Orthopedics 7

NSAID; Cox-2, Celebrex; Narcotic; Lidoderm patch; Anti-inflammatory; mx relaxants; Steroids

Ibuprofen 800 q6-8h pc; Naprosyn 500 BID

Percocet 5/325 q4-6h Vicodin 5/500 q 4-6h

NSAID, Cox-2

Flexeril; Skelaxin; Soma, Robaxin

Hold NSAIDs; Burst of oral steroids; consider trigger point

Acute or chronic injury to SI joint

Pain in SI area, Pos FABER, No discogenic pain

consider CBC, ESR, ANA, RF, HLA-B27

Ice, Stretch, NSAIDs, injection

L2-L4 nerve roots

Compression of nerve roots causes paralysis without spasticity (LMN)

Central disc herniation, abscess, hematoma

Loss of bladder/ bowel control, bilateral LE weakness & sensory deficits

Emergent Surgical Decompression

Progressive degeneration of disc & facet joints; Narrowing of canal; Compression of n. roots

Neurogenic claudication, radicular sx; Pain increased w/ sitting or spinal ext; Pain relieved w/ flexion, pt walks stooped-over

Sensory changes, dec DTR, mild weakness

Deficits may progress

may show narrowing of the IVD, old burst fx; MRI demonstrates stenosis

PT, core strength, NSAIDs, dec impact & bending, surgical decompression for progressive dz

Pars interarticularis stress fx

5%-8 % of population; Dancers, gymnasts, lifters

L5

Pain adjacent to midline, inc with extension & rotation

Scotty dog collar only on oblique xray

modify activity, core exercise, gradual RTP

Vertebral sliding (Dancers, gymnasts)

Step-off, may be asx.

Grade I – V (25 to >100%); Isthmic, degenerative

Lateral film shows slip

no restriction, core exercise

no restriction, core exercise, consider brace; Surgery for progressing slips or deficit

Irritation of sciatic n. (L4,5, S1,2,3) beneath piriformis mx

Trauma, spasm, anatomic

FROM of lumbar spine; Sciatic notch tenderness

HNP

Rest, ice, meds, stretch, injection

Scoliosis

observe

conservative Rx

T or L spine

Idiopathic

Girls 7x > than males

secondary dz & pain

Fusion & Rod

Forward flexion; Look for spine, scapula or hemi-thorax asymmetry

Measure angle from tilted vertebrae above & below apex of curve

mets to spine

BrCa, lung, prostate, colon, thyroid, kidney ca (hematogenous spread)

Night pain, n. root compression

primary

malignant

Osteosarcoma, Ewing Sarcoma, Chondrosarcoma

loss of articular cartilage & growth of new bone around facet joint

n. root compression by loss of disc height & facet hypertrophy

joint narrowing, sclerosis, osteophytes

Wt reduction, pt education; Pain relief

SI joint, and spine

HLA-B27 usually positive

Chronic low back pain in young adults; morning stiffness, improves with movement; 20% peripheral joint sx (Enthesopathies common; 25% with anterior uveitis)

Schobers test (normal is 5 - 7 cm movement)

Erosion & sclerosis on plain films

PT, NSAIDs, Sulfasalazine, Infliximab

Schobers Test

2 midline marks 10 cm apart starting at PSIS (dimple of Venus); remeasure w/ lumbar spine at maximal flexion

pathology

Calcification btw vertebral bodies at edge of discs; gives appearance of bamboo stalk; sclerosis of SI joint

Reduction in bone mass (Low peak mass; inc bone loss; hyperparathyroid, chronic steroids)

T score of < -2.5

vertebral compression fracture

Causes 4% of LBP

Oral Ca & Vit D; exercise, SMK cessation; Estrogen in postmen reduces bone reabsorption; Bisphosphonates augment bone density; Raloxifene inc bone density & dec total & LDL-C

Only .01% of all causes of LBP

Fever, leukocytosis; hx of other infections, hematogenous spread

Osteomyelitis; Septic Discitis; Paraspinous abscess; Shingles

2% of LBP

GB; Pancreas; AAA; Endometriosis; Chronic PID; Prostate CA; Renal stones or pyelonephritis

Rarely needed in nontraumatic, recent onset ALBP

Plain films approp: trauma/ longstanding sx ; if conservative Rx fails

AP / Lateral; Obliques; Flex & Ext

discopathy

primary tumors, metastatic disease, or infection

Fx; Disc space changes; Arthritic changes; Listhesis; Tumors

an owls head, straight on; each eye = pedicle; beak = spinous process

fx or dislocation

Fx, DDD, HNP

Missing eye (destrn); pedicle

Chance fx (seat belt fx)

Burst fx

Burst fx

Chance fx or spinous process fx

a collar

inf intervertebral articular processes

superior intervertebral articular processes

the lamina

a pedicle

a transverse process

the pars interarticularis

right lamina (& vice versa for left)

degenerative disc dz

fx & listhesis.

fx, DDD, & HNP

changes in ht cf to the others (Burst or wedge fx)

black (lucent) fx lines

Wedge fx; spinous process fx

Burst fx; Chance fx

lateral

MVA: lap belt immobilizes pelvis & thorax is forcefully flexed forward

crack thru eyes (pedicles), or open beak (crack through spinous process)

Collapse of vert body

smaller vertebral body

inc distance btw pedicles

fall from a ht, landing on feet or buttocks

may extend into spinal canal causing neuro S/S

Collapse of ant vert body w/ an intact posterior wall

hyperflexion injury and / or osteoporosis.

Lucency thru spinous process

C-spine (Clay Shovelers fx)

sudden forceful ligamentous traction on spinous process, or a direct blow to the process

Fall on coccyx

rectal to R/O hematoma, displaced fx

Radiographs not indicated

Ctrl pain; Reduce inflame; relative rest; Pain free ROM; correct inflexibilities & strengthen core mx; aerobic conditioning; wt reductn; correction of biomechanics; prevent recurrence

protection, rest, ice, compression, elevation, modalities, activity/ modification, meds

Regular strength/ flexibility exer; correct lifting & moving tech; posture standing/ sitting; proper body wt

Trauma, OA, infection

Gait; Scars; Swelling

Iliopsoas bursa; Gr trochanter/ bursa; Ant iliac spine; Ischial tuberosity/ bursa

Hip flex/ ext; Abd/ addn; Int / ext rotation; resisted ROM for strength

Normal =2-4 in heel to heel; Wide based gaits = instability

Normal gait oscillates no more than 2 in. vertically; pain & mx weakness => pt shifts COG over affected hip

S/B flexed in all phases of stance ex. heel strike; pt hikes up affected leg or swings it out & around to front

pelvis & trunk shift laterally 1 in. to wt bearing side

lateral shift is accentuated to the side involved

Ave length is 15 in. With age/ fatigue/ pathology: step is shortened

Ave cadence is 90-120 steps/ min. With age/ fatigue/ pain: cadence is decreased to conserve energy

Normal during swing phase = 40 degrees in leg that is moving forward; if pain or stiffness in hip, pelvis will not rotate normally

Limp from pain

Instability from cerebellar disease or peripheral neuropathy

Weak ankle dorsiflexors results in increase knee & hip flexion

Gastrocnemius/ Soleus weakness (S1-S2 radiculopathy)

Quadriceps weakness forces pt to push on thigh w/ hand to try to lock knee in stance phase

Gluteus medius weakness (L5); pt lurches toward weak side to place COG over hip

Gluteus max weakness (S1); pt thrusts thorax posteriorly to maintain hip extension

Weakness of tibialis anterior (L4)

disrupted in 2 places

inner & outer main ring cortices; 2 small obturator rings; acetabulum for step off; SI joint spaces s/b equal; symph pubis should align, < 5mm joint space

fx identified or suspected

organ & vascular laceration

AP pelvis w/ both hip joints; Lateral of affected hip

Smooth cortex w/ no buckle, step or ridge; Normal trabecular pattern; No transverse sclerotic lines

Cf to other hip; No lucency across the bone; No cortical defect

90% in > 65 y.o. pt

Pain, shorter, rotated leg

Falls, MVA

Age, sex, nutrition, meds

PE, pneumonia

AVN

Screws, partial or total hip replacement

Calcium, activity, exercise, safety

Incomplete fx w/ valgus impaction; ORIF

Complete fx w/o displacement; ORIF

Complete fx / partial displacement; Prosthetic replacement

Complete fx w/ total displacement; Prosthetic replacement

ORIF

ORIF

Open or closed reduction; Interlocking nail or screw

Closed reduction & Nail

ORIF with plate & screws

Thin, female endurance athletes (AAO)

Groin pain with running, progressing to ADL pain

Pain limits extremes of int. & ext. rotation

Xray may be negative; Bone scan pos in 2-8 days

Femoral neck

ORIF

NWBA 6-8 weeks

ORIF

90% are posterior

hip flexed, adducted & internally rotated

Xray, pain relief, reduction; Poss N/V entrapment

Anesthesia; Assistant stabilizes pelvis w/ pressure on iliac sp; Gently flex hip to 90; apply progressive traction to extremity; apply adduction/ internal rotation

Achy pain over hip & ant groin; Loss of ROM

Decreased Joint space; Sclerosis; Osteophytes

NSAIDs; Intraarticular injection; Hip replacement

Separation or widening of apophysis

knee flexed & hip hyper-extended

origin of Sartorius

Pain over ASIS & with resisted hip flexion

Xray may reveal avulsion fx

RICE, progressive wt bearing, splint with knee flexed, ORIF for displaced fx

Origin of hamstring

Vigorous hip flexion/ knee extension

Pain in buttock

TTP at ischial tuberosity

RICE, progressive wt bearing, ORIF for displace fx

Forced abduction during fall or collision

Pain at origin of adductors

Increased pain on resisted adduction

Hernia, torsion

Rest, ice, meds, stretching & strengthening

Direct blow to iliac crest

Swelling, tenderness, ecchymosis at iliac crest

Xray to R/O fx

Ice, compression, pain meds; Progressive stretching

Avascular necrosis of the femoral head

Child 2-11 y.o.

Insidious groin/ thigh pain; Limp

Loss of int / ext rotation

Mottled femoral head

Containment of femoral head with bracing / casting

self limiting, revascularization occurs in some

Obese, pre-pubescent boys & girls; 40% are bilateral; most are idiopathic

Limp & hip, thigh, or knee pain; loss of IR, flexion, & abduction

surgical fixation & non wt bearing

1: ITB snaps over Gr trochanter; 2: Iliopsoas tendon snaps over ASIS

Hip pain worse with activity; Snapping with hip flexion

Pain with resisted hip flexion; Pain lateral with ITB, anterior with ASIS

Ice, meds, activity modification, S&S, injection

Pain over Gr trochanter when moving hip into full flexion; Extreme point tenderness; Pain at night lying on affected side

Moving hip from extension to flexion reproduces pain; poss crepitus over trochanter; TTP over affected greater trochanter

Hip stretches, meds, injection

Benign, non traumatic, self limiting hip pain; lasts 3-7 days

septic hip; Legg-Calve-Perthes

Inflam immune response to URI; inc synovial fluid in hip joint causing pain

Painful ROM; Joint held in flex, abd & ext rotation

Capsular swelling

WBC & ESR normal; Joint fluid aspiration is normal

Symptomatic

URI

GAS, S. aureus

H. flu, GAS, E. coli, N. gono

Fever, joint or bone pain, leukocytosis

Bone scans localize osteomyelitis; Joint aspiration to ID organism

Parenteral Abx, I&D

Lateral femoral cutaneous n. entrapment; Exits pelvis near ASIS

Pain & burning over lateral thigh

Obesity, tight clothing, repetitive trauma/ activity

Correct offending source; pain relief; chronic pain may need injection or surgical release

developmental dysplasia of the hip

DDH (Peds); Tumor; Osteosarcoma; Ewing; Metastatic dz; Multi myeloma