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Home , Achilles bursitis, Arthropathy, Bursitis, Olecranon bursitis, Oligoarthritis, Prepatellar bursitis

Musculoskeletal Disorders and Conditions of Adults

Frank Caruso DMSc, PA-C, EMT-P Skin, , Hearts & Private Parts 2019 2 Goals :

• Review MSK pearls - briefly • Review common musculoskeletal disorders of the adults – diagnosis and treatment • Review common Rheumatologic conditions • Review common fractures/dislocations/ of the MSK • Review Benign and Malignant Soft Tissue Tumors Seven Part :

• Part I: Physical Exam • Part VI: Common Key Points/General Fractures – Basics of Principles Fracture Care • Part II: Conditions of the Adult/Child Adult MSK - Treatments • Part VII: Benign and • Part III: Pregnancy Malignant and • Part IV: Older Adults Soft Tissue Tumors • Part V: Rheumatologic Conditions – Common, overview

4 Part I

Examination Key Points

5 Examination Key Points

• Area needs to be well exposed – gown your patients!!! • Understand normal functional • Observe normal activity • Palpation • Range of Motion • Strength/neuro-vascular assessment • Specific provocative assessment Where Do Patients Go that have Pain? YOUR

OFFICE!!

8 Musculoskeletal System

• The musculoskeletal system provides the stability and mobility necessary for physical activity. • Physical performance requires bones, muscles, and that function smoothly and effortlessly. General Principles

• Musculoskeletal exam performed if symptoms (i.e. , pain, decreased function) – different from a “screening exam” • Focused on the symptomatic area • Musculoskeletal complaints common

10 Historical Clues

• What’s the functional limitation? • Symptoms in single vs multiple joints? • vs slowly progressive? • If injury – mechanism? • Prior problems with this area? • Systemic symptoms?

11 Terminology

• Anatomic Position and planes of the body • Flexion: – moving forward out of the frontal plane of the body – except and foot) • Extension – Movement in the direction opposite to flexion • Abduction – Movement that brings a structure away from the body • Adduction – Movement that brings a structure towards the body

12 13 14 History

15 MUSCULOSKELETAL PROBLEMS QUESTIONS TO ASK • Any trauma? • Medical history? • Location of pain? – Systemic ? • Any radiation? • What makes it better? • Occupation? • What makes it worse? • Hobbies/Daily • Have you had this before? Activities? • Any surgery? • Any medication/treatments? • Any functional problems – Loss of motion, weakness, numbness?

16 Examination Keys to Evaluating Any • Have area well exposed • Inspect joint(s) in question, any signs of , injury (swelling, redness or warmth) Any deformity – compare to opposite side • Understand normal functional anatomy • Observe normal activity – what can’t they do? Any specific limitations?

17 Examination Keys

• Palpate joint – any warmth? Point tenderness? What structures are involved? • Range of motion – active(patient moves) and passive (you move it) • Strength, neuro-vascular assessment • Specific provocative maneuvers • If acute injury and pain – may be difficult to assess as the patient attempts to “protect” the area injured – Attempt to examine the unaffected side first (gain confidence, develop sense of their normal)

18 General Exam Musculoskeletal Overview

End Feel

• The sensation the examiner feels in the joint as it reaches the end of the range of motion of each passive movement • Bone to bone: This is hard, unyielding – normal would be extension. • Soft–tissue approximation: yielding compression that stops further movement – elbow and knee flexion. End Feel

• Tissue stretch: hard – springy type of movement with a slight give – toward the end of range of motion – most common type of normal end feel : knee and metacarpophalangeal joint extension. Abnormal End Feel

• Muscle spasm: invoked by movement with a sudden dramatic arrest of movement often accompanied by pain - sudden hard – “vibrant twang” • Capsular: Similar to tissue stretch but it does not occur where one would expect – range of motion usually reduced. Abnormal End Feel

• Bone to bone: similar to normal bone – to bone but the restriction or sensation of restriction occurs before the normal end of range of movement • Empty: detected when considerable pain is produced by movement - - no real mechanical resistance – acute - Abnormal End Feel

• Springy block: similar to a tissue stretch – occurs where one would not expect it to occur – usually found in joints with menisci. There is a rebound effect – example: would feel a springy block end feel with a torn of a knee when it is locked or unable to go into full extension.

29 Range of Motion

• Active ROM and passive ROM for each joint and related muscle group • Note – Pain – Limited or spastic movement – Joint instability – Deformity – Range of Motion

• Passive ROM may exceed active ROM by 5 degrees. • Active ROM and passive ROM should be equal in contralateral joints. • Discrepancies may indicate muscle weakness or disorder. • Use goniometer where there is increased or limited ROM.

NEUROLOGICAL EXAM

35 Let's Put It All Together!!

Common Conditions Musculoskeletal System Part II

Conditions of the Adult Musculoskeletal System

37

Most Common Outpatient Orthopedic Conditions

1. Common presenting symptoms 2. Physical exam findings 3. Diagnosis 4. Treatment Cervical

Cervical Strain- ICD9 847.0, ICD10 S13.4 “Oh my aching, stiff, Special tests: x-rays, painful neck” MRI, EMG/PNCV PE: Trigger points, Treatment: Reduce reduced motion, muscle irritability normal neurologic, no and spasm and re- bony tenderness establish the normal cervical lordosis Greater Occipital Neuralgia ICD 9 723.8/10M79.2 • Headaches • Piercing throbbing, electrical shock pain • Starts in neck spreads to ear, frontal area • Reproduction of pain upon compression of the greater occipital nerve against the edge of the occiput. – Treat trigger point Cervical Spondylosis

• Also known as degenerative cervical disc • Common radiographic finding after age 50, frequently asymptomatic • Complaints of neck stiffness/pain, loss of motion • Treat symptomatically, rarely needs surgery – involve early on in the course of symptoms

44 45 Cervical Radiculopathy

“My and fingers feel numb” Special tests: x-rays, MRI, “I think I have a pinched EMG/PNCV nerve” Treatment: Reduce pressure PE: Abnormal upper extremity over the nerve, improve neurologic exam, loss of neurologic function, motion, +spurling sign, vertical traction may not help, improve neck flexibility, paracervical tenderness. Look neurosurgical consultation for muscle atropy – change in reflexes

Myofascial Pain

• Chronic disorder • Pressure or sensitive points in muscles (trigger points) causes pain in the muscle • Treatment: Physical therapy, trigger point, work station analysis

48 Shoulder ICD-9 ICD 10

• Shoulder pain – 719.41 • Shoulder pain – M25.51 • Rotator cuff - • Rotator cuff sprain - 840.4 S43.4 • Rotator cuff tendonitis • Rotator cuff tendonitis – 726.10 – M75.1 50 51 52 Supraspinatus

53 54 Infraspinatus

55 Teres Minor

56 Subscapularis

57 Shoulder: Impingement Syndrome

“It’s too painful to raise Special tests: X-Ray, MRI my arm up”, I can’t Treatment: Increase the sleep on my shoulder at subacromial space, night” physical therapy, PE: +FAR, AC tenderness, injection, rotator cuff strength subacromial should be normal decompression Shoulder: Rotator Cuff Tendinitis

“I can’t reach up or back Special tests: x-rays, MRI anymore” Treatment: Reduce cuff PE: Subacromial inflammation, physical tenderness, FAR therapy, prevent present, painful arc, rotator cuff strength can be diminished

Shoulder: Rotator Cuff Tear

“I have no strength in my arm”, Special testing: x-ray, MRI I have loss motion” Treatment: Recover and PE: Loss of motion, weakness improve lost strength, in rotator cuff testing, high return of range of motion, riding humeral head on x- therapy, surgery, rehab ray, atrophy of infra/supraspinatis over scapula

Biceps

• CPT code: 20550 – Injection of single sheath • ICD-9 Code: 726.12 • ICD-10 Code: M75.2 Biceps Tendinitis

“ The front of my Special tests: x-rays, MRI shoulder hurts every Treatment: Reduce time I lift my brief case, inflammation, I have this lump in my strengthen the biceps muscle” muscle and tendon, PE: Local tenderness in surgical debridement the bicipital groove, pain aggravated by flexion of the elbow, a bulge in the arm.

Glenohumeral Joint

ICD-9 ICD-10 • Shoulder pain: 719.41 • Shoulder pain: M25.51 • Shoulder adhesive • Shoulder adhesive capsulitis: 726.0 capsulitis: M75.0 • GH joint , • GH joint arthritis, unspecified: 716.91 unspecified: M 13.91 • GH joint arthrosis, post- • GH joint arthrosis, post- traumatic: 715.11 traumatic: M19.01 • GH joint arthrosis , • GH joint arthroisis , secondary: 715.21 secondary: M19.21 Glenohumeral

“My shoulder makes a terrible Special tests: x-ray, MRI to clunking noise, my shoulder evaluate rotation cuff is stiff” Treatment: combine exercises PE: Crepitation with to improve ROM, circumduction or clunking injections, Surgery sensation, restricted abduction and external rotation

Shoulder: Adhesive Capsulitis

“My shoulder is stiff; I can’t Special tests: x-ray, MRI reach back to my wallet or Treatment: Gradually stretch get to my bra” out the glenohumeral joint PE: Loss of ROM glenohumeral lining, return of normal joint, especially abduction ROM/strength, and external rotation, no manipulation, debridement evidence DJD on x-ray

Scapulothoracic Syndrome

ICD-9 ICD10 • Bursitis of shoulder: 727.3 • Bursitis of shoulder: M75.5 • Specified injury to scapula: • Specified injury to scapula: 719.48 S49.8 • Unspecified injury to • Unspecified injury to scapula: scapula: 959.2 S49.9 • Other specified of • Other specified arthropathy scapula: M19.81 of scapula: 716.81 • Unspecified arthropathy of • Unspecified arthropathy of scapula: M19.91 scapula: 716.91 Subscapular Bursitis

“My shoulder blade is Special tests: none killing me” Treatment: reduce the PE: Local tenderness just acute inflammation under the superomedial and to prevent further angle of the scapula episodes by improvement of posture, steroid injection

Acromioclavicular Joint

ICD-9 ICD-10 • AC joint pain: 719.41 • AC joint pain: M25.51 • AC joint sprain: 840.0 • AC joint sprain: S43.5 • AC joint subluxation/dislocation: • AC joint 831.04 subluxation/dislocation:S43.1 • AC joint arthritis, unspecified: • AC joint arthritis, unspecified: 716.91 M13.91 • AC joint arthrosis, primary: • AC joint arthrosis, primary: 715.11 M19.01 • AC joint arthrosis, posttraumatic: • AC joint arthrosis, posttraumatic: 716.11 M19.11 • AC joint arthrosis, secondary: • AC joint arthrosis, secondary: 715.21 M19.21 Acromioclavicular strain/OA

“I can’t lie on my Special tests: x-ray, shoulder” weighted PE: Local tenderness at Treatment: reduce direct AC joint, increase pain pressure and traction with passively at the AC joint, adducting arm across surgically debridement the chest

Multidirectional Instability of the Shoulder “It feels like my shoulder s Special tests: X-ray, CT/MRI going to pop out, I don’t arthrogram trust my shoulder for Treatment: toning exercises sports” to improve stability, PE: Downward traction causing isotonic exercises in the sulcus sign, increased external and internal anteroposterior mobility of rotation, surgery the humeral head, positive apprehension sign 86

Sternoclavicular Joint

ICD:9 ICD:10 • SC joint pain: 719.41 • SC joint pain: M25.51 • SC joint sprain: 848.41 • SC joint sprain: S43.6 • SC joint : 739.61 • SC joint: S43.2 (subluxation/ (subluxation/dislocation) dislocation) • SC joint arthritis: 716.91 • SC joint arthritis:M13.91 • SC joint arhrosis, primary: • SC joint arhrosis, primary: M19.01 715.41 • SC joint arthrosis, post- • SC joint arthrosis, post- traumatic: M19.11 traumatic: 716.11 • SC joint arthrosis, secondary: • SC joint arthrosis, secondary: M19.21 715.21

Sternoclavicular Joint

• Supine on the examination • Fold patients' across abdomen • Rotate patients head away form side being injected • Treatment: local inflammation, injection ELBOW

91 92 Lateral Epicondylitis

“I can’t even lift a cup of coffee Special tests: none with out pain, after playing Treatment: allow microtorn tennis my elbow aches” common extensor tendon PE: Local tenderness at the to heal, restore forearm lateral epicondyle, lateral muscle strength, cross elbow pain increased by friction massage, PT, resistance of wrist sleeve, steroid injection, extension surgery

Lateral Epicondylitis

• CPT: 20551 Injection of tendon origin or insertion • ICD-9: 726.32 • ICD-10: M77.1 Medial Epicondylitis

• CPT: 20551 – Injection of tendon origin or insertion • ICD 9: 726.31 • ICD 10: M77.0 Medial Epicondylitis:

“My elbow aches after using Special testing: none my computer, I’m losing Treatment: allow the micro strength of my grip, my torn common flexor tendon elbow hurts so bad” to heal, restore forearm PE: Local irritation at the muscle strength, steroid medial epicondyle, loss of injection, surgery strength – weakness of grip, pain aggravated by resisting wrist flexion and radial deviation

Olecranon Bursitis

• CPT Code: 20605 – Aspiration and/or injection of intermediate bursa • ICD-9: 726.33 • ICD-10: M70.2

“I have this golf ball swelling at Special testing: Bursal fluid the end of my elbow, all of a analysis, x-ray sudden I developed this red, Treatment: determine cause hot, swollen area over my of swelling, aspiration, elbow” drainage lab analysis, PE: compression, surgery Swelling, redness, and heat over the olecranon process, FROM, characteristic aspirate

Cubital Tunnel Injection

• CPT code: 64450 – injection, nerve block, therapeutic, other peripheral nerve or branch • ICD-9: 354.2 • ICD-10-G56.2

Radial Nerve Entrapment

• CPT code: 64450 • ICD:9 354.2 • ICD:10: G56.3

Radial Nerve Entrapment

• Caused by entrapment of deep branches of the radial nerve • Pain, weakness and dysfunction • Treatment: therapy, injection, surgery Wrist Joint

ICD-9 ICD-10 • Wrist pain: 719.43 • Wrist pain: M25.53 • Wrist sprain, unspecified: • Wrist sprain, unspecified 842.00 S63.5 • Wrist joint arthritis: 716.93 • Wrist joint arthritis:M13.93 • Wrist joint arthrosis, primary: • Wrist joint arthrosis, primary: 716.13 M19.03 • Wrist joint, post-traumatic: • Wrist joint, post-traumatic 716.13 M19.13 • Wrist joint arthrosis, • Wrist joint arthrosis, secondary: 715.23 secondary: M19.23 Wrist/Hand

111 Wrist: De Quervain Tenosynovitis

“I can’t grip anymore, my bone is Special test: : plain films wrist and getting bigger, it hurts right here!” Treatment: reduce the inflammation PE: Local tenderness at the tip of the in the tenosynovial sac, to radial styloid, pain aggravated by prevent adhesion from forming, resisting thumb extension or and to prevent recurrent abduction, positive Finklestein tendinitis. Steroid injections test (passive stretching the placed at the radial styloid, thumb in flexion, distensible surgery tenosynovial sac

De Quervain’s

• CPT code: 20550 injection of single • ICD9: 727.04 • ICD10: M65.4 Carpometacarpal Osteoarthritis

“ I can’t knit anymore because Special tests: x-rays wrist and of the constant pain in my thumb thumb, what is this terrible Treatment: relieve swelling swelling?” and inflammation, PE: local joint tenderness, joint subluxation. Avoid crepitation, and painful exposure to vibration, local motion, positive grind test injection, splinting, surgery

Gamekeeper’s Thumb (Ulnar collateral Ligament Injury) “I took a bad fall while skiing, Special tests: x-ray, MRI to My thumb got caught in my look for severe ligament pole strap” injury PE: MCP joint is examined for Treatment: immobilization for swelling, tenderness, acute injury, splinting swelling, and instability, during rehab, decreased pinch strength, reconstructive surgery excessive motion with valgus stress

Carpal Tunnel

“My thumb and first two Special tests: PNCV/EMG fingers go to sleep at night, Treatment: to reduce my hand falls asleep when I compression of the median drive the car, my hand nerve, treat concurrent keeps going numb” flexor tenosynovitis, PE: Sensory loss in the first adjustments in work three fingers, positive Tinel station, splinting, steroid sign, Phalen or compression injection, surgery

Dorsal Ganglion

• CPT code: 20550 – injection of • ICD9: Ganglion cyst of joint: 727.41 • ICD10: Ganglion cyst of joint: M67.4 • ICD9: Ganglion cyst of tendon sheath: 727.42 • ICD10: Ganglion cyst of tendon: M67.4 Dorsal Ganglion

“ I had this lump on the back of Special testing: sometimes my wrist for a long time but it MRI recently has grown bigger” Treatment: Simple aspiration, PE: highly mobile, fluctuant cyst steroid, bracing, surgery that transilluminates light, min tenderness, normal wrist motion, highly viscous aspirate

Trigger Finger • CPT code: 20550- injection of single tendon sheath • ICD9: 727.03 • ICD10: M65.3

“My finger is locked down in Special tests: none the morning and is very Treatment: reduce the painful to unlock” swelling and inflammation PE: local tenderness at the in the flexor tendon sheath, MCP head, mechanical allow smoother movement locking pain aggravated by of the tendon under the A- stretching the finger in 1 pulley, steroid injection, extension surgery

Dupytren Contracture

“ My finger(s) will not straighten out, Special tests: none been getting worse for a long Treatment: Surgical procedure, time, I can’t hold a hammer or partial fasciectomy to debride small tools anymore” and release the fibrotic tissue PE: Puckering of the skin over flexor enveloping the tendon or tendon in the palm with forced extension of the finger, painless palmar nodules, fixed contracture of the affected fingers (usually the fourth and fifth fingers

Chest Sternochondritis Costochondritis “It hurts right here. I think I’m Special tests: local anesthetic having a heart attack!” block is diagnostic PE: localized tenderness and Treatment: reassure the swelling at the patient, reduce local costochondral or inflammation, PT, sternochondral junctions medication and pain aggravated by chest wall compression

Complex Regional Pain Syndrome

• “My foot burns, constantly • Special tests: bone scan, cold- painful and changes color for stress tests months” • Treatment: dystrophic • Dysfunction of central or medication, nerve blocks, peripheral nervous system requires team approach!! No PE: cure! • Dramatic changes in color and temperature of the body part effective PT: • Intense burning pain, skin sensitivity, swelling, sweating

Muscular Trigger Points

ICD:9 ICD:10 • Fibromyalgia/Fibromyositis: • Fibromyalgia/Fibromyositis: 729.1 M79.7 • Myalgia/Myositis: 729.1 • Myalgia/Myositis: M79.1 • Spinal : 720.1 • Spinal enthesopathy: M46.0 • Cervicalgia: 723.1 • Cervicalgia: M54.2 • unspecified • Rheumatism unspecified – 729.0 – M79.0 • Tension Headache: 307.81 • Tension Headache: G44.2 Trigger Points

• “Everything hurts, my muscles are constantly sore, can’t sleep at night”

138 Muscular Trigger Points

• Areas of muscular ischemia • Can occur anywhere • Usually involve the back muscles • Common with patients with fibromyalgia/fibrositis • Treatments: May “dry needle” or only inject anesthetic, therapy, alternative medicine, etc. Lumbar Spine 141 Lumbosacral Strain

“Oh my aching back, I get Special tests: X-rays, CT or MRI these terrible lower back Treatment: reduce spasm by spasms” stretching and toning, treat PE: look for degree of any underlying structural paraspinal muscle spasm back condition and tenderness, along with ROM, normal neurologic exam unless there is concomitant radiculopathy Lumbar Radiculopathy, Herniated Disk, Sciatica

“I have this shooting pain down my Special testing: X-rays, CT scan, MRI, leg to my toes, my leg feels numb EMG/PNCV and weak” Treatment: confirm diagnosis, PE: Abnormal straight-leg raising, reduce the pressure over the percussion tenderness over the nerve, improve neurologic spinous process, abnormal function, evaluate for need for neurologic exam: sensory loss, surgery loss of deep tendon reflex, motor weakness, loss of bowel or bladder control

Sacroiliac Strain

“ I have this sharp pain in my Special tests: x-rays, bone buttock, it feels like an ice scan, MRI, CT –confirmation pick is being shoved into my by local anesthetic block, back” blood work (Sed rate) PE: local tenderness directly Treatment: reduce over the sacroiliac joint, inflammation of the SI tenderness aggravated by joint, williams flexion compression or by pelvic exercise, medication, torque steroid injection

Trochanteric Bursitis

“I can’t lay on my side, I have Special tests: x-rays of hip, this sharp pain in my hip, I bone scanning, CT or MRI can’t stand for very long” Treatment: reduce PE: local tenderness at the inflammation in the bursa, greater trochanter, ROM hip correct any underlying normal disturbance of gait, steroid injection, therapy, surgery Trochanteric Bursitis

• CPT code: 20551 injection of tendon origin or insertion • ICD-9 : 726.5 • ICD-10: M70.6

Knee

ICD:9 ICD:10 • : 719.46 • Knee pain • Knee sprain, unspecified • Knee sprain, unspecified site site • , unspecified • Knee arthritis, unspecified • Knee arthrosis, primary • Knee arthrosis, primary • Knee arthrosis, • Knee arthrosis, posttraumatic posttraumatic • Knee arthrosis, secondary • Knee arthrosis, secondary Knee

152 153 Knee: Patellofemoral Disease

“I have pain going up and Special tests: four views of down steps, I have these knee, MRI painful crunchy ” Treatment: improve PE: Painful retropatellar patellofemoral tracking and crepitation, full ROM but alignment, reduce pain and with abnormal swelling, and retard the patellofemoral tracking, development of negative apprehension patellofemoral arthritis. steroid injection, arthroscopy, replacement

Knee Effusion

• “My knee is swollen; I can’t Special tests: x-rays of knee, flex extend my knee analysis after because of the swelling” aspiration, arthroscopy • PE: general fullness and Treatment: diagnose the loss of medial and lateral underlying cause of the peripatellar dimples, effusion, to reduce swelling synovial milking sign, and inflammation, and to suprapatellar bulging, loss restore the stability of the of motion joint, aspiration

Prepatellar Bursitis 163 Pes Anserine Busitis

• CPT code: 20551 – Injection of single tendon origin or insertion • ICD:9 726.61 • ICD:10 M70.5

• Inflammation of pes anserine bursa, medial side of the knee • Often mistaken for inflammation inside the knee joint • Frequent with post op knee arthroplasties, and runner – Treatment – physical therapy, injection – think orthotics too

165 Osteoarthritis of the Knee

“My knee gets stiff and • Special testing: weight painful, my knees are not bearing x-rays, bone scan, straight any more” CT/MRI PE: joint line tenderness, loss • Treatment: ice, PT, Steroid of full flexion or extension injection, HA, arthroscopy, partial, total joint arthroplasty , resurfacing

Meniscal Tear of The Knee

“My knee is swelling and Special tests: x-ray, MRI I’m having Treatment: define the catching/locking type and extent of the PE: effusion, joint line tear, strengthen the tenderness, positive muscular support and McMurrays determine the need for surgery

Ankle

175 176 Ankle Sprain

“ I injured my ankle years ago, and it Special tests: MRI, to role out has been weak ever since” ligament rupture, PE: tenderness, swelling, or bruising osteochondrititis dissecans of the anterior and inferior to the lateral talar dome malleolus, pain aggravated by Treatment: allow the lateral forced inversion, ankle instability ligaments of the ankle to (positive drawer sign) reattach to their bony insertions, to strengthen the tendons that cross the ankle, surgery

Achilles Tendinitis

“ My shoes hurt the back of Special testing: MRI my heel” Treatment: allow the micro PE: tenderness and thickening torn tendon to heal, reduce above the calcaneus, pain the peritendinous swelling aggravated by resisting and thickening, to prevent plantar flexion, ROM ankle frank rupture of the tendon usually normal and to increase strength of the tendon

Pre-

“ I have this bump on the back Special testing: none of my heel” Treatment: reduce the friction PE: Local tenderness and over the heel, reduce the swelling directly over the bursal inflammation, and posterior calcaneus, normal to prevent recurrent range of motion bursitis b y means of stretching exercises, injection

Posterior Tibialis Tenosynovitis

“ I have this sharp pain around the Special testing: none/occasional MRI inside of my ankle when ever I to rule out posterior tibial tendon step” dysfunction PE: local tenderness and swelling just Treatment: reduce the inflammation inferior and posterior to the in the tendon sheath and to medial malleolus, pain correct any underlying aggravated by resisting ankle abnormalities of the ankle joint inversion and plantar flexion, or ankle alignment. Correct ankle associated conditions, including pronation, pes planus or pes ankle pronation, pes planus, or cavus pes cavus

Foot/Toes (UFS) 190

“I can’t get a pair of shoes to Special testing: none, x-rays fit properly, my toes look Treatment: reduce joint horrible” inflammation, retard PE: MTP joint tenderness and further valgus deformity. enlargement, typical hallux Wide toe box shoes, toe valgus deformity spacers, and adhesive pads, surgery

Plantar

• CPT code: 20550 – injection of aponeurosis • ICD 9: 728.71 • ICD10: M72.2

“ In the morning when I get Special testing: x-ray, out of bed my heel hurts, occasional bone scan whenever I put pressure Treatment: reduce down on my heel, I get a inflammation in the severe sharp pain” longitudinal arch and to PE: Local tenderness at the improve the mechanics of calcaneal origin of the the heel and ankle. plantar , tight achilles Injection tendon

Gout

“I woke up in the night with severe, Special testing: demonstration of sharp pain in my big toe, my big monosodium urate crystals is the toe is very red and swollen” diagnostic test of choice. Light PE: Acute swelling, redness, and heat microscopy reveals the arising from the MTP joint, severe characteristic needle-shaped tenderness at the MTP joint, pain monosodium urate crystals that aggravated by even the slightest appear bright yellow under movement of the joint polarized light. Treatment: rapidly reduce the acute inflammation within the MTP joint

Morton Interdigital Neuroma

• CPT code: 64450 – Injection, nerve block therapeutic, other peripheral nerve or branch • ICD-9: 355.6 • ICD-10: G57.6 Morton Neuroma

“My two toes have gone Special testing: x-rays numb; I have sharp pain Treatment: reduce the between my toes” pressure over the nerve PE: Maximum tenderness in and to eliminate the the web space, pain associated inflammation. aggravated by the MTP Steroid injection, surgery squeeze sign, loss of sensation along the inner aspects of the adjacent two toes

Part III

Pregnancy

203 Pregnant Women

• Increased mobility of pelvic joints – Hormones • Progressive lordosis of spine – Compensate for enlarging uterus • Lower back pain • Muscle cramps Pregnant Women

• Postural changes – Lordosis – Forward cervical flexion – Waddling gait • Assess for: – Lumbosacral hyperextension • Causes lower back pain – • Secondary increased fluid retention Part IV

Older Adults

206 Older Adults

• Loss of bone density – At risk for fractures • Deterioration of joint cartilage – Decreased mobility Older Adults

• Weakness – Onset – Associated symptoms • Increases in minor injuries • Change in ease of movement • Nocturnal muscle spasm • History of injuries or excessive use of a joint or group of joints, claudication, known joint abnormalities • Previous fractures Older Adults

• Muscle mass decreases: – Muscle tone and strength decrease. – Reaction time and speed decrease. – Endurance decreases. • Sedentary lifestyle promotes degeneration of musculoskeletal system. Older Adults

• Assessment of activities of daily living for fine and gross motor skills • Osteoporosis Risk Assessment Instrument to screen for osteoporosis • Inspect: – Dorsal kyphosis – Base of support broader (feet more widely spaced) – Reduction in total muscle mass Older Adults

• Palpate muscle for the following: – Tone – Atrophy • Assess muscle strength and ROM. – Treatment: manage their disease state, encourage exercise, therapy, YMCA programs Think Prevention!!!

Osteoporosis Fragility Fractures Men and Women!!! Part V

Rheumatologic Disorders

213 Definition:

Rheumatologic (or Rheumatic) Disease: diseases characterized by pain and inflammation in joints and connective tissues, often referred to as “collagen-vascular diseases”. Diversity of Rheumatologic Diseases: Common and Uncommon Diseases Involving Inflammatory and Immune Responses

Inflammatory Diseases (innate immunity) Osteoarthritis* * Pseudogout

Immunologically-Mediated Diseases (adaptive immunity) * Systemic Erythematosus* * (Reiter’s Syndrome) Spondylitis associated with IBD Sjogren’s Syndrome Polymositis/Dematomyositis Lyme Disease Rheumatic Behcet’s Syndrome Systemic Sclerosis () Wegener’s Granulomatosis Giant Arteritis*

. Major Rheumatic Diseases

 Osteoarthritis  Poly-Dermatomyositis  Crystal - Induced  Rheumatoid Arthritis Arthritis  Systemic Lupus  erythematosus  Vasculitis  Systemic Sclerosis  Spondyloarthropathies Rheumatoid Arthritis

• Usually insidious onset with morning stiffness and pain in affected joints • Symmetric with predilection for small joints of the hands and feet; deformities common with progressive disease • Radiographic finds: juxta-articular osteoporosis, joint erosions, and joint space narrowing

217 218 RA

• Rheumatoid factor and antibodies to cyclic citrullinated peptides (anti-CCP) are present in 70-80% • Extra-articular manifestations: subcutaneous nodules, pleural effusion, pericarditis, lympadenopathy, splenomegaly with leukopenia, and vaxculitis

219 RA

• Primary objective are reduction of inflammation and pain, preservation of function, and prevention of deformity • Early, effective pharmacologic intervention, disease –modifying antirheumatic drugs (DMARDS) should be started as soon as the diagnosis is certain.

220 Systemic Lupus Erythematosus

• Occurs mainly in young women • Rash over areas exposed to sunlight • Joint symptoms in 90% of patients – multiple system involvement • Anemia, leukopenia, thrombocytopenia • Glemerulonephritis, central nervous system disease, and complications of antiphospholipid and antibodies are major sources of disease morbidity

221 222 Lupus

• Serologic findings: antinuclear antibodies (100%), anti-native DNA antibodies (2/3), and low serum complement levels (especially during disease flares) • Treatment : Patient education and emotional support – very important!! • Drug therapy tailored to disease severity

223 Raynaud Phenomenon

• Paroxysmal bilateral symmetric pallor and cyanosis followed by rubor of the skin of the digits • Precipitated by cold or emotional stress; relieved by warmth • Primarily affects young women • Primary form benign; secondary form can cause digital ulceration or gangrene

224 225 Raynaud Treatment

• Keeping the body warm • Calcium channel blockers – first line; angiotensin-converting enzyme inhibitors, sympatholytic agents, topical nitrates, selective serotonin reuptake inhibitors, parenteral prostaglandins, and others • Sympathectomy may be indicated when attacks become frequent and severe

226 Seronegative Spondyloarthropathies • Ankylosing spondylitis • Psoriatic arthritis • Reactive arthritis (formerly Reiter syndrom) • Arthritis associated with inflammatory bowel disease

227 Ankylosing Spondylitis

• Chronic low backache in young adults, generally worst in the morning • Progressive limitation of back motion and or chest expansion • Transient (50%) or persistent (25%) peripheral arthritis • Anterior uveitis in 20 – 25% • Diagnostic radiographic changes in sacroiliac joints • Negative serologic tests for rheumatoid factor • HLA – B27 testing is most helpful where there is indeterminate probability of disease

228 229 230 Treatment Ankylosing Spondylitis

• NSAID’s first line • TNF inhibitors for NSAID – resistant axial disease – improved outlook dramatically

231 Psoriatic Arthritis

• Psoriasis precedes onset of arthritis in 80% of cases • Arthritis usually asymmetric , with “sausage’ appearance of fingers and toes • Sacroiliac joint involvement common • Radiographic findings: osteolysis; pencil-in – cup deformity; relative lack of osteoporosis; bony , asymmetric sacroiliitis

232 233 234 Treatment of Psoriatric Arthritis

• NSAIDS are usually sufficient in mild cases • Methotrexate for those not responding • TNF inhibitors if refractory to methotrexate

235 Reactive Arthritis (formerly Reiter syndrome) • Reactive arthritis precipitated by antecedent gastrointestinal and genitourinary • Manifests as an asymmetric sterile , typically of the lower extremities • Extra-articular manifestations: urethritis, conjunctivitis, uveitis, and mucocutaneous lesions

236 237 Reactive Arthritis

• Fifty to eighty percent of patients are HLA-B27 positive • Oligoarthritis, conjunctivitis, urethritis, and mouth ulcers most common features • Usually follows dysentery or a sexually transmitted

238 Treatment: Reactive Arthritis

• NSAIDS • given at the time of a nongonococcal sexually transmitted infection • Sulfasalazine

239 Key Risk Factors: Septic Arthritis

• Bacteremia (injection drug use, endocarditis, infection at other sitesO • Damaged or prosthetic joints • Compromised immunity (, advanced chronic kidney disease, , cirrhosis, immunosuppressive therapy) • Loss of skin integrity (cutaneous ulcer or psoriasis)

240 Osteomyelitis

• Often difficult to diagnose and treat • Consequence of hematogenous dissemination of • Invasion from a focus of infection, • Skin breakdown in the setting of vascular insufficiency

241 Infections of Bones

• Acute pyogenic osteomyelitis – Fever and chills associated with pain and tenderness of involved bone – Diagnosis usually requires culture of bone biopsy – ESR often extremely high

242 Infective Arthritis

• Nongonococcal acute Bacterial (Septic) Arthritis – Acute onset of inflammatory monoarticular arthritis, most often in large weight - bearing joints and wrists – Previous joint damage or injection drug abuse common risk factors – Infection with causative organisms commonly found elsewhere in body – Joint effusions are usually large, with white blood counts commonly >50,000/mcl.

243 244 Infectious Organisms

• most common • Methicillin-resistant S aureus and group B • Gram-negative septic arthritis – common in injection drug users • Escherichia coli and Pseudomonas aeruginosa are the most common gram-negative isolates in adults.

245 Treatment of Septic Arthritis

• Appropriate therapy • Drainage of the infection joint • Early treatment critical in preserving joint function and preventing osteomyelitis

246 Neurogenic Arthropathy (Charcot Joint) • Joint destruction resulting from loss or diminution of proprioception, pain, and temperature perception • Frequently seen in diabetic neuropathy, syringomelia, spinal cord injury, pernicious anemia, leprosy and peripheral nerve injury • Normal muscle tone and protective reflexes are lost, secondary degenerative joint disease progresses

247 248 Charcot Joint

• Results in enlarged, boggy , relatively painless joint with extensive cartilage erosion, formation. • Radiographic changes may be degenerative or hypertrophic • Treatment: directed toward the primary disease; mechanical devices are used to assist in weight bearing and prevention of further trauma

249 Osteonecrosis Avascular Necrosis of Bone • Complication of corticosteroid use, alcoholism, trauma, SLE, pancreatitis, gout, sickle cell disease, dysbaruric syndromes and infiltrative diseases (Gaucher Diesease) • Common sites: proximal and distal femoral heads, ankle, shoulder and elbow • Osteonecrosis of the jaw been rarely associated with the use of bisphosphonate therapy

250 251 Common Fractures

Part VI

252 Learning Objectives

• Understand how bone functions in the human skeleton and reacts to injuries • Be able to accurately describe bone injuries to another provider • Understand what fractures can be treated in the primary care office setting. Develop a list of supplies and materials that are needed in treating bone injuries in the primary care setting. • Develop a better understanding of when to refer a bony injury to an orthopedic specialist. • Learn how to access educational resources to help guide the primary care provider with the management of fractures in adult and pediatric patient populations. Introduction

• 80% of primary care providers are involved in fracture management • 1/3 of all visits to a family practice office are for musculoskeletal concerns Things to Avoid….In Your Practice

• Adverse outcome for missed or inaccurate fracture diagnosis, with resulting delay in treatment/referral and underestimating the seriousness of injury Fracture

• Break in the structural continuity of bone • Think of the forces that caused the mechanism of injury! • Remember that there is always some degree of with a fracture What is bone…… BEFORE WE FIX IT OR REFER IT WE SHOULD KNOW WHAT IT IS!! What is Bone?

• Primary structural element of the body – Provides a framework for motion – Protects vital internal organs • Storage depot – 99% of total body calcium • Producer of circulating blood cells Keep in Mind How Fractures Happen

• A single traumatic incident? • Repetitive stress? • Abnormal weakening of the bone? (osteoporosis, fragility fractures, pathological fracture, malnutrition) • Remember to treat the patient and not just the fracture! Forces that Cause Fractures

• Twisting causes a spiral fracture • Compression causes a short oblique fracture • Bending results in fractures with a triangular “butter- fly” fragment • Tension tends to break the bone transversely Simple Diagnostic Tool for Fractures

• Let your hand do the walking!!! • Examine: touch, feel, examine contours, compare to opposite extremity Factors that Affect Fracture Healing

• The energy transfer of the injury – High energy injury – Low energy injury • The tissue response – Two bone ends in opposition or compressed? micro-movement or no movement? Signs of infection? • The patient – age, hormones, other drug use • The method of treatment

Stages of Fracture Healing • Inflammation – Hematoma Formation • Source of Growth Factors • Repair – Cartilage Formation and Maturation • Similar to endochondral ossification at physis • Proliferation---hypertrophy---calcification – Angiogenesis • Brings perivascular mesenchymal cells – converted to osteoblasts • Calcified cartilage (nearly identical to primary spongiosa) is replaced by woven bone (nearly identical to secondary spongiosa) • Remodeling Phases of Healing

• Inflammatory phase: begins immediately after injury, swelling, , bruising, pain, impaired function • Repair phase: hard callus begins to form at about 2 – 3 weeks; fracture site becomes “sticky”, movement and pain decrease at the fracture site • Remodeling phase – begins at 6 weeks after injury; re-shapes the repair tissue with mature bone; tenderness and pain with motion resolves Fracture Healing – Age Dependent (example: Clavicle) • 1- 3 weeks for newborn clavicle to heal completely • 9 – 12 months for adult clavicle to heal completely • Cellular turnover rate is what drives healing!! • Are there confounding processes that will slow healing? Local Factors

Good Stability + Poor Biology = Atrophic Nonunion ______

Stability Biolo Poor Stability + Good Biology gy = Hypertrophic Nonunion Local Factors

• Biology – Blood Supply • Location of Fracture – Scaphoid, Talar Neck • Periosteal Stripping – Injury – Iatrogenic • Other disruptions of blood supply – Compartment Syndrome – 2x longer to heal – Vascular Injury – 3x greater incidence of delayed union Exogenous Factors

• Enhancement of Fracture Healing – – Pulsed Electromagnetic Fields If we have a bone injury we almost always have to take a picture………. GET THE RIGHT X-RAYS!! (VIEWS, WEIGHT BEARING VS NON-WEIGHT BEARING Fundamentals in the Roentgenological Study Of Trauma

• Any bone: Obtain a minimum to one another of two views at 90 degrees • Paired Long Bones: Desirable to see entire shaft of both bones, include joint nearest the injury • Joint injuries: Need minimum of four views, particularly for the detection of vertical fractures which involve the articular surface • Axial or Tangential Views: for certain bones such as : patella, calcaneus, olecranon process of ulna, ribs, skull, nasal bones, mandibular condyles, etc. • Referred Pain Mechanism in Hip and Knee Injuries: Hip trauma by virtue of pain referred via the sciatic nerve can sometime produce knee pain. A patient with a hip injury may have referred knee pain, but it may also be due to a fracture in the distal end of the femur with referred pain in the hip. X-ray the entire femur. A fracture is identified….. WELL NOW WHAT DO I DO….TREAT OR NOT???? Goals of Fracture Treatment

• Prevent fracture and soft tissue complications – respect the soft tissue envelope!! • Get fracture to heal and in satisfactory position for optimal functional recovery • Intra-articular fractures frequently needs accurate reduction and rigid fixation– non- articular fracture of bone require anatomical reduction and stable fixation • Rehabilitate as early as possible by active and passive exercises • Restore patient to optimal functional state Potential Fracture Complications

• Arterial injuries – displaced fractures or dislocations of the elbow or knee • Nerve injury • Compartment Syndrome • Infection – open fractures • Skin tenting causing ischemia • Soft tissue damage • Complex Regional Pain Syndrome • Osteomyelitis – delayed • Blood Clot (DVT) – complication associated with immobilization /bracing Basic Tenets of Fracture Care

• Hold • Move • Speed • Safety Principles of Treatment

• Manipulation • Splints • Joint movement and function: must be preserved • Exercise and early weight bearing • Reduce! Hold! Exercise! Manipulation

• Closed manipulation is suitable for: – All minimally displaced fractures – Most fractures in children – Fractures that are likely to be stable after reduction • Unstable fractures are sometimes reduced “closed” prior to mechanical fixation • Three fold maneuver: anesthesia and muscle relaxation (REFER) – Distal part of the limb is pulled in the line of the bone – The fragments are repositioned as they disengage – Alignment is adjusted in each plane

Splintage/Cast

• Plaster of Paris is still used as a splint, especially for distal limb fractures and for most children's fractures (custom products – all in one) • “safe” – if not applied too tightly or unevenly • “holding” – not a problem • “negative” – joints encased in plaster cannot move and are liable to stiffen. Can cause pressure sores, skin abrasions or lacerations Splinting

• Plaster/Fiberglass splinting – Ulnar, radial gutter, thumb spica – Posterior splints – Hanging plaster, etc. • Commercial splints General Casting Routine

• Apply cast in position of function – (most of the times) • Repeat x-ray in 1 – 3 weeks depending on fracture and age of patient • Return in 3 – 5 weeks for x-ray out of cast. Check for callus formation, note any skin breakdown – palpate for tenderness at fracture site – review motor/sensory exam • May progress to plastic custom splint if warranted. • Begin early physical therapy

Casting Pitfalls

• Incorrect placement can lead to unnecessary stiffness of unaffected joints • Improperly applied • Poor post cast patient instructions/crutch instructions • Incorrect amount of time in cast/splint Casting Pearls

• Pad well/proximal distal cast • Use enough padding over bony prominences • Cover rough edges with stockinette • Trim cast before it sets • With short arm and thumb spica ,take time to well pad the thumb • Make weight bearing casts strong enough to weight bear! Always use a cast shoe! Functional Bracing

• Prevents while still permitting fracture splinting and loading • Most commonly used for fractures of the femur/tibia/fibula • Since not very rigid usually applied only when the fracture is beginning to unite • Think about cost!

Internal Fixation

• Holds securely with precise reduction • Movements can begin at once – (no stiffness or ) • Speed: patient can leave hospital as soon as wound is healed, full weight bearing is unsafe for some time • Safety: biggest is ! – Risk depends on patient, surgeon, facilities and the injury

Indications for Internal Fixation

• Fractures that cannot be reduced • Fractures that are inherently unstable and prone to re- displacement after reduction • Fractures that unit poorly and slowly • Pathological fractures • Multiple fractures • Fractures in patients who present severe nursing difficulties Complications of Internal Fixation

• Many are due to poor technique, equipment, or operating conditions • Infection – Iatrogenic infection is now the most common cause of chronic osteomyelitis • Non-union – Excessive stripping of the soft tissues – Unnecessary damage to the blood supply – Rigid fixation with a gap between the fragments • Implant Failure • Re-fracture External Fixation

• Permits adjustment of length and angulations • May allow reduction of the fracture in all three planes • Used frequently in long bones and the pelvis Indications External Fixation

• Fractures associated with severe soft-tissue damage where the wound can be left open for inspection, dressing, or definitive coverage • Severely comminuted and unstable fractures, which can held out to length until healing commences • Fractures of the pelvis, • Fractures associated with nerve or vessel damage • Infected fractures, for which internal fixation might not be suitable • Un-united fractures, where dead or sclerotic fragments can be excised and the remaining ends brought together in the external fixator Complications of External Fixation

• Requires high degree of training and skill – often used in the most difficult fractures which increases the likelihood of complications • Damage to soft-tissue structures • Over distraction – No contact between the fragments • Pin-track infection Fracture Healing Complications

• Delayed Union • Non-union • Mal-union • Post-traumatic arthritis • Growth abnormalities • Joint stiffness, non-use atrophy, Sudeck atrophy Fractures

• Most fractures associated with major skeletal trauma are evaluated in the emergency room • Nearly 1/2 of the population will experience a bony fracture at some time in their life • The 10 most common fractures account for 90% of all fractures • 10-15% of all fractures require open reduction and internal fixation Fractures that Present to Primary Care Practitioner • Avulsion fractures • Non-displaced fractures associated with severe • Vertebral compression fractures (osteoporosis) • Stress fractures in athletes, dancers, and military recruits • Segmental collapse fractures in avascular necrosis of the femoral head • Pathologic fractures of metastatic involvement of the spine, femur, tibia, and humerus Fracture Distribution

• Ankle 23% • Wrist 17% • Fingers 14% • Toes 7 % • Ribs 7 % • Knee 7 % • Clavicle 6 % • Elbow 6 % • Tarsus 3 % • Hip 2 % • Other 9 % Primary Care Management of Non- Surgical Fractures • Primary care general approach to fracture management – maximizing outcomes and minimizing risks (AKA – staying out of trouble) • Management of common upper and lower extremity fractures • Pediatric specific issues • Splinting and casting techniques • What supplies do I need in my office? • Billing issues with fracture management Avoid Risk

• In general, the following fracture issues and concerns increase the risk of problematic outcomes: – Missing surgical indications – Not recognizing complications of the soft tissue component – Intra-articular fractures – Comminuted fractures – Significant displacement or impaction fractures – Treatment of high risk fractures that are known for non- union complications: • Scaphoid, proximal fifth metatarsal, growth plate involvement Communication is Key!

• Have a relationship with an orthopedic provider • Digital imaging has improved the instantaneous sharing of information- use your smart phone! • Appropriate knowledge of bone descriptions – Describe findings anatomically – Use landmarks for positioning: styloids, tuberosities, joints, malleoli, condyles, etc. – Distal vs proximal – Lateral vs medial – Dorsal vs volar/plantar – Location on long bone (mid-shaft, distal, proximal, etc) Yes you have to…..Don’t call me if you don’t!!!!! LEARN THE LANGUAGE OF FRACTURE CARE….. Bone Description

• In growing bones: Metaphysis – end or neck of bones, Diaphysis is the shaft of the bones • In Immature bones: above plus: Physis is the growth plate and the Epiphysis is outside of the physis.. Fracture Description

• Transverse • Oblique • Spiral • Comminuted • Segmental • Avulsed • Impacted • Torus • Greenstick • Open/Closed • Stress • Pathologic Salter-Harris Classification: Epiphyseal Fractures • Type 1 – Through epiphyseal plate with displacement • Type 2 – Type 1 plus triangular segment of metaphysis is fractured • Type 3 – Runs from joint surface through epiphyseal plate and epiphysis • Type 4 – Type 3 but also through adjacent metaphysis • Type 5 – Crush injury of the metaphysis Fracture Description

• Displacement • Angulation(volar, dorsal, lateral) • Any intra-articular component Alignment or Angulation

• Describe relationship of fragments along the long axis of the bone • Degrees of angulations of the distal fragment in relation to the proximal fragment. Goniometer

• A must have tool • Most software programs will let you measure angles as well Position or Displacement

• Contact of the fracture surfaces • Amount of displacement – partial or complete • Percentage of surface displaced (mm or cm)– compare cortices Degree of Displacement

• The degree of displacement or angulations that can be accepted depends on the particular bone involved, and the age of the patient • 50% displacement and 30 degree angulations is the upper limit of acceptability for most bones – Depending on your experience, and for the sake of safety, you may pick 15 degrees of angulation or less as your upper limit.

Shortening or Distraction

• Fragments overriding each other • Separation of fragments that have been pulled apart. Intra-Articular Component

• Fracture goes through the joint line • Prone for traumatic osteoarthritis and Open Fractures

• Have contact with the external environment • Most commonly seen in high impact trauma • High risk for infection • Closed fractures – no communication with the external environment

Transverse Fracture

• Usually produced by bending force applied directly to the fracture site • Fracture line runs 90 degrees to long axis f the bone Oblique Fracture

• Usually are by torsional force applied at a angle the fracture site • Fracture runs at an angle less than 90 degrees to the long axis of the bone Spiral Fracture

• Produced by twisting or rotational forces

Greenstick Fracture

• Incomplete long bone fracture • Seen in children due to increased bone elasticity Torus/Buckle Fracture

• Buckled cortex • Caused by compression force on the long axis of the bone in children Comminuted Fracture

• Produced by direct trauma • A fracture into more than two pieces of bone Avulsion Fracture

• Produced by forcible resisted contraction of muscle that pulls off a fragment of bone at the muscle insertion Impacted Fracture

• Fracture ends are compressed together • Usually very stable Stress Fracture

• Caused by repetitive overuse leading to micro- fracture of the bone

Pathologic Fracture

• Occurs at the site of bone weakened by osteoporosis or tumor Fracture/Dislocation

• Fracture of the bone near a joint, also involving dislocation of the joint Rotation

• Described clinically by looking at the fractured extremity. Types of Healing

• Union: refers to healing of a fracture; clinical union permits resumption of limb motion (occurs earlier than radiographic union_ • Delayed healing : healing that takes longer than usual • Mal-union: healing of a fracture with residual deformity • Non-union: failure of a fracture to unit; false joint appears between the fracture ends – May have fibrous union with pain free normal function

Fractures You Should be Able to Treat!

Primary Care Fractures That Can Be Managed Non-Operatively General Categories: • All stress fractures – reduced running, standing, repetitious use • All non-displaced extra-articular fractures – Casting for 3 to 6 weeks • Most small avulsion fractures – casting for 2 – 4 weeks • Some non-displaced, single-fragment intra- articular fractures – casting for 4 – 6 weeks

“Safe Fractures”

• Fracture Clavicle – Skin not compromised, lungs clear with good air exchange, neck has full range of motion, neurovascular exam of upper limb normal, x-rays show mid-shaft fracture with minimal or no angulations or displacement • Fracture neck of humerus • Fractures of lower radius and ulna • Fractures of metacarpal • Fracture phalanx (finger) (toe) • Fracture metatarsal • Type I Epiphyseal plate injury Fractures That Are Managed Operatively

• Multifragment intra-articular – • Fracture dislocations – Difficulty of reduction, risk of arthritis • Metastatic lesion of bone – Risk of pathologic fracture • Comminuted fractures – risk of nonunion and angulation • Compound fractures – risk of infectious complication • Fractures associated with neurovascular compromise Benign and Malignant Bone and Soft Tissue

Part VII Thank you to Dr Cynthia Emory!!

337 Benign and Malignant Bone and Soft Tissue • Musculoskeletal complaint – Dull, aching pain – Progressive , perhaps starting with activity – progressing to constant – Night pain – Plus/minus mass – Sometimes incidental finding

338 Lesions by Age

• Birth - 5 yrs old – Malignant • Leukemia, metastatic neuroblastoma, metastatic rhabdomyosarcoma – Benign • Osteomyelitis, osteofibrous sysplasia

339 Bone Lesions by Age

• 10-25 years of age – Malignant • Osteosarcoma, Ewing sarcoma, leukemia – Benign • Eosinophilic granulla, osteomyelitis, enchondroma, fibrous dysplasia, hyperparathyroidism, giant cell tumor,

340 Bone Lesions by Age

• 40-80 years of age – Malignant • Metastatic disease, multiple myeloma, lymphoma, Paget’s sarcoma, post-radiation sarcoma – Benign • Paget’s disease • Enchondromas

341 Bone Lesions by Age

• Lytic bone lesion in an adult> 40 years old – Metastatic disease – Myeloma – Lymphoma

342

• References

• Anderson, Bruce. Office Orthopedics for Primary Care Diagnosis and Treatment. Saunders. 1999 • Hoppenfeld, Stanley . of the Spine and Extremities. Appleton-Century Crofts. 1976 • McNabb, James A Practical Guide to Joint and Soft Tissue Injection and Aspiration , 2010. Lippincott Williams and Wilkins. Second Edition • Saunders, S; Longworth, S. Injection Techniques in Orthopaedics and Sports Medicine 2009. Churchill Livingston – Third Edition Thank you!!

Best of luck!

• Any questions/comments please email: Frank Caruso MPS, PAC – [email protected] – [email protected]