrauterine position, usually resolves by 12 mos/walking age) -Toddlers learning to walk often have a wide baed gait, can be mistaken for this dx.

In-toeing

-Definition: Feet or toes point inward toward mindline -Main etiologies= internal tibial torsion, femoral anteversion, metatarsus adductus -Examination: Observe gait, Measure Measurments: -Heel bisector line: knee flexed, ankle dorsiflexed parallel to ceiling. Line parallel from heel to toe. 2nd toe is normal -Thigh-foot angle: prone w/ knees flexed to 90, foot neutral. Angular difference b/t axis of foot and thigh. Normal is 10-15 degrees -Hip IR and ER: IR >90 degrees in femoral anteversion.

Cervical Spondylosis

-Degenerative arthritic changes in the cervical spine: vertebral discs, zygapophyseal and uncovertebral joints, and vertebral bodies. Gradually, there is bone formation in these areas= osteophyte. -Biomechanical response to disk degeneration: disk dessication (dehydration), decreased disk height, osteophyte formation, facet arthropathy (inc size and diastasis) -Compression of exiting nerve roots and/or SC with neurological dysfunction -Common in 3rd and 4th decades -Worsens w/ advancing age -+/- hx of trauma -Onset= insidious -Sx= monoradicular (dermatomal pattern), DTR's decreased, muscle weakness, variable sensory loss -

Clubfoot

-Equinovarus foot, 1:1000 incidence -Ankle plantar flexion (equinus) -Medial angulation of the hindfoot (varus)- Heel inverted and IR'ed -Adduction/supination of the forefoot (metatarsus adductus) ———PE——- -clinical diagnosis is uncomplicated -Rigid deromity- cannot be passively corrected ——-Types——— 1) Idiopathic: hereditary 2)Neurogenic 3) Assocaited w/ syndromes (examine carefully for anomalies) ——Imaging—— -Often picked up on prenatal US -X rays of little value unless dx is made late. Used if surgical intervention being considered or if child has reached walking age. Can quantify the completeness of correction after surgical tx or casting ——-Tx———- -Should begin at birth, always required -Manipulation and serial casting: stretched contracted muscles. Cast weekly x 6-8 wks. Ponseti technique (independent ambulation only 2 mos later than those w/o deformity) -Rigid or refractory club foot: achilles tenotomy and corrective surgery. Post op casting and PT

Leg length Discrepancy

-Etiologies: Multiple (various reasons): developmental dislocation of hip, abduction contracture of hip, congenital limb deficiencies, acquired causes (infection, inflammatory conditions, trauma) —-Asessment——- -Infants: best assessed supine -Older children: best assessed in standing position (standing on blocks to level the pelvis provides very accurate measurment) -Confirmatory: long standing x-rays. Provides both an estimate of the difference in length as well as potential etiology. ——-tx——- -depends upon etiology, severiety, amount of growth potential remaining -Most adults tolerate up to 2cm difference w/o major difficulty -2-5cm: longer limb slowed to allower shorter to catch up ->5cm: limb lengthening or prosthetic fitting.

Kyphosis

-Excessive convex curvature of the thoracic spine that tends to progress w/ age and can lead to complications like diminished resp function and frequent falls, if not corrective -Present with excessive rounding of the back= Hunchback apperance, heads forward. Pt may complain of back pain and stiffness. -Morbidities associated w/ this:= impaired resp function w/ restrictive respirations, poor physical funciton, frequent falls= ^ fx risk -Dx made by clinical exam as well as imaging to measure extent of spinal curvature -TX= sx management, rehab to train the muscles, and surgial realignment

Calcaneovalgus foot

-Extreme dorsiflexion of ankle joint: dorsum of foot near anterior tibia -Result of intrauterine molding. 0.4-1/1000 live births -Associated with posteromedial bowing of tibia -Manifestations: Extreme dorsiflexion. *Bottom of foot is flat* (NOT rocker bottom) -TX: passive exercises (plantarflexion stretching), rarely: plaster cast. Resolves w/in 3-6 mos.

Types of hip fx further info

-Femoral neck= MC in elderly, little brusing, ^^ risk of avascular necrosis. Painful, esp in hip/groin, may not be able to walk. Stress fx seen here in running athletes, often present with groin pain and pain during IR/ER. Pain with hopping on affected leg= universally present. Surgery if superior fx of neck, conservative if inferior fx of neck. -Intertrochanteric fx= extracapsular= lower risk of avascular issues. May occur d/t fall in elderly or major trauma in younger ppl. Pain, swelling, echhymosis. Shortened and ER leg if displaced. Significant ecchymosis. Tenderness over trochanteric area, but should not have tenderness over femoral shaft or pelvis. -Subcapital tx= Hemiarthroplasty if displaced, Parallel screw fixation if non-displaced

Spondylolisthesis

-Forward/Posterior displacement of cranial vertebrae on adjacent caudal vertebrae. Bilateral pars intercularis injury -Less common than spondylolysis -Caused by defect/stress fx of pars interarticularis -Need wt-bearing/dynamic xrays to fully appreciate degree of subluxation -Can lead to: mechanical low back pain, nerve root irritation, lower extremity radiculopathy, spinal stenosis with neurogenic claudication, cauda equina syndrome (rare) -MC 10-15 y -Sx:*Pain during lumbar extension*. Typically present w/: hyperlordosis, kyphosis, pain w/ hyperextension, and in severe cases, palpable step off. -Standing lateral radiograph used to make d, graded based on % of slippage: grade 1 (0-24%), grade 2(25-49%), grade 3 (50-74%), grade 4 (75-100%) -Complications: May cause bowel or bladder dysfunction -TX: low grade: sx relief, activity restriction, PT, bracing -TX: high grade: surgical (can't return to activities for at least 1 year and may not be able to return to previous sporting activities)

Galeazzi Fracture

-Fracture of distal 1/3 of radius -Dislocation of distal radioulnar joint -MOI: FOOSH -Sx: Fracture/deformity at radial side of wrist. Ulnar head will appear prominent at wrist (bc it is dorsaly displaced) -Neurovascular exam: anterior interosseous nerve susceptible. Damage will be lost or weakness of pinch action -Imaging: x-ray -Child tx: Closed reduciton, ORIF if unstable -Adult tx: *ORIF*... long arm splint; sugar tong splint temporarily

Monteggia fracture

-Fracture of proximal 1/3 of ulna -Dislocation of proximal radial head -MOI: FOOSH, direct blow to forearm -Manifestations: elbow pain, thumb paresthesias. Dislocated radial head can damage the radial nerve (posterior interosseous nerve according to Shaun)—> radial nerve injury= May develop *wrist drop* -Imaging: X-ray -Child tx: closed reduction -Adult tx: ORIF

Femoral retroversion

-Hip ER>IR -> in obese kiddos - On exam: hip ER almost 90 degrees

Legg-Clave-Perthes disease

-Idiopathic avascular necrosis of the femoral head in children d/t ischemia of capital femoral epiphysis in children -*MC in children 4-8*, M4x>F, low incidence in blacks ———-sx———— -Persistent pain= MC sx (according to current) -Patient may present with limp and limited ROM (loss of abduction and IR) -May have intermittent thigh, knee, groin pain -Another presentation (according to Pance prep pearls): painless limping x weeks (worsen w/ continued activity especially at end of day) —————Imaging———- -Early findings= effusion of joint associated w/ slight widening of joint space and periarticular swelling. Decreased bone density. Necrotic ossification center apperas denser than the surrounding viable structures, and femoral head is collapsed and narrowed. -Further progression: alternating areas of rarefaction and relative density= fragmentation of epiphysis -Late: Deformity, *crescent sign (microfractures w/ collapse of bone)* ——-dx——- -Transient synovitis of hip may be ddxed from this condition by serial radiographs ——-tx———- -Protection of joint by minimizing impact= principal tx -If joint deeply seated w/in acetabulum and normal joint ROM maintained, a reasonably good hip can result -Little benefit seen from bracing -Surgical tx controversial.

Femoral anteversion

-In-toeing age 3-6 yrs -Patella also points toward midline -Hip IR>ER -Child may sit in W position ——-Tx—— -Usually resolves w/ growth -Encourage ER exercises -Surgery(osteotomy) is rare, only if persistent and painful

Internal tibial torsion

-In-toeing under 3 yerars old -IR of tibia (normal tibial rotation is 20 degrees at birth, decreases to neutral at 16 mos of age) -Accentuated by laxity of knee -Self limited

Hill-Sachs lesions

-Indented compression fractures at posterior-superior part of the humeral head associated w/ anterior shoulder dislocation. -Seen when back of humeral head strikes against the front of the glenoid, creating that indentation fracture. Makes it easier for shoulder to dislocate.

Infectious tenosynovitis

-Inflammation of a tendon and it's synovial sheath. Occurs /MC in wrist and hands. -Infection can spread to adjacent areas, and eventually result in compartment syndrom and tissue necrosis. -3 mechanisms of infection: trauma w/ direct inoculation (laceration, puncture, bit), continguous spread from adjacent soft tissues, hematological ——————-sx————- -If in finger area: *Kanavel signs (FLEX): 1)Finger held in flexion, 2)Length of tendon sheath is tender, 3) Enlarged finger (fusiform swelling), 4) Xtension of the finger causes pain (pain with PASSIVE extension)* -+/- fever -Infections of extensor tendon sheaths unusual, d/t lacking retinacular structures. ——————-Dx————— -Dx usually suspected on clinical grounds, confirmed by microbio and histo eval -Aspiration and/or biopsy are required for both diagnostic and therapeutic purposes -Radiographs usually normal, but are useful to r/o bony involvement or presence of foreign body. -US and MRI may also be useful to confirm tendon sheath abnormalities and for perop eval to localize extent of infection -Blood cultures if pyogenic and sysemic sx -TB skin test or interferon-gamma release assay if suspected M. Tuberculosis infection ———————TX————- -Surgical intervention and abx therapy -Surgery- debridement -Abx- pending definitive dx, start with empiric IV abx (Vanco+ Cipro OR Ceftriaxone in place of cipro)

Olecranon bursitis

-Inflammation of the bursa overa a bony prominence. May be 2ry to trauma, infection, or arthric conditions. Other common site aside from this one= prepatellar bursa. This condition can become septic -Sx: Abrupt *goose-egg* swelling, painful acutely. May affect joint motion (flexion). -Tenderness, erythem and warmth, cellulitis, a report or trauma, or evidence of skin lesion MC sign of septic, but can be seen in aspetic. 1/3 w/ septic condition are afebrile ——————-Imaging——————- -Often unnecessary unless concern for osteomyelitis, trauma, orunderlying pathology. ——————-Special tests———— -Acute swelling and redness at a bursal site calls for aspiration to r/o infection esp if pt is either febrile or has prebursal warmth (temp dif >2.2 celsicus lol). *Bursal fluid >1000/mcL indicates inflammation from infection, RA, or gout.* Bursal fluid from septic condition usually has: purulent aspirate, fluid:serum glucose ration <50%, White count >3000 cells/mcL, PMN's >50%, + gram stain for bacteria.* -MC bacteria= Staph Aureus —————-TX———————- -Trauma case= local, heat, rest, NSAIDs, local steroid injection, elbow padding -Septic= I&D and abx (usually IV) -Chronic stable: usually doesn't need aspiration. -

Gamekeeper's thumb

-Injury to ulnar collateral ligament from forced abduction of the thumb MCP joint -Usually this is an tear or avulsion at the insertion site of the proximal phalanx -Common during skiing injury to those who fall while holding onto their ski poles -Classical presentation: I fell on my hand and now I can't hold a coffee cup -Sx: pts complain of pain over medial aspect of the MCP joint and pain with apposition or pinching. May have some swelling or brusing over the thenar eminence -If radiograph shows avulsed fragment <2mm= thumb spica cast -If no fragment, <35 degrees of lateral joint space opening, or >15 degrees difference in joint space compared to uninjured thumb= spica cast 4-6 weeks -Surgery in more severe cases

Lateral Epicondylitis (tennis elbow)

-Involves the wrist extensors, esp extensor carpi radialis brevis. Usually caused by lifting with wrist and the elbow extended -ddx: ulnar neuropathy, cervical radiculopathy -Sx: pt describes pain with arm and wrist extended (shaking hands, lifting objects, using a computer mouse, hitting a backhand in tennis). -PE: tenderness to palpation over lateral epicondyle. Can reproduce pain with resisted wrist extension and 3rd digit extension. Check ulnar nerve and do Spurling test for cervical radiculopathy -Imaging: Radiographs often normal, small traction spur (enthesopathy) may be present in chronic cases. Often not needed unless pt does not improve after 3 mos of conservative tx. At that point, a pt who demonstrates significant disabiliity should be assesed w/ US or MRI -Tx: Conservative: Activity modification, Ice, NSAIDs, Mainstay= PT exercises (stretching, strengthening), brace may help but no evidence supporting use. PRP injections 2nd line after PT -When to refer: Not responding to 6 mos of conservative tx- refer for injection, surgical debridement, or tendon repair.

Medial epicondylitis (Golfer's elbow)

-Involves the wrist flexors (MC pronator teres tendon) -ddx: ulnar neuropathy, cervical radiculopathy -sx:pain during motions which arm is repetitively pronated or the wrist is flexed. -PE: tenderness over the medial epicondyle present, esp over the posterior aspect where the tendon insertion occurs. Pain can be reproduced by doing resisted wrist pronation and wrist flexion. Pain can also be reproduced with passive stretching of affected muscle gropus. -Clinical tests: check ulnar nerve (posteromedial elbow) for tenderness, and peform Spurling test for cervical radiculopathy -Imaging: Radiographs often normal, small traction spur (enthesopathy) may be present in chronic cases. Often not needed unless pt does not improve after 3 mos of conservative tx. At that point, a pt who demonstrates significant disabiliity should be assesed w/ US or MRI -Tx: Conservative: Activity modification, Ice, NSAIDs, Mainstay= PT exercises (stretching, strengthening), brace may help but no evidence supporting use. PRP injections 2nd line after PT -When to refer: Not responding to 6 mos of conservative tx- refer for injection, surgical debridement, or tendon repair.

Hallux Valgus (Bunion)

-Lateral deviation of the hallux; medial deviation of the metatarsal head -F>M -Etiology unsure. Result of genetics, anatomy, shoe wear (poorly fitted shoes MC), other (RA)? ——Hx———- -Pain w/ activity -Pain w/ shoe wear -Loss of balance -Medial eminence pain w/ 1st metatarsal lateral deviation (remember the metatarsal head will be medially deviated tho) ——PE——- -Medial tenderness -Thicken bursas -Callus formation ——-TX—— -Wide shoes -Toe spacers -Night splint -Surgery: if no response to conservative tx

Lisfranc Injury

-Leveon Bell had this injury a while back, fun fact -Lisfranc joint= bases of the 1st 3 metatarsal heads and their respective cuneiforms -Injury= disruption b/t articulation of the medial cuneiform and the base of the 2nd metatarsal -MOI: varied; rotational (midfoot), severe axial load ———SX——- -Pain and swelling of the midfoot and refusal to bear weight or stand on their toes following acute trauma -Plantar ecchymosis is highly suggestive of TMT joint complex injury but may be absent -Do neurovascular test ——Dx—— -MC variant is one metatarsal away from other toes -Radiography -Fleck sing= fx at the base of the 2nd metatarsal= pathognomic for disruption of tarsometatarsal ligaments. May be associated w/ multiple fx of metatarsals —-tX- -ORIF followed by non weight bearing casts x 12 wks -Older ppl/nonathletes can do noop tx: around 4 mos recovery. Normally takes 6-9 mos to get back to sport Even with proper tx, some pts unable to resume prior level of activity.

Cauda Equina Syndrome

-Loss of functions of 2+ of the 18 cauda equina nerve roots -Caused by any narrowing of SC resulting in compression, such as: lumbar stenosis, spinal trauma/hemorrhage, herniated nucleous pulposus, neoplasm, spinal infection/abscess, idiopathic (spinal anesthesia), spina bifida and subsequent tethered cord syndrome -------------Sx------------ Combo of any of following depending on nerve roots affected: -LBP, often w/ pain radiating to 1 or both legs -Weakness of plantar fexion -Decreased LE reflexes -Bladder and rectal sphincter paralysis (associated urinary incontinence is *OVERFLOW incontinence*) -Sensory loss or changes ------------Dx--------- -*Non-contrast MRI Lumbar Spine* -Labs: CBC, CMP, lactic acid (infectious), UA, type and screen (pre-op), PT/INR (pre-op) -----------Tx-------- -*Neurosurgical emergency* -Dexamethasone IV (controversial, discuss with nuerosurgery) -Pain control -Definitive tx= surgical decompression. Prognosis: Even w/ surgical decompression, steroids, pts may not regain lost function/sensation ------Note-------------- Any pt who presents w/ LBP must have following addressed in hx: fever/chills, hx trauma, hx malignancy, bowel/bladder dysfunction, dysuria/urinary frequency, saddle paresthesias, foot drop, gait distrubance, LE weakness, LE paresthesias -Any pt who presents with LBP must have following completed on PE: VS, abdominal exam, back exam, LE strength, reflexes, sensation gait. If any abnormality found on exam, a rectal exam is needed to assess sphincter tone/ sensation.

Pes Planus

-Loss of the longitudinal arch of the foot. -Normal in infants (normal arch develops if heel cord length intact) -^ in obese males w/ joint laxity -Most related to ligamentous laxity ——-ddx——- If rigid or short heel cord, consider other causes: -Neurologic disorder -Tarsal Coalition= fusion of tarsal bones ——-Tx—— -Time and growth improve appearance -If pain persists, supportive shoe or orthotics can be used.

Adhesive Capsulitis (Frozen Shoulder)

-MC 40-65, F>M (esp perimenopausal), ^ incidence after breast cancer care) -Self limiting but very debilitating ————-sx———————— -Very painful shoulder triggered by minimal or no trauma -Limited ROM both PASSIVELY and ACTIVELY -Limitation of ER with elbow by side of trunk -Strength usually normal, but can be diminished when patient is in pain 3 phases= inflammatory, freezing, thawing -Inflammatory: 4-6 mos duration, painful shoulder out of proportion to clinical findings. -Freezing: 4-6 mos duration, shoulder becomes stiffer even though pain is improving -Thawing: Can take up to a year, shoulder regains motion. Total duration= ~24 mos; can be ^^ for pts w/ trauma or endocrinopathy ————-imaging——————— -Standard AP, axillary, and lateral glenohumeral radiographs to r/o Glenohumeral (GH) arthritis- since it can also present w/ limited active and passive ROM -Can also r/o calcific tendinitis. -Usually a clinical dx, don't need extensive diagnostics —————-tx—————— -During freezing phase: NSAIDs and PT. +/-: intra-articular CS injection or oral prednisone. PT critical. -Thawing phase: NSAID's not as helpful but do your thang -Surgical tx, rarely indicated, include: mainuplation under anesthesia and arthroscopic release ————When to refer——— -When pt doesn't respond after >6 mos of conservative tx -When no progress or worsening ROM over 3 mos

Patella Fracture

-MC d/t direct blow (fall on a flexed knee, +/- forceful quad contraction) -MC in young patients -Manifestations: Pain, swelling deformity. Limited knee extension with pain -Dx: *Sunrise view radiographs= best view* -Tx: Nondisplaced: knee immobilizer, leg cast x 6 wks. Displaced: surgery

Scaphoid fracture

-MC fractured carpal bone -Complication: Avascular necrosis: esp as you go more proximal -*These have a high rate of nonunion if unnoticed, particuarly in fx of proximal pole d/t poor blood supply* -MOI: MC FOOSH Pt commonly presents d/t: -Pain after a fall on an outstretched hand -Pain with use of the thumb —Labs, Studies and Physical Exam Findings— -*Pain with palpation of the anatomical snuffbox* -May be missed on x-ray (may appera normal). -Despite normal radiographs, if evidence of snuffbox tenderness and swelling is present, if there is tenderness along volar aspect of scaphoid, or there is pain w/ radial deviation or active wrist ROM; wrist must be further evaled by MRI acutely or immobilized x 10 days then reassesed both clinically or with radiographs -MRI ————————————— Treatment -Nondisplaced: at least 6 wks in thumb spica cast -Displaced: Operative mangement

Ganglion Cyst

-MC soft tissue tumor of the hand -Cystic structures which arise from torn or degenerated joint capsule or tendon synovial sheath -MC locations= wrist dorsum, volar radial wrist, base of the finger at proximal annular ligament of the flexor tendon sheath. -*MC d/t ^^ in repetitive activity* -Usually more painful and more prominent with fleor or grasping activity. Can be intermittent. On PE: nonpulsatile, mildly tender mass. No erythema or edema. Transilluminates when penlight placed next to it. Percussion of mass does not produce distal paresthesias. -Radiographs should be obtained to r/o bony pathology -TX= immoboilization with orthoses, aspiration, or surgical excision -Do not aspirate if on volar radial wrist, as its proximity to radial artery makes aspiration risky

Colle's Fracture

-MC wrist injury -Results from FOOSH -Presentation: Swollen, ecchymotic, tender wrist. Can look deformed. -Ipsilateral lateral elbow and shoulder should be evaled for concomitant injury. -Ulnar styloid may be fractured -Neurovascular exam: motor and sensory of median, ulnar, radial nerve. (Motor= a-ok, finger spread, thumbs up sign) (Sensory= volar aspect of thumb, index, middle fingers, volar aspect of small finger, dorsal aspect of thumb.). -Carpal tunnel common complication d/t traction injury, fracture fragment truama, hematoma, or ^ compartment pressure. Can also damage Exensor Pollicis longus (EPL). -Xray: *Silver fork or dinner fork deformity*. Dorsal angulation of the plane of distal radius. Distal radius fragment displaced proximally and dorsally. . -TX: splint/cast if not displace.d Ok to try closed reduction +/- ehmatoma block. Immobilize for 12 weeks -If displaced= ORIF

Shoulder dislocation and instability

-MC= anterior -Usually d/t fall on outstretched or abducted arm. Can also hear of this happening with basketball players trying to block someone or volleyball players spiking/blocking. -*Pts complain of pain and feeling of instability when arm is abducted and ER.* -Posterior dislocations: usually d/t falls from a height, epileptic seizures, or electric shocks -Traumatic shoulder dislocation can lead to instability -Pts 21 or younger: 70-90% risk of redislocation; pts 40+: 20-30% -90% of young active ppl w/ traumatic dislocaiton have Bankart lesions (anterior inferior labrum torn), which an lead to continued instability -Older pts more likely to have rotator cuff tears or fractures after dislocaiton -Also seen in swimmers, gymnasts, pitches, other overhead atheltes —————————————-Sx—————————- -Acute traumatic dislocations: obvious deformity with humeral head dislocated anteriorly. *Squared off shoulder* -Pt holds shoulder and arm in ER position. Complains of acute pain and deformity improved with manual relocation of shoulder -Even after reduction, can have decreased ROM for 4-6 wks especially after 1st time dislocation -Posterior:easy to miss d/t pts typically holding shoulder/arm in IR. Pts often complain of difficulty pushing open a door. -Atraumatic shoulder instability: usually well tolerated w/ ADL's. Pts may complain of "sliding" sensation during exercises or strenuous activities. -*Sulcus Sign*= posterior shoulder has void beneath acromion —————————-Diagnostics——————— -Clinical tests: Apprehension tests, load and shift test, O'Brien Test Imaging: -AP and axillarly lateral scapula views to r/o fractures -Orthogonal views to ID posterior dislocation (easy to miss with 1 AP view of shoulder) -Scapual Y view in acute setting insufficient to dx -For chronic injuries or symptomatic instabiltiy, the imaging mentioned above should be sufficient to dx bony injuries and Hill-Sachs lesions -MRI commonly used to show soft tissue injuries to labrum and vizualize possible rotator cuff tears -Traumatic incident and unilateral dislocation: bankert lesion usually present ————————-TX————————— -Acute dislocations:Reduce shoulder ASAP. Stimson method least traumatic and quite effective. Then immobile in sling for 4-6 wks if <30, and >30 years start motion. along with pendulum exercises. Early Pt and activity modification. A younger person you hold them down longer. Older ppl move right away -Operative intervnetion only tx shown to decrease recurrent dislocations (may be impt to consider in pts at risk for 2nd dislocation like: young pts, job holders like cops, firefighters, rock climbers; or ppl not responding to conservative tx may need surgical referall too) -TUBS: Traumatic, Unilateral, Bankart, Surgery -Atrumatic shoulder instability:PT and regular maintence prgoram consisting of scapular stabalization and rotator cuff strengthening exerciseds. Surgery less successful than traumatic dislocations.

Midshaft femur fx

-MCC by high energy trauma in young adults and in older pts d/t low energy falls. -Dx based on MOI, prescence of pain, swelling, and deformity. Extensive soft tissue injury and bleeding common. -AP and lateral x ray of thigh. Femoral neck fracture may be seen too. -Tx= ortho consult, surgery (get a rod)If open fx= antibiotics and teanus prophylaxis. Everyone get anlagesia -Reduce limb after analgesia if neurovascular compromise seen.

Low Back Pain

-MCC of disability in pts <45, 2nd MCC for primary care visits. Multifactorial -Alarm sx (cancer) w onset of LBP: unexplained wt loss, failure to improve w/ tx, pain >6 wks, *pain at night (wakes you up)* or at rest, hx of cancer, age >50, may have tenderness on PE -Alarm sx (infection): fever, rest pain, recent infection (UTI, cellulitis, pneumonia), or hx of immunocompromise or injection drug use -Alarm sx (cauda equina): urinary retnetion or incontinence, saddle anesthesia, decreased sphincter tone, bilateral LE weakness, progressive neuro deficits -RF's for back pain d/t vertebral fx: age >70, use of CS, hx of osteoporosis, severe trauma, presence of contusion or abrasions -Other serious medical problems associated w/ LBP: AAA, PUD, kidney stones, pancreatitis. -Red flags for peristent LBP: Fever, wt loss, intractable pain (no improvment in 4-6 wks), nocturnal pain or ^ pain severity, monring back stiffness w/ pain onset before age 40, neuro dficits, bowel/bladder incontinence -------Findings------------ -Examine for spinal asymmetries. -Any pt who presents w/ LBP must have following addressed in hx: fever/chills, hx trauma, hx malignancy, bowel/bladder dysfunction, dysuria/urinary frequency, saddle paresthesias, foot drop, gait distrubance, LE weakness, LE paresthesias -Any pt who presents with LBP must have following completed on PE: VS, abdominal exam, back exam, LE strength, reflexes, sensation gait. If any abnormality found on exam, a rectal exam is needed to assess sphincter tone/ sensation. -Flexion, extension, rotation, lateral bending -One leg standing extension test + if pars interarticulars fx or facet joint arthritis -Muscle strength testing, reflexes -Supine ROM, esp IR. SLR test puts traction and compression forces on the lower lumbar nerve roots -Prone position: palpate for tenderness. -Rectal exam if Cauda equina syndrome expected -How to dx IBD back disease: 5 ?'s (4 out of 5 yes= high sensitivity and specificity): 1) Insidious onset? 2) Duration > 3 mo? 3) Sx began before age 40?, 4) Morning stiffness >1 hr?, 5) Activity improves sx? -Schobers test one of best for spinal mobility -Pseudoclaudication= back pain worse when walking or standing. ---------Imaging--------- -No imaging unless Red flags -Acute LBP radiograph criteria (2): 1)Possible fx: major trauma, minor trauma in pts >50, long term CS use, Osteoporosis, >70 yrs 2)Possible tumor or infection: >50 y.o., <20 y.o., hx of cancer, constitutional sx, recent bacterial infection, injection drug use, immunosuppression, supine pain, nocturnal pain - Most clinician obtain radiographs for new back pain in pts >50 yrs. AP and lateral views -MRI= method of choice in eval of sx not responding to conservative tx or in presence of red flags of serious conditions --------Special tests------ -EMG or nerve conduction stadies may help w/ posssible nerve root sx >6 wks,. Usually not necessary if dx of radiculopathy is clear --------TX-------- -Conservative: *Education*, PT, manipulation, TENS, ergonomics, activity modification. NSAID's effective in early tx. Opioids, muscle, relaxants, gabapentin, epidurals may also help. -Surgical indications= cauda equina syndrome, ongoing morbidity with no response to >6 mos of conservative tx, cancer, infection, or severe spinal deformity. -We treat recurrent the same way we do acute. Just make sure to r/o red flags each time. W/ each recurrence, make sure to be more and more vigilent of potential neurological disease.

Plantar Fasciitis

-MOI: Inflammation of the plantar fascia (aponeurosis) d/t overuse (esp in pts w/ flat feet or a heel spur) ——Hx—- -Plantar heel pain -Pain 1st step in the AM -Pain first step after sitting for a time -Pain usually decreases throughout the day -Repetitive impact activities (runners)) ——PE—— -Tender at plantar medial aspect of heel -Tender over medial or lateral plantar foot border -Tight heel cords; decreased dorsiflexion —-Dx—— Radiographs may show a flat foot deformity or heel spur —-Tx—— -STretching -NSAIDs -Soft arch supports -Avoid barefoot -Night splint -Cortisone injections (caution in that it may cause fascia rupture) -Surgery(in severe cases)= Plantar fascia release.

Ankle sprains

-MOI: Inversions (lateral ligaments MC injurued), eversions damage deltoid ligament (complex), or rotation -Lateral: ATFL MC, CFL 2nd MC -Deltoid complex: connects medial malleolus to calcaneus, talus, and other bones. Isolated injury rare. Injured along w/ other injuries (fibula fx) results in an unstable ankle fx -Syndesmotic ligaments: hold tibia and fibula together (injured in *high ankle sprains* -Hx: hear a pop, occured when running, jumping, cutting, may not be able to bear wt, pain w/ walking, may complain of instability (chronic) -PE: mild-severe swelling, ecchymosis, pain inferior to lateral malleolus, tender over ligaments -Special test: + anterior tilt or (+) talar tilt ——-Severity——————- -Grade 1: partial tear of ATFL (MC). Mild-moderate. Some laxity on anterior drawer. Stable talar tilt (CFL intact) -Grade 2: Complete ATFL tear + partial tear of CFL. Substantial difficulty with weight-bearing. Definite laxity on anterior drawer (ATFL torn). Some laxity with talar tilt (CFL stretched) -Grade 3: *Complete Tear* of the ATFL and CFL, +/- PTFL. Significant edema. Cannot bear weight in acute setting. Very lax ankle w/ *(+) Anterior drawer AND Talar Tilt* ———Ottawa Ankle rules———— X-Ray if any of these are positive: -Tenderness at tip of medial or lateral malleolus, -inability to bear weight - pain at the base of the 5th metatarsal -navicular (midfoot) pain -5th metatarsal pain) ———Tx——- -RICE -NSAIDs -PT -Crutches -CAM boot or ASO

Stress fractures of leg

-MOI: Repetitive trauma -Definition: Microfracture of bone -SX: same as shin splints, may be able to pinpoint pain. (Leg pain w/ activity, Decrease pain w/ rest, Described as dull ache,May have edema and ecchymosis ——-Tests——— -X ray (may see new bone deposit, thickening of bone) -Bone scan or MRI ——-Common Areas—— -Lower 1/3 of tibia -Supramalleolr region of fibula -Calcaneus -Metatarsals ———TX———- -Rest -No impact activities x 4-6 wks -Crutches -Ice ——Complications—— -^ risk of complete fx -If multiple stress fx- consider bone density exam to r/o osteoporosis or other rheumatologic disorder

Tibial Plateau Fracture

-MOI: axial loading/rotation/direct trauma (MC in children in MVA). Lateral plateau MC -Complications= post degenerative arthritis (>50%), loss of joint congruity. Commonly associated with LATERAL MENISCUS TEAR -Type 4 fx= bad, associated with vascular injury. -ACL injuries common in type 4 and 5 fx ———Manifestations———- -Pain, swelling, hematrthoris -IF displaced, check for peroneal nerve injury= foot drop -May be hard to see on radiographs, may need to confirm w/ CT or MRI ——-TX———- -Nondisplaced: conservative tx: initial splinting (in full extension); non weight bearing cast x6-8 wks, anlagesia -Displaced: orif Knee replacement pretty much inevitable in most down the road (as mentioned in complications, degnerative arthritis occurs)

Morton's Neuroma

-MOI: degeneration/proliferation of the plantar digital nerve= painful mass near the tarsal heads. MC in women 25-50 y.o. Especially if they wear tight shoes/high heels/flat feet. -Neuroma at bifurcation of the plantar digital nerve ——-Sx———- -Seen in 2nd and 3rd web spaces MC (3rd metatarsal head) -Sx: burning, tingling, pain -Lancinatiaating pain especially w/ ambulation. Reproducible pain on palpation +/- palpable mass -May be associated with numbness/paresthesias of the toes -SX often relieved w/ going bare foot ——-dx——- -MRI may be needed for dx -Cortisone can be used diagnostically and therapeutically. ——-Tx——- -Metatarsal bars -Wide shoes -*Cortisone (diagnostic and therapeutic)* -Surgery

Patellar and Quadriceps Tendon ruptures

-MOI: forceful quad contraction (fall on flexed knee, walking up/down stairs) -MOI in nonathletes: person falls backward while foot or feet caught or fixed to ground and unable to move them -MC males >40 y.o, hx of systemic disease (Gout, DM, renal disease -Patellar>quad. Quads usually >40, patellar <40 ——-Manifestations——— -Sharp proximal knee pain w/ ambulation, inability to extend knee/SLR (limited extension in partial, absent in full) -Quad tendon rupture= Patella Baja= palpable defect above knee -Patellar tendon rupture= Patella Alta= palpable defect below knee ——-Imaging———- -Aside from bedside US, diagnostic imaging not indicated for most injuries, dx made clinically based on hx and exam findings -Radiographs not usually done, but can show avulsions -MRI obtained only when presentation unusual, concerning, or no improvement seen. Test to use if ultrasound somehow not available. ——-TX——- -Knee immobilizer, non or partial weight bearing, RICE -Surgical repair w/in 7-10 days

Fibula fracture

-MOI: forces applied directly to fibula or indirectly through stress on knee or ankle -Dx: Radiographs (also impt to do to r/o other causes) -Widening of tibiotalar joint space suggests presence of a rupture of tibiofibular syndesomosis and possibly Maisonneuve fracture. Tx: urgent ortho consult or immobilization and referral. Often managed successfully nonoperatively since it is a non-weight bearing bone. Complete healing usually 6-8 wks

Ankle dislocation

-MOI: major trauma, high velocity injury -Posterior dislocation MC -+/- Peroneal nerve injury ———Manifestations———- -Pain, edema, deformity, inability to bear weight ———-Tx———— -Closed reduction + posterior spline - +/- ORIF in severe cases

Medial Tibial Stress Syndrome (Shin splints)

-MOI: repetetive trauma (running, jumping) -Definition: Inflammation at the insertion of calf muscles to periosteum ——HX—— -Leg pain w/ activity -Decrease pain w/ rest -Described as dull ache -May have edema and ecchymosis —-PE—— -Lower 1/3 medial tibia tenderness (MC Location) ——Tx——- -Relative rest -Avoid impact activities -ICE -NSAIDs -Stretching -PT R/o Stress fx or compartment syndrome if unresponsive to tx (MRI or bone scan)

Midshaft humerus fractures

-MOI: typically d/t trauma like direct blow or bending force. Less commonly, d/t FOOSH or elbow. Can also occur from strong muscle contractions like high-velocity throwing or arm wrestling. -Sx: severe arm pain in area of mid-arm, but can have referred pain to shoulder or elbow. Swelling and ecchymosis afte rinjury common. -PE: significant tenderness to palpation and creptitus. Shortening of upper arm suggests signifcant displacement -Initial eval= detailed neurovascular exam of arm, including assessment of radial and ulnar arteries and function of radial (esp impt), median (rare), and ulnar (more rare) nerves. -Radial nerve MC injured= weakness of wrist, finger, thumb extension, some weakness of elbow supination. Test with thumbs up sign and resisted thumb extension. Sensory loss on dorsum of hand easily tested -FX descriptors: open v closed, location (proximal, middle, distal 1/3), non displaced v displaced, transverse, oblique, spiral, segmental or comminuted fx, intrinsic condition of bone (osteopenic or not), any articular extension -Tx: most can be put in a sugar-tong (coaptation) splint. Surgery if: open fx, neurovascular injury, pathological fx, floating elbow (concomitant fx of forearm bones), segmental fx, intra-articular extension, bilateral humeral fx). Delay surgery if no nerve improvement shown on EMG. Altho most radial nerve injuries have function return in 3-4 mos.

Achilles Tendon Rupture

-MOID: Mechanical overload from eccentric contraction of gastrocsoleus complex ——HX——- -Males age 30-50 MC (Kobe). 75% occurs as a sports related injury. *^risk w/ fluoroquinolone use* -Hear a "pop" -Felt like someon kicked them -Able to bear weight on extremity -Unable to push off in gait -Weakness -Immediate swelling and bruising ——-Sx/PE findings——— -Sudden heel pain after push off movment, "pop", sudden sharp calf pain -Swelling, ecchymosis, palpable sulcus -*(+) Thompson test (weak, absent plant flexion when gastroc is squeezed) ———Tx——— -Surgery -Non-Surgical: casting in equinus position (90 degrees). But has greater risk of re-rupture andweakness

Hammer Toe

-Me AF -Contraction of flexor tendon -Flexion of PIP joint and hyperextension of MTP and DIP joint -Callus formation at PIP joint; stretching of extensor tendon -2nd Toe MC affected, typically d/t poor footwear. ^^ incidence in female. Sometimes seen w/ hallux valgus -Sx: aside from what you can see, PIP pain d/t contact w/ shoe. PIP deformity. ——-TX——— -Budin splint/metatarsal bar -Proper fitting shoes -Surgery

Proximal Humerus/Humeral Head fractures

-Mechanism of injury: FOOSH, direct blow to arm. Common site for pathologic fx in metastatic breast cancer -MC occurs in elderly w/ osteoporosis -Associated injuries include: neurovascular injuries, dislocation, rotator cuff tears -Clinical manifestations: *arm held in adducted position*.+/- ecchymosis and crepitus. -Assess distal pulses. Neurovascular injury occurs MC w/ displaced fx or fx-dislocations and usually involves axillary or suprascapular nerve. Axillary nerve function should be assessed testing sensation over lateral shoulder, overlying deltoid (motor testing not usually possible d/t pain Axillary nerve injury manifests as deltoid weakness and dimiinshed sensation over mid-deltoid region. Suprascap nerve injury can manifest as supra and infraspinatus weakness. ————————-Imaging———————- -Imaging:Radiography: AP, lateral, scapular Y, axillary. *Axillary view best for evaluating glenoid articular fx and dislocations*. Velpeau axillary view can be done if axillary view can't be obtained -CT can be used to further eval articular involvement, fx displacement, impression fx, glenoid rim fx —————————————TX/Referral——————- -Tx: 80% of fx are nondisplaced or minimally displaced and therefore can be done non-operatively. Non operative management= Initial immobilization w/ a standard or collar and cuff sling, ice, analgesics. Neither splinting or casting required (if 1 part fx). Pendulums can be done in sling beginning 1-2 wks after injury. -If complex fracture: Closed reduction not recommended prior to ortho referral. -Orthopedic referral if: fx involves anatomical neck (*d/t high rate of osteonecrosis*), neurovascular complications, concomittant shoulder dislocation, or treating clinican not experienced in fracture management ——————F/U and Return to work—————————— -Peds f/u: asses ROM, strength, function. 1st appt normally ~1 wk after injury, subsequent f/u every 2 weeks for 2 months, followed by every 3-4 wks until radiographic healing is documented -Return to work expected in 2-3 wks if pt can perform required duties in sling. Return to occupations that require full use of shoulder or to sports not advised until strength and ROM are acceptable and stable healing apparent on radiographs.

AC Separation

-Mechanism= Direct blow to and adducted shoulder. Lateral aspect of shoulder. -MC cause= fall on point of shoulder. -Manifestations= pain w/ lifting arm, unable to lift arm at shoulder. +/- deformity at AC joint. -Obrien may have equal pain with palm up or down. -SX: Athletes present w/ focal soft tissue swelling and tenderness over AC joint. Severe injries have deformity -Involves stretching or tearing of AC and/or coracoclavicular ligaments -*+cross-arm test*, pain localized to AC joint -Dx: Radiograph taken w/o weights or with weights to reveal mild separation -Class 1= normal CXR (ligamental sprain) -Class 2= slight widening (AC ligament ruptured, CC ligament intact) -Class 3= Significant widening: rupture of both AC and CC ligaments -TX: supportive=Grade 1-3= reduction, ice, analgesia, ortho f/u. Type 3 may need surgery (no test ? Will ask grade 3).Return to activity can be accomplished in 1-6 wks. Anything above grade 3= surgery

Avulsion fx of 5th metatarsal

-More common than jones -FX at tuberosity of the base of the 5th metatarsal -Usually extraarticular but can extend into cuboid-metatarsal joint -Inversion can cause this fx.

Boxer's Fracture

-Neck fracture of the 4th or 5th metacarpal -Hx of poor punching technique or punching hard surface -Sx: knuckles may no longer be prominent, obvious deformity may be present -Imaging: X-ray to visualize fx -<40 degrees angulation is acceptable -Prior to definitive tx of hand-based casting for 4 weeks, they can be temporarily immobilized w/ ulnar guttar splint w/ MCP's flexed to 70 degrees. -Surgery may be needed in more severe cases (open fractures or severe angulation, etc.): Open reduction and internal fixation or closed reduction with pinning (if pseudoclawing or severe angulation)

Genu Valgum (knock knees)

-Normal between ages 3-5 -Should have normal adult alignment by 8 yrs old (5-9 degrees anatomic valgus Measure inter-malleolar distance -Supine w/ legs extended -Patella anterior w/medial femoral condyles touching -Measure space b/t *medial malleoli*: *>8cm or 3 inches is abnormal for any age.* -Ortho referral: Severe knock knees (>8cm distance b/t medial malleoli), progressive knock-knees deformity (after age 4-5 yrs), persistent knock knees (after age 7), unilateral or asymmetric valgus deformity, medial thrust w/ ambulation, short stature, hx of: metabolic disease, LE fx, infection, tumor, or joint swelling/warmth

Genu Varum (Bow legs)

-Normal in infancy to 3 yrs of age -Becomes more apparent w/ standing -Measurement of inter-condylar distance (supine, legs extended w/ patella facing anteriorly): abnormal for all ages= *>6cm or 2.5 cm* -Radiographic eval: Usually not necessary, consider if past age 3 -Consideration for referral -severe bowing (>6 cm distance), progressive bowing, persistent bowing, unilateral or asymmetric bowing, lateral thrust with ambulation, short stature, hx of: metabolic disease, LE fx, infection, or tumor.

Osgood-Schlatter Disease

-Osteochondritis of the patellar tendon at tibial tuberosity from *overuse* (repeated stress) or small avulsions (d/t quad contraction on the patellar tendon insertion on tibia) -*MCC of chronic knee pain in young, active adolescents* -MC males, boys commonly 12-15, girls 11-13, with *growth spurts* (bone growth faster than soft tissue growth, so quads contraction transmitted thru patellar tendon to tuberosity ——-Manifestations———- -Activity related knee pain/swelling (running, jumping, kneeling) -Painful lump below knee, *tenderness to anterior tibial tubercle* -Prominent tibial tuberosity ————Dx——— -Radiographs (not usually used) show prominence or heterotropic ossification at tibial tuberosity. Demonstrate fragmentation or irregular ossification of the tibial tubercle ———tx——- -RICE -NSAIDs -Quad stretching, PT -Surgery only in refractory cases (if done, usually performed after growth plate has closed)

Developmental hip dysplasia

-Pathophys: neonate hip unstable 2ry to undeveloped muscle, easily deformed cartilaginous surfaces, lax ligaments. Exaggerated positoing may occur in utero= excess stretching of posterior hip capsule. This instability may lead to subluxation/dislocation, causing abnormal development of femoral head and acetabular structures. Usually unilateral, *L>R* -RF's: Female, breech positon >/= 34 weeks gestation, fam hx, tight swaddling. -Assocaited conditions: birthweight >4kg, torticollis, plagiocephaly, metatarsus adductus, clubfoot, oligohydraminos, multiple gestation pregnancy, 1st born ——————-Sx—————— -Newborn= instability on PE -Infant= limited abduciton -Toddler= assymetric gait -Adolescent= activity-related pain -Adult= OA ————PE———- -Eval begins as newborn. Continue eval at well checks until 9 mos of age or walking independtly. 2-week and 4-week old exams particularly impt ———clinical tests—— -Asymmetric skin folds: dislocated hip displaces proximally= leg shorter and creates accordian phenomen of the thigh skin folds. Most signifcant fold is b/t genitals and glut max (not reliable alone, occurs in 25% of all infants). -<3 mos: *Ortalani, Barlow*: Ortalani- confirms dislocation, trying to relocate the hip. Palpable "clunk" represents reduction of femoral head back into acetabulum. Technique: supine, hip, knee flexed to 90. Index and middle finger along greater trochanter, thumb on inner thigh. From adducted position, gently abduct while pushing trochanter anteriorly. Barlow- provactive test that picks up unstable but located hip, *trying to dislocate the hip*. *CI'd* if child has dislocated hip. Technique: supine, hip and knee flexed to 90. Thumb on inner thigh, middle and index finger on greater trochanter. Gently adduct and apply downward pressure. Palpate for posterior movement of femoral head. ->3 mos, not yet ambulating: *Galeazzi Sign, passive hip abduction* Galeazzi: detect dislocated hip/shortened femur. Technique: supine on table w/ flexed knees and feet flat on table w/ femurs aligned. Observe height of knees: position self at end of table near pts feet. Passive hip abduction: Normal ROM= >75 degrees abduciton, at least 30 degrees adduction. Abnormal: *<45 degrees= most reliable sign* unilateral limited hip adduction after 8 weeks is 78% sensitive, 93% specific -Walking age= trendelenburg—> inability to maintain pelvis horizontally while standing on ipsilateral leg resulting in *swaying gait* ———Imaging———- -<4-6 mos: US (if breech delivery, FH of DDH, or clinical findings) ->4-6 mos: Radiographs (ossified nucleus in femoral head deveops, single AP view w/ hips held in 20-30 degrees flexion) ———TX——— -Goals= obtain concentric reduction of hip into acetabulum, maintain reduction, and allow normal growth stimulation to correct acetabular dysplasia. 0-1 Month old: -Laxity: reassess at 6 wks -Dislocation: Referral and *Pavlik Harness* 0-6 months old -Pavlik harness used -If reduction can not be maintained, closed reduction and spica casting x 6 wks 6-18 mos (before walking) OR failed Pavlik -Closed reduction and spica cast 18 mos to 2 yrs+ -If reduciton/casting has failed, open reduction w/ pelvic and/or femoral osteotomy and post-op casting required, followed by prolonged bracing to resolve residual dysplasia q

Prepatellar bursitis

-Penetrating trauma and jobs that required prolonged kneeling (clergy, carpet laying, mining) common cause ———-sx———- -sx= localized tenderness and swelling anterior to patella or patellar tendon. ——————-dx——————- -usually clinical dx -To confirm etiology: lab testing, bursal fluid analysis (key component= r/o septic bursitis), and imaging (AP and Lateral knee, ) ——————-Special tests———— -Acute swelling and redness at a bursal site calls for aspiration to r/o infection esp if pt is either febrile or has prebursal warmth (temp dif >2.2 celsicus lol). *Bursal fluid >1000/mcL indicates inflammation from infection, RA, or gout.* Bursal fluid from septic condition usually has: purulent aspirate, fluid:serum glucose ration <50%, White count >3000 cells/mcL, PMN's >50%, + gram stain for bacteria.* -MC bacteria= Staph Aureus —————-TX———————- -usually self limiting. -Don't inject into the joint -Knee braces when kneeling can't be avoided. -Septic bursitis: immobolize knee in splint, abx, aspirations as needed.

Meniscus injuries

-Pt may or may not report an injury -Injury can lead to pain, clicking, and locking sensation -MOI: acute injuries (esp in young patients) or repeated microtrauma, such as squatting or twisting (usually in older pts) -Medial 3x MC >Lateral ————-Findings—————- -Pt may have an antalgic (painful) gait and difficulty squatting -May complain of *catching or locking* -Swelling usually occurs during 1st 24 hrs after injury or later -PE: effusion or *joint line tenderness*. Pts can usually point out the area of maximal tenderness along the joint line -(+) Mcmurray test and (+) Thessaly test -(+) pain with deep squatting and when waddling (duck walking) ——-ddx——- -Meniscus tears rarely lead to immediate swelling commonly seen with fx or ligament tears ———Imaging———- -Radiographs: usually normal but may show joint space narrowing, early OA changes, or loose bodies -*MRI= dx tool of choice*= high signal through meniscus= tear -*Difficulty w/ knee extension suggest internal derangement that should be evaluated urgently w/ MRI. —TX——- -Conservative tx for degenerative tears in older pts: analgesics, PT -Acute tears in young and active pts w/ clinical signs of internal derangement (catching and swelling) w/o signs of arthritis on imaging or pts w/ acute mechanical locking w/ a displaced meniscus can be best txed *arthroscopically* w/ meniscus repair or debridement

Nursemaids Elbow (1,2,3 Weeee injury)

-Radial head subluxation from annular ligament -*MC elbow injury in children*.. Agest 1-4 MC. By age 5, annular ligament thick and strong. F>M. Left>Right -MOI: axial traction on pronated forearm w/ extended elbow. *Child stumbles while holding adult's hand. Or swung around by arms* ————-Sx———- -Clinical presentation: Child stops using affected arm. Holds elbow close to side, slightly flexed (take pressure off/reduce pain), pronated. Complains of elbow pain and *avoids motion at elbow*. Point tenderness over radial head ———-Imaging————- -X-rays: usually normal. Not needed if consistent MOI. Use it to r/o fx if swelling, bruising, or other MOI ———-Tx——— REDUCTION (techniques below) -Hyperpronation technique: support elbow, finger applying pressure to radial head. Other arm pronates forearm until palpable click -Supination/flexion technique: Support elbow, finger applying pressure over radial head. Other arm pulls traction, while flexing and supinating elbow ————-Referral/ Other info——— -27-39% recurrence. No long term issues -Refer if: unable to reduce OR child won't use arm despite normal x-ray

Congential Vertical Talus (CVT)

-Rare -Characterized by talus positioned in marked plantar flexion and talonavicular joint dislocation -Often confused w/ calcaneovalgus foot or flexible flatfoot -Neurologic in origin (spina bifid) -Rigid *"rockerbottom"* deformity with equinus (plantar flexion) of the hindfoot and dorsiflexion/abduction of the forefoot ——-TX——— -Strictly surgical, best performed before walking age

IT band syndrome/ trochanteric bursitis

-Result when bursa and IT band become inflamed d/t repetitive friction form underlying greater trochanter -Pain when hip is flexed. -MC cause of knee pain in runners. -Manifestations: *Lateral knee pain* (or lateral hip) during onset of running then resolves. Worse w/ climbing stairs or running downhill. Pain during movement and may cause limited movement. -*(+)Ober test: pain or resistance to adduction of the leg parallel to the table in neutral position* -(+) lateral condyle tenderness -Tx: alter offending activity, stretching program, core and pelvic stabiliszation -US and CS injections may be used after conservative tx has failed.

Burst Fracture

-Results from direct axial load with forward bending in high energy trauma -Affects entire vertebral body (anterior and posterior cortices involved) -50%: T11-L2 (high stress transition zone; T-spine= rigid, L-spine= flexible) -lumbar mc in elderly. Pathologic fx in malignancy -MC associated w/ falls and MVA -Neuro deficits in 42-58%... *all should be considered unstable* -Posterior element involves ^ risk of neuro deficits. -Manifestations: pain and point tenderness at the level of compression -Imaging:Radiographs, CT if this fx is suspected for any reason. Often misdiagnosed on plain radiograph b/c displaced bone fragments often lie at the level of the pedicles. -Tx: ortho and neurosurg consult. Analgesics; +/- kyphoplast/vertebroplasty.

Biceps tendon rupture

-Rupture of the biceps tendon from its insertion into the radial tuberosity -Often preceded by a chronic tendinitis. -Degenerative changes in the tendon make it more susceptible to rupture with a traumatic event ———PE—— Antecubital pain often associated with pain and swelling Biceps tendon is nonpalpable or feels smaller than contralateral side Pain and weakness with resisted elbow flexion and supination. Strength decreased by 20-50% Possible "Popeye" deformity ——Tx——- All distal biceps tendon ruptures require surgery Surgery is recommended within the first 2-3 weeks after the injury Delay in repair may make repair more difficult (grafting, etc) or impossible

Knee dislocation

-Severe limb threatening emergency (popliteal artery rupture severe complciation) -MOI: high velocity trauma, often assocaited w/ multiple trauma -Clinical manifestations: Gross deformity, may reduce by iteslf (so believe patients). Pain and swelling seen. Often significant hemarthrosis and ecchymosis. -If (+) dimple sign (transverse groov in skin at medial joint line caused by invagination of a portion of medial capuse) it indicates a posterolateral knee dislocaiton that can NOT be manually reduced ——-types————- -Posterior: direct blow to proximal tibia that displaces it posterior to distal femur -Anterior: hyperextension injury to knee that tears the posterior structures and drive the distal femur posterior to proximal tibia -Medial: result from valgus forces to proximal tibia -Lateral: result from varus forces to proximal tibia ———————————- -Complications: popliteal artery injury in 1/3 so arteriography. +/- peroneal or tibial nerve injury -Management: immediate ortho consult. Prompt reduction via longitudinal traction. —-Tx Algorithm from UTD—— -If dislocation—> reduce immediately—> examine distal and popliteal pulses, obtain ABI, perform bedside US if available: -If pulses strong, ABI >0.9 and normal US: admit for observation and perform serial vascular exams, ortho consult for surgery -If limb well perfused but assymetric pulses, ABI <0.9, or abnormal duplex US: obtain urgent arteriogram or comprable vascular study in consultation w/ vascular surgery -If weak or absent pulses and/or signs of ischemic limb or vascular injury: emergency vascular surgery consult and operative repair.

SLAP tear

-Specific injury to superior portion of glenoid labrum that extends form anterior to posterior in a curved fashion. -MC seen in overhead throwing athletes and overhead laborers -Pathophys: Shear forces created by movement of humeral head anteriorly and superiorly (overhead activities particularly when arm is abducted and externally rotated) can cause the tear. Abduction and ER causes biceps tendon to twist= ^ stress on tendon attachment=^ risk of labral tear. ——————Types————————— 4 types: -Type 1: Degenerative fraying w/ intact biceps tendon insertion ( associated w/ ^ age, rotator cuff disease, osteoarthritis) -Type 2: Detachment of biceps insertion (overhead sports MC) -Type 3: Bucket-handle tear w/ intact biceps tnedon attachments to bone (High demand occupations) -Type IV: Intrasubstance tear of biceps tendon w/ bucket-handle tear of superior labrum (high demand occupations MC) ————-Sx/HX————————- -*May complain of episodic clicking or comprable mechanical sx when arm placed in cocking position of throwing (Abd and ER)- this is a very impt sx* -Night pain uncommon (suggests rotator cuff tear) -Shoulder instability/paresthesias uncommon (suggests instability of shoulder like tear/dislocation) -Significant muscle attrophy suggest neuro problems or other cause -Declined function or velocity of throwing. -Classic complaint of baseball players is arm "went dead" -Typically not associated with acute anterior shoulder dislocations -Common concomitant injuries= rotator cuff impingement/tears, bankart lesions, biceps tendon injurym, GH OA. ————PE findings/Clinical tests- -+/- tenderness to palpation of proximal biceps tendon, decreased ROM -Tests that help w/ dx: Anterior glide test, compression rotation test, O'Brien's test, Crank test, Speeds test (speeds also great for biceps tendon injury) ———-imaging/diagnostics————- -Plain radiographs to r/o other injuries, typically performed 1st: Anteroposterior, scapular Y, axillary views -Definitive dx requires arthroscopy or MRA (most accureate), but often unnecessary and a clinical dx adequate if: pt not a good surgical candidate, the hx and PE supports dx, and others can be ruled out by examination and US. -Up to date recommeds ortho referral before doing MRA ————TX——— -Nonoperative preferred when possible—PT (^ strength and ROM, reduce pain/inflammation), anti-inflammatories -High level throwing or overhead athletes and pts w/ high overhead occupational demands should be referred for surgical consult. Takes around 6-12 mos to recover from surgical repair.

Maisonneuve Fracture

-Spiral proximal fibular fx d/t rupture of the distal talofibular syndesmosis and interrosesus membrane rupture as a result of distal medial malleolar fx and/or deltoid ligament rupture. -*Anyone w/ a distal ankle fx should have a proximal view to r/o a Maisonneuve fx* -TX: refer to ortho if associated injuries. . If it's magically an isolated injury, long leg cast or a brace immobilizer.

De Quervain Tenosynovitis

-Stenosing tenosynovitis of the Abductor pollicus longus and extensor pollicus brevis. Affects as they pass through a fibro-osseus tunnel at the styloid process of the radius. Non=inflammatory thickening of the radius -MOI; excessive thumb use w/ repetitive action. Seen in golfers, clerical workers, etc. ———-Sx—————- -*Pain along the radial aspect of the wrist radiating to the forearm*. Worse with thumb and wrist movement. Usually some swelling and tenderness at the radial side of wrist ————dx——————— -Dx: based on hx and PE findings, particularly: 1) tenderness and enlargement at the radial styloid at the 1st dorsal compartment 2) *+ Finkelstein test: pain w/ ulnar deviation or thumb extension* ———Tx———— -Tx: Thumb spica splint x 3 wks, Nsaids x 10-14 days, can also do PT -IF persistent pain and swelling despite nonop tx of splinting and NSAID's OR severe sx at initial presentation, try glucocorticoid injection (methylprednisone or triamcinolone +lidocaine) -For pts w/ persistent sx despite splinting and 1 or 2 glucocorticoid injections, surgical therapy may help relieve sx

Anterior Cruciate Ligament injury

-This ligament connets posterior aspect of the lateral femoral condyle to the anterior aspect of tibia, main function= control anterior translation of tibia on femur -Common in sporting injuries. Can occur from both direct contact (valgus blow to knee) and non contact (jump, pivot, decleration). -Pt usually falls down folllwing injury, has acute swelling and difficulty with bearing weight and complains of instability. ———-sx————- -Acute swelling immediately (or w/in 2 hrs) -After swelling has resolved- stiff knee gait may be seen or quadriceps avoidance -Instability occurs w/ lateral movement activities and going downstairs -(+) Lachman's (84-87% sensitive, 93% specifice), (+) anterior drawer test (48% sensitive, 87% specific). -Pivot test used to determien amount of rotational laxity of knee. PT must remain very relaxed to have positive tests ————Imaging———— -Plain radiographs: usually negative, just used to r/o fx. -A small avulsion injury can sometimes be seen over lateral compartment of knee (*Segond fx*) and is pathognomonic -*MRI= test of choice* ————-tx————- -Surgery typically used, def if young and active -Nonop tx usually reseved for older pts or those with very sedentary lifestyle: PT.

Jones Fracture

-Transverse fracture through the diaphysis of the 5th metatarsal -Tx: Non-weight bearing x 6-8 wks, followed by repeat radiographs as itis often complicated by * high rate of nonunion/malunion*. Frequently requires ORIF/pinning. —-ddx- -PseudoJones: Transverse avulsion fx at teh base (tuberosity) of the 5th metatarsal)

Peroneal Tendon Injury

-Types: inflammation (tendonitis), subluxation, or tear -Often unrecognized or misdiagnosed as an ankle sprain -Relatively uncommon (< 1% of all ankle injuries) -Pain posterior to the lateral malleolus -In ATFL injuries, pain more anterior -Pain with resisted eversion Treatment: -Similar to ankle sprains -PT (if torn; will not respond to therapy) -CAM boot or ASO -NSAIDs -If no improvement with conservative treatment, consider MRI to evaluate for tear -Surgery is best treatment for tendon tear

Cubital Tunnel

-Ulnar nerve compression at the cubital tunnel along the cubital tunnel along the medial elbow—> paresthesias/pain along the ulnar nerve distribution (worse with elbow flexion) -Sx: Aside from what's above, may also have elbow pain, nocturnal wakening, and worsening of sx with prolonged elbow flexion. Sensory sx in 4th and 5th digits. Sx can be provoked by activiting that requires sustained or repetitive grip, or repeated forearm pronation and supination. Weakness . -PE: + Tinel's sign at the elbow; + Froment's sign (ulnar nerve eval via adductor pollicis- holds paper & compensates with flexion of IP joint- pinching effect) -Dx confirmed with EMG. Can also do US and MRI —————tx—————- -Conservative tx.: splints, pads, activity modification, avoidance of provoking factors, nerve gliding exercises -Do conservative if: mild-moderate ulnar neuorpathy who have intermittent or persistent sensory loss and weakness without wasting. Or if pts have mod-severe but <6 mos -Mod-severe >6 mos referactory to conservative= ulnar nerve decompression -Tx PANCE PREP: wrist immobilization esp w/ sleep, NSAIDs, intraarticular steroids (if chronic)

Torticollis

-Unilateral contracture of SCM--> Posterior occiput tilts to affected side, chin points away from affected side -Association with DDH -Etiology= uknown, possibly delivery injury. Can occur 2ry to swelling around C1/C2, Cerebellar tumor, SC injury, after URI -PE: may palpate smooth mass in SCM -Imaging: radiographs if you suspect anomaly of C-spine -TX: Passive stretching w/in 1st yr. Refractory cases= surgical SCM release. -Complications if untreated= Facial asymmetry

Lumbar Disk Herniation

-Usually d/t bending or heavy lifting--> causes hernation or extrusion of disk contents (nucleus pulposus) into SC raea -Can also be d/t Degenerative disk disease (dessication of annulus fibrosis) in pts b/t 30-50, L5-S1 affected in 90% of these cases -Radicular pain occurs d/t compression of neural structures. -Cauda equina syndrome can occur d/t compression of SC ---------Findings----------- -Pain w/ back flexion or prolonged sitting (like driving) -Radicular pain into the leg d/t compression of neural structures -Lower extremity numbness and weakness -Pain localized to low back, but can create sciatica like pain radiation (can be below knee) -Worse with activity -Significant disease- weakness with plantar flexion (L5/S1) or dorsiflexion (L4/L5). ------------Imaging------------ -Plain radiographs helpful to assess spinal alignment, disk space narrowing, OA changes -MRI= best ------Tx---------- -Acute exacerbations= bed rest x 48 hrs -1st line= modified activities, NSAIDs, other anlgesics (prednisone, gabapentin), PT, core stabilization/McKenzie exercises. Epidrual/transforaminal CS shots may help -Surgery (try conservative first)(microdiscectomy)= sequestered fragments, sx duration >6 mos, higher levels of LBP, or not working or not disabled 40% recurr and take long to resolve pain.

Posterior Cruciate Ligament Injury

-Usually follows an anterior trauma to the tibia, such as a dashboard injury during an MVA -1/3 have neurovascular injuries, so DO NEUROVASCULAR EXAM -Usually assocaited with multi-ligament injuries and knee dislocations ———Sx———— -Difficulty w/ ambulation -Anterior bruising (esp to anteromedial aspect of proximal tibia). Large effusion -PTs w/ chronic injuries can ambulate w/o gross instability, but may complain of looseness and report pain and dysfunction, esp w/ bending -*Sag sign*= pt placed supine, knee and hips flexed to 90. Bc of gravity, the PCL-injured knee will have an obvious set-off at the anterior tibia that is sagging posteriorly -(+) Posterior drawer test (90% sensitive, 99% specific) -Can get false + anterior drawer -Pain, swelling, pallor, and numbness in affected extremity may suggest a knee dislocation w/ possible injury to popliteal artery ———Imaging———- -Radiographs nondiagnostic but required to dx any fx -MRI test of choice ——-TX——- -If isolated= non operative: knee brace with knee extension with crutches. PT. -Many are associated with other injuries and may require operative reconstruction.

Radial head fracture

-Usually from FOOSH -Represent nearly half of all elbow fractures Present with pain, limited ROM -Point tenderness over radial head -Dx: Use radiocapitellar view- allows visualization of radial head w/o coronoid overlap. -Nondisplaced fractures treated conservatively with early ROM to aprevent stiffness -Displaced fractures require ORIF, excision of radial head or silastic implants

External tibial torsion

-Usually unilateral, R>L -Commonly discovered ages 4-7 -Measure thigh-foot angle -RArely causes pain or functional abnormality: ^ likelihood of patellofemoral pain, difficulty with parallel skiing

Smith's Fracture

-Volar angulation of the plane of the distal radius -Distal radius fragment is displaced proximally and volarly -Radial displacement of the carpus -The fracture line extends obliquely from the dorsal surface to the volar surface 1-2 cm proximal to the articular surface.

-Bankart Lesion -Aside from Xray, MRI WITH contrast -Anterior inferior labrum tear. Commonly seen in unilateral traumatic shoulder dislocations.

-What is this called? -Imaging -What is mechanism of injury? (Sorry can't think of how to phrase this question)

Hip Fractures

-^ mortality rate in older adults, 25-30% die w/in 1 yr of fx -RF's= osteoporosis, female, ht >5'8", age over 50 -MOI: MC falls. Minor or indirect trauma in elderly. High-impact in younger pts. -MOI for femoral neck fx in elderly= fall directly on lateral hip, twisting mechanism in which pts foot is planted and body rotates, a sudden spontaneous completion of a fatigue fracture= fall ————-Sx———— -Typically report pain in groin, though pain radiating to lateral hip, butt, or knee can also commonly occur. -Inability to walk, unless minimally impacted may continue to bear weight. -Little brusing in intracapsular fx. -Displaced fx= pt will NOT be able to bear weight and leg may be ER'd -Shortened, *Externally rotated,* abducted. ————PE/tests——— -Gentle logrolling of leg w/ patient supine helps r/o fx -+ Pain to deep palpation of femoral trianagle -*Pain w/ hip IR= most sensitive test to id intra-articular hip pathology.* -if stress fx: less pain, but typically have pain w/ weight bearing ———-Imaging———— -AP of pelvis and bilateral hips and frog-leg lateral views of painful hip -CT or MRI may be needed to ID fx pattern or eval non-displaced fx -Classified by location: Intracapsular= femoral head and neck, extracapsular (defined as from extracapsular femoral neck to area just distal to lesser trochanter)= intertrochanteric and subtrochanteric fx -Intracapsular fx= ^ rate of nonunion/malunion, and avascular necrosis. -Subtrochnateric fx have ^ need for implant devivces d/t high stresses on placed on this part of femur. *high association w/ bisphosphonates* ——————Tx———- -Admit for pain control, *surgery recommended w/in 1st 24 hrs* -If stress fx= protected weight bearing and gradual return to activities, may take 4-6 months to be fully back to normal. -Femoral neck fx= hemiarthroplasty or total hip replacment -Peritrochanteric hip fx= ORIF -Common complications after surgery= dislocation, prsothetic fx, and avascular necrosis of hip. -Mobilize pts ASAP to avoid pulmonary complications and pressure ulcers -Supervised PT and rehab after surgery.

Supracondylar fracture

-present with pain, swelling , and tenderness over lateral elbow, and inability to fully extend elbow. Significant swellnig, tenderness and limited elbow ROM -Neurovascular exam done on all elbow fx. *Anterior Interosseous nerve neurpraxia (branch of median nerve- unable to make A-ok sign)A decreased or absent radial pulse common in kids and often 2ry to brachial artery inmury. -Early major complication= *Volkman's iscehmic contracture (compartment syndrome of forearm)*. Signs= refusal to open hand, pain w/ passive extension of fingers, forearm tenderness. Absence of radial pulse does not constitute ischemia unless acommpanied by these other signs. -2 types: extension and flexion type. 1)Extension= MC, occurs d/t FOOSH. Distal fragment displaces posteriorly. Anterior interossues neurpraxiam MC nerve palsy= weakness of flexor digitorum profunds and flexor pollicis muscle (can't do OK sign or bend tip of index finger). Radial nerve pusly 2nd mc, weakness in finger and wrist extension. 2)Flexor type: rare, occurs by falling on flexed elbow. Distal fragment displaced anterioly. May have ulnar nerve neurpaxia (decreased sensation to little finger and clawing of hands. -Complications early: radial/median/ulnar nerve injury, volkman's ischemia -Complicaitons late= nonunion, malunion, myositis ossificans, loss of motion.

Normal radiography of the wrist

23 degrees of radial incliniation 11 mm of radial length 11 degrees of palmar or volar tilt

Unhappy triad

ACL, MCL, medial meniscus

Shoulder injurites based on age (MC)

Age: 15 - 35: Instability, labrum injuries, overuse tendinitis (esp. in throwers/swimmers) 35-65: RC tendinitis/tears, adhesive capsulitis, AC joint arthritis/ SLAP 65 and up: GH DJD, chronic RC tears

Shoulder stability tests

Apprehension, load and shift, O'brien.

AMBRI

Atraumatic Multidirectional Bilateral (frequently) Rehabiliation (often responds to) Inferior capsular shift (best alternative to nonop, do only after you do vigorous 6 mos rehab with no response)

2 Complications of shoulder dislocations

Bankart and Hill-Sachs lesions

Spondylolysis

Break or defect in pars interarticularis portion of lamina. -Pars interarticularis defect from either failure of fusion or stress fx -MC form of back pain in children and adolescents. This dx is around 50% of cases in adolsecents presenting with LBP. MC at L5/S1 -OFten from repetitive hyperextension trauma (football players, gymnasts) -sx: *LBP with extension*+/- sciatica sx.....presents quite similar to sponylolethesis.... pain during lumbar extension. Palpable tenderness over lower lumbar vertebrae. + STork test (pain with single leg hyperextension). Tight hamstrings -Imaging:AP, lateral, oblique x ray (*scottie dog sign*. CT, MRI, SPECT can show better detail (Ct very good) - typically don't image unless constitituinoal signs/other red flags. If pain has persisted more than a few weeks, then imaging needed. MRI confirms dx, radiograph usually done 1st tho -TX: no gold standard tx. S relief, activity restriction, PT, bracing. Return to play 8-12 wks or longer.

Sciatica

Compresssion of Sciatic nerve -Can see this with herniated disc, amongst a bunch of other things -Non specific term -Defined as: sharp or burning pain radiating down from the buttock along the course of the sciatic nerve (the posterior or lateral aspect of the leg, usually to the foot or ankle) ————-Manifestations————- -Back pain radiating to thigh/butt—> lower leg (below the knee) down the L5-S1 dermatome -PE: + Straight leg raise, + crossover test, +/- strength reflex and sensation defects —————-Nerves affected———————— Sensory=ALP -L4= Anterior thigh pain, sensory less to medial ankle -L5= Lateral thigh/leg hip groin paresthesias and pain. Dorsum of the foot: esp b/t 1st and 2nd toes -S1= Posterior leg/calf gluteus. Plantar surface of the foot. Motor/reflexes affected: L4= ankle dorsiflexion.... loss of knee jerk, weak knee extension (quads) L5= Big toe extension, walk on heels more difficult than on toes..... Reflexes usually normal, +/- lose ankle jerk S1= Plantar flexion, walking on toes more difficult than on heels... loss of ankle jerk

Rotator vs labrum pathology

GET CONTRAST WITH LABRUM pathologies Don't need contrast with rotator cuff pathologies

Ankylosing Spondylitis

Identify

Boxer's fracture

Identify

Colle's fracture

Identify

Galeazzi fracture

Identify

Monteggia Fracture

Identify

Proximal humerus fracture (humeral head fx)

Identify

Scaphoid fracture

Identify

Smith's Fracture

Identify

Scottie dog sign

Identify What is this is a sign of?

Fat pad sign

Identify.

Avascular necrosis of the hip

Identify. Be specific.

Anterior shoulder dislocation Axillary View

Identify. Be specific. What view is diagnostic?

Note about radius/ulna fx and tib/fib

If you break one, you tend to break the other. So if you fx radius, you tend to fx ulna too. Same with tibia and fibula.

Fat pad sign (sail sign

Kids: Think supracondylar fx Adults: think radial head fx

Tibial Plateau fracture

Lateral meniscus more commonly torn with this than medial

Shoulder impingment tests

Neers and Hawkins

Cervical Radiculopathy

Nerve pain caused by pressure on the spinal nerve roots in the neck region. -Can cause neuro sx in upper extremities, usually involving C5-C7 -Manifestations= neck, shoulder, or arm pain. Or upper extremity muscle wkness, sensory sx, or diminished DTRS, either alone or in combo -Danger signs (think not this dx): 1)Lhermitte phenomenon (shock-like paresthesia w/ neck flexion, may be seen w/ MS or herniation/spondylosis). 2) Gait disturbance.... 3) hx of fever, chills, unexplained wt loss, immunosuppression, cancer, or IV drug use (cancer, tumor, infection suspicion) ———————-Evaluation—————- -Spurling maneuever and shoulder abduction relief ttest= high specificity but poor sensitivity ————-dx testing————— -Immediate dx testing not necessary if dx suspected and pt has little or no motor deficit and not at increased risk of neoplasm, infectious, or inflammatory etiology. -Neuroimaging and electrodiagnostics indicated when significant neuro findings or localized sx present, including myotomal weakness or myelopathy, or when persistent radicular sx that do NOT resolve with conservative therapy -MRI= study of choice for INITIAL eval in most pts. -*CT myelography = gold standard for dx of foraminal compression and remains >MRI in distinction of osteophyte form soft tissue. -Imaging studies of C-spine may be completely normal in nondegenerative cases. -*Dx CONFIRMED by EMG*—> frequently reveals a myotomal pattern of denervation. This study alone is not sensitive. Sensitivity reduced when sx present for <3 wks ————TX—— -Low risk of neoplasm, infectious or inflammtory causes OR disc herniation/foraminal stenosis w/o persistent pain or progressive motor deficits: Conservative tx—>Usually NSAIDs, short course of oral CS (if severe pain), avoidance of provacative activities, short term neck immobilization, PT (delay start until pain tolerable) -Can also do surgery (disectomy or foraminal decompression) if: disk herniation OR forminal stenosis w/ persistent radicular pain despite nonsurgical therapy for 6-12 wks OR progressive motor weakness that impairs function.

Tests for rotator cuff strength

Open can test Resisted ER Lift off test Belly press test

Patellar tendonitis

Overuse injury caused by repetitive loading of quads during running or jumping -Dx common in jumping sports like baseball and basketball -Tenderness located directly over the patellar tendon at its insertion site at the inferior pole of patella.

TUBS

Traumatic, unilteral, bankart, surgery

Supracondylar fracture Volkman's iscehmia

What is this? What is an important complication to be aware of?

Legg-Calve-Perthes Disease

avascular necrosis of the femoral head

Maisonneuve fracture

proximal fibular fx (near head) as a result of torsional stress (PER).

Slipped Capital Femoral Epiphysis

seen in children during growth-spurt years. the proximal epiphysis slips from its normal position on the femoral head