Orthopedics 2

Stretched or torn ligaments

Muscle or tendon injury

bruise or hematoma

Inflammation in tendon or tendon sheath caused by repeated stress

Mechanism of action: Decrease sensitization of peripheral nerves and central sensory neurons

MAO: Antipyretic and anti-inflammatory activity

MAO: Prevent prostaglandin synthesis

Adjuvant for bone pain; Analgesic ceiling; No tolerance or physiologic dependence

Less GI toxicity; More liver toxicity; Renal toxicity possible

Less anti-inflammatory activity than other NSAIDs

first line therapy for osteoarthritis

Irreversible platelet effects

GI Toxicity; Hematologic Effects; Hypersensitivity; Hepatotoxicity

Renal effects: Decreased renal prostaglandin (PG) synthesis

GI protective effects compromised by addition of aspirin

Minimal effects on platelet aggregation No renal protective effects

Sulfa allergy warning

Cardiovascular risk

Increased risk of CV thrombotic events (MI, stroke)

Respiratory depression; CNS effects; Nausea and vomiting; Constipation

Used for spasticity related to neuromuscular conditions (CP, MS, SCI)

Used for musculoskeletal spasms related to injury (short term use)

Baclofen (Lioresal®) Dantrolene (Dantrium®)Tizanidine (Zanaflex®)

Cyclobenzaprine (Flexeril®) Methocarbamol (Robaxin®) Tizanidine (Zanaflex®)

Most common adverse effects drowsiness and dizziness

Fatal hepatocellular injury reported with long-term (1 month or more) use

Tricyclic antidepressant structure; shares adverse effects including anticholinergic activity and possible adverse cardiac effects

In addition to drowsiness and dizziness, dry mouth a common side effect

Hypersensitivity characterized by rash & pruritus

AST, ALT, alkaline phosphatase and bilirubin elevations

Most common adverse effects hypotension, sedation, dry mouth, constipation

Sprains

Strains

C5

C6

C7

Impingement Syndrome

Impingement Syndrome

Injuries to the AC joint are

injuries to GH joint are

Bankart (labrum) and Hill Sachs (humeral head)

Most common fracture in the shoulder is

Medial epicondylitis

Lateral epicondylitis

DeQuervains diagnosed by

Finkelstein Test

Scapholunate dissociation

Carpal Tunnel Syndrome

Colles’ (FOOSH)

Smith (fall on flexed wrist)

Mallet finger

Boutonniere deformity

Heberden’s nodes

Bouchard’s nodes

Spondylolysis

Spondylolisthesis

HNP (herniated discs)

Hip avulsion fx sites: ASIS

Hip avulsion fx sites: AIIS

Hip avulsion fx sites: Ischial tuberosity

Legg Calve Perthes

ACL

PCL

MCL

LCL –

Meniscus

Osgood Schlatter Disease

Sever’s Disease

ATFL

Talar Tilt

Valgus (eversion)

5th Metatarsal Head fractures

Ottawa Imaging rules

Gout

Degenerative Joint Disease, “wear and tear”

Common joints: Hands, Knees, Hips, Spine

Joint space narrowing; Sclerosis; Osteophytosis

Base of thumb: 1st Carpometacarpal joint (CMC)

Distal interphalangeal joints (DIP)Proximal interphalangeal joints (PIP)

Medial compartment most commonly affected

Superior joint narrowing

Autoimmune arthritis

Commonly affected joints: Hands; Hips, Atlantoaxial joint (C1-C2), Shoulder

Soft tissue swelling, Osteoporosis, Joint space narrowing, Marginal erosions, Bilateral symmetry

Proximal Involvement: Carpal bones; MCP joints, Ulnar deviation at MCP

Superior joint space loss

Axial (central) joint space loss

Crystal induced arthropathy, Hyperuricemia: monosodium urate crystals in joints

Commonly affected joints: Feet; Hands

Well-defined erosions; Overhanging edges, Soft-tissue nodules (tophi); Random distribution; No osteoporosis

Calcium pyrophosphate deposition disease (CPPD)

Chondrocalcinosis (calcified cartilage) Associated osteoarthritis (atypical locations)

HLA-B27 Spondyloarthropathy

Spine (fracture risk)Sacroiliac joints

Spine: Marginal symmetric syndesmophytes, vertebral body squaring;

Spine: Nonmarginal asymmetric syndesmophyte

SI joints: unilateral or bilateral sacroiliitis

Hands/Feet: proliferative erosions (DIPs), soft-tissue swelling

HLA-B27 Spondyloarthropathy, associated with infection, occurs in men

Spine: Nonmarginal asymmetric syndesmophyte

SI joints: unilateral or bilateral sacroiliitis

Identical to psoriatic arthritis except affects feet more than hands

DIP erosions; “pencil-in-cup

SI joints: Bilateral sacroiliitis;

Pediatric fractures; Physis (growth plate) fractures

C1 ring fracture; Blow to top of head; Lateral masses of C1 split apart; Ring fracture

Tip of dens; Usually stable

Base of dens; Most common

Through C2 body; Unstable

Usually anterolisthesis of C2 on C3

Fracture through posterior elements of C2

Hyperextension and distraction; (head vs. dashboard);Unstable

Severe hyperflexion; Anterior vertebral body wedging; Disruption of posterior ligaments; Anterior avulsion fracture

Pars interarticularis defect “Scotty dog” fracture

Subluxation of adjacent vertebral bodies; Antero- and retrolisthesis, Laterolisthesis less common

Degenerative (osteoarthritis) change

Commonly occur at proximal 2/3 and distal 1/3 clavicle

normal shoulder that the humeral head slightly overlaps the glenoid

An anteroposterior view of the right shoulder shows the humeral head to lie medial to the glenoid and inferior to the coracoid process

aiming the x-ray beam parallel to the shoulder blade

Joint space narrowing; Bony overgrowth at edge of joint (osteophyte); Sclerosis (density along articular surfaces

Common pediatric elbow fracture

Common adult elbow fracture

Margin of anterior vertebral bodies

Margin of posterior vertebral bodies

Margin of the bases of the spinous processes

Posterior spinous line

C5-6 interspace

Cervical Sprain

Jefferson Fx

Hangman Fx

Clay Shoveler’s Fx

C5-T1: Burner; Spurling's maneuver

Cervical disc degeneration

UE radicular sx in dermatome pattern

Supraspinatus

Infraspinatus

Teres Minor

Subscapularis

Apprehension sign / Sulcus sign

Abduction; Resisted abduction; Hawkin’s sign; Neer’s sign

Scarf or Cross Over test

Internal rotation; “Lift-Off” test

External rotation; Resisted External rotation

Yergason’s test (resisted supination); Speed’s test (resisted forward flexion)

resisted supination

resisted forward flexion

Avulsion of the antero-inferior glenoid labrum

Compression fx of posterior humeral head

touch opposite ear over head

prone, weights off table

traction / counter traction

Inspect for: Cortical defects; Radiocapitellar line; Anterior humeral line; Fat pad sign

Usually normal; Sail sign

Always pathologic; Radial head fx in adults; Supracondylar fx in kids

PE: Pain over lateral epicondyle with resisted wrist extension & supination

Hx: Elbow pain from repetitive wrist extension

Golfer’s elbow; Mechanism: Repeated flexion Dx: Resisted wrist flexion/ pronation

Hx: May be traumatic or insidious. D/D: Infection, Gout, triceps rupture. PE: Red, swollen joint, + pain

PE: Red, swollen joint, + pain

Percuss over the median nerve in the carpal tunnel.

Acute flexion of wrists for 60-90 seconds

Compression of the median nerve

Mechanism: Repetitive motion. Sx: Night pain, numbness in median nerve distribution. May advance to thenar wasting

a beak, bulge or density at the fused epiphyseal line is not a fracture but a

Distal radial fx with volar angulation of the distal fragment

Distal radial fx with dorsal angulation of the distal fragment

Most common carpal fracture; 70-80% of carpal injuries; FOOSH injuries; Snuffbox pain

1/3 will develop osteonecrosis; May not be evident acutely, repeat films 10 days

“Letterman Sign”

Ring and small palmar fascia contracture

Stenosing tenosynovitis

UCL injury

Associated deformities

5th MC neck

DIP avulsion fracture

Osteoarthritis at PIP joint

Osteoarthritis at DIP joint (more common)

Hard & painless; Due to bony overgrowth; Thumb CMC joint pain site for early sx in women

Ulnar deviation of fingers

Swan neck deformity & Boutonniere deformity

Chronic swelling, decreased ROM; Bony erosion; Rheumatoid nodules on lateral forearm

Pain on hip flexion reproduces radicular pain

Foot dorsiflexion increases pain

Raising ipsilateral leg causes radicular pain on contralateral leg

Pain in SI joint

Pain & back extension when raising affected leg in seated position. One of the Waddell’s signs.

Reveals weakness of the hip abductors of the standing leg

PE: Tender paravertebral or erector spinae muscles. Minimal radiation

History, mechanism of injury, site of pain; 70% of LBP

L4-5, L5-S1 most common

SX: Sciatica; Signs: Positive SLR, Pain worse in certain positions

Mechanism: Flexion & rotation; Tears in annulus

Radiating pain, numb & weakness to lower extremity

for primary tumors, metastatic disease, or infection

Collapse of anterior wall of vertebral body

Lucency through the spinous process

Crack through the eyes, or an open beak

Increased distance between Pedicles, or a decrease in vertebral body height

Pars interarticularis fx; Dancers, gymnasts, lifters; Most occur L5

Pain adjacent to midline, á with extension & rotation; Scotty dog on oblique x-ray

Vertebral sliding, Dancers, gymnasts

PE: Step-off, may be asx.; Grade I – V (25- >100%); Isthmic, degenerative; Lateral film shows slip

Lateral curvature; Occurs in T or L spine; Idiopathic most common; Girls 7x > than males

associated with organ & vascular laceration

Fx commonly disrupted in 2 places

90% in those > 65 y/o

Sx: Pain, shorter, rotated leg. Risk: Age, sex, nutrition, meds

90% are posterior; PE: Hip flexed, adducted & internally rotated; Lateral x-ray

Origin of sartorius

Mechanism: knee flexed & hip hyper-extended

PE pain over ASIS, & with resisted hip flexion

Dx: x-ray may reveal avulsion fx. Rx: RICE, progressive weight bearing, splint with knee flexed, S&S, surgery for displace fx

Origin of hamstring

Vigorous hip flexion/knee extension. Pain in buttock

PE: pain at ischial tuberosity

Thin, female endurance athletes. Amenorrhea, anorexia, osteoporosis

Groin pain with running, progressing to pain with ADL pain; NIGHT PAIN; PE: pain limits extremes of int. & ext. rotation

Lateral femoral cutaneous nerve entrapment. Exits pelvis near ASIS

Sx: Pain & burning over the lateral thigh. Etiology: Obesity, tight clothing, repetitive trauma (tight jeans)

Avascular necrosis of the femoral head. Child 2-11 y/o

Insidious groin/thigh pain; Limp. PE: loss of int / ext rotation. X-ray: mottled femoral head

Obese, adolescents; 40% are bilateral; Most are idiopathic; X-ray: Slipped ice cream cone

Presents with limp and hip, thigh, or knee. PE: Loss of IR, flexion, & abduction

Lachman 15-20º, Anterior Drawer (90 deg knee flex)

Sag sign, Posterior Drawer

Varus

Valgus stress

McMurray test, joint line pain

Q-angle, Patella grind, anterior pain, tracking

Radiographic changes

Lateral femoral condyle

Tibial Tubercle Apophysitis

Apprehension sign

Pain over tendon insertion

ACL / MCL / Medial meniscus

Medial tibial plateau

Axial blow to the head with force transmitted through the occipital condyles; Forces the lateral masses of C1 outward

bilateral C2 pedicle fractures (usually due to combo of forces; eg, hyperextension and sudden violent distraction)

Thickened palmar fascia forms nodules over the flexor tendons causing a flexion contracture