Orthopedics 6

Loss of central slip insertion on proximal dorsal middle phalanx

Flexion of PIP & hyperextension of DIP

Surgical

Central slip rupture of extensor tendon over PIP causing PIP flexion contracture with DIP extension contracture; Forced flexion of actively extended PIP

TTP over dorsal PIP, loss of motion, & extensor lag

Serial casting, static extension splint

Joint Synovitis secondary to RA

Flexion of the DIP & hyperextension of the PIP

Surgical correction

Gamekeepers thumb

UCL injury: Abduction stress

X-Ray prior to exam

Non-displaced fx or mild laxity

Immobilize 3-6 weeks; thumb Spica Cast

surgical fixation

Significant laxity; Stener lesion; surgical fixation

Aponeurosis interposed between ligament

Fx of thumb metacarpal base

Axial blow or adduction stress to thumb; APL inserts into base of thumb causing displacement of fragment

must have ORIF

Rolando fx

Boxers fx

loss of prominence of MCP head

CRPP

Index 10, middle 20, ring 30

cast for 4 wks, then functional splint

Displaced fx may angulate, rotate, or shorten & s/b evaluated for CRPP

Direct impact from racquet, baseball bat

TTP over hamate, check ulnar n.

CT view; may need CT scan

Excision of fragment vs 4-6 wks casting

Rx w/ protective DIP splint symptomatically

consider CRPP

stability (rotation, displacement, shortening)

Splint or buddy tape stable fx for 3-4 wks

ORIF; Protect w/ activity for 8 wks

Ulnar gutter splint or cast for 3-4 wks, then functional splint

Varus or valgus stress to PIP

assess stability passively & actively

may buddy tape 4 wks w/ protected ROM

surgery indicated

Rupture of extensor tendon distal to DIP

Axial load causing forced flexion

Unable to actively extend DIP

< 50% of articular surface involved

Stax splint or DIP extension splint 24/7 for 6 wks; mallet finger protocol

Forceful extension of DIP; FDP avulsion

Pt unable to flex DIP; most common to ring finger

Surgical repair

Dorsal

Disruption of volar plate a&nd collateral ligaments

to R/O fx

Reduce; splint w/ PIP in 30 degree flexion for 2-4 wks

(Rare); disruption of collateral ligs & central slip

X-ray, Reduction; extension splint 4-6 wks

Similar to dislocations

(>30% of volar plate articular surface); Surgical fixation

Splint 3-4 weeks, early ROM exercises; may play buddy taped

Tibia

MOI ( twist, blow to knee, trauma); Pain; Instability, pops, clicks, grinding; swelling; pain hip/ ankle/ foot; prior

contralateral joint (cf)

Within first few hrs; Hemarthrosis

ACL Tear; Patella Dislocation; Fx; Meniscus tear (not always)

Patellofemoral dysfxn; Patellar tendinitis; Plica/ Fat Pad irritation

Meniscus, DJD, MCL; Pes Anserine Bursitis; Chondral lesion

Meniscus, LCL, ITB; Posterolateral corner (PLC); Chondral lesion

ACL, PCL, PLC, ITB

ACL, fx, dislocation, meniscus

Meniscus, gout, chondral lesions

Infection, arthritis, referred pain, neoplasm

Swelling/Effusion (1+ to 3+ ; Local vs diffuse; Acute vs Chronic); Bruising; Deformity (fx; prior surg); Scars; Quad atrophy

Joint line (Menisc ); Condyle (Chondral lesion); Plica; Pes Ans bursa; MCL; Medial retinaculum (patella dislocn)

Joint line (Menisc); LCL; Iliotibial Band (Gerdy tub.; Bursa); Condyle (Chondral lesion; Patella dislocation); Femoral head (Peroneal n. Sx); PLC (posterior)

Bakers cyst (Menisc); Meniscus tears; Poplit art; Poplit mx; Gastrocnemius tear; Hamstring tear (distal)

Flexion (135-140; goniometer); ext 0 degree (some: 5-10 degree natl hypertext); cf to nml knee; Squat (ltd ? Menisc tear)

Med/Lat glide; Apprehension (instability); Inhib test (PFS); Q angle; J Tracking; Poplit Angle (Hamstring tightness); Modified Thomas Test (Quad/ hip flexor tightness)

angle formed by line: ASIS to ctr of patella & line fr ctr of patella thru tibial tubercle; <20 degrees = nl

MCL or Valgus; McMurray;

O & 20-30 degrees flexion

Concomitant ACL

no opening, but pain

opening with endpoint

no endpoint

Only 65%

Ext rotation w/ flexion & valgus

Internal rotation w/ flexion & varus

A click (not pain)

Not usually helpful

Ober; Nobles compression; PLC; reverse pivot; posterolateral drawer; dial

Same grade as for MCL

Obers; Nobles compression test

Inability for Up Leg to go down to table (= tight lateral structures)

Pain over lat. Fem condyle at 20 deg knee flexion

in ACL and/ or multi-ligament knee injuries

Recurvatum (with PCL); dial test at 30 degrees flexion; reverse pivot shift

Lachman; ant drawer (unreliable); Pivot shift (difficult)

Lachman

Post drawer & recurvatum; sag sign; quad active; dial test at 90 degrees flexion

easily missed or mistaken for ACLs (Hx important)

Much better than ant. Drawer

AP, Lateral; Merchant; Tunnel view (look for OCD)

Tumors; Fx; DJD; Surgeries/ Hardware

Patella (Instability; DJD; Chondral lesions)

Flattened Tib. plateau; cec. joint space; Osteophytes; Subchondral cysts

• soft tissue
• MRI in ortho: for:
• ACL ( >95%); Menisc (>85%); chondral lesion (cannot quantify size); MCL,LCL,PLC,PCL; Bone Contusions/ Edema; tumors; fx?

fracture characterization

evaluating soft tissue injuries

When quad mx is activated, pulls tibia forward; when it relaxes, tibia sags

Pulling up on toe to about 15 degrees of hyperextension, then just falling back (as if not attached properly at knee)

At 20 degrees flexion; stabilize femur, pull up on tibia

knee is flexed to 90, then pull on tibia

If hip flexors are tight, when pull one leg up, other leg also pulls up somewhat

Valgus injury (Soccer, ice hockey)

MCL

Medial pain (on joint line, above & below); Grade I,II,III; Valgus stress

conservative; NSAIDs; Ice; Rest; Bracing; PT; RTP?; Surgical: Rare

symptomatic tx

4-6 weeks, start in extension

Twisting injury (Acute); Degenerative; Swelling +/- ; Locking/ catching

MJL tenderness; McMurray; Apley; Cyst

conservative vs surgical

Osteochondritis Dissecans

Intermittent swelling after exercise, locking, catching, vague pain

small effusion, TTP MFC or LFC

NWB, progress slowly over 6 weeks or more

snapping, esp with squats (can also be MMT)

palpable plica, localized swelling; Imaging (r/o other injuries)

PT, ice post exercise; iontophoresis; NSAIDs; Injection; Surgical excision

Lat Meniscus Tear; LCL Tear; IT Band; Patella disloc/ subluxation; PLC; OCD; Hamstring strain/ tear; PFSS

Runners Knee

Snapping knee or hip; Occasional instability

biomechanics, flexibility; Mileage

PT, local distal injection, orthotics, different shoes or surfaces

Varus injury (do varus stress test)

conservative; 1-2 wks(I), 4-6 wks (II)

consider surgical repair/ reconstruction; assess for concomitant injuries (PLC)

visual sublux/ dislocation, twisting motion; previous occurrence? Brace? N/V status

Ant Knee exam; biomechanics

AP/Lat, Merchant view

extension brace 1-2 wks; quad strengthening; RTP w/ buttress brace

consider surgical repair

Extension Post-op brace locked at 0 deg or knee immobilizer for very short term (until referred); mostly for protection; ACE for swelling; NSAIDs; PT (Prehab); Refer; consider brace

MRI to R/O other injuries

9-12 mos

Posterior drawer; sag sign; Recurvatum; Quad active test

seated, kneecap pushes into articular cartilage (spongy, water is displaced); sit up, kneecap pushes into waterless sponge space: pain.

PT; Short course of NSAIDs; open patella brace optional; footwear/ orthotics ; modify activity; Surgery (Last Resort)

VMO (vastus medialis obliqus) (co-contract with adductors); hip abductors/ ext rotators

60-80%

Low Back Pain

obesity, sedentary, improper biomechanics

70% improved in <1 week & asymptomatic in <1 month; 90% asymptomatic in 6-12 wks

central nucleus pulposus; peripheral annulus fibrosis

degeneration overloads facet joints in verts

herniation impinges nerve roots

Abdominal & Psoas

Erector Spinae, Iliocostal, longissimus & spinalis

Multifida

Intersegmental

control trunk movement

lower extremities

Nonspecific pain in lower back or one or both buttocks

Brief, sharp, shooting, increased by cough, standing, & sitting.

Severe, constant pain persisting at night

> 50 y.o.; kids; Night Pain; Fever, malaise, wt loss; Bladder/ bowel dysfunction; Progressive deficit; Prior ca; Pain > 1 month

C/C, meds, allergies

Initiating event, MOA; Site of pain; OLDCARTS; priors, tx, studies

Gait; Posture; Deformity

Bony; Soft Tissue; Pulses

Flex, ext, lateral flex, rotation

SLR; FABER test; Neuro Exam (Sensory, Motor, DTRs)

Pain on straight leg flexion reproduces radicular pain

Foot dorsiflexion increases pain

Raising contralateral leg causes radicular pain on ipsilateral leg

Pain in SI joint

Symmetry/ Deformity/ Scars

Hip flexion

Hip adductors

Knee extension

Ankle dorsiflexion

Hallicus Longus extension

Hallicus Longus flexion

Upper outer thigh

Mid anterior thigh

Below patella

Medial ankle

First web space

Lateral ankle

L2,3,4

S1

Non-organic Physical Signs in LBP

Superficial skin tenderness over wide area; Non-localized deep tenderness

Axial load should not cause LBP

Flip test

Widespread muscle pain in various groups

Pain out of proportion

MOI; site of pain

Lumbar Strain

Tender paravertebral or erector spinae mx; min radiation

Pain relief, modified activity, exercise, education, & encouragement; Injection with trigger point pain; PRICEMMM

Herniated Nucleus Pulposus

L4-5, L5-S1

HNP

Flexion & rotation; Tears in annulus

Sciatica (radiating pain, numbness & weakness to LE)

Pos SLR, Flip sign, Pain worse on back ext

Infection, tumor

MRI / CT

17-36%

5%, pain & numbness above knee

5%, numbness to shin, weak ankle dorsiflexion

67%, weakness of EHL & numbness top of foot and 1st web space

28%, numb lateral foot, weak plantarflexion

Conservative, NSAIDs, mx relaxants, Exercise & Education

surgery d/t progressive neurologic deficit